Triplane fractures of the adolescent ankle commonly require operative management. A number of classification systems exist showing a variety of fracture patterns, making fixation planning complex. Our institute has previously presented a classification system that simplifies the fracture pattern. Our aim was to find a fixation method that could be used in all cases.

We devised a universal screw trajectory for the epiphyseal fracture based on a partially threaded screw placed medial-to-lateral at 20 degrees to the inter-malleolar axis of the ankle. We retrospectively reviewed the axial CT images of 59 consecutive operatively managed triplane fractures from a single institute to simulate the placement of the screw.

In all 59 subjects, the simulated universal screw placement was in a satisfactory position to adequately, and safely, reduce the fracture. Two cases were classified as ‘Tillaux variants’, which are classically managed with a lateral-to-medial screw, but they were deemed to be potentially suitable for the universal screw, indeed in one case the treating surgeon used a medial-to-lateral screw and had a successful outcome.

Our classification system demonstrates a reproducible fracture line that is amenable to a universal screw fixation method in the world's largest published triplane series. It offers a low-tech solution to a difficult problem. This could simplify the preoperative plan and obviate the need for a CT scan, which is relevant to departments treating populations without access to such resources.

Intramuscular injections of botulinum neuro toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last two decades. In India, the treatment is now offered to children with spastic cerebral palsy (CP). However, despite its use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A will not reduce energy cost during walking, improve walking capacity, reduce pain or improve self-perceived performance and satisfaction.

Between the period of 2012 and 2014, 35 children with spastic CP less than 10 years of age were included. The patients were classified according to their gross motor function classification system (GMFCS) and their pre-and post-injection gait analysis were performed. Spasticity assessed by Modified Ashworth Score [MAS]. Trained parents were utilised for the post injection physiotherapy as these children will be more complaint to them. GMFCS and MAS scoring done every three months till one year follow up.

Therapeutically, effect was found in 90% of the patients, an average duration of the medical effect was 6–12 months. The improvement in GMFC functional score in serial measurements was seen in these patients though some deterioration in spasticity scores at one year. Despite mild recurrence in spasticity, majority maintained independent (42%) or assisted ambulation (48%) at one year. No major side effects occurred. Botox may prove a useful adjuvant in conservative management of the spasticity of cerebral palsy. Apart from being very cost effective in these financially deprived populations, successful management with these injections may allow delay of surgical intervention until the child is older and at less risk of possible complications, including the need for repeated surgical procedures.