Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article: Bone Joint J 2023;105-B(5):471–473

Purpose of study: A single dynamic hip screw is the recommended method of fixation for slipped upper femoral epiphysis (SUFE). Current practice favours placement of the screw in the centre of the femoral head on both anteroposterior and lateral planes. This study investigated screw placement in the femoral head for SUFE and the prevalence of AVN, chondrolysis, late slippage, and time to physeal closure. Method: Clinical notes and radiographs of 38 consecutive patients (61 hips), who underwent single screw fixation for SUFE, were evaluated retrospectively with a minimum follow up of 24 months (24–56). Two way ANOVA and post hoc tests were performed to analyse the correlation between the different variables and the outcome, at a 5% significance level. Results: There were 16 acute slips, 18 chronic slips and 10 acute on chronic slips. 17 slips were treated prophylactically. Mild slip was noted in 39 hips, moderate in 4 and severe in 1 hip. A central-central position was only achieved in 50% of cases. No significant difference between the time to physeal closure and the screw position was found. No late slippage, AVN or chondrolysis occurred in this series. Conclusions: Our results demonstrate that positions of the screw, other than in the centre of the femoral head, provide adequate stability. There is no correlation between screw position and the time to physeal closure, the risk of avascular necrosis or chondrolysis. We recommend that positions other than the “optimal central-central position” be accepted if not initially achieved, especially for mild SUFE. The potential hazards from several attempts to achieve the optimum position outweigh the benefits

Aim. With the link between obesity and Slipped Upper Femoral Epiphysis (SUFE) well established and a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the incidence of vitamin D deficiency in SUFE patients and whether low vitamin D levels increases the time to proximal femoral physeal fusion post surgical fixation. Method. All paediatric patients presenting to the orthopaedic department at University Hospital Southampton with a SUFE and tested for vitamin D between June 2007 to present day and who were subsequently found to have low levels of vitamin D, were eligible for inclusion in the study. A deficient level of vitamin D (25-(OH)D) was determined as < 52 nmols/L and insufficiency between 52–72 nmols/L. Levels > 72 nmols/L were considered to be normal. The normal time for 50% of physeal fusion on anteroposterior radiograph quoted in the literature is 9 months. Results. This study includes a cohort of 28 patients and 45 hips. All of these patients were treated with pinning insitu. Eighty six per cent were found to be vitamin D deficient. The mean physeal closure for these patients post fixation, including those yet to fuse and which have exceeded 12 months, was 23 months (range 9–64 months). Conclusion. This study has shown a correlation between vitamin D deficiency and prolonged physeal closure in SUFE patients. With an increasing prevalence of vitamin D deficiency, it is recommended that all patients presenting with a SUFE, be tested for low vitamin D levels, so that early treatment with supplementation can be initiated

Purpose. The importance of femoral head-neck morphology in the development of early hip osteoarthritis is recognized in femeroacetabular impingement (FAI), however no studies have examined FAI morphology in the developing hip, i.e. pre-closure of the proximal femoral physis. We developed a pilot project to study prevalence of CAM-type FAI hip morphology in both the pre- and post-closure proximal femoral physes of asymptomatic children using MR-imaging. We also examined biologic markers possibly related to FAI etiology, including Vitamin D metabolites, BMI, family history, and activity levels. Method. Recruitment included volunteers with asymptomatic lower extremities, and either pre- or post-closure of the proximal femoral physis. Males were 10–12 years (pre-closure) or 15–18 years (post-closure); females were 8–10 years or 14 18 years. Phlebotomy and urine sampling were used to assess metabolic markers. MRI of bilateral hips and a clinical exam including hip impingement tests were conducted. MR imaging assessment was independent and blinded and recorded using established parameters including alpha angles measured at both the 3:00 (anterior head-neck junction) and 1:30 (antero-superior head-neck junction) radial image positions. Results. Fifty-two volunteers were recruited (32 boys, 20 girls), of whom 44 had bilateral hips imaged (88 hips). Radiographic analysis showed no CAM-type morphology in pre-closure hips and 14% in post-closure hips, using established criteria (alpha > 50.5). The difference between alpha angle measurements at 3:00 and 1:30 positions (5.16) appears significant in developing hips. Conclusion. Results confirm our ability to recruit a cohort of asymptomatic children for the proposed methodology. Collected data found FAI in 14% of the closed-physes group and 0 % in the open physes group suggesting possible physeal closure importance. The difference between 3:00 and 1:30 alpha angle measurements was significantly less than in published adult figures, further suggesting a developmental role in CAM-Type FAI. This is the first published attempt to assess CAM-type FAI morphology in the developing hip. Preliminary data suggests the period just prior to physeal closure may have significant etiological implications. New parameters for imaging angles are suggested. The study results will guide future cohort study designs

Purposes:. See if permanent damage of the growth plate after physeal distraction is the rule and. Identify factors with influence on the viability of the physis after physeal distraction. Introduction: Surgeons have always been concerned about the fate of the growth plate after physeal distraction and for that reason this technique has usually been considered only in patients nearing maturity. Previous experimental work has shown that the velocity of distraction has an influence on the viability of the growth plate at follow-up (recommended rate: 0.5 mm/day). Clinically, it has also been our observation that the condition of the physis prior to distraction is another important factor related to physeal function in the long term. Patients and methods: Since 1987 we have used low velocity physeal distraction in 43 bone segments of which 37 cases have been followed-up at least for 24 months and this has been the group included in this study. The indications were lengthening (14), angular deformity correction (19) and resection of benign bone tumours (4). Most patients (24) were older than 10 y.o. and 22 of them were followed-up until maturity. We have retrospectively reviewed these patients looking at the radiological morphology and function of the distracted growth plate at follow-up. Results: Out of the 24 children older than 10 y.o., twenty showed a premature complete physeal closure. We looked with interest at the 13 cases younger than 10 y.o. since the repercussions of iatrogenic physeal damage would obviously be bigger in this age group. Five out of the 13 showed premature closure and in the remnant eight an open growth plate was observed at follow-up. All patients with open and/or functioning physes after distraction had no local injuries in the growth plate prior to distraction (4 congenital short femora and 4 normal physes). On the contrary, four out of the five cases with prematurely closed physes, had a local physeal damage prior to distraction (3 bony bridges and one non-union), and the remnant was a congenitally short femur. Growth after distraction was difficult to assess in the congenitally short femora but it has been very satisfactory in the 4 cases of previously normal physes (2 benign tumours and 2 femoral shortenings due to hip disorders). In three cases of congenital short femur in pre-teenagers we were able to repeat distraction twice through the same physis, since it had remained open after the first distraction. Conclusions: Physeal premature closure often follows physeal distraction, but not always. The condition of the physis prior to lengthening is an important factor with influence on its viability after distraction

This study was performed to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction in children with open physes. Between 2001 and 2009, 31 knees in 29 patients with a mean age of 14.1 years (10-16) underwent transphyseal, arthroscopic ACL reconstruction using an autogenous four-strand hamstrings graft. The technique was identical to that used in the adult population in our unit, except that care was taken to ensure fixation did not cross the physes. The patients were followed up to the point of physeal closure at skeletal maturity. The mean length of follow up was 25 months. The primary outcome measure was graft survival. Functional outcome was measured using Lysolm scores, International Knee Documentation Committee (IKDC) scores and the Tegner activity scale. Post-operative clinical examination and radiological findings were also recorded. There were two cases of re-rupture following a further sports injury, one 12 months post-operative and one at six years. Both patients later had successful revision ACL reconstructive surgery. The re-rupture rate in this case series was 6%. Two patients underwent repair of a concomitant lateral meniscal tear at the time of surgery. The mean post-operative Lysolm score was 88 and the mean IKDC score was 88.1. The mean Tegner activity scale was 7.95. There was no evidence of growth disturbance radiologically or leg length inequality clinically. There was one case of deep infection which was successfully treated with two subsequent arthroscopic washouts. This study demonstrates that transphyseal arthroscopic ACL reconstruction using hamstrings graft and an ‘adult’ technique, in skeletally immature patients, provides good functional outcomes, has a low revision rate and is not associated with physeal growth arrest or disturbance

Out of a total of 112 children with displaced forearm shaft fracture treated with Percutaneous Kirschner (K) wire fixation in the past 9 years, 84 cases with fracture of both the radius and ulna were reviewed. 64 (76%) had fixation of both the radius and ulna, 10 (12%) the radius only and the other 10 (12%) the ulna only. In 60 (71%) patients were successful with one stage close reduction and pinning, while in the remaining 24 (29%) a semi- open reduction through a small incision was required. The K-wire was inserted through the radial styloid or the Lister tubercle for the radius, and through the tip of the olecranon for the ulna. All the patients reviewed were found to have good functional results with no non-union, deep infection or premature physeal closure at a mean follow-up of 48 months. Initial pre-operative shortening or translation of the fracture were associated with significantly higher chance of open reduction. We concluded that percutaneous K-wiring for forearm diaphyseal fracture in children is a convenient, effective and safe operation, with minimal complications

Purpose of study: The majority of children with cerebral palsy suffer from fixed flexion contractures of their knees. Procedures commonly used to correct these deformities include hamstring releases, anterior femoral hemi-epiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are unpopular because of the risk of permanent physeal closure. Soft tissue procedures are usually only partially effective, with a high recurrence rate. We present our initial experience of correcting of knee flexion deformities using the 8-plate technique which uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity. Method: The case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate technique between April 2005 and August 2006 were analysed. A total of 18 limbs in 12 patients underwent this procedure. The pre- and post-operative flexion deformity was measured with a goniometer. Results: The mean age of the patients was 12.8 years (range 9–16) and the mean follow up was 8.5 months (range 3–15). The mean correction achieved was 16.15 degrees (range 5–40). Conclusions: This is a simple technique with a learning curve of 1 case and with few complications to date. All patients in our series have shown sustained gradual correction. We also present technical tips in the use of the 8-plate for anterior femoral hemi-epiphyseodesis

Purpose. To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix). Methods. We reviewed case notes and radiographs of 71 children (130 segments) with lower limb deformities treated with temporary hemiepiphyseal arrest using the 8-plate. 96% of deformities were in the coronal plane, 4% sagittal. 72% of coronal deformities demonstrated valgus malalignment. We defined three types of complications:. early (perioperative) complications eg infection and/or wound breakdown, bleeding, neurological impairment. implant related complications such as soft tissue irritation, plate breakage or migration,. complications involving the growth plate including rebound deformity, early physeal closure or iatrogenic deformity. Complications were related to variables of patient age, gender, diagnosis, location of deformity and associated surgery. Results. The average age at surgery was 10 years (range 3-16). There were 41 boys, 30 girls. 3/70 patients were treated for an idiopathic deformity: the remainder were affected by a wide range of pathologies (20% skeletal dysplasia, 20% metabolic bone disease). Full correction has occurred in 38% of patients. The remaining 45 children are all showing improvement in their deformity. 10 patients (14%) have had a complication: 3 patients had early complications (wound infection, wound breakdown and intra-operative hypotensive crisis) and 2 patients have had implant related complications (irritation and migration). In a further 5 patients there have been physis related problems: 1 over-correction, 1 recurrence and 3 cases in which the timing of the procedure or the ill-health of the physis did not allow correction to occur. Conclusion. The 8-plate is an effective device in the management of deformity secondary to pathological conditions. 10% of patients had complications: the majority were minor but care should be taken regarding the timing of the procedure related to the growth potential of the pathological physis

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity. Materials and Methods: We analysed the case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate techinique between April of 2005 and August 2006. A total of 18 limbs in 12 patients underwent this procedure. Preoperative and post operative flexion deformity was measured using a goniometer. All measurements were made by the senior surgeon. Results: The mean age of the patients was 12.8 years (range between 9–16). Mean follow up time for the patients after they had undergone the procedure was 8.5 months (range 3 – 15). The Mean correction achieved – 16.15 degrees (range 5 – 40). Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date. We also present technical tips in the 8-plate anterior femoral hemi-epiphyseodesis procedure

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity. Materials and Methods: We reviewed a consecutive series of 25 children with fixed flexion deformity of the knee who underwent anterior femoral hemiepiphysiodesis using a two-hole plate (8-plate) between April 2005 and April 2008. The pre-operative and postoperative knee flexion deformity (in degrees) and complication rates were also recorded. Paired t-Test was undertaken to assess the correction in the fixed flexion deformity post-operatively. Results: Total number of patients – 25, male:female = 19:6. Total number of limbs – 46. The mean age of the patients was 11.04 years (range between 4–16). Mean follow up time for the patients after they had undergone the procedure was 16.2 months (range 3 – 34). The Mean correction achieved − 21.52 degrees (range 5 – 40). Mean correction per month − 2.05 degrees. A paired ‘t’ test showed the correction was found to be highly statistically significant (p value < 0.001). Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date

The purpose of this study is TO describe and illustrate a new method of reversible hemi-physeal tethering utilized for correcting various angular deformities of the extremities. Since hemi-physeal stapling was first introduced by Dr. Blount in 1950, this method has waxed and waned in popularity. Some associated problems include staple migration or breakage necessitating premature revision surgery. The author has devised a new construct comprising a two-hole plate and two screws to achieve gradual correction of deformities while averting the problems of hardware migration or breakage. In a pilot study, 25 children with 40 physeal deformities have been treated since 2001 utilizing the plate method. The children ranged in age from 19 months to 15 years and had a variety of underlying diagnoses. The plate is placed extraperiosteally and is removed upon attaining a neutral mechanical axis. No postoperative immobilization or limitation of weightbearing is required. In all cases short-term follow-up reveals improvement or resolution of deformity without need for osteotomy. Complications have included two early migration of short screws (< 16 mm) necessitating exchange for longer screws. There have been no premature or permanent physeal closures and no other significant peripoerative complications. Growth guidance employing a two hole plate and screws offers a secure and flexible means of redirecting the physis (es) in order to accomplish safe and gradual correction of angular deformities in children. Growth is reversible; the treatment is modular and may be repeated prn

Purpose of study: To evaluate the results of a consecutive series of displaced intracapsular paediatric femoral neck fractures treated by early closed reduction and Austin Moore Pin fixation. Method: Between 2001 and 2004, 14 paediatric patients with a mean age of 10 years suffering femoral neck fractures were identified. All traumatic epiphyseal, trans-cervical and basi-cervical femoral neck fractures were included. Pathological and intertrochanteric fractures were excluded. There were 11 male and 3 female patients. All patients were treated by reduction and internal fixation using Austin Moore pins. Patients were allowed to mobilize non-weight bearing with crutches for 3 months, followed by partial to full weight bearing. The mechanism of injury, associated injuries, time to reduction and time to union were reviewed. All patients were followed up till union. Mean follow up was 18 months. Patients were assessed clinically for pain, limp, use of walking aid, walking distance, stair climbing, cross leg sitting and squatting. Hip movements and limb length discrepancy were noted. Radiographs were analyzed to determine the adequacy of reduction, fracture healing and changes of avascular necrosis (AVN). Results: Mean injury-operation interval was 38.5 hours. Mean time to union was 16 weeks. All patients had excellent initial reduction which was maintained till healing. All patients’ fractures healed uneventfully. There were no complications in the form of non-union, AVN, premature physeal closure, angular deformity or implant back-out. Conclusions: Paediatric femoral neck fractures can be treated successfully with expeditious reduction and internal fixation. The risk of the devastating complication of AVN can be lessened with urgent surgery and near anatomical reduction

We appraised whether deformity of the inferior limbs, routinely treated with external fixation (EF), can be corrected when synthesis with locked intramedullary nails is associated with the synthesis and what the indications are. In all, 24 patients with a deformity of the inferior limbs treated between 1997 and 2003 were included in the study and divided into two groups: (1) patients with external fixation, average 23 years, deformity axial 20° (9–28°); and (2) patients with osteotomy and interlocked nailing. average 35 years, deformity axial 16° (10–25°). The indications for treatment with interlocked nail were set according to the following criteria: (a) possibility to correct the deformity with only restoration of the anatomical axis without necessity of lengthening; (b) previous use of EF; (c) EF refused by the patient, and (d) physeal closure. In both groups complete correction of the deformity was achieved. In the group of patients treated with EF the time of consolidation was on average 5.5 months (range 4–8 months). In this group the time of consolidation proportionally increased to time required to effect a bone lengthening. In the group of patients treated with osteotomy and nailing the times of consolidation were different with respect to age, to the side and the type of osteotomy and to the type of deformity. The time of consolidation was 7 months (range 3–12 months). The most rapid consolidation corresponds to the congenital deformities treated with oblique osteotomy. Correction of deformities by osteotomy and interlocked nail introduces the advantage of not limiting joints and immediate correction of the angular and rotatory deformity. The indication for this technique is that there is no residual hypometry. In this case the treatment of choice is corticotomy and external fixation

Treatment of patellar instability in adolescents is controversial. Some investigators have advocated early repair of the medial structures, whereas others have treated this injury nonoperatively. The medial patellofemoral ligament, is a primary restrictor and stabilizer of the patella, and has acquired a significant role in the treatment of instability in children and adolescents. The authors present a prospective study of 39 consecutive patients (45 knees), without physeal closure, who underwent plasty of the medial patellofemoral ligament for the treatment of symptomatic patellofemoral instability with autologous Gracilis tendon, according to Chassaing’s technique. There were 26 female and 13 male patients with an average age of 15, 9 years. Mean follow-up was 44 months (6–65). All patients presented with clinical evident patellar tilt. This population presented a TA-GT within a normal range (12+/− 5 mm), but presented in 80% of cases a trochlear dysplasia. Clinical functional results were evaluated using the Kujala scale. Arthroscopic evaluation was systematically performed searching for intra articular injuries or patellar tilt. Early rehabilitation protocols were used in all cases. At the last follow up evaluation, 90% of the patients presented good or very good results. Kujala Score was 84, 5 +/−9,7 after surgery compared with 54,9+/−11,8 before surgery (p< 0,0001). There were 3 minor complications: 2 hematomas and 1 superficial infection that resolved without complications. Four patients kept complaining of residual anterior knee pain as result of patellar chondropathy that was diagnosed intra operatively. Three patients complained of graft donor site pain. One patient presented with a patellar dislocation three years after the surgery, and two patients still present clinical instability two years after the procedure. There was no stiffness in the knee in any patient. The technique presented in this study has allowed very good clinical results, with few complications, using a small incision to reconstruct in an isometric fashion, this important patellar stabilizer

The majority of pediatric proximal humerus fractures are successfully treated non-operatively. Significantly displaced fractures have traditionally been treated surgically with percutaneous pinning. This review of twenty-three surgically treated patients demonstrates a high rate of infection associated with percutaneous pinning. The technique of cannulated screw fixation offers a safe surgical alternative for the treatment of these fractures in the adolescent population. To compare the results of percutaneous pinning to cannulated screw fixation for the treatment of pediatric proximal humerus fractures. A high complication rate, including pin tract infection and loss of reduction, was observed in the percutaneous pinning group. Given the rigid fixation afforded by cannulated screws and the minimal morbidity associated with proximal humeral physeal arrest in the older adolescent, this technique offers a safe alternative for the treatment of proximal humerus fractures. Average age was 13.0 years for the pinning group and 14.7 years for the cannulated screw group. Regardless of fixation technique, all fractures healed completely with no difference in rates of physeal closure. Significant pin tract drainage was encountered in six of twenty patients treated with pinning: Two with Staphylococcus Aureus infection and one deep infection requiring surgical debridement. Loss of reduction and pin migration was noted in a seventh patient. The only complication observed in the cannulated screw group was a transient axial nerve paresthesia. There were no significant differences in operative time, rate of open reduction, or length of hospitalization (p> 0.05). Twenty-three pediatric proximal humerus fractures treated operatively over a seven-year period were followed clinically and radiographically. Thirty percent of the patients treated with pinning developed pin tract infections. Similar to femoral external fixation pins, proximal humeral pins also cross a large muscle group that may result in pin micro-motion. This may create persistent drainage that ultimately leads to infection

Introduction. Paediatric hip fracture accounts for less than one percent of paediatric fractures. Previous studies report complication rates between 20 and 92%. Method. We retrospectively identified patients with fixation for neck of femur fractures at Birmingham Children's Hospital. All patients were under age sixteen. Data were reviewed over a 10 year period (1997-2006). Fractures were classified by Delbet's classification and Ratliff's system to grade avascular necrosis (AVN). Function was assessed using Ratcliff's criteria, incorporating clinical examination and radiographic findings. Results. 15 femoral neck fractures were treated in 14 patients over a ten year period (R=1997-2006). One patient sustained bilateral fractures. Three patients had osteogenesis imperfecta and one osteopetrosis. Mean age at injury was 10.3 years (R=6-14 years). Mean follow-up was 31 months (R=6-110 months). Two fractures were Delbet type-I (13.3%), four type-II (26.7%), six type-III (40%) and three type-IV fractures (20%). Associated injuries included calcaneal fracture, head injury, pubic rami, acetabular and tibial fractures, hip dislocation, and depressed skull fracture with extradural haematoma. Eleven patients were operated on within 24 hours (R=4-19 hours) and four after 24 hours (R=2-11 days). One patient operated on within seven hours had a poor outcome. Premature physeal closure (PPC) occurred in all patients with physeal penetration (Fishers Exact test: p=0.077). The results were ‘good’ in 14 patients (93%) and ‘poor’ in one patient with Ratliff's Type I avascular necrosis (6.7%). This 13 year old male sustained a Delbet type 1 fracture with dislocation of the femoral epiphysis after a road traffic accident. The AVN and PPC rates were 6.7% and 33%. Coxa vara was diagnosed in two patients. One patient developed a significant leg length discrepancy (>2cm). Superficial wound infections occurred in two patients. No non-unions occurred. Conclusion. Complication rates are lower than historical studies

Introduction: Percutaneous epiphyseodesis is a simple method of achieving leg length equality in cases of minor leg length discrepancy, however few studies document its effectiveness. A retrospective study was undertaken to assess this. Materials and methods: Patient notes and radiographs were reviewed. The growth remaining method was used to estimate timing. Percutaneous epiphyseodesis was performed with a drill and curette under radiological guidance. Results: A total of 24 skeletally mature patients with a mean preoperative leg length discrepancy (LLD) of 2.8cm were identified. Skeletal age was significantly different from chronological age in 5 of 11 cases where it had been performed. In all patients, there was radiographic evidence of physeal closure soon after epiphyseodesis. At skeletal maturity, 14 patients have a LLD of 0–1cm and are considered to have a satisfactory outcome. 10 patients have a LLD> 2cms. In 6 of these, either presentation was too late or the amount of discrepancy too large for complete correction to be expected. In the other 4, skeletal age assessment may have been useful in 3, and in one additional case of overgrowth of the short limb prior to maturity. A successful outome was more likely when skeletal age assessment had been used (82% versus 57%). Of the 18 cases where there was sufficient time for a full correction to be achieved, the overall success rate was 72%. There were no significant clinical or radiological complications. Conclusions:. Percutaneous drill epiphyseodesis is an effective method of achieving physeal ablation with no significant complications. While the growth remaining method is a crude estimate of the timing of epiphyseodesis, it was accurate in the majority of cases in this small series. The determination of skeletal age was found to be a useful adjunct to management in a small proportion of cases

Slipped upper femoral epiphysis (SUFE) is an uncommon condition with potentially severe complications including avascular necrosis (AVN) and chondrolysis. Children with a ‘slip’ are at a significantly higher risk of a contralateral slip. Controversy remains as to when to undertake prophylactic pinning. The primary aim of this study was to assess the Posterior Sloping Angle (PSA, as described by Barrios et al in 2005) as a predictor for contralateral slip in a large, multi ethnic cohort. All consecutive patients treated for SUFE presenting to Waikato Hospital between January 2000 and December 2009 were identified via medical coding. Patients without radiographs and those with bilateral slips on presentation were excluded. Clinical records were reviewed to document demographic data, slip characteristics and follow up outcomes. Radiographic analysis of the PSA in the unaffected hip was performed by a single author. Statistical analysis was performed using a student's t-test with Microsoft Excel 2003. 182 patients were identified, 50 were excluded [26 bilateral slips, 24 no radiograph available] to total a study population of 132 patients. 93 patients were male [72%]. Mean age was 11.8 years [6.2–15.6 years]. 72% were of Maori ethnicity and 26% were of New Zealand European descent. 90 patients [69%] had a unilateral slip, 42 [32%] had a contralateral slip. 48% were not followed until physeal closure and 50% did not attend at least one scheduled appointment Mean PSA of those with a unilateral slip was 10.8° [2–21°]. Patients who subsequently developed a contralateral slip had a statistically significantly higher mean PSA of 17.2° [6–36°] [p<0.0001]. Children with a contralateral slip were significantly younger 11.1 years than those with a unilateral slip 12.2 years (p<0.0001). No significant differences in PSA were found between Maori and NZ European children. If a PSA of 14° was used as an indication for prophylactic fixation in this population 35/42 [83.3%] of contralateral slips would have been prevented. 19/90 hips would have been pinned unnecessarily. The number needed to treat demonstrates that 1.79 hips are prophylactically pinned to prevent one slip in this population. This large retrospective cohort study demonstrates that a PSA of 14° in an unaffected hip after one sided SUFE could warrant prophylactic pinning in an unaffected hip to prevent subsequent slip and the complications associated with this, potentially protecting a population that can be difficult to follow up

Distal femoral growth plate (DFGP) fractures were originally described as the ‘wagon wheel’ fractures, because they were noted to occur in the young boys who ran alongside wagons passing at speed and got their leg caught between the spokes. The resultant high energy injury was a forceful hyperextension and twisting of the knee. There was a significant incidence of severe complications with these injuries. In our setting, in a developing country, we noted that DFGP injuries appeared more common and tended to occur with a lower energy mechanism of injury. To investigate if this were a real phenomena, we designed a prospective study looking at DFGP injuries with the primary outcome measure being the mechanism of injury and the secondary outcome measures including method of fixation and functional outcome. The inclusion criteria for the study were all patients that presented with a DFGP fracture over a period of one year. There were no exclusion criteria. All data was collected prospectively on a standard proforma. Patients were treated according to a standard treatment regimen: where the fracture could be reduced closed and was stable, plaster cast only. Where a fracture could be reduced closed and was unstable, percutaneous pin fixation, where a fracture could not be reduced closed, open reduction and internal fixation. Forty-three patients were included in the study. 39/43 (91%) of the patients were boys, and the average age was 15.5 years (standard deviation, SD, 3.2 years). Thirty-three (77%) of the injuries resulted from low energy trauma, with the majority (28/33) resulting from sporting injuries, predominately football, with others having simple falls (3/33) or falling off bicycles (2/33). The 10 high energy injuries resulted from pedestrians (3/10) or cyclists (1/10) hit by cars and falling from a height (6/10). Some significant differences were seen in the mean ages of the high and low energy groups. The low energy group were significantly older, with a mean age of 16.3 years (SD 2.8 years) compared to 13.1 years (SD 3.1 years) for the higher energy group (Student’s t-test, p=0.004). When comparing the type of fracture, according to the Salter Harris classification, significantly more Salter Harris IV and V fractures were seen in the high energy group (Chi Squared test, p=0.039) compared to the low. Open fractures were 1/10 (10%) of the high energy group, but there were no open fractures in the low energy group. Complications including infection and amputation, only occurred in the high energy group. This is the first study to show, that in some countries, the DFGP injury may be more commonly due to a low energy mechanism of injury. The reasons for this may include delayed physeal closure, that has been previously shown in this group