Pediatric acute compartment syndrome (ACS) is an orthopedic emergency which requires timely recognition and management. There are unique considerations in children, as they may present with a wide ...array of symptoms and capacities to communicate. We sought to investigate the presentations, treatments and outcomes of pediatric ACS, hypothesizing that decompressive fasciotomy results in good outcomes, even with delayed treatment (>24 h). We performed a retrospective review of pediatric ACS from 2009 to 2018. Exclusion criteria were age ≥18 years, exertional compartment syndrome, and incomplete data. Twenty-one patients (mean age 11 years) were included. Swelling (100%) and worsening pain (100%) were the most common presenting signs and symptoms followed by paresthesias (75%). Increasing analgesia requirements were documented in six (29%) patients. Compartment pressures were measured in 52% of patients. All patients were managed with decompressive fasciotomies, which were performed at a median time of 20 h from injury. Strength and range of motion deficits (10%) were the most commonly reported complications. There were no infections. All patients who were treated in a delayed fashion (≥24 h) were found to have a good functional recovery, but 38% had minor complications. Overall, patients had good outcomes, achieving full functional recovery with return to preinjury activity level. Pediatric ACS should be approached as a distinct clinical entity from adult ACS, where risks of infection and wound complications from delayed fasciotomy generally outweigh the benefits. We recommend considering decompressive fasciotomy for all cases of pediatric ACS, including those with prolonged time from injury to diagnosis.
What's Important: Ortho, I Screwed Up Pirkle, Sean; Chen, Antonia F; Samora, Julie B ...
Journal of bone and joint surgery. American volume,
06/2023, Volume:
105, Issue:
12
Journal Article
Background There is substantial corroborating evidence that orthopaedic surgery has historically been the least diverse of all medical and surgical specialties in terms of race, ethnicity, and sex. ...Growing recognition of this deficit and the benefits of a diverse healthcare workforce has motivated policy changes to improve diversity. To measure progress with these efforts, it is important to understand the existing representation of sexual and gender minorities among orthopaedic professionals. Questions/purposes (1) What proportion of American Academy of Orthopaedic Surgeons (AAOS) members reported their identity as a sexual or gender minority? (2) What demographic factors are associated with the self-reporting of one’s sexual orientation and gender identity? Methods The AAOS published the updated membership questionnaire in January 2022 to collect information from new and existing society members regarding age and race or ethnicity and newly added categories of gender identity, sexual orientation, and pronouns. The questionnaire was updated with input from a committee of orthopaedic surgeons and researchers to ensure face validity. The AAOS provided a deidentified dataset that included the variables of interest: membership type, gender identity, sexual orientation, pronouns, age, race, and ethnicity. Of 35,427 active AAOS members, 47% (16,652) updated their membership questionnaire. To answer our first study question, we calculated the prevalence of participants who self-reported as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority identity (LGBTQ+) and other demographic characteristics of the 16,652 respondents. Categorical demographic data are described using frequencies and proportions. Median and IQR were used to describe the central tendency and variability. To answer our second study question, we conducted a stratified analysis to compare demographic characteristics between those who self-reported LGBTQ+ identity and those who did not. Visual methods (quantile-quantile plots) and statistical tests (Kolmogorov-Smirnov and Shapiro Wilk) confirmed that the age of AAOS member was not normally distributed. Therefore, a Kruskal Wallis test was used to determine the statistical associations between age and self-reported LGBTQ+ status. Chi-square tests were used to determine bivariate statistical associations between categorical demographic characteristics and self-reported LGBTQ+ status. A multivariable logistic regression model was developed to identify the independent demographic characteristics associated with respondents who self-reported LGBTQ+ identity. Further stratified analyses were not conducted to protect the anonymity of AAOS members. An alpha level of 5% was established a priori to define statistical significance. Results Overall, 3% (109 of 3679) and fewer than 1% (3 of 16,182) of the AAOS members (surgeons, clinicians, allied healthcare providers, and researchers) who updated their membership profiles reported identifying as a sexual (lesbian, gay, bisexual, queer) or gender minority (nonbinary or transgender), respectively. No individual self-identified as transgender. Five percent (33 of 603) of women and 3% (80 of 3042) of men self-identified as a sexual minority (such as lesbian, gay, bisexual, or queer). AAOS members who self-identified as LGBTQ+ were younger (OR 0.99 95% confidence interval (CI) 0.98 to 0.99; p < 0.001), less likely to self-identify as women (OR 0.86 95% CI 0.767 to 0.954; p < 0.001), less likely to be underrepresented in medicine (OR 0.49 95% CI 0.405 to 0.599; p < 0.001), and less likely to be an emeritus or honorary member (OR 0.75 95% CI 0.641 to 0.883; p < 0.003). Conclusion The proportion of self-reported LGBTQ+ AAOS members is lower than the 7% of the general US population. The greater proportion of younger AAOS members reporting this information suggests progress in the pursuit of a more-diverse field. Clinical Relevance The study findings support standardized collection of sexual orientation and gender identity data to better identify and address diversity gaps. As orthopaedic surgery continues to transform to reflect the diversity of musculoskeletal patients, all orthopaedic professionals (surgeons, clinicians, allied healthcare providers, and researchers), regardless of their identities, are essential in the mission to provide equitable and informed orthopaedic care. Sexual and gender minority individuals may serve as important mentors to the next generations of orthopaedic professionals; individuals from nonminority groups should serve as important allies in achieving this goal.
Orthopaedic surgeons in training and in their careers can experience a lack of confidence and imposter syndrome. Confidence is built early through continuous improvement, accomplishments, support, ...and reinforcement. Although it is normal to lack confidence at times, the goal is to recognize this issue, work on visualizing success, and know when to seek help. Mentors can help mentees to build confidence and to normalize thoughts of insecurity and imposter syndrome. It is critical to develop and to maintain resilience, grit, emotional intelligence, courage, and vulnerability during training and throughout one's entire orthopaedic career. Leaders in the field must be aware of these phenomena, be able to talk about such issues, have methods to combat the harmful effects of imposter syndrome, and create a safe, supportive environment conducive to learning and working. Leading well builds not only confidence in oneself but also self-confidence in others. Leaders who are able to build the confidence of individuals will enhance team dynamics, wellness, and overall productivity as well as individual and organizational success.
A deeper investigation of medical and musculoskeletal conditions in patients with ulnar longitudinal deficiency (ULD) is needed. The association between the severity of the manifestations of ULD in ...the hands and forearms has not been firmly established. The purpose of this study was to describe the medical and musculoskeletal conditions associated with ULD and examine the relationship between hand and forearm anomalies.
The Congenital Upper Limb Differences registry was queried for all patients with a diagnosis of ULD, as defined by the Oberg-Manske-Tonkin classification system, between 2014 and 2020. The patients' demographic information, medical and musculoskeletal comorbidities, radiographs, and clinical images were reviewed. The participants were classified using the Bayne, Cole and Manske, and Ogino classification systems.
Of 2,821 patients from the Congenital Upper Limb Differences registry, 75 patients (2.7%) with ULD (14 bilateral), with 89 affected extremities, were included. Hand anomalies were present in 93% of the patients. Approximately 19% of the patients had an associated medical comorbidity, and 20% of the patients had an associated musculoskeletal condition. Cardiac anomalies were present in 8.0% of the patients, and 12% of the patients had a lower extremity abnormality. Radial head dislocation was observed in 13 of 18 patients with Bayne type II or III ULD compared with 8 of 43 patients with other types of unilateral ULD. There was a significant positive association among the Bayne and Ogino, Bayne and Cole/Manske, and Ogino and Cole/Manske classification systems in patients with unilateral ULD.
Associated medical and musculoskeletal conditions are common in patients with ULD, of which cardiac and lower extremity abnormalities are most frequently observed. There is a significant positive association between the severity of forearm anomalies and that of hand anomalies in patients with unilateral ULD. All patients with ULD should undergo a thorough cardiac evaluation by their pediatrician or a pediatric cardiologist.
Symptom prevalence study III.
The relationship between orthopaedic surgeons and the internet is complicated. Social media allows surgeons to educate their patients while marketing to them at the same time. Conversely, patients ...are able to better communicate with their surgeons while anonymously rating their service and expertise. This study aims to look at the complex relationship between surgeons and social media use.
BACKGROUND:Pneumonia is a common lower respiratory tract infection (LRI) and the leading cause of pediatric hospitalization in the United States. Given its frequency, children with pneumonia may ...require surgery during their hospital course. This poses serious anesthetic and surgical challenges because preoperative pulmonary status is among the most important risk factors for postoperative complications. Although recent adult data indicated that preoperative pneumonia was associated with poor surgical outcomes, comparable data in children are lacking. Therefore, our objective was to investigate the association of preoperative pneumonia with postoperative mortality and morbidity in children.
METHODS:Using the National Surgical Quality Improvement Program database, we assembled a retrospective cohort of children (<18 years) who underwent inpatient surgery between 2012 and 2015. Our primary outcome was the time to all-cause 30-day postoperative mortality that we evaluated using Cox proportional hazards regression models. For the secondary outcomes, including 30-day postoperative morbidity events, we used Fine-Gray models to account for competing risk by mortality. We also evaluated the association of preoperative pneumonia with duration of postoperative mechanical ventilation and postoperative hospital length of stay. We used propensity score weighting methods to adjust for potential confounding factors, whose distributions differ across the pneumonia groups.
RESULTS:Among 153,242 children who underwent inpatient surgery, 0.7% (n = 867) had preoperative pneumonia. Compared with those without preoperative pneumonia, children with preoperative pneumonia had a higher risk of mortality throughout the 30-day postoperative period (hazard ratio HR, 4.10; 95% confidence intervals CI, 2.42–6.97; P < .001). Although not statistically significant, children with preoperative pneumonia were twice as likely to develop cardiovascular complications compared to children without preoperative pneumonia (HR, 2.10; 95% CI, 1.17–3.75; P = .012). Furthermore, children with preoperative pneumonia had longer duration of postoperative ventilation (incidence rate ratio, 1.47; 95% CI, 1.26–1.71; P < .001). Finally, children with preoperative pneumonia were estimated to be 56% less likely to be discharged within the 30 days following surgery, compared to children without preoperative pneumonia (HR, 0.44; 95% CI, 0.40–0.47; P < .001).
CONCLUSIONS:Preoperative pneumonia was strongly associated with increased incidence of postoperative mortality and complications in children. Clinicians should make concerted efforts to screen for preoperative pneumonia and consider whether proceeding with surgery is the most expedient course of action. Our findings may be helpful in preoperative discussions with parents of children with preoperative pneumonia for risk stratification and postoperative resource allocation purposes.
Pediatric trigger finger (PTF) is an acquired condition that is uncommon and anatomically complex. Currently, the literature is characterized by a small number of retrospective case series with ...limited sample sizes. This investigation sought to evaluate the presentation, management, and treatment outcomes of PTF in a large, multicenter cohort.
A retrospective review of pediatric patients with a diagnosis of PTF between 2009 and 2020 was performed at three tertiary referral hospitals. Patient demographics, PTF characteristics, treatment strategies, and outcomes were abstracted from the electronic medical records. Patients and families also were contacted by telephone to assess the downstream persistence or recurrence of triggering symptoms.
In total, 321 patients with 449 PTFs were included at a mean follow-up of 3.9 ± 4.0 years. There were approximately equal numbers of boys and girls, and the mean age of symptom onset was 5.4 ± 5.1 years. The middle (34.7%) and index (11.6%) fingers were the most and least commonly affected digits, respectively. Overall, PTFs managed operatively achieved significantly higher rates of complete resolution compared with PTFs managed nonsurgically (97.1% vs 30.0%). Seventy-five percent of PTFs that achieved complete resolution with nonsurgical management did so within 6 months, and approximately 90% did so within 12 months. Patients with multidigit involvement, higher Quinnell grade at presentation, or palpable nodularity were significantly more likely to undergo surgery. There was no significant difference in the rate of complete resolution between splinted versus not splinted PTFs or across operative techniques.
Only 30% of the PTFs managed nonsurgically achieved complete resolution. Splinting did not improve resolution rates in children treated nonsurgically. In contrast, surgical intervention has a high likelihood of restoring motion and function of the affected digit.
Therapeutic IV.
Microaggressions, bullying, harassment, sexual harassment, and discrimination continue to be experienced by orthopaedic physicians in the workplace. Oftentimes, these behaviors go unreported because ...of fear of retaliation, and many perpetrators are not held accountable. This article provides examples of stories anonymously submitted to #SpeakUpOrtho on the topics of microaggressions, bullying/harassment, sexual harassment, discrimination, and retaliation by orthopaedic surgery residents, fellows, and attending surgeons. Commentary by experts in the field is also included to provide ways to manage and prevent the perpetuation of these behaviors.
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