Thoracoplasty has been described as primarily a cosmetic resection of the rib hump. The purpose of our study was to investigate whether removal of a normal spine stabilizer affected the correction of the spine, particularly in the sagittal plane. Thirty-eight adolescent idiopathic scoliosis patients who underwent thoracoplasty were compared with eighteen controls in terms of maintenance of correction and patient satisfaction using the SRS questionnaire. Thoracoplasty had no effect on curve correction in the coronal plane. It did show a significant effect on sagittal plane correction of the thoracic hypokyphosis without any significant detractors in terms of patient outcome

To investigate whether thoracoplasty affected spinal correction. We also compared patient outcomes thoracoplasty patients and controls, as well as long-term curve maintenance.

Thoracoplasty did increase the correction of thoracic hypokyphosis, without any significant detractors in terms of patient outcome.

Current understanding of the scoliotic curve as a three dimensional helix has led to increased recognition of the importance of sagittal contour and balancing the spine’s reciprocal curves to avoid problems such as flat back syndrome. Correction of the scoliotic curve intraoperatively may require the removal of spine stabilizers such as the disc and annulus, posterior facet and capsule, and thoracic cage stabilizers such as the ribs.

Thirty-eight patients who had either concave para-median or convex Steel mid-rib thoracoplasty were reviewed and compared to eighteen controls. Prospective patient outcomes using the Scoliosis Research Society instrument with an average of > one year follow-up were available for thirty patients. Degree of curve settle and maintenance of correction was measured on follow-up radiographs.

Thoracoplasty had no effect on curve correction in the coronal plane. It did show a significant effect on sagittal plane correction of thoracic hypokyphosis. The paramedian group showed a mean increase of tweleve degrees, the Steel group 8.7 degrees, and, the control group 3.1 degrees. No significant difference between pain, satisfaction, function, and self-image was found. Long-term radiographic follow-up (average three years) showed a mean coronal curve settle of 4.6 degrees (thoracoplasty) versus 3.1 degrees (non-thoracoplasty), and an accompanying improvement in sagittal plane correction of 4.2 and 3.0 degrees, respectively.

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires.

The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur.

Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus.

To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided.

A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm.

NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires.

Purpose: The purpose of this study was to assess the clinical, radiological, and functional outcomes following the treatment of a lumbar Chance fracture and to analyze the spectrum of associated abdominal injuries as seen in the Seat Belt Syndrome.

Methods: All patients diagnosed with L1 to L4 Chance fractures were included in this study. Patient data, injuries, treatment and complications were collected from hospital charts. A review of all available spinal radiology was done to measure pre-treatment, post-treatment and follow-up kyphosis angles. We have also described and calculated a Chance Fracture Deformity Index. Patients were seen in follow-up to assess for range of motion, tenderness and neurological status. A functional outcome questionnaire by the AAOS Pediatric Instruments was completed by the patients.

Results: Between December 1984 and February 2001, 27 patients aged 3 to 17 were treated for lumbar Chance fractures. The mean age at injury was 11.1 years. There were 17 females and 8 males. All injuries occurred as a result of a motor vehicle accident. Of the 25 patients, 17 were treated surgically. 12 patients had abdominal injuries. 3 cases involved abdominal arterial vascular trauma. Significant improvement in intra-vertebral kyphosis, segmental kyphosis, and vertebral kyphosis redmodelling (6.5 vs. 4 degrees) was noted in the operative group compared to the non-operative group. The disease specific AAOS Lumbar Spine Questionnaire scores were poor for pain and disability, 29.22, (26.41–31.98), but the SF-36 scores for both MCS and PCS were within the normal range, 47.79 (44.03–51.54) and 47.71 (42.59–52.82), respectively.

Conclusions: An abdominal and spinal CT must be taken when presented with a Chance fracture with abdominal symptoms. Injury type and kyphosis angle are the main factors that aid in treatment planning in paediatric lumbar chance fractures. A purely soft-tissue injury or a kyphosis angle greater than 20 requires surgical intervention.

Introduction The goals of this study were to investigate the association between paediatric flexion-distraction fractures of the lumbar spine and abdominal injuries and to analyse the variety of the abdominal injuries seen with this type of fracture.

Methods A retrospective chart review was performed at three hospitals (British Columbia Children’s Hospital, Vancouver, Canada, Mater Children’s Hospital and Royal Children’s Hospital, Brisbane). All patients under the age of fifteen who had suffered a flexion-distraction fracture were included. Data collected from the chart related to seating position, the use of seat belts and the spinal and abdominal injuries. The time elapsed from presentation to the time of diagnosis of abdominal injury was also recorded.

Results Forty one patients were included. There were 16 male and 25 female patients. All injuries were due to motor vehicle accidents. The average age at the time of accident was 9 years and 8 months. Twenty-two of the forty-one patients (53%) suffered an intra-abdominal injury. Twenty-one of these patients required operative intervention for their abdominal trauma. The spectrum of injuries included small bowel, large bowel, mesenteric and solid organ injuries. Eighteen of the twenty-two patients sustained a small bowel injury.

Discussion Abdominal trauma after flexion-distraction fractures of the lumbar spine is common. Often the abdominal trauma is significant and may require a laparotomy. A high index of suspicion should be maintained for all patients who present to the orthopaedic department with this type of injury.

Introduction and Aims: The anterior approach to dealing with complex spinal deformities around the cervical thoracic junction presents a surgical challenge. With the help of a cardiothoracic surgeon, a sternal splitting technique was utilised in five paediatric patients to resolve this difficulty and gain access to spinal deformities around the cervical thoracic junction.

Method: A longitudinal incision is made parallel to the sternocleido muscle and extended across the sternum for a median sternotomy. The sternocleido muscles are retracted to the lateral aspect of the incision. The carotid and jugular vein are dissected out. To continue with the dissection and exposure of the upper thoracic spine, a full sternotomy is done. The sternum is opened. The dissection of the right carotid is extended over the innominate artery, including the bifurcation of the right subclavian artery. The jugular vein is dissected out coming down to the superior vena cava. The innominate vein is isolated. The lower end of the anterior scalenus muscle is divided up.

Results: This technique was employed in five paediatric patients, aged three to 15 years, at the authors’ institution. Diagnoses included Klippel-Feil Syndrome, Proteus Syndrome, Larsen Syndrome and, Neurofibromatosis (two patients). All patients had severe cervical thoracic kyphosis requiring surgical instrumentation. This technique resulted in a range of access from C5 to T6 being granted. In one patient, a separate thorocotemy was performed in order to gain access to the lower thoracic spine.

Conclusion: This approach was invaluable in gaining access to the cervical thoracic junction to address complex spinal deformities. Access to the lower cervical and the upper thoracic spine is granted. No significant complications occurred. The aid of a cardiothoracic surgeon is advised.

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated.

Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old).

Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients)

Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents.

Introduction and Aims: Hereditary Multiple Exostosis is an autosomal dominant condition in which multiple benign cartilage-capped tumors grow in relation to the growth plates of long and flat bones. The purpose of this study was to determine the relationship between the genotype and phenotype in HME.

Method: Ten families were identified with HME. Genotyping was completed by linkage analysis of all families and the EXT 1 or 2 gene was sequenced based on these results. Mutation identification and confirmation was performed. Phenotyping consisting of clinical and radiographic examinations generated 89 features for each subject.

Results: Eight of 10 mutations were identified, confirmed and segregation verified. Six of the mutations were unique and two previously had been reported in the literature. Three mutations were in EXT 1 and five in EXT 2. Two were missense, three nonsense, two splice site and one frameshift. EXT 1 patients were found to have more exostoses, with a higher percentage of flat and pelvic bone involvement. EXT 1 patients had more malalignment and were shorter. Males also had a more severe phenotype and modulated the severity of EXT 1 expression. No other genotypic factors were found to influence phenotype.

Conclusion: An established genotype phenotype correlation will aid in patient management in terms of surveillance, determining prognosis and management. It was found that a genotype phenotype correlation exists where EXT 1 is linked to a more severe phenotype.

Introduction and Aims: The aims of this study were to assess the clinical and functional outcomes following the treatment of a lumbar Chance fracture and to analyse the spectrum of associated abdominal injuries as seen in the Seat Belt Syndrome.

Method: All patients diagnosed with L1 to L4 Chance fractures at the British Columbia Children’s Hospital were included in this study. Patient data, injuries, treatment and complications were collected from hospital charts. A review of all available spinal radiology including pre-treatment, post-treatment and follow-up x-rays, CTs and MRIs was done to measure pre-treatment, post-treatment and follow-up kyphosis angles, as well as to help classify the Chance fracture. Patients were seen in follow-up to assess for range of motion, tenderness and neurological status. Furthermore, a functional outcome questionnaire by the American Academy of Orthopaedic Surgeons Pediatric Instruments was completed by the patients.

Results: Between December 1984 and February 2001, 27 patients aged three to 17 were treated for lumbar Chance fractures. The mean age at injury was 11.1 years. There were 18 females and nine males. All injuries occurred as a result of a motor vehicle accident. Nineteen were rear-seat passengers and eight were front-seat passengers. Of the 27 patients, 19 were treated surgically. Of these 19, nine were treated with either pedicle screws or laminar hooks and rods, four with intersegmental spinous process (ISP) wires alone, two with sublaminar wires and four with a combination of screws/hooks, rods and ISP wires. One patient had a post-operative urinary tract infection. Of the eight patients treated conservatively, four were treated with a hyperextension cast and four were treated with a hyperextension brace. Neurological impairment was seen in seven of the 19 surgical patients pre-operatively. Post-operatively impairment was impoved in two of the seven patients. One of the eight patients treated conservatively had neurological impairment which spontaneously resolved. A total of 13 patients underwent surgery for an associated abdominal injury. Three cases involved abdominal arterial vascular trauma and 12 involved small bowel injury.

Conclusion: An abdominal and spinal CT must be taken when presented with a Chance fracture with abdominal symptoms. Injury type and kyphosis angle are the main factors that aid in treatment planning in paediatric lumbar chance fractures. A purely soft-tissue injury or a kyphosis angle greater than 20 requires surgical intervention.