Pediatric Orthopedic Patients Research Articles

Efficiency of immersive virtual reality game technology on pain management in children with limb fractures: A randomized controlled trial.

Children with fractured limbs usually have moderate to high pain, and distraction can help reduce their pain and anxiety. Virtual reality technology is an emerging method of distraction. We investigated whether the use of immersive virtual reality gaming technology to treat perioperative pain in children with school-age limb fractures effectively. Ninty-nine patients who had limb fracture surgery between October 2021 and September 2022 were randomly assigned to receive immersive virtual reality game therapy (Group A), non-immersive virtual reality game therapy (Group B), or conventional treatment group (Group C). Changes in pain, anxiety, fear, and biochemical markers were assessed at various time points in the three groups using subjective and objective rating scales. Both Group A and Group B consistently showed lower pain scores, fear levels, and anxiety levels compared to Group C after surgery, statistical analysis revealed significant differences among the three groups (p<0.001). Additionally,serum levels in group A were significantly lower than those in other groups, showing a notable statistical discrepancy (p<0.001). Both immersive and non-immersive virtual reality gaming significantly reduce perioperative pain, fear, and anxiety in children with limb fractures, and have practical significance for pain management of pediatric orthopedic patients. Immersive virtual reality, however, appears to have a more pronounced effect. The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry(ChiCTR210004583).

Information and Access for Safe Narcotic Disposal: A Cluster-Randomized Trial Among Pediatric Orthopaedic Surgical Patients in Los Angeles County

Introduction: Greater than two-thirds of individuals report unused opioids following surgical procedures. The need for improved prescribing practices notwithstanding, efforts to improve safe narcotic disposal are requisite to decreasing aberrant narcotic availability and opioid-related hospitalizations. This study aimed to evaluate the additive efficacy of education and access to DEA-compliant narcotic return receptacles on narcotic disposal rates among pediatric orthopaedic surgical patients. Methods: From July 2021 to July 2023, patients aged 5 to 17 years at two disparate sites were recruited for enrollment. Cluster randomization was done weekly to determine whether education was given on safe narcotic disposal versus standard discharge instructions. Halfway through the study, narcotic disposal receptacles were introduced as an additive intervention. Postoperatively, participants were asked to self-report opioid disposal rates and complete the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form to gauge pain control. Two sample z test of proportions and Fisher exact tests were used to compare disposal rates from both the isolated and combined interventions. Results: Analysis was restricted to 131 of 576 total patients: 44 (33.6%) disposed of unused narcotic medications and 87 (66.4%) did not. No notable difference was observed in disposal rates between those who received education or not (28/70 [40.0%] vs. 16/61 [26.2%], P &gt; 0.05) and those who had bin access or not (18/59 [30.5%] vs. 26/72 [36.1%], P &gt; 0.05). Furthermore, no notable difference was found between the control group and combination intervention group receptacles (6/25 [24.0%] vs. 8/23 [34.8%], P &gt; 0.05) or the education only and combination intervention group (20/47 [42.5%] vs. 8/23 [34.8%], P &gt; 0.05). Discussion: Neither preoperative education alone nor the addition of convenient disposal bins improved narcotic disposal rates following surgery. Conclusion: Retention rates remained high despite either intervention. Therefore, efforts to decrease narcotic availability must be nuanced and multimodal. Further studies may investigate the role of longitudinal patient education to better influence risk perception and subsequent behavioral changes.

Readability of Online Pediatric Orthopaedic Trauma Patient Education Materials.

The importance of web resources for educating orthopaedic trauma patients is well recognized. Yet these resources often exceed the sixth-grade reading level and are too complex for most patients to understand. This study examines the readability of the American Academy of Orthopaedic Surgeons' (AAOS) pediatric trauma-related educational content compared with similar materials from the Pediatric Orthopaedic Society of North America (POSNA). Eleven AAOS (https://www.orthoinfo.org/) and nine POSNA (https://orthokids.org) pediatric trauma education articles were included. Articles' readability was assessed by two independent examiners using (1) the Flesch-Kincaid Grade Level (FKGL) and the Flesch Reading Ease (FRE) algorithms. The FKGL mean was compared with the sixth-grade level and the average American reading level using a one-sample t-test. A two-sample t-test evaluated the differences in readability between the AAOS and POSNA materials. A total of 15 unique articles were included. Excellent agreement (>90%) was noted between reviewers for FKGL and FRE. The average (SD) FKGL for AAOS and POSNA articles were 8.5 (0.8) and 9.0 (1.5), respectively, and the FRE scores were 61.2 (3.8) for AAOS and 61.7 (7.7) for POSNA. Only one AAOS article met the sixth-grade reading level. The average readability levels of the AAOS and POSNA articles were markedly higher than the recommended sixth-grade level (P < 0.001). No notable difference was found in FKGL (P = 0.47) or FRE (P = 0.89) when comparing AAOS and POSNA articles. This study indicates that the readability of the AAOS pediatric trauma and POSNA trauma-related articles is well above that which is recommended for the general public, and this has remained so for more than a decade. Both POSNA and AAOS trauma education materials have high readability levels, potentially hindering patient understanding. Improving the readability of these widely used trauma education resources is overdue and will likely improve patient comprehension.

Effectiveness of the Pediatric Nursing Excellence Model on Nurses' Knowledge and Practice in Pediatric Orthopedic Surgery Care: A Randomized Controlled Trial.

Pediatric orthopedic nursing requires specialized competencies to optimize patient outcomes, particularly in the complex realm of pediatric surgery. This study explores the effectiveness of the Pediatric Nursing Excellence (PNE) Model in enhancing nurses' knowledge and clinical practice in providing perioperative care for pediatric orthopedic patients in tertiary care inpatient settings. A double-blind, randomized controlled trial was conducted from February to July 2024, involving 100 nurses from two tertiary care hospitals in Tanta, Egypt. Participants were randomly assigned to receive PNE Model training (n = 50) or routine care (n = 50). Nurses' knowledge, practical skills, and adherence to PNE principles were assessed at baseline, immediately post-intervention, and after one, three, and six months using validated tools. The intervention group showed significantly greater improvements in knowledge (20.62 ± 6.7 vs. 8.16 ± 5.5, p < 0.001) and practice scores (62.28 ± 4.1 vs. 40.06 ± 14.7, p < 0.001) post-intervention, sustained over six months. Path analysis revealed that the PNE Model enhanced nursing practice directly (β = 0.25, p < 0.001) through improvements in engagement and adherence to excellence principles and indirectly (β = 0.53, p < 0.001) by significantly enhancing nurses' knowledge (β = 0.70, p < 0.001), which in turn positively influenced their clinical practice (β = 0.75, p < 0.001). Post-intervention, 82% of nurses in the intervention group achieved high levels of professional excellence, compared to 8% at baseline (p < 0.001). The PNE Model demonstrates robust effectiveness in enhancing nurses' knowledge, clinical practice, and professional excellence in pediatric orthopedic surgery care, with sustained long-term benefits. This evidence supports implementing specialized nursing education models to improve pediatric care quality in orthopedic settings.

The impact of obesity on pediatric orthopedic polytrauma patients

Objectives: The effect of obesity on fracture care and management in the adult population has been well documented in the literature; there is a scarcity of evidence-based research reporting the impact of obesity on pediatric orthopedic polytrauma patients. The aim of this study was to objectively investigate the impact of obesity on pediatric orthopedic polytrauma patients to optimize care and fracture management. Methods: A single-center retrospective cohort study of pediatric polytrauma patients aged 2–18 years old admitted to a level 1 trauma center was conducted over three years. Patients were categorized based on their body mass index (BMI). A logistic regression model was used to identify significant variables between the study groups. Results: A total of 60 patients were included in the analysis and divided into normal weight group (n = 36) and overweight/obese group (n = 24). A trend of lower injury severity score (ISS) was observed in the overweight/obese group compared to the normal weight group. Non-orthopedic injuries, including head, chest, and abdominal injuries, were found to be less in the overweight/obese group. Higher rates of spine and extremity fractures were reported in the overweight/obese group, as well as the need for surgical fixation (P = 0.05). No specific differences in complications, outcome, or discharge facility were found between the two groups. Conclusion: The paradoxical association between BMI and ISS/non-orthopedic injuries, in contrast to spine and extremity fractures, reflects the complex relationship between obesity and polytrauma patterns. Large multi-center prospective studies are needed to predict clinical outcomes in pediatric orthopedic polytrauma patients.

Automated Measurements of Long Leg Radiographs in Pediatric Patients: A Pilot Study to Evaluate an Artificial Intelligence-Based Algorithm.

Assessment of long leg radiographs (LLRs) in pediatric orthopedic patients is an important but time-consuming routine task for clinicians. The goal of this study was to evaluate the performance of artificial intelligence (AI)-based leg angle measurement assistant software (LAMA) in measuring LLRs in pediatric patients, compared to traditional manual measurements. Eligible patients, aged 11 to 18 years old, referred for LLR between January and March 2022 were included. The study comprised 29 patients (58 legs, 377 measurements). The femur length, tibia length, full leg length (FLL), leg length discrepancy (LLD), hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured automatically using LAMA and compared to manual measurements of a senior pediatric orthopedic surgeon and an advanced practitioner in radiography. Correct landmark placement with AI was achieved in 76% of the cases for LLD measurements, 88% for FLL and femur length, 91% for mLDFA, 97% for HKA, 98% for mMPTA, and 100% for tibia length. Intraclass correlation coefficients (ICCs) indicated moderate to excellent agreement between AI and manual measurements, ranging from 0.73 (95% confidence interval (CI): 0.54 to 0.84) to 1.00 (95%CI: 1.00 to 1.00). In cases of correct landmark placement, AI-based algorithm measurements on LLRs of pediatric patients showed high agreement with manual measurements.

Reducing Postoperative Opioids in Pediatric Orthopaedics: An Updated Tiered Prescription Guideline with a “Tier 0”

BackgroundThere is growing data on strategies to reduce opioid prescriptions in pediatric orthopaedics. Our institution implemented tiered guidelines for opioid discharge prescriptions in 2018 to standardize prescribing patterns across our entire pediatric orthopaedics practice. In 2022, we updated the tiered system with a goal to further minimize the quantity of opioids prescribed and eliminate opioids altogether for certain procedures. The aim of this project was to evaluate the effects of the updated tiered guidelines for discharge opioid prescribing following common pediatric orthopaedic procedures. MethodsA quality improvement project was conducted at a single academic institution. Guidelines for discharge opioid prescriptions were updated in January 2022 and established 5 tiers of increasing invasiveness for 28 procedures. The updated guidelines included a “Tier 0” which provided no opioids, reorganized surgical tiers based on prior data, and decreased the doses recommended for tiers. Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of updated guideline eras, comparing 2020–2021 and 2022. ResultsOverall, 747 patients (2020–2021, n ​= ​500; 2022, n ​= ​247) were included. The proportion of patients receiving discharge opioid prescriptions decreased from 89.8% to 80.6% (P ​< ​0.05), between 2020 and 2021 and 2022. This resulted in decreased overall OME prescribed (median 75 vs 45, P ​< ​0.05) and OME prescribed in those >10 years (135 vs 113, P ​< ​0.05) while 30-day refill rates (9.4% vs 6.1%), and OME per kilogram in those <11 years of age (median 0.9 vs 0.8) remained unchanged (both P ​> ​0.05). Discharge prescriptions falling within overall guidelines increased after guideline implementation (83.3% vs 85.4%), though this was not statistically significant and guideline adherence was low among Tier 0 ​at 31%. ConclusionsIncluding “Tier 0” of procedures receiving no opioid prescriptions, reorganizing procedures within tiers, and decreasing the recommended doses to an already strict tiered guideline for discharge opioid prescriptions significantly decreased the quantity of opioids prescribed. We noted continued excellent overall adherence and, importantly, no overall increase in refills, with areas for improvement in Tier 0. Quality improvement projects can continue to reduce the amount of opioids prescribed following pediatric orthopaedic procedures. Key Concepts(1)Updated tiered guidelines, including a “Tier 0” for discharge opioid prescriptions following pediatric orthopaedic procedures were effective in reducing the quantity of opioids provided at discharge.(2)A continued high adherence rate was observed with the updated guidelines, though areas for improvement include adherence to no opioids in Tier 0.(3)Refill rates remained similar after implementation of the updated guidelines.(4)The study results suggest opportunities for continued improvement projects to reduce the number of unnecessary opioids prescribed to pediatric orthopaedic patients. Level of EvidenceIII.

Post-surgical Dental Precautions/Prophylaxis in Pediatric Patients: Results of a 2023 Survey of the Membership of the Pediatric Orthopaedic Society of North America

IntroductionGuidelines regarding postsurgical dental care have been common in adult total joint arthroplasty patients despite limited supporting evidence in the literature. There is anecdotal evidence that similar precautions are implemented frequently in postoperative pediatric orthopaedic patients without any published evidence to guide clinicians. MethodsA survey of the Active Members of the Pediatric Orthopaedic Society of North America (POSNA) was performed to assess the use of postsurgical guidelines regarding dental care (procedures and prophylaxis) in pediatric patients. A 20-question survey regarding this subject was developed with the input of, and approved by, the Evidence-Based Practice Committee of POSNA, and a link to participate was distributed to the Active Membership. ResultsOne hundred seventy-three POSNA Members opened the link to the survey. One hundred sixty-three respondents self-identified as Active, for a response rate of 19.8%. One hundred fifty-seven (96.3%) reported direct involvement in surgical and postsurgical care of pediatric orthopaedic patients. Sixty-two (39.4%) indicated use of a postoperative protocol regarding dental interventions. Forty percent of those indicating use of guidelines were uncertain of the specifics of the protocol(s) used at their institution. Eighty-five percent of those utilizing protocols felt that the use of guidelines was a valuable topic for investigation. ConclusionsThese results demonstrate that many of the active Members of POSNA utilize postsurgical guidelines for dental care, particularly for those patients who have undergone spinal surgery with permanent implants. This is despite the fact that there is limited evidence to support their use in adult total joint patients and no literature regarding use of such guidelines in pediatric orthopaedic patients. Key Concepts(1)There is limited and contradictory evidence that postsurgical dental guidelines are indicated in adult orthopaedic patients.(2)There is no published evidence supporting postsurgical dental guidelines in pediatric orthopaedic patients.(3)Almost 40% of active Pediatric Orthopaedic Society of North America Members responding to a survey appear to utilize postsurgical dental care guidelines in pediatric patients, particularly after spinal procedures utilizing implants. Level of EvidenceLevel V

Medial Patellofemoral Ligament Reconstruction in Adolescents: What Parents Care About.

Numerous techniques exist for pediatric medial patellofemoral ligament (MPFL) reconstruction (MPFL-R). Pediatric orthopaedic surgeons and patient families must navigate choices between allograft and autograft, incision type, and surgery cost. While previous research has found similar surgical outcomes among different MPFL-R techniques, minimal data exists on what patients and their families prefer. To engage in shared decision-making (SDM), pediatric orthopaedic surgeons must understand family preferences, including between incision type and cost. We conducted a study utilizing choice-based conjoint (CBC) analysis to explore these preferences. A survey was developed using Sawtooth Software (Lighthouse Studio version 9.2.0) to gather demographic information and preferences on surgical scenarios via CBC analysis. Anonymous participants, recruited via the Prolific crowdsourcing platform, qualified if they were US residents over 18 years of age with children aged 13 to 17. Data analysis involved the Hierarchical Bayes (HB) method to generate utility scores to determine the desirability of attributes. The study included 496 participants who prioritized surgical success (average importance 48.8%) followed by co-pay amount (21.5%), incision size (17.4%), and return to sport (12.3%). Participants earning over $200,000 annually prioritized incision size over cost (25.8% vs. 12.1%, P <0.0053). Those with incomes below $50,000 valued recovery time at a lesser extent than other income groups (10.4% than 12.3% overall importance P <0.0003). The sex of the child significantly influenced preferences: incision size was more important to parents of girls (21.1%) than boys (14.0%, P <.0001). The importance of surgery success and recovery time also differed by sex, being higher for boys (50.4%, 13.1%) than girls (47.0%, 11.7%; P =0.025, 0.026, respectively). This CBC analysis suggests parents of adolescent patients undergoing MPFL-R most value surgical success (avoiding revision surgery), followed by copay, incision size, and time to return to sport. Of note, parent income level and sex of the child significantly influenced parental preferences. We hope this information will assist orthopaedic surgeons in SDM in MPFL-R surgery. Level III.

Validation of Patient-Reported Outcome Measurement Information System for Detection of Posttraumatic Stress in Children and Adolescents Following Procedures for Acute Orthopaedic Trauma.

The efficiency and validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were determined for pediatric orthopaedic trauma patients with posttraumatic stress disorder (PTSD) symptoms in a clinic setting. Prospective cohort study. Single-institution, Level I trauma center. All consecutive children aged 8-18 years undergoing procedures or surgery for orthopaedic trauma. The convergent, divergent, and discriminant validity of the PROMIS Anger and Anxiety computerized adaptive tests (CATs) were evaluated and compared with the previously validated Child PTSD Symptom Scale (CPSS). The efficiency in time to completion of the outcome measures was compared between the CPSS and PROMIS surveys. Cutoffs for increased likelihood of PTSD were established for the PROMIS questionnaires. A total of 233 subjects were included in this study (mean age 13.1 years with SD 2.8 years, 71% male). The majority (51%) of injuries were related to sports, and most (60%) involved the upper extremity. Of those included, 41 patients had high levels of PTSD symptoms on the CPSS (18%; 95% CI, 13.1-23.2%). The CPSS took 182 (interquartile range [IQR] 141-228) seconds versus 52 (IQR 36-84) and 52 (IQR 36-70) seconds for PROMIS Anger and Anxiety CATs, respectively. Convergent validity showed patient scores on both PROMIS instruments significantly correlated with CPSS scores (Anger: P < 0.001, r = 0.51; Anxiety: P < 0.001, r = 0.41). Neither PROMIS score correlated with University of California Los Angeles Activity Score (Anger: r = -0.26; Anxiety: r = -0.22), a functional outcome measure, demonstrating divergent validity. Both PROMIS instruments sufficiently discriminated across PTSD risk groups (Anger P < 0.001; Anxiety P < 0.001). A score of at least 53 on PROMIS Anger or at least 48 on PROMIS Anxiety indicated an increased likelihood of PTSD risk. PROMIS Anger and Anxiety CATs are efficient and valid for evaluating posttraumatic stress in children following orthopaedic trauma procedures. Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Predicting appointment no-shows in pediatric orthopedic patients using machine learning

Predicting appointment no-shows in pediatric orthopedic patients using machine learning

Effect of Short-term Deep Breathing Exercises on Perioperative Anxiety and Pain in Pediatric Orthopedic Patients: A Randomized Controlled Trial

PurposeThere are currently no pediatric studies examining the effects of deep breathing on perioperative pain and anxiety. This study sought to determine the effect of short-term deep breathing exercises on perioperative anxiety and pain in pediatric patients and their parents. DesignA randomized controlled trial was conducted in the Department of Orthopaedic Surgery where pediatric patients about to undergo surgery were allocated to a control group or a deep breathing group. In the intervention group, patients and their main guardian were guided to practice 10 minutes of deep breathing exercises twice a day for 3 to 4 days prior to surgery. Perioperative anxiety and pain were measured for both the children and parents as outcome indicators. MethodsPerioperative anxiety was measured using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) and state anxiety was measured using the State-Trait Anxiety Inventory (STAI). Patients reported their pain levels daily using the Wong-Baker FACES Pain Rating Scale. The following cutoffs were determined as high levels of anxiety: STAI (adult) > 44, STAI (child) > 36, and mYPAS-SF ≥ 30. FindingsNo significant differences were found in the STAI, mYPAS-SF, and Wong-Baker FACES Pain Rating Scale scores of the patients between the intervention and control group. Overall statistics showed that parents had significantly higher postoperative state anxiety levels toward female children (44.93 ± 9.01) compared to male children (40.18 ± 9.89). Preoperative and postoperative parental state anxiety levels were correlated with the child’s postoperative anxiety. Furthermore, children’s postoperative state anxiety was slightly correlated with postoperative pain. ConclusionsShort-term use of our deep breathing exercises was ineffective in reducing incidences of perioperative pain and anxiety in pediatric orthopedic patients. A longer period of deep breathing administration may be required for the intervention to be effective. Parental anxiety may have an effect on anxiety levels in children, and postoperative parental anxiety may be affected by the gender of the child.

The Impact of Social Deprivation on Health Care Utilization Patterns Following Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

BackgroundDisparities in social determinants of health have been linked to worse patient reported outcomes, higher postoperative pain, and increased risk of revision surgery following orthopaedic procedures. Identification of perioperative predictors of healthcare utilization is of particular interest to mitigate cost and improve patient outcomes. The aim of this study is to elucidate the effect of social deprivation levels, using the Area Deprivation Index (ADI), on healthcare utilization following pinning of supracondylar humerus (SCH) fractures. Identifying risk factors for discrepancies in healthcare utilization following SCH fracture fixation can help mitigate unnecessary healthcare spending and improve care of vulnerable patient populations. MethodsThis is a retrospective review of a single institution’s experience with SCH fracture pinning between 2010 and 2023. Demographic variables and healthcare utilization data were recorded within 90 days of surgery. The ADI was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. Results1186 patients from a single level one trauma center were included in this study. The upper, middle, and lower terciles of ADI consisted of 226, 458, and 502 patients, respectively. The most deprived tercile had greater emergency department visitation within 90 days of surgery relative to the least and intermediate deprived terciles (IRR 1.85, 95% CI 1.10-3.08). Identifying as White was an independent risk factor for increased outpatient clinic utilization (IRR 1.17, 95% CI 1.03-1.34). Higher levels of social deprivation were independent risk factors for increased ED visitation. There was no difference in 90-day inpatient readmission rates or telephone/telehealth calls made to the clinic between the least, intermediate, and most deprived patients. ConclusionsThis study begins to shed light on how social determinants of health impact the postoperative care of the pediatric orthopedic patient and which patient populations are the most at-risk for disproportionate resource utilization after pinning of SCH fractures. Understanding these differences may lead to improved patient outcomes while decreasing potentially unnecessary burden on the healthcare system. Level of EvidenceIII; retrospective comparative study Key Concepts1.Social determinants of health impact the postoperative care of the pediatric patient in the setting of supracondylar humerus fractures, more socially deprived patients are at higher risk of postoperative emergency department visits, patient race is shown to be a factor in postoperative clinic utilization.

Rare genetic skeletal disorders: Evolving terminology, therapies, education and advocacy

In the US, rare diseases are defined as disorders affecting fewer than 200,000 US residents or disorders for which there is no reasonable expectation that drug development costs will be recoverable by US sales. Almost 800 of the approximately 10,000 defined rare diseases are bone disorders. Until recently, their rarity and heterogeneity have unfortunately hindered their exploration at both clinical and scientific levels. However, wider availability of genetic testing, development of new surgical and pharmaceutical treatment options, and patient advocacy have motivated efforts to study, diagnose, and treat these disorders. Thus, care of the patient with a rare skeletal disorder is now evolving rapidly. This report presents a brief summary of important developments in skeletal disorders impacting bone quality and frequently co-managed by pediatric orthopaedic surgeons. Key Concepts(1)Although a “cure” is not yet available for most rare bone disease patients, new agents are frequently being advanced as new genes and their products are identified as molecules to target.(2)Medical therapies, often combined with surgical interventions and physical therapy, are reducing pain and increasing function in many pediatric orthopaedic patients with rare bone disorders.(3)New tools for physician education and patient management are increasingly available to assist the pediatric orthopaedic surgery community.

Therapy deserts: A call to action to address inequitable access to therapy services among pediatric orthopaedic patients

Background"Food deserts" are areas with limited access to affordable and healthy foods, disproportionately affecting low-income and ethnic minority communities in the United States. Analogous disparities exist in other disciplines. Our interprofessional team observed "therapy deserts” in orthopaedic and rehabilitation settings, wherein pediatric patients (particularly those with Medicaid-type insurance) appeared to lack equal access to physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. Inadequate access to therapy services places patients at risk for worse outcomes. MethodsWe conducted a quality improvement project to assess pediatric patients’ access to therapy care in our region. We surveyed all local PT, OT, and SLP clinics identified from a comprehensive listserv maintained by pediatric therapy teams in our institution. Using a scripted questionnaire, we contacted 113 PT, 38 OT, and 82 SLP clinics external to our institution, collecting data on accepted conditions, appointment waitlist periods, and accepted insurance types. Our primary objective was to determine the percentage of clinics that accepted patients with Medicaid-type insurance. We supplemented our survey with an examination of the Area Deprivation Index (ADI) for each clinic location. Results59 PT clinics (52%), 15 OT clinics (39%), and 36 SLP clinics (44%) completed the survey. Clinics often had limited capacity to care for medically complex conditions. Waitlist times varied, with a median wait of 1 week for PT services, 1 month for OT services, and immediate availability for SLP services. Only 14% of responding PT clinics, 53% of OT clinics, and 22% of SLP clinics accepted patients with Medicaid-type insurance. Insufficient reimbursement rates were frequently cited as the reason for not accepting Medicaid-type insurance. Waitlist times were longer for PT and SLP clinics that accepted Medicaid-type insurance compared to those that did not. Moreover, clinics that accepted Medicaid-type insurance were, on average, in more disadvantaged locations. ConclusionsOur findings suggest the existence of “therapy deserts,” where limited access to therapy services is influenced by insurance type and patient complexity. These restrictions likely exacerbate existing health disparities and illustrate a systemic problem rooted in complex social drivers of health. Addressing "therapy deserts" requires collaborative efforts from multidisciplinary teams. Level of EvidenceLevel III

Are radiographs overutilized in pediatric orthopaedic emergency room care?

BackgroundIt is estimated that $12.8 billion to $28.6 billion is wasted annually on unnecessary imaging studies and treatment in the United States. This is especially important to the pediatric population, which is unable to make decisions for themselves and vulnerable to radiation exposure. We hypothesized that a significant number of unnecessary radiographs are performed in the pediatric emergency department, leading to excessive time, cost, and radiation exposure to pediatric patients. MethodsWe retrospectively reviewed 406 patients who were evaluated in a pediatric emergency department (ED) for possible fracture at a single institution during the 2020 calendar year. Records were reviewed for demographics, history and physical exams, as well as the sequential order that radiographs were performed. All radiographs were evaluated by the senior author to determine if they resulted in a change in management. All data was recorded and analyzed by the senior author and our statistician using Student’s t-test. Results406 patient encounters were included. 2807 radiographs were deemed unnecessary, with an average of 6.9 radiographs per patient. $454,734 were spent on radiographs that ultimately did not change management. A total of 216 hours and 43 minutes were spent in the x-ray suite alone, for an average of 32 minutes per patient. The estimated amount of radiation exposure that did not change management was potentially as high as 69 millirem per patient. ConclusionsThere is an excessive amount of monetary waste, radiation exposure, and encounter time spent in pediatric orthopedic patients in the ED. There are several potential strategies to alleviate this problem, which we hope can be taken into consideration to help address this widespread healthcare issue.

Remote Patient Monitoring for Postoperative Pediatric Patients with Peripheral Nerve Catheters

Background: Close follow up of postoperative orthopedic and pectus excavatum surgical patients discharged with a nerve catheter is required to ensure adequate pain management and recognize medication toxicity. Assessing ambulatory pediatric patients using a smartphone application is convenient and effective. Methods: A novel Remote Patient Monitoring (RPM) program was developed to improve follow-up and ability to assess postoperative pain management, analgesic toxicity, and catheter site. Adherence and successful graduation were measured to determine the success of the program. Additionally, patient and caregiver experience and opioid use were measured. Interventions: Patients were enrolled in RPM postoperatively for four days. The RPM nursing team reviewed patient reported data in real-time to address concerns and develop a plan of care. Pain management education was provided via video prior to removing the nerve catheter. Results: Adherence to RPM is over 90% for both populations, with 82% success rate in orthopedic patients and 93% success rate in pectus excavatum patients. Experience scores have been high, and opioid prescriptions have been reduced by half for the orthopedic population. Conclusions: RPM is an effective tool used to manage pediatric postoperative orthopedic and pectus excavatum surgical patients with significant patient and caregiver buy-in.

Urinary tract infections in pediatric orthopedic surgical patients: a Single Institution National Surgical Quality Improvement Program Study.

Perioperative urinary tract infections (UTIs) are poorly studied among pediatric orthopedic surgical patients. We evaluated the incidence of and risk factors for UTI in a large volume of pediatric orthopedic surgical patients. Children <18 who underwent orthopedic surgery between March 2015 and December 2018 were analyzed using our institution's National Surgical Quality Improvement Program (NSQIP) data. Demographic, perioperative and outcome data of patients who developed a UTI within 30 days of surgery were compared to patients without UTI. NSQIP data were available for 520 surgeries (324 girls and 196 boys). Median age at surgery was 13.5 years. A Foley was placed in 301/520 cases (88/196 boys and 213/324 girls) in 264 children. Six cases of UTI occurred within 30 days of surgery (1.2% of surgeries). The UTI rate among patients with a Foley was 2.3%, and among girls with a Foley was 2.8%. No UTIs occurred without a Foley, nor any in boys. All six occurred in the American Society of Anesthesiologists Class 2 females, ages 7-15 undergoing elective surgery with Foley for over 48 h. Factors associated with an increased odds of developing UTI included: higher BMI [OR, 1.12 (CI, 1.01-1.22; P = 0.03)], developmental delay [OR, 7.82 (CI, 1.40-43.7; P = 0.02)], structural central nervous system abnormality [OR, 17.5 (CI, 3.89-90.4; P = 0.01)], longer duration with Foley [OR, 1.68 (CI, 1.22-2.32; P = 0.002)] and hospital readmission within 30 days [OR 14.2 (CI, 2.32-87.3; P = 0.004)]. Risk of UTI is low after pediatric orthopedic surgery. Girls with comorbidities including structural central nervous system abnormality, developmental delay and higher BMI with prolonged Foley catheterization may have higher postoperative UTI risk. Level of Evidence: II.

Orthopedic Trauma Epidemiology in Pediatric Patients at a Tertiary Care Trauma Center in North India

Abstract Introduction: In North India, orthopedic trauma, which refers to injuries affecting the bones, joints, and soft tissues, occurs frequently in pediatric patients. The aim of this study is to investigate the epidemiology, etiology, mechanisms of injury, and outcomes of orthopedic trauma in pediatric patients who are admitted to a tertiary care trauma center located in North India. Materials and Methods: This prospective study was carried out over 1 year between January 2019 and December 2019, which included 479 pediatric orthopedic trauma patients between the age group of 0 and 18 years. The collected data were systematically classified and analyzed with respect to the mode of trauma, type of injury, and outcome across various age groups and genders. Results: Age of children ranged from 0 to 18 years, of which 298 (62.2%) were male and 181 (37.8%) were female. Most fractures occurred at aged 9–12 years (38.4%) and the trend decreased with age. Fall injuries were the most common mode of trauma (49.9%, n = 239) followed by road traffic accident (29.4%, n = 141). Among operated patients, most injuries were closed (47.2%, n = 138) followed by compound injuries (32.2%, n = 94) and crush injuries (20.6%, n = 60). Sixty-three percentage of patients recovered well with independent functional status, while 30% recovered with supported functional status/residual deformity. Conclusion: Orthopedic trauma in pediatric population is growing up and prehospital care is lagging which is more required than adult counterpart. An effective and aggressive management of accident prevention programme is required, which should also include changes in lifestyle and environment, overcoming obstacles such as ignorance, inadequate resources, and illiteracy.

Comparison of the radiographic and functional outcome in pediatric orthopaedic patients with Gartland type II supracondylar fracture treated by operative versus non operative management

Background: The non-operative method of closed reduction and application of long arm posterior splint and the operative method of closed reduction and percutaneous pinning are both putative management for Gartland II supracondylar fracture. The purpose of this study is to compare which method is superior in the management of this type of fracture thru the comparison of the radiographic as well as the functional outcome. Methods: This study includes 51 pediatric patients undergoing supracondylar fracture treatment. The enrolled participants were randomly allocated to one of the two groups to receive either non operative or operative treatment. Radiographic and functional outcome was assessed post treatment. Results: The operative group exhibited significant superiority versus the non operative group as reflected by the results of the post-treatment radiographs utilizing the anterior humeral line while the Baumann’s angle showed no significant difference between the two groups. Moreover, the operative group demonstrated a better Mayo elbow performance score total per follow up, only in the first 3 months but showed no significant difference thereafter. Conclusions: We therefore conclude that non operative and operative management are both effective treatment for Gartland II supracondylar fracture. The operative group showed significant superiority with results of the anterior humeral line falling mostly at the central one-third of the capitellum. The operative group manifested a better Mayo elbow performance score total only during the first 3 months of follow up.