Howard R. Epps

Isolated fractures of the lesser trochanter in children

In a retrospective study of 1126 children with fractures of the proximal third of the femur, three children were found to have isolated fractures of the lesser trochanter. This fracture occurred from a fall in one child and following sporting activities, without a history of injury, in the others. In the latter children, the clinical presentations were similar to those of children with transient synovitis of the hip or Perthes disease. In each child, plain radiographs showed an avulsion fracture of the bony portion of the lesser trochanter. Early and complete recovery followed symptomatic treatment even when there was marked proximal displacement of the avulsed segment of the lesser trochanter.

Mangled Extremity Severity Score in Children

Treatment of the severely traumatized or mangled lower extremity poses significant challenges. The Mangled Extremity Severity Score (MESS) is a scale that uses objective criteria to assist with acute management decisions. Most research on the MESS has been in adults or combined series with few children. The study was performed to investigate the MESS in children exclusively. The MESS was applied retrospectively to 36 patients with grades IIIB and IIIC open lower extremity fractures collected from two level 1 pediatric trauma centers. Patients were divided into limb salvage and primary amputation groups based on the decision of the treating surgeon. In the salvage group there were 18 grade IIIB fractures and 10 grade IIIC fractures. The MESS prediction was accurate in 93% of the injured limbs. In the amputation group eight limbs met the inclusion criteria; the MESS agreed with the treating surgeon in 63% of cases. These findings suggest the MESS should be considered when managing a child with severe lower extremity trauma.

The treatment of pediatric supracondylar humerus fractures.

Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children. Two each of these recommendations are graded Weak and Consensus; eight are graded Inconclusive. The two Moderate recommendations include nonsurgical immobilization for acute or nondisplaced fractures of the humerus or posterior fat pad sign, and closed reduction with pin fixation for displaced type II and III and displaced flexion fractures.

Immediate single-leg spica cast for pediatric femoral diaphysis fractures.

Purpose: Immediate spica cast application is the standard of care for young children with isolated femur fractures. We evaluated the outcomes and function of children treated with single-leg spica casts. Methods: We performed a retrospective review of 45 children treated with single-leg spica casts. Demographic data, mechanism of injury, hospitalization time, time in cast, and complications were collected by chart review. Children returned for a physical examination and radiographs. Subjects completed a questionnaire about the childs functional level and the Activities Scale for Kids. Results: There were 33 boys and 12 girls. The average age was 3.3 (9 months to 9 years). The mechanism of injury was a fall in 71%. The mean hospitalization was 1 day (0-4 days) and the mean time to union was 6 weeks (4-9 weeks). Ninety-five percent of the patients crawled in the cast, 90% pulled to stand, 81% cruised, and 62% walked either independently or with assistive devices. One half of the patients in school or daycare returned while in the cast. Two children failed because of unacceptable shortening. Two children required repeat reductions under anesthesia due to unacceptable alignment. Five casts broke at the hip joint. At final review, there was 1 rotational malunion. There were no radiographic malunions. The median Activities Scale for Kids score was 95 of 100 possible points. Conclusions: The single-leg spica can safely, effectively manage low-energy femur fractures in young children. Significance: The single-leg spica may address some of the social concerns associated with the use of a spica cast for simple femur fractures.

Pediatric orthopaedic practice management: The role of midlevel providers

The efficient functioning of a pediatric orthopaedic office practice is subject to many variables. Determining the number and nature of care providers is a challenging problem and unique to each practice. The threshold to hire new or additional personnel will depend on the core practitioners’ perception of practice satisfaction and patient mix. The number of operative pediatric orthopaedic surgeons necessary in a practice, as well as how many nonoperative care providers, is related to many different practice characteristics. Hiring additional surgeons to provide nonoperative patient care may be neither feasible nor possible. Personal decisions regarding the surgeons’ lifestyle and compensation requirements will impact decisions regarding the chosen provider mix. A well-run office should be efficient and comfortable for both patients and staff, have sufficient ancillary support, and be financially sound. The composition of this office will vary, depending on practice location and size. There are several different types of employees who combine as a team to run an office practice. In many circumstances, a practice may experience a marginally increased demand on its outpatient services, but this demand may not be enough to justify the increased capacity and financial overhead associated with hiring an additional pediatric orthopaedic surgeon. In other circumstances, the practice may experience a large increase in office work, but surgical volume may not keep pace, creating a practice opportunity that is not appealing to a pediatric orthopaedic surgeon desiring a heavy surgical load. Physiatrists and pediatricians with specialized musculoskeletal training may fill this void, but there are downsides to the incorporation of these individuals into pediatric orthopaedic practices. This article covers some of these concerns. The use of midlevel providers (MLPs), specifically nurse practitioners (NP) and physician assistants (PAs), functioning as physician extenders has become increasingly popular in all medical and surgical fields. The large volume of office pediatric orthopaedic work, frequently uncomplicated musculoskeletal complaints, lends itself well to the use of MLPs. This article reviews the use of MLPs in today’s pediatric orthopaedic practice setting.

Preventable childhood injuries

Background: This is a literature review generated from The Committee on Trauma and Prevention of Pediatric Orthopaedic Society of North America to bring to the forefront 4 main areas of preventable injuries in children. Methods: Literature review of pertinent published studies or available information of 4 areas of childhood injury: trampoline and moonbouncers, skateboards, all-terrain vehicles, and lawn mowers. Results: Much literature exists on these injuries. Conclusions: Preventable injuries occur at alarming rates in children. By arming the orthopaedist with a concise account of these injuries, patient education and child safety may be promoted. Level of Evidence: 3.

Emergency department on-call status for pediatric orthopaedics: a survey of the POSNA membership.

Background: The emergency room on-call status of pediatric orthopaedic surgeons is an important factor affecting their practices and lifestyles and was last evaluated in 2006. Methods: The entire membership of the Pediatric Orthopaedic Society of North America (POSNA) was surveyed in 2010 for information regarding their emergency room on-call status with 382 surveys returned of over 1000 e-mailed to members of POSNA. Detailed information about on-call coverage, support, and frequency was obtained in answers to 14 different questions. Results: Compared with the prior survey in 2006, the 2010 survey indicated that a higher percentage of pediatric orthopaedic surgeons receive compensation for taking emergency room call; a higher percentage cover pediatric patients only when on-call; and accessibility to operating rooms in a timely manner for trauma cases, although limited, has improved for pediatric patients. Utilization of support staff to meet on-call trauma coverage demands, such as residents, physician’s assistants, and nurse practitioners, is becoming more common. Conclusions: Concentration of pediatric orthopaedic trauma has increased the coverage demands on pediatric orthopaedists. This has resulted in a change in reimbursement strategies, and allocation of OR time and hospital staffing resources.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Opinion survey regarding pediatric orthopaedic trauma call and emergency trauma management.

Background: To determine the attitudes and practices of pediatric orthopaedic surgeons regarding on-call coverage and emergency fracture management. Methods: A 32-question online survey was sent to all 597 active members of the Pediatric Orthopaedic Society of North America. There were 296 completed surveys, for a response rate of 49.6%. Results: Of the respondents, 85.1% were male. The respondents ranged in age from 30 to older than 70 years, with 54% between 36and 50 years of age, corresponding to an average of 15 years in practice. Seventy-seven percent of the respondents felt that taking trauma call is an integral aspect of being a pediatric orthopaedist. Of the respondents, 64.9% take call 1 to 9 times per month, 15.8% take 10 to 19 calls, 2.7% take 20 or more, and 16.6% take no call. The number of orthopaedists taking call per practice was fairly evenly distributed between 3 and 10. Call was shared equally in 32% of practices, and mandatory in 72%. Twenty-eight percent of the respondents were additionally compensated for taking calls, in amounts ranging from

Impact of fractures on school attendance.

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