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.

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

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

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

Introduction. Through the paediatric LCP Hip plating system, the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to paediatrics. The purpose of this study was to review the outcome of the paediatric LCP Hip plate use in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications. Materials and methods. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Hip 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. Results. Forty-three Paediatric LCP hip plates were used in forty patients 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, DDH, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of SUFE. 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. There were no implant related complications. Conclusion. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric hip conditions in children with and without neuromuscular disease

Introduction. Four weeks after the earthquake in Kashmir, multidisciplinary surgical teams were organised within the UK (MiST). The aim was to help with disaster victims who had been transferred to Rawalipindi. We reviewed the work carried by one such team from the 5-18 November 2005. Patients. There were 78 patients: 50 lower limb injuries only, 21 upper limb, 7 combined, injuries. Mean age was 24 (0.5-80). 24 patients were under 10 and only 5 over 60. 274 procedures were performed over 11 days (average 25 per day). Results. The majority of injuries involved 3B open injuries n=50 (64%) of which there were already 12 lower limb amputees before we arrived. 202 EUAs, washouts and debridements, 34 definitive orthopaedic procedures and 57 definitive plastic procedures were performed (19 combined procedures). The majority of wounds required multiple washouts prior to definitive procedures. Definitive orthopaedic procedures included 11 Taylor spatial frame fixation of long bone, 4 Ilizarov frames (9 of which required acute shortening), 5 ORIF long bones, 7 K wire fixation, 5 MUA, 2 Application of hip Spica. Definitive plastic procedures included 21 Split Skin Grafts, 4 amputations, 11 revision of amputations, 17 fasciocutaneous flaps (1 proximal based, 1 sural artery, 15 distally based) 3 musculocutaneous flaps (gastrocnemius, soleus and tensor Fascia lata) and 1 free flap (rectus). Conclusion. There is a need for a multidisciplinary approach in the management of disaster trauma. This is essential in decision making regarding the management of bone and soft tissue injury, especially with regards to amputation. The amputation rate was less than 1% (707 out of 120,000 injured) in the aftermath of the earthquake. The concern now is that the amputation rate may increase fourfold due to complications of the initial severe trauma and inadequacies of local healthcare