Background: Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture. Methods: Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics. Results: Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex. Conclusions: Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To aid in the interpretation of Pedi-IKDC scores by characterizing normative data in children and adolescents. Also, to validate the Pedi-IKDC by examining differences in Pedi-IKDC scores between patients with knee ailments compared to patients without a history of knee problems. Methods: Cross-sectional survey of 2000 children and adolescents aged 10-18 years living in the United States, recruited by ORC International to obtain equal numbers by sex and by integer age group. In addition to completing the Pedi-IKDC for one study-designated "index" knee (right or left), subjects were asked demographic questions and for information on history of knee surgery and recent (four weeks) activity limitations. Raw Pedi-IKDC total scores were re-scaled to a 0-100 scale. Non-parametric Wilcoxon or Kruskal-Wallis tests were used to compare subgroup scores and the van Elteren test was used to adjust for age. Unadjusted and adjusted p-values were similar and only unadjusted values are reported. Results: Numbers of respondents are uniform with respect to age and sex, with 11% in each age group (10-18) and 50% female. 68% identified themselves as white, and 86% as non-Hispanic. 49 states and DC are represented. 136 (7%) reported prior surgery in one or both knees; 79(4%) in the index knee. The Pedi-IKDC score distribution is skewed left with mean score (±SD) of 86.7(±16.8), median 94.6 and 34% reaching the ceiling value of 100. Subjects reporting prior surgery or limited activity in the index knee had median Pedi-IKDC scores about 25 points lower than those without these histories (p<0.0001 for both comparisons). In contrast, although statistically significant, the variation by age (p=0.02), race (p=0.02), ethnicity (p=0.01), and level of sports/exercise participation (p=0.04) was much smaller (all ranges of median scores <4.5). There were no significant differences by sex or geographic region. Conclusion: There is only minor variation in Pedi-IKDC scores across demographic factors. The strong association between Pedi-IKDC score and prior knee surgery and also with recent limitation of activity in the index knee supports the construct validity of the Pedi-IKDC. Using a large, broadly representative sample, this study supports the use of the Pedi-IKDC as a knee specific outcome instrument for pediatric patients aged 10-18 and provides normative values to aid the interpretation of scores in this age range.

We describe a rare and apparently unique neuropathic syndrome among Navajo children living on the Navajo Reservation. Clinical features include sensorimotor neuropathy, corneal ulcerations, acral mutilation, poor weight gain, short stature, sexual infantilism, serious systemic infections, and liver derangement including Reye's syndrome-like episodes. Progressive CNS white matter lesions were diagnosed through magnetic resonance imaging. We identified 20 definite and 4 probable cases occurring between 1959 and 1986. Mean age at the time of 1st recognized symptom was 13 months (range, 1 month to 4 years 6 months). Ten individuals have died; 6 of the deaths occurred before 5 years of age. The incidence of this syndrome on the western Navajo reservation is 5 times higher than that on the eastern reservation (38 compared with 7 cases per 100,000 births). Although the etiology is unknown, this syndrome is consistent with an inborn error of metabolism, inherited in an autosomal recessive manner.

Level V.