Robert F. Murphy

Accessibility and quality of online information for pediatric orthopaedic surgery fellowships.

Background: Pediatric orthopaedic fellowship applicants commonly use online-based resources for information on potential programs. Two primary sources are the San Francisco Match (SF Match) database and the Pediatric Orthopaedic Society of North America (POSNA) database. We sought to determine the accessibility and quality of information that could be obtained by using these 2 sources. Methods: The online databases of the SF Match and POSNA were reviewed to determine the availability of embedded program links or external links for the included programs. If not available in the SF Match or POSNA data, Web sites for listed programs were located with a Google search. All identified Web sites were analyzed for accessibility, content volume, and content quality. Results: At the time of online review, 50 programs, offering 68 positions, were listed in the SF Match database. Although 46 programs had links included with their information, 36 (72%) of them simply listed http://www.sfmatch.org as their unique Web site. Ten programs (20%) had external links listed, but only 2 (4%) linked directly to the fellowship web page. The POSNA database does not list any links to the 47 programs it lists, which offer 70 positions. On the basis of a Google search of the 50 programs listed in the SF Match database, web pages were found for 35. Of programs with independent web pages, all had a description of the program and 26 (74%) described their application process. Twenty-nine (83%) listed research requirements, 22 (63%) described the rotation schedule, and 12 (34%) discussed the on-call expectations. A contact telephone number and/or email address was provided by 97% of programs. Twenty (57%) listed both the coordinator and fellowship director, 9 (26%) listed the coordinator only, 5 (14%) listed the fellowship director only, and 1 (3%) had no contact information given. Conclusions: The SF Match and POSNA databases provide few direct links to fellowship Web sites, and individual program Web sites either do not exist or do not effectively convey information about the programs. Clinical Relevance: Improved accessibility and accurate information online would allow potential applicants to obtain information about pediatric fellowships in a more efficient manner.

Subaxial Cervical Spine Injuries in Children and Adolescents

Background: Limited data exist on pediatric subaxial cervical spine injuries. The goal of this study was to characterize the injuries and initial treatment of a large consecutive series of patients with injuries from C3 to C7. Methods: Medical records and radiographs of consecutive patients admitted with cervical spine fractures and/or dislocations at a single level 1 pediatric trauma center from 2003 to 2013 were reviewed. Data abstracted included age, injury type and level, mechanism of injury, associated nonspine injuries, neurological status, length of hospitalization, and initial treatment. Results: Fifty-one patients were grouped into 3 age ranges: infant, 0 to 3 years (2); youth, 4 to 12 years (13); and adolescent, 13 to 16 years (36). Isolated fractures were identified in both infants and accounted for most of injuries in youths (85%) and adolescents (86%). Single vertebra or single vertebral level injuries were present in 65% of patients, most commonly at C7 (36%) or C6 (29%). No correlation existed between cervical level injured and patient age. Multiple cervical spine injuries occurred in 1 infant, 3 youths, and 14 adolescents. Other concomitant thoracic and/or lumbar spine injuries were found in 1 infant and 3 adolescents. The most common mechanisms of injury were motor vehicle accidents (53%) and sports (14%). High-energy trauma was associated with higher rates of noncontiguous spinal injuries and associated nonspinal injuries, with a longer length of hospitalization. Neurological deficits were observed in 8 patients: 1 infant, 2 youths, and 5 adolescents, of which 5 resulted from high-energy trauma. One infant and all youth patients were treated nonoperatively; 26 adolescents (73%) were treated in a cervical collar or with observation, 1 was treated with halo-vest immobilization, and 9 had surgical treatment. Conclusions: Most subaxial cervical spine injuries in pediatric and adolescent patients are isolated fractures at C6 and C7. High-energy mechanisms are associated with noncontiguous spinal injuries and other nonspine injuries. Most patients can be treated in a cervical collar, but adolescent patients are more likely to require halo placement or surgical intervention. Level of Evidence: Level IV—retrospective, diagnostic.

Musculoskeletal education in medical school: deficits in knowledge and strategies for improvement.

➤ Improvements in medical student physical examination skills and performance on validated musculoskeletal competency examinations correspond with undergraduate curricular reform.➤ Curricular reform success in the United States has been achieved by multidisciplinary collaboration.➤ International efforts are focused on improving medical student physical examination skills through patient partners and structured clinical examinations.➤ Technologies such as simulators and online learning tools are effective and well received.

Levels of Evidence in the Journal of Pediatric Orthopaedics: Update and Comparison to the Journal of Bone and Joint Surgery.

Background: Periodic review of the published research in pediatric orthopaedics is helpful to evaluate the state of scientific methodology. The purpose of this paper was to review the levels of evidence (LOE) and types of evidence (TOE) published in the Journal of Pediatric Orthopaedics (JPO) from 2009 to 2013 and to compare the percentage of articles with each LOE to pediatric orthopaedic articles published in the Journal of Bone and Joint Surgery-American Volume (JBJS) during the same time. Methods: All articles published in JPO from January 1, 2009, to December 31, 2013, were reviewed. Articles were classified as scientific studies, case reports, commentaries/letters to editor, reviews, expert opinion, and basic science articles. All scientific articles in the pediatrics section of the online version of JBJS were reviewed. If listed, the LOE was recorded from all clinical scientific studies. In addition, articles were abstracted for self-reported TOE (therapeutic, diagnostic, prognostic, or economic analysis). Results: We found 850 citations in JPO over the study period; 646 (76%) were identified as scientific articles and, of those, 552 (85%) had a LOE listed. There were 18 level I articles (3%), 101 level II (18%), 184 level III (34%), and 289 level IV (45%). The TOE was listed in 213 (39%) articles: 114 (54%) therapeutic, 37 (17%) prognostic, 55 diagnostic (26%), and 7 (3%) economic analysis. Comparing 2009 to 2013, the percentage of scientific studies with a self-reported LOE improved significantly (from 81% to 93%, P=0.001). Compared with JPO, JBJS had a significantly higher rate of level I (12% vs. 3%, P=0.006) and a significantly lower rate of level III (23% vs. 34%, P=0.01) articles. Conclusion: From 2009 to 2013, 3% of articles in JPO were level I. Significantly more articles are now including a level of evidence designation. Approximately half of published studies are level IV, and most are therapeutic type. A higher percentage of level I studies were published in JBJS during the same time period. Level of Evidence: Unclassifiable.

Asynchronous Onset of Bilateral Blountâs Disease

In children with bilateral Blount’s Disease, the vast majority of patients present with deformity of both legs concomitantly at the time of initial diagnosis. Although the severity of deformity may not be identical in each limb, it is generally present to some degree on both sides. Asynchronous presentation of bilateral Blount’s Disease has been reported in the Japanese literature8, but to our knowledge there are no reports of such a presentation in the English literature. We report this case due to its apparent rarity, and also as a reminder to maintain vigilance for the possible late development of contralateral deformity in patients with presumed unilateral tibia vara.

A lumbar discal cyst in a professional athlete

D iscal cysts are intraspinal, extradural cysts with a distinct connection to the corresponding intervertebral discs. There are few reported cases of these distinct lesions. The etiology of discal cysts is still imprecise, due to unclear pathogenesis of the cyst’s initial formation and progression over time. Some believe that different spinal morphology, activity, and sport may play a role in their occurrence. However, few reports exist to strengthen this argument. We report a case of a professional athlete with a symptomatic lumbar cyst of the L5-S1 disc space. We detail the clinical and MRI presentation, pathophysiology, intraoperative findings, and follow-up. Informed consent for publication of the data was obtained from the patient.

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. Both patients and their parents were informed that data concerning their cases would be submitted for publication, and they all provided consent. Case 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). Fig. 1-A Fig. 1-B Figs. 1-A through 1-F Radiographs of Case 1. Figs. 1-A and 1-B Fixation of SCFE with partially threaded cannulated screw. Fig. 1-C Fig. 1-D Figs. 1-C and 1-D One month after return to sports, the broken screw was seen. No …