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

Summary Statement. This study examined the fixation stiffness of 13 tibial and 12 femoral Salter-Harris fracture fixation methods, and determined that screws and screws+ k-wires methods provided the highest stability. In situations where k-wire use is unavoidable, threaded k-wires are preferable. Introduction. Salter-Harris fractures of the proximal tibia and distal femur are common in pediatric patients that present to orthopedic surgeons. Salter-Harris type I fractures are characterised by breaks that extend only through the physis while Salter-Harris II fractures are the most common, accounting for 85% of Salter-Harris fractures, and extend past the growth plate, exiting through the metaphyseal bone. Fixation of these fracture types can be accomplished using a variety of methods including the use of Kirschner wires, cannulated screws, and a combination of both materials. Stability of fracture fixation is of utmost importance as persistent motion at the fracture margin leads to deformity. The purpose of this study is to analyze the biomechanical efficacy of various fixation methods used to stabilise Salter-Harris I and II fracture patterns in both the proximal tibia and distal femur. Stiffness, the primary gauge of efficacy, will be tested in flexion and extension, varus and valgus movement, and internal and external rotation and will be compared to determine the optimal fixation method. Materials and Methods. This study utilised 39 tibia and 36 femur 4. th. generation synthetic bones (Model 3401 and 3403, Pacific Research Laboratories Inc.) The synthetic bones were fractured and fixated to model Salter-Harris fractures and common fixation methods. Fixation methods used employed 6.5mm cannulated screws, 4.5mm cannulated screws, 2mm smooth K-wires, and 2mm threaded K-wires. Tibias were fractured according to Salter-Harris I, valgus Salter-Harris II, and flexion Salter-Harris II patterns with 13 different fixation methods. Femurs were fractured according to Salter-Harris I and Salter-Harris II patterns with 12 different fixation methods. Testing was performed in three orientations, flexion/extension, varus/valgus, and internal/external rotation, on a materials testing machine (Model 8874, Instron, Norwood, MA) and cyclic displacement tests were performed using Wavematrix software. These displacement tests recorded the torque required to reach an angulation of ±5° for 10 cycles. From this data, the rotational stiffness of the loading phases for each cycle was determined. Statistical analysis was performed to compare construct stiffness and differences between groups using analysis of variance. Results. Results show superior fixation for threaded k-wires in both femoral and tibial Salter-Harris I fractures. Methods utilizing transverse screws were least optimal for the fixation of femoral Salter-Harris II fractures, while a combination of k-wires and screws or the use of oblique screws was more effective. Fixation utilizing a combination of k-wires and screws yielded greater stiffness in valgus and flexion tibial Salter-Harris II fractures. Internal and external rotational stiffness values were low for all fixation methods and no significant variance existed for internal and external rotational stiffnesses in most fracture patterns. Discussion/Conclusion. Based on the results and statistical analysis, we believe that significant variance exists between most of the studied fixation methods for each fracture type. Fixation methods utilizing screws and a combination of screws and k-wires would provide optimal stability. In situations where the use of k-wires is unavoidable, threaded k-wires are preferable

Distal femoral physeal fractures in children have a high incidence of physeal arrest, occurring in a mean of 40% of cases. The underlying nature of the distal femoral physis may be the primary cause, but other factors have been postulated to contribute to the formation of a physeal bar. The purpose of this study was to assess the significance of contributing factors to physeal bar formation, in particular the use of percutaneous pins across the physis. We reviewed 55 patients with a median age of ten years (3 to 13), who had sustained displaced distal femoral physeal fractures. Most (40 of 55) were treated with percutaneous pinning after reduction, four were treated with screws and 11 with plaster. A total of 40 patients were assessed clinically and radiologically after skeletal maturity or at the time of formation of a bar. The remaining 15 were followed up for a minimum of two years. Formation of a physeal bar occurred in 12 (21.8%) patients, with the rate rising to 30.6% in patients with high-energy injuries compared with 5.3% in those with low-energy injuries. There was a significant trend for physeal arrest according to increasing severity using the Salter-Harris classification. Percutaneous smooth pins across the physis were not statistically associated with growth arrest

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

Fractures through the physis account for 18–30% of all paediatric fractures, leading to growth arrest in 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients < 1 8 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators and radiographic data were collected at baseline, one and two years post-injury. A total of 167 patients had at least one year of follow-up. Average age at injury was 10.4 years, 95% CI [9.8,10.94]. Reduction was required in 51% of cases. Right-sided (52.5%) and distal (90.1%) fractures were most common. After initial reduction 52.5% of fractures had some form of residual angulation and/or displacement (38.5% had both). At one year follow-up, 34 patients (21.1%) had evidence of a bony bridge on plain radiograph, 10 (6.2%) had residual angulation (average 12.6°) and three had residual displacement. Initial angulation (average 22.4°) and displacement (average 5.8mm) were seen in 16/34 patients with bony bridge (48.5%), with 10 (30.3%) both angulated and displaced. Salter-Harris type II fractures were most common across all patients (70.4%) and in those with bony bridges (57.6%). At one year, 44 (27.3%) patients had evidence of closing/closed physes. At one year follow-up, there was evidence of a bony bridge across the physis in 21.1% of patients on plain film, and residual angulation and/or displacement in 8.1%. Initial angulation and/or displacement was present in 64.7% of patients showing possible evidence of growth arrest. The incidence of growth arrest in this patient population appears higher than past literature reports. However, plain film is an unreliable modality for assessing physeal bars and the true incidence may be lower. A number of patients were approaching skeletal maturity at time of injury and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine the true incidence and impact of growth arrest

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure. Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor. Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification. Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures

Fracture separation of the distal epiphysis of the tibia constitutes 10% of all epiphyseal fractures occurring in children. We studied 120 cases, which were treated stationary at our Department over the 10 year period between 1990 – 2000. The ratio between boys and girls was 2:1. The average age was 12,5 years (8–15 years). In 96 cases (80%) the injury occurred after a fall on the playground, in 12 cases (10%) after a roadtraffic accident and in 12 cases (10%) after a fall from a height. The average follow up is 7,2 years (2–12 years). According to the Salter-Harris classification 6 cases (5%) were Salter I, 90 cases (80%) were Salter II, 9 cases (9%) were Salter III and 6 cases (5%) were Salter IV. In all cases a closed reduction under general anaesthesia was attempted. If the reduction was succesful a whole leg plaster was applied. If the reduction was unstable a transcutaneous stabilisation or open reduction and internal fixation was performed. If a reduction could not be acchieved open reduction and internal fixation (ORIF) was performed using Kirschner wires or screws. Closed reduction was performed in 94 cases (78,34%), transcutaneous osteosynthesis in 2 cases (1,66%) and ORIF in 24 cases (20%). We conclude that sports and for instance football is the main cause, where this injury occurs. The treatment is mainly conservative and complications are rare, when anatomical reduction is acchieved. The most common complication is angulation resulting from the injury at the epiphyseal plate, for instance varus angulation, which occurs from supination injuries mainly of Salter-Harris type III and IV

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

Background and Aims:. Forearm fractures are common in the paediatric population and most are treated in a moulded plaster of Paris (POP) cast. It is our concern that many casts applied by our registrars are sub-optimal and that we need to improve our training process. The aim of our study was to review the adequacy of forearm cast application in paediatric patients at our institution and to identify if there is a need for a more formal training program with regard to plaster cast application. Methods:. A retrospective review of control x-rays of forearm fractures treated at our institution was undertaken. X-rays that were reviewed were done as part of the routine treatment protocol. X-ray measurements to assess POP application were the cast index and the gap index. A cast index of > 0.81 and Gap index of > 0.15 were regarded as an indication of poor cast application. Results:. Adequate control X-rays of twenty eight patients with a forearm fracture were available. The average patient age range was 5–12 years. There were thirteen distal metaphyseal fractures, nine diaphyseal fractures and six Salter-Harris type fractures. Of the 28 patients, 20 patients had a poor cast index and 17 patients had poor gap index. In 12 patients both the gap and the cast index were unacceptable. Conclusion:. Our study suggests that paediatric forearm plaster cast application by registrars at our institution is inadequate. This indicates a need for a strategy to improve the training in plaster cast application amongst our registrars

Ankle sprains are common athletic injuries, with a peak lifetime incidence between the ages of 15 and 19 years, especially in young males. However, an unclear history, an imprecise physical exam, and unhelpful radiographies lead to frequent misdiagnosis of paediatric ankle traumas, and subsequently, inappropriate treatment. Improper management may lead to residual pain, instability, slower return to physical activity, and long-term degenerative changes. The purpose of this study was to evaluate the initial management and treatment of acute paediatric ankle sprains at our center, a tertiary care paediatric hospital. Our hypothesis was that the initial diagnosis is often incorrect, and treatment varies considerably amongst orthopaedic surgeons. We conducted a retrospective study of all cases of ankle sprains and Salter-Harris one (SH1) fractures referred to our orthopaedic surgery service between May and August 2014. Exclusion criteria included ankle fractures other than SH1 types, and cases where treatment was initially undertaken elsewhere before referral to our service. Patients were evaluated on a clinical and radiographic basis. Primary outcome was the difference between initial and final diagnosis. Secondary outcome was variation in immobilisation duration for each diagnosis. The main variables we considered were age, sex, mechanism of trauma, referral delay, patient symptoms, physical exam findings, radiographic findings, type and duration of immobilisation, prescription of any medication, and referral to physical therapy. A total of 3047 patients were reviewed and 31 cases matched our inclusion criteria, comprised of 17 girls and 14 boys, with a mean age of 10.4 years. Patients were seen at a mean of 10.3 days after injury. Initial diagnosis was SH1 fracture in 20 cases, acute ankle sprain in 8 cases, and uncertain in 3 cases. Final diagnosis was SH1 fracture in 11 cases, acute ankle sprain in 13 cases, uncertain in 5 cases, and other in 3 cases. During follow up, 48.5% of cases saw a change in diagnosis. Forty five percent (9/20) of cases initially diagnosed as SH1 fractures proved to be incorrect, with 55.5% (5/9) of these being ultimately diagnosed as acute ankle sprains. Amongst cases initially diagnosed as acute ankle sprains, 37.5% (3/8) received a different final diagnosis. Duration of immobilisation was significantly different between acute ankle sprain and SH1 fracture groups, with an average of 17.3 days and 26.1 days, respectively. Physical therapy was prescribed to 33.3% of acute ankle sprains and 9.1% of SH1 fractures. Initial distinction between acute ankle sprains and SH1 fractures can be difficult in paediatric ankle trauma. Case management and specific treatments vary considerably, as there is neither an evaluation algorithm nor consensus on treatment of these paediatric pathologies. This study reinforces the need to develop a systematic diagnostic and treatment protocol for paediatric ankle sprains

We observed the healing process under rigid external fixation after Salter-Harris type-1 or type-2 physeal separation at the proximal tibia in immature rabbits. Metaphyseal vessels grew across the gap with little delay; the site of separation then came to lie in the metaphysis and was bridged by endochondral ossification. Union was achieved within two days in all rabbits. Progression of endochondral ossification repaired the separated physis, thus showing ‘primary healing of physeal separation’. This depends on accurate reduction and stable fixation to allow the survival of vessels across the gap

The February 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

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.

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

The October 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast.

Paediatric bone sarcomas are a dual challenge for orthopaedic surgeons in terms of tumour resection and reconstruction, as it is important to minimize functional and growth problems without compromising survival rates. Cañadell’s technique consists of a Type I epiphysiolysis performed using continuous distraction by an external fixator prior to resection. It was designed to achieve a safe margin due to the ability of the physeal cartilage to be a barrier to tumour spread in some situations, avoiding the need for articular reconstruction, and preserving the growth capacity most of the times. Despite initial doubts raised in the scientific community, this technique is now widely used in many countries for the treatment of metaphyseal paediatric bone sarcomas. This annotation highlights the importance of Cañadell’s work and reviews the experience of applying it to bone sarcoma patients over the last 40 years.

Cite this article: Bone Joint J 2023;105-B(1):11–16.

A retrospective study of 23 acetabular fractures in patients up to 17 years of age is presented, with an average follow-up of eight years. Good or excellent functional results were achieved in 21 patients; radiographic results were good or excellent in 16. Conservative treatment gave consistently good results in fractures with minimal initial displacement, stable posterior fracture-dislocations and Salter-Harris type 1 and 2 triradiate cartilage fractures. Less favourable results were seen in type 5 triradiate cartilage fractures and in comminuted fractures, but operation was no better. Unstable posterior fracture-dislocations and irreducible central fracture-dislocations need operative treatment but the results may still be unsatisfactory

Aims

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery.

We reviewed 24 displaced fractures through the physis of the medial epicondyle of the distal humerus. One was a Salter-Harris type-II fracture-separation of the whole distal humeral epiphysis; the others involved only the medial epicondylar centre of ossification. Two cases had presented as pseudarthroses. One fracture had been treated closed in a plaster slab and 21 had had open reduction and internal fixation with sutures, Kirschner wires or Palmer nails. At 2 to 13 years later we found five types of deformity of the epicondyle: pseudarthrosis, an ulnar sulcus, a double-contoured epicondyle, hypoplasia or hyperplasia. Pseudarthrosis had developed after either no treatment, closed reduction and plaster, or open reduction and suturing. Hypoplasia followed nailing, as did a trend to varus tilting of the joint surface. One very young patient, with fracture-separation of the whole distal epiphysis treated by nailing, developed marked cubitus varus