Abstract. Objectives. Epiphysiodesis is a commonly used treatment for lower limb angular deformities. However, in recent years, distal tibial growth modulation using ‘eight plates’ or screws has emerged as an alternative treatment for
Our study seeks to determine whether characteristics of radiographs taken post-reduction of a forearm fracture can indicate future risk of refracture or loss of reduction. We hypothesize that reducing forearm fractures too precisely may be counterproductive and provide less benefit than reductions left slightly offset prior to cast immobilization. We conducted a retrospective review of 1079
To investigate changes in quadriceps and hamstrings muscle groups during sustained isokinetic knee flexion and extension. 125
‘Safety’ is at the centre of surgical practice with the aim of minimising the risks of complications and adverse events. Much evidence, based on either retrospective case series or prospective cohorts, concerns the frequency of adverse events. There may be a temptation to describe a procedure as ‘safe’ if no – or few – serious adverse events (the numerator) have occurred out of a number of procedures performed (the denominator). In 1983, Hanley and Lippman-Hand described a simple algorithm to calculate the 95% upper Confidence Interval for data sets in which the numerator is zero (ie series in which there no adverse events).
Purpose. Flat feet are an important cause of foot problems in children. The flexible flat foot is the most common form and is normally physiological and asymptomatic. Further assessment is necessary when a symptomatic flat foot persists. Surgical interventions are indicated when conservative therapies have failed. The Kalix arthroereisis is a surgical option and is placed in the subtalar joint of the foot, thereby preventing hyperpronation, and stabilizes the foot against excessive movements. The purpose of this study was to evaluate the functional and radiological outcomes of
Supracondylar fractures of the humerus (SCFH) are the most common type of
Femoral shaft fractures are potentially devastating injuries. Despite this, clinical studies of the biomechanics of this injury are lacking. We aimed to clinically evaluate bone behaviour under high and low energy trauma in
Forearm fractures are a common
The process of gaining informed consent can be a complex and much debated pursuit, especially within a
Introduction. Two randomised trials concluded cast type (above or below elbow) makes no significant difference in the re-displacement rate of
Pelvic fractures in children are uncommon. Despite their potentially serious nature, there is little information in the literature regarding their epidemiology. We performed a retrospective review of case notes and radiographs, if available, of all patients admitted with bony pelvic injuries to our unit over a 28 year period (1980-2008). Sixty-four children with pelvic fractures were identified (median age 8 years, 75% male). 58% were pedestrians involved in road traffic accidents (RTA), 19% were caused by a fall from a height and 8% were crush injuries. There was seasonal variability, with a 50% increase in pelvic injuries in Autumn and 33% decrease in Winter - compared to Spring/Summer months (in contrast to the peak in overall fracture incidence in the Summer). Median length of stay was 8 days (range 1-180), 11% requiring direct admission to ITU and 5% to HDU. There is a high incidence of associated major injuries - for Stable fractures 52%, Partially stable fractures 60% and Unstable fractures 100%. Five required surgery to the bony pelvis, and 6 for-non pelvic orthopaedic injury. 3 required operative intervention from other specialities, 1 urological repair, 1 laparotomy and 1 lobectomy. Pelvic fractures in children are potentially serious injuries with a high proportion of major associated injuries. Multiple injuries were sustained in 55% of pedestrian/RTA accidents, 100% of crush injuries and 58% of falls from a height. In this series, 52% of “Stable” pelvic injuries were associated with other major injuries. All
Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for
Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department. Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children. The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination. 30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function. While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in
To investigate differences in the drop vertical jump height in female adolescents with an ACL injury and healthy controls and the contribution of each limb in this task.
Forty female adolescents with an ACL injury (ACLi, 15.2 ± 1.4 yrs, 164.6 ± 6.0 cm, 63.1 ± 10.0 kg) and thirty-nine uninjured (CON, 13.2 ± 1.7 yrs, 161.7 ± 8.0 cm, 50.6 ± 11.0 kg) were included in this study. A 10-camera infrared motion analysis system (Vicon, Nexus, Oxford, UK) tracked pelvis, thigh, shank, and foot kinematics at 200Hz, while the participants performed 3 trials of double-legged drop vertical jumps (DVJ) on two force plates (Bertec Corp., Columbus, USA) sampled at 2000Hz.The maximum jump height normalised by dominant leg length was compared between groups using independent samples t-test. The maximum vertical ground reaction force (GRFz) and sagittal ankle, knee and hip velocities before take-off were compared between limbs in both groups, using paired samples t-test.
The normalised jump height was 11% lower in the ACLi than in the CON (MD=0.04 cm, p=0.020). In the ACLi, the maximum GRFz (MD=46.17N) and the maximum velocities of ankle plantar flexion (MD=79.83°/s), knee extension (MD=85.80°/s), and hip extension (MD=36.08°/s) were greater in the non-injured limb, compared to the injured limb. No differences between limbs were found in the CON. ACL injured female adolescents jump lower than the healthy controls and have greater contribution of their non-injured limb, compared to their injured limb, in the DVJ task. Clinicians should investigate differences in the contribution between limbs during double-legged drop vertical jump when assessing patients with an ACL injury, as this could help identify asymmetries, and potentially improve treatment, criteria used to clear athletes to sport, and re-injury prevention.
The pattern of appearance of secondary ossification centers in the elbow has been based on historical studies and is popularly referred to with the mnemonic CRITOL. However the six secondary ossification centers can be variable in their presentation and pose a challenge in assessment of children with elbow injuries. Furthermore limited studies available in the current literature have reported an aberration to the sequence of appearance especially with the ossification centers of trochlea and olecranon. The aim of the study was to evaluate the relative sequence of appearance of secondary ossification centers for the trochlea and olecranon.Background
Aims
We noted, in the immature ankle, a discrepancy between the alignment of the distal tibial physis, the distal tibial articular surface and the talar dome in the coronal plane. This led to variability in the orientation of wires and half pins used for limb reconstruction depending on which landmark was used. We aimed to investigate the variability in normal ankle joints to determine which is the most reliable landmark to use for correct wire or pin insertion. Radiographs of the ankle of 98 children were analysed. A variety of angular measurements were made with respect to the axis of the tibia and classified according to methods described by Shapiro & Mulhotra. We investigated the inter- and intra-observer variation in these measurements and classifications. Using the Bland-Altman method we found that the talar plafond angle (TPA) showed less variation than the lateral distal tibial angle (LDTA) with narrower limits of agreement and coefficients of repeatability. This was the same across the age and gender groups studied. The Shapiro classification of distal tibial epiphyseal shape did not appear to correlate with age or gender, but showed more inter- and intra-rater variation using weighted Kappa analysis. This study suggests that when measuring the orientation of the ankle joint from plain radiographs that the TPA is a more reliable measurement than the LDTA and this should be taken into consideration during decision making and pre-operative planning of lower limb deformity correction.
During the cold snap in the West of Scotland 20 December 2009 to 10 January 2010 there was a cluster of uncommon lower limb injuries in children from sledging accidents. These cases are presented as a series. This retrospective descriptive study details acute orthopaedic admissions for the period of the cold snap. The case-notes for all admissions were reviewed for diagnosis, mechanism of injury. Five (ex 20 ie 1/4) trauma admissions involved sledging: (1) combined avulsion of anterior and posterior cruciate ligaments left knee (2) Lisfranc injury, (3) distal femoral fracture, (4) distal tibial plafond fracture, (5) pelvis, patella also forearm and facial fractures. These cases are analysed in more detail Sledging injuries comprise a substantial portion of workload and morbidity. In children, there is a propensity for lower limb and higher energy trauma. Tertiary referrals and non-standard trauma equipment may be required.
We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome. We present the history and operative management. The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate. No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged. To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position.