The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation.Aims
Methods
Background: Anterior cruciate ligament (ACL) injury and re-injury rates are high and continue to rise in adolescents. After surgical reconstruction, less than 50% of patients return to their pre-injury level of physical activity. Clearance for return-to-play and rehabilitation progression typically requires assessment of performance during functional tests. Pain may impact this performance. However, the patient's level of pain is often overlooked during these assessments. Purpose: To investigate the level of pain during functional tests in adolescents with ACL injury. Fifty-nine adolescents with ACL injury (ACLi; female n=43; 15 ± 1 yrs; 167.6 ± 8.4 cm; 67.8 ± 19.9 kg) and sixty-nine uninjured (CON; female n=38; 14 ± 2 yrs; 165.0 ± 10.8 cm; 54.2 ± 11.5 kg) performed a series of functional tests. These tests included: maximum voluntary isometric contraction (MVIC) and isokinetic knee flexion-extension strength tests, single-limb hop tests, double-limb squats, countermovement jumps (CMJ), lunges, drop-vertical jumps (DVJ), and side-cuts. Pain was reported on a 5-point Likert scale, with 1 indicating no pain and 5 indicating extreme pain for the injured limb of the ACLi group and non-dominant limb for the CON group, after completion of each test. Chi-Square test was used to compare groups for the level of pain in each test. Analysis of the level of pain within and between groups was performed using descriptive statistics. The distribution of the level of pain was different between groups for all functional tests (p≤0.008), except for ankle plantar flexion and hip abduction MVICs (Table 1). The percentage of participants reporting pain was higher in the ACLi group in all tests compared to the CON group (Figure 1). Participants most often reported pain during the strength tests involving the knee joint, followed by the hop tests and dynamic tasks, respectively. More specifically, the knee extension MVIC was the test most frequently reported as painful (70% of the ACLi group), followed by the isokinetic knee flexion-extension test, with 65% of ACLi group. In addition, among all hop tests, pain was most often reported during the timed 6m hop (53% of ACLi), and, among all dynamic tasks, during the side-cut (40% of ACLi) test (Figure 1). Furthermore, the tests that led to the higher levels of pain (severe or extreme) were the cross-hop (9.8% of ACLi), CMJ (7.1% of ACLi), and the isokinetic knee flexion-extension test (11.5% of ACLi) (Table 1). Adolescents with and without ACL injury reported different levels of pain for all functional tasks, except for ankle and hip MVICs. The isokinetic knee flexion-extension test resulted in greater rates of severe or extreme pain and was also the test most frequently reported as painful. Functional tests that frequently cause pain or severe level of pain (e.g., timed 6m and cross hops, side-cut, knee flexion/extension MVICs and isokinetic tests) might not be the first test choices to assess function in patients after ACL injury/reconstruction. Reported pain during functional tests should be considered by clinicians and rehabilitation team members when evaluating a patient's readiness to return-to-play. For any figures or tables, please contact the authors directly.
Iliopsoas tendinopathy occurs due to friction of the iliopsoas tendon on the iliopectineal bar or the hip capsule causing pain and snapping of the hip. In adolescent cases this condition is generally treated conservatively with physiotherapy, stretching and NSAIDs. Our aim was to study the outcome of non-operative management of iliopsoas tendinopathy. A retrospective 4-year study identified adolescent patients with a clinical diagnosis of psoas tendinopathy managed non-operatively. These patients were followed up by postal questionnaire, which included functional assessment using the Non-Arthritic Hip Score (NAHS). A custom study questionnaire assessed current symptoms and the effects of physiotherapy. All patients not treated conservatively were removed from the study.Aim
Method
To compare the functional outcome of Distal Tibial Metaphyseal fracture treated with Circular frame compared vs. Locking Plate Distal Tibial Metaphyseal fractures were retrospectively identified over an 18 month period. Each fracture was assessed individually using radiographs. All paediatric, compound, tibial plateau and intra-articular fractures were excluded from the study. Other methods of fixation including intramedullary nailing were also excluded. The remaining fractures were assigned to either the circular frame fixation or the locking plate intervention group. Outcomes were assessed using radiographs for union dates and microbiology results for evidence of infection. Patients were followed up by postal questionnaires, which included a modified American Orthopaedic Foot and Ankle Score (AOFAS), the Olerud and Molander Score (O&M) and a custom questionnaire. The custom questionnaire asked about co-morbidities, smoking status and work days lost following surgery. After exclusions, 30 patients (Frame=15, Plate=15), were sent out questionnaires via post. We received completed questionnaires from 21 patients (Frame=11, Plate=10) giving us a response rate of 70%. Results show no difference in infection rates, skin necrosis, non-union or re-operation rates. There was also no significant difference in patient AOFAS and O&M scores at follow up.Statement of Purpose
Methods and Results
Circular frames treatment for limb reconstruction involves repeated follow up visits, and a substantial number of these appointments are for pin site review only, and incur a significant cost to the NHS. We advocate ‘Telemedicine’ as a logistically and economically viable option for routine post-operative review of pin-sites. The senior author performs fifty to sixty frame circular frame treatments in adults for trauma every year. For the past 12 months, we have been encouraging our frame patients to take photographs of their pin-sites when they do their weekly dressing changes. This is done with digital cameras by the patients themselves, and the images are then emailed to the senior author on his work email address, and get replied to by the next day. If the images are a cause for concern, further steps are initiated (Images 1 and 2 demonstrate pin-sites before and after a course of antibiotics, started because the first image was a cause for concern). This arrangement is for pin-site reviews only. This method has been used for the post-op pin site review of five patients with circular frames.Statement of purpose
Methods and results
Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9)
AVN scores
Closed Reduction (n=34) : Grade 1 : 5. Open Reduction (n= 11) : Grade 1: 2, Grade 2: 1, Grade 3: 1. Open, with shortening (n=24): Grade 1: 5, Grade 2: 1. Severin Scores: Closed I: 22 II:3 III:8 IV:0 Open I:6 II:1 III:2 IV:2 Shortening I: 8 II:8 III:3 IV:2
The controversial issues in the management of distal radius fracture involve what constitutes a degree of fracture displacement and angulation likely to be compensated by remodelling with growth over time, indications for fracture stabilisation with wires or other invasive methods compared with plaster casting alone, details of the position of the arm during immobilisation in a cast, and whether the cast should immobilise the wrist alone or both, the wrist and the elbow. The management of buckle fractures of the distal radius is relatively uncontroversial, involving splintage for symptomatic relief from pain. Some authors have advocated removable wrist supports, with discontinuation of splintage at the parents’ discretion. We performed a systematic review of all areas of the management of distal radius metaphyseal fractures in children. Growth plate injuries were not included for analysis.
Types of outcome measures:
Radiological deformity Effect of cast index Complications of k-wiring Remanipulation rates Compliance with splintage Cost of various forms of splintage Effect of intact ulna Upper limb function while immobilised Wrist and elbow ROM 10 studies complied with the inclusion criteria and were analysed using Review Manager software provided by the Cochrane Collaboration
Regarding displaced metaphyseal fractures:
K wire fixation reduces redisplacement There is no proven increase in complications with k wires Intact ulna favours redisplacement Long casts do not reduce displacement Short casts allow better early function Regarding stable compression fractures:
Removable splints are not associated with displacement Patients prefer removable splints for buckle fractures Removable splints cause less discomfort and allow better early function
