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Paediatric orthopaedic outpatient clinic referral patterns
Motivos de derivación a una consulta ambulatoria de Traumatología Infantil
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Aproximadamente el 90% de los pacientes con una variante de la normalidad (alteraciones torsionales o angulares de los miembros inferiores, alteraciones de la estática de los pies) mejoran espontáneamente en los primeros 8-10 años de vida, lo que explica el descenso de este diagnóstico en la adolescencia (17%).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Moraleda, M. Castellote" "autores" => array:2 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Moraleda" ] 1 => array:2 [ "nombre" => "M." 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Moraleda, M. Castellote" "autores" => array:2 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Moraleda" "email" => array:1 [ 0 => "l.moraleda@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Castellote" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Traumatología y Ortopedia Infantil, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Especialidades de Peñagrande, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Motivos de derivación a una consulta ambulatoria de Traumatología Infantil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 952 "Ancho" => 1667 "Tamanyo" => 53447 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Incidence of normal variant diagnosis in different age groups. Approximately 90% of the patients with normal variants (rotational or angular abnormalities in the lower limbs, abnormalities in static foot structure) improve spontaneously in the first 8–10 years of life, which accounts for the decrease in this diagnosis observed in adolescence (17%).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Musculoskeletal disorders are very prevalent and account for 20–30% of paediatric primary care visits.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> For example, 6% of paediatric visits are due to musculoskeletal pain.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> However, this high clinical prevalence is not reflected in paediatric residency programmes nor in medical school curricula. At present, only 2.3% of the curriculum time of medical students is devoted to the study of musculoskeletal problems.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Training in residency programmes is no better, so that when final-year paediatrics residents are asked about their level of comfort in treating various medical problems in the paediatric age group, they report the lowest levels of comfort in the management of musculoskeletal problems.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> As a consequence, in most cases the paediatrician chooses to refer the patient to the paediatric orthopaedist, who becomes the de facto primary care physician for children with musculoskeletal complaints.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">As of now, preventing referrals is not the solution, as there is evidence that when it comes to certain disorders, over half of the cases are misdiagnosed if the patient is not seen by a paediatric orthopaedist.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Delayed or incorrect diagnoses can result in permanent disabilities for the patient or a vast increase in costs for the healthcare system.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> We need to improve paediatrics residency training in the management of musculoskeletal problems in order to achieve correct and early diagnoses, which would result in reduced costs and better outcomes.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to determine the most frequent reasons for referral to our paediatric orthopaedic outpatient clinic. This would enable the development of a training programme for paediatrics residents on the most common orthopaedic conditions found in clinical practice.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a prospective descriptive study between September 2012 and September 2013 in the paediatric orthopaedics office of an outpatient specialty clinic affiliated with our hospital. The outpatient clinic where these paediatric orthopaedic visits are held belongs to a tertiary care hospital in a health area that covers a population of 503<span class="elsevierStyleHsp" style=""></span>175 inhabitants (66<span class="elsevierStyleHsp" style=""></span>109 of whom are younger than 14 years) through 20 outpatient health care centres. The orthopaedics office that participated in this study only serves patients younger than 15 years referred to the Orthopaedics and Orthopaedic Surgery service. However, the Orthopaedics and Orthopaedic Surgery service covers another 26 weekly shifts at the four outpatient specialty clinics for both children and adults. Thus, this particular paediatric orthopaedics office is not the only site where paediatric patients can receive care, and it also offers care to paediatric patients from other health care areas referred to our clinic by the centralised scheduling centre of our autonomous community. Office hours were held by a single specialist in orthopaedics and orthopaedic surgery that completed a paediatrics orthopaedic surgery fellowship at a children's hospital affiliated to the University of California (United States) and is part of the team at the paediatric orthopaedics department of our hospital (LM). Thus, the study included patients less than 15 years of age referred to our paediatric orthopaedics office in an outpatient specialty clinic affiliated with our hospital. We excluded patients who sought care for traumatic injuries. We collected demographic data, the reason for referral, and the final diagnosis given by the paediatric orthopaedist.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between September 2012 and September 2013, 3174 patients less than 15 years of age received care in the shifts that the Orthopaedics and Orthopaedic Surgery department covers in the outpatient specialty clinics in our health area. Of these patients, 455 younger than 15 years referred from primary care were seen at the PTRA22 office for a non-traumatic condition. These were the 455 patients included in this study.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients were referred from 37 health care centres. Eighty-eight came from centres that belong to our health area. The percentage of patients referred from each healthcare centre ranged between 0.3% and 16%.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> gathers the demographic data for our sample. Ninety-one percent of referrals were made to assess musculoskeletal pain (37%), foot deformities (20%), spinal deformities (15%), gait patterns (11%), lower limb alignment (4%) or hip development (4%). The most frequent reasons for referral varied by age group: in the first year of life, it was assessment of hip development; in toddlers and early childhood, assessment of a foot deformities or gait abnormalities; and in mid-childhood and adolescence, assessment of musculoskeletal pain (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The incidence of musculoskeletal pain increased with patient age, and it affected school-aged children and adolescents most frequently. The location of the pain also varied with age: the most frequent location was the foot in school-aged children and the knee in adolescents. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the most frequent diagnoses in patients that sought care for musculoskeletal pain.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In 42% of the patients, the physical examination was normal (10%) or revealed normal variants: angular (4%) or rotational (9%) deformities of the lower limbs within the normal range, postural deformities of the feet within the normal range (14%), growing pains (3%), postural kyphosis (1%) and leg length discrepancy of less than 1<span class="elsevierStyleHsp" style=""></span>cm (1%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The percentage of patients that had normal variants was higher in middle childhood and preschool age (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Seventeen percent of patients had mild conditions that require assessment by a paediatric orthopaedist only when treatment with anti-inflammatory agents and rehabilitation has failed: self-limiting osteochondroses (Sever 3%, Osgood–Schlatter 3%, Sinding–Larse–Johanson <1%, or apophysitis of the fifth metatarsal base <1%); back pain with no abnormal findings in the examination (6%); transient synovitis of the hip (0.4%); symptomatic accessory navicular bone (1%), and tendinitis, periostitis, sesamoiditis, trochanteritis or coccydynia (3%).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Eight percent of patients had a deformity that only requires treatment if symptomatic: clinodactyly in the feet, claw foot, overlapping fifth toe, tailor's bunion, hallux valgus, hallux interphalangeus, or ganglion or Baker's cysts.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The rest of the patients had one of the following disorders: scoliosis (9%), anterior knee pain syndrome (4%), metatarsus adductus, tarsal coalition, cavovarus foot, delta phalanx, trigger finger, nonspecific limp, ankle instability, patellar instability, shoulder instability, meniscus tear, knee osteochondritis dissecans, osteochondroma, angioma, idiopathic toe walking, torticollis, scapular dyskinesis, genu valgum in patients more than 10 years of age, genu varum in patients more than 18 months of age, fibrous cortical defect, postural plagiocephaly, calcaneovalgus foot or immature hip.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">There are established guidelines and protocols for the referral of patients from primary care to a paediatric orthopaedics clinic.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> However, these guidelines have proved ineffective, as paediatricians continue to refer patients with conditions that they should treat themselves.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,8,9</span></a> McCarthy et al. declared that 75% of the patients referred to their office came from the primary care paediatrician, and that 95% of referrals were for mild conditions or normal variants.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> The study of Hsu et al. reported that 47% of the patients referred to their office should have been treated by their paediatrician.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> The rate of appropriate referrals to the paediatric orthopaedist based on the recommendations of the American Academy of Pediatrics ranges from 14% to 35% in the published literature.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,8</span></a> In our series, 67% of the referrals corresponded to normal variants or mild conditions that should be managed, at least initially, by the paediatrician.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We believe that the failure of the referral guidelines does not stem from an unwillingness to treat these patients on the part of paediatricians, but to a lack of training, both during medical school and in residency programmes, on the development of the musculoskeletal system during growth and on the most common musculoskeletal disorders.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> The official curriculum for the paediatrics specialty and its specific areas published by the BOE does not include a mandatory rotation in paediatric orthopaedics.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> This gap in training results in a lack of confidence of paediatricians in the management of these patients,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> so that paediatric orthopaedists become the primary care physician for musculoskeletal disorders.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Thus, paediatrics residents must be trained on the normal variants that occur in the development of the musculoskeletal system, and also on the most common mild pathologies affecting this system. In our study, we found that angular or rotational problems of the lower limb and abnormalities of the static foot structure within normality are a frequent source of concern in parents. These reasons for referral occur more frequently in age ranges where genu valgum is physiological or in which there is a higher prevalence of flexible flat foot.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11,12</span></a> The official curriculum for the paediatrics specialty and its specific areas establishes that the primary objectives of care are “evaluating normality in children and adolescents through the various stages of development by means of specific assessment methods” followed by “the identification of deviations from normality by means of the appropriate diagnostic methods”.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Thus, paediatricians must be familiar with the normal development of the lower limbs through childhood to be able to reassure and advise parents on this subject.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11–16</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Similarly, our study found that musculoskeletal pain was the most frequent reason for referral, especially in schoolchildren and adolescents. Most of the causes of musculoskeletal pain involve mild disorders that only require symptomatic treatment and rehabilitation, as well as informing the parents of the self-limited course and lack of sequelae at skeletal maturity of many of these causes.</p><p id="par0085" class="elsevierStylePara elsevierViewall">There are limitations to this study concerning the representativeness of its sample due to its size, to the fact that the paediatric orthopaedics specialty clinic is not the only site offering care to paediatric patients in our health area (only 14% of patients that received care through the Orthopaedics and Orthopaedic Surgery service were seen in our clinic) and because the sample consists only of patients from our health area. Furthermore, we need to emphasise that the cited studies were conducted in countries with health systems that differ from Spain in the way patients are referred from primary care to specialised paediatric orthopaedic care, and thus, comparing figures poses challenges. However, we do not believe that there is a referral bias in any of the paediatricians. The percentage of patients that corresponded to each healthcare centre ranged between 0.3% and 16%. Sixty-four percent of patients came from six healthcare centres that serve 39% of the population under 15 years of age in our health area, while 15% of the patients came from nine healthcare centres that serve 41% of the population under 15 years of age in our health area. Considering that four outpatient specialty clinics in our health area offer orthopaedic surgery and orthopaedics services, we believe that the differences in the percentages of referrals from the different healthcare centres are due to their distribution among the different outpatient specialty clinics.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion, most referrals from paediatrics departments to a paediatric orthopaedics specialist are due to normal variants or to mild pathologies that only require symptomatic treatment. An improvement in the paediatric residency training on the development of the musculoskeletal system through childhood and on the most prevalent mild musculoskeletal disorders could decrease the number of referrals or requested imaging tests, which would reduce healthcare costs and save the parents unnecessary worry and healthcare visits.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres541360" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec560894" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres541359" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec560893" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-29" "fechaAceptado" => "2014-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec560894" "palabras" => array:3 [ 0 => "Orthopaedic" 1 => "Paediatric" 2 => "Referrals" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec560893" "palabras" => array:4 [ 0 => "Traumatología" 1 => "Ortopedia" 2 => "Motivos de consulta" 3 => "Infantil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to identify the commonest referrals to a paediatric orthopaedic outpatient clinic and, therefore, to be able to improve the paediatric residency programme in managing musculoskeletal problems.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Demographic data, referrals and final diagnosis were collected prospectively on all patients that were evaluated in a paediatric orthopaedic outpatient clinic.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The majority of referrals were to evaluate musculoskeletal pain (37%), foot deformity (20%), spine deformity (15%), walking pattern (11%), alignment of the lower limbs (4%), and development of the hip (4%). A normal physical examination or a normal variation was observed in 42% of patients. A mild condition was observed in 17% of patients that should have only been referred to a paediatric orthopaedic clinic after failing to resolve pain with anti-inflammatories or physiotherapy. A mild deformity that only needed treatment if it became symptomatic was seen in 8% of patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The majority of referrals were due to a normal variation or mild conditions that only required symptomatic treatment. Paediatric residency programmes do not reflect the prevalence of musculoskeletal conditions in clinical practice.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio fue conocer los motivos de consulta más frecuentes en una consulta de Traumatología Infantil de un Centro de Especialidades y así poder mejorar el programa de formación de los residentes de Pediatría en el manejo de problemas músculo-esqueléticos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se recogieron prospectivamente los motivos de consulta, la edad, el sexo y el diagnostico final de todos los pacientes menores de 15 años derivados a una consulta específica de Traumatología Infantil de un Centro de Especialidades.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los motivos de consulta más frecuentes fueron el dolor músculo-esquelético (37%), valorar una posible deformidad de los pies (20%), una posible deformidad de la columna (15%), el patrón de marcha (11%), la alineación de los miembros inferiores (4%) y el desarrollo de la cadera (4%). El 42% de los pacientes presentaron una exploración normal o una variante de la normalidad. El 17% de los pacientes presentaron una patología que únicamente requiere ser valorada por parte de Traumatología Infantil si un tratamiento previo con antiinflamatorios no esteroideos o rehabilitación no resuelve la sintomatología. El 8% presentaba una deformidad que solo requiere tratamiento si es sintomática.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayoría de las consultas correspondieron a variantes de la normalidad o a condiciones leves que solo precisan tratamiento sintomático. El programa de formación de la residencia de Pediatría no refleja la prevalencia de los problemas músculo-esqueléticos en la práctica clínica diaria.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Moraleda L, Castellote M. Motivos de derivación a una consulta ambulatoria de Traumatología Infantil. An Pediatr (Barc). 2015;83:89–93.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 784 "Ancho" => 3156 "Tamanyo" => 139633 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The normal course of development of lower limb alignment (there is a physiological genu valgum between 2 and 8 years of age that peaks between 3 and 4 years of age) correlates with a high number of referrals for the assessment of the lower limbs in early childhood and preschool age (left chart). The normal development of the footprint,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> with the presence of flat foot in 44% of children between 3 and 6 years of age,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> is associated with considerable concern for static foot structure in early childhood and preschool age (right chart).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 952 "Ancho" => 1667 "Tamanyo" => 53447 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Incidence of normal variant diagnosis in different age groups. Approximately 90% of the patients with normal variants (rotational or angular abnormalities in the lower limbs, abnormalities in static foot structure) improve spontaneously in the first 8–10 years of life, which accounts for the decrease in this diagnosis observed in adolescence (17%).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Number of patients</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">455 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">202 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">253 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Age, years</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.1<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span>8.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Patients by age group, mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD, years</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span>0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Toddlerhood (1–3 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span>2.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Preschool (3–6 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span>4.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Middle childhood (6–12 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">167<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span>9.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Adolescence (>12 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">143<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span>13.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab869349.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics of the sample.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infancy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Toddlerhood \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preschool \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Middle childhood \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adolescence \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Musculoskeletal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Foot deformity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gait pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lower limb alignment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hip development \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Spinal deformity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bulge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Limited mobility of the thumb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chest deformity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab869348.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients that sought care by reason for referral and age group.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean age<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Back pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patellofemoral pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.3 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sever's disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.4 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Osgood–Schlatter disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Growing pains in lower limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.9 years (median 4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ankle instability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.8 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Accessory navicular bone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.6 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tarsal coalition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.8 years \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab869347.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Most frequent diagnoses in patients referred for musculoskeletal pain, their percentages, and the mean age at the time of referral.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Referral patterns to a pediatric orthopedic clinic: implications for education and practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 13 | 22 |
| 2024 October | 41 | 38 | 79 |
| 2024 September | 54 | 32 | 86 |
| 2024 August | 52 | 66 | 118 |
| 2024 July | 46 | 36 | 82 |
| 2024 June | 64 | 32 | 96 |
| 2024 May | 48 | 42 | 90 |
| 2024 April | 53 | 40 | 93 |
| 2024 March | 41 | 22 | 63 |
| 2024 February | 35 | 28 | 63 |
| 2024 January | 31 | 21 | 52 |
| 2023 December | 26 | 24 | 50 |
| 2023 November | 25 | 19 | 44 |
| 2023 October | 37 | 44 | 81 |
| 2023 September | 31 | 31 | 62 |
| 2023 August | 33 | 24 | 57 |
| 2023 July | 33 | 27 | 60 |
| 2023 June | 34 | 26 | 60 |
| 2023 May | 46 | 31 | 77 |
| 2023 April | 29 | 25 | 54 |
| 2023 March | 33 | 24 | 57 |
| 2023 February | 41 | 19 | 60 |
| 2023 January | 30 | 23 | 53 |
| 2022 December | 54 | 36 | 90 |
| 2022 November | 61 | 29 | 90 |
| 2022 October | 61 | 45 | 106 |
| 2022 September | 33 | 40 | 73 |
| 2022 August | 39 | 56 | 95 |
| 2022 July | 33 | 36 | 69 |
| 2022 June | 52 | 79 | 131 |
| 2022 May | 56 | 35 | 91 |
| 2022 April | 89 | 32 | 121 |
| 2022 March | 121 | 57 | 178 |
| 2022 February | 107 | 37 | 144 |
| 2022 January | 91 | 30 | 121 |
| 2021 December | 67 | 35 | 102 |
| 2021 November | 72 | 68 | 140 |
| 2021 October | 111 | 53 | 164 |
| 2021 September | 54 | 38 | 92 |
| 2021 August | 57 | 35 | 92 |
| 2021 July | 149 | 43 | 192 |
| 2021 June | 36 | 43 | 79 |
| 2021 May | 30 | 36 | 66 |
| 2021 April | 58 | 71 | 129 |
| 2021 March | 51 | 38 | 89 |
| 2021 February | 21 | 22 | 43 |
| 2021 January | 28 | 33 | 61 |
| 2020 December | 29 | 27 | 56 |
| 2020 November | 19 | 18 | 37 |
| 2020 October | 24 | 18 | 42 |
| 2020 September | 27 | 31 | 58 |
| 2020 August | 31 | 19 | 50 |
| 2020 July | 19 | 23 | 42 |
| 2020 June | 22 | 20 | 42 |
| 2020 May | 33 | 20 | 53 |
| 2020 April | 31 | 28 | 59 |
| 2020 March | 32 | 18 | 50 |
| 2020 February | 30 | 21 | 51 |
| 2020 January | 20 | 10 | 30 |
| 2019 December | 29 | 21 | 50 |
| 2019 November | 24 | 14 | 38 |
| 2019 October | 26 | 15 | 41 |
| 2019 September | 27 | 13 | 40 |
| 2019 August | 23 | 15 | 38 |
| 2019 July | 25 | 41 | 66 |
| 2019 June | 43 | 34 | 77 |
| 2019 May | 58 | 15 | 73 |
| 2019 April | 68 | 28 | 96 |
| 2019 March | 38 | 16 | 54 |
| 2019 February | 35 | 17 | 52 |
| 2019 January | 56 | 17 | 73 |
| 2018 December | 44 | 33 | 77 |
| 2018 November | 93 | 28 | 121 |
| 2018 October | 126 | 30 | 156 |
| 2018 September | 78 | 13 | 91 |
| 2018 August | 6 | 0 | 6 |
| 2018 July | 4 | 0 | 4 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 12 | 0 | 12 |
| 2018 April | 64 | 0 | 64 |
| 2018 March | 75 | 0 | 75 |
| 2018 February | 29 | 0 | 29 |
| 2018 January | 84 | 0 | 84 |
| 2017 December | 22 | 0 | 22 |
| 2017 November | 23 | 0 | 23 |
| 2017 October | 12 | 0 | 12 |
| 2017 September | 26 | 0 | 26 |
| 2017 August | 12 | 0 | 12 |
| 2017 July | 20 | 0 | 20 |
| 2017 June | 36 | 8 | 44 |
| 2017 May | 35 | 5 | 40 |
| 2017 April | 95 | 7 | 102 |
| 2017 March | 10 | 2 | 12 |
| 2017 February | 20 | 6 | 26 |
| 2017 January | 14 | 4 | 18 |
| 2016 December | 42 | 9 | 51 |
| 2016 November | 56 | 11 | 67 |
| 2016 October | 67 | 7 | 74 |
| 2016 September | 72 | 11 | 83 |
| 2016 August | 27 | 1 | 28 |
| 2016 July | 12 | 1 | 13 |
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