Purpose. This study evaluated the acceptability of performing manipulations with intranasal diamorphine and inhaled Entonox to parents of children presenting to our Emergency Department. Method. 65 fractures were manipulated in the Emergency Department in a 4-month timespan. Parents were invited to complete a questionnaire to indicate their experience with the procedure. Fracture position post-reduction was calculated as well as conversion rate to surgery. 32 patients who were admitted and had their forearm fractures managed in theatre were also asked to complete the questionnaire as a comparison group. Results. Overall response rate was 82% . 100% of parents of children who had a manipulation in the emergency department would recommend the treatment to parents of children with similar injuries. Relative risk of perceived distress to parents was 2.42 (0.8–7.2) with manipulation in the emergency department compared to theatre management. Relative risk of distress to the child was 1.45 (0.7–3.3) with manipulation in the emergency department compared to theatre management. This was not statistically significant. Mean (S.D.) fracture displacement was 29.2 (13.0)° pre reduction and 5.8 (5.9)° post reduction. Mean (S.D.) length of stay was 5.5 (3.2) hours from time of injury to discharge for patients receiving manipulation in the Emergency Department and 27.9 (14.3) hours for patients receiving procedures in theatre (p< 0.001). Overall, parents and children were satisfied about manipulations in the Emergency Department. Operative re-intervention rate was 2% when protocol violations were excluded. Reduction was as effective as previous reports and within acceptable treatment limits. Conclusion. Manipulation of paediatric forearm fracture is an effective and acceptable technique when performed with a diamorphine and Entonox protocol

This retrospective matched cohort study tested the hypothesis that an incomplete periacetabular acetabuloplasty, as an added step to delayed open reduction, diminishes the risk of developing acetabular dysplasia. 29 hips from 23 patients with idiopathic DDH that underwent intentionally delayed open reduction and acetabuloplasty at our institution from 2003 to 2010 were matched for age at presentation and bilaterality to historic controls. These were 29 hips from 26 patients, treated with open reduction alone from 1989 to 2003. Residual dysplasia treated with pelvic osteotomy, AVN grade II-IV, and rate of re-intervention were the outcome measures. The mean ages at diagnosis and at surgery were 8.62 weeks and 12.97 months, respectively. At latest follow-up, 27 hips in the acetabuloplasty group and 22 in the open reduction alone group had satisfactory radiographic outcome (Severin class Ia, Ib or II) (p=0.16). 18 of the 58 hips (31.0%) had AVN, 7 (24.14%) in the case group and 11(37.93%) in the control group. Further surgery was required in 15 of the 29 hips in the open reduction alone group. These included 2 revision of open reductions, 5 pelvic osteotomies, 3 varus derotation osteotomies, and 5 apo or epiphysiodesis whilst only one patient in the acetabuloplasty group required a medial screw epiphysiodesis for late lateral growth arrest. There is a positive association between the need for further surgery and open reductions alone: the odds ratio is 14.00 and the 95% confidence interval (1.97, 99.63), p=0.0017. The five hips in the open reduction alone group that required a pelvic osteotomy were intervened at an average of 31.45 (±9.07) months. The addition of an incomplete periacetabular periacetabuloplasty to all hips undergoing open reduction eliminated residual acetabular dysplasia in this cohort whilst it does not appear to have deleterious effects, as evidenced by the similar Severin and McKay scores