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Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK.

Aims

Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition.

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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.

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Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities.

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We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes.

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The aim of this study was to explore parents’ experience of their child’s recovery, and their thoughts about their decision to enrol their child in a randomized controlled trial (RCT) of surgery versus non-surgical casting for a displaced distal radius fracture.

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The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

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The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury.

Introduction. 2010 marked a century since Perthes' disease was first described, but the aetiology and mechanism remain unknown. Worldwide, the incidence of Perthes' disease varies widely, yet this may be through differences in study design, population denominators or case ascertainment. It is suggested that differential exposure to adverse socioeconomic circumstances may be a key precipitant, although this remains the subject of debate. This work draws on several epidemiological studies that have sought to develop the understanding of Perthes' disease by examining a case register from Merseyside, discharge data from Scotland and the world's largest community disease register. A systematic review was performed to ensure a robustness and homogeneity between published studies in order to allow meaningful comparisons. Methods. Studies were based on data from the Merseyside Perthes' Disease Register (1976–2008), the UK General Practice Research Database (GPRD, 1990–2008) and hospital discharge data for Scotland (2000–2009). Temporal trends and geographic patterns were analysed and the relationship to deprivation investigated. A systematic review of the published literature was used to explore international variations in incidence up to December 2010 focusing upon the influence of race and latitude. Analyses were conducted using Poisson regression. Results. Systematic Review: 21 studies were included which described 27 populations in 16 countries, observing 124 million person years. The annual incidence ranged from 0.2 – 19.1 per 100,000 0–14 year-olds. Race was a key determinant with East Asians least affected and Whites most affected (East Asian IRR 1.0 (Ref), South Asian IRR 2.9 (2.4, 3.5), White IRR 8.8 (8.2, 9.6)). Latitude was a strong predictor of disease, even after adjusting for race. Each 10 degree increase in latitude resulted in the incidence rate increasing by a factor of 1.44 (1.30, 1.58). GPRD Study. There was a dramatic decline in Perthes' disease incidence within the UK, with annual incidence rates falling from 12.2 to 5.7 cases/100,000 0–14 year-olds over the 19 year study period (p<0.001). There was marked geographic variation in incidence with incidence rates in Scotland more than twice those in London (10–39 (95%CI 8.05 – 13.2) vs 4.6 (95% CI 3.4 – 6.1) per 100.000 0–14 year-olds). A more rapid decline in incidence was apparent in the Northern regions compared to Southern regions. The most deprived quintile had the highest disease incidence (rate ratio 1.49 (95% CI 1.10 – 2.04)) and, with the exception of London, regional incidence showed a strong linear relationship to regional deprivation score (p<0.01). Merseyside. There was a dramatic decline in Perthes' disease incidence within Liverpool with rates falling from 14.2 to 7.7 cases/100,000 0–14 year-olds over the 34-year study period (p<0.001). Incidence rates similarly halved within the nearby region of Knowsley (p=0.01) but remained largely static in the more affluent regions of Sefton where the incidence has remained around 7.2 cases/100,000 0–14 year-olds (p=0.73). The association with socioeconomic deprivation is striking with over three times the incidence in the most deprived quintile of multiple deprivation compared to the most affluent quintile of IMD (11.5 vs 3.8 cases/100.000 0–14 year-olds (p<0.001). The incidence, by ward region, was strongly correlated to the ward index of deprivation (p<0.001) (IRR 1.014 (1.007 – 1.021)). Scotland. Hospital discharge rates due to Perthes' disease fell annually by 5.6% (95% CI 2.4% – 8.8% p<0.001) between 2000–2010. Given that there has been no significant change in treatment practice during this period and the results of the above studies, this is likely to represent a real change in disease incidence. There was a strong association between socioeconomic deprivation and disease with rates amongst the most deprived quintile more than twice those of the most affluent (RR 2.1 (1.5 – 2.9)). Similar incidence gradients for deprivation were seen in both urban and rural environments. Conclusions. These studies provide strong evidence to suggest a declining incidence of Perthes' disease within the UK and a strong relationship to socioeconomic deprivation. Although Perthes' disease incidence is falling it remains an important cause of child morbidity and exemplifies socioeconomic inequalities in health. The striking UK North–South divide is similar to that seen in adult diseases such as cardiovascular disease and osteoporosis. Latitude has an independent association with disease which may be through the action of sunlight and Vitamin D. A deprivation-related exposure (probably acting prenatally) appears critical but the aetiological determinants remain elusive

Northern Ireland has previously demonstrated high incidence of Perthes' disease (11.6 per 100,000). The aim of this study is to confirm a declining incidence in this diagnosis in Northern Ireland. Methods. A reduction in new Perthes' patients had been noted by the senior author. A retrospective study was designed to identify patients with a new diagnosis of this disease over a 7 year period (2004–10). Clinical notes were interrogated using word searches. Further cross referencing with x-ray system reports were utilised to capture all new patients presenting with subsequently proven Perthes'. Patients not resident in Northern Ireland at the time of diagnosis were excluded. Patients with epiphyseal dysplasia or avascular necrosis secondary to treatment of developmental dysplasia of the hip were also excluded. A previous study from this unit had demonstrated 313 new cases over the 7 year period 1992–1998, with average incidence of approximately 45/year for the population. Results. All years in our study (2004–10) have had less than 30 for the entire population (<8.3 per 100,000). Significant variation between years with some years much less detected, so further searches are been undertaken to ensure completeness if data capture. Conclusions. Perthes' disease incidence appears to have reduced significantly. Factors such as a lower threshold for investigation, better radiological diagnostics and better understanding of Perthes' should artificially increase the incidence. However, these study findings suggest a decrease. Passive smoking has long been debated as a possible cause in Perthes' disease. The prevalence of smoking is falling in N. Ireland. The 2007 introduction of a workplace smoking ban coincided with a statistically significant fall in smoking behaviour from 25% in 2006/07 to 23% in 2007/08. The cause of Perthes' is undoubtedly multifactorial, but these findings do coincide with decreasing smoking habits in this captive population

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Obesity is thought to be an aetiological factor for slipped capital femoral epiphysis (SCFE). We analysed changes in the incidence of SCFE in Scotland over the last two decades. During this period rates of childhood obesity have risen substantially and evidence for a relationship between these changes and the incidence of SCFE was sought. We found that the incidence of SCFE increased from 3.78 per 100 000 children in 1981 to 9.66 per 100 000 in 2000 (R. 2. = 0.715): a two and a half times increase over two decades. It was seen at a younger age, with a fall in the mean age at diagnosis from 13.4 to 12.6 years for boys (p = 0.007) and 12.2 to 11.6 for girls (p = 0.047). More children under eight years old were seen with SCFE in Scotland in the decade to 2000 than in the previous decade (p = 0.002, R. 2. = 0.346). A close correlation was observed between rising childhood obesity over the last 20 years in Scotland and an increasing incidence of SCFE

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Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

A femoral fracture in an adolescent is a significant injury. It is generally agreed that operative fixation is the treatment of choice and rigid intramedullary nailing is a surgical treatment option. We present on experience of treating adolescent femoral fractures using a lateral entry intramedullary nail. We reviewed 15 femoral fractures in 13 children who we treated in our unit between 2011 and 2014. Two patients had bilateral fractures (non-simultaneous). Data collected included patient demographics, mechanism of injury, type of fracture, associated injuries, size of nail, time to unite and complications. The mean age of the patients at time of surgery was 12 years (range 10–15). There were 7 male and 6 female. 10 fractures were caused by a fall whilst 5 were due to road traffic collisions (RTC). 8 fractures involved the middle third, 2 of theses were open fractures and were caused by a RTC. The remaining 7 involved the proximal third of the femur. The mean time to radiological union was 3.4 months (range 2.5–5) in 14 fractures. One patient had a delayed union that required bone grafting and united fully at 7.5 months post injury. The only other complications were a broken proximal locking screw in one patient and an undisplaced femoral neck fracture in another patient. These complications did not compromise the outcome. No patients had infection or developed avascular necroses at the latest follow up. Intramedullary nailing of adolescent femoral fractures using the lateral entry point is safe and effective

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This observational study examines the effect of the COVID-19 pandemic upon the paediatric trauma burden of a district general hospital. We aim to compare the nature and volume of the paediatric trauma during the first 2020 UK lockdown period with the same period in 2019.

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The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study.

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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.

We have reviewed the incidence of bacteriologically or radiologically confirmed acute haematogenous osteomyelitis in children under 13 years of age resident in the area of the Greater Glasgow Health Board between 1990 and 1997. In this period there was a fall of 44% in the incidence of both acute and subacute osteomyelitis, mainly involving the acute form (p = 0.005). This mirrors the decline of just over 50% previously reported in the same population between 1970 and 1990. Using multiple regression analysis a decline in incidence of 0.185 cases per 100 000 population per year was calculated for the 28-year period (p > 0.001). Staphylococcus was the most commonly isolated pathogen (70%). Only 20% of patients required surgery and there was a low rate of complications (10%). In general, patients with a subacute presentation followed a benign course and there were no complications or long-term sequelae in this group. Haematogenous osteomyelitis in children in this area is becoming a rare disease with an annual incidence of 2.9 new cases per 100 000 population per year

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Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group.

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The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.