Aims. Torus fractures of the distal radius are the most common fractures in children. The NICE non-complex fracture guidelines recently concluded that bandaging was probably the optimal treatment for these injuries. However, across the UK current treatment varies widely due to a lack of evidence underpinning the guidelines. The Forearm Fracture Recovery in Children Evaluation (FORCE) trial evaluates the effect of a soft bandage and immediate discharge compared with rigid immobilization. Methods. FORCE is a multicentre, parallel group randomized controlled equivalence trial. The primary outcome is the Wong-Baker FACES pain score at three days after randomization and the primary analysis of this outcome will use a multivariate linear regression model to compare the two groups. Secondary outcomes are measured at one and seven days, and three and six-weeks post-randomization and include the Patient Reported Outcome Measurement Information System (PROMIS) upper extremity limb score, EuroQoL EQ-5D-Y, analgesia use, school absence, complications, and healthcare resource use. The planned statistical and health economic analyses for this trial are described here. The FORCE trial protocol has been published separately. Conclusion. This paper provides details of the planned analyses for this trial, and will reduce the risks of outcome reporting bias and data driven results. Cite this article: Bone Joint Open 2020;1-6:205–213

The aim was to assess the value of the GP 6–8 week hip examination.

In a 15-year prospective observational longitudinal cohort study, every infant referred by the GP with suspected pathological developmental dysplasia of the hip (DDH) had their hip joints clinically and sonographically examined in a specialist hip screening clinic. Graf Type IV and dislocated hips were classified as pathological. Screening failures were defined as those who had not been identified by the 6–8 week check and presented with late instability. Secondary univariate and multivariable analysis was performed to determine which clinical findings are predictive of instability.

64,518 infants underwent the 6–8 week GP check. Of 176 referrals, 5 had pathological hips. 13 screening failures, presented between the ages of 17 and 80 weeks. The 6–8 week check has a sensitivity of 28% and a specificity of 99.7%.

Univariate analysis revealed positive Ortolani tests and patients referred as ‘unstable hip’ to be significant predictors of hip pathology. Clicky hips, asymmetric skin creases, and leg length inequality were not predictive of pathological hips. A multivariable model showed a positive Ortolani test to be the sole independent predictor of instability at 6–8 weeks.

This is the first attempt to test the validity of the 6–8 week GP clinical hip check. A low rate of hip pathology was identified. The high rate of false negatives raises questions about the value of screening at this age. At 6–8 weeks, clinical signs of hip instability are unreliable as hips become irreducible and stiff.

Based on our findings, we recommend that at 6–8 weeks, referrals are only made if the Ortolani test is positive. We advocate the reintroduction of the 8-month check, including an assessment for limited hip abduction, which may improve the detection rate of those missed by initial screening.

This pilot study aims to investigate the utility and feasibility of a unique upright MR scan for imaging hips affected by Legg-Calve-Perthes Disease (LCPD) with patient standing up, in comparison to the standard supine scans.

Protocol development using this unique upright MRI included healthy adult and child volunteers. Optimum patient positioning in a comparable way between supine to standing was assessed. The balance between shorter scan time (to what a child can tolerate) and longer scan time (for better image acquisition). The study protocol has begun in 2 children with LCPD. Patient recruitment continues.

Early results indicate a dynamic deformity of the femoral head in early stage LCP disease. Femoral epiphysis height decreased on standing (7.8 to 6.8mm), width increased on standing (16.6 to 20.9mm) and lateral extrusion increased (3.5 to 4.1mm). Overall epiphyseal shape changed from trapezoidal (LCP femoral head when supine) to flattened triangular (LCP femoral head when standing). Differences were thus demonstrated in all parameters of bony epiphyseal height, width, extrusion and shape of a femoral head with LCP Disease when the child stood and loaded the affected hip.

Satisfactory image acquisition was possible with Coronal T1 GFE sequences, with both hips in the Field of View. 2.5min scans were performed with the child standing first, then supine. Hip position was comparable when standing and supine. Longer scans were not tolerated by younger children, more so those with LCP disease.

To our knowledge this is the first reported use of standing MRI in LCPD. A dynamic deformity has been demonstrated, with flattening, widening and worsened lateral extrusion when the child is standing compared to supine. This proof of concept investigation demonstrates the feasibility of upright MRI scanning and may demonstrate previously undetected deformity.

Aims

The purpose of this study was to calculate the dislocation rate following open or closed reduction for developmental dysplasia of the hip (DDH) in our unit. In addition we evaluated the posterior neck line as a method of determining hip relocation and assessed the morphology of the dysplastic acetabulum on single slice CT scan.

A goal attainment scale (GAS) was used to evaluate outcomes of surgical and non-surgical interventions to improve gait in children with diplegic cerebral palsy (CP).

Personal goals were recorded pre-intervention from children and/or their carers attending the Edinburgh Gait Laboratory since 2012. Twenty children underwent orthopaedic surgery (Group 1) and 25 children underwent a non-orthopaedic intervention (Group 2). Patients were excluded if the intervention was <9 months before the study period. Post-operatively children and/or their carers were contacted by telephone to complete the mGAS questionnaire, rating the achievement of goals on a 5-point scale. The majority of goals related to structure and function and were similar between groups, with goals relating to stability and lower limb structure most frequently recorded. Attaining an improvement in pain was stated more frequently by Group 1 children. The GAS formula was used to transform the composite GAS into a standardised measure (T-score) for each patient. A t-test was used to determine if the change in T-score was significantly different from 0, i.e. no change. Both groups on average achieved their goals (mean change in T-score for Group 2 11.1, vs 21.1 for Group 1). The difference between these two means was significant (p = 0.012). Additionally 16 children had undergone a follow-up gait analysis, but the relationship between the change in Gait Profile Score and GAS, assessed by Pearson's correlation coefficient was statistically insignificant.

Both surgical and non-surgical interventions enabled children to achieve their goals, although Group 1 reported higher achievement. GAS reflect patients’ aspirations and may be as relevant as post-intervention kinematic or kinetic outcomes.

Somatosensory evoked potentials (SSEPs) measure the conduction pathways from the periphery to the brain and can demonstrate the site of neurological impairment in a variety of locomotor conditions.

SSEPs were studied in 44 children (64 feet) with surgically corrected club feet. Four children had unreproducible responses, 18 showed abnormal recordings and 22 showed normal responses. In a further 31 feet (21 children) subjected to motor electrophysiological tests, 16 (52%) were abnormal.

Overall, 44 of 95 feet (46%) showed abnormal SSEPs or motor electrophysiological tests. Neurological abnormality was related both to the severity of the deformity and the surgical outcome. It was seen in 38% of feet with grade-2 and in 53% of feet with grade-3 deformity. A fair surgical result was obtained in 36% of feet with a conduction deficit and in only 6% with no abnormality. These results suggest an association between neurological abnormality as demonstrated by SSEPs or motor electrophysiological studies and the severity of deformity in club foot and its response to surgical treatment.

Aims. The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius. Methods. A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective, as well as a broader societal point of view. Health resources and quality of life (the youth version of the EuroQol five-dimension questionnaire (EQ-5D-Y)) data were collected, as part of the Forearm Recovery in Children Evaluation (FORCE) multicentre randomized controlled trial over a six-week period, using trial case report forms and patient-completed questionnaires. Costs and health gains (quality-adjusted life years (QALYs)) were estimated for the two trial treatment groups. Regression was used to estimate the probability of the new treatment being cost-effective at a range of ‘willingness-to-pay’ thresholds, which reflect a range of costs per QALY at which governments are typically prepared to reimburse for treatment. Results. The offer of a soft bandage significantly reduced cost per patient (saving £12.55 (95% confidence interval (CI) -£5.30 to £19.80)) while QALYs were similar (QALY difference between groups: 0.0013 (95% CI -0.0004 to 0.003)). The high probability (95%) that offering a bandage is a cost-effective option was consistent when examining the data in a range of sensitivity analyses. Conclusion. In addition to the known clinical equivalence, this study found that the offer of a bandage reduced cost compared with rigid immobilization among children with a torus fracture of the distal radius. While the cost saving was small for each patient, the high frequency of these injuries indicates a significant saving across the healthcare system. Cite this article: Bone Joint J 2024;106-B(6):623–630

Aims. The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV. Methods. The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children’s Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results. Results. The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached ‘consensus in’, no statements reached ‘consensus out’, and 18 reached ‘no consensus’. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached ‘consensus in’, no statements reached ‘consensus out’, and three reached ‘no consensus’ and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages. Conclusion. We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758–764

Aims. The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. Methods. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. Results. A total of 133 children’s orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached ‘consensus in’, 0 ‘consensus out’, and 11 ‘no consensus’. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as ‘consensus in’, resulting in a total of 40 approved statements. Conclusion. In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe. Cite this article: Bone Joint J 2023;105-B(7):815–820

Aims. This study sought to estimate the clinical outcomes and describe the nationwide variation in practice, as part of the feasibility workup for a National Institute for Health and Care Excellence (NICE) recommended randomized clinical trial to determine the optimal treatment of torus fractures of the distal radius in children. Methods. Prospective data collection on torus fractures presenting to our emergency department. Patient consent and study information, including a copy of the Wong-Baker Faces pain score, was issued at the first patient contact. An automated text message service recorded pain scores at days 0, 3, 7, 21, and 42 postinjury. A cross-sectional survey of current accident and emergency practice in the UK was also undertaken to gauge current practice following the publication of NICE guidance. Results. In all, 30 patients with a mean age of 8.9 years were enrolled over a six-week period. Of the 150 potential data points, data was captured in 146, making the data 97.3% complete. Pain scores were recorded at day 0 (mean 6.5 (95% confidence interval (CI) 5.7 to 7.3)), day 3 (4.4 (95% CI 3.5 to 5.2)), day 7 (3.0 (95% CI 2.3 to 3.6)), day 21 (1.2 (95% CI 0.7 to 1.7)) and day 42 (0.4 (95% CI 0.1 to 0.7)). Of the 100 units who participated in the nationwide survey, 38% were unaware of any local or national protocols regarding torus fractures, 41% treated torus fractures with cast immobilization, and over 60% of patients had follow-up arranged, both contradictory to national guidelines. Conclusion. We have demonstrated the severity, recovery trajectory, and variation in pain scores among children with torus fractures. We demonstrate excellent follow-up of patient outcomes using text messages. Despite national guidelines, there is significant variation in practice. This data directly informed the development of an ongoing nationwide randomized clinical trial – the FORearm Fracture Recovery in Children Evaluation (FORCE) study

Aims

There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

The aim was to assess the long-term impact of humeral and forearm rodding on functional ability, grip strength, joint range of motion and angular deformity in children with osteogenesis imperfecta. A retrospective chart review was conducted on 57 children with osteogenesis imperfecta who underwent humeral rodding or forearm rodding at our institution between 1996 and 2013. Functional ability was assessed using the self-care and mobility domains of the Pediatric Evaluation and Disability Inventory (PEDI). Grip strength was measured using a dynamometer and joint range of motion with a goniometer. Deformity was measured on radiographs of the humerus or forearm. Outcomes were assessed pre-operatively and every year post-operatively. Differences between pre-operative and 1-year post-operative outcomes were compared using paired T-tests. In 44 patients with a minimum of 2 years follow-up, outcome measures at 1-year post-surgery were compared to those at the latest clinic visit (mean follow-up = 8.0 years). Humeral and forearm rodding resulted in a significant improvement in PEDI self-care score (mean change =5.75, p=0.028 for the humerus, mean change = 6.77, p=0.0017 for the forearm) and mobility score (mean change =3.59, p=0.008 for the humerus, mean change =7.21, p=0.020 for the forearm) at 1 year post-surgery. Grip strength improved following forearm rodding (mean change = +6.13N, p=0.015) but not humeral rodding. Joint range of movement improved following humeral rodding but not forearm rodding. There was a significant improvement in radiographic angular deformity of the forearm and humerus following surgery (p<0.0001). Over 80% of improvements were maintained in the long-term. Humeral and forearm rodding in children with osteogenesis imperfecta leads to long-term improvement in functional ability and angular deformity

Aims

This study aims to define a set of core outcomes (COS) to allow consistent reporting in order to compare results and assist in treatment decisions for idiopathic clubfoot.

Purposes of study. Evaluation of the pre-operative documentation of neurovascular status in children presenting with Gartland Grades 2 and 3 supracondylar fractures and the development of an Emergency Department Proforma. Methods and results. A retrospective case-note review was performed on patients with Gartland Grade 2 and 3 supracondylar fractures observed in a two-year period from July 2008 – July 2010. 137 patients were included; sixteen patients (11.7%) sustained a Gartland Grade 2a fracture, sixty patients (43.8%) a Gartland Grade 2b fracture and sixty-one (44.5%) a Gartland Grade 3 fracture. Mean patient age at presentation was 5.59 years (range 12 months to 13 years). Nineteen patients (13.9%) had evidence of neurological deficit at presentation and thirteen patients (9.5%) presented with an absent radial pulse. Only twelve patients (8.8%) and nineteen patients (13.9%) respectively had a complete pre-operative neurological or vascular assessment documented. Regarding the individual nerves, fifty-nine (43.1%) patients had median nerve integrity documented, fifty-five (40.1%) ulnar nerve and forty-nine (35.8%) radial nerve integrity documented. Only eighteen patients (13.1%) had their anterior interosseous nerve function documented. Ten patients (7.3%) had post-operative neurological dysfunction, consisting of eight ulnar nerve injuries, and two radial nerve injuries. vi) Conclusions. Pre-operative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of anterior interosseous nerve examination was particularly poor. We propose the introduction of a proforma (Liverpool Upper-limb Fracture Assessment – LUFA) to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries

Aims

The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery.

The results of a functional, clinical and radiological study of 30 children (60 hips) with whole-body cerebral palsy were reviewed at a mean follow-up of 10.2 years (9.5 to 11). Correction of windsweep deformity of the hips was performed by bilateral simultaneous combined soft-tissue and bony surgery at a mean age of 7.7 years (3.1 to 12.2). We were able to recall 22 patients; five had died of unrelated causes and three were lost to follow-up. Evaluation involved interviews with patients/carers and clinical and radiological examination. The gross motor functional classification system was used to assess overall motor function and showed improvement in seven patients. Of the 12 patients thought to have pain pre-operatively, only one had pain post-operatively. Improved handling was reported in 18 of 22 patients (82%). Those with handling problems were attributed by the carers to growth of the patients. All patients/carers considered the procedure worthwhile. The range of hip movements improved, and the mean windsweep index improved from 50 pre-operatively to 36 at follow-up. The migration percentage and centre-edge angle were assessed on plain radiographs. Radiological containment improved, the mean migration percentage improved from 50 pre-operatively to 20 at follow-up and the mean centre-edge angle improved from −5° to 29°. No statistical difference was noted between the three-year and ten-year follow-up results, indicating that the improvements in clinical and radiological outcome had been maintained

Aims

The aim of this study was to investigate the changes in femoral trochlear morphology following surgical correction of recurrent patellar dislocation associated with trochlear dysplasia in children.

This retrospective study was designed to evaluate the outcomes of re-dislocation of the radial head after corrective osteotomy for chronic dislocation. A total of 12 children with a mean age of 11 years (5 to 16), with further dislocation of the radial head after corrective osteotomy of the forearm, were followed for a mean of five years (2 to 10). Re-operations were performed for radial head re-dislocation in six children, while the other six did not undergo re-operation (‘non-re-operation group’). The active range of movement (ROM) of their elbows was evaluated before and after the first operation, and at the most recent follow-up.

In the re-operation group, there were significant decreases in extension, pronation, and supination when comparing the ROM following the corrective osteotomy and following re-operation (p < 0.05).

The children who had not undergone re-operation achieved a better ROM than those who had undergone re-operation.

There was a significant difference in mean pronation (76° vs 0°) between the non- re-operation and the re-operation group (p = 0.002), and a trend towards increases in mean flexion (133° vs 111°), extension (0° vs 23°), and supination (62° vs 29°). We did not find a clear benefit for re-operation in children with a re-dislocation following corrective osteotomy for chronic dislocation of the radial head.

Cite this article: Bone Joint J 2015;97-B:1582–7.

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104).

The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies.

Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure.

Cite this article: Bone Joint J 2015;97-B:1577–81.