Growth Plate Injuries of the Lower Extremity: Case Examples and Lessons Learned.

BackgroundThe presence of growth plates at the ends of long bones makes fracture management in children unique in terms of the potential risk of developing angular deformities and growth arrest.Materials and methodsWe discuss three distinct cases depicting various aspects of physeal injury of the lower extremity in children.ResultsThe case illustrations chosen represent distinct body regions and different physeal injuries: Salter-Harris II fracture of the distal femur, Salter-Harris VI perichondrial injury of the medial aspect of the knee region, and Salter-Harris III fracture of the distal tibia. The clinical presentation, pertinent history and physical findings, imaging studies, management, and subsequent course are presented.ConclusionsGrowth plate injuries of the lower extremity require a high index of suspicion and close monitoring during skeletal growth. Early recognition and proper management of these injuries can minimize long term morbidity. The treatment plan should be individualized after a comprehensive analysis of the injury pattern in each patient. Establishing a long term treatment plan and discussing the prognosis of these injuries with the child's caretakers is imperative

Availability and Quality of Online Information on Sub-Internships in U.S. Orthopaedic Residency Programs.

BackgroundThe purpose of the present study was to assess the availability and quality of online information regarding sub-internships in orthopaedics among U.S. orthopaedic residency programs.MethodsEach U.S. orthopaedic surgery residency program web site was assessed for the following 4 criteria: any mention of a sub-internship offered by that program, contact information regarding the sub-internship, a list of learning objectives to be met by the rotating student during the sub-internship, and presence of a web page dedicated solely to the orthopaedic sub-internship. Each web site was given a sub-internship score (SI score) from 0 to 4 based on how many of the above criteria were met.ResultsFrom the 151 analyzed U.S. orthopaedic surgery residency program web sites, 69 (46%) did not have any mention of a sub-internship and thus received a score of 0, 4 (3%) received a score of 1, 18 (12%) received a score of 2, 20 (13%) received a score of 3, and 40 (26%) received a score of 4. The average SI score was 1.05 for the community-based orthopaedic residency programs, compared with 1.98 for the university-based orthopaedic programs (p = 0.003). Subgroup analysis based on SI scores (0 vs. 1 to 4) revealed that the higher-score group (1 to 4) had a higher percentage of university-based programs than the lower-score (0) group (80% vs. 62%; p = 0.003) and was associated with a greater number of residents per program than the lower-score group (mean, 26.4 vs. 21.0; p = 0.04). There was a weak association between the SI score and the number of residents in a given program (R2 = 0.074, p = 0.0004).ConclusionsThe availability and quality of online information regarding sub-internships offered at orthopaedic residency programs in the U.S. are variable. Nearly half of the programs did not have any available online information on their web sites regarding orthopaedic surgery sub-internships. Larger and university-based orthopaedic programs have more robust information regarding sub-internships than smaller and community-based programs.Clinical relevanceThere needs to be greater awareness and more uniformly accessible online information regarding orthopaedic surgery sub-internships for senior medical students seeking elective orthopaedic rotations prior to applying for residency training

Variability in Exposure to Subspecialty Rotations During Orthopaedic Residency: A Website-based Review of Orthopaedic Residency Programs.

IntroductionThe variability in exposure to various subspecialty rotations during orthopaedic residency across the United States has not been well studied.MethodsData regarding program size, resident's sex, department leadership, university-based status of the program, outsourcing of subspecialty rotation, and geographic location were collected from websites of 151 US allopathic orthopaedic residency programs. The relationship of these factors with the time allotted for various clinical rotations was analyzed.ResultsThe number of residents in a program correlated positively with time allocated for elective rotations (r = 0.57, P = 0.0003). Residents in programs where the program director was a general orthopaedic surgeon spent more time on general orthopaedic rotations (22 versus 9.9 months, P = 0.001). Programs where the program director or chairman was an orthopaedic oncologist spent more time on oncology rotations ([3.8 versus 3 months, P = 0.01] and [3.5 versus 2.7 months, P = 0.01], respectively). Residents in community programs spent more time on adult reconstruction than university-based programs (6.6 versus 5.5 months, P = 0.014). Based on multiple linear regression analysis, time allotted for adult reconstruction (t = 2.29, P = 0.02) and elective rotations (t = 2.43, P = 0.017) was positively associated with the number of residents in the program.ConclusionsSubstantial variability exists in the time allocated to various clinical rotations during orthopaedic residency. The effect of this variability on clinical competence, trainees' career choices, and quality of patient care needs further study

Predictors for Nonaccidental Trauma in a Child With a Fracture-A National Inpatient Database Study.

BackgroundDespite heightened awareness and multidisciplinary efforts, a predictive model to help the clinician quantify the likelihood of nonaccidental trauma (NAT) in a child presenting with a fracture does not exist. The purpose of this study was to develop an evidence-based likelihood of NAT in a child presenting with a fracture.MethodsUsing the 2012 Kids' Inpatient Database, we identified all available pediatric inpatients admitted with an extremity or spine fracture. Children with a fracture were subcategorized based on the diagnosis of NAT. Multivariate analysis using multiple logistic regression was used to generate odds ratios and create a predictive model for the probability of NAT in a child with a fracture.ResultsOf the 57,183 pediatric fracture cases, 881 (1.54%) had a concurrent diagnosis of NAT. Of these children, those presenting with multiple fractures had the highest rate of NAT (2.8%). The overall mortality rate in patients presenting with fractures and abuse was 1.8%, which was twice as high as patients without abuse (odds ratio [OR] = 2.0). Based on multivariate analysis, younger age (OR = 0.5), black race (OR = 1.7), intracranial injury (OR = 3.7), concomitant rib fracture (OR = 7.2), and burns (OR = 8.3) were positive predictors of NAT in a child with a fracture. A weighted equation using regression coefficients was generated and plotted on a receiver operative characteristic curve, demonstrating excellent correlation and probability of NAT (area under curve = 0.962). (Equation - ln (P/(1 - P)) = -1.79 - 0.65 (age in years) + 0.51 (black race) + 1.97 (rib fracture) + 1.31 (intracranial injury) + 2.12 (burn)).ConclusionUsing a large, national inpatient database, we identified an overall prevalence of 1.54% of NAT in children admitted to the hospital with a fracture. Based on five independent predictors of NAT, we generated an estimated probability chart that can be used in the clinical workup of a child with a fracture and possible NAT. This evidence-based algorithm needs to be validated in clinical practice.Level of evidencePrognostic study, Level III (case-control study)

Chylous Leak During Posterior Approach to Juvenile Scoliosis Surgery: A Case Report.

CaseWe report the first documented case of chylous leak recognized intraoperatively during posterior spinal instrumentation and fusion for juvenile scoliosis in a female patient with a history of thoracotomy and decortication for an empyema.ConclusionsThoracic duct injury can lead to severe morbidity and mortality because of chylothorax formation. Although chylous leaks are a well-documented complication of the anterior approach to spine surgery, leaks during the posterior approach are rarely reported. When these chylous leaks are recognized intraoperatively, the likelihood of serious complications may be minimized by drain placement before closure

Limb Lengthening and Reconstruction Society AIM Index Reliably Assesses Lower Limb Deformity

Abstract Background Although several systems exist for classifying specific limb deformities, there currently are no validated rating scales for evaluating the complexity of general lower limb deformities. Accurate assessment of the complexity of a limb deformity is essential for successful treatment. A committee of the Limb Lengthening and Reconstruction Society (LLRS) therefore developed the LLRS AIM Index to quantify the severity of a broad range of lower extremity deformities in seven domains. Questions/Purposes We addressed two questions: (1) Does the LLRS AIM Index show construct validity by correlating with rankings of case complexity? (2) Does the LLRS AIM Index show sufficient interrater and intrarater reliabilities? Methods We had eight surgeons evaluate 10 fictionalized patients with various lower limb deformities. First, they ranked the cases from simplest to most complex, and then they rated the cases using the LLRS AIM Index. Two or more weeks later, they rated the cases again. We assessed reliability using the Kendall's W test. Results Raters were consistent in their rankings of case complexity (W = 0.33). Patient rankings also correlated with both sets of LLRS AIM ratings (r 2 = 0.25; r 2 = 0.23). The LLRS AIM Index showed interrater reliability with an intraclass correlation (ICC) of 0.97 for Trial 1 and 0.98 for Trial 2 and intrarater reliability with an ICC of 0.94. The LLRS AIM Index ratings also were highly consistent between the attending surgeons and surgeons-in-training (ICC = 0.91). Conclusions Our preliminarily observations suggest that the LLRS AIM Index reliably classifies the complexity of lower limb deformities in and between observers

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Growth Plate Injuries of the Lower Extremity: Case Examples and Lessons Learned.

BackgroundThe presence of growth plates at the ends of long bones makes fracture management in children unique in terms of the potential risk of developing angular deformities and growth arrest.Materials and methodsWe discuss three distinct cases depicting various aspects of physeal injury of the lower extremity in children.ResultsThe case illustrations chosen represent distinct body regions and different physeal injuries: Salter-Harris II fracture of the distal femur, Salter-Harris VI perichondrial injury of the medial aspect of the knee region, and Salter-Harris III fracture of the distal tibia. The clinical presentation, pertinent history and physical findings, imaging studies, management, and subsequent course are presented.ConclusionsGrowth plate injuries of the lower extremity require a high index of suspicion and close monitoring during skeletal growth. Early recognition and proper management of these injuries can minimize long term morbidity. The treatment plan should be individualized after a comprehensive analysis of the injury pattern in each patient. Establishing a long term treatment plan and discussing the prognosis of these injuries with the child's caretakers is imperative