Open thigh muscle lacerations in skeletally immature patients are rare, and evidence on optimal management and outcomes is limited. Among sports, skiing represents a frequent mechanism of injury due to sharp ski edges, yet data on pediatric cases remain scarce. We aimed to describe injury patterns, surgical management, and recovery of pediatric patients with open quadriceps tears. In a retrospective two-center cohort, we included skeletally immature patients with open thigh muscular lacerations treated surgically. Mechanism of injury, contamination status, muscle involvement, and complications were recorded. The Euro Quality of Life 5-Dimension, Pediatric International Knee Documentation Committee (Ped-IKDC), Simple Knee Value (SKV) score, and Tegner Activity score were collected at a minimum 1-year follow-up. Eleven patients (mean age: 13.1 years, range: 7-17) were treated. A total of 73% of the patients experienced a sports-related injury, predominantly sharp ski-edge cuts (55%), and 64% (7/11) presented with contaminated wounds. Vastus lateralis was most frequently involved (55%). One patient presented with an associated sciatic nerve injury. No infections, re-ruptures, or neurovascular sequelae were detected. At the final follow-up, the mean SKV was 93.5%, the mean Pedi-IKDC was 97.6%, and the Euro Quality of Life 5-Dimension 5-Level of Severity was 100%. The return to sport was acceptable with a mean Tegner score of 6.8 (range: 4-9), without reinjuries. Open thigh muscle lacerations in skeletally immature patients - most often related to ski accidents - can be effectively treated with prompt operative exploration, layered repair, short immobilization, and early rehabilitation, resulting in excellent function and full return to sport without reinjury.
This study evaluates the clinical, radiographic, and caregiver-reported outcomes of two palliative hip surgery (PHS) techniques - Egermann resection and Girdlestone resection - in nonambulatory children with cerebral palsy. A retrospective cohort of 30 Gross Motor Function Classification System (GMFCS) V children (41 hips) who underwent PHS between 2014 and 2025 at two tertiary referral centers was reviewed. Proximal femoral migration (PFM) was assessed on anteroposterior pelvic radiographs obtained immediately after surgery, at 6-12 months, and at final follow-up. Clinical outcomes were evaluated using the caregiver-reported Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL-Child), and pain using a visual analog scale. Postoperative complications were recorded and classified according to the Clavien-Dindo-Sink (CDS) system. Both surgical techniques were associated with satisfactory pain relief and caregiver-reported quality of life. At final follow-up, PFM did not reach a statistically significant difference between the two groups (3 ± 20 mm vs 14 ± 18 mm; P > 0.05). Technique 2 was associated with fewer painful heterotopic ossifications requiring surgical revision. The overall complication rate was 32% of hips (13/41), with CDS III complications requiring reintervention in 12% of hips (5/41). Caregiver-reported CP QOL-Child scores were comparable between groups. PHS provides effective pain relief and satisfactory caregiver-reported quality of life in GMFCS V children. Both techniques represent viable palliative options, with distinct profiles of PFM and soft tissue-related complications. Surgical decision-making should be individualized according to patient anatomy and anticipated functional needs.
Open forearm fractures (FFs) are common injuries in pediatric patients with variable management, including operative and nonoperative debridement. In this study, we aim to assess trends in management and determine differences in infection rates and costs between operative and nonoperative management for type I and II open both-bone forearm fractures in pediatric patients. This is a retrospective cohort study utilizing the Pediatric Health Information System database. Patients were included if they were aged 16 or younger and had open forearm fractures between 2018 and 2022. Descriptive statistics, χ2 tests, t -tests, linear regression, and logistic regression were used to assess associations between operative and nonoperative management, infection rates, and costs. A total of 3279 patients were included in this study. Approximately 73% of patients were treated with an operative irrigation and debridement (I&D), and 27% of patients were treated nonoperatively. There was no significant trend in management over the study period ( P = 0.91). Non-White patients and younger patients were more likely to be treated nonoperatively ( P < 0.01). The rate of infection was 2.2% and increased over time ( P = 0.03). There was no difference in infection between operative and nonoperative I&D (odds ratio: 1.10, 95% confidence interval: 0.63-1.94, P = 0.74). However, operative management was significantly more expensive ($13 132 vs. $2930; P < 0.01). There has been no significant change in the management of types I and II open forearm fractures over the past 5 years. While there is no significant difference in the infection rate between patients treated operatively and nonoperatively, operative management is significantly more expensive. LEVEL OF EVIDENCE:Level III.
This study defines normal lower limb morphology in healthy children using computed tomography (CT) to distinguish normal variants from pathological deformities during lower limb growth. Our pilot study showed that measurements of femoral anteversion angle (FAA) and intracanal diameter (ICD) on CT were not feasible under age 6. CT scans were retrospectively analyzed in 172 patients (318 femurs) aged between 6 and 17. Measurements included FAA, ICD, and femoral antecurvatum. The distribution of the parameters according to age, gender, and side comparisons were evaluated. Mean FAA was 19.2 ± 10.4°. Girls had significantly higher mean FAA [23.5 ± 8.5° in girls vs. 18.1 ± 10.5° in boys ( P < 0.001)]. Mean FAA showed a trend of decrease of around 50% as age increased. A total of 2.9% of the study population had femoral retroversion. Right-to-left side difference in FAA was more than 5° in 24.6%, and more than 10° in 3.33% of the study population. The mean ICD increased 56% as age increased. Girls had significantly lower mean ICD as compared with boys [8.7 ± 1.8 mm in boys vs. 7.3 ± 1.9 mm in girls ( P < 0.01)]. Femoral antecurvatum did not change significantly throughout growth. This study provides CT-based normative data on femoral morphology (FAA, ICD, and femoral antecurvatum) in a healthy pediatric population aged 6-18 years. FAA showed a negative correlation with age. Girls had higher FAA but lower femoral antecurvatum and narrower ICD than boys. These findings should be confirmed in larger, longitudinal studies.
Pediatric humeral shaft fractures associated with radial nerve palsy are rare, with an incidence of 4–4.35%. There exists one study on this topic; this systematic review and pooled analysis aim to shift the focus from incidence to recovery, apply patient-level analyses, reassess previously reported associations, identify discrepancies to inform clinical decision-making, and elucidate possible factors associated with poor recovery using exploratory and hypothesis-generating analyses. PubMed, Cochrane Central, and Google Scholar were searched using the following terms: (radial nerve palsy) AND (humerus fracture) AND (pediatrics OR children). Inclusion criteria included case reports, retrospective or systematic reviews, patients aged 1–18 years, and humeral shaft fractures with radial nerve palsy. Exclusion criteria included non-English studies. This yielded 13 studies; 11 provided sufficient data for analysis (32 patients). Oblique fractures were observed more frequently with delayed recovery (>4 months) or no recovery ( P = 0.040). Neurotmesis and fibrosis surrounding the nerve were observed with delayed recovery ( P = 0.002). Closed reduction and fixation were associated with worse nerve outcomes than conservative treatment ( P = 0.013). Patients undergoing nerve procedures were frequently observed with impaired nerve recovery ( P = 0.017). However, when evaluating for ordinal differences in recovery, there was no significant difference (Kruskal–Wallis H test P = 0.282). This review found that, unlike adults, distal and oblique humeral shaft fractures in children are associated more frequently with poorer outcomes of radial nerve injury. Clinicians may consider careful, early assessment of the radial nerve in displaced, distal, oblique humeral fractures.
Pediatric physeal fractures of the distal tibia are a complex and clinically significant subset of pediatric orthopedic injuries. In this study, we aimed to determine the incidence of physeal pathologies and their correlation with fracture patterns, treatment methods, and patient age within a substantial patient cohort. Prospectively recorded medical charts of 54 children who were followed for an average of 6.1 (range, 3-11.5) years were retrospectively evaluated. Thirty-one (57%) patients had sustained Salter-Harris type 1 and 2 fractures, seven had type 3 fractures, and 16 (27%) had simple or triplane type 4 fractures. Thirty-eight (70%) of the patients underwent surgery. Premature physeal closure (PPC) was detected in 14 (26%) patients. American Orthopedic Foot and Ankle Society scores were good and excellent in 52 (96%) patients and moderate in 2 (3.8%) patients. The patients who experienced PPC were significantly younger at the time of injury, with a mean age of 10.3 ± 3 years, compared to 11.9 ± 2.3 years for those who did not sustain PPC ( P = 0.04). In addition, the time to union was significantly longer for patients who experienced PPC ( P = 0.03). The mean time to union was 51.7 ± 42.2 days (ranging from 30 to 160 days) for patients with PPC, while it was 36.7 ± 9.9 days (ranging from 25 to 70 days) for those without PPC. Delayed union and younger age at the time of injury are associated with an increased risk of PPC. However, PPC does not significantly impact clinical outcomes during mid-term follow-ups.
In-situ screw fixation (ISSF) is the gold standard for treatment of slipped capital femoral epiphysis (SCFE). While central screw placement within the epiphysis is known to reduce the risk of intra-articular penetration, the impact of the screw starting point on the proximal femur and the resulting screw trajectory relative to the proximal femoral physis on radiographic or clinical outcomes remains unclear. This study evaluated whether screw starting point or inclination affects outcomes following ISSF. A retrospective review was performed of SCFE patients treated with ISSF at a single institution between 2008 and 2023. Demographic data, postoperative hip pain, early complications, and reoperations were recorded. Radiographic parameters included screw starting point, screw inclination angles, Southwick angles, number of threads crossing the physis, and epiphyseal screw position. Screw starting points were either anterior screw starting point (ASSP) or lateral screw starting point (LSSP). Outcomes were compared between groups. A total of 177 patients had a mean follow-up of 36 months. ASSP was identified in 83 hips and LSSP in 94 hips. The ASSP group demonstrated a more orthogonal trajectory on both anteroposterior (AP) and lateral views (P < 0.05). The middle third of the epiphysis was engaged more frequently on AP and lateral radiographs in the LSSP group. No significant differences were found in hip pain, complication rates, or reoperations between groups. Although ASSP yields a more orthogonally placed screw relative to the proximal femoral physis compared with LSSP, the overall screw starting point and the orthogonal relationship of the screw to the physis do not impact clinical outcomes or reoperation rate. LEVEL OF EVIDENCE:Level IV.
The optimal management of minimally displaced pediatric lateral humeral condyle fractures remains controversial because some fractures may displace or heal late despite apparently stable initial radiographs. This study aimed to identify radiographic predictors of instability and delayed union in conservatively treated fractures. We retrospectively reviewed 58 children with lateral humeral condyle fractures treated nonoperatively between 2019 and 2024 using a standardized radiographic protocol including anteroposterior, lateral, and internal oblique views. Serial displacement, time to radiographic union, and complications were analyzed. Predictors of displacement progression and delayed union were evaluated using multivariable analyses. Radiographic union was achieved in 57 of 58 fractures (98.3%). Clinically relevant displacement progression (≥1 mm) occurred in six patients (10.3%). The presence of a radiographic articular gap strongly predicted displacement progression (odds ratio = 12.0, 95% confidence interval = 1.80-80.05, P = 0.019) and was associated with major complications ( P < 0.001). Initial displacement greater than or equal to 2 mm was associated with longer time to union (29.7 ± 5.3 vs. 24.6 ± 4.2 days; P = 0.001) and independently predicted delayed union (+4.75 days, P = 0.008). All major complications occurred in fractures with initial displacement greater than or equal to 2 mm. Most minimally displaced lateral humeral condyle fractures treated conservatively achieve reliable union. However, fractures demonstrating an articular gap or displacement approaching 2 mm represent a higher-risk subgroup prone to displacement progression, delayed union, and complications. Incorporating these radiographic markers into initial assessment may help guide surveillance intensity and treatment decisions in pediatric patients. LEVEL OF EVIDENCE:Level III - retrospective cohort study.
Pelvic fixation is frequently used in posterior spinal fusion for neuromuscular scoliosis (NMS) to improve alignment and construct stability, particularly with significant pelvic obliquity. However, concerns remain regarding its association with increased surgical complexity and postoperative morbidity. This study compared short- and long-term postoperative outcomes between pediatric NMS patients who underwent posterior spinal fusion with and without pelvic fixation. A retrospective cohort study was conducted using the TriNetX Research Network, a federated database aggregating deidentified electronic health records from 106 healthcare organizations. Pediatric patients (≤21 years) with NMS who underwent posterior spinal fusion with or without pelvic fixation were identified. Before matching, 985 patients had undergone pelvic fixation, and 1492 had not. Following 1 : 1 propensity score matching, 592 matched pairs were retained for analysis. Matching controlled for differences in demographics, comorbidities, number of vertebral levels fused, and neuromuscular diagnosis. Postoperative complications were assessed at two time windows: short-term (1-365 days) and long-term (≥365 days). Pelvic fixation was associated with significantly higher short-term complication rates, including postoperative infections and wound breakdown. Mortality did not differ significantly between groups in either follow-up period. No statistically significant differences were observed in long-term complication rates, including pseudoarthrosis, revision surgery, and additional instrumentation. Pelvic fixation in pediatric posterior spinal fusion for NMS is associated with increased short-term morbidity, particularly wound complications and infections, which can affect recovery. Long-term outcomes, including hardware failure, pseudarthrosis, and revision, were comparable between groups. Careful perioperative management and counseling are essential when pelvic fixation is planned.
This review aims to evaluate the treatment and outcomes of femur fractures in children with cerebral palsy (CP). Femur fractures are common in this population because of physiological and mechanical factors. Treatment approaches vary based on functional status and fracture characteristics. Medline, Embase, Central, and Scopus databases were systematically searched for studies investigating outcomes following femur fractures in children aged 0-18 with CP who received surgical or nonsurgical treatment. Primary outcomes were fracture location, ambulatory status, treatment types, and complications. A meta-analysis was conducted when data homogeneity permitted, using mean differences for continuous outcomes and risk ratios for dichotomous outcomes. Of 213 screened articles, seven were included, reporting 335 femur fractures in 258 patients. Most fractures occurred in the distal femur (52%) followed by mid-diaphyseal fractures (32%). Treatment varied by ambulatory status and fracture location, with 60% managed nonoperatively, typically in nonambulatory patients and for distal fractures. Nonoperative treatment, mainly spica casting, showed higher malunion rates (29%) and complications like pressure sores (11%). In contrast, operative treatment, preferred for proximal and mid-diaphyseal fractures, resulted in lower malunion rates in nonambulatory children (7%; P = 0.02) but had risks of postoperative pneumonia (6%) and surgical site infection (13%). Outcomes indicated improved healing and function with operative treatments in ambulatory children. Femur fractures in children with CP require individualized treatments based on the patient's fracture type and ambulatory status. Future studies should incorporate fracture mitigation metrics, functional outcomes, and caregiver impact to inform optimal patient-centered care.
After the osteosynthesis of congenital pseudarthrosis of the tibia (CPT), an intramedullary rod is usually left behind to prevent refracture. However, whether a nonelongating rod may fulfill this goal or an elongating rod has a superior effect is not known. We investigated the outcomes of nonelongating rod installations and attempted to assess potential benefit and disadvantage of an elongating rod installation. A retrospective study was performed on 37 cases of CPT in 29 patients in which a nonelongating rod remained in situ after successful osteosynthesis. The temporal and spatial patterns of refracture after osteosynthesis were analyzed by reviewing serial radiographs and medical records. Elongating rod installation was simulated using preoperative radiographs to determine whether an additional osteotomy was necessary. The mean age of the patients at the index operation was 4.4 ± 2.2 years. Fourteen out of 37 cases sustained refractures at an average of 30.6 months postoperation (range = 7-69). Refractures occurred in areas protected by an indwelling nonelongating rod in all cases. Thirteen of 14 refractures occurred at the previous pseudarthrosis or fracture site. If an elongating rod were to be installed, an additional osteotomy would have been required in 11 out of 37 cases (29.7%) because of proximal segment angular deformity. The findings suggested no clear evidence that an elongating rod would have prevented refracture, while potentially increasing procedural complexity. Hence, the role of elongating rods in the management of CPT warrants further comparative investigation. LEVEL OF EVIDENCE:Therapeutic studies, Level IV.
Distal femoral hemiepiphysiodesis is a minimally invasive procedure used to correct pediatric knee angular deformities by guiding growth across an open physis. Intraoperative fluoroscopy is used to estimate the physeal midpoint for hardware placement; however, no standardized radiographic method has been established to identify this landmark. The purpose of this study was to determine the accuracy and reliability of three novel radiographic landmarks for approximating the distal femoral physeal midpoint. Perfect lateral digitally reconstructed radiographs of the knee were generated from computed tomography scans of pediatric patients using open-source image computing software. The physeal midpoint was identified and compared with three radiographic landmarks: the diaphyseal midpoint, the apex of the physeal undulation, and the inferior point of Blumensaat's line. The anteroposterior distance between each landmark and the physeal midpoint was measured, and intraclass correlation coefficients (ICCs) were calculated to assess reliability. Twenty-seven (71% male and 29% female) patients with a mean age of 13.6 ± 1.7 years were included. Relative to the physeal midpoint, the diaphyseal midpoint was 4.0 ± 2.4 mm anterior, the apex undulation was 1.6 ± 1.2 mm anterior, and the inferior Blumensaat's point was 1.2 ± 1.3 mm posterior. Reliability was good for the diaphyseal midpoint (ICC = 0.799) and apex undulation methods (ICC = 0.889), and excellent for the Blumensaat landmark (ICC = 0.987). These findings suggest that multiple radiographic landmarks can reliably approximate the distal femoral physeal midpoint on perfect lateral radiographs. The inferior point of Blumensaat's line demonstrated the greatest accuracy and reliability and may serve as a useful intraoperative guide for hardware placement during distal femoral guided growth procedures. LEVEL OF EVIDENCE:Level III.
To evaluate clinical outcomes, return to sport, complications, and reoperation rates associated with three internal fixation methods for unstable juvenile osteochondritis dissecans (JOCD). A retrospective review was conducted of patients less than or equal to 18 years with unstable JOCD who underwent internal fixation and had more than 1 year of follow-up. Fixation methods included metal screws ( n = 13), Smart Nails ( n = 15), and hybrid fixation ( n = 15). Demographic data, radiographic healing, complications, and reoperations were documented. Functional outcomes were assessed using Lysholm and Pediatric International Knee Documentation Committee Scales. Forty-three knees from 40 patients (26 males) were evaluated. The average age was 15.1 years (SD = 1.8 years) with a follow-up of 74.8 months. Healing occurred in 88.4% (38/43) of the knees after surgery. Complications were observed in 9.3% of the cases, including synovitis ( n = 3)and screw breakage ( n = 1). Ninety-three percent of the patients returned to sports within an average of 7.9 months (SD = 2.7 months). Fifty-three percent of the participants required a second intervention. Smart Nails were associated with a higher complication rate, whereas metal screws showed higher reoperation rates, primarily because of elective implant removal. Healing rates and functional outcomes were comparable across lesion location, fixation method, growth plate status, and lesion grade. Internal fixation for unstable JOCD in adolescents shows a high healing rate and a low rate of complications, with most patients successfully returning to sports within a year. Nevertheless, a significant reoperation rate, mainly for elective hardware and loose body removal, should be considered in patient management plans. Level of Evidence: III
Adolescent idiopathic scoliosis (AIS), characterized by an abnormal curvature of the spine, is a prevalent condition among adolescents with a multifactorial etiology involving genetic, hormonal, and environmental influences. Recent studies have proposed the potential involvement of vitamin D in scoliosis pathogenesis; this study aimed to explore that possible association. A case-control analysis was conducted involving 177 adolescents aged 10–18 years, comprising 73 patients diagnosed with AIS and 104 controls. Anthropometric data (age, gender, height, weight, BMI, and Cobb angle) and biochemical markers [25-hydroxyvitamin D, calcium, phosphorus, parathyroid hormone (PTH), blood urea nitrogen, creatinine, and alkaline phosphatase] were collected and compared. While the mean serum vitamin D level was lower in AIS cases (26.4 ng/ml) than in controls (28.8 ng/ml), this difference did not reach statistical significance ( P = 0.096). However, categorical analysis revealed a significantly higher proportion of vitamin D deficiency among AIS cases (21.9%) than among controls (10.6%), with an unadjusted odds ratio of 2.37 (95% confidence interval: 1.03–5.47; P = 0.043). This association lost statistical significance after adjustment for confounders, including gender, BMI, and PTH levels, in a multivariate logistic regression model. These findings suggest that vitamin D deficiency alone may not be a direct causative factor in AIS. The results also underscore the importance of accounting for confounding factors such as hormonal markers, body composition, and gender. Further research, especially in diverse populations, is needed to clarify the role of vitamin D in the pathogenesis and clinical management of AIS. Level of Evidence Level III.
Chronic hematogenous osteomyelitis (CHOM) of long bones in children remains a major clinical challenge in low- and middle-income countries. The Beit CURE classification has been used to guide treatment, but its reliability across different centers and raters has not been established. Forty-four children with CHOM were evaluated using digital radiographs by 16 fellowship-trained pediatric orthopedic surgeons from five continents. All the raters were trained in Beit CURE classification and assessed each case twice, 4 weeks apart. Interobserver and intraobserver reliability were calculated using intraclass correlation coefficients (ICCs). The raters also predicted anticipated surgical management and the number of procedures needed. Interobserver reliability was fair overall (ICC: 0.467, 95% confidence interval: 0.36–0.59). Agreement was highest for types A and B4 (>80% consensus) and lowest for types B2, B3, and C (<25%). The reliability for growth plate involvement was moderate (ICC: 0.628) and was poor for site involvement (ICC: 0.269). Predictions regarding surgical planning were inconsistent, especially for B2, B3, and C lesions. The Beit CURE classification demonstrated only limited reproducibility among experienced pediatric orthopedic surgeons. While types A and B4 were reliably identified, other subtypes showed poor agreement, undermining clinical decision-making. Refinements – such as merging B2 and B3, providing clearer definitions of sclerosis and involucrum quality, and integrating clinical parameters – are needed before the Beit CURE classification system can serve as a reliable guide for treatment planning. Level of Evidence Level 2.
Displaced lateral humeral condylar fractures in children require anatomical reduction and rigid fixation because they are intraarticular fractures, and inappropriate treatment causes late complications. Although the tension band wiring technique can offer stronger stability for the fracture site than wires alone, subcutaneously buried wires require a second operation for removal. The purpose of this retrospective study was to compare surgical outcomes using buried tension band wiring (necessity of a second wire removal operation, group T-B), nonburied wires and buried strong suture material (wire removal at an outpatient clinic, group T-NB), and pinning (group P) at three institutions. Sixty-three patients were included in this study (24, 24, and 15 in the T-B, T-NB, and P groups, respectively). Clinical and radiological assessments were performed. Bony union was observed in all patients. There were no significant differences in the clinical outcomes regarding the range of elbow motion and the functional and cosmetic Flynn criteria. There was a significant difference in the number of operations under general anesthesia (2 ± 0 in group T-B, 1.1 ± 0.3 in group T-NB, 1 ± 0 in group P). Delayed union was observed in group P (0/24 in groups T-B and T-NB, and 6/15 in group P). Surgical site infection requiring surgical debridement occurred in two patients in the group T-NB. The three surgical techniques showed equivalent clinical results. The buried tension band wiring technique could be superior among the three techniques because it showed fewer complications, including delayed union and infection.
To systematically evaluate the accuracy, reliability, and clinical applicability of artificial intelligence and large language models (LLMs) in pediatric orthopedics, comparing their performance against established clinical guidelines and assessing their utility for patient education and clinical decision support. A search of PubMed and ScienceDirect (2020-2025) identified 2624 articles using the keywords 'ChatGPT', 'Gemini', 'Claude' and 'orthopedic pediatrics'. After screening and refinement using Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, 15 studies met inclusion criteria. Studies evaluated ChatGPT, Google Gemini, Meta AI, Microsoft Copilot, and Claude across multiple pediatric orthopedic conditions across conditions like developmental dysplasia of the hip, slipped capital femoral epiphysis, and scoliosis. Heterogeneity was assessed using Cochran's Q and I2 statistics, and publication bias was evaluated using funnel plots and Egger's test. LLM accuracy ranged from 44.3 to 93% (pooled: 74.1%), with pooled accuracy of 74.1%. Reproducibility was moderate, with ChatGPT demonstrating a Spearman coefficient of 0.55 for complex queries. Regional expert consensus scores varied significantly (Europe: 80, North America: 65; P = 0.034; Fleiss\kappa = 0.113). Up to 33% of responses to guideline-based questions were rated neutral or inaccurate. Reading complexity was elevated (Flesch-Kincaid grade: 12.7), exceeding the recommended sixth-grade level. Parent surveys indicated 82% trust in artificial intelligence as supplementary tools with professional oversight. Minimal statistical heterogeneity was observed (I2 = 0.00%), though publication bias was detected (Egger's test P = 0.0001). LLMs show potential for education and triage but lack consistency in complex scenarios, elevated reading complexity, and significant regional variability in expert assessments. These tools should be used as educational supplements under professional medical supervision rather than for independent clinical decision-making. Broader clinical application requires domain-specific tuning, standardized evaluation, and readability optimization. LEVEL OF EVIDENCE:Level V- systematic review.
Epiphyseal fractures of the proximal phalanx of the hallux are rare in pediatric patients. While various management techniques exist, studies detailing outcomes, complications, and pathogenic mechanisms of Salter-Harris (S-H) 3 and S-H 4 fractures in children are limited. This study evaluates the radiographic, clinical, and functional outcomes of pediatric patients with these injuries and identifies potential risk factors for adverse results. A retrospective review was conducted on 11 pediatric patients diagnosed with S-H 3 and S-H 4 fractures. Demographics, injury mechanisms, and treatment modalities were collected. Radiographic and clinical evaluations assessed fracture healing, range of motion (ROM), and the presence of premature physeal closure (PPC) or other complications over multiple follow-up intervals. The cohort included six S-H 3 and five S-H 4 fractures (mean age: 12.9 years). Mean follow-up was 6.5 ± 3.7 for S-H 4 and 8.5 ± 3.9 years for S-H 3 fractures. Ten cases with displacement less than 2 mm underwent closed reduction and Kirschner (K) wires fixation; one case (>2 mm displacement) required open reduction and a 2.0 mm compression screw. All patients achieved satisfactory radiographic healing without PPC or angular deformity. Clinically, most regained near-normal ROM without major complications such as joint incongruity or infection. Surgical treatment of S-H 3 and S-H 4 hallux fractures using closed reduction and K-wires is safe and effective, ensuring stable fixation and favorable long-term outcomes. PPC rarely results in malalignment because these fractures typically occur when skeletal growth is nearly complete.
Internal rotation contractures of the shoulder are common sequelae of obstetric brachial plexus palsy (OBPP) and can markedly impair upper limb function. Although arthroscopic capsular release improves passive range of motion (ROM), tendon transfer may be needed to improve active external rotation and abduction. This study compared clinical and functional outcomes after isolated arthroscopic release versus arthroscopic release combined with latissimus dorsi tendon transfer. Thirty-two pediatric patients surgically treated for OBPP-related shoulder contracture between 2018 and 2024 were retrospectively analyzed. Group A (n = 18) underwent isolated arthroscopic capsular release, whereas group B (n = 14) underwent arthroscopic release with simultaneous latissimus dorsi tendon transfer. In all patients, the subscapularis muscle was preserved, and only the anterior capsule was released. ROM and functional test scores (hand-to-neck, hand-to-abdomen, hand-to-mouth) were assessed preoperatively and at 1-year follow-up by the same clinician. Both groups demonstrated significant postoperative improvements in shoulder ROM. External rotation and abduction increased significantly in both groups, with a greater abduction gain in group B (P = 0.007). Internal rotation was preserved postoperatively in both groups and improved significantly in group A (P = 0.011). Functional scores showed mild improvements in both groups, but none reached statistical significance. Arthroscopic capsular release is an effective, minimally invasive option for shoulder contractures secondary to OBPP. In appropriately selected patients, simultaneous latissimus dorsi tendon transfer may provide additional improvement in active shoulder abduction without causing a clinically relevant loss of internal rotation. Preservation of the subscapularis muscle helps maintain postoperative internal rotation function.
Pediatric spine deformity surgery in the prone position predisposes patients to pressure-related complications, ranging from ulcers to perioperative vision loss (POVL). Previous studies have identified that Gardner-Wells tongs with 15 lbs. of vectored traction at 45° elevation above horizontal can minimize facial pressure. We hypothesized that vectored traction would lead to a complication rate significantly lower than reported in the literature. Medical charts of 3088 consecutive patients undergoing spinal deformity surgery between 2008 and 2023 at a single site were queried. Cases in patients aged 2-18 years lasting more than 2 h (2680 patients) were included after confirming Gardner-Wells tong use. Charts were queried using complication-related keywords, and mean surgical time was compared between patients with and without complications (α = 0.05). A total of 38 (1.42%) cases had pressure-related complications: 17 facial abrasions (44.7%), 12 pressure sores/ulcers (31.6%), and nine instances of facial swelling (23.7%). There were no cases of POVL, cellulitis, abscess, or local infection. Complications were associated with longer surgery time (409 vs. 308 min; 95% confidence interval = 38.2-163.8; P < 0.005). Pressure-related complications were much lower with vectored traction compared with previous reports without facial elevation. All complications were minor and reversible, and POVL was not observed. Vectored traction with Gardner-Wells tongs is a safe and effective intervention for minimizing facial pressure during prone spine surgery. LEVEL OF EVIDENCE:Level IV.
