The extensor mechanism of the knee-consisting of the four muscles of the quadriceps, the quadriceps tendon, the patella, and the patellar ligament-is essential for lower extremity function during both standing and ambulation. The presence of articular cartilage and growing physes in the pediatric knee, coupled with the generation of significant tensile force, creates an opportunity for pathology unique to the pediatric population.Tibial tubercle fractures and patella injuries are quite rare, and even pediatric-trained orthopaedic surgeons may not be exposed to these injuries on a regular basis. It is the intent of this article to discuss the current literature regarding the mechanism of injury, diagnostic workup, classification, indications for surgical versus non-surgical management, and techniques for operative management for both tibial tubercle and patella (transverse and sleeve) fractures.

Shoulder pain is a common clinical problem affecting most individuals in their lifetime. Despite the high prevalence of rotator cuff pathology in these individuals, the pathogenesis of rotator cuff disease remains unclear. Position and motion related mechanisms of rotator cuff disease are often proposed, but poorly understood. The purpose of this study was to determine the impact of systematically altering glenohumeral plane on subacromial proximities across arm elevation as measures of tendon compression risk. Three-dimensional models of the humerus, scapula, coracoacromial ligament, and supraspinatus were reconstructed from MRIs in 20 subjects. Glenohumeral elevation was imposed on the humeral and supraspinatus tendon models for three glenohumeral planes, which were chosen to represent flexion, scapular plane abduction, and abduction based on average values from a previous study of asymptomatic individuals. Subacromial proximity was quantified as the minimum distance between the supraspinatus tendon and coracoacromial arch (acromion and coracoacromial ligament), the surface area of the supraspinatus tendon within 2 mm proximity to the coracoacromial arch, and the volume of intersection between the supraspinatus tendon and coracoacromial arch. The lowest modeled subacromial supraspinatus compression measures occurred during flexion at lower angles of elevation. This finding was consistent across all three measures of subacromial proximity. Knowledge of this range of reduced risk may be useful to inform future studies related to patient education and ergonomic design to prevent the development of shoulder pain and dysfunction.

Background: Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. Methods: A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids’ Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. Results: A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. Conclusions: Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. Level of Evidence: Level III—case series, database study.

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