James H. Beaty

Fractures of the head and neck of the femur in children.

Fractures of the head and neck of the femur in children are rare compared with such fractures in adults, especially when compared with those in elderly patients who have osteoporotic bone’222t’”#{176}373t’. Unlike in adults, most of these fractures in children result from severe high-velocity trauma ( 196 [85 per cent] of 231 fractures in four series7t’3”4t’). Only a few of these fractures in children result from trivial trauma or child abuse on are pathological fractures (such as those in patients who have a unicameral bone cyst or fibrous dysplasia). Fractunes of the head and neck of the femur account for fewer than 1 per cent of all pediatric fractures4t’, and the prevalence of fractures of the hip in children is less than 1 per cent of that in adults. Therefore, most orthopaedic surgeons treat only a few such fractures in children in their entire professional career2239. This type of fractune remains of interest, however, not because of its frequency. but because of the frequency of its complications. which include avascular necrosis, coxa vana, premature physeal closure, limb-length discrepancy, and non-uniont’533 ’3 t’5t’.

Unilateral angular deformity of the distal end of the femur secondary to a focal fibrous tether. A report of four cases.

Difference de pronostic, au niveau des membres inferieurs entre les deformations angulaires bilaterales qui disparaissent avec la croissance et les deformations unilaterales plus severes et en relation avec des conditions pathologiques. A propos de 4 cas de deformation en varus ou valgus de lextremite distale du femur. Premiere description dans la litterature

Congenital Pseudarthrosis of the Tibia: Long-Term Follow-Up Study

Review of the literature reveals how difficult it is to assess the results of treatment of pseudarthrosis of the tibia. There is disagreement as to when the result can be considered final. This study reviewed the long-term results of treatment to determine if skeletal maturity could be considered the definitive end point of treatment or if the results deteriorate past skeletal maturity. In addition, the effect of neurofibromatosis on pseudarthrosis of the tibia is analyzed. Forty-one patients were reviewed. Only 25 had sufficient follow-up data to be included in this study. Eighteen of the 25 had neurofibromatosis. The results were classified according to criteria developed by Morrissy et al. At skeletal maturity, there were ten good results, three fair results, and three poor results, with nine patients having had amputation. At long-term follow-up evaluation (average 36 years; range five to 62 years), one patient with a fair result had elected amputation. About one half of the patients with neurofibromatosis required amputation. This study suggests that the results at skeletal maturity are reliable indicators of long-term results.

Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are.

BACKGROUNDnCertain fracture configurations, especially spiral fractures, are often thought to be indicative of nonaccidental trauma in children. The purpose of this study was to determine whether femoral fracture morphology, as determined by an objective measurement (fracture ratio), was indicative of nonaccidental trauma in young children.nnnMETHODSnConsecutive patients who were three years of age or younger and had a closed, isolated femoral shaft fracture treated at an urban pediatric level-I trauma center between 2005 and 2013 were identified. Anteroposterior and lateral fracture ratios (fracture length/bone diameter) were calculated for each patient by a fellowship-trained pediatric orthopaedic surgeon who was blinded to the patients clinical history. The presence or absence of a Child Protective Services referral as well as institutional Child Assessment Program evaluations were reviewed. Nonaccidental trauma was deemed to be present, absent, or indeterminate by Child Protective Services or an on-site Child Assessment Program team. To further evaluate and quantify the likelihood of nonaccidental trauma, the criteria of the Modified Maltreatment Classification System were used.nnnRESULTSnOf 122 patients identified, ninety-five met the inclusion criteria for this study. Of these ninety-five, fifty-one (54%) had either a Child Protective Services or a Child Assessment Program consultation because of suspected nonaccidental trauma. Thirteen (25%) were found to have nonaccidental trauma as determined by Child Protective Services or the Child Assessment Program team and seven (14%) had indeterminate Child Protective Services or Child Assessment Program investigations. All thirteen patients with nonaccidental trauma, as well as the seven patients with an indeterminate Child Protective Services or Child Assessment Program investigation, had positive Modified Maltreatment Classification System scores for physical abuse. Patients who had nonaccidental trauma had significantly decreased mean anteroposterior fracture ratios compared with those who had confirmed accidental trauma (p < 0.0001).nnnCONCLUSIONSnThe fracture ratio can be helpful to determine fracture morphology and can be used as part of the assessment of a child with suspected nonaccidental trauma. While not diagnostic, the presence of a transverse diaphyseal femoral fracture in a young child should raise the index of suspicion for nonaccidental trauma.nnnLEVEL OF EVIDENCEnPrognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Workforce, work, and advocacy issues in pediatric orthopaedics

The subspecialization of the orthopaedic surgery profession has led to a division of work; competition among orthopaedic subspecialties with regard to graduating residents seeking fellowships and patients seeking care for problems involving different subspecialties; potential splintering of the profession regarding reimbursement and advocacy initiatives; and disagreement about the role, responsibilities, and work of a so-called general orthopaedic surgeon. The issues of cost and access are now prominent in the ongoing health-care reform discussions and pending legislation, and legislative decisions may profoundly impact patients and physicians. This symposium reviews how these issues are affecting pediatric orthopaedics.nnIn a survey at the 2007 Annual Meeting of the American Orthopaedic Association1, 59% of the audience considered pediatric orthopaedic surgery to be the most undersupplied subspecialty. Trauma was a distant second at 17%, and oncology was third at 8%. The reasons considered for the perceived undersupply include the burden of taking pediatric trauma call, medicolegal liability risks that may extend for many years, the lower pay differential compared with other orthopaedic subspecialties, too much nonoperative time, and dealing with parents. Today, this perception remains. But is pediatric orthopaedics undersupplied at the present time and, if so, why? Statistics from the Annual Meeting of the Pediatric Orthopaedic Society of North America (POSNA) in May 2009 showed continued growth, with 807 members in the United States, sixty-four members in Canada, and seventy-six members from the remaining countries worldwide2. Of the North American POSNA members, however, many have retired or will do so in the next several years. As almost 20% of the members have senior status, 80% of the 871 North American POSNA members can be considered full-time pediatric orthopaedic surgeons. Do these 648 U.S. and forty-nine Canadian full-time practicing pediatric orthopaedic surgeons represent a sufficient number to provide orthopaedic care for …

The future of orthopedics

Just as fi ctional stories, such as 1984 by George Orwell and Our Posthuman Future by Francis Fukuyama, have not accurately portrayed the future of the human race, predictions about the future of orthopedics made during past years have seldom become a reality. If the truth be known, most changes occur with progression of existing trends that are improved by a few genuine advances, which most of us can see only by looking back in time, sometimes revealed by startling changes that progress quite rapidly. So then, could anybody have predicted the last 30 years of changes in orthopedics alone? Think back for a moment: Forty years ago children with Perthes disease might have been non-weight bearing for 2 years. Children with scoliosis may have been placed in skeletal traction followed by use of a brace well into adolescence. Adults undergoing spinal fusion and those with spinal fractures were immobilized in a plaster cast extending from neck to pelvis for many months. Orthopedic hospitals had teams of personnel who did nothing but evaluate the mechanics of traction. The inpatient stay for complex fractures was often months. Many fractures were treated without surgical fi xation, and fracture surgery 40 years ago was restricted primarily to the forearm and occasionally the ankle. Intramedullary nailing was an interesting thought but not frequently used. Charnley, in England, had moved forward with an interesting hip replacement, but it had not yet been accepted by the orthopedic community. Orthopedic surgery, much like the other surgical specialties, was under the control of general surgery. The major trends of 40 years ago were decreasing the amount of time in the hospital and stabilizing fractures to allow early mobilization, including the advent of internal fi xation, joint replacement, and arthroscopic surgery. All of these goals were greatly assisted by advances in anesthesia and pain relief for patients. The 40 years between 1968 and 2008 have seen great advances in many areas of orthopedics: internal fi xation of fractures, including intramedullary nailing and plating techniques and devices; joint replacement, including joints other than the hip and knee; arthroscopic surgery, including the development of therapeutic as well as diagnostic applications; minimally invasive techniques; cartilage regeneration; biological implants; and genetic engineering. So then, let us address some initial thoughts about predictions for the future. Certainly, minimally invasive techniques will be developed further, and stays in the hospital will become even shorter. Long hospital admission times will be rare except for patients with multiple trauma and other extensive procedures. Several global issues will have a major infl uence on the future of orthopedics. All over the world, the population shift is from rural to urban settings; it is estimated that within the next 10–15 years 60% of the world’s population will live in urban environments, placing enormous demands on the health care facilities in urban areas and exacerbating the current “trauma-call and emergency-care” crisis. Longer life expectancies mean that people expect a better quality of life for a longer period than ever before — the “baby boomers” aren’t sitting in their rocking chairs. Along with these longer, more active lives come increased bone and joint injuries and chronic musculoskeletal diseases. Approximately 40% of women over the age of 40 years have some form of osteoporosis, and more than 1 million women have vertebral compression fractures. Arthritis is the most common reason for consulting an orthopedist and is the most important medical problem affecting the quality of life in this age group. We can look to the day when the average life expectancy will go from the eighties to well into the nineties and beyond. That is going to generate a large group of patients who are going to require a signifi cant amount of orthopedic care. Offprint requests to: J.H. Beaty Received: November 26, 2008

Factors that predict instability in pediatric diaphyseal both-bone forearm fractures

The aim of this study was to determine the factors that may predict failure of closed reduction and casting of diaphyseal forearm fractures in children. Demographic and radiographic data of children with closed reduction and casting of these fractures in the emergency department were evaluated. Of 174 patients with adequate follow-up to union, 19 (11%) required a repeat procedure. Risk factors for repeat reduction included translation of 50% or more in any plane, age more than 9 years, complete fracture of the radius, and follow-up angulation of the radius more than 15° on lateral radiographs or of the ulna more than 10° on anteroposterior radiographs.

Implant Failure in Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents. The current standard treatment in North America is percutaneous fixation with either a fully threaded or partially threaded cannulated screw1-3. Although several historical references have described implant complications4,5, failure of modern implants is rare. We present two cases of implant failure in SCFE in two adolescents. We found no other recent reports in the literature of broken partially threaded cannulated screws used for fixation of SCFE as occurred in our patients.nnBoth patients and their parents were informed that data concerning their cases would be submitted for publication, and they all provided consent.nnCase 1. After three weeks of experiencing slowly progressive anterior hip pain, a fourteen-year-old boy had in situ fixation of an unstable right SCFE with a single 6.5-mm partially threaded cannulated screw (Figs. 1-A and 1-B). The initial postoperative course was uneventful. Against the advice of the surgeons, he began participating in contact sports six months after surgery. One month after resuming sports activity, the hip pain returned. Radiographs revealed that the screw was broken in the smooth shaft portion, distal to the physis and distal to the screw-shaft junction (Figs. 1-C and 1-D). No evidence of physiodesis was present. The broken portion of the screw was removed, and a 7.0-mm fully threaded screw was inserted for revision fixation. Six months later, radiographs demonstrated physeal fusion, and the patient was asymptomatic with no hip pain (Figs. 1-E and 1-F).nnnnFig. 1-A nnnnFig. 1-B nFigs. 1-A through 1-F Radiographs of Case 1. Figs. 1-A and 1-B Fixation of SCFE with partially threaded cannulated screw.nnnnnnFig. 1-C nnnnFig. 1-D nFigs. 1-C and 1-D One month after return to sports, the broken screw was seen. No …