Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

This purpose of this study was to investigate whether prophylactic pinning of the contralateral hip in unilateral slipped upper femoral epiphysis affects subsequent femoral morphology.

To determine the effect of prophylactic pinning on growth we compared contralateral hip radiographs of 24 proximal femora prophylactically pinned with 26 cases observed, in a cohort of patients with unilateral SUFE. Validated measurements were used to determine hip morphology; the articulo-trochanteric distance (ATD) and the ratio of the trochanteric-trochanteric distance (TTD) to articulo-trochanteric distance (TTD:ATD) in addition to direct measurement of the femoral neck length. Post-operative radiographs were compared to radiographs taken at a 12–84 months follow-up.

Comparing pinned and unpinned hips the neck length was shorter (mean 5.1 mm vs 11.1 mm) and the ATD was lower (p=0.048). The difference between initial and final radiograph TTD:ATD ratio for each case was calculated. The average was 0.63 in the prophylactically pinned group and 0.25 in the unpinned group (p=0.07).

When hips of the same patient were compared on final radiographs, there was a smaller difference in TTD:ATD between the two sides when the patient had been prophylactically pinned (0.7) as opposed to observed (1.47). This was not statistically significant (p=0.14).

Universal prophylactic pinning of the contralateral hip in slipped upper femoral epiphysis is controversial and alteration of the proximal femoral morphology is one reason for this.

Our results show that prophylactic pinning does not stop growth but does alter subsequent proximal femoral morphology by causing a degree of coxa vara and breva. Some loss of growth in the prophylactically pinned hip contributes to reduction in leg length inequality at skeletal maturity which is advantageous.

No iatrogenic complications were observed with single cannulated screw fixation. Prophylactic pinning prevents the potential catastrophe of a subsequent slip, is safe and the effect on growth is, if anything, beneficial.

Level of evidence: III

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity.

From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified.

There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction.

Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability).

Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction.

Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies.

Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction.

Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures.

Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended.

Statement of purpose

To demonstrate how contemplating reconstructive options among members of Orthoplastic team can prevent accidental damage during initial wound debridement in foot and ankle injuries

Complex defects of the foot and ankle often require input from plastic and orthopaedic surgeons. There are different reconstructive options but one excellent regional option for small defects is the Extensor Digitorum Brevis muscle (EDB) flap. The anatomy of the flap and surgical technique and utility are described and demonstrated through a case series.

We present a series of 4 consecutive cases of the use of the pedicled EDB flap for soft tissue coverage of difficult defects around the foot and ankle. This regional pedicled flap can be proximally based to cover defects around the ankle or distally based for distal foot coverage. When possible, it facilitates a reconstruction with minimal donor site morbidity, shorter operating times, and fewer complications than alternative options

The flap would usually be performed by the plastic surgical member of the orthoplastic team, but an understanding of it by foot and ankle and reconstructive orthopaedic surgeons is relevant as it's vascular supply via the lateral tarsal artery can be easily damaged, preventing its use in the management of wound complications or trauma.

Aim

Case Report presentation of traumatic cartilage loss in a child.

Discitis in childhood is rare. It can be difficult to diagnose, particularly in the younger child, often leading to a delay in initiation of appropriate treatment. It is not known whether it represents an infective or an inflammatory process.

Our aim was to review all cases treated at a regional children's hospital since the introduction of the departmental database. A retrospective review (64,058 cases), for the period 1990-2008 was performed. 12 cases were identified (3 male/9 female), with a biphasic age distribution; eight [mean 22 months old (12-32)] and four [mean 12 years old (11-13)]. Mean time to diagnosis from onset was 22 days, (5-49). Symptoms varied with age, no one less than 28 months complained of back pain, while all over 28 months did, to a varying degree. All the younger children presented primarily with a gait abnormality. 92% (11/12) were apyrexial on admission. WBC and CRP were normal in 83% (10/12). Venous blood cultures were negative in 89% (8/9). Only ESR was mildly raised, mean 30 (10-65). Radiographs showed loss of intervertebral disc height in 91% (10/11), earliest by 10 days following onset symptoms, mean 28 days. A technetium bone scan was performed in 42% (5/12) and an MRI of the lumbar spine, in 58% (7/12). All were positive for discitis. All occurred in the lumbar spine, 50% at L3/4. Antibiotics were used in 11/12 (92%), flucloxacillin alone in the majority 9/11. One had non-steroidal medication alone. No form of brace was used. Mean follow-up was 13.3 months (2-36). In all, symptoms had resolved by mean 6.5 weeks (2-12). No recurrence was noted.

The common features of childhood discitis are presented; knowledge of these may aid the physician to come to a more rapid diagnosis of this uncommon paediatric condition.

We have reviewed the complication rate over a ten year period for removal of screws placed for slipped capital femoral epiphysis (SCFE) and have surveyed the views of orthopaedic surgeons with an adult hip practice in Scotland on leaving the metalwork in situ. Whilst screw removal is favoured by many orthopaedic surgeons, a recent review of the literature reported that the complication rate for removal of implants placed for SCFE was 34%.

Between 1998 and 2007 84 patients had insertion of screws for SCFE. Of these 54 patients had screws removed, 51 of these records were available. The median duration between insertion and removal of screws was 2 yrs 7 months. Of the 51 children, overall five (9.8%) had complications - three (5.9%) major and two (3.9%) minor. Two screws could not be removed; one patient sustained a fracture after screw removal and two developed an infection.

We assessed the attitudes of adult hip surgeons on this topic using an electronic questionnaire which was completed by 29 out of 40 recipients. 78.6% of respondents support routine removal and 21.4% favour leaving the screw permanently in place. 82.2% had needed to remove metalwork from a hip requiring arthroplasty in a patient whose metalwork was inserted during childhood; and described their experience of this including the complications encountered.

We have identified a lower complication rate following screw removal inserted for SCFE than in published series. Most adult hip surgeons support routine removal once the physis is closed but studies regarding the long-term outcome of retained orthopaedic implants are needed since even with this lower complication rate the question of routine removal remains unclear.

Tarsal fractures are rare in children. Clinical and radiographic evaluation of these injuries can be difficult. We present a retrospective study documenting all tarsal fractures presenting to an inner-city children’s hospital in the UK over a fifteen year period.

Of 70 case notes retrieved from the hospital database, 7 patients were excluded due to inadequate data. This resulted in 69 tarsal injuries in 63 patients being included. Mean age at presentation was 9.3 years (2.5 – 13.9). 80% were male. 72% were calcaneal fractures, 12% cuboid, 9% navicular, 4% talus and 2% medial cuneiform. The main method of diagnosis was plain x-rays. Cause of injury was predominantly fall from height, crush or road traffic accident. 25% had another associated lower extremity injury. Three patients had bilateral tarsal injuries. Only 3% had upper limb injuries and there were no injuries with spinal involvement. Calcaneal fractures were treated with a short leg cast for a mean time of 4.1 weeks (2–6). Mean time to recovery was 5.7 weeks (2–20). Mean time to discharge from clinic was 7 weeks (2–40). There were two patients with open fractures requiring surgical debridement. One patient with a talar fracture had percutaneous fixation. Only one patient re-presented with pain following discharge. X-rays showed healing avascular necrosis of the proximal talus.

Tarsal fractures are rare, usually benign and most require simple immobilisation for only a short period of time. Surgical intervention is only occasionally required in complex injuries. Complications and long term problems are rare, even following open injuries.

Introduction: Early treatment with antibiotics is advocated in the management of septic arthritis. Whilst some argue for mandatory arthrotomy we have used arthrotomy selectively. The results of this approach over a ten year period were reported 20-years ago.

Aim: To review the outcome of joint aspiration and selective rather than mandatory arthrotomy for the management of septic arthritis in children.

Method: We compared the outcome for cases of septic arthritis in children reported from this centre in the decade 1982–1991 (Group I) with a contemporary cohort, from 1997–2006 (Group II) using the same criteria for diagnosis and the same treatment principles.

Results: Group I comprised 61 children, Group II 42. The mean incidence of septic arthritis in children (< 13 years old) was similar for Groups I and II (2.9/100,000 and 3.1/100,000). Infection caused by Haemophilus species declined from 10 of 56 (18%) in Group I to none in Group II. Staphylococcus Aureus reduced from 27/56(48%) in Group I to 13(31%) in Group II. As previously, infections particularly of the infant hip were at highest risk of causing permanent joint damage. There were eleven (18%) sequellae in Group I and two (5%) in group II.

Conclusions: These results continue to support joint aspiration for the management of early acute septic arthritis in children. However involvement of the hip in infants requires arthrotomy, as does late (≥4 days) diagnosis in older children.

The Morscher Cup is an acetabular component that was popular in the Bay of Plenty Region in the early 1990’s. It is an implant for which there are limited follow up results published in the international literature. Concerns have been raised that in some centres there has been marked, ballooning acetabular bone damage or osteolysis and that the implant may be associated with a higher dislocation rate. This paper will present the 13 – 15 year follow up in patients from Tauranga.

Ethical approval was gained from the Northern Region Y Ethics Committee. Patients who had had a Morscher Cup acetabular component in Tauranga from January 1992 until December 1994 were identified using the Bay of Plenty District Health Board NHI coding system and hospital logbooks. They were then invited to take part in the research which involved completion of WOMAC, Oxford hip score and SF 12 questionnaires, clinical review and an X-ray.

Of 81 patients with 91 Morscher Cup acetabular components implanted during the study period 62 patients with 70 Morscher Cup acetabular components were eligible for the study. Of these, 46 patients were available for clinical review, the remainder of the patients having passed away prior to final follow up. The average age at time of surgery for patients available for final follow up was 58 years. The average length of follow up was 13.7 years. The average Oxford hip score and WOMAC were 34.8 and 17.8 respectively. The average SF-12 PH was 40.9 and the average SF-12 MH was 54.8.

The Morscher Cup is an acetabular component that is still commonly used in New Zealand. The 13 –15 year results indicate that patients in this study are satisfied with their implant, but there is a lack of published data to compare them to other patient groups who have had a Morscher Cup acetabular component.

Aim: To assess the efficacy of selective ultrasound screening for DDH, with and without an orthopaedic examination.

Method: From 2002 our secondary DDH screening program was changed. Newborns with risk factors were referred directly for hip ultrasound. The orthopaedic surgeon was not involved if ultrasound was normal. An audit for 1997–2001 found an average annual incidence of 0.57(29 cases). The audit was extended to 2005 by identifying late DDH cases presenting from 2002 onwards, using the same criteria.

Results: Ninety-six cases were identified. After excluding children born outside Glasgow 36 cases were left for audit. The yearly incidence per 1000 live-births is shown below. The average incidence for 2002–2005 was 0.95. No significant difference between the two periods was found (p= 0.3).

Average age at diagnosis was 14.9 months. Two had risk factors but had not been screened. Thirty-one hips were dislocated, two were subluxed and one had borderline dysplasia that resolved. Twenty needed open reduction. Sixteen of 22 patients over 1 year at treatment required open reduction compared to 5 of 13 treated age 1 year or less (p = 0.046). Ten had femoral osteotomy, five a pelvic osteotomy, and five both femoral and pelvic osteotomy. There was one postoperative infection.

Conclusion: Direct ultrasound screening of infants with risk factors without concomitant assessment by an orthopaedic surgeon has not significantly altered the incidence of late DDH.

Introduction: There remains little evidence to discern whether K-wires or screws have different outcomes in the management of lateral condylar mass (LCM) fractures in children. We studied 77 displaced (Jacob types II and III) fractures of the lateral humeral condyle in 77 children in order to infer the relative benefit of one strategy over another.

Materials and methods: Between 1995 and 2005, we identified 77 LCM fractures in the departmental database. Information was collected from theatre-charts, casenotes and radiographs. We analysed demographic data, fracture features, treatment modalities, complications, and clinical and radiographic results. We excluded all complex LCM associated with elbow dislocations, olecranon fractures and bi-condylar fractures. The mean follow-up was 5.3 months (range, 6 weeks to 3 years).

Results: We reviewed the results of screw osteosynthesis (n=44) versus K-wire (n=33) at an average age of 5.3 years (range, 8 months to 10.9 years). There were 49 boys and 28 girls. The average interval between the injury and the operation was 1.6 days. The mean duration of implant removal was 3.6 weeks (for K-wires, removed without anaesthesia) and 20.7 weeks (for screws, removed under general anaesthesia). There was no non-union in this series. None of the patient needed a revision of osteosynthesis. Superficial wound infection (all K-wires) was found in three patients, which was completely settled with antibiotic therapy. One patient had cubitus valgus deformity (screw), which required a corrective osteotomy. Loss of range of motion of 10–50° was found in 6 cases (3 in each group).

Conclusions: Based on our observations, we believe that K-wire fixation had comparatively similar outcome to screw fixation, although, this necessitates a second procedure for removal of screw.

Introduction: Forearm shaft fractures are common injuries in children (3.4% of the total of children’s fractures. The majority are treated with closed reduction (CR) and plaster cast application. Percutaneous Intramedullary (IM) wires are indicated in compound, and grossly unstable fractures, or following failed CR.

Method: In this study, we examined the complication rate associated with IM wiring of these fractures in 92 children treated in our institution over a 7-year period. K wires were usually used.

Results: Six percent of 3,446 forearm shaft fractures were treated with internal fixation. Ninety-two fractures had IM wires, 15 (16%) of which were compound. Nerve injuries were present in 3 cases. Following treatment, there were 33 complications (36%), with 9 cases of delayed union, and 5 cases of malunion. Infection occurred in 10 cases, refracture in 6, and failure to pass wires in 2. Growth arrest occurred in 1 patient.

Discussion: IM wiring is a very useful and usually straightforward technique. However it is not risk-free and therefore should only be done on selected cases. Meticulous wound and pin site care is necessary to avoid infection, and fracture healing should be carefully assessed prior to and following wire removal. Careful cast technique after wire removal, or burying and retaining wires for longer, should be carried out to prevent malunion.

Introduction: To measure the incidence of late presenting DDH following the introduction of selective ultrasound screening of neonatal hips with associated risk factors.

Method: Retrospective cohort study of children with late diagnosed DDH in a defined population of Greater Glasgow Region. A hip ultrasound program was introduced in the year 1997 for secondary screening of children with risk factors for DDH. The departmental and theatre database was used to identify children with late diagnosed DDH. (Defined as diagnosed 3 months after birth) Demographic details, age at presentation, presence of risk factors (Breech presentation, family history, clicks, caesarian section) and details of treatment were recorded. The number of live births for each year was obtained from the General Registrar Office for Scotland. The incidence of late presenting DDH was calculated taking in to account the year of child’s birth. The incidence of late DDH was then compared between the period 1992 –1996 and 1997– 2001.

Results: 78 children were identified, of which 49 babies were between 1992 – 96 and 29 between 1997 –01. The average age at diagnosis was 17 months (Median 15 months, range 5 –84 months). The average annual incidence from 1992 –6 was 0.84 per 1000 live births and from 1997 – 2001 was 0.57 per 1000 live births. This decrease in incidence of late DDH was not significant at 5% level (chi squared p = 0.088). 64 children (82%) with late diagnosed DDH had no factors that could be perceived as risk factors for the condition.

Discussion: Targeted ultrasound screening of babies with risk factors appears to have reduced the average incidence of late DDH from 0.84 to 0.57 per 1000 live births. However this reduction in incidence is not statistically significant. The vast majority of late presenters (82%) do not have risk factors. It remains unclear whether universal ultrasound screening program, practiced in some parts of United Kingdom is a cost effective alternative to eliminate the incidence of late presenting DDH.

Femoral fractures are a common injury in the paediatric population. The purpose of this study was to audit the cost and early outcomes of femur fractures treated at the Starship Childrens Hospital

Forty-eight femur fractures treated between January 1998 and December 2002 were reviewed. 25 fractures were treated by application of an early hip spica, 12 by IM nails and 11 by other methods.

Children treated by early hip spica averaged 3.8 years in age. They went to theatre an average of 29.1 hours after admission and had an average length of stay of 3.8 days. In the 30 days after discharge, five patients were readmitted for loss of fracture position.

Children treated with IM elastic nails averaged 9.5 years and went to theatre on average 35.1 hours after admission. Their length of stay averaged 8.3 days. Complications in hospital included return to theatre to shorten a wire (1 patient), remanipulation and application of a hip spica (2 patients) and difficulty mobilizing (1 patient). In the first 30 days after discharge, two patients required readmission for further surgery due to prominence of the wire.

Children treated with external fixator (7), femoral rod (1) or crossed k-wires (3) averaged 8.7 years in age. They went to theatre on average 58 hours after injury and had an average length of stay of 24 days. Two patients were readmitted with superficial pin-site infections.

Most femur fractures are being operated on the next day, however surgery is delayed in some patients. The readmission rate in the first 30 days is significant and is not reduced by operative fixation. Cost containment should focus on ways to reduce the early readmission rate.

Aim: To identify the significant risk factors that influence patient mortality and morbidity in the management of displaced subcapital neck of femur fractures in independent elderly patients (aged > 70 years) managed with total hip arthroplasty through a modified Hardinge approach.

Methods: Thirty-seven primary hip arthroplasties performed for displaced fractures of the neck of femur in “Healthcare Hawkes Bay” between 1998 and 2000 were reviewed. The surgery was carried out by one surgeon (VP), using a modified lateral approach. The patients’ records were screened for outcomes and complications. An independent review was made (DA, NW) using the modified Harris hip score.

Results: The average age of the patients was 85 years (range: 70 to 92 years). At an average of 1.8 years (12 months to 24 months), no patient had suffered a dislocation or had needed another operation on the hip. The majority of the patients were satisfied with the outcome. However, there were significant medical complications (total of 38 complication in 22 patients). There were two deaths in the first 12 months.

Conclusions: The incidence of dislocation and a reduced revision rate can be achieved with a modified lateral approach (Hardinge). However, aggressive treatment is necessary before and after the surgery, as there is high incidence of medical complications. The number of existing medical conditions at the date of admission to hospital was a significant factor influencing patient morbidity.

We performed a prospective randomised controlled trial of a new mechanical method of prophylaxis for venous thrombo-embolism in 60 patients undergoing knee replacement surgery. The method uses the A-V Impulse System to produce cyclical compression of the venous reservoir of the foot. The overall incidence of deep-vein thrombosis was 68.7% in patients receiving no prophylaxis and 50% in those using the device. The difference was not significant. There was, however, a reduction of the extent of thrombosis in the treated group. There were 13 major calf-vein thrombi and six proximal-vein thrombi in the control group compared with only five major calf-vein thrombi in the treated group. This difference was significant (p = 0.014). No patient developed clinical features of a pulmonary embolism.

We have reviewed 61 children treated for septic arthritis from 1972 to 1981. The diagnosis in all cases was confirmed by bacteriology or by radiographic changes. Routine arthrotomy was not performed, but most patients had a joint aspiration. The management and outcome are described. We suggest that arthrotomy should be selective rather than mandatory. Septic arthritis of the hip in infants requires arthrotomy, but in the older child an infected hip can be treated by aspiration if the duration of symptoms is less than four days; arthrotomy may be needed if there has been more delay. Infected joints other than the hip can be satisfactorily managed by aspiration.