Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

Aims

The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE).

Aim. With the link between obesity and Slipped Upper Femoral Epiphysis (SUFE) well established and a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the incidence of vitamin D deficiency in SUFE patients and whether low vitamin D levels increases the time to proximal femoral physeal fusion post surgical fixation. Method. All paediatric patients presenting to the orthopaedic department at University Hospital Southampton with a SUFE and tested for vitamin D between June 2007 to present day and who were subsequently found to have low levels of vitamin D, were eligible for inclusion in the study. A deficient level of vitamin D (25-(OH)D) was determined as < 52 nmols/L and insufficiency between 52–72 nmols/L. Levels > 72 nmols/L were considered to be normal. The normal time for 50% of physeal fusion on anteroposterior radiograph quoted in the literature is 9 months. Results. This study includes a cohort of 28 patients and 45 hips. All of these patients were treated with pinning insitu. Eighty six per cent were found to be vitamin D deficient. The mean physeal closure for these patients post fixation, including those yet to fuse and which have exceeded 12 months, was 23 months (range 9–64 months). Conclusion. This study has shown a correlation between vitamin D deficiency and prolonged physeal closure in SUFE patients. With an increasing prevalence of vitamin D deficiency, it is recommended that all patients presenting with a SUFE, be tested for low vitamin D levels, so that early treatment with supplementation can be initiated

Aim. We evaluated the outcome of conservative versus surgical treatment in lateral humeral condyle fractures in children. The management in some of these fractures remains controversial, ultimately relying upon the individual practitioner. Methods. We identified 73 children who sustained such fractures, with varying degrees of displacement, during the period between April 2006 and October 2011. Results. There were 41 boys and 32 girls. The mean age at the time of injury was 5.2 years (range 0.84–11.92). According to Milch's classification, there were 4 type I and 69 type II fractures. Undisplaced fractures (Jakob grade I, n= 30) were almost universally treated conservatively (n=29) whilst all severely displaced fractures (Jakob grade III, n= 15) were treated surgically, by closed or open reduction and k-wires or screws. However, the protocol differed for those fractures displaced 2–3 mm (Jakob grade II) and was mainly based on surgeon's preferences and clinical examination. Fifteen of 28 (53.57%) were initially treated in plaster whilst 13 (46.43%) were operated upon. Two of the former (2/18 or 11.11%), plus one minimally displaced (1/30 or 3.33%), required subsequent surgical fixation. One of the k-wire fixations was revised into a compression screw due to the fracture not uniting after 4 weeks. Other complications after treatment included fourteen mal-unions (2 after conservative and 12 after surgical treatment). There was no avascular necrosis or deep infection in this series. Conclusion. Although surgical treatment has been advocated as the gold standard for all displaced fractures, some initially displaced fractures may be stable and go on to heal in plaster with an acceptably low conversion rate. However, this requires close follow-up and careful examination to indicate surgical treatment if healing does not occur, or there is further fracture displacement

Aims

Although atlantoaxial rotatory fixation (AARF) is a common cause of torticollis in children, the diagnosis may be delayed. The condition is characterised by a lack of rotation at the atlantoaxial joint which becomes fixed in a rotated and subluxed position. The management of children with a delayed presentation of this condition is controversial. This is a retrospective study of a group of such children.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome.

We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027).

This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Cite this article: Bone Joint J 2015;97-B:134–40.