Paediatric wrist fractures are routinely managed with closed reduction and a molded cast. Gap(GI) and Cast indices(CI) are useful in predicting re-displacement following application of cast. Over 6 months we audited the efficacy of molded cast application following closed reduction of distal radial fractures in paediatric patients. The standard was that proposed by Malviya et al where GI >0.15 and CI >0.8 indicate an increased risk of re-displacement. Age, date and time of operation and surgeon's grade were collected. Pre-op displacement, post-reduction GI and CI and subsequent re-displacement were measured using imaging. Post audit intended changes to practice were presented to all surgeons, a “one-pager” was placed above scrub sinks. Re-audit was conducted at 1 year. The audit and re-audit included 28 and 24 patients respectively. Cast molding (CI) improved minimally following intervention (32% to 29%). Cast padding (GI) improved significantly (82% to 63%). Loss of reduction decreased slightly (14% to 12%), this was not accurately predicted by GI and CI in the re-audit. Audit demonstrated that casts were loose, over-padded and did not hold reduction adequately. Re-audit demonstrated that tighter, less padded but still inadequately molded casts were being applied with minimal change in loss of reduction.

Intra-operative Tip-Apex Distance (TAD) estimation optimises dynamic hip screw (DHS) placement during hip fracture fixation, reducing risk of cut-out. Thread-width of a standard DHS screw measures approximately 12.5 millimetres. We assessed the effect of introducing screw thread-width as an intra-operative distance reference to surgeons. The null hypothesis was that there were no differences between hip fracture fixation before and after this intervention. Primary outcome measure was TAD. Secondary outcome measures included position of the screw in the femoral head, quality of reduction, cut-out and surgeon accuracy of estimating TAD.

150 intra-operative DHS radiographs were assessed before and after introducing screw thread-width distance reference to surgeons.

Mean TAD reduced from 19.37mm in the control group to 16.49mm in the prospective group (p=<0.001). The number of DHS with a TAD > 25mm reduced from 14% to 6%. Screw position on lateral radiographs was significantly improved (p=0.004). There were no significant differences in screw position on antero-posterior radiographs, quality of reduction, or rate of cut-out. Significant improvement in accuracy (p=0.05) and precision (p=0.005) of TAD estimation was demonstrated.

Awareness and use of screw-thread width improves estimation and positioning of a DHS screw in the femoral head during fixation of hip fractures.

Background: There is limited evidence on long-term outcome following ACL reconstruction. Concern has been raised that degenerative joint disease is common in the long-term and this may be associated with use of patellar tendon autograft.

Methods: 162 patients underwent single-surgeon arthroscopic ACL reconstruction (1991–1993) were identified from our prospective database. Patient-centred outcome was by Lysholm and Subjective IKDC score, objective outcome measures were clinical examination, arthrometry and X-rays.

Results: 13 year outcome (10–15 years) is known in 115/161 patients (71%). The median subjective scores were 94% (Lysholm) and 90% (IKDC). Ipsilateral graft rupture rate was 4%, with contralateral ACL injury in 8%. Mean manual maximum KT 1000 was 9mm in the grafted knee and 8mm in the contralateral knee. Clinical laxity scores of grade 0 or 1 were found in over 93% patients. Radiographically 66% were normal or near normal (Grade A or B). When compared to the contra-lateral uninjured knee we found no significant difference in the proportion of normal/near normal x-rays (grade A/B) versus abnormal/severe (grade C/D) for the medial, lateral nor patellofemoral compartments. There was no significant difference in the radiological IKDC grades in the medial compartment when compared to the contra-lateral uninjured knee, but there was a difference in the lateral and patellofemoral joints.

Conclusions: At 13 years patellar tendon ACLR provides excellent patient satisfaction, with clinically objective knee stability and low risk of re-rupture. Radiographically degenerative change was seen in 34%. There was no significant side to side difference to the uninjured contralateral medial knee joint, but there was a small but significant difference in the lateral and patellofemoral joints. The lateral joint differences may reflect underlying bone bruising at the time of injury. We do not believe that the patellar tendon autograft is the cause of arthrosis after BTB ACLR.

Objective: To assess the clinical and radiological outcome of isolated hemivertebrae and multiple vertebral anomalies in the very young.

Design: A cohort of patients with congenital scoliosis were identified on antenatal ultrasound and followed prospectively from twenty weeks in-utero (IU) for a mean of two years (range IU – five years).

Subjects: Twenty fetuses with congenital hemivertebrae were identified from 16, 000 routine antenatal scans over a five-year period. Each was X-rayed at six weeks and investigated for renal and cardiac abnormalities.

Outcome Measures: Clinical assessment included trunk balance, neurological abnormality and associated congenital abnormalities. Radiological assessment of curve magnitude and curve progression was performed using the Cobb method. The potential for progression (based on site, degree of incarceration, growth potential and presence of a congenital bar) was assessed. In all cases a clinical and radiological assessment was made at maximal follow-up.

Results: One of the twenty fetuses aborted spontaneously at 23 weeks, three remain in-utero, leaving 16 live births. Thirteen of 20 had an isolated hemivertebra, and seven of twenty had multiple vertebral abnormalities. Two fetuses had renal agenesis, two had VATER’s syndrome and one had rib and abdominal wall abnormalities. The mean antenatal Cobb angle was 30°. IU curve progression was noted in three. Seven of the 16 live births required surgery based on curve magnitude, curve progression, truncal imbalance and the potential for progression. Surgery included anterior and posterior convex hemi-epiphyseodesis in two, and hemivertebra excision with fusion in five. The mean pre-operative Cobb angle was 36° (range 25–42) reducing to a mean of 21° (range 0–45) at maximal follow-up.

Conclusions: Multiple vertebral abnormalities were more commonly associated with renal and cardiac abnormalities. If associated with the oligohyramnios sequence the fetus appeared to be at high risk. In general US detected isolated fetal hemivertebrae carry a good prognosis, nevertheless 38% of these cases at our institution underwent surgery within the first two years of life.