Injuries to growth plates may initiate the formation of reversible or irreversible bone-bridges, which may lead to partial or full closure of the growth plate resulting in bone length discrepancy, axis deviation or joint deformity. Blood vessels and vascular invasion are essential for the formation of new bone tissue. The aim of our study was to investigate the spatial and temporal expression VEGF and its receptors R1 and R2 as well as the ingrowth of vessels in the formation of bone bridges in a rat physeal injury model. Quantitative Real Time - Polymerase Chain Reaction (qRT-PCR) was performed for Vascular Endothelial Growth Factor (VEGF) and its R1 and R2 receptors. Samples from the proximal epiphysis, physis and metaphysis of the tibial bone were prepared for immunohistochemical analysis to demonstrate the spatial expression of VEGF and its R1 and R2 receptors as well as laminin. Kinetic expression of VEGF and VEGF-R1 mRNA documented a tendency towards an expression increase on day 7. Histological analysis showed a haematoma containing bone fragments on day 1which was replaced by a bony bridge by day 14. This remodelled and consolidated by day 82. These trabeculae were accompanied by vessel formation. Expression of VEGF was observed on the bone fragments and the haematoma from day 1 through to day 82. Although VEGF-R1 was expressed at all time points the expression of VEGF-R2 was noted until the 14th day. Physeal bone bridge formation is a combination of both enchondral and intramembranous ossification. This is in part triggered by the bony debris observed within the lesion in the first few days. By washing this debris out the likelihood of bone bridge formation may be reduced. We recommend this practice when operating on the physis in order to avoid iatrogenic physeal bar formation

Introduction. Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Methods. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined. Results. Between January 2019 and August 2023, 50 MPFL reconstructions were performed in 37 children using partial thickness quadriceps autograft. Patient age at time of surgery ranged from 5 to 17 years (median age 13 years). The technique was utilised for a variety of indications including recurrent traumatic and habitual patellofemoral instability, fixed dislocations, and revision MPFL reconstruction. Conclusion. Partial thickness quadriceps tendon autograft can be used safely to primarily reconstruct the medial patellofemoral ligament in paediatric population, including those children with open growth plates. It also has utility in revision cases following previous failed hamstring MPFL reconstruction. We have noted that the younger the child, the more distal to the physis lies the femoral point of isometricity, rendering this a safe and reproducible treatment in this age group. Use of this technique has increased in our unit as we have observed that patients seem to be satisfied with their clinical and functional outcomes with a low incidence of short- and medium-term complications

Kirschner wires are commonly used in paediatric fractures, however, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. Bioabsorbable pins that remain in situ and allow definitive closure of skin at the time of insertion could provide such advantages. Three concurrent studies were performed to assess the viability of bioabsorbable pins across the growth plate. (1) An epidemiological study to identify Kirschner wire infection rates. (2) A mechanical assessment of a bioabsorbable pin compared to Kirschner wires in a simulated supracondylar fracture. (3) The insertion of the implants across the physis of sheep to assess effects of the bioabsorbable implant on the growth plate via macroscopic, pathohistological and micro-CT analysis. An infection rate of 8.4% was found, with a deep infection rate of 0.4%. Mechanically the pins demonstrated comparable resistance to extension forces (p=) but slightly inferior resistance to rotation (p=). The in vivo component showed that at 6 months: there was no leg length discrepancy (p=0.6), with micro-CT evidence of normal physeal growth without tethering, and comparable physeal width (p=0.3). These studies combine to suggest that bioabsorbable pins do not represent a threat to the growth plate and may be considered for physeal fracture fixation

Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans. We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers’ assessments were compared using the paired Student’s t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs. We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures

Prophylactic pinning of the contralateral hip in the treatment of slipped upper femoral epiphysis has been shown to be safer than continued observation of the contralateral hip. This treatment remains controversial due to the potential for harm caused to an apparently unaffected hip. There is evidence that pinning of an already slipped epiphysis causes growth disturbance of the proximal femur, however Hagglund showed that there is not necessarily growth arrest at the physis after pinning, as the slip occurs at the hypertrophic layer of the growth plate with no damage to the germative layer. This was confirmed by Guzzanti who confirmed that a single screw provided epiphyseal stability and preserved potential for growth. We conducted a pilot study to determine whether prophylactic pinning affects subsequent growth of the unaffected hip. In order to determine the effect of prophylactic pinning we compared radiographs skeletally mature patients who had either undergone the procedure (group 1), not undergone the procedure but had pinning of the affected side (group 2), and adults with no history of SUFE (group 3). We measured the articulo-trochanteric distance and calculated the ratio of the trochanteric-trochanteric distance to articulo-trochanteric distance. These measures have been used in previous studies and shown to be reliable indicators of disturbed proximal femoral growth. As this was a pilot study we recruited 8 to each group. The absolute sum of the ATDs were 219mm (average 27.3mm) Group 1, 213mm (average 26.6mm) Group2 and 258mm (average 32.5mm). The average trochanter-trochanter: ATD ratio in group 1 was 2.7 (1.9 - 3.8) compared to 2.7 (2.3 - 3.2) and 2.3 (1.9 - 2.7) in groups 2 and 3 respectively. Our results suggest no difference in subsequent growth between hips that are prophylactically pinned and those that are not. They also show that unpinned hips go on to grow abnormally when compared to normal hips suggesting perhaps sub-clinical SUFE. These results have prompted expansion of the study to include much a higher number of patients

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.

Aims

To determine whether there is any difference in infection rate at 90 days between trauma operations performed in laminar flow and plenum ventilation, and whether infection risk is altered following the installation of laminar flow (LF).

Corticosteroid use has been implicated in the development of osteonecrosis of the femoral head (ONFH). The exact mechanism and predisposing factors such as age, gender, dosage, type and combination of steroid treatment remain controversial. Between March and July 2003, a total of 539 patients with severe acute respiratory syndrome (SARS) were treated with five different types of steroid. There were 129 men (24%) and 410 women (76%) with a mean age of 33.7 years (21 to 59). Routine screening was undertaken with radiographs, MRI and/or CT to determine the incidence of ONFH.

Of the 129 male patients with SARS, 51 (39.5%) were diagnosed as suffering from ONFH, compared with only 79 of 410 female patients (19.3%). The incidence of ONFH in the patients aged between 20 and 49 years was much higher than that of the group aged between 50 and 59 years (25.9% (127 of 491) versus 6.3% (3 of 48); p = 0.018). The incidence of ONFH in patients receiving one type of steroid was 12.5% (21 of 168), which was much lower than patients receiving two different types (28.6%; 96 of 336) or three different types of steroid (37.1%; 13 of 35).

Cite this article: Bone Joint J 2014;96-B:259–62.

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.

Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score.

Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3° (25° to 82°) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis.

Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion.

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.