Aims

To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures.

Aims. The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. Methods. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders. Results. The systematic review and interviews identified 85 outcome domains as relevant to professionals or families. The Delphi survey prioritized 30 upper and 29 lower limb outcome domains at first round, an additional 17 upper and 18 lower limb outcomes at second round, and four additional outcomes for upper and lower limb at the third round as important domains. At the consensus workshop, the core outcome domains were agreed as: 1) pain and discomfort; 2) return to physical and recreational activities; 3) emotional and psychosocial wellbeing; 4) complications from the injury and treatment; 5) rturn to baseline activities daily living; 6) participation in learning; 7) appearance and deformity; and 8) time to union. In addition, 9a) recovery of mobility and 9b) recovery of manual dexterity was recommended as a core outcome for lower and upper limb fractures, respectively. Conclusion. This set of core outcome domains is recommended as a minimum set of outcomes to be reported in all trials. It is not an exhaustive set and further work is required to identify what outcome tools should be used to measure each of these outcomes. Adoption of this outcome set will improve the consistency of research for these children that can be combined for more meaningful meta-analyses and policy development. Cite this article: Bone Joint J 2021;103-B(12):1821–1830

Aims. This study evaluates the quality of patient-reported outcome measures (PROMs) reported in childhood fracture trials and recommends outcome measures to assess and report physical function, functional capacity, and quality of life using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards. Methods. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of OVID Medline, Embase, and Cochrane CENTRAL was performed to identify all PROMs reported in trials. A search of OVID Medline, Embase, and PsycINFO was performed to identify all PROMs with validation studies in childhood fractures. Development studies were identified through hand-searching. Data extraction was undertaken by two reviewers. Study quality and risk of bias was evaluated by COSMIN guidelines and recorded on standardized checklists. Results. Searches yielded 13,672 studies, which were screened to identify 124 trials and two validation studies. Review of the 124 trials identified 16 reported PROMs, of which two had validation studies. The development papers were retrieved for all PROMs. The quality of the original development studies was adequate for Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility and Upper Extremity and doubtful for the EuroQol Five Dimension Youth questionnaire (EQ-5D-Y). All other PROMs were found to have inadequate development studies. No content validity studies were identified. Reviewer-rated content validity was acceptable for six PROMs: Activity Scale for Kids (ASK), Childhood Health Assessment Questionnaire, PROMIS Upper Extremity, PROMIS Mobility, EQ-5D-Y, and Pediatric Quality of Life Inventory (PedsQL4.0). The Modified Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was shown to have indeterminate reliability and convergence validity in one study and PROMIS Upper Extremity had insufficient convergence validity in one study. Conclusion. There is insufficient evidence to recommend strongly the use of any single PROM to assess and report physical function or quality of life following childhood fractures. There is a need to conduct validation studies for PROMs. In the absence of these studies, we cautiously recommend the use of the PROMIS or ASK-P for physical function and the PedsQL4.0 or EQ-5D-Y for quality of life. Cite this article: Bone Joint J 2020;102-B(12):1599–1607

Aims. Torus fractures are the most common childhood fracture, accounting for 500,000 UK emergency attendances per year. UK treatment varies widely due to lack of scientific evidence. This is the protocol for a randomized controlled equivalence trial of ‘the offer of a soft bandage and immediate discharge’ versus ‘rigid immobilization and follow-up as per the protocol of the treating centre’ in the treatment of torus fractures . Methods. Children aged four to 15-years-old inclusive who have sustained a torus/buckle fracture of the distal radius with/without an injury to the ulna are eligible to take part. Baseline pain as measured by the Wong Baker FACES pain scale, function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb, and quality of life (QoL) assessed with the EuroQol EQ-5D-Y will be collected. Each patient will be randomly allocated (1:1, stratified by centre and age group (four to seven years and ≥ eight years) to either a regimen of the offer of a soft bandage and immediate discharge or rigid immobilization and follow-up as per the protocol of the treating centre. Results. At day one, three, and seven, data on pain, function, QoL, immobilization, and analgesia will be collected. Three and six weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the Wong-Baker FACES pain scale at three days post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardian. Cite this article: Bone Joint Open 2020;1-6:214–221

Aims. To analyze outcomes reported in trials of childhood fractures. Methods. OVID MEDLINE, Embase, and Cochrane CENTRAL databases were searched on the eighth August 2019. A manual search of trial registries, bibliographic review and internet search was used to identify additional studies. 11,476 studies were screened following PRISMA guidelines. 100 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Study quality was not evaluated. Outcomes reported by trials were mapped onto domains in the World Health Organization (WHO) International Classification of Function framework. Results. In all, 525 outcomes were identified representing 52 WHO domains. Four domains were reported in more than 50% of trials: structure of upper/lower limb, sensation of pain, mobility of joint function, and health services, systems and policies. The Activities Scale for Kids performance (ASK-p) score was the most common outcome score reported in 6/72 upper limb and 4/28 lower limb trials. Conclusion. There is a diverse range of outcomes reported in trials of childhood fractures covering all areas in the International Classification of Functioning, Disability and Health (ICF) framework. There were three common upper limb and three common lower limb outcomes. In the absence of a core outcome set, we recommend that upper limb trials report pain, range of movement and radiograph appearance of the arm and lower limb trials report pain, radiograph appearance of the leg and healthcare costs to improve consistency of reporting in future trials. Cite this article: Bone Joint Open 2020;1-5:167–174

3D imaging is commonly employed in the surgical planning and management of bony deformity. The advent of desktop 3D printing now allows rapid in-house production of specific anatomical models to facilitate surgical planning. The aim of this pilot study was to evaluate the feasibility of creating 3D printed models in a university hospital setting. For requested cases of interest, CT DICOM images on the local NHS Picture Archive System were anonymised and transferred. Images were then segmented into 3D models of the bones, cleaned to remove artefacts, and orientated for printing with preservation of the regions of interest. The models were printed in polylactic acid (PLA), a biodegradable thermoplastic, on the CubeX Duo 3D printer. PLA models were produced for 4 clinical cases; a complex forearm deformity as a result of malunited childhood fracture, a pelvic discontinuity with severe acetabular deficiency following explantation of an infected total hip replacement, a chronically dislocated radial head causing complex elbow deformity as a result of a severe skeletal dysplasia, and a preoperative model of a deficient proximal tibia as a result of a severe tibia fracture. The models materially influenced clinical decision making, surgical intervention planning and required equipment. In the case of forearm an articulating model was constructed allowing the site of impingement between radius and ulnar to be identified, an osteotomy was practiced on multiple models allowing elimination of the block to supination. This has not previously been described in literature. The acetabulum model allowed pre-contouring of a posterior column plate which was then sterilised and eliminated a time consuming intraoperative step. While once specialist and expensive, in house 3D printing is now economically viable and a helpful tool in the management of complex patients

Aims

We present the clinical and radiographic outcome of 81 children with Gartland type I to III supracondylar humeral fractures at a minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following injury.

Aim. Although non-union is a devastating and costly consequence of trauma for the child, family and society it is felt to be a rare complication in children. Currently there is no data available in the literature regarding its incidence either per fracture or per head of population. Should we be taking paediatric fracture non-union more seriously regarding research, resource allocation and informed consent? Our aim was to determine the incidence of non-union per child and per fracture. Method. In Scotland Information Services Division (NHS Scotland) records every inpatient admission by ICD-10 diagnosis. As almost all fracture non-unions require intervention ISD provides accurate non-union figures by site and age. However, many fractures are treated as outpatients. Using local data of overall fracture numbers we were able to calculate a ratio of inpatient to total fracture numbers and apply this nationally. Results. Over a 5-year period there were 180 cases of non-union between the ages of 0–14 years, (4.21/100,000pa) and an incidence of 15,335 fractures/100,000pa giving an overall risk of 0.24% non-union per fracture. The risk of non-union per fracture did not change throughout childhood but notably increased in the late teenage years (15–19yrs). Both the incidence of fractures and non-union were far greater in boys, however incidence of non-union per fracture was similar in both sexes in childhood. Non-union per fracture was twice as frequent in the lower than upper limb, this trend reversed in the 15–19 year age group. Conclusion. The annual incidence of fractures in children is 15.3%, more frequent in the upper than lower limb; increasing with age, particularly in boys. The risk of non-union is around 1/400 per upper limb and 1/250 per lower limb fracture in childhood. Fracture non-union is rare in the paediatric population but even so 4.2 cases would be expected per 100,000 population or 240 cases per 100,000 fractures

Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team

Payments by the NHS Litigation Authority continue to rise each year, and reflect an increase in successful claims for negligence against NHS Trusts. Information about the reasons for which Trusts are sued in the field of trauma and orthopaedic surgery is scarce.

We analysed 130 consecutive cases of alleged clinical negligence in which the senior author had been requested to act as an expert witness between 2004 and 2006, and received information on the outcome of 97 concluded cases from the relevant solicitors. None of the 97 cases proceeded to a court hearing. Overall, 55% of cases were abandoned by the claimants’ solicitors, and the remaining 45% were settled out of court. The cases were settled for sums ranging from £4500 to £2.7 million, the median settlement being £45 000. The cases that were settled out of court were usually the result of delay in treatment or diagnosis, or because of substandard surgical technique.

The mammalian growth plate is a complex structure which is essential for the elongation of long bones. However, an understanding of how the growth plate functions at the cellular level is lacking. This review, summarises the factors involved in growth-plate regulation, its failure and the consequence of injury. We also describe some of the cellular mechanisms which underpin the increase in volume of the growth-plate chondrocyte which is the major determinant of the rate and extent of bone lengthening. We show how living in situ chondrocytes can be imaged using 2-photon laser scanning microscopy to provide a quantitative analysis of their volume. This approach should give better understanding of the cellular control of bone growth in both healthy and failed growth plates.

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children.

Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%).

A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients.

The number of skate related injuries has seen a resurgence in the western world with almost 51000 patients in 1999 presenting to US hospitals with a skateboard related injury, almost 90% of these being male and almost 70% of these are orthopaedic related injuries. Protection , particularly wrist guards, elbow pads, knee pads and recognized helmets are all necessary in protecting the young child against orthopaedic injuries. However despite these physical barriers little training or supervision exists in adequately educating children as to the dangers of these devices. Having observed an increased number of referrals to our Accident and Emergency Dept with fractures sustained whilst roller-blading and skateboarding we set about prospectively evaluating the epidemiology and nature of such injuries. 100 successive referrals to the orthopaedic service as a result of roller/skate injuries were evaluated. Childs age, sex, time using apparatus, mechanism of injury, and whether the injury occurred in a dedicated skatepark or on the street was recorded. Whether the child was wearing any form of protective gear and what type was also recorded. The type of fracture and its treatment and follow up was evaluated. All results were recorded on standard excel spreadsheets and statistical analysis was performed using Instat statistics (Graphpad USA 2002). The Male to female ratio in street injuries was 1:1, whereas in ramp injuries 4:1. 60 injuries occurred on the street whereas 40 occurred whilst using the ramps. The mean age was 11.4yrs. The mean length of time using rollerblades/skateboards was 20 and 19 months for street and ramps respectively. The number of children wearing some form of protective gear shows only 20 children out of the 100 studied wore gear, of these 15 wore helmets only. The treatment initiated shows almost 80% of ramp related injuries required formal manipulation under general anaesthesia or open reduction and internal fixation, where as only 25% of street fractures required this form of treatment, The usage of ramps demonstrates an increased relative risk of 4.26 (95% CI 3.5–5.1) This study shows that skateboards and rollerblades still constitute a major component of childhood fracture admissions. Only 20% of children use some form of protective gear whilst skating, this needs to be addressed on a national level. The wearing of helmets whilst protecting the child against head injury do not prevent serious orthopaedic injuries. Wrist guards should be worn by all children skating as the fall onto outstretched hand still remains a childs defensive mechanism when thrown off balance. Almost 75% of all fractures involve the wrist or the forearm. We urge better education and a tighter supervision of children whilst skating. Dedicated skateparks should only be used by experienced and older children and they should at least be supervised during their first attempts at using the parks, 85% of ramp injuries occurred during first or second time users. A child using a skatepark particularily for the first time is three times more likely to sustain a fracture, and almost 4 and a half times more likely to require definitive surgical treatment of this fracture. This constitutes a huge orthopaedic burden as well as it’s associated morbidity and financial costs to the health service. Children should be encouraged to use limb protectors as well as helmets whilst skating and should be supervised more closely during their initial attempts

Thirty-five patients (28 children and seven adults) were reviewed six months to 22 years after sustaining the common childhood fracture of the intercondylar eminence of the tibia. The aim was to assess both short-term and long-term results and prognosis by clinical and radiological examination and to discover whether conservative treatment was adequate for those severe fractures where a fragment of the tibial crest had been totally displaced. All the less severe fractures and 14 of the 17 severe fractures were treated conservatively. Early improvement occurred in more patients when the knee was immobilised in extension rather than in flexion, but long-term results were similar. Seven patients had slight discomfort, two of whom had had operative treatment. Radiographs of all patients showed a projection at the fracture site but its size did not correlate with the extent of displacement of the fragment nor with the degree of discomfort suffered; in the severe group a smaller projection developed after open reduction and after immobilisation in extension than after immobilisation in flexion. There was no instability due to functional lengthening of the cruciate ligaments and no increased incidence of degenerative change