The case of a sternal injury in an adolescent who went on to develop painful arthritis of the manubriosternal joint is presented. This was treated with plating and arthrodesis of the arthritic joint with the assistance of the general surgery team.

INTRODUCTION:Pediatric femur fractures are treated with rigid intramedullary nails, flexible intramedullary nails, and plates, which are usually removed after fracture union. This study aimed to analyze complications, estimated blood loss (EBL), length of stay, and operative times for implant removal after successful surgical management of pediatric diaphyseal femur fractures. METHODS:After IRB approval was received, data were collected from pediatric patients at a major level I trauma center from 2008 to 2023. Fixation types were separated based on flexible nail, rigid nail, and plating. Postoperative complications included wound dehiscence, wound abscess, infection, and hematoma. RESULTS:Admission rates were higher for the rigid nail group than for the flexible nail group. No difference was found for admission rates between the plate and nail groups. In terms of OR time, plates were the longest at 63 minutes on average, rigid nails at 58 minutes, and flexible nails at 36 minutes. EBL was greater for plate removal than for all nail removal, and greater for rigid nail removal than for flexible nail removal. Bony overgrowth was on the implant in 17 nail and 8 plate patients. It was statistically higher in the rigid nail group compared with the flexible nail group. Time between fixation and removal was greater for the nail group than the plate group. When comparing flex nails to rigid nails regarding time to removal, this remained significant (9.4 and 12.4 mo, respectively; P <0.0001). There was one incidence of refracture, which occurred in the flexible nail group. CONCLUSION:Operative time and EBL were higher for plate-removal patients. Bony overgrowth and time between fixation and removal were significantly higher for the nail group. Eleven intraoperative complications and 8 postoperative complications were documented for the nail-removal patients; none were documented intraoperatively or postoperatively for the plate-removal patients. Refracture in the short-term follow-up period was very low. SIGNIFICANCE:Implant removal following pediatric femur fractures has a low complication rate, with greater operative time and EBL for plates. LEVEL OF EVIDENCE:Level III.

Background: In the United States, the number of pediatric fractures treated in ambulatory surgery centers (ASCs) continues to increase. Few studies have compared the outcomes and complications of treating these injuries in a freestanding ASC versus in a hospital setting. The purpose of this study was to compare clinical and radiographic outcomes, treatment times, and costs for treatment of pediatric foot and ankle fractures in the ASC and hospital. Methods: A retrospective review identified pediatric patients with isolated, closed, and acute (below 3 wk) distal tibia, ankle, or foot fractures who underwent closed reduction in an operating room or operative fixation between January 2015 and December 2019. The patients were divided into 2 groups: ASC and hospital. Medical records were reviewed for patient demographics, mechanism of injury, surgical time, facility time, costs for treatment, and complications. Preoperative and postoperative alignment was assessed on radiographs. Clinical outcomes included pain, weight-bearing, or deformity at final follow-up. Multivariable generalized linear models and logistic regression were used to determine the association between surgical setting and treatment outcomes, times, and costs. Results: Two hundred and twenty-three patients were identified; 115 treated in the ASC and 108 treated in the hospital. Adjusted for age at treatment, injury type, procedure performed, and preoperative alignment, there were no differences in surgical time, clinical or radiographic outcomes, or complications between groups. The mean total operating room time, total facility time, and total charges were significantly lower in patients treated in the ASC than in the hospital. Conclusion: Pediatric distal tibia, ankle, and foot fractures can be safely treated in an ASC with equivalent outcomes and complications compared with those in a hospital setting. Benefits include shorter total surgical and facility times as well as decreased cost of care. These findings could allow for patients to receive more timely and efficient treatment with less financial burden. Level of Evidence: Level III—therapeutic.

Background:The use of advanced imaging in children is increasing and unexpected findings (UFs) are often detected. The present literature lacks studies investigating the rate of UFs in pediatric lumbar spine magnetic resonance imagings (MRIs) and the sequelae of these findings. This study aimed to determine the overall incidence of UFs in adolescent lumbar MRIs, characterize these findings, stratify UFs based on patient characteristics, and determine any influences on patient treatment plans. Methods:Medical records of 1409 patients aged 10 to 18.5 years old that had a lumbar MRI ordered by an orthopaedic surgeon from 2010 to 2020 were reviewed retrospectively. Demographics, insurance, reason for MRI, and change in treatment plans were noted. Unexpected findings were characterized as spinal cord, infra-peritoneal, retroperitoneal, peritoneal, or vascular-related. The relationship between patient characteristics and UFs was investigated using a t test and Chi-square test. The statistical relationships between UFs and treatment plan changes were evaluated using generalized linear models with a log link and a binomial error distribution. Results:The average age of the 1409 patients was 15.5 years (95% CI: 15.4, 15.6). Back pain (90.1%) was the most common reason for lumbar MRI. Thirty-five UFs were found in 33 patients (2.3%): 19 were spinal cord-related, 15 were peritoneal-related, and one was vascular. Eight peritoneal findings involved the kidneys: two atrophy, two hypoplasia, two renal cysts, one pelvic kidney, and one hydronephrosis. Five patients had a syrinx, and two had spine tumors. Out of 33 patients with UFs, 11 required a change in treatment plan (33.3%). Back pain was not associated with an increased risk of UF. Patients with an UF on MRI had 2.60 times higher odds of experiencing a change in treatment plan. Conclusions:The prevalence of UFs was 2.5% on lumbar MRIs and were mainly spinal cord or retroperitoneal-related. UFs were associated with an altered treatment plan 33% of the time and were unrelated to standard demographic characteristics or insurance type. Key Concepts:(1)Overall, 33.3% of patients with an unexpected finding had a change in treatment plan.(2)Unexpected findings should be interpreted in the context of the patient's overall clinical picture, symptoms, and health to help elucidate the next steps in treatment.(3)The clinical significance of unexpected findings needs to be further studied. Level of Evidence:Level III, Retrospective.

Background: Starting in 2021, the Centers for Medicare and Medicaid Services and the American Medical Association revised the Evaluation and Management (E&M) criteria of the Current Procedural Terminology coding selection. This retrospective study determined the changes in E&M coding level for pediatric orthopaedic patients and examined the effect of the changes on percentage of work relative value units (wRVUs) from clinic and surgery. Methods: Coding levels for all outpatient visits at our institution were analyzed from 2020, January 2021, December 2021, and January 2023. The total number of pediatric orthopaedic visits were collected, tabulated under the corresponding E&M code, and expressed as a percentage of total E&M codes within the corresponding time frame. The total change in wRVU generated from the E&M coding changes was compared between the clinic and operating room by examining the total average coding and percentage of total average for each group and the overall total and total percentage change in wRVUs. Results: There was a statistically significant difference in level of coding for both established and new patients from 2020 compared with January 2021, December 2021, and January 2023. Established patients showed a large decrease in level-2 visits and a complimentary increase in level-3 visits. New patients demonstrated a statistically significant increase in level-4 visits, which was sustained at the 2-year mark. From 2020 to 2021, there was a 29% increase in percentage of wRVUs from clinic, and a 6-point increase in wRVUs from clinic compared with surgery. Conclusions: Our study found an increase in level of coding after the E&M guideline changes, especially for new patients. This finding does not indicate that there were more complex pediatric orthopaedic cases but rather the new E&M guidelines accurately captured the complexity of each visit. There was a substantial increase in wRVUs from clinics, comparing immediately before and after the guideline change, which was largely sustained at the 2-year mark. Key Concepts: (1) This study is important because it highlights specific specialty information for pediatric orthopaedic surgeons before and after the evaluation and management (E&M) guideline changes. (2) It is vital for pediatric orthopaedic surgeons to understand and appropriately apply the guidelines to each patient visit to ensure accurate coding. (3) Our study was the first to demonstrate the changes in level of coding after the E&M guidelines changed, and the effects of percent of work relative value units originating from clinic encounters. Level of Evidence: Level III, retrospective case control

Background: Although proximal femoral locking compression plates (PF-LCP) have been used with increasing frequency in the fixation of proximal femoral fractures in the pediatric population, there is a lack of literature regarding their use. The purpose of this study was to examine the failure rates of PF-LCP fixation in comparison to other accepted fixation methods within a pediatric population. Methods: Retrospective review identified consecutive children treated for proximal femoral fractures from September, 2008 to February, 2019, who had a minimum follow-up of 12 weeks. Patient charts and radiographs were reviewed, and demographic information was compiled. In the case of failures, timing and method of failure were documented. Results: Sixty-four proximal femoral fractures (61 children) were studied. The average age at the time of presentation was 10.4 years. Twenty-six fractures were treated with PF-LCPs and 38 with other fixation methods (compression hip screws, rigid locked intramedullary nailing, cannulated screws, or a combination of hip screw side plate and intramedullary nailing). Failure occurred in four of the 26 fractures treated with locking compression plating (15.4%), compared to none of the 38 treated with other fixation types (p<0.05). Conclusions: This study demonstrates an increased risk of failure in proximal femoral fractures treated with locking compression plates (12.9%) compared to 0% other fixation methods (no failures). As a result of this study, we no longer use locked plating systems for pediatric femoral neck fractures at our institution.

BackgroundGunshot injuries are the leading cause of death among children in the United States. The goal of this study was to better understand if certain age groups, mechanisms of injury, and type of firearms were associated with the increasing rates of pediatric gun-related trauma. We hypothesized that the extremities were disproportionately targeted when compared with the random likelihood of striking specific body-surface areas.MethodsThis study includes pediatric firearm-related injury (FRI) patients who presented to a single free-standing level 1 pediatric hospital or died at the scene from 2010 to 2021. The hospital data was collected prospectively as part of a level 1 trauma system electronic database. Death data was collected from the local coroner’s office.ResultsBetween 2010 and 2021, 1,126 pediatric FRI occurred in the geographic region studied. Demographic information available for 1,118 patients showed that 897 (80.23%) were male, and that black individuals had a statistically significant increased rate of FRI compared with white or Hispanic individuals. Mean age was 13.69 years. Most injuries were caused by handguns.ConclusionsThis data could help leaders design strategies to combat the violence, such as legislation that limits handgun access to all, especially children, and mandates safe storage of handguns. Gun-lock programs, universal background checks, and firearm-ownership education also might help stem this tide of violence.Level of EvidenceLevel II Prognosis study

Current technologies for image guidance navigation and robotic assistance with spinal surgery are improving rapidly with several systems commercially available. Newer machine vision technology has several potential advantages. Limited studies have shown similar outcomes to traditional navigation platforms with decreased intraoperative radiation and time required for registration. However, there are no active robotic arms that can be coupled with machine vision navigation. Further research is necessary to justify the cost, potential increased operative time, and workflow issues but the use of navigation and robotics will only continue to expand given the growing body of evidence supporting their use.

Background: The American Society of Anesthesiologists (ASA) recommends fasting before surgery: clear liquids (2 hrs), breast milk (4 hrs), light meal (6 hrs), and fried foods/fatty foods/meat (> 8 hrs). In emergencies, guidelines are bypassed for timely surgical intervention. Pediatric post-anesthesia complications caused by violating fasting guidelines remain controversial. The aim of this study was to compare the risk of post-anesthetic complications in patients who met and did not meet ASA fasting guidelines for pediatric orthopaedic emergency procedures.Methods: Patients were retrospectively identified who had emergent procedures at a level 1 pediatric trauma center from 2010 to 2020. Patients were divided into two groups: those meeting current ASA fasting criteria of fasting and those who did not. Charts were reviewed for complications of gastric content aspiration during or following anesthesia.Results: There were 321 patients who met inclusion criteria for emergency orthopaedic surgeries. Of these, 264 (82%) met fasting guidelines, and 57 (18%) did not. One patient who met preoperative fasting status needed postoperative supplemental oxygen and met criteria to be reported as an adverse event. Of the 57 patients not meeting fasting guidelines, there were no anesthesia-reported adverse events.Conclusions: No increased risk was found with anesthesia in nonfasted patients with orthopaedic emergencies undergoing general anesthesia during the perioperative period in this underpowered, pilot study. No respiratory complications (pulmonary aspiration, intraoperative or postoperative emesis, or postoperative respiratory support) were reported in patients who did not meet fasting guidelines. The authors believe this is a valuable starting point for further research into fasting criteria in pediatric trauma patients.Level of Evidence: IIIKey Concepts•No increased risk was found with anesthesia in nonfasted patients with orthopaedic emergencies undergoing general anesthesia during the perioperative period.•Modern anesthesia techniques are tailored to minimize risk of pulmonary aspiration in patients with unknown fasting status.•The rate of pulmonary complications following modern anesthesia in children remains so small as to suggest that additional research is needed to determine if fasting guidelines are truly necessary in the majority of cases or if other factors beyond the time since last oral intake should be more carefully considered.

Background:Exposure to ionizing radiation in patients with Multiple Hereditary Exostoses (MHE) is inevitable and necessary for the diagnosis and treatment of MHE. Radiation exposure has many potentially dangerous consequences, including the increased risk of developing cancer. This is especially concerning in the pediatric patient population since children are more likely to develop adverse effects from radiation than adults. This study aimed to quantify radiation exposure over a five-year period among patients diagnosed with MHE since such information is not currently available in the literature. Methods:Diagnostic radiographs, computed tomography (CT) scans, nuclear medicine studies, and intraoperative fluoroscopy exposures were analyzed for radiation exposure in 37 patients diagnosed with MHE between 2015 and 2020. Results:Thirty-seven patients with MHE underwent 1200 imaging studies, 976 of which were related to MHE and 224 unrelated to MHE. The mean estimated MHE cumulative radiation dose per patient was 5.23 mSv. Radiographs related to MHE contributed the most radiation. Patients from the ages of 10- to 24-years-old received the most imaging studies and exposure to ionizing radiation, especially compared to those under age 10 (P = 0.016). The 37 patients also received a total of 53 surgical-excision procedures, with a mean of 1.4 procedures per person. Conclusions:MHE patients are exposed to increased levels of ionizing radiation secondary to serial diagnostic imaging, with those ages 10-24 years old being exposed to significantly higher doses of radiation. Because pediatric patients are more sensitive to radiation exposure and are at an overall higher risk, the use of radiographs should always be justified in those patients.

This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice. Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate. Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis . Treatment depends on the degree of curvature, skeletal maturity, and age of the patient. Once the curve reaches 50 degrees, posterior spinal fusion (PSF) is necessary to stabilize the spine and prevent further progression of the curve. PSF causes significant trauma to the tissues and often results in significant pain postoperatively. The purpose of this article is to provide the audience with a review of preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF.

We reviewed pediatric open fractures treated at a large Level 1 children's trauma center to determine the rate of infection after open fractures, potential risk factors for infection, and the rate of infection caused by antibiotic-resistant organisms. A retrospective review identified 288 open fractures in children 1 to 17 years of age. Post-traumatic infections developed in 24 (8.3%) open fractures. There was no significant association between the development of infection and mechanism of injury (p = 0.33), time to surgical debridement (p = 0.93), or type of empiric antibiotic given (p = 0.66). Infection occurred more frequently in overweight and obese patients (odds ratio = 2.22; 95% confidence interval: 0.93, 5.46, p = 0.07). There was one infection (4.2%) caused by methicillin-resistant staphylococcus aureus (MRSA). The most commonly identified organisms on culture were methicillin-sensitive staphylococcus aureus (n = 3) and pseudomonas (n = 3). Obesity is a significant risk factor for the development of infection after an open fracture in the pediatric population. (Journal of Surgical Orthopaedic Advances 31(2):073-075, 2022).

Purpose: Fracture stability is important in choosing the optimal treatment for pediatric femoral fractures, although there is no consensus for characterizing a fracture as “stable” or “unstable.” The authors sought to measure interobserver and intraobserver reliability in classifying femoral fracture stability and examined the relationship between fracture ratio and perceived fracture stability and morphology. Methods: Fracture ratios were calculated from anteroposterior and lateral radiographs from 65 children aged 5 to 12 years, who were treated for femoral shaft fractures at a level 1 pediatric trauma center. Deidentified radiographs were placed into a PowerPoint presentation in random order and were shown to six fellowship-trained pediatric orthopaedic surgeons at two time points, 4 months apart. Raters classified stability as “stable/unstable” and morphology as “spiral/oblique/transverse.” Cohen and Fleiss kappa (k) values were calculated to determine intraobserver and interobserver reliability. Generalized linear modeling was used to compare FR to rater fracture stability and morphology. Results: The mean k for fracture stability for all raters was 0.68 (strong intraobserver agreement). The k for fracture stability during Round 1 was 0.53 (67.7% interobserver agreement, moderate). The k for fracture stability during Round 2 was 0.68 (75.4% interobserver agreement, strong). The mean k for fracture morphology for all raters was 0.79 (strong intraobserver agreement). The k for fracture morphology during Round 1 was 0.38 (15.4% agreement, fair). The k for fracture morphology during Round 2 was 0.46 (24.6% agreement, moderate). The average anteroposterior ratio in stable fractures was 1.32 compared with 1.78 in unstable fractures (P < 0.001). The average lateral ratio in stable fractures was 1.34 compared with 2.10 in unstable fractures (P < 0.001). Average anteroposterior and lateral ratios were highest in spiral fractures and lowest in transverse fractures (P < 0.003). Conclusions: Raters demonstrated strong intraobserver and interobserver agreement in classifying radiographic femoral fracture stability. Anteroposterior and lateral fracture ratios were significantly higher in unstable fractures.

BACKGROUND:Lower extremity brace-wear compliance has been studied in pediatrics, but failure to acquire a prescribed brace has not been included. The purpose of this study was to evaluate brace acquisition as a component of brace-wear compliance.METHODS:Records of patients (0 to 21 y) prescribed lower extremity braces from 2017 to 2019 were reviewed. Diagnoses included cerebral palsy, spina bifida, short Achilles tendon, clubfoot, and other. Brace type was categorized as clubfoot foot abduction orthosis, ankle-foot orthosis, knee, hip, or custom/other braces. Brace prescription and acquisition dates were recorded. Insurance was classified as government, private, or uninsured. Patient demographics included age, sex, race, and calculated area deprivation index.RESULTS:Of the 1176 prescribed lower extremity braces, 1094 (93%) were acquired while 82 (7%) were not. The odds ratios (OR) of failure to acquire a prescribed brace in Black and Hispanic patients were 1.64 and 2.71 times that in White patients, respectively (95% confidence interval: 1.01-2.71, P=0.045; 1.23-5.6, P=0.015); in patients without insurance, the OR was 8.48 times that in privately insured patients (95% confidence interval: 1.93-31.1, P=0.007). The ORs of failure to acquire were 2.12 (P=0.003) in patients 4 years or more versus 0 to 3 years, 4.17 (P<0.0001) in cerebral palsy versus clubfoot, and 4.12 (P=0.01) in short Achilles tendon versus clubfoot. There was no significant association between sex or area deprivation index and failure of brace acquisition.CONCLUSIONS:In our cohort, 7% of prescribed braces were not acquired. Black or Hispanic race, lack of insurance, and older age were associated with failure to acquire prescribed braces. Braces prescribed for clubfoot were acquired more often than for cerebral palsy or short Achilles tendon. Brace-wear compliance is an established factor in treatment success and recurrence. This study identified risk factors for failed brace acquisition, a critical step for improving compliance. These results may help effect changes in the current system that may lead to more compliance with brace wear.LEVEL OF EVIDENCE:Level III-retrospective cohort study.

Orthopaedic surgery residency education is evolving from the historic mantra of "see one, do one, teach one" to incorporating more formal skill programs into curricula.Each training environment possesses unique resources and constraints, with no single one-size-fits-all approach.Cost remains the single greatest barrier to the development of orthopaedic surgery skills programs.Time also is a concern, as trainees have a finite amount of time to spend in the training environment.Furthermore, time spent in simulation or a skills workshop has the potential to interfere with time spent on direct patient care.Training programs must therefore utilize all available resources in a thoughtful and efficient manner to maximize the educational potential of such a program.By enlisting the help of enthusiastic educators and partners, program directors can build a team with shared common goals.This includes collaboration between training programs, medical schools, and industry.Experience across all levels of orthopaedic knowledge can be incorporated in a top-down fashion to both facilitate trainee education and create an environment conducive to future growth.As educational technology becomes more accessible and educational research advances, skills programs will be able to adapt and adopt evidence-based strategies to improve orthopaedic trainee education. Key Concepts:• The key to developing a formal orthopaedic skills program is to utilize available resources and opportunities.• Program directors should seek willing partners with a shared interest in improving patient care and trainee experience.• Skills programs should involve trainees of all levels of experience to maximize potential learner benefit and foster an educational culture.

Background: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). Methods: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, >= 95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. Results: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). Conclusion: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES.

Background: An area of enlargement of the metaphyseal socket around the epiphyseal tubercle, termed the peritubercle lucency sign, has recently been introduced as a possible predictor of contralateral slipped capital femoral epiphysis in patients with previous unilateral slipped capital femoral epiphysis. This study aimed to assess intraobserver and interobserver reliability for detecting the presence or absence of the peritubercle lucency sign. Methods: Thirty-five radiographs were presented to 6 fellowship-trained pediatric orthopaedic surgeons on 2 separate occasions 30 days apart, ensuring that the images were shown in a different order on the second exposure. Both times the reviewers recorded whether the peritubercle lucency sign was present or absent in each of the radiographs. Statistical analysis was performed to determine the intraobserver and interobserver reliability. Results: In the intraobserver analysis, percent agreement between the first and second time the radiographs were reviewed varied between 62.9% and 85.7%, for an average intraobserver agreement of 74.8%. κ values for the 6 reviewers varied between 0.34 and 0.716, with an average intraobserver κ value of 0.508. The interobserver percent agreement was 40.0% for the first time the radiographs were reviewed, 42.9% the second time, and the overall interobserver percent agreement was 29%. The interobserver κ value was 0.44 the first time the radiographs were reviewed, 0.45 the second time, and the overall interobserver κ value was 0.45. Discussion: On the basis of our findings, the peritubercle lucency has modest intraobserver and interobserver reliability at best and should be used with other currently used factors, such as age, presence of endocrinopathy, status of triradiate cartilage, posterior sloping angle, and modified Oxford score, in determining the need for prophylactic pinning. Further refinement of the definition of the peritubercle lucency sign may be needed to improve agreement and reliability of the sign. Level of Evidence: Level III—prognostic study.

Orthopaedists are typically skilled diagnosticians as orthopedic training involves frequent evaluation of radiographs, but even a seasoned orthopedist has the potential to miss certain anomalies on radiographic images. Misdiagnosis can lead to morbidity, malunion, increased need for surgical procedures, or osteonecrosis of a large joint. “RAMBO” lesions, or radiographic anomalies missed by orthopaedists, are a subset of traumatic pediatric injuries that can be missed by an orthopaedist. These include transphyseal fracture of the distal humerus, Monteggia injury, entrapped medial epicondyle fracture of the elbow, hip dislocation with incongruous hip after reduction, and lower extremity ipsilateral second fractures. Radiographs of skeletally immature patients offer additional challenges in interpretation as many providers may be unfamiliar with the radiographic anatomy of younger patients. Understanding the characteristics of pediatric radiographs and a high index of clinical suspicion help prevent missing certain subtleties on radiographs. The purpose of this article is to review a few key traumatic pediatric radiographic anomalies missed by orthopaedists, deemed RAMBO lesions, with the aims of further educating highly skilled orthopaedic surgeons and preventing radiographic anomalies from being missed.