Symptoms of obstetric brachial plexus injury (OBPI) vary widely
over the course of time and from individual to individual and can
include various degrees of denervation, muscle weakness, contractures,
bone deformities and functional limitations. To date, no universally
accepted overall framework is available to assess the outcome of patients
with OBPI. The objective of this paper is to outline the proposed
process for the development of International Classification of Functioning,
Disability and Health (ICF) Core Sets for patients with an OBPI. The first step is to conduct four preparatory studies to identify
ICF categories important for OBPI: a) a systematic literature review
to identify outcome measures, b) a qualitative study using focus
groups, c) an expert survey and d) a cross-sectional, multicentre
study. A first version of ICF Core Sets will be defined at a consensus
conference, which will integrate the evidence from the preparatory
studies. In a second step, field-testing among patients will validate this
first version of Core Sets for OBPI.Background
Methods
Aims. Within healthcare, several measures are used to quantify and compare the severity of health conditions. Two common measures are
Aims. To analyze outcomes reported in trials of childhood fractures. Methods. OVID MEDLINE, Embase, and Cochrane CENTRAL databases were searched on the eighth August 2019. A manual search of trial registries, bibliographic review and internet search was used to identify additional studies. 11,476 studies were screened following PRISMA guidelines. 100 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Study quality was not evaluated. Outcomes reported by trials were mapped onto domains in the World Health Organization (WHO) International Classification of Function framework. Results. In all, 525 outcomes were identified representing 52 WHO domains. Four domains were reported in more than 50% of trials: structure of upper/lower limb, sensation of pain, mobility of joint function, and health services, systems and policies. The Activities Scale for Kids performance (ASK-p) score was the most common outcome score reported in 6/72 upper limb and 4/28 lower limb trials. Conclusion. There is a diverse range of outcomes reported in trials of childhood fractures covering all areas in the International Classification of Functioning,
Aims. Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked
The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures. This study was a cross-sectional, questionnaire-based study conducted at a tertiary care orthopaedic centre. All cases of idiopathic paediatric trigger thumbs which underwent A1 pulley release between 2004 and 2011 and had a minimum follow-up period of ten years were included in the study. The abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH) was administered as an online survey, and ipsi- and contralateral thumb motion was assessed.Aims
Methods
Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria.Aims
Methods
The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation.Aims
Methods
Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes. A systematic review identified a list of measurements previously used in studies reporting radiological hip outcomes in children with CP. These measurements informed a two-round Delphi study, conducted among orthopaedic surgeons and specialist physiotherapists. Participants rated each measurement on a nine-point Likert scale (‘not important’ to ‘critically important’). A consensus meeting was held to finalize the CMS.Aims
Methods
Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app). A total of 20 pelvis radiographs (40 hips) were used to measure MP by using the HS app. Measurements were performed by five different members of the multidisciplinary team, with varying levels of expertise in MP measurement. The same measurements were repeated two weeks later. A senior orthopaedic surgeon measured the MP on picture archiving and communication system (PACS) as the gold standard and repeated the measurements using HS app. Pearson’s correlation coefficient (r) was used to compare PACS measurements and all HS app measurements and assess validity. Intraclass correlation coefficient (ICC) was used to assess intra- and inter-rater reliability.Aims
Methods
Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs. A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters.Aims
Methods
The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard. We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively.Aims
Methods
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. Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment.Aims
Methods
The aim of this study was to compare outcomes of guided growth and varus osteotomy in treating Kalamchi type II avascular necrosis (AVN) after open reduction and Pemberton acetabuloplasty for developmental dysplasia of the hip (DDH). This retrospective study reviewed patients undergoing guided growth or varus osteotomy for Kalamchi type II AVN between September 2009 and January 2019. All children who had undergone open reduction and Pemberton acetabuloplasty for DDH with a minimum two-year follow-up were enrolled in the study. Demographic and radiological data, which included the head-shaft angle (HSA), neck-shaft angle (NSA), articulotrochanteric distance (ATD), Sharp angle (SA), and lateral centre-edge angle (LCEA) at baseline, two years, and at the extended follow-up, were compared. Revision rates were evaluated. Clinical outcomes using the Harris Hip Score were assessed two years postoperatively.Aims
Methods
Aims. 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. Patients and Methods. 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
The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.Aims
Methods
The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders.Aims
Methods
A retrospective study was performed in 18 patients
with achondroplasia, who underwent bilateral humeral lengthening
between 2001 and 2013, using monorail external fixators. The mean
age was ten years (six to 15) and the mean follow-up was 40 months
(12 to 104). . The mean
Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score.Aims
Methods
Aims. We wished to examine the effectiveness of tibial lengthening
using a two ring Ilizarov frame in skeletally immature patients.
This is a potentially biomechanically unstable construct which risks
the loss of axial control. Patients and Methods. We retrospectively reviewed a consecutive series of 24 boys and
26 girls, with a mean age of 8.6 years (4 to 14), who underwent
52 tibial lengthening procedures with a mean follow-up of 4.3 years
(4.0 to 16.9). Tibial alignment was measured before and after treatment
using joint orientation lines from the knee and a calculation of
the oblique plane axis. Results. The mean percentage length gain was 20% (13 to 31) with a mean
bone-healing index (BHI) of 34 days per centimetre (20 to 54). Age
at surgery and location of the osteotomy site showed a strong relationship
as the location of the osteotomy migrated more proximally with age.
However, no significant correlation was found between BHI and the
position of the osteotomy. The coronal and sagittal joint orientation
of the lengthened tibias were within the normal range in 67% and
92% of cases, respectively. The oblique plane angulation calculation revealed
a statistically significant change pre- to post-operatively in both
magnitude (p <
0.05) and direction (p <
0.01), but without
clinical consequence. The majority of complications were minor (n
= 40 in 27 patients; 1.48 complications per segment lengthened)
with no residual
The aims of this study is to report the clinical and radiological outcomes after pre-, central-, and postaxial polydactyly resection in children from a tertiary referral centre. All children who underwent resection of a supernumerary toe between 2001 and 2013 were prospectively enrolled and invited for a single re-assessment. Clinical parameters and several dedicated outcome scores (visual analogue scale (VAS), Paediatric Outcomes Data Collection Instrument (PODCI), Activities Scale for Kids (ASK), and American Orthopaedic Foot and Ankle Society Score (AOFAS)) were obtained, as were radiographs of the operated and non-operated feet along with pedobarographs.Aims
Methods
We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable. Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners.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
The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL. Paediatric patients attending a speciality outpatient clinic were recruited through consecutive sampling. Two groups of patients were included: idiopathic scoliosis, and paediatric orthopaedic upper and lower limb condition without scoliosis. Patients were asked to complete PedsQL 4.0 generic core scales, Youth version of 5-level EuroQol-5-dimension questionnaire, and Refined Scoliosis Research Society 22-item (SRS-22r) questionnaire. Statistical analyses included scores comparison between scoliosis and limb pathology patients using independent-samples 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
We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair. The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108). Of the 45 patients, 42 reported no pain or functional
Children with a mucopolysaccharidosis or mucolipidosis suffer progressive
The aim of this study was to establish the incidence of developmental dysplasia of the hip (DDH) diagnosed after one-year of age in England, stratified by age, gender, year, and region of diagnosis. A descriptive observational study was performed by linking primary and secondary care information from two independent national databases of routinely collected data: the United Kingdom Clinical Practice Research Datalink and Hospital Episode Statistics. The study examined all children from 1 January 1990 to 1 January 2016 who had a new first diagnostic code for DDH aged between one and eight years old.Aims
Patients and Methods
Delayed diagnosis is a well-known complication of a Monteggia
fracture-dislocation. If left untreated, the dislocated radial head
later becomes symptomatic. The purposes of this study were firstly,
to evaluate the clinical and radiological results of open reduction
of the radial head and secondly, to identify the factors that may
affect the outcome of this procedure. This retrospective study evaluated 30 children with a chronic
Monteggia lesion. There were 18 boys and 12 girls with a mean age
of 7.4 years (4 to 13) at the time of open reduction. The mean interval
to surgery, after the initial fracture, was 23.4 months (6 to 120).
Clinical grading used a Kim modified elbow score: radiological outcome
was recorded. The effect of the patient’s age, gender, duration
from initial injury, Bado classification, and annular ligament reconstruction
were analyzed. The mean follow-up was 42.2 months (15 to 20).Aims
Materials and Methods
The aim of this study was to investigate the changes in femoral
trochlear morphology following surgical correction of recurrent
patellar dislocation associated with trochlear dysplasia in children. A total of 23 patients with a mean age of 9.6 years (7 to 11)
were included All had bilateral recurrent patellar dislocation associated
with femoral trochlear dysplasia. The knee with traumatic dislocation
at the time of presentation or that had dislocated most frequently
was treated with medial patellar retinacular plasty (Group S). The
contralateral knee served as a control and was treated conservatively
(Group C). All patients were treated between October 2008 and August
2013. The mean follow-up was 48.7 months (43 to 56). Axial CT scans
were undertaken in all patients to assess the trochlear morphological
characteristics on a particular axial image which was established
at the point with the greatest epicondylar width based on measurements
preoperatively and at the final follow-up.Aims
Patients and Methods
The purpose of this study was to evaluate the long-term outcome
of adolescents with cerebral palsy who have undergone single-event
multilevel surgery for a flexed-knee gait, followed into young adulthood
using 3D motion analysis. A total of 59 young adults with spastic cerebral palsy, with
a mean age of 26 years (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
Despite the presence of screening programmes, infants continue
to present with late developmental dysplasia of the hip (DDH), the
impact of which is significant. The aim of this study was to assess
infants with late presenting dislocation of the hip despite universal
clinical neonatal and selective ultrasound screening. Between 01 January 1997 to 31 December 2011, a prospective, longitudinal
study was undertaken of a cohort of 64 670 live births. Late presenting
dislocation was defined as presentation after three months of age.
Diagnosis was confirmed by ultrasound and plain radiography. Patient
demographics, referral type, reason for referral, risk factors (breech
presentation/strong family history) and clinical and radiological
findings were recorded.Aims
Patients and Methods
It is well established that there is a strong association between
Perthes’ disease and worsening socioeconomic deprivation. It has
been suggested that the primary determinant driving this association
is exposure to tobacco smoke. This study aimed to examine this hypothesis. A hospital case-control study (n = 149/146) examined the association
between tobacco smoke exposure and Perthes’ disease, adjusting for
area-level socioeconomic deprivation. Tobacco smoke exposure was
assessed by parental questionnaire of smoking habits during pregnancy,
and by quantitative assay of current exposure using the urinary
cotinine-creatinine ratio, which is a widely used and validated
measure of tobacco smoke exposure.Aims
Patients and Methods
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:
We present the validation of a translation into
Danish of the Oxford ankle foot questionnaire (OxAFQ). We followed the
Isis Pros guidelines for translation and pilot-tested the questionnaire
on ten children and their parents. Following modifications we tested
the validity of the final questionnaire on 82 children (36 boys
and 45 girls) with a mean age of 11.7 years (5.5 to 16.0) and their
parents. We tested the reliability (repeatability (test–retest),
child–parent agreement, internal consistency), feasibility (response
rate, time to completion, floor and ceiling effects) and construct
validity. The generic child health questionnaire was used for comparison.
We found good internal consistency for the physical and the school
and play domains, but lower internal consistency for the emotional domain.
Overall, good repeatability was found within children and parents
as well as agreement between children and parents. The OxAFQ was
fast and easy to complete, but we observed a tendency towards ceiling
effects in the school and play and emotional domains. To our knowledge
this is the first independent validation of the OxAFQ in any language.
We found it valid and feasible for use in the clinic to assess the
impact on children’s lives of foot and/or ankle disorders. It is
a valuable research tool. Cite this article:
Slipped capital femoral epiphysis (SCFE) is uncommon
in India and we routinely look for associated metabolic or endocrine
abnormalities. In this study we investigated a possible association
between vitamin D deficiency and SCFE. All children presenting with
SCFE during the study period had their 25-hydroxyvitamin D levels
measured as part of an overall metabolic, renal and endocrine status
evaluation, which included measurement of body mass index (BMI).
Vitamin D status was compared with age-, gender- and habitat-matched
controls with acute trauma or sepsis presenting to our emergency
department. A total of 15 children (12 boys and three girls) with a mean
age of 13 years ( Cite this article:
Of 48 consecutive children with Gartland III
supracondylar fractures, 11 (23%) had evidence of vascular injury,
with an absent radial pulse. The hand was pink and warm in eight
and white and cold in the other three patients. They underwent colour-coded
duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate
the patency of the brachial artery and arterial blood flow. In seven
patients with a pink pulseless hand, CCDS showed a displaced, kinked
and spastic brachial artery and a thrombosis was present in the
other. In all cases UV showed reduced blood flow in the hand. In
three patients with a white pulseless hand, scanning demonstrated
a laceration in the brachial artery and/or thrombosis. In all cases,
the fracture was reduced under general anaesthesia and fixed with
Kirschner wires. Of the seven patients with a pink pulseless hand
without thrombosis, the radial pulse returned after reduction in
four cases. The remaining three underwent exploration, along with
the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting
in children in whom the radial pulse remains absent in spite of
good peripheral perfusion should be revisited. Vascular investigation
using these non-invasive techniques that are quick and reliable
is recommended in the management of these patients. Cite this article:
Perthes’ disease is an osteonecrosis of the juvenile
hip, the aetiology of which is unknown. A number of comorbid associations
have been suggested that may offer insights into aetiology, yet
the strength and validity of these are unclear. This study explored
such associations through a case control study using the United
Kingdom General Practice Research database. Associations investigated
were those previously suggested within the literature. Perthes’ disease has a significant association with congenital
genitourinary and inguinal anomalies, suggesting that intra-uterine
factors may be critical to causation. Other comorbid associations
may offer insight to support or refute theories of pathogenesis.
In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna. There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68° (40° to 80°) to a pre-planned position of 10° of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.
The medial rotation contracture caused by weak external rotation secondary to obstetric brachial plexus injury leads to deformation of the bones of the shoulder. Scapular hypoplasia, elevation and rotation deformity are accompanied by progressive dislocation of the humeral head. Between February and August 2005, 44 children underwent a new surgical procedure called the ‘triangle tilt’ operation to correct this bony shoulder deformity. Surgical levelling of the distal acromioclavicular triangle combined with tightening of the posterior glenohumeral capsule (capsulorrhaphy) improved shoulder function and corrected the glenohumeral axis in these patients. The posture of the arm at rest was improved and active external rotation increased by a mean of 53° (0° to 115°) in the 40 children who were followed up for more than one year. There was a mean improvement of 4.9 points (1.7 to 8.3) of the Mallet shoulder function score after surgical correction of the bony deformity.
Club foot was diagnosed by ultrasonography in 91 feet (52 fetuses) at a mean gestational age of 22.1 weeks (14 to 35.6). Outcome was obtained by chart review in 26 women or telephone interview in 26. Feet were classified as normal, positional deformity, isolated club foot or complex club foot. At initial diagnosis, 69 feet (40 fetuses) were classified as isolated club foot and 22 feet (12 fetuses) as complex club foot. The diagnosis was changed after follow-up ultrasound scan in 13 fetuses (25%), and the final ultrasound diagnosis was normal in one fetus, isolated club foot in 31 fetuses, and complex club foot in 20 fetuses. At birth, club foot was found in 79 feet in 43 infants for a positive predictive value of 83%. Accuracy of the specific diagnosis of isolated club foot or complex club foot was lower; 63% at the initial ultrasound scan and 73% at the final scan. The difference in diagnostic accuracy between isolated and complex club foot was not statistically significant. In no case was postnatal complex club foot undiagnosed on fetal ultrasound and all inaccuracies were overdiagnoses. Karyotyping was performed in 25 cases. Abnormalities were noted in three fetuses, all with complex club foot and with additional findings on ultrasound.
We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable. We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.
We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus.
There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5° (11° to 67.5°) and the mean neck-shaft angle 147.5° (130° to 178°). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4° (11° to 50°) at gross motor function classification system level I, 35.5° (8° to 65°) at level II and then plateaued at approximately 40.0° (25° to 67.5°) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9° (130° to 145°) at gross motor function classification system level I to 163.0° (151° to 178°) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy.
The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0). A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity. We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.
A total of 47 non-walking patients (52 hips) with severe cerebral palsy and with a mean age of 14 years, (9 to 27) underwent a Dega-type pelvic osteotomy after closure of the triradiate cartilage, together with a derotation varus-shortening femoral osteotomy and soft-tissue correction for hip displacement which caused pain and/or difficulties in sitting. The mean follow-up was 48 months (12 to 153). The migration percentage improved from a pre-operative mean of 70% (26% to 100%) to 10% (0% to 100%) post-operatively. In five hips the post-operative migration percentage was greater than 25%, which was associated with continuing pain in two patients. Three patients had persistent hip pain and a migration percentage less than 25%. In five hips a fracture through the acetabulum occurred, and in another there was avascular necrosis of the superior acetabular segment, but these had no adverse effect on functional outcome. We conclude that it is possible to perform a satisfactory pelvic osteotomy of this type in these patients after the triradiate cartilage has been closed.
We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.
Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding. We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98).
We present the long-term results of pectoralis major transfer to restore elbow flexion in seven patients (ten procedures). The early results in all the patients were encouraging but with longer follow-up a gradual and progressive flexion deformity was observed with a decrease in the arc of flexion in eight elbows, reaching ≥ 90° in all cases. The results of pectoralis major transfer deteriorate with time due to the development of a recalcitrant flexion deformity of the elbow. With bilateral involvement we now recommend that the procedure be undertaken on one side only to allow the hand to reach the mouth for feeding, while the opposite side remains in extension for perineal toilet.
Difficulties posed in managing developmental dysplasia of the hip diagnosed late include a high-placed femoral head, contracted soft tissues and a dysplastic acetabulum. A combination of open reduction with femoral shortening of untreated congenital dislocations is a well-established practice. Femoral shortening prevents excessive pressure on the located femoral head which can cause avascular necrosis. Instability due to a coexisting dysplastic shallow acetabulum is common, and so a pelvic osteotomy is performed to achieve a stable and concentric hip reduction. We retrospectively reviewed 15 patients (18 hips) presenting with developmental dysplasia of the hip aged four years and above who were treated by a one-stage combined procedure performed by the senior author. The mean age at operation was five years and nine months (4 years to 11 years). The mean follow-up was six years ten months (2 years and 8 months to 8 years and 8 months). All patients were followed up clinically and radiologically in accordance with McKay’s criteria and the modified Severin classification. According to the McKay criteria, 12 hips were rated excellent and six were good. All but one had a full range of movement. Eight had a limb-length discrepancy of about 1 cm. All were Trendelenburg negative. The modified Severin classification demonstrated four hips of grade IA, six of grade IB, and eight of grade II. One patient had avascular necrosis and one an early subluxation requiring revision. One-stage correction of congenital dislocation of the hip in an older child is a safe and effective treatment with good results in the short to medium term.