Aims

The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

Abstract. In the pediatric population, scoliosis is classified into congenital, syndromic, idiopathic, and neuromuscular in aetiology. Syndromic scoliosis represents a wide range of systemic anomalies associated with scoliosis. The primary challenge for a clinician is to think beyond the scoliotic curve, as the underlying pathology is multisystemic. The aim of this review is to identify the systemic anomalies, associated with syndromic scoliosis. MEDLINE, EMBASE, and CINAHL databases were searched, dating from 1990–2020, relevant to the purpose of our study. Keywords used: “scoliosis”+ “syndrome” + “genetic”. Retrospective, prospective studies were included. Case reports that had fewer than 4 patients were not included. Delineating 60 articles, we found a total of 41 syndromes to be associated with scoliosis. Thoracic region was the most common level of scoliosis curve, being noted in 28 syndromes. Mental retardation, seizures, and ataxia were the commonly noticed CNS anomalies. VSD, ASD, and TGA were the anomalies associated with CVS; Hypotonia, rib and vertebral malformations were the most identified neuromuscular anomalies; pulmonary hypoplasia, renal agenesis, and strabismus were other associations. A multidisciplinary approach, involving spinal surgeons, paediatricians, geneticists, anesthesiologists, and allied health professionals, is vital for the best care of patients with syndromic scoliosis. The location of the scoliotic curve reflects the associated anomalies, as thoracic curvature is more closely linked with cardiac anomalies, while lumbosacral curvature is seen to be often linked with genitourinary anomalies. We hope that this article provides a clear overview of the systemic associations in syndromic scoliosis and thus, facilitates and streamlines the management protocol

The aim of this study was to ascertain the results and effectiveness of targeted screening of babies. All the newborn babies (30585 births from 1997 to 2002) in the geographical area served by our trust were assessed by the paediatricians (neonatologists) and general practitioners (GP). They were assessed for abnormal hip examination finding including clinical instability and risk factors for DDH. The risk factors were positive family history, abnormal lie or presentation other than vertex during pregnancy or at birth, oligohydramnios or other congenital abnormalities. On referral, they were assessed clinically and by ultrasound (US) scan in a special Hip screening clinic. The data were obtained prospectively. Over the period of these six years, 2742 babies were examined in the clinic. Many had more than one risk factor or abnormal hip examination finding (15.9% of babies with abnormal hips and 7.4% of babies with normal hips). Only five babies presented at or after 4 months of age (delayed presentation). They had been treated by the GP (1 patient), at a private hospital (1 patient) or were from outside our area (3 patients). All had abnormal hips on clinical examination. Of these, 3 were 3A or 3B Graf grade (US scan), 1 was 2B and another 2A+. Screening of babies with above risk factors has identified all patients with abnormal hips in our area, thus avoiding late presentation of DDH. Raising awareness of GPs and paediatricians about these factors should also reduce the number babies to be seen in the hip screening clinic to minimum yet safe levels

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Aims

Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app).

Background and Aims:. In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients. Methods:. We looked at patients seen in the clinic from January 2013 to March 2014. We recorded the age, gender and primary caregiver. We also recorded the reason for referral. Clinically we wanted to know the type and distribution of the CP, GMFCS score, attainment of milestones and type of schooling. We recorded underlying aetiologies and HIV status of the patients. Finally the access the patients had to physiotherapy and Occupational therapy. Results:. We saw 41 patients in total with 18 males and 23 females. The ages ranged from 5 months to 9 years (mean 4.9 years). 36 of 41 (88%) had spastic CP, 2 (5%) dystonic, 1 (2%) mixed and 2 (5%) were not recorded. Diplegic and hemiplegic predominated with 15 (37%) and 14 (34%) respectively, there were 6 (15%) quadriplegics, 1 double hemiplegic and 5 were not recorded. 13 (31%) of patients had birth asphyxia as an aetiology, 13 (31%) had brain anomalies, 9 (22%) were premature babies, the remaining 16% comprised HIV, post natal sepsis and injury. 38 (93%) were cared for by at least one parent and the remaining 3 (7%) were cared for by a grandparent. 39 (95%) had access to physiotherapy and 30 (73%) had access to occupational therapy. 21 (51%) had no access to appropriate schooling. 9 (22%) were known to be HIV positive. The recommended orthopaedic interventions were continued physiotherapy for 17 (41%) and botox in 22(54%). Discussion:. The combined clinic has highlighted the diverse nature of cerebral palsy and the challenges facing our patients. It is an invaluable tool in the goal directed management of complex cases

Introduction: The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial. Aim: To assess any improvement following upper limb Botulinum toxin A injections and to evaluate patient’s and parents’ expectation and satisfaction of the procedure. Method: During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with a mean age of 6 years old. A questionnaire was devised to assess the outpatient consultation, peri-operative care and the post-operative outcome. Subjective improvement and the patient’s and parents’ evaluation of the procedure were also recorded. Results: Good to excellent results were achieved in most areas. Daily activities were improved by 52% with an average duration of 4 months. The majority of the patient achieved their expectation. Most patients/parents were satisfied with the procedure and would consider further injections. Conclusions: Botulinum toxin A injection to the upper limb was generally well received with good short term results. Most would consider further injections

The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial, moreover only selected few orthopaedic surgeons have experience in managing it. The aim is to assess the functional improvement following an upper limb Botulinum toxin A injections to the upper limb and then to evaluate the patient’s and parents’ satisfaction after the procedure. During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with an age range between 2 to 17 years (average age was 2 years). Following the surgery, all patients received a course of an intense exercise regime with the physiotherapist and occupational therapist. All patients were prospectively followed-up by the clinic with no loss to follow-up. We also assessed the functional movement of the patients as well as the patient’s and parents’ subjective evaluation of the procedure. Overall, the range of movement of the upper limb has improved following the Botulinum toxin A injection. Most patients/parents were satisfied with the procedure and would consider further injection in the future. Botulinum toxin A injection to the upper limb is generally well received with good short term results. Many would consider further injections to sustain improve function

Renal failure in children is associated with a wide range of musculoskeletal disorders such as osteonecrosis, stress fractures, brown tumours, epiphysiolysis, joint infections and angular deformities. In this paper the authors report their experience concerning the surgical treatment of the angular deformities of the lower limbs in renal osteodystrophy (RO). Between 1995 to 2003, 10 children (five girls and five boys) with RO underwent surgical correction of angular deformities of the lower limbs. Of these, seven had femoral osteotomies because of knee deformities (three genu valgum, four genu varum) and three had osteotomies because of tibial angular deformity. The average age at surgery was 5 years (min. 2 years, max. 12 years). Different types of osteosynthesis were used (staples and cast, Ortho-fix and Ilizarov frames) according to the age of the child and the degree and the site of the angular deformities. All osteotomies healed without complications and the surgical correction was considered appropriate at the end of treatment. At an average follow-up of 4.5 years there was no significant relapse and no need for second surgery. Simple osteosynthesis (staples and cast) was most appropriate in the youngest children and in mildest deformities (particularly at the distal tibial metaphysis). External devices were more suitable in the oldest children and for genu valgum/varum deformities. To optimise the time of consolidation close collaboration with the paediatricians is required in order to perform surgery under the best metabolic conditions (elevation of the serum alkaline phosphatase concentration above 500/l is a good marker of bone metabolic healthy)

Aims

A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening.

Aims: The purpose of this study is the evaluation of the ultrasound screening process for DDH in a population of neonates from the prefecture of Chania, in Western Crete, an area with a history of excessively high incidence of DDH. Methods: Within the period between 1/7/99 and 1/7/01 (24 months) 1247 neonates (2494 hips) were examined clinically and ultrasonograþcally (transverse, oblique, dynamique views), all babies whose parents both descend from this area for generations. They were referred by a paediatrician for one or more of the following reasons: limited hip abduction (48%), hip laxity (6%), positive family DDH history (27%), musculoskeletal congenital abnormalities (11%), breech delivery (5.1%), paediatricianñs or parentsñ insecurity (18%).Results: We had the following þndings: signiþcant dysplasia-Graf III in 3.7%, milder dysplasia Ð Graf IIc, d in 7.2%, immature but satisfactory hips Ð Graf IIa, b in 19.3% and normal hips in 69.5% of the hips. Double diapers (sheets) were used in 43%, Frejka in 3% and Pavlik harness in 4.2% of the cases. In two cases the dysplasia persisted and we had to use a spica cast. Satisfactory results have been observed in all but one case. X-ray control was necessary in six children. Conclusion: Hip ultrasound, in experienced hands, is a safe, quick, well tolerated, non-inventory method for DDH screening, treatment and follow-up in neonates Ð babies in their þrst year of life

Aims

The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures.

Accepted treatment for acute septic arthritis in children involves drainage of the pus and systematic antibiotics. Review of published studies show that there is a tendency for paediatricians and physicians to drain pus by aspiration and for surgeons to drain the pus by arthrotomy and surgical lavage. There is however no published prospective study comparing the two methods of drainage. 201 consecutive children under 13 (134 boys and 67 girls) presenting to our hospital with acute septic arthritis were entered into a prospective study and randomised to either aspiration of the joint with a 14g needle or arthrotomy and lavage. Both groups had systematic antibiotics for six weeks. All patients were followed up with clinical examination and x-rays at 2, 6, 12, 24 and 52 weeks. There were 102 patients in the aspiration group and 99 in the lavage group. Both groups were similar in respect to mean age (2 yrs 5m and 2 yrs 10m respectively) and both groups had had symptoms for a mean of 6. 5 days. The commonest joint involved in both groups was the knee, followed by the shoulder, and the commonest organism involved was salmonella, followed by staphylococcus aureus. Aspiration failed in 9/102 patients who then underwent arthrotomy. Aspirated cases were discharged at a mean of 7. 9 days compared to 9. 8 days in the lavage group. There is no published method of measuring clinical improvement in septic arthritis so we devised the Blantyre septic joint score (BSJS) which measures pain, swelling, range of motion and function. Using the BSJS we found significant difference in scores between the aspirated and the lavage groups at any stage of follow up. We could not demonstrate any difference in clinical outcome between aspiration and arthrotomy with lavage in the treatment of septic arthritis

Aims

The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care.

Purpose: The prognosis of congenital hip displacement basically depends on the time of diagnosis and treatment. Recognising high-risk hips early remains a number one priority. We conducted a prospective study over a 20-year period from 1992 to 2002 to analyse the epidemiology of congenital hip displacement. Material and methods: The series included 1056 children with congenital hip disease (1491 hips). Epidemiological data, ultrasound and x-ray findings were recorded over 20 years. The objective was to identify risk factors and evaluate the impact of prevention measures. Results: The sex ratio showed female predominance, 6:1. The left hip was involved 1.8 times more often, with 41% bilateral involvement. Risk factors were major: family history (31%), breech presentation (25%), postural syndrome (12%); or minor: primiparity (54.4%), birth weight > 4 kg (9.2%). One or more major risk factors were found in 60.5% of the children and 30% had at least one minor risk factor. No risk factor was found in 40%. Screening efficacy improved with a rate of diagnosis before 4 months of 59% in 1983 and 96% in 2002. The number of hips discovered after the age of one year was 15% in 1983 and 6% in 2002. Discussion: The severity of the hip displacement is not influenced by risk factors nor bilateral involvement. Screening has enabled earlier diagnosis with a 37% increase in the rate of identification before the age of four months. This has been made possible by a systematic examination at birth and ultrasonography introduced in 1989. Conclusion: A regional map showing the paediatrician : maternity : general practitioner distributions is an important tool for screening campaigns. Despite adequate screening 40% of these children do not have any risk factor. Repeated examinations, communication and information exchange between healthcare professionals are the keys to success

Purpose: To evaluate the real effectiveness of orthopaedic prenatal diagnosis. Introduction: Sonographic early detection of fetal club foot, spine abnormalities like “spina bifida” or spondylocostal ‘” dysostosis, limb discrepancy have been often reported in prenatal orthopaedic diagnosis. But in all these cases the role of the orthopaedic surgeon is secondary: In the case reported the joined evaluation of obstetrician and orthopaedic surgeon was able to anticipate delivery, avoid a severe and constrictive amniotic band on the lover limb which might cause an amputation of the ankle and foot. Material and methods: At 25th week of pregnancy a morphologic sonographic examination was carried out in a Caucasian healthy woman. It demonstrated an healthy male fetus presenting a constrictive amniotic band on the distal right leg causing a mild oedema of the foot. Four weeks later the oedema of ankle and feet was dramatically increased and on the distal tibia an initial notch on the cortex was observed. The risk of self-amputation in utero was high, so a decision to bring forward delivery was made by a obstetrician, and paediatrician orthopaedic surgeon. In the last two weeks of uterine life the fetus was treated to obtain a satisfactory lung maturity and at 32nd week a caesarean delivery was carried out. The baby, normal, (agar score 7–9, 2750 kg.) presented a tremendous oedema of the dorsal foot causing a complete disappearance of normal shape. The skin constriction was detected on the distal leg deeply extended to the bone. An X -ray early performed showed a lesion of the anterior margin of the tibia. A Sonographic Doppler of the distal leg was able to demonstrate vascular normality so at the age of two days the baby was admitted to the plastic and reconstructive surgery for the release of the amniotic band and for reductive surgery of foot’s redundant tissue. The follow-up was good with a temporary oedema post-surgery. In 60 days the appearance of the foot was satisfactory normal. Discussion: The ultrasonographic prenatal diagnosis of an amniotic band in the reported case probably has been able to avoid an amputation of the distal lower limb. The aim of this communication is to stress the role of the prenatal diagnosis in paediatric orthopaedic to emphasize the importance of early detection of congenital skeletal abnormalities. Severe and stiff club-foot, congenital “genu recurvatum” and amniotic band as. well, ought to be treated as soon as possible. Therefore, when diagnosed in selected pregnancies, if the fetus is healthy and the lung maturity is obtained with corticosteroIds and sulfactante factor sommmlstratlon, we advise a premature delivery never before 32nd week of intrauterine life. At this stage the deformities are less stiff and every treatment (manipulation, bandage, casting) offers better results and less risk

Introduction: Infants referred under the Hip Screening Programme undergo both a clinical and ultrasonic assessment of hip stability. The majority are reviewed for repeat clinical assessment and X-ray of the hips before a diagnosis of DDH will be excluded. If we could safely rely on the ultrasound findings, then the number of children routinely reviewed with a hip radiograph could be reduced. As a result, many children would avoid the unnecessary and potentially harmful exposure to radiation. In addition, the burden on both the Orthopaedic Outpatients Department and the Radiology Department could be eased. Objective: The aim of the study was to assess the sensitivity of the ultrasound screening programme for DDH over a four year period. Study Design: A retrospective review of the 501 infants referred for hip screening between January 1997 and December 2000. Results: 28 patients were treated for DDH during the period of January 1997 to December 2000. Thirteen patients (46.4%) of those treated for DDH were referred via the Hip Screening Programme after their initial baby check by the paediatricians showed that they had a risk factor. The risk factors include Family History, Breech Deliver, and clinical instability. The remaining fifteen patients (53.6%) were referred via GP’s, Health Visitors and Paediatricians, following abnormal clinical findings ranging from ‘clicky hip’, abnormal skin creases, and decreased hip abduction at follow up baby checks. The average age of the infant in this group was 5.5 months. These 15 were diagnosed with X-ray only. All patients (501 patients) referred via the Hip screening programme underwent an ultrasound scan of both hips initially, and a pelvic X-ray 4–6 months after this. We identified 5 cases where the ultrasound had originally been interpreted as normal, yet the infant developed DDH as diagnosed by a later X–ray. Five infants (38.5%) of the thirteen diagnosed with DDH via the screening programme is unacceptable. These five infants could easily have been missed until they were a lot older, and subsequently their prognoses would have been worse. Three (20%) of the fifteen patients diagnosed with DDH which were not referred via the Hip Screening Programme had an identifiable risk factor at birth, yet were not sent for orthopaedic review and ultrasound examination via the Screening Programme. Conclusion: Normal ultrasound scan does not exclude a subsequent diagnosis of Developmental Dysplasia of the hip. X-ray is still considered the gold standard in assessing a child’s hips. Both the performance and interpretation of the hip ultrasound is skill with a steep learning curve and, for the meantime, will have to go hand in hand with pelvic X-rays in diagnosing DDH

Aims

To assess if congenital foot deformity is a risk factor for developmental dysplasia of the hip (DDH).

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.