Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients. Cite this article: Bone Joint J 2013;95-B:694–98

Aim. Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information. Methods. An electronic 18 item, single response multiple-choice questionnaire was designed to investigate various aspects of the surgical management of supracondylar fractures, with particular focus on areas that remain controversial in the literature. Members of BSCOS were invited by email, on three occasions, to complete the questionnaire, which was posted on the web-based SurveyMonkey™ platform (. www.surveymonkey.com. , California, USA). The survey was available for completion for a period of 10 weeks. Results. 102 responses were received (response rate 56.7%); all respondents completed the entire questionnaire. There was almost complete agreement (>90%) in only three areas: -The preferred management of Gartland 3 fractures; The management of the fracture with an absent radial pulse and impaired digital perfusion; An ulnar nerve palsy detected four weeks post-operatively. Majority agreement (>60%) was found regarding: - Possible consequences of delay in performing closed reduction; Management of the pink, perfused hand with an absent radial pulse; Necessity of anatomical reduction. There was no consensus regarding: - K-wiring of Gartland 2 fractures; Management of ulnar nerve palsy detected one week post-operatively; Open insertion of the medial K-wire. Conclusion. Reflecting current trends and attitudes, this survey provides information against which an individual surgeon can appraise their own practice. Strong consensus existed in areas in which clear evidence is available to inform practice. This highlights the importance of good-quality research, and identifies areas requiring further investigation

Aim. Vascular compromise following supracondylar fractures is frequently described. Near Infra-red Spectrometry (NIRS) is a technique through which real-time data can be gathered non-invasively on the oxygenation status of tissues. The drive now is to gain knowledge on how NIRS data can be interpreted and to validate its use in the clinical setting. Methods. This ethically approved prospective study looks at volar forearm compartment oxygen saturation (StO2) in 20 patients with supracondylar fractures requiring operative intervention. Both the injured limb and the contra-lateral, uninjured limb were monitored. 20 patients from a cohort of 29 had full data sets and are thus presented. Results. 12 patients were neurovascularly intact. Eight patients showed some neurovascular compromise. There was no difference (P=0.3475) between the StO2 of the injured and non-injured arms of the neurovascularly intact patients. Of the eight arms with an altered neurovascular status, four were pink and pulseless. We encountered no compartment syndromes in this series. Comparing the StO2 from the neurovascularly altered limbs (mean 66.84% range 45.43–89.53% SD 15.90) and the neurovascularly intact limbs (mean 81.62% range 64.21–98.89% SD 9.523) there was a significant difference (P=0.039). There was quick return to normal values after operation in those that were operated upon to release neurovascular compression. An improvement of 13.44% ± 8.769. Conclusion. NIRS data is shown to be valid in this model. Further studies are needed to delineate the normal values for StO2 and further investigate the indications for intervention. NIRS measurements of muscle tissue oxygenation can identify patients with clinical neurovascular compromise, and can identify the return of adequate perfusion following operative correction of supracondylar fractures. NIRS based tissue oxygenation monitoring may be a useful adjunct to clinical assessment, particularly in paediatric patients and those with altered consciousness

Aims

We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP).

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy.

Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head–shaft slip angle from 53.8^o (standard deviation (sd) 3.2) pre-operatively to 9.1^o (sd 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, sd 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention.

This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

Cite this article: Bone Joint J 2015;97-B:1718–25.

Compartment pressures have not previously been studied in healthy children. We compared the pressures in the four lower leg compartments of healthy children with those of healthy adults.

We included patients aged between two months and six years, and measured the pressures in 80 compartments of 20 healthy children using simple needle manometry. Measurements were repeated in a control group of 20 healthy adults.

The mean compartment pressure in the lower leg in children was significantly higher than in adults (p < 0.001). On average, pressures in the four compartments varied between 13.3 mmHg and 16.6 mmHg in the children and between 5.2 mmHg and 9.7 mmHg in the adults. The latter is in accordance with those recorded in the literature. The mean arterial pressure did not relate to age or to pressure in the compartment.

The findings of this study that the normal compartment pressure of the lower leg in healthy children is significantly higher than that in adults may be of considerable significance in clinical decision-making in children of this age.

The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered.

Cite this article: Bone Joint J 2014;96-B:1119–23.

Matrix metalloproteinases (MMPs), responsible for extracellular matrix remodelling and angiogenesis, might play a major role in the response of the growth plate to detrimental loads that lead to overuse injuries in young athletes. In order to test this hypothesis, human growth plate chondrocytes were subjected to mechanical forces equal to either physiological loads, near detrimental or detrimental loads for two hours. In addition, these cells were exposed to physiological loads for up to 24 hours. Changes in the expression of MMPs -2, -3 and -13 were investigated.

We found that expression of MMPs in cultured human growth plate chondrocytes increases in a linear manner with increased duration and intensity of loading. We also showed for the first time that physiological loads have the same effect on growth plate chondrocytes over a long period of time as detrimental loads applied for a short period.

These findings confirm the involvement of MMPs in overuse injuries in children. We suggest that training programmes for immature athletes should be reconsidered in order to avoid detrimental stresses and over-expression of MMPs in the growth plate, and especially to avoid physiological loads becoming detrimental.

Cite this article: Bone Joint J 2013;95-B:568–73.