Injuries In Pediatric Patients Research Articles

Patient-Reported Outcome Measures Following Surgical Intervention for Pediatric Sports-Related Injuries to the Knee: a Systematic Review.

Increased sports participation and early specialization has contributed to an increase in surgically managed musculoskeletal injuries to the knee in youth athletes. Established patient-reported outcome (PRO) measures have been extensively reported in adult patients to assess outcomes following sports-related knee surgery. However, current PRO measures for pediatric patients undergoing surgery for sports-related injuries have not been well-described. Strong emphasis has been placed on patient-reported outcomes in recent years, and surgeons have identified many different scoring systems that could be used for sports-related knee injuries in children and adolescents. Recent research has shown that substantial variability exists in the reporting of PRO measures assessing outcomes following surgical management of sports-related knee injuries in pediatric patients. With a paucity of studies using PRO measures in surgically managed pediatric knee injuries, only procedures involving the anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) showed preference for particular systems. Pediatric ACL procedures predominantly use the International Knee Documentation Committee (IKDC) scoring system, while MPFL procedures predominantly use the Kujala scoring system. Further studies are necessary to determine preferred and appropriate patient-reported outcome measures for specific sports-related knee procedures in pediatric patients.

597 Reconstruction of Lop Ear Deformities After Severe Burn Injury in Pediatric Patients: An 11-year Experience

IntroductionThe ear is one of the most highly visible structures on the face. One or both ears are frequently involved in panfacial burns. Because they are bilateral structures, asymmetries are clearly visible. Reconstruction of burned ear deformity often requires replacement or modification of skin and/or cartilage. Even these are successfully replaced, scar contractile forces can cause deformation of the ear. One of these deformities is lop or cup ear, in which the helical rim is either folded over, wrinkled or tight. We describe the necessity of applying otoplasty techniques to address this problem.MethodsA retrospective chart review analysis was performed to assess demographic variables, procedural indications and procedural outcomes in pediatric patients treated at our hospital for complex ear reconstruction for ear deformities after her surgery. Inclusion criteria were pediatric patients aged 0 to 21 years admitted to Shriners Hospital for Children-Boston from January 1, 2010 to January 1, 2021 for burn injury, who subsequently required follow-up complex ear reconstruction for ear deformities after burn injury. Of these patients, those with lop ear deformities who required construction were examined. Using the Trauma Registry of the American College of Surgeons (TRACS) and Shriners Hospital for Children Information Source (SHCIS) databases, we identified 12 eligible patients. Surgical procedure data was obtained from the SHCIS electronic medical records. Surgical photographs were obtained with patient informed consent. Those patients who required Medpor or cartilage frame reconstructions were excluded.Results12 patients required an otoplasty-type procedure to obtain desired results or symmetry with the contralateral ear. This technique involved a posterior incision in the auriculomastoidmastoid sulcus, are you a year and cartilage modification with sutures to to re-create the antihelical fold an superior crus as well as conchal setback sutures.ConclusionsBecause ears are bilateral structures, symmetry is extremely poor. Because of multiple contractile forces on the external ear from secondary healing or contraction of skin grafts, the ear is often displaced anteriorly and the upper portions become folded. Treatment requires reconstruction of the natural folds of the ear and shortening of the helical rim to mastoid distance. this requires an otoplasty approach with a posterior incision,, exposure of the cartilaginous framework and modification of the cartilage with incisions and sutures. This technique however requires adequate soft tissue coverage of the ear.

Impact of the Coronavirus Disease Pandemic on Patients with Head Injuries in South Korea.

ObjectiveThe coronavirus disease 2019 (COVID-19) pandemic is affecting the characteristics of patients with head injuries. This study aimed to evaluate the effect of the COVID-19 pandemic on patients with head injuries at a regional emergency medical center in South Korea. MethodsFrom April 2019 to November 2020, 350 patients with head injuries were admitted to our hospital. The study period was divided into the pre-COVID-19 (n=169) and COVID-19 (n=181) eras (10 months each). Patients with severe head injuries requiring surgery (n=74) were categorized into those who underwent surgery (n=41) and those who refused surgery (n=33). ResultsHead injuries in pediatric patients (<3 years) were more frequent in the COVID-19 era than in the pre-COVID-19 era (8.8% vs. 3.6%, p=0.048). More patients refused surgery in the COVID-19 era than in the pre-COVID-19 era (57.9% vs. 30.6%, p=0.021). Refusal of surgery was associated with old age (67.7±14.5 vs. 52.4±19.1, p<0.001), marital status (married, 84.8% vs. 61.0%, p=0.037), unemployment (42.4% vs. 68.3%, p=0.034), COVID-19 era (66.7% vs. 39.0%, p=0.021), and lower Glasgow coma scale scores (6.12±3.08 vs. 10.6±3.80, p<0.001). Multivariable logistic regression analysis revealed that refusal of surgery was independently associated with old age (adjusted odds ratio [OR], 1.084; 95% confidence interval [CI], 1.030–1.140; p=0.002), COVID-19 era (adjusted OR, 6.869; 95% CI, 1.624–29.054; p=0.009), and lower Glasgow coma scale scores (adjusted OR, 0.694; 95% CI, 0.568–0.848; p<0.001). ConclusionWe observed an increased prevalence of head injuries in pediatric patients (<3 years) during the COVID-19 pandemic. Additionally, among patients with severe head injuries requiring surgery, more patients refused to undergo surgery during the COVID-19 pandemic.

Surgical Management of Traumatic Brachial Plexus Injuries in the Pediatric Population

To evaluate demographics, treatment options, and outcomes of traumatic brachial plexus injuries in pediatric patients. Traumatic brachial plexus reconstructions in patients ≤17 years old were reviewed. Patients were stratified into pan-plexus and incomplete plexus injuries. Functional outcomes (modified British Medical Research Council grade) were reviewed after a minimum follow-up of 9 months. Brachial plexus reconstruction was performed in 71 patients at a mean age of 13.9 years (range, 2-17 years). Approximately half of the patients had a pan-brachial plexus injury (n= 33, 46.5%) with 59.2% having at least 1 preganglionic avulsion injury. Among the 25 patients with pan-brachial plexus injuries who had >9 months of follow-up, 12 (48%), 24 (96%), and 17 (68%) had reconstruction surgery for shoulder, elbow, and grasp function, respectively. At last follow-up, 50%, 83%, and 29% of these patients had a modified British Medical Research Council grade ≥3 in shoulder abduction, elbow flexion, and grasp, respectively. Of the 31 patients with incomplete brachial plexus injuries, 28 (90%) underwent reconstruction for shoulder function, and 13 (42%) underwent surgery for elbow flexion. At last follow-up, 71% and 100% of patients had modified British Medical Research Council grade 3 in shoulder abduction and elbow flexion, respectively. Pediatric traumatic brachial plexus injuries are often high-energy injuries resulting in nerve root avulsions. Most patients were able to regain antigravity elbow flexion or stronger after brachial plexus reconstruction, and more than half had similar improvement in shoulder function. Treatment should be directed with goals of elbow flexion, shoulder stability/external rotation, and rudimentary grasp.

Impact of intracranial pressure monitoring on outcome of traumatic brain injury in pediatric patients: a 15-year single center experience and literature review

Impact of intracranial pressure monitoring on outcome of traumatic brain injury in pediatric patients: a 15-year single center experience and literature review

Operative Pediatric Hand Trauma.

This study aims to describe the epidemiology of hand injuries in pediatric patients undergoing surgical treatment. A retrospective analysis of patients with traumatic hand injuries surgically treated over a 7-year period. A total of 155 patients were included. Fracture was the most common injury type (74.8%), most of which were open (54.3%). Incidence of articular fractures increased with age. The predominant mechanism of injury before age 10 was crush. In toddlers, only central digits were affected. Good functional results were achieved (Quick-DASH 1.37 ± 4.90). The incidence of hand injuries requiring surgery increased with age. The mechanism and segment affected varied with age groups. Although good functional results are expected, complications may occur 33% and secondary surgical procedures in 7.7%.

Epidemiology of Pediatric Baseball and Softball Player Injuries.

Background:Baseball and softball are popular sports in the United States and are responsible for a large number of youth sports injuries each year.Purpose:To investigate recent differences in youth baseball and softball injuries evaluated in nationwide emergency departments.Study Design:Descriptive epidemiology study.Methods:The National Electronic Injury Surveillance System (NEISS) database was examined for softball and baseball injuries in pediatric patients (age, 7-21 years) from 2010 through 2019. Patients were classified as children (age, 7-13 years), adolescents (age, 14-18 years), or young adults (age, 19-21 years). Case narratives were used to categorize injuries as contact injuries (hit by bat or ball), field injuries (sliding into base, collision with another player, catching, or running), throwing injuries, or other.Results:An unweighted total of 24,717 baseball injuries and 13,162 softball injuries were recorded. A nationwide estimate of 861,456 baseball injuries and 511,117 softball injuries were sustained during the studied time period, with estimated respective injury rates of 86,146 and 51,112 per year. Injured softball players were most commonly adolescent (47%) and female (92%), while injured baseball players were most commonly children (54%) and male (90%). There was a greater proportion of baseball-related injuries involving the head/neck (41%) as compared with softball-related injuries (30%) (P < .01). Conversely, a greater proportion of softball-related injuries involved the lower extremity (32%) as compared with baseball-related injuries (19%) (P < .01). When comparing diagnosis, softball injuries were more often sprains/strains (28%) than baseball injuries (18%) (P < .01). When comparing mechanisms of injury, baseball athletes were more likely to be evaluated with contact injuries than were softball athletes (49% vs 40%, P < .01).Conclusion:Youth baseball athletes were more likely to be injured through contact mechanisms and had a higher proportion of injuries related to the head/neck/face, whereas softball injuries more frequently involved the lower extremity and resulted in a sprain/strain. League guidelines should focus on reducing contact injuries within youth baseball, and injury-prevention programs should focus on reducing lower extremity injuries in youth softball.

Intraoperative Hypotension and Acute Kidney Injury after Noncardiac Surgery in Infants and Children: A Retrospective Cohort Analysis.

Age- and sex-specific reference nomograms for intraoperative blood pressure have been published, but they do not identify harm thresholds. The authors therefore assessed the relationship between various absolute and relative characterizations of hypotension and acute kidney injury in children having noncardiac surgery. The authors conducted a retrospective cohort study using electronic data from two tertiary care centers. They included inpatients 18 yr or younger who had noncardiac surgery with general anesthesia. Postoperative renal injury was defined using the Kidney Disease Improving Global Outcomes definitions, based on serum creatinine concentrations. The authors evaluated potential renal harm thresholds for absolute lowest intraoperative mean arterial pressure (MAP) or largest MAP reduction from baseline maintained for a cumulative period of 5 min. Separate analyses were performed in children aged 2 yr or younger, 2 to 6 yr, 6 to 12 yr, and 12 to 18 yr. Among 64,412 children who had noncardiac surgery, 4,506 had creatinine assessed preoperatively and postoperatively. The incidence of acute kidney injury in this population was 11% (499 of 4,506): 17% in children under 6 yr old, 11% in children 6 to 12 yr old, and 6% in adolescents, which is similar to the incidence reported in adults. There was no association between lowest cumulative MAP sustained for 5 min and postoperative kidney injury. Similarly, there was no association between largest cumulative percentage MAP reduction and postoperative kidney injury. The adjusted estimated odds for kidney injury was 0.99 (95% CI, 0.94 to 1.05) for each 5-mmHg decrease in lowest MAP and 1.00 (95% CI, 0.97 to 1.03) for each 5% decrease in largest MAP reduction from baseline. In distinct contrast to adults, the authors did not find any association between intraoperative hypotension and postoperative renal injury. Avoiding short periods of hypotension should not be the clinician's primary concern when trying to prevent intraoperative renal injury in pediatric patients.

Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma

BackgroundPediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. MethodsThis retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. ResultsA total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). Conclusions and relevanceOcular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.

Sociodemographic Factors Associated With Decreased Compliance to Prescribed Rehabilitation After Surgical Treatment of Knee Injuries in Pediatric Patients.

Background:Rehabilitation is an important component of care in postsurgical knee patients, especially as it pertains to return to preinjury activity level. Despite the established significance of rehabilitation in improving outcomes after certain surgical procedures, there is a lack of investigation into compliance rates and factors that affect compliance in pediatric patients.Purpose/Hypothesis:The purpose of this study was to evaluate sociodemographic factors associated with noncompliance in pediatric patients after knee surgery to characterize health disparities in this population. Our hypothesis was that certain sociodemographic factors would be associated with decreased compliance.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A retrospective review of medical records was used to gather data on compliance rate, demographics, and socioeconomic factors for pediatric patients undergoing rehabilitation after knee surgery. Compliance rate was determined by counting the total scheduled appointments, cancellations, and no-shows (defined as visits for which patients did not show up and did not provide notification of cancellation). Various types of knee injuries were included in this study. Data were evaluated using bivariate analyses in addition to hierarchical linear and binary logistic regression to assess for associations between sociodemographic factors and compliance rate.Results:Our total sample size was 186 patients. When compared with patients from non–single-parent households, patients from single-parent households were found to have a lower rate of physical therapy compliance (72.2% vs 80.1%; P < .001), were less likely to reach the 85% compliance threshold (9.1% vs 42.4%; P < .001), and had an increased amount of cancellations and no-shows (16.7 vs 11.7 visits; P = .02). Although a small sample size, Hispanic/Latino patients were shown to have a lower achievement of the 85% compliance threshold compared with non-Hispanic/Latino patients (0% vs 38.2%; P = .04). Increased distance from the rehabilitation clinic was associated with lower achievement of the 85% compliance threshold (P = .033).Conclusion:Overall, there were several significant demographic and socioeconomic variables associated with rehabilitation compliance, specifically single-parent status, distance to rehabilitation clinic, and ethnicity. These results suggest potential predictors of decreased compliance that warrant prospective investigation.

Brachiocephalic Vein Injury in a 4-Year-Old Male from Motor Vehicle Accident

<h3>Introduction and Objective</h3> We present a case of a 4-year-old male who sustained a blunt injury to the left brachiocephalic vein following a motor vehicle accident. The injury was successfully managed with non-operative therapy consisting of pressure dressing and serial exams. To our knowledge, this is the first report published of blunt trauma resulting in a brachiocephalic vein injury in a child and we present a review of management of these injuries in pediatric patients. <h3>Case Report</h3> A 4-year-old-male presented to our trauma center via ambulance following a head-on-collision in which he was a restrained passenger. The child was hemodynamically stable on arrival, conscious, and complained of left shoulder and right thigh pain. Initial exam and work up was notable for a right femur fracture, left clavicular deformity, left cervical seat belt sign with associated abrasion, and a left chest hematoma above and below the left clavicle. Computed tomography angiography (CTA) of the neck was performed and demonstrated contrast extravasation at the posterolateral aspect of the left brachiocephalic vein at the confluence of the left subclavian and left internal jugular veins. A non-displaced left clavicular fracture was also noted. No other acute traumatic injury was noted to the vasculature of the neck or chest. A pressure dressing was fashioned of layered gauze and placed above and below the clavicle and a cervical collar was then fastened to hold the pressure dressing in place. The patient was admitted to the pediatric intensive care unit and serial exams were performed overnight noting no evidence of hematoma expansion. Hemodynamics and serial hemoglobin checks remained stable during his hospitalization. Orthopedic surgery provided a sling for the left clavicle fracture and inserted an intramedullary nail to the right femur on hospital day two. The child was discharged home on hospital day five. <h3>Discussion</h3> Venous injuries are generally resolved with steady and timely pressure. However, venous injuries located in areas that are anatomically not amenable to direct pressure present a clinical dilemma. The injury in our patient was not only behind the fractured clavicle, but on the posterior aspect of the vein. We elected to apply a pressure dressing on the hematoma both above and below the clavicle, theorizing that it may provide some benefit by compressing the hematoma and providing indirect pressure, essentially recreating the normal anatomy of the retro-clavicular space around the injury. While a rare occurrence, this case highlights the very real occurrence of pediatric central venous injuries associated with rapid deceleration.

Traumatic Dental Injuries in Pediatric Patients: A Retrospective Analysis.

AimThis retrospective study aimed to analyze dental traumatic injuries and their management in children up to 16 years of age.Materials and methodsRecords of the patients who sustained dental trauma from 2013 to 2018 were evaluated for age, gender, etiology, type of injuries, and their management. Children were divided into three groups—primary (0–5 years), mixed (6–11 years), and permanent dentition group (12–16 years). Dental trauma was assessed by Ellis and Davey's classification of tooth fracture along with other associated injuries.ResultsTotal records of 466 children with 750 injured teeth (665 permanent and 85 primary) were evaluated. Males were reported twice as females. Fall was noted as the major etiological factor (93.1%). The highest frequency of dental trauma was observed in the permanent dentition group (54.7%). Ellis class IV fracture was the most common dental injury and maxillary central incisor was the most frequently injured tooth. Soft tissue injury was noted as the most commonly associated injury. Most of the dental traumatic injuries in permanent teeth were treated by root canal treatment while the majority of primary dentitions were managed by observation and wound care.ConclusionEllis class IV fracture was noted as the most frequent type of dental injury and fall was a major etiological factor. The permanent dentition group of children was more affected and a male predominance was observed.Clinical significanceThe information gained from the present study would help in providing various preventive modalities to parents, caregivers, and teachers regarding these injuries in the future and also facilitate several new researches in this field.How to cite this articlePatidar D, Sogi S, Patidar DC, et al. Traumatic Dental Injuries in Pediatric Patients: A Retrospective Analysis. Int J Clin Pediatr Dent 2021;14(4):506–511.

Development of a concise injury severity prediction model for pediatric patients involved in a motor vehicle collision

Objective Transporting severely injured pediatric patients to a trauma center has been shown to decrease mortality. A decision support tool to assist emergency medical services (EMS) providers with trauma triage would be both as parsimonious as possible and highly accurate. The objective of this study was to determine the minimum set of predictors required to accurately predict severe injury in pediatric patients. Methods Crash data and patient injuries were obtained from the NASS and CISS databases. A baseline multivariable logistic model was developed to predict severe injury in pediatric patients using the following predictors: age, sex, seat row, restraint use, ejection, entrapment, posted speed limit, any airbag deployment, principal direction of force (PDOF), change in velocity (delta-V), single vs. multiple collisions, and non-rollover vs. rollover. The outcomes of interest were injury severity score (ISS) ≥16 and the Target Injury List (TIL). Accuracy was measured by the cross-validation mean of the receiver operator curve (ROC) area under the curve (AUC). We used Bayesian Model Averaging (BMA) based on all subsets regression to determine the importance of each variable separately for each outcome. The AUC of the highest performing model for each number of variables was compared to the baseline model to assess for a statistically significant difference (p < 0.05). A reduced variable set model was derived using this information. Results The baseline models performed well (ISS ≥ 16: AUC 0.91 [95% CI: 0.86-0.95], TIL: AUC 0.90 [95% CI: 0.86-0.94]). Using BMA, the rank of the importance of the predictors was identical for both ISS ≥ 16 and TIL. There was no statistically significant decrease in accuracy until the models were reduced to fewer than five and six variables for predicting ISS ≥ 16 and TIL, respectively. A reduced variable set model developed using the top five variables (delta-V, entrapment, ejection, restraint use, and near-side collision) to predict ISS ≥ 16 had an AUC 0.90 [95% CI: 0.84-0.96]. Among the models that did not include delta-V, the highest AUC was 0.82 [95% CI: 0.77-0.87]. Conclusions A succinct logistic regression model can accurately predict severely injured pediatric patients, which could be used for prehospital trauma triage. However, there remains a critical need to obtain delta-V in real-time.

890 Bilateral Acetabular Fractures Induced by An Epilepticseizure In a Paediatric Patient: A Unique Case Andits Management

Abstract Bilateral acetabular fractures following epileptic seizures are a rare but known occurrence in adults, with an 18.5% mortality rate. These fractures occurring post epileptic seizures have not been previously documented in children. We report a case of a 13-year-old boy who presented to hospital via ambulance following two violent generalised tonic–clonic seizures in a postictal state, metabolically acidotic and a low haemoglobin. Acute abdomen was suspected, and the patient underwent a CT scan which showed bilateral acetabular fractures with central dislocations of both femoral heads and free fluid in the abdomen. The patient underwent initial damage control intervention with insertion of bilateral distal femur skeletal traction. Definitive fixation of the acetabular fractures occurred 1 week later with an open reduction internal fixation with novel supra- pectineal plates using a Pfannenstiel incision. We use this report to increase awareness of significant pelvic injuries in paediatric patients post epileptic seizures.

Targeted Temperature Management Protocol in a Pediatric Intensive Care Unit: A Quality Improvement Project.

In patients with acute neurological injury, abrupt temperature change exacerbates increased intracranial pressures and negatively affects perfusion pressure and cerebral blood flow. Critical care nurses must provide coordinated and effective interventions to maintain normothermia without precipitating shivering immediately after acute neurological injury in pediatric patients. To improve hyperthermia management in a 40-bed pediatric intensive care unit, an interdisciplinary pediatric critical care team developed, implemented, and evaluated a targeted temperature management protocol. The project was guided by the organization's plan-do-study-act quality improvement process. Quality improvement was assessed retrospectively using electronic medical records of patients meeting eligibility criteria. Samples of pediatric patients who received temperature interventions were compared before and after protocol implementation. The protocol included environmental, pharmacological, and body surface cooling device interventions, as well as use of a bedside shivering assessment scale and stepwise interventions to prevent and control shivering. Before implementation of the targeted temperature management protocol, 64% of patients had documented temperatures higher than 37.5 °C, and body surface cooling devices were used in 10% of patients. After protocol implementation, more than 80% of patients had documented temperatures higher than 37.5 °C, and body surface cooling devices were used in 62% of patients. Four patients (6%) before and 5 patients (31%) after protocol implementation were treated with body surface cooling without requiring use of neuromuscular blockade. Creation and implementation of a targeted temperature management protocol increased nurses' documented use of body surface cooling to manage hyperthermia in pediatric intensive care unit patients with acute neurological injury.

Clinical and Radiographic Differentiation of Pediatric Patellar Sleeve Fractures and Other Inferior Pole Pathologies (165)

Objectives:Inferior pole patellar sleeve fractures (PSF) are rare injuries that occur in skeletally immature patients with sparse literature on the diagnosis, management, and outcomes of this injury. Diagnosis of PSF can be difficult based on radiographs alone, as only a small bony fragment is often seen. Consequently, PSFs may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larson-Johansson syndrome (SLJS) possibly leading to improper treatment and poor outcomes (Figure 1). The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF and SLJS to help improve diagnostic accuracy.Methods:This was a retrospective review of skeletally immature patients diagnosed with inferior pole patellar pathology between 2011-2019 at a single urban academic center. Patients were identified using both International Classification of Diseases 9th and 10th edition (ICD-9 and ICD-10) codes and Current Procedural Terminology (CPT) codes. Data from medical records (demographics, injury mechanism and physical exam) and lateral knee radiographs (fragment size, fragment displacement, number of fragments, Insall-Salvati, Caton-Deschamps, pre-patellar effusion, intra-articular effusion) was collected. ANOVA, Student’s t-test and Fisher’s exact test were used for comparisons between the three groups. Statistical significance was determined at p<0.05. This study was approved by our institutional review board.Results:A total of 125 patients were included: 82% male, average age 10.7 years (SD 2), 16 PSF, 51 IPF, 58 SLJS patients. There were no significant differences in patient demographics between the three groups (Table 1). Only 24% of SLJS patients presented with acute trauma compared to 100% of the PSF and IPF patients. Fewer PSF patients had an intact straight leg raise (37.5%) compared to IPF (94.1%) and SLJS (98.3%) (p<0.001). SLJS patients were less likely to present with knee swelling (41.4%) compared to PSF (93.8%) and IPF (94.1%) (p<0.001) . Knee effusion was more frequently seen in PSF (81.2%) compared to IPF (37.3%) and SLJS (3.4%) (p<0.001). More patients with SLJS were able to bear weight (87.9%) compared to IPF (11.8%) and PSF (0%) (p<0.001) (Table 2). Radiographically, compared to those with IFP and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 and 6.5 versus 12.9mm, p<0.001), intra-articular effusion (6.1 and 4.9 versus 9.2mm, p<0.001), maximum fragment size (26 and 17.7 versus 45.3mm, p<0.001) and maximum fragment displacement (1.24 and 1.45 versus 13.30mm, p<0.003) respectively. Compared to SLJS, PSF and IPF patients had higher patella alta with mean Insall-Salvati ratios > 1.2 (Table 3).Conclusions:Differences in clinical features such as straight leg raise, knee swelling, knee effusion, ability to bear weight and radiographic features such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location can all be helpful in improving the accuracy of diagnosing inferior pole injuries in pediatric patients.

Individual and Team Sports-related Hospitalizations for Traumatic Brain Injuries in Pediatric Patients (104)

Objectives:Pediatric sport participation continues to increase in the United States with a corresponding increase in sports related concussions or traumatic brain injuries (TBIs). Based on this impact, it is important to recognize which sports are at elevated risk, identify patient and hospital-associated risk factors for hospital admission and length of stay, as well as understand billing costs for both individual and team sport participants. Improved awareness may help avoid disproportionate treatments, reduce economic burdens, and allow physicians to more effectively manage these injuries.Methods:Pediatric patients (ages 5-18) from 2008 to 2014 were identified from the Healthcare Cost and Utilization Project (HCUP) National (Nationwide) Inpatient Sample (NIS). ICD-9 CM codes were used to include 894 patients who were hospitalized with a concussion resulting from either participating in an individual (N = 451) or team sport (N = 443) (Figure 1). An adjusted odds ratio was calculated using demographic and hospital information. Welch ANOVA was performed to evaluate differences in length of hospital stay and total charges between cohorts. This was repeated for a loss of consciousness subgroup analysis within each cohort.Results:Younger athletes in individual sports were more likely to have associated loss of consciousness, be self-pay, experience a greater number of procedures, and require an operating room procedure. (Table 1). When compared to team sports, TBI patients in individual sports had significantly longer (p < 0.001) and costlier (p < 0.001) hospital stays (Table 2). The only significant finding that was worse in team sports was that loss of consciousness led to greater total charges (p < 0.001) (Table 2). For team sports, American tackle football, (43.6%) and for individual sports, bike riding, (28.2%) were the most frequent sports associated with TBIs in their respective cohorts (Table 3).Conclusions:Individual sport TBIs may be associated with longer and more expensive hospitalizations. The explanation is likely multifactorial but may be complicated by reduced awareness and reduced compliance with strict return to play protocols in individual sports. Safety education information at a young age, clear discharge instructions, and baseline health assessments when possible may help mitigate these findings.

274 Characteristics of Intracranial Injury in Pediatric Patients in the National Emergency X-Radiography Utilization Study

Blunt head trauma remains an important and costly mechanism of injury in the pediatric population. This study aimed to investigate the characteristics of pediatric patients presenting to National Emergency X-Radiography Utilization Study (NEXUS) study centers with blunt head trauma and acute cranial injury, as well as determine the screening performance characteristics of physical exam for the detection of skull fracture. We performed a secondary analysis of pediatric computed tomography (CT) data from a previous NEXUS cohort. Demographic data, criteria for two well-established CT imaging decision instruments, and whether patients received neurosurgical interventions were analyzed for the 1018 enrolled patients under the age of 18 years. Radiologist interpretations of CT head results including classification of injury type, location of injury, mass effect, and associated injuries were abstracted for 128 injured patients. Provider detection of skull fractures was determined by response to a specific question on the decision instruments inquiring about signs of these injuries. Contingency tables were used to evaluate provider sensitivity to detect skull fracture. Between April 2006 and December 2015, 1018 pediatric patients were enrolled as part of the NEXUS validation study. 128 (12.5%) of children had a notable injury reported on CT head, 49 (4.8%) were deemed to have a significant injury, and 27 (2.7%) patients received neurosurgical intervention. The median age for injured patients was 9.96 (IQR 3.27 – 15.22) years old. Midline shift was observed in 7 children (5.4% of injuries), and none were observed to have herniation. The most common intracranial injuries were subdural hematomas (28.9%) and subarachnoid hemorrhage (29.7%). The majority of injuries were superior to the tentorium; 3 cerebellar injuries and no brainstem injuries were observed. Incidence of subarachnoid hemorrhage and parenchymal injuries was greater in teenage children (44% and 24%, respectively) than in school age (22.9% and 14.6%) and in infants and toddlers (16.7% and 6.7%). Patients with subarachnoid hemorrhage and parenchymal injuries more frequently presented with abnormal alertness or abnormal behavior. Skull fracture was present in the majority (66.4%) of children with intracranial injuries. The sensitivity and specificity of provider physical exam to detect skull fractures was 18.5% and 96.6%, respectively. Sensitivity and specificity for the detection of basilar or depressed skull fractures was 11.1% and 96.6%. These data suggest that while few pediatric patients presenting with blunt head trauma have a significant intracranial injury or require neurosurgical intervention, skull fracture may be present in a large proportion of children with intracranial hemorrhage. Despite its integration into head injury decision instruments, providers have poor sensitivity for detecting skull fractures in pediatric patients.

Experience in reconstruction of esophagus, epiglottis, and upper trachea due to caustic injuries in pediatric patients and establishment of algorithm.

Unintentional swallowing of corrosive agents cause problems in the pediatric population. Swallowing dysfunction can be seen after injuring the pharynx and/or epiglottis which leads to the obstruction of esophagus. An algorithm was established taking into account the injury to the epiglottis and restoring gastrointestinal continuity with isolated or combine free and or supercharged jejunum flap, or supercharged colon transposition flap. Seventeen patients between the ages of 3 and 16 (mean age: 7.7) were treated between 1985 and 2019. Three different procedures were performed based on endoscopic findings; for patients with no or minimal damage to epiglottis, pedicled colon transposition was done in 12 cases. For patients with epiglottic scarring or edema, a two-stage reconstruction was performed. In the first stage, free jejunum flap was implemented to the pharynx to facilitate food passage, followed by a pedicled jejunum in two cases, or a pedicled colon transposition in two cases to provide gastrointestinal continuity. For one patient with severe epiglottic scarring, a free jejunal flap was used as a diversion conduit in the first stage, followed by supercharged colon transposition to restore gastrointestinal continuity. Supercharged intestinal flaps were harvested with 3-4cm of extra intestinal tissue than the measured thoracic portion in each individual in order to reach the hypopharyngeal region. The size of the free jejunal flaps were 10cm. Oral feeding was initiated on the eighth postoperative day. Partial loss of the anterior wall of the jejunal flap was seen in one case, in which a free anterolateral thigh-vastus lateralis musculocutaneous flap was used for reconstruction. The mean follow-up time was 5.1 years and there was no stricture in the final outcome. A competent epiglottis is essential for proper swallowing reflex. Meticulous microsurgical dissection and performing supercharged intestinal flaps provide a complication-free end result.

Clinicoradiological Predictors of Severity of Traumatic Intra-Abdominal Injury in Pediatric Patients: A Retrospective Study.

BackgroundAdequate assessment of traumatic injury in patients of all age groups is essential for timely intervention and prevention of mortality and morbidity. This study aimed to assess the value of certain clinical as well as radiological factors as predictors of severity of the intra-abdominal injury as detected on computed tomography (CT) and to review the guidelines, protocols, and practices followed in imaging of abdominal trauma in patients of pediatric age group.MethodsThis retrospective observational study included 263 pediatric patients (18 years of age or younger) who presented to the emergency department (ED) with a history of trauma to the abdomen. The study was conducted over a period of 12 months. Correlation of five variables, i.e., age of the child, focused abdominal sonography in trauma (FAST) status, mechanism of injury, presenting complaints and clinical features (hypotension, tachycardia, etc), fractures identified on trauma X-ray series, was done with CT findings (severity of injury). All five variables were statistically analyzed and p-values were derived for age, mechanism of injury, presenting complaints, clinical features, and trauma x-ray series, while parameters like sensitivity and specificity were determined for FAST statusResultsAll variables well correlated with the severity of injury with p-values <0.05. On multivariate analysis, FAST status had the highest (47.94) odds ratio among the five variables for predicting severe intra-abdominal injury while vital signs had the lowest (0.076). Further, age group of 0-4 years was found most prone to higher grades of injury with odds ratio of 7.83. Motor vehicle crash had odds ratio of 26.6 for severe injury, the highest among mechanisms of injury. While for FAST status, sensitivity was found to be 89.4%, specificity 85%, and negative predictive value 90%, trauma series radiographs had a sensitivity of 42.27%, specificity of 77.85% and negative predictive value of 60.55%.ConclusionClinical parameters and traditional imaging techniques can predict the severity of injury on CT and guide further imaging and intervention.