Aims

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.

Introduction: Limp in a child is a common presentation to the emergency department. Most patients have no serious pathology. However, it is important not to miss specific problems and delay treatment. We therefore established a limping child protocol in conjunction with the emergency department, which was implemented in 2003. We aimed to assess our performance against agreed standards; 100% investigated as per protocol, and 100% admitted or seen in the next fracture clinic.

Methods: We examined all emergency department case notes of children aged less than 14 years old who presented with a lower limb problem over a 1 year period. Patients diagnosed as having soft tissue injuries or fractures were excluded. We were left with 58 patients. Information concerning investigations and disposal from the emergency department was sought from the case notes and the hospital computer system.

Results: Average age was 5.1 years. The protocol was followed correctly in only 21% of cases. 33% were followed-up incorrectly, and 22% received no documented follow-up.

Discussion: There was poor compliance in the emergency department. Incomplete investigations, follow-up and documentation were the main problems. Up to one quarter of serious pathology may have been missed. We attribute these problems to high staff turn over and poor awareness of the protocol. We have introduced changes to improve our performance.

Purpose of study: Glenoid dysplasia occurs early in the shoulders of some children affected by obstetric brachial plexus palsy (OBPP). Prompt treatment can reverse the deformity. A program has been devised to examine these children’s shoulders by ultrasound and the early results are described.

Method: Since March 2006, all neonates born in New-castle upon Tyne with a diagnosis of OBPP have been referred to the hip ultrasound clinic. The shoulders were examined clinically for range of movement and signs of instability. A static and dynamic ultrasound examination was then performed. Treatment of subluxed shoulders involved splinting the shoulder in adduction and external rotation for six weeks after injection of the internal rotator muscles with botulinum toxin, as recommended by Ezaki and co-workers.

Results: To date, six infants have been screened. Two had significant instability with ultrasonographic evidence of early glenoid dysplasia and have been treated. One had mild glenoid dysplasia with restricted external rotation which improved with physiotherapy alone. Three were clinically and ultrasonographically normal.

Conclusions: The early experience of this program confirms the high incidence of shoulder dysplasia in the neonatal period in these children, as reported by others. The examination is safe and relatively easy. In the early stages of the condition the treatment to date has been simple and effective. We plan to continue with ultrasound screening for shoulder dysplasia in neonates with OBPP.