Purpose: The aim of this study was to evaluate the clinical and radiological results and hospital stay of incorporated hip spica cast treatment in peadiatric diaphyseal femoral fractures. Material and methods: 49 femoral diaphyseal fractures of 48 children who were admitted to our institution between March 1998 and November 2001 were included in this study. Mean age was 4.5 years. Mean follow up was 30.5 months.The mechanisms of the fractures were: 45.7% road traffic accident, 8.3% falling and 6.2% sports injuries. Immediate supracondylar skeletal traction with a 3 mm. K-wire was applied to all patients under general anesthesia. This wire was incorporated with a hip spica cast after the reduction of the fracture under fluoroscopic control. All patients discharged from the clinic after 24 hours. Reduction and evidence of callus formation have been carefully checked with two plane X-rays taken on the follow-ups. We have removed the cast and K-wire in the evidence of callus formation on both AP and lateral X-ray views. After two weeks of careful rehabilitation program the patients were encouraged to walk with full weight bearing. The patients were followed in every three months in the first year and in every six months in the second year. Radiological assessment of roentgenograms and scoring of the final radiological result after fracture consolidation were evaulated as shown in Table 1. Findings: The average hospital stay was 24 hours. We have noticed pin tract infection only in 2 cases. We had only one re-fracture. Mean duration of cast removal was 6.9 weeks and mean consolidation time of the fracture was 13.3 weeks. On the final follow-up X-rays, mean overriding was 6mm(range 0–20 mm.). Mean shortening of the affected limb was 2mm. The mean deformity noted at the cast removal was as follows: Varus angulation 3.8 degrees, Valgus angulation 5.6 degrees, Anterior angulation 13.3 degrees. At the final examination we have noted the mean deformity angles as follows: Varus angulation 1.7 degrees, Valgus angulation 3.6 degrees, Anterior angulation 2.27 degrees. We have evaluated the results as excellent in 35 cases(72%), good in 9 cases(19%), moderate in 4 cases(9%). Conclusion: The treatment of femur fractures in children is controversial and highly variable. Each method of treatment has practical and theoretical advantages and disadvantages. The literature provides few comparative studies. Malunion is the most frequently used endpoint of treatment but every treatment is prone to different types of malunion. Any evaluation of treatment must consider all aspects of malunion including displacement, angulation, rotation, and length. Our study suggests that the clinical results of immediate incorporated hip spica cast application is a very reliable method compared with other choice of treatments. Safe and easy application, short hospital stay and low cost, are the major advantages of this method

Purpose of the study. To report the difference in the rates of avascular necrosis (AVN) of the femoral head following change in the hip abduction angle in the hip spica. Methods. Up until 2002, following closed and medial open reduction of the dislocated hip, the joint was immobilised in a 90° of flexion, 60° of abduction and 10-20° of internal rotation hip spica. The practice was changed after 2002 to 45° of hip abduction in the spica with other parameters remaining same. We audited the rates of radiologic AVN in these two groups of children. Group A, before 2002, had 20 children and in group B, after 2002 till Aug 2007, had 53 children. AVN was quantified on 2 year radiograph by the classification described by Salter and noted its progression on serial radiographs. Results. Twelve children (60%) in group A had radiographic evidence of AVN in the first two years after the procedure compared to 26 children (49%) in group B. This was usually in the form of delayed appearance of the ossific nucleus and delayed development of already appeared nucleus compared to other side. However, on serial radiographs when these patients were followed, at their latest follow-up, the femoral have developed symmetrically in all but 4 patients (20%) in Group A and 6 patients (11.3%) in Group B. Conclusion. Children treated in hip spica after closed or medial open procedure developed transient avascular changes in their femoral head which recovered in most patients. This transient ischemia is further reduced by decreasing the amount of hip abduction angle without compromising the hip reduction achieved

Femoral shaft fractures are fairly common injuries in paediatric age group. The treatment protocols are clear in patients of age less than 4 years and greater than 6 years. The real dilemma lies in the age group of 4–6 years. The aim of this study is to find whether a conservative line should be followed, or a more aggressive surgical intervention can provide significantly better results in these injuries.

This study was conducted in a tertiary care hospital in Bhubaneswar, India from January 2020 to March 2021. A total of 40 patients with femur shaft fractures were included and randomly divided in two treatment groups. Group A were treated with a TENS nail while group B were treated with skin traction followed by spica cast. They were regularly followed up with clinical and radiological examination to look out for signs of healing and any complications. TENS was removed at 4–9 months’ time in all Group A patients.

Group A patients had a statistically significant less hospital stay, immobilisation period, time to full weight bearing and radiological union. Rotational malunions were significantly lower in Group A (p-value 0.0379) while there was no statistically significant difference in angular malunion in coronal and sagittal plane at final follow up. Complications unique to group A were skin necrosis and infection.

We conclude that TENS is better modality for treatment of shaft of femur fractures in patients of 4–6 years age as they significantly reduce the hospital stay, immobilization period and rotational malalignment.

Aims

To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures.

The February 2024 Children’s orthopaedics Roundup. 360. looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures

Purpose. Ultrasound of the neonatal and infantile hip is a useful tool in diagnosis and treatment of the developmental dysplasia of the hip (DDH), especially given the fact that numerous cases of DDH do not present any findings in the clinical examination. Methods. Between January 2014 and May 2020, 10536 (5273 neonates and infants, 53% girls, 47% boys) consecutive neonatal and infantile hip joints were studied using the Graf Hip Ultrasound method. Results. 607 hips were diagnosed as abnormal. 523 (5%) hip joints were type IIA, 18 (0.17%) were type ΙΙΒ, 19 (0.18%) were type ΙΙC, 33 (0.31%) were type ΙΙΙ and 14 (0.13%) were type IV. 72% of patients were girls, 55% of patients were firstborns, 35,7% presented breech, 8,2% had a positive family history of DDH, 6% were part of a multiple pregnancy, while 27,2% had no predisposing factor for the disease. Type ΙΙΑ hips were treated with follow- up only and had all matured (turned to normal- type I hips) within a trimester. Type ΙΙΒ και ΙΙC hips were treated using an abductor harness and were normal (type I) within three months. 35.7% of type ΙΙΙ were treated with an abductor harness and 64.3% with hip spica. All type IV hips were treated with hip spica. The duration of therapy for type III and type IV hips was 3 months. Conclusion. The early use of a hip ultrasound provides us with the ability to diagnose and treat DDH efficiently, resulting in a normal hip joint within the first months of life

Through the paediatric LCP Hip plating system (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff), the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to pediatrics. We are presenting the outcome of the paediatric LCP hip plating system used for a variety of indications in our institution. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Forty-three Paediatric LCP hip plates were used in forty patients (24 males and 13 females) for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, developmental dysplasia of hip, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of Slipped Upper Femoral Epiphysis. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p= 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. Among the children treated without hip spica, 1 child suffered a periprosthetic fracture. Of the children treated in hip spica, 2 had pressure sores, 3 had osteoporotic distal femur fractures and 2 had posterior subluxations requiring further intervention. There were no implant related complications. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions

Femoral fractures are a common injury in the paediatric population. The purpose of this study was to audit the cost and early outcomes of femur fractures treated at the Starship Childrens Hospital. Forty-eight femur fractures treated between January 1998 and December 2002 were reviewed. 25 fractures were treated by application of an early hip spica, 12 by IM nails and 11 by other methods. Children treated by early hip spica averaged 3.8 years in age. They went to theatre an average of 29.1 hours after admission and had an average length of stay of 3.8 days. In the 30 days after discharge, five patients were readmitted for loss of fracture position. Children treated with IM elastic nails averaged 9.5 years and went to theatre on average 35.1 hours after admission. Their length of stay averaged 8.3 days. Complications in hospital included return to theatre to shorten a wire (1 patient), remanipulation and application of a hip spica (2 patients) and difficulty mobilizing (1 patient). In the first 30 days after discharge, two patients required readmission for further surgery due to prominence of the wire. Children treated with external fixator (7), femoral rod (1) or crossed k-wires (3) averaged 8.7 years in age. They went to theatre on average 58 hours after injury and had an average length of stay of 24 days. Two patients were readmitted with superficial pin-site infections. Most femur fractures are being operated on the next day, however surgery is delayed in some patients. The readmission rate in the first 30 days is significant and is not reduced by operative fixation. Cost containment should focus on ways to reduce the early readmission rate

The disadvantages of hip spica casts following hip surgery for cerebral palsy include fractures, plaster sores, soiling and general inconvenience. In this series, 56 hips in 31 children aged 4 to 16 years (mean 8) were treated for hip displacement in keeping with the recommendations of others (eg Miller et al 1997) between 2005 and 2008 by one consultant. There were 29 open reductions for a Reimer's migration index (RMI) greater than 50%. A blade plate was used for the femoral osteotomy, and an acetabuloplasty was performed for 22 hips. No casting or immobilisation of any sort was used. The average length of stay was 5 days. The results at 5 the year follow-up were chosen so that all patients were at the same stage. The average RMI pre-operatively for displaced hips was 76.9 +/− 21.3. At follow-up it was 18.8 +/− 19.7. 18 patients had pain prior to hip surgery; 6 had pain during follow-up, and 4 of these responded to removal of metal; and one required a proximal femoral resection. There were 3 complications: one re-dislocation in the immediate post-operative period, one mal-union because the blade plate cut out; and one of the three walking children fractured below the blade plate 2 ½ months after surgery. There were no infections. The radiographic and clinical outcomes of hip reconstruction without hip spica immobilisation are good, reproducible and long-lasting. The child may be nursed free post-operatively and discharged in his or her own chair. As a result of studying these patients, since 2009 we have introduced locking plates for better fixation, and pre- and post-operative Paediatric Pain Profiles and CPCHILD questionnaires

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months

Background. The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital. Patients and methods. Our protocol (1999-2002) uses flexible intramedullary nails for children older than five, early hip spica (within one week of injury) for the under five year olds, and external fixation for polytrauma (Early Active Group[EAG], n = 25). Prior to this (1999-2002), treatment consisted of late application of a hip spica (3-4 weeks following injury) or inpatient traction (Traditional Group [TG], n = 41). Outcome measures were length of hospital stay, degree of malunion, knee and hip movements, and leg length discrepancy. The financial burden to the family including waged and non-waged time lost, transport, childminder, and other extra costs were estimated. Hospital costs including inpatient stay, theatre, and implant costs were analysed. Results. A 40% reduction in the incidence of femoral fractures over the six-year period was noted. Mean hospital stay was 29 and 10 nights (p<0.001); family costs were £1,243 and £968; and hospital costs were £10,831 and £4,291 per patient (p<0.005) in the TG and the EAG respectively. Parents in both groups preferred early discharge (86%-94%). In the EAG, 10 patients were short at 3 months (0.5 - 3 cm). None was short at 2 years. Eight children were long at 2 years. At 2 years, all had good clinical and functional results. There was no significant difference in the mal-union rate between the two groups. All the fractures united by three months. Five out of nine complications occurred in the EAG. Conclusion. The use of our early active treatment protocol has resulted in a significant reduction in hospital stay, costs to the families and the hospital

Paediatric femoral fractures are a common result of significant trauma, and always require intervention. Hip spica casting, traction, and surgical fixation can all be used to treat these fractures. This variety in treatment options leads to a vast potential for variability in management decisions among surgeons and has prevented effective comparative studies to show which treatment methods provide optimal outcomes for patients. The purpose of this study was to identify practice variability in management and follow-up and assess patient outcomes to aid in the development of a comprehensive, prospective, evidence-based pathway for the management of paediatric femoral fractures. A retrospective chart review was performed of all patients treated surgically for isolated femoral fractures during a six year period at a single tertiary care paediatric centre. Patients were identified from a surgical database and were included if there was no pre-existing pathology and no history of previous femoral fracture. Demographic data, operative details, post-operative management, and clinical outcomes were collected. Radiographic images and reports were analyzed to determine fracture classification and imaging parameters. Variability in treatment among eight surgeons was assessed, including number of follow-up appointments and length of follow-up. Patient demographics and follow up measures were summarised for each surgeon and between surgeon variability was assessed with linear models. In total, 138 femoral fractures in 134 patients (101 male, 33 female) were included in analysis. Of these patients, 55 had right femoral fractures, 76 left, and three bilateral (one bilateral patient had three distinct femoral fractures). Of 138 total fractures, 131 were of the diaphysis of the femur. 14 patients sought initial surgical treatment at our institution but received follow-up management elsewhere. Across all patients, median follow-up time was 32.8 weeks (0–201.4) with a median of three follow-up visits (0–26) in that period. Mean number of follow-up clinic visits ranged from 3 to 4.8 among surgeons, and mean length of follow-up ranged from 31.8 to 62.3 weeks. No significant differences in follow-up between surgeons were found, but small sample sizes are a likely contributing factor. Summary statistics show large ranges in most variables and differences in patient demographics between surgeon groups. The large ranges in follow-up time and visit number suggest a lack of consensus on optimal management for paediatric femoral fractures. Further prospective study examining long-term functional and quality of life outcomes will be required to identify and develop optimized management guidelines

The aim of the study was to compared the various treatments of femoral diaphyseal fractures in children. The endpoints being length of hospital stay, clinical and functional outcome. The prospective part of the study started with the appointment of a dedicated children’s orthopaedic surgeon in 1999. Prior to this in patient traction was the main treatment. Now early hip spicas for the under 5 year old, Nancy nails for the over fives and external fixation for polytrauma are the treatments of choice. Anyone under the age of fifteen sustaining a traumatic femoral diaphyseal fracture was included in the study. In both groups’ details of the injury, demographic details, other injuries sustained, treatment performed and length of hospital stay were recorded. In the prospective group clinical and radiographic assessments were made at three months and one year. The range of movement of the affected limb was measured and compared to the unaffected side. There were 47 fractures in the retrospective group and 16 fractures in the prospective. In the retrospective group 94% were treated with traction, and in the prospective group the treatments were, early hip spicas 44%, external fixator 31% and flexible nails 19%. The mean hospital stay was 31 nights in the retrospective group and 16 in the prospective group. In the retrospective group 17% had a mal-union greater than ten degrees, and at three months in the prospective group this was 46%. Clinical follow up at three months in the prospective groups, they all had a full range of movement, and only two had any pain. The use of varied treatments result in shorter hospital stay which allows children home earlier and reduces the demand on hospital beds. The children returned to normal function with a good range of movement using these modern treatments

Purpose of study: To assess whether a plane x-ray at five months is needed in a DDH screening program. Method: Between 1990 and 2004 we operated selective hip screening, including ultrasound. Hips screened as normal had an X-ray at 5 months, initially instituted to cover the ultrasound learning curve. These were reported by a consultant radiologist and referred if thought abnormal. For the purposes of this study the notes, scans and X-rays of all patients referred at 5 months were reviewed. Results: In Nottingham there were approximately 108,500 births between 1990 and 2004. Of these 11,425 were referred for ultrasound scan. 53 were referred to orthopaedics following the x-ray at 5 months. 47 of these had a complete data set. Of these 47 children, 30 (64%) were watched, 9 (19%) had arthrograms only, 5 (11%) had adductor tenotomy and application of a hip spica. One (2%) child had Pavlik harness treatment and 2 (4%) had a femoral osteotomy. Graf’s alpha angles and percentage cover were reviewed from the original ultrasounds, many of which were of poor quality. This demonstrated that there was less than 50% cover for 14/30 (47%) who were watched, for 6/9 (78%) who had arthrograms, for 1/1 (100%) treated by harness, for 4/5 (80%) treated with adductor tenotomy and hip spica and for 2/2 (100%) requiring surgery. Alpha angles less than 60 degrees did not predict the need for intervention. There were no late cases from the group that had X-rays classed as normal at 5 months. Conclusions: The importance of measuring head cover was established and is now routine in the hip instability clinic. It was clear that a large population had received unnecessary X-rays. X-rays are now only performed if US at 6 weeks reveals a low alpha angle or less than 50% cover

Introduction & Discussion: From an experience of over 250 Salter osteotomies, 148 of which have been reviewed at skeletal maturity, certain technical tips merit discussion:-. Preoperative positioning and the incision. Psoas tenotomy, capsular exposure and the capsulotomy. Facilitation of the Gigli saw osteotomy. Sizing and procurement of the graft. Displacement and fixation of the osteotomy. Application of the hip spica. Some questions are worthy of debate:-. Can the osteotomy be safely combined with open reduction of the high dislocation?. Should the osteotomy be fixed before reducing the femoral head?. Are there alternatives to autogenous bone graft and K-wire fixation?. Is minimally invasive surgery an option?. Are the contraindications and alternatives to the Salter osteotomy fully appreciated?

A method of intra-articular arthrodesis of the hip is described in which fixation is obtained with a lag-screw. Two main advantages are claimed: first, that it is a compression arthrodesis and gives early bony fusion; and second, that it gives adequate internal fixation in most cases so that the disadvantages of a plaster hip spica are avoided, and the patient may walk with crutches two or three weeks after the operation. The results were satisfactory in forty-seven of the first fifty cases in which this method of arthrodesis was employed. There were two post-operative deaths and one failure to secure fusion in a case of massive necrosis of the femoral head

Purpose of Study. To evaluate the results of using external fixation to stabilise femoral derotation osteotomy involved in DDH surgery. Methods and results. A retrospective analysis was performed on 44 patients undergoing 48 femoral osteotomies for DDH surgery between the years 2001 and 2009 by a single surgeon (senior author MC). The external fixator was used either during the primary procedure involving femoral shortening to aid in hip reduction (4 patients) or to correct femoral malrotation in a reduced hip as a secondary procedure(40 patients). As the external fixator frame was within the hip spica it was not a cause of concern to the parents or the child. There was no evidence of any pin tract infection and all patients eventually progressed to satisfactory bony union. One patient had delayed union which was treated successfully with conservative management and one patient had a malunion requiring a further osteotomy and extended treatment with the external fixator. Conclusion. External fixation is a viable alternative for the traditional internal fixation used for femoral osteotomy involving DDH Surgery. Our study has shown that it produces satisfactory results with minimal complications. Apart from minimising tissue scarring in the muscle and subcutaneous planes, it gives a cosmetically better scar. If there is further need for revision surgery it provides healthy tissue planes for dissection. Furthermore it eliminates the need for additional surgery required for removal of plates

A protocol for the treatment of fractures of the middle third of the femur by the early application of a hip spica has been evaluated in 191 children aged 10 years or less. Children without other injuries spent only a few days in hospital for the application and later removal of the spica. At all ages, anterior angulation of less than 20 degrees and valgus angulation of less than 15 degrees were accepted at the one-week review. Acceptance of shortening varied with the age of the child and the stage of treatment, but was 10% or less of the femoral length at the time of spica removal. At late review leg-length discrepancy was rare and clinically insignificant. This method of treatment was simple and effective. It dramatically reduced the cost of care and freed a number of children's hospital beds

Purpose. Following closed or open reduction for developmental dysplasia of the hip (DDH), assessment of reduction is essential. With potentially poor accuracy in confirming reduction, the risk of abnormal hip development and ultimately poor outcome exists if reduction is not achieved. Computed tomography (CT) has been used in recent years to assess reduction. The aim of this study was to compare the accuracy in confirming hip reduction following closed or open reduction in children with DDH, using CT and plain radiographs and to decide whether CT scans improved the assessment of reduction. Methods. We retrospectively reviewed 6 patients treated for DDH at an Academic Hospital. The patients were treated with either closed or open reduction. Post operatively radiographs and CT scans were obtained to assess reduction. Reduction was assessed using Shenton's line, medial joint space, a femoral mid-cervical line through the tri-radiate cartilage and a tri-radiate intersectional line on axial CT. The CT scans were analyzed using Osirix on an Apple Macintosh computer. Results. We were able to obtain measurements in all parameters in only one radiograph, whereas in the CT images all parameters were determined. One patient had radiographs in which no values could be measured. The CT scan however confirmed reduction of that hip. In one patient we assessed a hip as reduced using all the parameters, whereas the tri-radiate intersectional line on axial CT and the Shenton's line on the coronal slice showed that in fact the head was posteriorly subluxed. Conclusion. We conclude that although CT scans did not change our management in this small patient series, CT scans did provide a better means of confirming hip reduction than plain radiographs for patients with DDH following closed or open reduction in a hip spica. NO DISCLOSURES

We report a femoral shaft fracture that reduced spastic muscle hypertonus of the affected lower limb of a child with cerebral palsy. The child was a five years old boy. He was borne with spastic quadriplegia (total body involvement). He could not sit, stand and walk by himself. The femoral shaft fracture occurred during physiotherapy. The injury itself was iatrogenic although the bones were accompanied by roentgenological bone atrophy. Such bone atrophy comes from disuse or low physical activity. The fracture was treated by a hip spica cast. The femoral bone was shortened at the time of immobilization. After removing the cast, the spastic muscle hypertonus was apparently reduced. This instructive case suggests osteotomy as a new effective treatment for spastic hypertonus. Osteotomies would make few scars in the muscles and tendons comparing to lengthening of multiple tendons and muscles. In this case, osteotomies are believed to be a non-invasive treatment rather than other available operative procedures