Spica Cast Research Articles

Frontal Crash Injury Metrics Are Below Mandated Limits for a Spica Casted Child Dummy in Currently Available Restraints.

There is a paucity of data defining safe transport protocols for children treated with hip spica casting. Although restraint devices for casted children are available, all federally mandated testing uses a noncasted anthropomorphic test device (ATD or crash dummy). The purpose of this study was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD to determine injury risk to the head, cervical spine, chest, and pelvis. Using a 3-year-old ATD, dynamic crash sled tests simulating frontal crash were performed in accordance with government safety standards. The ATD was casted in a double-leg spica and the following restraint devices were tested: a seat designed for spica casted children, a restraint vest-harness, a traditional booster seat, and 2 traditional forward-facing car seats. Although the presence of the cast increased many of the injury metrics measured, all seats passed current federal guidelines for the head and chest. No single seat performed best in all metrics. The greatest magnitude of neck loading and second-highest head injury criterion values were observed for the booster seat. The vest-harness produced the highest head injury criterion and the chest compression exceeded proposed federal limits. The results suggest safe transport in commercially available seats is possible with the child properly restrained in a correctly fitting seat. However, parents should not assume a child restraint system is appropriate for use just based on fit as, for example, seats with harnesses outperformed an easy to fit booster seat. Each child and the position of the child's cast are unique and discharge planning involves consideration of safe transportation. Although this study suggests several seats used to transport spica casted children pass the federal head and chest injury prevention requirements, it is important to recognize that some children may still require emergency vehicle transport.

Frequency of limb shortening in femoral shaft fractures treated by hip spica casting in children in Tertiary Care Hospital.

Objectives: In non-operative methods, hip spica casting is a gold standard for children under six years of age because of excellent bone union and remodeling qualities. The study was conducted to determine the frequency of limb shortening in femur shaft fractures in children treated by hip spica casting. Study Design: Descriptive cross sectional study. Setting: Orthopedics Department of Combined Military Hospital, Rawalakot, Pakistan. Period: One year from July, 2016 to June, 2017. Material and Methods: After approval of the study from institution’s ethical committee, all patients fulfilling the inclusion criteria were admitted through emergency or outpatient department for hip spica casting. It was descriptive cross sectional study and sampling was done by non-probability convenience sampling in 107 femur fracture patients treated by hip spica casting. Diagnosis of the fracture was based upon history of trauma with break in the continuity of shaft as seen by X-ray. Informed consent was obtained from parents/guardian to be included in the study. Results: The mean age was 5(± 2.04) years. Sixty eight percent patients were male and 32% were female. Sixty three percent patients had proximal femoral shaft fracture, 32% had middle femoral shaft fracture and 4% patients had distal femoral shaft fracture. The shortening of limb length was found in14% of patients. Conclusion: In closed femoral shaft fractures, hip spica casting is a safe treatment in children. It has a low risk of complications. We recommend its use except for open fractures, multiple fractures, or fractures in older children.

Safe Transport of Spica Casted Children in Passenger Vehicles is Possible: A Frontal Crash Test Analysis of Child Restraint Systems Using Spica Casted Crash Test Dummies

Purpose: There is a paucity of data defining safe transport protocols for children treated with hip spica casting. No current restraint device has been tested using casted anthropomorphic test devices (ATDs). Our goal was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD.
 Methods: Using an ATD simulating a 3-year-old child, dynamic crash sled tests simulating a frontal crash were performed in accordance with Federal Motor Vehicle Safety Standards 213 (FMVSS 213). Sensors within the ATD recorded: HIC36 (Head Injury Criterion score; predictive of skull fracture), neck injury assessment (Nij), chest compression, chest acceleration, and pelvic injury assessment. Test crash video visual assessment was performed (Figures 1&2). The ATD was casted in a double-leg spica. Five restraint devices were tested: seat designed for spica-casted children (Merrit Wallenberg), modified restraint harness (Modified EZ-On-Vest), commercially available booster seat (Britax Parkway SGL Booster), and two commercially available forward-facing car seats able to accommodate the casted ATD (Diono Radian R100, Graco Nautilus 65 LX). One test was performed for each restraint system. All tests were performed at 30 MPH on a deceleration sled.
 Results: Although the presence of the cast increased many of the injury metrics measured, all 5 seats that were tested passed current FMVSS 213 federal guidelines for the head and chest. However, there were marked differences between the 5 restraint options (Figures 3-5). No single seat performed best in all metrics. Additionally, visual analysis of the video from the test crash of the EZ-On-Vest demonstrated that the face and upper extremities of the ATD are impacted during the crash. The ATD does not have a way to record injury to the extremities, thus this is not captured in the quantitative data.
 Conclusions: Per the FMVSS 213 standard, these results suggest safe transport in the five evaluated restraint systems is possible with the child properly fitted and restrained. However, the Nautilus and Diono were found to have both the lowest HIC36 and chest acceleration values, suggesting casted children may not need specially designed seats. Additionally, review of the video of the EZ-On Vest appears to demonstrate that the vest may expose the casted child to additional facial and extremity injuries compared to systems that allow the child to sit upright.
 Significance: Parents should not assume a restraint system is automatically appropriate for use with their child. While there were differences in the performances of the tested restraint systems, each child is unique and a trained healthcare provider should be consulted to ensure the child is properly restrained.

Screening for extractables in additive-manufactured acrylonitrile butadiene styrene orthopedic cast

The use of additive-manufactured components in medical applications, specifically medical devices (e.g., orthopedic casts), has increased in recent years. Such devices may be fabricated at the point of care using consumer-grade additive manufacturing. Limited studies have been conducted to evaluate the extractable substances of these devices. Chemical characterization followed by toxicological risk assessment is one means of evaluating safety of devices. This study was designed to determine the extractables profile of additive-manufactured materials according to filament grade and post-processing method. Feedstocks for additive manufacturing were tested as filament and manufactured casts, while the cast from consumer-grade filament (CGF) was post-processed. Samples were extracted using three solvents of varying polarities. Extracts were analyzed by gas chromatography/mass spectrometry (GC/MS) and liquid chromatography/mass spectrometry (LC/MS) techniques. In GC/MS analysis, isopropanol extracts generated fewer compound identifications for USP Class VI filament (USPF)-based casts (3) compared with the respective filament (17) while hexane generated the most compound identifications for the finished cast manufactured from CGF. CGF was found to have the highest number of nonvolatile extractables for isopropanol (15) and hexane (34) by positive ion LC/MS. Additionally, CGF produced more non-polar extractables in hexane than the USPF. A known polymer byproduct and potential genotoxicant, styrene acrylonitrile (SAN) trimer, was one of the compounds identified in both GC/MS and LC/MS at quantities ranging from 19 to 270 μg g−1. Overall these results suggested that the extractables profile was affected by the filament material, printing procedure, and post-processing method.

Effect of abduction on avascular necrosis of the femoral epiphysis in patients with late-detected developmental dysplasia of the hip treated by closed reduction: a MRI study of 59 hips.

PurposeThe purpose of this study was to explore whether increasing the hip abduction angle would increase the incidence of avascular necrosis (AVN) in patients with late- detected developmental dysplasia of the hip (DDH) treated by closed reduction (CR) and spica cast immobilization.MethodsA total of 55 patients (59 hips) with late-detected DDH underwent MRI after CR. Hip abduction angle and hip joint distance were measured on postoperative MRI transverse sections. The acetabular index and centre-edge angle were measured on plain radiographs at the last follow-up. The presence of AVN according to Kalamchi and McEwen’s classification was assessed. We retrospectively analyzed the associations among abduction angles, hip joint distances, radiographic parameters, AVN and final outcomes, exploring the relationship between hip joint abduction angle and AVN rate.ResultsThe mean age at the time of CR was 14.4 months SD 5.5 (6 to 28), and the mean follow-up was 26.2 months SD 8.1 (12.4 to 41.7). The mean hip abduction angle was 70.2° SD 7.2° (53° to 85°) on the dislocated side and 63.7° SD 8.8° (40° to 82°) on the normal side; the mean hip joint distance was 5.1 mm SD 1.9 (1.3 to 9.1) on the dislocated side and 2.2 mm SD 0.6 on the normal side (1.3 to 3.3). Eight of 59 hips (13.6%) developed AVN. Neither the amount of abduction nor hip joint distance increased the AVN rate (p = 0.97 and p = 0.65, respectively) or the dislocation rate (p = 0.38 and p = 0.14, respectively).ConclusionAbduction angle up to 70.2° following CR did not increase the AVN rate in children aged six to 28 months with late-detected DDH treated by CR.Level of evidenceIII.

A clinical study of treatment of paediatric femoral shaft fractures with elastic intramedullary nail

Background: The fractures of paediatric femoral shaft is a common major fracture treated by Orthopaedic surgeon. The treatment of femoral shaft fractures in children is a subject of controversy. It is conventionally managed by traction and hip spica casting. Although the majority heals without long term sequelae but the closed intramedullary operative procedure allows early weight bearing and early rehabilitation. It has the advantage of haematoma preservation and restoration of continuity of bone.Methods: Twenty one children of aged 6-14 years with femoral shaft fractures were treated with elastic intramedullary nails. Seventeen fractures were in middle third, two in proximal third and two in distal third. Fourteen fractures were transverse, three oblique, two were spiral and two were comminuted. Average injury surgery interval was 5 days. All fractures were treated by closed reduction and elastic intramedullary nails. The patients were assessed clinically and radiologically for two years. The final results were evaluated using the criteria of Flynn et al.Results: Results were assessed for range of motion (ROM), irritation at the distal end of nail, deformity, limb length discrepancies and union. Radiologically union was achieved in a mean time of 9 weeks (6-12 weeks). The most common problem encountered was soft tissue discomfort near knee joint. Excellent results were achieved in 14 patients (67%), successful results in 5 patients (23%) and poor results in 2 patients (10%).Conclusion: It is concluded that paediatrics femoral shaft fractures treated by elastic intramedullary nail gives satisfactory results with minimal complications.

Fabrication, mechanical and optical performance of AM-gel casted YAG transparent ceramics

Aqueous gelcasting has been applied to form multiple advanced ceramics with large size or complex shape. However, the optical performance of transparent ceramics fabricated by gelcasting is not satisfactory due to the microstructure defects and residual organics. YAG ceramics with excellent optical transmittance were prepared through improving solid content of suspension, obtaining fine microstructure of fully dense ceramics without residual organics in this paper. The effects of ammonium citrate tribasic (TAC) and solid content on the rheological performance of suspension as well as the effect of solid content on the microstructure of green body were systematically investigated. The viscosity of suspension with 43 vol% solid content and 0.25 wt% TAC was as low as 0.03 Pa s at 100 s−1. The YAG ceramics (thickness 2.5 mm) with high optical transmittance (T = 83.2% at 1064 nm) were prepared from 43 vol% after vacuum sintering at 1780 °C for 8 h. The green body cast from 45 vol% solid content had an excellent bending strength about 29 MPa, and the residual pores were eliminated after vacuum sintering, while the residual organics was detected by optical microscopy and elemental analyzer inside YAG ceramics. The residual organics results in the decrease of in-line transmittance of YAG ceramic cast from 45 vol% solid content than that of ceramic cast from 43 vol%. This study suggests a promising prospect for AM gelling system in the cost-efficient manufacturing of highly transparent ceramics with high bending strength of green bodies.

Closed Reduction as Therapeutic Gold Standard for Treatment of Congenital Hip Dislocation

Congenital hip dislocation (luxation) has an incidence of 0.4 - 0.7% and is regarded as a prearthrotic deformity. Thus, if not being diagnosed and treated at a very early age, extensive surgical measures are inevitable in childhood and early adulthood. In the time between 01/2013 and 02/2019 we performed 28 600 hips sonographies in babies as part of general screening measures at U2 or U3. There were 71 instable, dysplastic or dislocated hips diagnosed that were treated by arthrographic, closed reduction. After a hip spica cast was applied, reposition was controlled by MRI, estimating the acetabular head index (ACI), the head coverage index (HCI) as well as the femoral head's sphericity or by sonography using the Graf method. Overall success rate was 91.6% for primary closed reduction. Patients with primarily irreducible hips were significantly older (p < 0.003) than patients with primarily successful reducible hips. Congenital dislocated hips had significantly higher ACIs (p < 0.001) and HCIs (p = 0.03) as well as significantly less well rounded femoral heads (sphericity; p < 0.001) compared to stable hips. Early diagnosis and treatment of congenital dislocated hips by closed reduction is essential for a sufficient and regular maturation of the hips without further surgical interventions.

Developmental dysplasia of the hip: update of management.

The term ‘developmental dysplasia of the hip’ (DDH) includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip.DDH alters hip biomechanics, overloading the articular cartilage and leading to early osteoarthritis. DDH is the main cause of total hip replacement in young people (about 21% to 29%).Development of the acetabular cavity is determined by the presence of a concentrically reduced femoral head. Hip subluxation or dislocation in a child will cause an inadequate development of the acetabulum during the remaining growth.Clinical screening (instability manoeuvres) should be done universally as a part of the physical examination of the newborn. After two or three months of life, limited hip abduction is the most important clinical sign.Selective ultrasound screening should be performed in any child with abnormal physical examination or in those with high-risk factors (breech presentation and positive family history). Universal ultrasound screening has not demonstrated its utility in diminishing the incidence of late dysplasia.Almost 90% of patients with mild hip instability at birth are resolved spontaneously within the first eight weeks and 96% of pathologic changes observed in echography are resolved spontaneously within the first six weeks of life. However, an Ortolani-positive hip requires immediate treatment.When the hip is dislocated or subluxated, a concentric and stable reduction without forceful abduction needs to be obtained by closed or open means. Pavlik harness is usually the first line of treatment under the age of six months.Hip arthrogram is useful for guiding the decision of performing a closed or open reduction when needed.Acetabular dysplasia improves in the majority due to the stimulus provoked by hip reduction. The best parameter to predict persistent acetabular dysplasia at maturity is the evolution of the acetabular index.Pelvic or femoral osteotomies should be performed when residual acetabular dysplasia is present or in older children when a spontaneous correction after hip reduction is not expected.Avascular necrosis is the most serious complication and is related to: an excessive abduction of the hip; a force closed reduction when obstacles for reduction are present; a maintained dislocated hip within the harness or spica cast; and a surgical open reduction.Cite this article: EFORT Open Rev 2019;4:548-556. DOI: 10.1302/2058-5241.4.180019

The Effect of Long Arm Cast and Thumb Spica Arm Cast in the Treatment of Patients with Distal Radius Fractures: A Randomized Clinical Trial

Background: Distal radius fracture is among the most common fractures of the long bones that are seen in all age groups. Treatment of these fractures in simple cases with displacement or intra-articular fractures is immobilizatgion, and if the fracture has dislocation, surgery may be required.Objectives: The aim of the study is a comparison of treatment efficacy and satisfaction in the methods of a long cast and thumb Spica cast in the patients with distal radius fractures without displacement.Methods: This study is a randomized clinical trial with a non blinded parallel design. Eighty patients with distal radius fractures without displacement were randomly assigned to long cast and thumb Spica cast groups. Patients were randomly using a random number table assigned to one of two long cast and thumb Spica castmethods. Both groupswere examined atweeks 4 and 5 and after six weeks plaster was opened and after one week they were evaluated by DASH questionnaire. Performance (limitation of motion, grip strength) and patients’ satisfaction was assessed in the two groups.Results: Themean age of patientswas 49.87±13.81 years. Therewere no significant differences between two groups regarding age(P= 0.84). In thumb Spica group 60% and in the long cast group 55% were male. There was no significant difference in sex distribution between treatment groups. The DASH scores in all subjectswere 11.68±5.53. Average total DASH score in thumb Spica cast group was 7.19 ± 6.80 and in the long cast was 16.02 ± 6.23. The mean of total DASH score in thumb Spica cast group was significantly higher than long cast group that presented better performance (limitation of motion, grip strength) in thumb Spica cast group respect to long cast group (P < 0.001). Satisfaction was similar between two groups (P = 0.40).Conclusions: Regarding better performance and treatment, thumb Spica cast is recommended as the preferred treatment for distal radius fractures without displacement.

Spica MRI predictors for epiphyseal osteonecrosis after closed reduction treatment of dysplasia of the hip.

Spica MRI with intravenous gadolinium contrast after closed reduction for developmental dysplasia of the hip (DDH) helps to determine successful reduction and attempts to identify patients at risk for epiphyseal osteonecrosis. The objective of our study was to evaluate spica MRI predictors for epiphyseal osteonecrosis after closed reduction. This was a retrospective study of all patients undergoing closed reduction for DDH followed by gadolinium-enhanced spica MRI between July 2011 and November 2014. Patient demographics and clinical follow-up through 2017, including the development of epiphyseal osteonecrosis and need for reintervention after the initial reduction, were recorded. MRI data included hip abduction angles and quantifying the percentage of femoral head enhancement. Twenty-five hips in 21 patients (16 girls, five boys, mean age: 0.99 years, range: 0.4-3.1 years) were included in our study. The mean follow-up period was 3 ± 1.5 years (range: 0.65-6.1 years). Eight (32%) of 25 hips went on to develop osteonecrosis. Epiphyseal osteonecrosis was more likely with less than 80% enhancement (sensitivity 87.5%, specificity 88.25%, positive predictive value 78%, negative predictive value 94%). The mean contrast enhancement for patients developing osteonecrosis compared with those who did not was 37.5 and 86.5%, respectively; P = 0.001. Immediate postspica MRI with gadolinium is a useful prognostic tool for determining future risk for epiphyseal osteonecrosis in children treated for DDH. Our data complement existing literature and suggest that even in cases with partial epiphyseal enhancement, osteonecrosis may still develop. When the epiphyseal enhancement is less than 80%, it is recommended that spica cast revision is considered.

Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries.

Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. Level II-prospective comparative study.

Long Leg Splinting For Pediatric Femur Fractures

Introduction: Pediatric femur fractures are frequently encountered injuries. For patients aged 6 months to 5 years old the most common treatment for these fractures is spica casting. It has been noted, however, that spica casts represent a significant burden to parents. Furthermore, at most centers spica casts are applied in an operating room under general anesthesia, increasing healthcare costs and exposing children to the potential complications associated with anesthesia. A possible alternative to spica casting is a long leg splint extending onto the flank. Such a splint could be …

Predicting the Need for Open Reduction in the Treatment of Developmental Dysplasia of the Hip

Purpose: Closed reduction of the hip and spica casting is generally attempted on children under 18 months of age who fail non-operative management for developmental dysplasia of the hip (DDH). However, many of these patients will not achieve concentric reduction by closed means and will require open reduction. Limited evidence exists to predict which patients can be adequately closed reduced versus those who will need open treatment. Therefore, the purpose of this study is to identify factors predictive of needing closed vs. open …

Safe Transportation in-Spica Following Surgical Treatment of Infantile DDH: Solutions and Threats.

Government regulations mandate appropriate vehicular restraints for children under 4 years of age. Patients treated for infantile developmental dysplasia of the hip (DDH) with spica casts often require special accommodations. Previous work suggests that car seat loaner programs may help achieve these goals while avoiding the need for costly ambulance transportation. The purpose of this study was to evaluate our center's experience with postdischarge transportation in a large population of DDH infants and identify future threats to our program. We performed a retrospective review of patients 4 years or younger of age who underwent closed or open reduction for DDH at our center between 2011 and 2018. Only the initial surgery of staged procedures was included. Patient demographic factors were recorded, as were procedure type, final restraint used for postdischarge transportation, and any potential discharge delays secondary to transportation issues. Costs were compared amongst transportation options. Our cohort consisted of 130 patients (mean age, 1.4±0.9 y; 98 females) treated for DDH. In total 41 children (31.5%) underwent closed reduction procedures, whereas 89 patients (68.5%) underwent open reductions. After reduction, 62 (47.7%) received 2-legged spica casts and 68 (52.3%) received 1.5-legged casts. The most common restraint was a hospital-loaned Hippo car seat (73, 55.8%) followed by family-owned car seats (27, 20.8%). Eight patients (6.2%) experienced delays in discharge while waiting for adequate restraints, 6 patients (4.6%) were transported by ambulance, and 4 patients (3.1%) left against medical advice with inadequate restraints. Following surgical treatment of DDH, over 50% of patients with a spica cast were discharged using our center's car seat loaner program. However, availability and cost can present barriers for patients, with 4.6% of patients still being transported home by ambulance and 3.1% with inadequate restraints against medical advice. Costs of car seats are significant both for patients' families intending to purchase them, as well as for hospitals maintaining loaner programs and replacing used/lost seats. Moving forward, the recent cessation of production of the most common "spica car seat" threatens the longevity of existing loaner programs and calls renewed attention to the issue of safe transportation in-spica from providers and car-seat manufacturers alike. Level III.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Femoral Neck Fracture Pearls and Pitfalls.

Pediatric hip fractures are uncommon injuries but are associated with a high complication rate including avascular necrosis, coxa vara, nonunion, and premature physeal arrest. This is due in part to the unique anatomy of the proximal femur. Management principles are aimed at minimizing the risk of complications and emphasize the importance of early treatment with anatomic reduction and stable internal fixation with a low threshold for supplementing fixation with a spica cast. The age of the patient and Delbet fracture type dictate the optimal type of fixation for a given case. This article will offer evidence and experience-based tips intended to benefit on-call surgeons caring for these injuries.

Assessing the Need for Common Perioperative Laboratory Tests in Pediatric Patients With Femoral Shaft Fractures.

Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures. We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook. We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin<8 g/dL postoperatively, however, there were no perioperative blood transfusions. Of these 4, 3 underwent either reamed intramedullary nails or open reduction internal fixation with plates/screws. Twenty-six patients (27.4%) had preoperative basic metabolic panels that did not alter medical care. On the basis of our criteria, over 72% of laboratories appeared unnecessary, with a total potential cost of $8567. Over 80% of orders were from the emergency department by residents or attending physicians. Perioperative laboratory orders may be unnecessary in most isolated pediatric femoral shaft fractures, subjecting patients to extraneous costs, and associated pain. However, laboratories may be justified based on clinical circumstances or for older patients treated with reamed nails or plates/screws. Evidence-based recommendations for perioperative laboratory orders offer the potential to improve quality and value and minimize harm in pediatric orthopaedic trauma. Level III-retrospective comparative study (therapeutic).

Commentary to ‘Impact of pelvic immobilization techniques on the outcomes of primary and secondary closures of classic bladder exstrophy’

The authors report the outcomes of bladder exstrophy closure based on the type of post-operative immobilization techniques from patients seen at their institution. Patients included in the study underwent bladder exstrophy closure at both their own institution and other institutions. They conclude that the success rate was highest with Buck's and Bryant's traction and lowest when using spica casting. However, none of the patients in the study population underwent bladder exstrophy closure with spica casting at their institution.

Femur Fracture: Functional Bracing vs. Hip Spica Cast

Femur Fracture: Functional Bracing vs. Hip Spica Cast

Patients under 4 years old treated with overhead extension for isolated femoral fractures - lessons learned concerning parents' satisfaction.

Conservative options are the standard for treatment of femoral fractures for patients under the age of 4 years. We investigated possible factors influencing the satisfaction of the parents in order to improve their experience. We analyzed 42 cases of children under the age of 4 years treated with overhead extension therapy (OHE) for femoral fracture. Our protocol requires transition to spica cast treatment (SCT) and discharge from the hospital after the initial 10-day OHE. X-rays were analyzed for fracture healing. A pseudonymized questionnaire was sent to the parents in order to evaluate their experiences during the treatment. The nature of the fracture was explained to 73.3% of the parents in a way that was "understandable and in detail". However, 23.3% stated that "many questions were not answered". Seventy percent of parents noticed behavioral abnormalities during treatment, and 63.3% reported treatment-specific problems. Additionally, 86.7% of parents were satisfied with the therapy outcome, 80% were content with the type of therapy, and 73.3% would choose OHE again. We found a high Spearman correlation between general satisfaction and parents who felt well informed. There was also a strong correlation between high general satisfaction and the opportunity for any problems to be discussed and addressed during the medical rounds. The reasons for nonsatisfaction were primarily due to communication problems. Thorough evaluation during medical rounds, communication with healthcare professionals and care provided by the nurses affects the contentment of the families significantly.