Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

https://pediatrics.aappublications.org/content/pediatrics/early/2014/01/22/peds.2013-3793.full.pdf

Evaluating Children With Fractures for Child Physical Abuse

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force “inconclusive” determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

https://pediatrics.aappublications.org/content/pediatrics/early/2016/11/17/peds.2016-3107.full.pdf

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

Importance In early 2020, the United States declared a public health emergency in response to coronavirus disease 2019 (COVID-19) and implemented a variety of social distancing measures The association between the COVID-19 pandemic and the number of pediatric admissions is unclear Objective To determine the changes in patterns of pediatric admissions in 2020 compared with the prior decade Design, Setting, and Participants This cross-sectional study included 49 US hospitals contributing to the Pediatric Health Information Systems database Inpatient admissions were transformed into time-series data, and ensemble forecasting models were generated to analyze admissions across a range of diagnoses in 2020 compared with previous years The setting was inpatient admissions All patients discharged between January 1, 2010, and June 30, 2020, from an inpatient hospital encounter were included Main Outcomes and Measures Number of hospital admissions by primary diagnosis for each encounter Results Of 5 424 688 inpatient encounters among 3 372 839 patients (median [interquartile range] age, 51 [07-133] years; 2 823 748 [521%] boys; 3 171 224 [585%] White individuals) at 49 hospitals, 213 571 (39%) were between January 1, 2020, and June 30, 2020 There was a decrease in the number of admissions beginning in March 2020 compared with the period from 2010 to 2019 At the nadir, admissions in April 2020 were reduced 454% compared with prior years (23 798 in April 2020 compared with a median [interquartile range] of 43 550 [42 110-43 946] in April 2010-2019) Inflation-adjusted hospital charges decreased 277% in the second quarter of 2020 compared with prior years ($4 327 580 511 in 2020 compared with a median [interquartile range] of $5 983 142 102 [$5 762 690 022-$6 324 978 456] in 2010-2019) Seasonal patterns were evident between 2010 and 2019 for a variety of common pediatric conditions, including asthma, atrial septal defects, bronchiolitis, diabetic ketoacidosis, Kawasaki syndrome, mental health admissions, and trauma Ensemble models were able to discern seasonal patterns in admission diagnoses and accurately predicted admission rates from July 2019 until December 2019 but not from January 2020 to June 2020 All diagnoses except for birth decreased below the model 95% CIs between January 2020 and June 2020 Conclusions and Relevance In this cross-sectional study, pediatric admissions to US hospitals decreased in 2020 across an array of pediatric conditions Although some conditions may have decreased in incidence, others may represent unmet needs in pediatric care during the COVID-19 pandemic

/pdf/trends-in-us-pediatric-hospital-admissions-in-2020-compared-596fzywtbi.pdf

Trends in US Pediatric Hospital Admissions in 2020 Compared With the Decade Before the COVID-19 Pandemic.

The epidemiology and risk factors for developmental dysplasia of the hip (DDH) are still being refined. We investigated the local epidemiology of DDH in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening. With a cohort study design, data were prospectively recorded on all live births in our region from January 1998 to December 2008. We compared data on babies treated for DDH with data for all other children. Crude odds ratios (ORs) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables. There were 182 children born with DDH (with a total of 245 dysplastic hips) and 37,051 without. The incidence was 4.9 per 1000 live births. Female sex (adjusted OR 7.2, 95% confidence interval [CI] 4.6–11.2), breech presentation (adjusted OR 24.3, 95% CI 13.1–44.9), positive family history (adjusted OR 15.9, 95% CI 11.0–22.9) and first or second pregnancy (adjusted OR 1.8, 95% CI 1.5–2.3) were confirmed as risk factors (p < 0.001). In addition, there was an increased risk with vaginal delivery (adjusted OR 2.7, 1.6–4.5, p < 0.001) and post-maturity (OR 1.7, 1.2–2.4, p < 0.002). One in 200 children born within our region requires treatment for DDH. Using both established and novel risk factors, we can potentially calculate an individual child’s risk. Our findings may contribute to the debate regarding selective versus universal ultrasound screening. Prognostic Study: Level 1.

/pdf/epidemiology-of-developmental-dysplasia-of-the-hip-within-3i0u2q0aym.pdf

Epidemiology of developmental dysplasia of the hip within the UK: refining the risk factors

Objectives The authors report the results of a selective ultrasound screening programme for congenital dislocation of the hip (CDH) over a period of 20 years, with the aim of defining the rate of screening, conservative treatment and late presentation requiring surgery. Methods All neonates born from June 1988 to December 2008 (inclusive) were included in the prospective cohort, with a minimum follow-up of 12 months. All underwent an early clinical examination of the hips and those with clinical instability were referred for ultrasound at 2 weeks; those with risk factors were sonographically examined at 6 weeks. Risk factors were defined as breech presentation, family history or foot deformity. Results 107 440 live births were clinically examined, 20 344 (18.9%) were referred for ultrasound assessment at either 2 weeks (due to clinical signs) or 6 weeks (due to risk factors). 774 (3.8%) were diagnosed with dysplasia with a crude overall treatment rate of 7.2 per 1000 live births. 37 (0.34 per 1000) presented late, that is, after 12 weeks of age; none had detectable clinical signs or risk factors. There were no false negatives. Conclusion Elective screening for developmental dysplasia of the hip in association with one stop treatment and monitoring is an effective programme. The number of infants referred increased statistically significantly year on year over the study period and generated more activity. Pavlik harness treatment rates remained acceptable and steady over the period, despite the increase in referrals. The incidence of late presenting cases ranged from 0 to 4 per year, with no secular trend and there were no ultrasound false negatives.

https://adc.bmj.com/content/archdischild/97/5/423.full.pdf

Twenty years experience of selective secondary ultrasound screening for congenital dislocation of the hip

Place intraosseous needles carefully and limit fluid infusion to avoid limb ischaemia in children

Amputation and intraosseous access in infants

Background Slipped upper femoral epiphysis is an adolescent hip disorder requiring rapid surgical intervention. Faced with the prospect of their child undergoing surgery, many fearful parents will turn to the internet to provide information and reassurance. Previous studies have shown the orthopaedic information can be difficult to comprehend. Objective Assess the readability of healthcare websites regarding slipped upper femoral epiphysis. Methods The term Slipped Upper Femoral Epiphysis was searched in Google, Bing and Yahoo. The websites were evaluated using readability software with seven specialised readability tests including the Flesch-Kincaid Reading Grade Level, the Flesch Reading Ease Score, the Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index and the Gunning Fog Index. The reading grade level (RGL) was also calculated. A Flesich Read Ease Score (FRES) score above 65 and an RGL of sixth grade and under was considered acceptable. Websites were also assessed for translation services. Results 21 unique websites were assessed. The average FRES was 52.5±15.4. Only 3 websites scored 65 or higher (14%). There was a statistically significant difference between website scores based on affiliation, with physician websites having the overall highest mean(p=0.004). The average RGL was 8.67±1.8. Only two websites met the accepted RGL criteria (9.5%) while five websites were marked as extremely difficult to understand (23.8%). Only five websites offered translations (23.8%). There was no statistically significant difference in readability scores between websites which offered translation and those which did not. One-sample t-tests showed that both the RGL (p Conclusion Most websites reviewed were above the recommended RGL, making content inaccessible. Improving readability and translation services would enhance the internet’s usability as a healthcare tool for parents.

https://bmjpaedsopen.bmj.com/content/bmjpo/4/1/e000782.full.pdf

SUFE and the internet: are healthcare information websites accessible to parents?

Diagnosis and management of developmental hip dysplasia

Postoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance. Traditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures. ISRCTN Registry ISRCTN76410775
 . Retrospectively registered on 30 June 2019.

/pdf/is-postoperative-non-weight-bearing-necessary-inwn-study-21xprdoyow.pdf

Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture.

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