Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up.

At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit.

Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%.

We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit.

Technology within medicine has great potential to bring about more accessible, efficient, and a higher quality delivery of care. Paediatric supracondylar fractures are the most common elbow fracture in children and at our institution often have high rates of unnecessary long term clinical follow-up, leading to an inefficient use of healthcare and patient resources. This study aims to evaluate patient and clinical factors that significantly predict necessity for further clinical visits following closed reduction and percutaneous pinning.

A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics, perioperative course, goniometric measurements, functional outcome measures, clinical assessment and decision making for further follow up were assessed. Categorical and continuous variables were analyzed and screened for significance via bivariate regression. Significant covariates were used to develop a predictive model through multivariate logistical regression. A probability cut-off was determined on the Receiver Operator Characteristic (ROC) curve using the Youden index to maximize sensitivity and specificity. The regression model performance was then prospectively tested against 22 patients in a blind comparison to evaluate accuracy.

246 paediatrics patients were collected, with 29 cases requiring further follow up past the three month visit. Significant predictive factors for follow up were residual nerve palsy (p < 0 .001) and maximum active flexion angle of injured elbow (p < 0 .001). Insignificant factors included other goniometric measures, subjective evaluations, and functional outcomes scores. The probability of requiring further clinical follow up at the 3 month post-op point can be estimated with the equation: logit(follow-up) = 11.319 + 5.518(nerve palsy) − 0.108(maximum active flexion). Goodness of fit of the model was verified with Nagelkerke R2 = 0.574 and Hosmer & Lemeshow chi-square (p = 0.739). Area Under Curve of the ROC curve was C = 0.919 (SE = 0.035, 95% CI 0.850 – 0.988). Using Youden's Index, a cut-off for probability of follow up was set at 0.094 with the overall sensitivity and specificity maximized to 86.2% and 88% respectively. Using this model and cohort, 194 three month clinic visits would have been deemed medically unnecessary. Preliminary blind prospective testing against the 22 patient cohort demonstrates a model sensitivity and specificity at 100% and 75% respectively, correctly deeming 15 visits unnecessary.

Virtual clinics and automated clinical decision making can improve healthcare inefficiencies, unclog clinic wait times, and ultimately enhance quality of care delivery. Our regression model is highly accurate in determining medical necessity for physician examination at the three month visit following supracondylar fracture closed reduction and percutaneous pinning. When applied correctly, there is potential for significant reductions in health care expenditures and in the economic burden on patient families by removing unnecessary visits. In light of positive patient and family receptiveness toward technology, our promising findings and predictive model may pave the way for remote health care delivery, virtual clinics, and automated clinical decision making.

Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury.

A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up.

Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury.

Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures.

Background

Primary dislocation of the patella is a common acute knee disorder in children, adolescents and young adults. While primary dislocation of the patella has traditionally been treated non-operatively, primary operative repair of the medial patella-stabilizing soft tissues has been popularized more recently and thought to reduce the risk of dislocation. However, several studies have shown substantial rates of redislocation with longer follow-up time, irrespective of treatment. The purpose of this systematic review was to compare operative and non-operative treatment for primary dislocation of the patella, regarding redislocation rates and symptoms.

Little is known about the priorities of patients undergoing surgery for idiopathic scoliosis. This study explores the priorities of adolescents and contrasts them from their parents and their surgeons. Fifty-five pairs of children and parents underwent structured interviews separately, to explore their concerns, desires and expectations both about scoliosis and surgery. Surgeons of these patients and from across Canada completed a similar questionnaire. We found a significant mismatch between child, parent and surgeon priorities. This mismatch has implications on matters relating to decision making, informed consent, understanding of patient satisfaction, and measuring outcomes that are meaningful to patients.

To define the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis and to contrast them from their parents and surgeons.

We conducted structured interviews of fifty-five pairs of adolescents and parents separately. The questionnaire had sections on concerns, desires and expectations regarding both scoliosis and surgery, with items pertaining to present and future effects on appearance, pain, physical and psychosocial function and health. Parents also reported what their child’s responses might be. Their surgeons (four) and paediatric spine surgeons (twenty-four) across Canada completed the same questionnaire. Analysis involved repeated measures ANOVA, intra-class correlation coefficients and kappa statistics.

Parents were more concerned than their children about present and future consequences of scoliosis. Surgeons were least concerned. Children, parents and surgeons agreed that improving physical appearance was the primary goal of surgery. Surgeons agreed very little about the natural history of scoliosis, other goals of surgery and the likelihood of specific outcomes. Parents wanted more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Adolescents had different priorities from their parents, but parents were aware of this difference and knew what their child’s priorities were.

Adolescents with idiopathic scoliosis, their parents and surgeons have different priorities. This mismatch might stem from uncertainty about the natural history of idiopathic scoliosis for individual patients.

Knowledge of patient priorities is vital for shared decision making, informed consent, understanding patient satisfaction, and for measuring outcomes that matter most to patients.

Funding:

Orthopaedic Research & Education Foundation: (Unni. G. Narayanan: AAOS/OREF Health Services research Fellowship award)

This study describes the development and initial validation of a new disease-specific outcome measure of health status and burden of care in children with severe cerebral palsy. The instrument, Caregiver Priorities and Child Health Index of Life with Disabilities(CPCHILD), has thirty-six items spanning six domains:

Personal care/ADLs,

The CPCHILD is a reliable and valid measure of caregivers’ perspectives on the health status, functional limitations, and well-being of children with severe cerebral palsy.

Develop and validate a disease-specific measure of health status and well-being of children with severe cerebral palsy.

The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) was constructed from recommendations of caregivers, health care providers, and review of other measures. The CPCHILD has thirty-six items spanning six domains. Items are rated on an ordinal scale. Standardized scores (0–100) are reported for each domain and in total. Primary caregivers(n=77) of children(5–18yrs) with cerebral palsy, categorized by the Gross Motor Function Classification System (GMFCS) level completed the CPCHILD. Caregivers of children with severe cerebral palsy(GMFCS-IV & V), also completed the PEDI, the CHQ, and a second administration of the CPCHILD two weeks after the first.

The mean CPCHILD scores for children with severe cerebral palsy(GMFCS-V) was fifty-nine (Range:35–93) and did not demonstrate the floor effects of the PEDI and CHQ. The mean CPCHILD scores for children in GMFCS levels I to V were 22.0, 38.2, 23.0, 44.5.8 and 59.3 respectively (p < 0.0001 by ANOVA). Reliability was tested in the 41/52 caregivers who reported no health status change between the twoadministrations of the CPCHILD. The intraclass correlation coefficient(ICC) was 0.94(95% CI: 0.90–0.97).

Children with severe cerebral palsy often undergo interventions to improve quality of life and ease burden of care. The CPCHILD seems to be a reliable and valid measure of caregivers’ perspectives on the health status, functional limitations, and well-being of these children. Further validation in a larger mutli-centred study is planned.

Funding:

Paediatric Orthopaedic Society of North America (POSNA) research grant award.

Introduction and Aims: Little is known about the priorities of patients undergoing surgery for idiopathic scoliosis. Surgery, a major undertaking, is recommended to correct or prevent worsening deformity, and to avoid uncertain future consequences. This study aims to define the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis.

Method: We conducted structured interviews of 55 pairs of adolescents, who had spinal fusion, and their parents separately. The questionnaire included sections on concerns, desires and expectations regarding both scoliosis and surgery, with items about present and future effects on appearance, pain, physical and psychosocial function and health. Parents reported both their priorities and what their child’s responses might be. Patients’ surgeons (four) completed the same questionnaire. Paediatric spine surgeons across Canada (24) were also surveyed. Surgeons were asked to respond as if their child was a patient. Analysis involved repeated measures ANOVA, intra-class correlation coefficients and kappa statistics.

Results: Parents were significantly more concerned than their children about present and future consequences of scoliosis and of spine fusion surgery. Surgeons were the least concerned about the consequences of scoliosis, even when asked to respond as if their child was the patient. Children, their parents and surgeons did agree that improving physical appearance was the primary goal of surgery. However, surgeons agreed very little among themselves about the natural history of scoliosis, other goals of surgery and about the likelihood of specific outcomes. Consequently, with the exception of improving physical appearance, surgeons’ goals and expectations of surgery were significantly different from those of either the patients or parents. Parents consistently wanted and expected more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Although adolescents had different priorities from their parents, parents were aware of these differences and reliably predicted what their children’s priorities were.

Conclusion: Idiopathic scoliosis patients, their parents, and surgeons have different priorities. Surgeons’ opinions about the natural history of scoliosis and treatment goals are discordant. These findings have important implications on shared decision-making and informed consent, and might contribute to better understanding and measurement of outcomes that matter to patients, including satisfaction.

Seventy-eight children, with 79 femoral fractures, treated with titanium elastic intramedullary nails were reviewed for complications.

Insertion site symptoms (41), malunion (8), refracture (2), transient neurological deficit (2), superficial wound infection (2), and reoperation prior to union (10).

Malunion/loss of reduction was increased with mismatched nails (p=0.02) and comminution (p=0.02). Insertion site symptoms were increased with nail ends that were bent (p=0.02), or > 10mm prominent (p=0.002). Nails remain implanted in 25 children without problems.

Nail ends should lie against the femur to avoid insertion site symptoms. Nails of different diameters should not be implanted. Comminuted fractures require close monitoring.