Aims

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.

Aims. Children treated for osteosarcoma around the knee often have a substantial leg-length discrepancy at skeletal maturity. The aim of this study was to investigate the results of staged skeletal reconstruction after a leg lengthening procedure using an external fixator in these patients. Patients and Methods. We reviewed 11 patients who underwent staged reconstruction with either an arthroplasty (n = 6) or an arthrodesis (n = 5). A control group of 11 patients who had undergone wide excision and concurrent reconstruction with an arthroplasty were matched for gender, location, and size of tumour. We investigated the change in leg-length discrepancy, function as assessed by the Musculoskeletal Tumor Society Scale (MSTS) score and complications. Results. A mean 5.2 cm (1.7 to 8.9) of lengthening was achieved. The mean MSTS scores significantly improved after staged reconstruction (p = 0.003) but were still worse than those of the control group (p = 0.049). However, the MSTS scores of the arthroplasty subgroup were comparable with those of the controls, although the extensor lag was greater and the range of movement was less. The patient group experienced more complications, but all of these resolved. Conclusion. Approximately 5 cm of lengthening and significant functional improvement can be achieved by staged reconstruction and lengthening, without major complications. Although it has limitations, this method of treatment seems to be a satisfactory surgical option for growing children with a significant leg-length discrepancy after excision of an osteosarcoma around the knee. Cite this article: Bone Joint J 2017;99-B:401–8

1. Thirty-nine displaced fractures of the lateral humeral condyle in children are reported. In one-third of the children the injury was accompanied by postero-lateral dislocation of the elbow. In some cases there was evidence that dislocation had occurred even when there was little persistent displacement of the condylar fragment. 2. All the fractures were treated by internal fixation with a specially designed screw. Thirtyfive children attended for review. 3. lt is concluded that all displaced fractures should be treated by internal fixation and that the method described is simple and reliable. Undisplaced fractures, or those with little displacement, may be treated conservatively when there is no evidence of associated dislocation of the elbow

1. Continued follow-up of the 113 children with acute osteomyelitis previously reported and a study of a further thirty-eight proven cases has not changed our opinion that the correct management is rest and effective antibiotics. Operation should be undertaken only if pus is detectable clinically. 2. Bacteriological evidence shows that the flora causing this disease are less sensitive to benzylpenicillin than ten years ago and that a proportion are also likely to become resistant to methicillin and cloxacillin. 3. The most effective antibiotic combination used was fusidic acid and erythromycin. This lowered the failure rate to 10·5 per cent in thirty-eight proven cases. Two of the four failures were in haemophilus infections. No staphylococcal infection of a long bone became chronic, and all lesions were healed within three months of onset. 4. The duration of treatment (twenty-one days) and the method of splintage (removable plaster slabs) remained the same as in the previous series. 5. Careful watch must be kept on the incidence of haemophilus infections. If it rises, increasing the erythromycin or adding ampicillin may be necessary. 6. Use of the newer aqueous suspension of fusidic acid may lower the incidence of troublesome vomiting (12 per cent in this series). 7. Only 7 per cent of staphylococcus aureus infections in this hospital, and 17 per cent of such infections in our thirty-eight cases were sensitive to benzylpenicillin. It is thought that this drug has outlived its usefulness in osteomyelitis. 8. It is recommended that, on diagnosis, fusidic acid aqueous suspension 5 millilitres should be given three times a day to children aged one to five, and 10 millilitres twice a day for children aged six to twelve, with erythromycin stearate 30 milligrams per kilogram of body weight each day in divided doses

1. Stress fractures are described in children. The fibula and tibia are most often affected. 2. Stress fractures of the humerus are described in two boys aged fifteen. 3. Stress fractures are described in the pelvis in children

We examined differences in the rate of open reduction, operating time, length of hospital stay and outcome between two groups of children with displaced supracondylar fractures of the humerus who underwent surgery either within 12 hours of the injury or later. There were 77 children with type-3 supracondylar fractures. Of these, in 43 the fracture was reduced and pinned within 12 hours and in 34 more than 12 hours after injury. Both groups were similar in regard to gender, age and length of follow-up. Bivariate and logistical regression analysis showed no statistical difference between the groups. The number of peri-operative complications was low and did not affect the outcome regardless of the timing of treatment. Our study confirmed that the treatment of uncomplicated displaced supracondylar fractures of the humerus can be early or delayed. In these circumstances operations at night can be avoided

We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients. We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy

In a retrospective study we reviewed 28 refractures of the forearm in children, which occurred at a mean of 14 weeks after conservative treatment of the primary fracture. The cause for the refracture was incomplete healing of a primary greenstick fracture in 21 cases (84%). Twenty-two recurrent fractures were treated conservatively, but two had a second refracture. Fifteen patients were followed for over two years. Definitive angulation of more than 10° caused a deficit of forearm rotation. To prevent refracture of the forearm in children, complete and circular consolidation of the primary fracture must be guaranteed

The term "floating knee" describes the flail joint resulting from fractures of the shaft or adjacent metaphyseal region of the ipsilateral femur and tibia; we have reviewed 15 children with this combined injury seen at the Winnipeg Children's Hospital. All had been involved in motor vehicle accidents, eight having been struck while cycling; the biomechanics of such an injury have also been studied. Treatment is difficult and the regimes varied. Results were poor when both fractures were treated nonoperatively and we recommend that at least one of the fractures should be rigidly fixed

Thirty-three Monteggia fracture-dislocations occurring in patients aged 2 to 15 years were reviewed. A follow-up of 2 to 7 years in 25 patients revealed that 88% had good to excellent results and 12% had results which were fair or poor. Closed reduction was successful in 24 of 28 cases and appeared to be very effective. Open reduction was required only for older children or when treatment was begun late. A mild hyperextension deformity at the elbow noted on follow-up of patients with anterior dislocation of the radial head seemed to support the theory that the injury is caused by hyperextension. A new classification of Monteggia fracture-dislocations in children is proposed

Forty-six children with Monteggia fracture-dislocations have been studied. The circumstances of the accident could rarely be recalled so that the mechanism of injury remains unclear. The study did, however, confirm the importance of conservative management of the injury in children; unlike the adult variety, this gave very satisfactory results. Our review also supports the classification into three basic types of Monteggia lesion according to the direction of displacement of the dislocated radial head. For simplicity, all other types, variations or equivalents can be regarded as belonging to these basic patterns; in particular we include those controversial cases in which the radiohumeral dislocation is combined with a fractured olecranon

The results of 75 total hip replacements in 42 children with juvenile chronic arthritis are reported after a mean follow-up of 5.4 years. Their ages ranged from 11 to nearly 17 years at operation and many had active disease. Severe pain and marked stiffness of the hips were limiting their independence. At least half of the children were still growing and continued to grow after operation. The patients were carefully selected and gratifying results were obtained, but pre-operative assessment and overall supervision by a rheumatologist are important. Technical difficulties related to the size and maldevelopment of the hip are discussed. There was no infection and the single case of loosening of a femoral component after nine years has been successfully revised

We have attempted to describe the epidemiology of femoral fractures in children in the West Midlands region of the National Health Service in England. Our source of data was the Regional Hospital Episode Statistics database for the years 1991-2 to 2001-2. Cases were defined as emergency hospital admissions in patients aged under 16 years, with a diagnostic code of femoral fractures in any field, and resident in the West Midlands. Between 1991-2 and 2001-2, 3272 children aged under 16 years with femoral fractures were admitted to hospital. The crude incidence during this period decreased from 0.33 to 0.22 femoral fractures/1000/year. Those caused by traffic accidents decreased by 43%, and by falls by 29%. The peak age-gender-specific incidence (0.91/1000/year) was in two-year-old boys, and this was 50% higher than in the next highest age-gender group. In the first year of life, the incidence in boys and girls was the same. Thereafter the rate in boys exceeded that in girls, varying from 1.6 times at 11 years to 4.7 times at 14 years. Falls accounted for 49% of the fractures, varying from 77% in one-year-olds to 26% in eight-year-old children. Traffic accidents were responsible for 26% of fractures varying from 55% in ten-year-old to 2% in one-year-old children. Maltreatment was recorded in 1.3% of all cases, and in 8.5% of children under one year. Twice as many fractures were seen in May to August than in January (winter). The rates of fractures were associated with deprivation for all age-gender groups. Fractures of the shaft accounted for 58% of all fractures, varying from 70% in three-year-old to 34% in 13-year-old children. Our findings show that there has been a decrease in the incidence of femoral fractures during the 1990s and early 2000s. Two-year-old boys had twice the rate than any other single-year age-gender group. More deprived areas had much higher rates which suggests the potential for greater prevention. A relatively low rate of maltreatment was recorded compared with that in some other studies

A total of 35 children with Erb’s palsy and shoulder abduction of < 90° underwent transfer of teres major. In 18 cases (group 1) a trapezius transfer was added (combined procedure). In 17 cases (group 2) teres major transfer was carried out in isolation (single procedure). The mean gain in abduction was 67.2° (60° to 80°) in group 1 and 37.6° (20° to 70°) in group 2, which reached statistical significance (p < 0.001). Group 2 was further divided into those who had deltoid power of < M3 (group 2a) and those with deltoid power ≥ M3 (group 2b). The difference in improvement of abduction between groups 2a and group 2b was statistically significant (p < 0.001) but the difference between group 2b and group 1 was not (p = 0.07). We recommend the following protocol of management: in children with abduction ≥ 90° a single procedure is indicated. In children with abduction < 90°: a combined procedure is indicated if deltoid power is < M3 and a single procedure is indicated if deltoid power is ≥ M3. If no satisfactory improvement is achieved, the trapezius can be transferred at a later stage.

The late results of treatment of calcaneal fractures in 17 children (19 fractures) were reviewed at a mean of 16.8 years after injury. With the exception of one patient, all fractures had been treated conservatively. At follow-up there were few complaints. All but two patients had full or slightly reduced mobility of the subtalar joint and unrestricted foot function, including the ability to walk comfortably on uneven surfaces. Minor radiological abnormalities of the hindfoot were common; there were two cases of post-traumatic osteoarthritis. Clinical scoring of the ankle and hindfoot using the American Orthopaedic Foot and Ankle Society rating system averaged 96.2 points. The results suggest that up to 16.8 years after injury almost all children achieve excellent long-term functional results with conservative treatment of fractures of the os calcis. Open management may only be appropriate for adolescents with severe displacements

The progression of post-tubercular kyphosis in 61 children who received ambulatory chemotherapy was studied prospectively. The angles of deformity and kyphosis were measured for each patient at diagnosis, 3, 6, 9, 12 and 18 months later and every year thereafter for 15 years. During the course of the disease signs of instability appeared on the radiographs of some of the children. These were dislocation of the facets, posterior retropulsion of the diseased fragments, lateral translation of the vertebrae in the anteroposterior view and toppling of the superior vertebra. Each sign was allocated one point to create a spinal instability score. The influence on the progression of the deformity of the level of the lesion, the vertebral body loss, the number of segments involved, the angle of deformity before treatment and the spinal instability score was analysed. The mean angle of deformity at the start of treatment was 35°. This increased to 41° at 15 years. Progression occurred during the active phase of the disease and again after cure when variations in progression were observed. Type-I progression showed an increase in deformity until growth had ceased. This could occur either continuously (type Ia) or after a lag period of three to five years (type Ib). Type-II progression showed decrease in deformity with growth. This could occur immediately after the active phase (type IIa) or after a lag period of three to five years (type IIb). Type-III progression showed minimal change during either the active or healed phases and was seen only in those with limited disease. Multiple regression analysis showed that a spinal instability score of more than 2 was a reliable predictor of patients with an increase of more than 30° in deformity and a final deformity of over 60°. Since signs of radiological instability appear early in the disease, they can be reliably used to identify children whose spine is at risk for late progressive collapse. Surgery is advised in these cases

We describe a method of pinning extension supracondylar fractures of the humerus in children. Following closed reduction, a posterior intrafocal wire is inserted and a second lateral wire added when needed for rotational stability. Between May 2002 and November 2005 we performed this technique in 69 consecutive patients. A single posterior wire was used in 29 cases, and two wires in 40. The mean follow-up was two years (21 to 30 months). The results were assessed according to Flynn’s criteria. In the single-wire group there were 21 excellent, five good and one poor result. Two patients were lost to follow-up. In the two-wire group there were 32 excellent, two good and three poor results. Three were lost to follow-up. The poor results were due to a failure to achieve adequate reduction, fixation or both. We conclude that the intact posterior periosteal hinge can be used successfully in the clinical situation, giving results that compare well with other techniques of pinning. The posterior route offers an attractive alternative method for fixation of supracondylar fractures of the humerus in children

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN. Cite this article: Bone Joint J 2013;95-B:135-41

Displaced extension supracondylar fractures of the elbow 1. One hundred and ten children were treated by reduction and stabilisation by two pins inserted laterally at an angle of 30 degrees to one another. 2. The complications before and after treatment included fifteen nerve lesions in thirteen patients. The ulnar nerve was involved on one occasion only. Solitary radial nerve injuries occurred with postero-medial displacement of the distal fragment, while median nerve and brachial artery injuries were associated with postero-lateral displacement. All the lesions recovered spontaneously. 3. There were no ischaemic complications after treatment, despite the ligation of one ruptured brachial artery. 4. The average stay in hospital was four days, compared with twenty days for thirty-two other patients treated in traction because of gross oedema. 5. Of eighty patients seen six months to five years after the fracture, seventy (or 87·5 per cent) had excellent or good results, seven patients with marked varus deformities had fair results, and two patients had poor results with very stiff elbows. Displaced flexion fractures 1. The clinical features, complications and treatment of seventeen cases are described. 2. There were no complications involving the median or radial nerves or the brachial artery, but three patients had a lesion of the ulnar nerve. 3. Nine children had closed reduction and fixation by two lateral percutaneous pins. 4. Reduction was difficult and the results poor compared with extension fractures. Closed reduction failed in one-third of the children, and the functional and cosmetic results were unsatisfactory in over half the patients reviewed