Aims

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.

Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

The aim was to assess the effect of caudal block on patients who have had proximal femoral &/or pelvic osteotomy compared to patients who have had epidural anaesthesia with regards to pain relief and hospital stay. We looked at two patient cohorts; epidural & caudal pain relief in aforementioned procedures. Interrogation of our clinical database (WinDip, BlueSpeir&clinical notes) identified 57 patients: 33 proximal femoral osteotomy, 13 pelvic osteotomy and 11 combined(25 Males 32 Females), aged 1–18 years-old between 2012–2014, in two institutions. A database of demographics, operative indications, associated procedures, analgesia and type of anaesthesia was constructed in relation to daily pain score and length of hospital stay. 39 patients had epidural anaesthesia, and 18 had caudal block. Cerebral palsy with unstable hips was the commonest indication(21), followed by dysplastic hip(10), Perthes disease(8) and other causes(18). The Face, Legs, Activity, Cry, Consolability(FLACC) scale was used to assess pain. Length of hospital stay in caudal block patients was 3.1 days(1–9), in epidural anaesthesia patients stay was 4.46 days(2–13). Paediatrics high dependency unit after an epidural was needed in 20(Average stay 3.4 days) compared to 1 who received caudal block. Caudal block FLACC pain score in the first 36 hours was 1.23(0–4) compared to 0.18(0–2) in patients who had an epidural. Caudal block is associated with less hospital stay and fewer admissions to the high dependency unit, it also provides adequate pain relief post osteotomies when compared to epidural, therefore could be performed at units lacking epidural facilities. A change in related practice however should be cautious and supported by further studies

Aims

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.

Aims

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.

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

Aims

The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic.

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

Of the 34 723 infants born between 1 June 1992 and 31 May 2002, the hips of 2578 with clinical instability or at-risk factors for developmental dysplasia of the hip were imaged by ultrasound.

Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the ‘at-risk’ groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when foot deformity were considered as risk factors. Of those hips which were ultrasonographically stable, 88 had type-III dysplasia.

A national programme of selective ultrasound screening of at-risk factors for the diagnosis of hip dislocation or instability alone cannot be recommended because of its low predictive value (1:88). However, the incidence of type-III dysplasia and hip dislocation or dislocatability in the groups with clinical instability, family history, breech position and possibly postural foot deformity as risk factors could justify a programme of selective ultrasound imaging.