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ces measured in flexion, therefore, may represent more stringent criteria for defining normal hips. Level of evidence Level III-diagnostic study.Background EOS imaging offers a low-radiation alternative to conventional radiography (CR) and has little to no magnification effects. However, it is unclear how radiographic measures may be affected using EOS. The present study aims to determine the reproducibility of measures of acetabular morphology on EOS images as compared with CR, and to directly compare the 2 imaging modalities. Methods A total of 21 consecutive patients (66.7% female; 14.4±4.7 y) indicated for an open hip preservation procedure with both an anterior-posterior pelvis radiograph and EOS image performed preoperatively were included. Three orthopaedic surgeons measured Tönnis angle, lateral center edge angle (LCEA), acetabular depth-width ratio (ADR), and extrusion index (EI). Measurements were performed twice, 2 weeks apart. Reliability between observers and time points was measured using intraclass correlation coefficients, and agreement between time points and modalities was measured using Bland-Altman analysis. Results On EOS images, gating a diagnostic test.Introduction Timing of wound closure in pediatric Gustilo-Anderson grade II and IIIA open long bone fracture remain controversial. Our aims are (1) to determine the proportion of patients with these fractures whose wounds can be treated with early primary wound closure (EPWC); (2) to compare the complication rates between EPWC and delayed wound closure (DWC); and (3) to determine factors associated with higher likelihood of undergoing DWC. Patients and methods At a level-1 pediatric trauma center, 96 patients (younger than 18 y) who sustained Gustilo-Anderson grade II and IIIA open long bone fractures (humerus, radius, ulnar, femur, or tibia) within a 10-year period (2006-2016) were included for this study. Decision for EPWC versus DWC was at the discretion of the attending surgeon at time of initial surgery. Data collection was via retrospective review of charts and radiographs. Particular attention was paid to the incidence of return to operating room rate, nonunion, compartment syndrome, and infection. Median follow-up duration was 7.5 months (interquartile range 3.6 to 25.3 mo). All patients were followed-up at least until bony union. Results Overall, 81% of patients (78/96) underwent EPWC. Of the grade II fractures, 86% underwent EPWC. Four patients (5%) in the EPWC group and 1 patient (6%) in the DWC group had at least 1 complication. When controlling for mechanism of injury, Gustilo-Anderson fracture type and age, there was no difference in rate of complications between the EPWC and the DWC groups. Grade IIIA fractures and being involved in a motor vehicle accident were factors associated with a higher likelihood of undergoing DWC. Conclusion The majority of grade II and IIIA pediatric long bone fractures may be safely treatable with EPWC without additional washouts. Future prospective research is required to further define the subgroups that can benefit from DWC. Level of evidence Level IV-therapeutic, case cohort study.Background Lateral ankle injuries are one of the most common musculoskeletal injuries sustained by pediatric and adolescent athletes. These injuries can result in significant time lost from competition, affect performance when returning to play, and represent a significant burden on the health care system as a whole. The purpose of this study was to systematically review the literature on the diagnosis, treatment, and prevention of acute lateral ankle injuries and their chronic effects in pediatric and adolescent athletes (younger than 19 y). Methods This systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines between September and December 2018. PubMed and Google Scholar were systematically searched using the search terms ("distal fibula fracture" OR "ankle sprain") AND ("youth" OR "pediatric" OR "adolescent"). All authors participated in article review (N=172) for relevance and age restrictions in which 30 met the inclusion criteria. Results Thirty articles met inclusion criteria [Levels of Evidence I to IV (I n=4, II n=16, III n=9, and IV n=1)] including distal fibula fracture diagnosis and treatment, and risk factors, prevention, and chronic sequela of lateral ankle injuries in pediatric and adolescent patients. Conclusions Low-energy, lateral ankle injuries are common in pediatric and adolescent patients, yet underrepresented in the medical literature. There is a lack of high-quality literature on diagnosis, treatment, and outcomes after Salter-Harris I distal fibula fractures. Available literature, however, suggests that there remains over diagnosis and over treatment of presumed Salter-Harris I distal fibula fractures. Adolescent ankle sprains dominate the available literature likely due to the high recurrence rate. Youth athletes and coaches should address risk factors and engage in injury prevention programs to prevent and minimize the effect of acute lateral ankle injuries. Levels of evidence Level III-Systematic review.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 less then 0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P less then 0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P less then 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.Background Annual rankings by US News and World Report are a widely utilized metric by both health care leaders and patients. One longstanding measure is time to treatment of femur shaft fractures. Hospitals able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department score better as part of the overall pediatric orthopaedic ranking. Therefore, it is important to determine whether the 18-hour treatment time for pediatric femur shaft fractures is a clinically meaningful metric. Methods A retrospective review of clinical outcomes of 174 pediatric patients (aged below 16 y) with isolated femur shaft fractures (Injury Severity Score=9) was conducted from 1997 to 2017 at a single level I pediatric trauma center. The 2 comparison groups were patients receiving fracture reduction within 18 hours of emergency department admission (N=87) or >18 hours (N=87). this website Results Patient, injury, and surgical characteristics were similar between the 2 groups. Both groups had a similar mean age (treatment 18 h=8.1 y). Patients who received treatment within 18 hours were more often immobilized postoperatively (70.1% vs. 53.5%; P=0.0362) and had a shorter median hospital length of stay (2 vs. 3 d; P=0.0047). There were no statistically significant differences in any outcomes including surgical site infection, time to weight-bearing (treatment less then 18 h mean=48.1 d vs. 52.5 d), time to complete radiographic fracture healing (treatment less then 18 h mean=258.9 d vs. 232.0 d), decreased range of motion, genu varus/valgus, limb length discrepancy, loss of reduction, or persistent pain. Conclusions Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes. National quality measures should therefore use evidence-based metrics to help improve the standard of care. Level of evidence Therapeutic level III.Background Missed posterolateral corner (PLC) injuries are a known cause of anterior cruciate ligament reconstruction (ACL) failure in the adult population. Failed ACL reconstruction causes significant morbidity in the skeletally immature pediatric population. There is little literature on the character and potential significance of PLC injuries in skeletally immature patients. Methods Magnetic resonance imaging studies of the knee at a tertiary care children's hospital for patients who underwent an ACL reconstruction without PLC surgery were retrospectively reviewed. Demographic variables were obtained through chart review, and magnetic resonance imaging studies were evaluated for PLC (popliteus, fibular collateral ligament, popliteofibular ligament, and arcuate ligament) injury, and ACL, medial collateral ligament (MCL), bone bruise, fracture, and meniscal pathology by an experienced pediatric musculoskeletal radiologist. Results A total of 50 patients with a mean age at 13.3 years at injury were analyzed. dicted the likelihood of PLC injury. Further research is needed regarding the risk of ACL reconstruction failure from associated PLC injury and the indications for PLC reconstruction in skeletally immature patients. Level of evidence Level IV-diagnostic study.Background Medial epicondyle fractures represent up to 20% of elbow fractures in children and adolescents. There is a growing body of literature to support surgical fixation for displaced fractures. However, controversy regarding imaging modality for displacement measurement and surgical indications remain controversial. The purpose of this survey was to gauge Latin American surgeons' practices and preferences for the evaluation and treatment of medial epicondyle fractures. Methods A web-based survey containing 19 questions was distributed to active members of SLAOTI (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil) in November 2018. The survey elicited information regarding surgeon demographics, evaluation methods, the factors involved in the decision to perform surgery, and their experience in cases of symptomatic nonunion. Categorical variables were summarized using frequencies and proportions. Analysis of associations between surgeon demographics and treatment preferences were carried out. Results A total of 193 out of 354 completed questionnaires were returned (54% response rate). In total, 74% of the participants (142/193) favored radiographs for the evaluation of the fracture displacement, and 25.4% (49/193) added a computed tomography scan for a more detailed evaluation. The majority of respondents (48.2%) would consider a 5 mm displacement as the cutoff for surgical treatment, 21.8% 2 mm, 20.7% 10 mm, and 9.3% 15 mm. There were no differences between the experience of the participants, academic versus private setting, or training regarding surgical/nonsurgical management. Conclusions There are significant differences in opinions between SLAOTI members as to the optimal management of medial epicondyle fractures. Implications of disagreement in evaluation and treatment support the need for multicenter prospective studies to develop evidence-based guidelines for the management of this fracture. Level of evidence Level V-expert opinion. Cross-sectional electronic survey.