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 purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy.

Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05).

Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement.

These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences.

Introduction and Aims: To review paediatric elbow dislocations treated in our institution over a ten year period and assess outcome

Method: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a ten-year period. Thereafter, a comprehensive case note and radiological review was performed

Results: 1761 elbow injuries exclusively treated in our unit in a ten-year period. Sixty-three elbow dislocations were identified. Male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation. Eighty percent of all dislocations occurred as a result of a low fall or simple sporting injury. Sixty of the 63 dislocations were posterior with two anterior and one divergent dislocation. Associated fractures were common (46%), with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. Two dislocations were open; there were two neuropraxias and no vascular complications. Twelve cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases. Reduction of fracture dislocations under sedation was associated with a higher incidence of medial epicondyle entrapment in the joint compared with general anaesthetic reduction. Post-operative management consisted on average of three weeks in plaster. No significant long-term loss of movement occurred in any patient. In the timeframe used there was one re-dislocation and no re-referrals for ongoing instability.

Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries. Although closed reduction is almost always possible, fracture dislocations should be reduced under general anaesthesia. Unlike in adults there appears to be problem with immobilisation for up to five weeks and the results of conservative treatment are excellent.

We performed a prospective, randomised study on 57 patients older than 60 years of age with unstable, extra-articular fractures of the distal radius to compare the outcome of immobilisation in a cast alone with that using supplementary, percutaneous pinning.

Patients treated by percutaneous wires had a statistically significant improvement in dorsal angulation (mean 7°), radial length (mean 3 mm) and radial inclination (mean 3 mm) at one year. However, there was no significant difference in functional outcome in terms of pain, range of movement, grip strength, activities of daily living and the SF-36 score except for an improved range of movement in ulnar deviation in the percutaneous wire group. One patient developed a pin-track infection which required removal of the wires at two weeks.

We conclude that percutaneous pinning of unstable, extra-articular fractures of the distal radius provides only a marginal improvement in the radiological parameters compared with immobilisation in a cast alone. This does not correlate with an improved functional outcome in a low-demand, elderly population.

Aims: To review paediatric elbow dislocations treated in our institution over a ten year period in terms of incidence, aetiology, management and follow up. Methods: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a ten year period. This was followed by a case note and x ray review. Results: 1761 elbow injuries exclusively treated in our unit in a ten year period. Of these patients 63 had elbow dislocations. We found a male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation with more injuries in the summer months. 80% of all dislocations occurred as a result of a low fall or simple sporting injury. 60 of the 63 dislocations were posterior with 2 anterior and 1 divergent dislocation. Associated fractures were common with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. 2 dislocations were open; there were 2 neuropraxias and no vascular complications. 12 cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases Those patients with associated fractures of the medial epicondyle who underwent reduction under sedation had a much higher requirement of open reduction of the fragment (3 out of 4) compared with those having reduction under general anaesthesia (4 out of 16). Post operative management consisted on average of 3 weeks in plaster. In the timeframe used there were no - recurrent dislocations, no patients re referred for assess- ment of ongoing elbow problems and no complaints of ongoing stiffness. Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries, are more common in boys and on the left. They generally arise from low energy trauma and are usually posterior. Closed reduction we found always to be possible but if there was an associated fracture then reduction is probably best carried out under general anaesthesia since this appears to aid reduction of associated fragments.

We present three cases of recurrent instability of the elbow in association with the Ehlers-Danlos syndrome. The pattern of instability has not previously been reported. We describe our procedure for achieving stability using a bone graft to the olecranon fossa which gave a functional range of movement.