Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament
Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included.Aims
Methods
Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap).Aims
Methods
Perthes’ disease is a condition leading to necrosis of the femoral head. It is most common in children aged four to nine years, affecting around one per 1,200 children in the UK. Management typically includes non-surgical treatment options, such as physiotherapy with/without surgical intervention. However, there is significant variation in care with no consensus on the most effective treatment option. This systematic review aims to evaluate the effectiveness of non-surgical interventions for the treatment of Perthes’ disease. Comparative studies (experimental or observational) of any non-surgical intervention compared directly with any alternative intervention (surgical, non-surgical or no intervention) were identified from: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMcare, Allied and Complementary Medicine Database (AMED), and the Physiotherapy Evidence Database (PEDro). Data were extracted on interventions compared and methodological quality. For post-intervention primary outcome of radiological scores (Stulberg and/or Mose), event rates for poor scores were calculated with significance values. Secondary outcomes included functional measures, such as range of movement, and patient-reported outcomes such as health-related quality of life.Aims
Methods
Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group. Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years.Aims
Methods
We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP). We were able to follow-up on 775 patients (395 girls, 380 boys) who sustained a SCHF from 2004 to 2017. Patients completed questionnaires including the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH; primary outcome), and the Pediatric Quality of Life Inventory (PedsQL).Aims
Methods
To identify a suite of the key physical, emotional, and social outcomes to be employed in clinical practice and research concerning Perthes' disease in children. The study follows the guidelines of the COMET-Initiative (Core Outcome Measures in Effectiveness Trials). A systematic review of the literature was performed to identify a list of outcomes reported in previous studies, which was supplemented by a qualitative study exploring the experiences of families affected by Perthes’ disease. Collectively, these outcomes formed the basis of a Delphi survey (two rounds), where 18 patients with Perthes’ disease, 46 parents, and 36 orthopaedic surgeons rated each outcome for importance. The International Perthes Study Group (IPSG) (Dallas, Texas, USA (October 2018)) discussed outcomes that failed to reach any consensus (either ‘in’ or ‘out’) before a final consensus meeting with representatives of surgeons, patients, and parents.Aims
Methods
To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up.Aims
Methods
The aim of this study was to assess whether supine flexibility predicts the likelihood of curve progression in patients with adolescent idiopathic scoliosis (AIS) undergoing brace treatment. This was a retrospective analysis of patients with AIS prescribed with an underarm brace between September 2008 to April 2013 and followed up until 18 years of age or required surgery. Patients with structural proximal curves that preclude underarm bracing, those who were lost to follow-up, and those who had poor compliance to bracing (<16 hours a day) were excluded. The major curve Cobb angle, curve type, and location were measured on the pre-brace standing posteroanterior (PA) radiograph, supine whole spine radiograph, initial in-brace standing PA radiograph, and the post-brace weaning standing PA radiograph. Validation of the previous in-brace Cobb angle regression model was performed. The outcome of curve progression post-bracing was tested using a logistic regression model. The supine flexibility cut-off for curve progression was analyzed with receiver operating characteristic curve.Aims
Methods
Open reduction is required following failed conservative treatment
of developmental dysplasia of the hip (DDH). The Ludloff medial
approach is commonly used, but poor results have been reported,
with rates of the development of avascular necrosis (AVN) varying
between 8% and 54%. This retrospective cohort study evaluates the
long-term radiographic and clinical outcome of dislocated hips treated
using this approach. Children with a dislocated hip, younger than one year of age
at the time of surgery, who were treated using a medial approach
were eligible for the study. Radiographs were evaluated for the
degree of dislocation and the presence of an ossific nucleus preoperatively,
and for the degree of AVN and residual dysplasia at one and five
years and at a mean of 12.7 years (4.6 to 20.8) postoperatively.
Radiographic outcome was assessed using the Severin classification,
after five years of age. Further surgical procedures were recorded.
Functional outcome was assessed using the Pediatric Outcomes Data
Collection Instrument (PODCI) or the Hip Disability and Osteoarthritis
Outcome Score (HOOS), depending on the patient’s age.Aims
Patients and Methods
The aim of this study was to describe the epidemiology of closed
isolated fractures of the femoral shaft in children, and to compare
the treatment and length of stay (LOS) between major trauma centres
(MTCs) and trauma units (TUs) in England. National data were obtained from the Trauma and Audit Research
Network for all isolated, closed fractures of the femoral shaft
in children from birth to 15 years of age, between 2012 and 2015.
Age, gender, the season in which the fracture occurred, non-accidental
injury, the mechanism of injury, hospital trauma status, LOS and
type of treatment were recorded.Aims
Patients and Methods
The aim of this study was to evaluate the correlation between
Salter’s criteria and Kalamchi’s classification of avascular necrosis
in patients treated for developmental dysphasia of the hip (DDH). The study involved a retrospective analysis of 123 patients (123
hips) with DDH treated by operative and non-operative reduction
before the age of two years, with a minimum follow-up of ten years.
Salter’s criteria (S1 to S4) were determined from radiographs obtained
at one to two years post-reduction, whilst the Kalamchi grade was determined
from radiographs obtained at ten or more years of age. Early post-reduction
radiographs were also used to evaluate the centre-head distance
discrepancy (CHDD) and the occurrence of a dome-shaped deformity
of the proximal femoral metaphysis (D-shaped metaphysis). The prognosis was described as good (Kalamchi grade K0 or KI),
fair (Kalamchi grade KII) or poor (Kalamchi grade KIII or KIV) for
analysis and correlation with the early Salter criteria, CHDD and
D-shaped metaphysis.Aims
Patients and Methods
We present the clinical and radiographic outcome of 81 children
with Gartland type I to III supracondylar humeral fractures at a
minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following
injury. The clinical and functional outcomes are compared with normal
age- and gender-matched individuals. The population-based study
setting was first identified from the institutional registries;
the rate of participation was 76%. Controls were randomly selected
from Finnish National Population Registry.Aims
Patients and Methods
This study analysed the clinical and radiological outcome of
anatomical reduction of a moderate or severe stable slipped capital
femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified
Dunn osteotomy) through the surgical approach described by Ganz. We prospectively studied 31 patients (32 hips; 16 females and
five males; mean age 14.3 years) with SCFE. On the Southwick classification,
ten were of moderate severity (head-shaft angle >
30° to 60°) and
22 were severe (head-shaft angle >
60°). Each underwent open reduction
and internal fixation using an intracapsular osteotomy through the
physeal growth plate after safe surgical hip dislocation. Unlike
the conventional procedure, 25 hips did not need an osteotomy of
the apophysis of the great trochanter and were managed using an
extended retinacular posterior flap. Aims
Patients and Methods
Aims. Although atlantoaxial rotatory fixation (AARF) is a common cause
of torticollis in children, the diagnosis may be delayed. The condition
is characterised by a lack of rotation at the atlantoaxial joint
which becomes fixed in a rotated and subluxed position. The management of
children with a delayed presentation of this condition is controversial.
This is a retrospective study of a group of such children. Patients and Methods. Children who were admitted to two institutions between 1988 and
2014 with a diagnosis of AARF were included. We identified 12 children
(four boys, eight girls), with a mean age of 7.3 years (1.5 to 13.4),
in whom the duration of symptoms on presentation was at least four weeks
(four to 39). All were treated with halo
The aims of this study were to report functional
outcomes of salvage procedures for patients with cerebral palsy (CP)
who have chronic dislocation of the hip using validated scoring
systems, and to compare the results of three surgical techniques. We reviewed 37 patients retrospectively. The mean age at the
time of surgery was 12.2 years (8 to 22) and the mean follow-up
was 56 months (24 to 114). Patients were divided into three groups:
14 who underwent proximal femoral resection arthroplasty (PFRA group
1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2),
and 13 who underwent subtrochanteric valgus osteotomy with resection
of the femoral head (SVO with FHR group 3). All patients were evaluated
using the Caregiver Priorities and Child Health Index of Life with
Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory
(PedsQL). Significant improvements occurred in most CPCHILD and PedsQL
subsection scores following surgery in all patients, without significant
differences between the groups. There were 12 post-operative complications.
Less severe complications were seen in group 1 than in groups 2
and 3. Salvage surgery appears to provide pain relief in patients with
CP who have painful chronic dislocation of the hip. The three salvage
procedures produced similar results, however, we recommend the use
of PFRA as the complications are less severe. Take home message: Salvage surgery can be of benefit to patients
with CP with chronic painful hip dislocation, but should be limited
to selected patients considering complications. Cite this article:
Slipped upper femoral epiphysis (SUFE) is the
most common hip disorder to affect adolescents. Controversy exists over
the optimal treatment of severe slips, with a continuing debate
between Between 2001 and 2011, 57 patients (35 male, 22 female) with
a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to
our tertiary referral institution with a severe slip. The affected
limb was rested in slings and springs before corrective surgery
which was performed via an anterior Smith-Petersen approach. Radiographic
analysis confirmed an improvement in mean head–shaft slip angle
from 53.8o (standard deviation ( This is a technically demanding operation with variable outcomes
reported in the literature. We have demonstrated good results in
our tertiary centre. Cite this article:
End caps are intended to prevent nail migration
(push-out) in elastic stable intramedullary nailing. The aim of
this study was to investigate the force at failure with and without
end caps, and whether different insertion angles of nails and end caps
would alter that force at failure. Simulated oblique fractures of the diaphysis were created in
15 artificial paediatric femurs. Titanium Elastic Nails with end
caps were inserted at angles of 45°, 55° and 65° in five specimens
for each angle to create three study groups. Biomechanical testing
was performed with axial compression until failure. An identical
fracture was created in four small adult cadaveric femurs harvested
from two donors (both female, aged 81 and 85 years, height 149 cm and
156 cm, respectively). All femurs were tested without and subsequently
with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly
different between the three groups (p = 0.613). Push-out force was
significantly higher in the cadaveric specimens with the use of
end caps by an up to sixfold load increase (830 N, standard deviation
(SD) 280 These results indicate that the nail and end cap insertion angle
can be varied within 20° without altering construct stability and
that the risk of elastic stable intramedullary nailing push–out
can be effectively reduced by the use of end caps. Cite this article:
The management of children’s fractures has evolved
as a result of better health education, changes in lifestyle, improved
implant technology and the changing expectations of society. This
review focuses on the changes seen in paediatric fractures, including
epidemiology, the increasing problems of obesity, the mechanisms
of injury, non-accidental injuries and litigation. We also examine
the changes in the management of fractures at three specific sites:
the supracondylar humerus, femoral shaft and forearm. There has
been an increasing trend towards surgical stabilisation of these
fractures. The reasons for this are multifactorial, including societal
expectations of a perfect result and reduced hospital stay. Reduced hospital
stay is beneficial to the social, educational and psychological
needs of the child and beneficial to society as a whole, due to
reduced costs. Cite this article:
We describe our experience in the reduction of
dislocation of the hip secondary to developmental dysplasia using ultrasound-guided
gradual reduction using flexion and abduction continuous traction
(FACT-R). During a period of 13 years we treated 208 Suzuki type
B or C complete dislocations of the hip in 202 children with a mean
age of four months (0 to 11). The mean follow-up was 9.1 years (five
to 16). The rate of reduction was 99.0%. There were no recurrent
dislocations, and the rate of avascular necrosis of the femoral
head was 1.0%. The rate of secondary surgery for residual acetabular
dysplasia was 19.2%, and this was significantly higher in those
children in whom the initial treatment was delayed or if other previous
treatments had failed (p = 0.00045). The duration of FACT-R was significantly
longer in severe dislocations (p = 0.001) or if previous treatments
had failed (p = 0.018). This new method of treatment is effective and safe in these difficult
cases and offers outcomes comparable to or better than those of
standard methods. Cite this article:
