Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article: Bone Joint J 2023;105-B(5):471–473

Distal femoral physeal fractures in children have a high incidence of physeal arrest, occurring in a mean of 40% of cases. The underlying nature of the distal femoral physis may be the primary cause, but other factors have been postulated to contribute to the formation of a physeal bar. The purpose of this study was to assess the significance of contributing factors to physeal bar formation, in particular the use of percutaneous pins across the physis. We reviewed 55 patients with a median age of ten years (3 to 13), who had sustained displaced distal femoral physeal fractures. Most (40 of 55) were treated with percutaneous pinning after reduction, four were treated with screws and 11 with plaster. A total of 40 patients were assessed clinically and radiologically after skeletal maturity or at the time of formation of a bar. The remaining 15 were followed up for a minimum of two years. Formation of a physeal bar occurred in 12 (21.8%) patients, with the rate rising to 30.6% in patients with high-energy injuries compared with 5.3% in those with low-energy injuries. There was a significant trend for physeal arrest according to increasing severity using the Salter-Harris classification. Percutaneous smooth pins across the physis were not statistically associated with growth arrest

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

The February 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

We observed the healing process under rigid external fixation after Salter-Harris type-1 or type-2 physeal separation at the proximal tibia in immature rabbits. Metaphyseal vessels grew across the gap with little delay; the site of separation then came to lie in the metaphysis and was bridged by endochondral ossification. Union was achieved within two days in all rabbits. Progression of endochondral ossification repaired the separated physis, thus showing ‘primary healing of physeal separation’. This depends on accurate reduction and stable fixation to allow the survival of vessels across the gap

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

The October 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast.

Paediatric bone sarcomas are a dual challenge for orthopaedic surgeons in terms of tumour resection and reconstruction, as it is important to minimize functional and growth problems without compromising survival rates. Cañadell’s technique consists of a Type I epiphysiolysis performed using continuous distraction by an external fixator prior to resection. It was designed to achieve a safe margin due to the ability of the physeal cartilage to be a barrier to tumour spread in some situations, avoiding the need for articular reconstruction, and preserving the growth capacity most of the times. Despite initial doubts raised in the scientific community, this technique is now widely used in many countries for the treatment of metaphyseal paediatric bone sarcomas. This annotation highlights the importance of Cañadell’s work and reviews the experience of applying it to bone sarcoma patients over the last 40 years.

Cite this article: Bone Joint J 2023;105-B(1):11–16.

A retrospective study of 23 acetabular fractures in patients up to 17 years of age is presented, with an average follow-up of eight years. Good or excellent functional results were achieved in 21 patients; radiographic results were good or excellent in 16. Conservative treatment gave consistently good results in fractures with minimal initial displacement, stable posterior fracture-dislocations and Salter-Harris type 1 and 2 triradiate cartilage fractures. Less favourable results were seen in type 5 triradiate cartilage fractures and in comminuted fractures, but operation was no better. Unstable posterior fracture-dislocations and irreducible central fracture-dislocations need operative treatment but the results may still be unsatisfactory

Aims

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery.

We reviewed 24 displaced fractures through the physis of the medial epicondyle of the distal humerus. One was a Salter-Harris type-II fracture-separation of the whole distal humeral epiphysis; the others involved only the medial epicondylar centre of ossification. Two cases had presented as pseudarthroses. One fracture had been treated closed in a plaster slab and 21 had had open reduction and internal fixation with sutures, Kirschner wires or Palmer nails. At 2 to 13 years later we found five types of deformity of the epicondyle: pseudarthrosis, an ulnar sulcus, a double-contoured epicondyle, hypoplasia or hyperplasia. Pseudarthrosis had developed after either no treatment, closed reduction and plaster, or open reduction and suturing. Hypoplasia followed nailing, as did a trend to varus tilting of the joint surface. One very young patient, with fracture-separation of the whole distal epiphysis treated by nailing, developed marked cubitus varus

McFarland fractures of the medial malleolus in children, also classified as Salter–Harris Type III and IV fractures, are associated with a high incidence of premature growth plate arrest. In order to identify prognostic factors for the development of complications we reviewed 20 children with a McFarland fracture that was treated surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven children (35%) developed premature growth arrest with angular deformity. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale for all patients was 98.3 (87 to 100) and the mean modified Weber protocol was 1.15 (0 to 5). There was a significant correlation between initial displacement (p = 0.004) and operative delay (p = 0.007) with premature growth arrest. Both risk factors act independently and additively, such that all children with both risk factors developed premature arrest whereas children with no risk factor did not. We recommend that fractures of the medial malleolus in children should be treated by anatomical reduction and screw fixation within one day of injury.

Cite this article: Bone Joint J 2013;95-B:419–23.

Aims

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

Fractures of the proximal humerus with concomitant vascular injury are rare in children. We describe the presentation, diagnosis, and treatment of a fracture of the proximal humerus in association with an axillary artery injury in a child.

Excision of a physeal bar and filling the space with interposition material may allow resumption of normal growth. Both the extent and the location of the bar and the amount of growth remaining from physis must be determined. Computer-assisted surgery is being used increasingly in various fields of orthopaedics. We describe the management of a patient with premature physeal arrest of the right distal tibia in which resection of a physeal bar was achieved under real-time three-dimensional intra-operative monitoring by computer-assisted navigation.

The advantage of this method over other means of imaging is that intra-operative identification can increase the accuracy of resection of the bar.