Paediatric distal radial and forearm fractures account for 37.4% of all fractures in children. We present our 2.5-year results of a novel safe approach to the treatment of simple distal radial and diaphyseal fractures using intranasal diamorphine and entonox in a designated fracture reduction room in the emergency department. All simple fractures of the distal radius and forearm admitted to our ED between March 2012 and August 2014 that could be reduced using simple manipulation techniques were included in this study. These included angulated diaphyseal fractures of the forearm, angulated metaphyseal fractures of the distal radius and Salter Harris types I and II without significant shortening. All children included were given intranasal diamorphine as well as entonox. The orthopaedic registrar on call performed all reductions. 100 children had their distal radius or forearm fracture reduced in the emergency department using entonox and diamorphine analgesia and had a same day discharge. Average age was 10 years (range 2.20–16.37 years). No complications were reported regarding the use of the analgesia and all children and parents were pleased with their treatment not requiring a hospital admission. The mean initial dorsal angulation of all fracture types was 28.05° degrees (23.91–32.23 95% CI) which was reduced to 7.03° (5.11–8.95 95% CI) post manipulation. There were 9 cases lost to follow up. Two cases lost the initial reduction of the fracture on subsequent clinic follow up and underwent internal fixation in theatre. The use of entonox and intranasal diamorphine is a safe, effective treatment of providing adequate analgesia for children with distal radial and forearm fractures to allow manipulation of displaced dorsally angulated fractures in the emergency department. By facilitating a same day discharge, over £45,000 was saved using this safe method of treatment

Aim. The use of intraoperative cell salvage as a tool for reducing allogenic transfusion has been demonstrated in pelvic osteotomies. The aims of this audit were to identify any problems or complications with cell salvage, reduction in allogenic transfusion and identify procedures that would benefit. Methods. The use of cell salvage and allogenic transfusions were prospectively recorded over a 27-month period for all those who had major non spinal surgery looking at whether cell-salvage reduced allogenic transfusions and where cell salvage was used it was matched to procedure, diagnosis and age with cases where it was not used over the same time period. Results. Cell salvage was used in 61 cases. For these, average blood loss was 624mls and re-transfused volume 176mls (range=0-888mls). There were no complications. 4 problems occurred, 2 where suction became desterilised and 2 with insufficient sample to process. Of those that were matched, 3/55 cases required allogenic transfusion versus 11/55 that did not have cell salvage (p=0.03). Sub group analysis according to procedure did not reach significance. Excluding those with osteogenesis imperfecta, no isolated femoral osteotomy required allogenic transfusion (total number=48). Conclusion. Overall its use has reduced the number of children receiving allogenic blood and negates the need to cross match preoperatively. Group and save sample is probably sufficient for most major paediatric orthopaedic surgery with cell salvage. The specific indications for cell salvage have not been identified by this study, though useful in OI

Aim. To determine if the instigation of Magnetic Resonance Extremity (MRE) scanning in our unit as part of the management of suspected paediatric scaphoid fractures has prevented overuse of splints or casts reduced unnecessary clinic appointments and saved our department financially. Methods. Children with traumatic anatomical snuffbox tenderness and negative radiographs are seen 10 days following injury having been given a Futura® splint. If repeat radiographs are negative with on-going positive clinical findings the child has an MRE scan, which is usually reported the same day. If negative, the splint is removed on that day, but if positive, a cast is applied and the child referred onto paediatric fracture clinic. Results. Over a one-year period, 65 acute injuries were referred for MRE scanning. Fourteen bony injuries (22%) were identified including 10 scaphoid, 1 capitate and 3 distal radius fractures. The delay until MRE scanning averaged 11 days from emergency department and 14 days from outpatient clinic. Of these positive cases, the average time to clinic was 15 days equating to an average of 5 weeks from injury to orthopaedic review. The saving of orthopaedic clinics offsets the cost of the MRE scan by £5000 per annum. Fractures were identified in 22% of patients referred for MRE scanning with normal radiographs. Conclusion. The practice of streamlined MRE scanning for suspected paediatric scaphoid fractures can tailor management more efficiently. It has reduced the length of immobilisation in those normal cases and eradicated the need for continuing orthopaedic clinic review without increasing costs

A study to assess the clinical importance of asymmetric thigh creases as the sole clinical sign in the diagnosis of developmental dysplasia of the hip. METHOD. All consultant clinic letters have been saved on a hospital hard drive since 1999. This drive was searched for the terms “thigh crease” and “skin crease”. Irrelevant letters and referral letters describing factors that would indicate screening in our unit were excluded leaving those with the sole referral complaint of asymmetric thigh creases (ATC). We also reviewed the original referrals of developmental dysplasia of the hip (DDH) patients managed by open or closed reduction. These patients were identified through operative coding. All available hard copy notes were reviewed and patients with neuromuscular conditions or longitudinal deficiency were excluded. Results were inputted into an Excel spreadsheet and analysed by a statistician at the University of Sheffield assuming a background population incidence for DDH of 1 in 1000. RESULTS. 399 computer files containing the search terms were identified. Many contained whole clinics of patient letters. After exclusions we identified 229 patients with the sole referral complaint of ATC. Three of the 229 patients had DDH, which was not statistically significant (p=0.107). The majority of the normal patients had radiological investigations. Hard copy notes were available and relevant for 130 of the 289 operatively managed patients, of whom one was initially referred with the sole complaint of ATC. Orthopaedic specialist examination demonstrated all four patients initially referred with only ATC had decreased abduction and shortening. CONCLUSION. We suggest if the primary health care professional is not confident to exclude DDH in the patient with ATC there is justification for referral, but in the absence of other clinical features or risk factors in the orthopaedic consultation there is no need for further investigation or follow up

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money. Over a six-month period, we randomised 201 consecutive patients with this injury to treatment with either a traditional forearm plaster-of-Paris cast or a ‘Futura-type’ wrist splint. All patients were treated for a period of three weeks, followed by clinical and radiological review. There was no difference in outcome between the two groups, and all patients had a good result. Only one patient did not tolerate the splint which was replaced by a cast. The questionnaire showed a marked variation in the way in which these injuries are treated with regard to the method and period of immobilisation, the number of follow-up visits and radiographs taken. We suggest that a ‘Futura-type’ wrist splint can be used to treat these fractures. The patient should be reviewed on the following day to confirm the diagnosis and to give appropriate advice. There is no evidence that further follow-up is required. This simple treatment has major benefits in terms of cost and reduction of the number of attendances

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blount’s disease. The mean age of patients was 9.1 years (7 to 13.5).

All knees were in Langenskiöld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time.

The mean pre-operative angle of depression of the medial tibial plateau of 49° (40° to 60°) was corrected to a mean of 26° (20° to 30°), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6° (14° to 66°) was corrected to 0° to 5° of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2° to 5° of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis.