The June 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children.

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.

Aims. The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial. Methods. Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment. Outcomes. At six weeks, and three, six, and 12 months, data on function, pain, sports/music participation, QoL, immobilization, and analgesia will be collected. These will also be repeated annually until the child reaches the age of 16 years. Four weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the PROMIS upper limb score at 12 months post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardians. The NHS number of participants will be stored to enable future data linkage to sources of routinely collected data (i.e. Hospital Episode Statistics). Cite this article: Bone Jt Open 2024;5(1):69–77

Musculoskeletal diseases are having a growing impact worldwide. It is therefore crucial to have an evidence base to most effectively and efficiently implement future health services across different healthcare systems. International trials are an opportunity to address these challenges and have many potential benefits. They are, however, complex to set up and deliver, which may impact on the efficient and timely delivery of a project. There are a number of models of how international trials are currently being delivered across a range of orthopaedic patient populations, which are discussed here. The examples given highlight that the key to overcoming these challenges is the development of trusted and equal partnerships with collaborators in each country. International trials have the potential to address a global burden of disease, and in turn optimize the benefit to patients in the collaborating countries and those with similar health services and care systems.

Cite this article: Bone Joint J 2023;105-B(7):719–722.

Aims. The aim of this study was to explore parents and young people’s experience of having a medial epicondyle fracture, and their thoughts about the uncertainty regarding the optimal treatment. Methods. Families were identified after being invited to participate in a randomized controlled trial of surgery or no surgery for displaced medial epicondyle fractures of the humerus in children. A purposeful sample of 25 parents (22 females) and five young people (three females, mean age 11 years (7 to 14)) from 15 UK hospitals were interviewed a mean of 39 days (14 to 78) from injury. Qualitative interviews were informed by phenomenology and themes identified to convey participants’ experience. Results. The results identify parents’ desire to do the best for their child expressed through two themes: 1) ‘uncertainty’ (being uncertain about the best treatment option); and 2) ‘facilitating recovery’ (sharing the experience). Parents and young people were shocked when confronted with uncertainty about treatment and they felt responsible for the decision. They searched for further information, drew on their own experience, and struggled to weigh up risks of the treatments. Discussion with surgeons provided crucial support for decision-making, and young people were involved to a varying degree. In facilitating recovery, parents balanced increasing activity with protecting their child, but lacked knowledge about pain management, and how to improve strength and function of the arm. They hoped for a return to normal, including competitive sports. Conclusion. Surgeons are aware of the impact of injury on children and their parents; however, they may be less aware of the turmoil created by treatment uncertainty. Confident surgeons who appreciate and contextualize the importance of pre-existing experience and beliefs are best placed to help the family develop confidence to embrace uncertainty, particularly regarding participation in clinical trials. Cite this article: Bone Jt Open 2021;2(6):359–364

Aims

The purpose of this study was to evaluate the relationships between the degree of injury to the medial and lateral collateral ligaments (MCL and LCL) and associated fractures in patients with a posterolateral dislocation of the elbow, using CT and MRI.

Aims

The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury.

Aims

High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics.

The June 2015 Children’s orthopaedics Roundup. 360 . looks at: ACL reconstruction in paediatric knees; Hips, slips and cams; The adolescent clavicle; 3D fluoroscopy in DDH?; The psychiatric aspects of hip pain in adolescents; Adolescent bunions: dealer’s choice?; Medial epicondylar fractures revisited

The aim of our study is to report on our experience with elbow dislocations in childhood, the spectrum of the associated injuries and the various treatment modalities used. In a period of 18 years, 52 children (33 male and 12 female) with elbow dislocations were treated in our clinic. 45 patients were followed-up with an average time of 7.2 years. 13(29%) dislocations were pure while associated injuries were present in 32(71%). Three had compound injuries. 23 of the associated injuries involved medial epicondyle fractures, 6 radial head fractures, 2 coronoid fractures, 2 lateral humerus condyle fractures, 1 ulnar diaphysis fracture and 1 radial peripheral metaphysic fracture. 27 patients treated conservatively while 18 patients treated surgically. At the final re-examination, according to Roberts PH criteria, the clinical results were excellent in 24(56%) patients, good in 11(27%) patients, fair in 4(13%) and poor in 2 (4%) patients. A transit ulnar nerve paresis was perceived in 1 patient. The x-ray findings demonstrated 6 patients with medial epicondyle pseudartrosis and 6 patients with ectopic ossification. Most elbow dislocations are associated with elbow fractures, therefore examination for an associated fracture is necessary. Closed reduction is the treatment of choice for elbow dislocations. Surgical treatment is indicated in elbow dislocations that are not reduced closely, in open injuries and in the presence of associated injuries that demand surgical treatment. The clinical and x-ray results are usually excellent. The presence of associated fractures, especially fractures of the radial head tent to lead in poor results

Shockwave treatment in our unit is provided in conjunction with our Urological colleagues. Shock Wave Therapy has been used as a last option in patients with difficult and chronic Orthopaedic conditions with an informed consent for all patients. Material and Methods: 28 patients from Ealing Hospital and West Middlesex Hospital were referred to The Lithotripsy unit at Charing Cross Hospital for Shock wave therapy. Patients were consented by the Orthopaedic surgeon and the treatment was administered by urologist. The cases included:. 4 Humeral fractures: 1 Case in HIV +ve 19 years old. 5 Femoral non-union: 1 case bilateral in Osteogenesis imperfecta. 4 Tibial non-union: 1 Recurent Fracture in 65 years old man. 2 Osteochondritis of the Talus. 2 Osteochondritis of the knee. 4 Scaphoid fractures: 1 case had been fixed and grafted. Medial Epicondyle fracture non union. 5. th. Metacarpal Fracture. Trochanteric Bursitis. Tennis Elbow. 4 Planter fasciitis. – The Shock wave Machine used is Storz SLX – F2 Electromagnetic shock wave generator which focus the shock wave low energy high frequency in focal zone with no harm to other tissues. Frequency 4 htz = 4 shockwave/sec. – Energy level 1–3 generate pressure value in the focal area of 5–30 megapascal. – Size of focal zone 9X 50 mm or 6X 28 mm. – Total shock wave applied per session 2000 to 3000 shock. – large focus and small focus were used in fracture of large bones and small bones respectively. Most of cases required 2–3 session with 4–6 weeks interval. – in Soft tissue Treatment Less energy was used and patients required 1 to 2 sessions. Results: There was complete resolution of symptoms in the 4 cases of soft tissues. – Clinical and radiological union in 3 of the 4 Humeral Fracture including HIV+ve and in 2 of 3 tibial fracture and 1 of 2 scaphoid. – 50% pain relief in Psedo arthrosis. – Union is promoted by Cellular stimulation and pain relief is by unknown mechanism but explained by increase vascularity and neuro-modulation. – None of the patient’s have so far required subsequent operative interventions, several had residual symptoms. Discussion: Shock wave therapy is a new consevative treatment modality used in orthopaedic as the last option before surgery but there is a need for RCT

Certain technical advances, such as flexible intramedullary fixation and bioreabsorbable implants, have further increased enthusiasm for surgical management of pediatric fractures.» (Flynn et al.). In the Paediatric Surgery Department biodegradable pins of solid polydioxanone (PDS) in management of paediatric fractures have been used since April 1986. PDS pins are too soft for the osteosynthesis in fractures with fragments under high tensile pressures. However, we have successfully carried out a large number of internal fixations in children’s elbows. This is based on accurate distribution of PDS pins and careful positioning of periostal sutures and the adjacent disrupted muscles. Our technique, as presented at the 2nd European Congress of Paediatric Surgery in Madrid in 1997, is to fix temporarily the repositioned fractured fragment with Kirschner’s metal wire. Following osteosynthesis with PDS, the protruding K-wire is left in place for seven days until the limb is safely immobilized. A total of 96 patients were operated. The purpose of the study is to compare osteosynthesis with PDS pins (Group A) with that of metallic K-wire (Group B). Each group consisted of 48 children. General characteristics (age, sex, and fracture types) were statistically the same (P > 0.05). In Group A, with children between 2 and 13 years, or 9.3 on average, 21 children were with the lateral condyle fractures (43.75%), 25 children with medial epicondyle fractures (52.08%), and 2 children with medial condyle fractures (4.16%). In Group B, with children between 2 and 14 years, or 8.7 on average, 26 children were with lateral condyle fractures (54.16%), 19 children with medial epicondyle fractures (39.58%), and 3 with medial condyle fractures (6.25%). The study excludes Milch Type II fractures of medial and lateral condyles. The results have been examined in the follow-up period of one, three, and six months of two different methods according to Flynn’s criteria. After statistical evaluation the differences obtained had no statistical significance (P > 0.05). However, satisfaction score (0 – 10) is significantly higher in Group A than in Group B for both parents and evaluators (P < 0.05). Both treatments exhibit good results with the exception that the use of metal osteosynthetic material requires another operation. If metal wires are used and cut just underneath the skin, protruding with local inflammation may appear. Proper use of PDS pins requires no further operation. This is to the benefit for both the patient and rehabilitation staff

Introduction and Aims: To review paediatric elbow dislocations treated in our institution over a ten year period and assess outcome. Method: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a ten-year period. Thereafter, a comprehensive case note and radiological review was performed. Results: 1761 elbow injuries exclusively treated in our unit in a ten-year period. Sixty-three elbow dislocations were identified. Male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation. Eighty percent of all dislocations occurred as a result of a low fall or simple sporting injury. Sixty of the 63 dislocations were posterior with two anterior and one divergent dislocation. Associated fractures were common (46%), with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. Two dislocations were open; there were two neuropraxias and no vascular complications. Twelve cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases. Reduction of fracture dislocations under sedation was associated with a higher incidence of medial epicondyle entrapment in the joint compared with general anaesthetic reduction. Post-operative management consisted on average of three weeks in plaster. No significant long-term loss of movement occurred in any patient. In the timeframe used there was one re-dislocation and no re-referrals for ongoing instability. Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries. Although closed reduction is almost always possible, fracture dislocations should be reduced under general anaesthesia. Unlike in adults there appears to be problem with immobilisation for up to five weeks and the results of conservative treatment are excellent

Aims: To review paediatric elbow dislocations treated in our institution over a ten year period in terms of incidence, aetiology, management and follow up. Methods: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a ten year period. This was followed by a case note and x ray review. Results: 1761 elbow injuries exclusively treated in our unit in a ten year period. Of these patients 63 had elbow dislocations. We found a male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation with more injuries in the summer months. 80% of all dislocations occurred as a result of a low fall or simple sporting injury. 60 of the 63 dislocations were posterior with 2 anterior and 1 divergent dislocation. Associated fractures were common with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. 2 dislocations were open; there were 2 neuropraxias and no vascular complications. 12 cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases Those patients with associated fractures of the medial epicondyle who underwent reduction under sedation had a much higher requirement of open reduction of the fragment (3 out of 4) compared with those having reduction under general anaesthesia (4 out of 16). Post operative management consisted on average of 3 weeks in plaster. In the timeframe used there were no - recurrent dislocations, no patients re referred for assess- ment of ongoing elbow problems and no complaints of ongoing stiffness. Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries, are more common in boys and on the left. They generally arise from low energy trauma and are usually posterior. Closed reduction we found always to be possible but if there was an associated fracture then reduction is probably best carried out under general anaesthesia since this appears to aid reduction of associated fragments

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 premature physeal closure. Avascular necrosis of the radial head is most commonly associated with open reduction. Distal Radius – It is the most common fracture separation in children and represent 46% of all fractures involving the growth plate. A fracture of the ulna is associated in 6 to 11% of the injuries. The average age is 12 years with a minimum of 7 and a maximum of 16 years. Although this high incidence it is very uncommon subsequent growth disturbance. The usual mechanism of injury is similar to the proximal radius injury and result from a fall on the outstretched upper extremity with the wrist hyperextended. This type of injury is classified by the Salter-Harris classification for physeal fractures and the most commons are the types I and II. The clinical symptoms vary from mild tenderness over the fracture site to a noticeable deformity most often with the apex volar. Attention should be given to the possibility of vascular and neural injury associated, mostly from the time of the acute deformation, and the diagnosis is made by x-ray view (AP and lateral) with the fracture well visualized. The prognosis is in general good since even in the presence of a markedly displaced fracture it can be expected a remarkably remodeling even in an older child. Treatment in a nondisplaced fracture only requires a below elbow cast for 4 weeks. In a displaced fracture a closed reduction should be performed under hematoma block or general anesthesia (in a young child). The reduction is stable most of the times in a plaster with the wrist in slight flexion. The incidence of complications is very rare