The April 2024 Children’s orthopaedics Roundup360 looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.
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
Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide. All patients with SCFE who underwent fixation using FG SCFE screws after its introduction at our institution, with minimum three years’ follow-up, were reviewed retrospectively as part of ongoing governance. All pre- and postoperative radiographs were evaluated. The demographics of the patients, the grade of slip, the extent of lengthening of the barrel of the screw and the restoration of Klein’s line were recorded. Subanalysis was performed according to sex and age.Aims
Methods
Perthes’ disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths. All patients treated for PD in our institution between January 2013 and June 2020 were reviewed retrospectively. Patients with unilateral PD, LLD of ≥ 5 mm, and long-leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD), and subtrochanteric femoral length were compared between PD side and the unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis.Aims
Methods
Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer’s migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw.Aims
Methods
Preserving growth following limb-salvage surgery of the upper
limb in children remains a challenge. Vascularized autografts may
provide rapid biological incorporation with the potential for growth
and longevity. In this study, we aimed to describe the outcomes
following proximal humeral reconstruction with a vascularized fibular
epiphyseal transfer in children with a primary sarcoma of bone.
We also aimed to quantify the hypertrophy of the graft and the annual
growth, and to determine the functional outcomes of the neoglenofibular
joint. We retrospectively analyzed 11 patients who underwent this procedure
for a primary bone tumour of the proximal humerus between 2004 and
2015. Six had Ewing’s sarcoma and five had osteosarcoma. Their mean
age at the time of surgery was five years (two to eight). The mean
follow-up was 5.2 years (1 to 12.2).Aims
Patients and Methods
The treatment of late presenting fractures of the lateral humeral
condyle in children remains controversial. We report on the outcome for 16 children who presented with a
fracture of the lateral humeral epicondyle at a mean of 7.4 weeks
(3 to 15.6) after injury and were treated surgically.Aims
Methods
Two types of fracture, early and late, have been
reported following limb lengthening in patients with achondroplasia (ACH)
and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72
segmental limb lengthening procedures involving the femur and/or
tibia, between 2003 and 2011. Gender, age at surgery, lengthened
segment, body mass index, the shape of the callus, the amount and
percentage of lengthening and the healing index were evaluated to determine
predictive factors for the occurrence of early (within three weeks
after removal of the fixation pins) and late fracture (>
three weeks
after removal of the pins). The Mann‑Whitney U test and Pearson’s
chi-squared test for univariate analysis and stepwise regression
model for multivariate analysis were used to identify the predictive factor
for each fracture. Only one patient (two tibiae) was excluded from
the analysis due to excessively slow formation of the regenerate,
which required supplementary measures. A total of 24 patients with
70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of
the callus (lateral or central callus) was the only statistical
variable related to the occurrence of early fracture in univariate
and multivariate analyses. Late fracture was observed in six limbs
and the mean time between removal of the fixation pins and fracture
was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing
index, and lateral or central callus were related to the occurrence
of a late fracture in univariate analysis. A multivariate analysis
demonstrated that the shape of the callus was the strongest predictor
for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91
to 128). Lateral or central callus had a significantly larger risk
of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction
is important to prevent early and late fracture of lengthened limbs
in patients with ACH or HCH. In patients with thin callus formation,
some measures to stimulate bone formation should be considered as
early as possible. Cite this article:
Fractures of the femoral neck in children are
rare, high-energy injuries with high complication rates. Their treatment has
become more interventional but evidence of the efficacy of such
measures is limited. We performed a systematic review of studies
examining different types of treatment and their outcomes, including
avascular necrosis (AVN), nonunion, coxa vara, premature physeal
closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies
were included, comprising 935 patients. Operative treatment and
open reduction were associated with higher rates of AVN. Delbet
types I and II fractures were most likely to undergo open reduction
and internal fixation. Coxa vara was reduced in the operative group,
whereas nonunion and PPC were not related to surgical intervention. Nonunion
and coxa vara were unaffected by the method of reduction. Capsular
decompression had no effect on AVN. Although surgery allows a more
anatomical union, it is uncertain whether operative treatment or
the type of reduction affects the rate of AVN, nonunion or PPC,
because more severe fractures were operated upon more frequently.
A delay in treatment beyond 24 hours was associated with a higher
incidence of AVN. Cite this article:
This study evaluated the effect of limb lengthening
on longitudinal growth in patients with achondroplasia. Growth of
the lower extremity was assessed retrospectively by serial radiographs
in 35 skeletally immature patients with achondroplasia who underwent
bilateral limb lengthening (Group 1), and in 12 skeletally immature
patients with achondroplasia who did not (Group 2). In Group 1,
23 patients underwent only tibial lengthening (Group 1a) and 12 patients
underwent tibial and femoral lengthening sequentially (Group 1b). The mean lengthening in the tibia was 9.2 cm (59.5%) in Group
1a, and 9.0 cm (58.2%) in the tibia and 10.2 cm (54.3%) in the femur
in Group 1b. The mean follow-up was 9.3 years (8.6 to 10.3). The
final mean total length of lower extremity in Group 1a was 526.6
mm (501.3 to 552.9) at the time of skeletal maturity and 610.1 mm
(577.6 to 638.6) in Group 1b, compared with 457.0 mm (411.7 to 502.3)
in Group 2. However, the mean actual length, representing the length
solely grown from the physis without the length of distraction,
showed that there was a significant disturbance of growth after
limb lengthening. In Group 1a, a mean decrease of 22.4 mm (21.3
to 23.1) (4.9%) was observed in the actual limb length when compared
with Group 2, and a greater mean decrease of 38.9 mm (37.2 to 40.8)
(8.5%) was observed in Group 1b when compared with Group 2 at skeletal
maturity. In Group 1, the mean actual limb length was 16.5 mm (15.8 to
17.2) (3.6%) shorter in Group 1b when compared with Group 1a at
the time of skeletal maturity.
Hip arthroscopy is particularly attractive in
children as it confers advantages over arthrotomy or open surgery,
such as shorter recovery time and earlier return to activity. Developments
in surgical technique and arthroscopic instrumentation have enabled
extension of arthroscopy of the hip to this age group. Potential
challenges in paediatric and adolescent hip arthroscopy include
variability in size, normal developmental change from childhood to
adolescence, and conditions specific to children and adolescents
and their various consequences. Treatable disorders include the
sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’
disease and slipped capital femoral epiphysis, and the arthritic
and septic hip. Intra-articular abnormalities are rarely isolated and
are often associated with underlying morphological changes. This review presents the current concepts of hip arthroscopy
in the paediatric and adolescent patient, covering clinical assessment
and investigation, indications and results of the experience to
date, as well as technical challenges and future directions.
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.
A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3° and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7° per month in the femur (0.3° to 1.5°), 0.5° per month in the tibia (0.1° to 0.9°) and 1.2° per month (0.1° to 2.2°) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered. The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.
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,
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
Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes
Proximal Radius – Fractures of the proximal radius in children account for slightly more than 1% of all children’s fractures, represent 5 to 10% of all elbow fractures and accounts for 5% of all fractures involving the growth plate. The average age in the literature is 10 years (4 to 16 years) with no difference between boys and girls. The anatomical aspects should be emphasized for the comprehension of this fracture: 1) the radial head of the child only starts to ossify at age 5 so it is very rare to have a fracture before this age since all the head is cartilaginous and therefore more resistant to trauma. At the same time it makes more difficult the diagnosis because of the absence of ossification of the epiphysis. 2) There is a valgus angulation of 12.5° between the radial head and the shaft of the radius in the AP plan and an anterior angulation of 3° on the lateral plane that should not be misinterpreted as fractures. 3) The radial head is intrarticular in a similar way like the femoral head and trauma to this region may lead to AVN as a result of damage to the vascular supply of the epiphysis. 4) The proximal radioulnar joint has a very intimate continuity contributing to exact congruence of the articular surfaces. The axis of rotation lies directly in the center of the radial neck. Any deviation of the epiphysis over the neck has a major reflect over the axis of rotation causing a “cam” effect when the radial head rotates with loss of pronosupination. The mechanism of injury responsible for this injury result from a fall on the outstretched upper extremity in which the elbow is extended and a valgus force is applied to the elbow joint. In more rare cases it result from direct pressure to the radial head during dislocation of the elbow. There are different classifications mostly based on the anatomical lesion or degree of deformity. Wilkins divides this fracture in two major groups: Group I (valgus fracture) subdivided in three types: type A – the Salter-Harris type I and II, type B – Salter-Harris type IV and type C – fractures involving only the proximal radial metaphysis and Group II (fractures associated with elbow dislocation) subdivided in two types: type D – reduction injuries and type E – dislocation injuries. O’Brien divides the common valgus injury in three types according to the degree of angulation between the radial head and the axis of the radius: Type I (0 to 30° angulation) Type II (between 30° and 60°) and Type III (more than 60°). The clinical symptoms may vary according to the magnitude of the injury. The child will mostly complaint of pain and tenderness on the lateral side of the joint. In young children pain may first be referred to the wrist. The pain usually increases with pronosupination and extension of the elbow. The diagnosis relies mostly on the x-ray view (AP and lateral) and the fracture will be easily visualized in either film. In the cases where the fracture line is superimposed over the ulna an oblique view will be necessary. In the young child, whereas the epiphysis is still not ossified, an ultrasound may be helpful differentiating the position of the radial head. An arthrogram may also be of benefit especially during the process of reduction to check the accuracy of the treatment. The prognosis of this lesion depends on several factors. A poor result can be expected if the fracture is associated with other injuries such as elbow dislocation and ulna or medial epicondylar fractures. A residual tilt of the radial head, provided is not superior to 30°, is more tolerable than a translocation of the radial head superior to 4mm. Age is also an important factor since the older the child the less remodeling it will have. The treatment has also an important role in the prognosis of this injury since it is unanimous acceptable that an open reduction is associated with poor results. Therefore the treatment of a young child with an isolated minimal displaced fracture-separation of the proximal radius (less than 30°) should be a simple long arm cast. In a more displaced fracture (more than 30° of tilt) a closed reduction should be performed under general anesthesia as suggested by Patterson. If the maneuver is not successful other attempts should be made with lateral pin compression applied directly to the radial head as suggested by Pesudo or an indirect reduction by an intramedullary kirschner wire as suggested by Metaizeau. Open reduction should be only reserved for dislocated Grade IV Salter-Harris type fractures, incarcerated radial head or in the presence of failure of closed treatment. The incidence of complications especially if associated with a dislocation of the elbow or other fractures can be high. The most common are loss of motion, radial head overgrowth usually with no clinical significance, notching of the radial neck and
