Aim

Paediatric fractures are common but those occurring in non-ambulant children are associated with higher rates of Non Accidental Injury (NAI). There is little published on the mechanisms of injury associated with accidental fracture in young children. This study explores the aetiology of long bone fractures in non-ambulant children.

Introduction

Venous thromboembolism (VTE) is an uncommon complication of foot and ankle surgery but has the potential for significant morbidity and mortality. The incidence, risk factors and prevention of VTE in foot and ankle surgery is not clear.

Introduction

Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy.

In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards.

Background: Postoperative pain following hindfoot surgery can be difficult to control with opioid analgesics. Popliteal nerve blocks have been shown in the literature to be effective in both delaying the onset of postoperative pain and reducing the intensity of the pain, with a variable duration of effect. In 2007 we established a ‘block team’ of anaesthetists available to administer popliteal blocks preoperatively.

Methods: Forty-nine consecutive patients undergoing hindfoot surgery were selected. Data was collected: The proportion of patients having a block; opiate requirement during surgery, in the recovery room and on the ward; pain score; time to mobilize after surgery; and length of stay.

We compared two techniques used for popliteal block and also compared post-operative pain control with and without a popliteal block.

Results: There was a considerable increase in the percentage of patients who had a popliteal block after the block team was established (40% to 91%). Six of 23 (23%) patients needed opiates in the recovery room in the nerve block group; compared to12 of 20 (60%) patients who did not have a block. Comparing the two techniques used for the nerve block, ultrasound guidance reduced postoperative intravenous opiate usage compared to blocks given with the aid of a nerve stimulator (p< 0.05). Fifteen of 16 (94%) patients mobilized on the first post operative day in the ultrasound group compared to 16 of 23 (64%) in the patients who had no block. There were no complications recorded as a result of popliteal nerve blocks.

Conclusions: Establishing a block team has improved the proportion of patients receiving a popliteal block in hindfoot surgery in our hospital. The ultrasound guided technique gives superior results in terms of pain relief and earlier mobilization, when compared blocks administered using a nerve stimulator.

Introduction: Long waiting times for surgery and government targets places added pressure on the administration of surgical units. In an effort to decrease waiting times from initial referral to surgery and to meet new to follow-up patient ratios set by the government, a policy of early discharge from follow-up was introduced for many procedures involving the foot and ankle. This audit assessed whether this policy increased procedure morbidity and patient dissatisfaction.

Methods: A 12-month retrospective audit was performed (October 2005 – September 2006) on the foot and ankle surgery cases performed at the Great Western Hospital, Swindon and Marlborough Trust, UK. Procedure and out-patient appointment data was accessed including new, follow up and ‘SOS’ patient attendances. Appointments were considered SOS if a patient sought consultation with a surgeon following discharge in the post operative setting.

Results: A total of 1128 foot and ankle procedures were performed on 639 patients. Eighty five percent (958) procedures met the early discharge from follow-up criteria. There were 2750 appointments for the respective period. Twelve hundred and seven (44%) were new patient appointments and 1543 (56%) were follow-up appointments. There were 84 SOS attendances related to a surgical episode, comprising 2% of appointments and 6% of procedures. Sixty-seven of the SOS attendances (80%) were related to an early discharge from follow-up procedure. A high proportion of SOS attendances were associated with joint stiffness, digital malposition and dysesthesia relating to Hallux Valgus correction, lesser digit arthrodesis and intermetatarsal neurectomy respectively.

Discussion: In this series, the aforementioned complications are consistent with those reported in the literature and we conclude they were not a consequence of early discharge. Early discharge from follow-up following selected common surgical procedures for the foot and ankle can potentially increase productivity of the out patient department without impact on procedure morbidity and patient satisfaction.

Aims:

1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.

Methods: This is a prospective study of 57 children aged 4 to 15 with metaphyseal and Salter-Harris II wrist fractures treated with simple manipulation. Under fluoroscopic imaging, a simple stability test involving moving the hand at the wrist in the dorsopalmar, and radioulnar planes was performed following reduction, and x-ray images were saved. We recorded and compared the displacement and angulation on the initial x-rays, during the test, and at one-and 6-week follow-up. We also recorded the skin-cast distance (SCD), and the cast index (CI).

Results: 38 patients had isolated radius fractures and 19 had radius and ulna fractures. Four patients needed remanipulation with K-wire fixation. Multiple regression analysis revealed significant correlation between percentage loss of reduction on testing and subsequent re-displacement (relationship between the two sets of values r = 0.6167, (p< 0.001)). This indicates that instability on testing (seen as a significant percentage loss of reduction) is likely to be associated with some loss of reduction on follow-up. There was a significant relationship between the skin cast distance and the cast index, and loss of reduction on one week follow-up. (p=0.006). Isolated radius fractures had a higher risk of re-displacement than radius and ulna fractures (3.9% and 0.9% respectively; p< 0.05%)

Conclusion: Stable reduction on stability testing in wrist fractures in children immobilised in a good cast (reflected in a low SCD, and CI) is associated with a good outcome. Isolated radius and ulna fractures are more likely to re-displace than radius and ulna fractures. There is a relationship between instability and loss of position at the 1-week follow-up. Potentially unstable fractures can be prevented from slipping by a good cast. A stable fracture on our stability test rarely slips. We therefore feel that stability test is a useful adjunct in decision-making.

Introduction: The results of treatment of Achilles tendinopathy are described in the sporting community little is known of the long-term results in the general population. Our aim was to assess these results in a district general hospital setting.

Materials/Methods: Patients who had undergone treatment for Achilles tendinopathy were identified from hospital records and assessed by postal questionnaire. This consisted of two parts (the VISA-A and a section about occupation, duration of symptoms prior to referral, prior sporting activities, and satisfaction). This was sent out with a stamped addressed return envelope, in the case of non-reply this was followed by a second one, and finally the patient was contacted by phone. Clinical notes of responders were reviewed.

Results: 71 patients were identified and the response rate was 83% with an equal, male to female split. Average age was 45; mean time to follow up was 8 years. Patients had undergone a wide variety of treatments (73% physiotherapy, 45% heel raises, 24% steroid injection {there were no ruptures reported}, and 12% operative). Duration of symptoms prior to referral ranged from 2 weeks to 27yrs. 78% were very satisfied or satisfied. 46% undertook sport prior to onset of symptoms, and at the time of follow up 40% undertook sport. 81% did not change their occupation. Average VISA-A score was 50 (range 10–90).

Discussion: Despite an average VISA-A score of 50 (excellent 90–100, good 75–85, fair 60–70, poor< 50), after a follow period up of 8 years, most patients were satisfied with the treatment they had received. We could find no correlation between treatment and eventual outcome.

Conclusion: Patients generally have continued symptoms from their Achilles Tendinopathy, many years later, despite standard treatments, which is reflected in poor VISA-A scores.

Purpose: An audit was undertaken to evaluate the patients’ experience of foot surgery at the great Western Hospital in 2004 following the appointment of a podiatric surgeon to the orthopaedic department.

Method: The first 100 patients that were operated on by the podiatric surgeon (Group 1) were matched by OPCS code to a randomly selected patient cohort that had been operated on by orthopaedic surgeons (Group 2). All patients were at a minimum of 6 months post-surgery (range 6–10 months Gp. 1, 11–20 months Gp. 2). The audit department sent out an anonymous questionnaire relating to the patients’ experience both before and after their surgery as well as current levels of satisfaction with the outcome of their surgery.

Results: The response rate was 64% in Gp.1 and 68% in Gp.2.

The patients’ overall satisfaction with the result of their foot surgery was determined using a Likert scale and the results can be seen in Table 1.

Patients in the podiatric surgical group were significantly more satisfied with the result of their foot surgery than those in the orthopaedic group (p< 0.008; Mann Whitney U test).

Similar statistically significant differences were also seen between the two groups relating to patient satisfaction with their pre and post-operative consultations and information concerning their proposed surgery and its outcome.

Conclusion: The results of this audit suggest that the satisfaction of patients following foot surgery can rise significantly following the appointment of a podiatric surgeon to a general hospital orthopaedic department.

A prospective randomised clinical trial was undertaken to compare biodegradable polyglycolic acid pins with standard Kirschner wires used to fix displaced elbow fractures in children. Twenty-four children were enrolled in the trial; 14 had fractures of the lateral condyle of the humerus, eight of the medial epicondyle and two had olecranon fractures. Eleven fractures were fixed with Kirschner wires and 13 with polyglycolic acid pins. Fracture union with full function occurred in all cases within six months. Kirschner wires caused problems including infection in three cases, soft-tissue ossification in one and they required removal under general anaesthesia in nine cases. No such complications occurred with polyglycolic acid pins but one patient in this group developed avascular necrosis and premature fusion of the medial epicondyle.

We report three cases of thoracic spine translocation without neurological deficit. In each case bilateral pedicular fractures, demonstrated by computed tomography, produced 'floating arches' which account for the sparing of the cord. If computed tomography demonstrates adequate canal dimensions, these patients may be treated conservatively, but the treatment of choice at specialist spinal centres is operative stabilisation.

We reviewed the cases of 38 children with 45 congenitally dislocated hips who presented for primary treatment after the age of three years. Of these, 34 hips were managed by the 'direct approach' of Somerville and Scott (1957); 14 of these required secondary operations for subluxation, often with a poor outcome. Eleven hips were treated by combined pelvic and femoral osteotomy which, in general, gave good results. At a mean follow-up of 16.7 years, 80% of the whole series had a good or excellent clinical result and 51% were good or excellent radiologically. Simultaneous correction both above and below the hip is considered to be the best treatment for the older child with congenital hip dislocation.

An area of fibrous dysplasia of bone may undergo rapid enlargement which may be due to either cystic degeneration or malignant transformation. These complications may be clinically and radiologically indistinguishable and, unless both are borne in mind, incorrect management may follow. Magnetic resonance imaging was used in one of our cases and was the only imaging modality to demonstrate the true nature of the condition.

We describe 95 patients with previously treated congenital dislocation of the hip who underwent femoral osteotomy after the age of five years. The commonest indication for surgery was progressive uncovering and subluxation of the femoral head; other reasons were coxa vara, long leg dysplasia and persistent anteversion. Femoral osteotomy for uncovering of the femoral head (Severin Grade III) in this age group gave good results at maturity only when the acetabular angle was less than 25 degrees before operation. Femoral osteotomy alone was inadequate for true subluxation of the hip (Severin Grade IV).