We undertook a retrospective comparative study of all patients with an unstable slipped capital femoral epiphysis presenting to a single centre between 1998 and 2011. There were 45 patients (46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular cuneiform osteotomy and 30 underwent pinning in situ, with varying degrees of serendipitous reduction. No patient in the osteotomy group was lost to follow-up, which was undertaken at a mean of 28 months (11 to 48); four patients in the pinning in situ group were lost to follow-up, which occurred at a mean of 30 months (10 to 50). Avascular necrosis (AVN) occurred in four hips (25%) following osteotomy and in 11 (42%) following pinning in situ. AVN was not seen in five hips for which osteotomy was undertaken > 13 days after presentation. AVN occurred in four of ten (40%) hips undergoing emergency pinning in situ, compared with four of 15 (47%) undergoing non-emergency pinning. The rate of AVN was 67% (four of six) in those undergoing pinning on the second or third day after presentation.

Pinning in situ following complete reduction led to AVN in four out of five cases (80%). In comparison, pinning in situ following incomplete reduction led to AVN in 7 of 21 cases (33%). The rate of development of AVN was significantly higher following pinning in situ with complete reduction than following intracapsular osteotomy (p = 0.048). Complete reduction was more frequent in those treated by emergency pinning and was strongly associated with AVN (p = 0.005).

Non-emergency intracapsular osteotomy may have a protective effect on the epiphyseal vasculature and should be undertaken with a delay of at least two weeks. The place of emergency pinning in situ in these patients needs to be re-evaluated, possibly in favour of an emergency open procedure or delayed intracapsular osteotomy. Non-emergency pinning in situ should be undertaken after a delay of at least five days, with the greatest risk at two and three days after presentation. Intracapsular osteotomy should be undertaken after a delay of at least 14 days. In our experience, closed epiphyseal reduction is harmful.

Cite this article: Bone Joint J 2015;97-B:412–19.

The aim of this study was to validate the SENIAM recommendations for surface electromyography placement(sEMG) over rectus femoris(RF) muscle in healthy children and in children with cerebral palsy(CP) during gait analysis and compare placement using these guidelines to using ultrasonography.

Flexible flat foot is considered one of the commonest normal variants in children's orthopaedic practice. The weightbearing foot is usually regarded as flexible on the basis of results from clinical and radiographic examination as well as measured foot-ground pressure pattern.

Our aim was to compare the pedobarographic and radiographic findings of normal arched and symptomatic flexible flat feet and investigate if there were sensitive markers that could be used in selecting patients for surgical correction.

We retrospectively collected data from eighteen patients (ten to sixteen year old). Our control group consisted of ten patients (twenty feet) with normal arched feet and the study group of eight patients (fifteen feet) with symptomatic flat feet who were awaiting surgical correction.

The mean and standard deviations of three radiographic markers (Calcaneal pitch, Naviculocuboid overlap and lateral Talo-1st metatarsal angle) in addition to foot pressures measured at the hindfoot, medial/lateral/total midfoot (MMF, LMF, TMF), forefoot and the percentage of weight going through the MMF over the TMF (medial midfoot ratio (MMFR) during the mid-stance gait phase are reported. In addition, the sensitivity, specificity, positive predictive value and negative predictive value of the pedobarographic parameters were estimated.

There was a significant difference in the Naviculocuboid overlap (P<0.001 T test) and Calcaneal pitch (P<0.05 T test) between both groups. The flat feet group had significantly higher MMF, LMF, TMF and MMFR (P < 0.001 Mann-Whitney). LMF had the highest sensitivity and negative predictive value (94%) whereas MMF, TMF and MMFR had the highest specificity and positive predictive value (100%).

Compared to our control group, patients with symptomatic flexible flat feet had significantly higher pressures distributed in the midfoot, in particular in the medial midfoot. Pedobarography appears to be a sensitive and specific tool that can be used, in conjunction with clinical and radiographic findings, in diagnosing flat feet.

Our study suggests that pedobarography could be used to measure the degree of deformity before and after surgical intervention.

The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment.

Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms.

In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem.

In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails.

In all the other cases there were no complications.

In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible.

Introduction

Some patients with Cerebral Palsy who had a de-rotation osteotomy performed for correction of excessive anteversion had persistence of internal foot progression even after surgery. Potential causes which have been implicated include: weak hip abductors, spasticity of the anterior fibres of the gluteus medius, hip adductor spasm and persistent femoral anterversion. The aim of this study was to see if there is any relationship between significant abductor weakness [less than Grade III: MRC] and persistence of internal foot progression.

Aims

To evaluate the results of Elastic Stable Intramedullary Nailing (ESIN) for displaced, unstable paediatric forearm diaphyseal fractures.

A significant proportion of children with cerebral palsy (CP) are malnourished. This is particularly the case for trace elements, vitamins and minerals. Children with CP undergoing major orthopaedic procedures lose blood intra operatively leading to post operative anaemia. The aim of our study was to estimate the prevalence of low levels of serum ferritin in children with CP awaiting major orthopaedic surgical intervention.

The ferritin levels and haemoglobin (Hb) were estimated pre-operatively in 35 children with CP (CP group) undergoing major orthopaedic surgery (Hip reconstruction or Single event multi-level surgery). During the same period, we randomly identified 1000 children (Control group) who underwent Ferritin estimation as part of routine investigations. A significant proportion of children in the study group had low levels of serum ferritin in spite of having normal haemoglobin.

It is well-recognised that commencement of iron either orally or intravenously in the post-operative period does not accelerate recovery from anaemia secondary to blood loss. It is important to note that many patients who have normal Hb levels preoperatively are iron deficient. Hb estimation alone is inadequate in this group. We therefore conclude that children with cerebral palsy undergoing major orthopaedic surgery must have their ferritin levels estimated and optimised well in advance of their surgery.

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Materials and Methods: We reviewed a consecutive series of 25 children with fixed flexion deformity of the knee who underwent anterior femoral hemiepiphysiodesis using a two-hole plate (8-plate) between April 2005 and April 2008. The pre-operative and postoperative knee flexion deformity (in degrees) and complication rates were also recorded. Paired t-Test was undertaken to assess the correction in the fixed flexion deformity post-operatively

Results: Total number of patients – 25, male:female = 19:6. Total number of limbs – 46

The mean age of the patients was 11.04 years (range between 4–16). Mean follow up time for the patients after they had undergone the procedure was 16.2 months (range 3 – 34). The Mean correction achieved − 21.52 degrees (range 5 – 40). Mean correction per month − 2.05 degrees. A paired ‘t’ test showed the correction was found to be highly statistically significant (p value < 0.001).

Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date.

Scarf osteotomy is a commonly performed method of hallux valgus correction. Release of deforming lateral soft tissue structures is an integral part of this correction. The aim of this study was to determine if there was any difference in the correction achieved by dorsal and transarticular releases as part of a scarf osteotomy.

This radiological study was performed at a single institution. One surgeon utilised the dorsal first web approach for the distal soft tissue release and one the transarticular approach. There were 23 patients in each group. The same post-operative regime was used on both sets of patients. Data was collected on hallux valgus angle (HVA), intermetatarsal angle (IMA) and AFS sesamoid scoring.

The pre-operative deformity as measured by hallux valgus angle and intermetatarsal angle where similar for both groups (p= 0.25, 0.79 respectively) with a significant difference in severity of AFS scoring in the dorsal group (p < 0.001). Patients who underwent a dorsal approach release had a mean improvement in IMA of 5.46 degrees compared to 3.86 in the transarticular group. The HVA improved by 17.92 degrees in the dorsal group compared to 8.08 in the transarticular group. Both these results were statistically significant (p= < 0.01,< 0.002 respectively). There was a statistically significant difference in number of patients returning to within normal limits of the HVA (p= < 0.05); 18 patients returned to a normal hallux valgus angle after undergoing the dorsal approach compared to 9 patients in the transarticular group.

Our study shows that when performing a distal soft tissue release in conjunction with a scarf osteotomy for correction of hallux valgus, a dorsal first web approach is significantly better at correcting the HVA as compared to a transarticular approach. We would, therefore, recommend the use of a dorsal approach when performing this surgery.

Purpose: The aim of this study was to see if there is any relationship between a positive hamstring shift test, which is a measure of knee flexion deformity after eliminating pelvic tilt with anterior pelvic tilt during the gait cycle.

Methods: We included all patients with cerebral palsy who had a gait analysis and a full physical assessment including measurement of the popliteal angle and hamstring shift test between August and December 05. The difference in measurement of knee flexion between the popliteal angle at 90 degrees and the hamstring shift test was termed hamstring length (HL). There were 33 patients of which 9 [18 limbs] were selected who fulfilled the criteria of a significant positive hamstring shift [> 10 degrees difference]. Maximum dynamic hip extension and average pelvic tilt were estimated from the gait analysis graph. SPSS13.0 was used to analyse the data.

Results: Mean HL was found to be 15.28 degrees. 6 (33.3%) patients had average pelvic tilt < 5 degrees, 8 (44.4%) was between 5–10 degrees and 4 (22.2%) patients had pelvic tilt of more than 10 degrees. The data had a normal distribution. There was no co relation between HL and pelvis tilt [p value:0.363 and r= −0.228.] or between average anterior pelvic tilt and the hip fixed flexion deformity. (p=0.361). However, it was found that maximum dynamic hip extension had strong negative association with average pelvic tilt (p=0.05, r = −0.455).

Conclusion: This study suggests that hamstring shift test does not have any correlation with pelvic tilt. In patients with a positive hamstring shift test, correcting the pelvic tilt will not correct the flexion deformities of the knee.

Purpose: Some patients with Cerebral Palsy who had a de-rotation osteotomy performed for correction of excessive anteversion had persistence of internal foot progression even after the surgery. The aim of this study was to see if there is any relationship between significant abductor weakness [less than Grade III: MRC] and persistence of internal foot progression.

Methods: We included all ambulatory patients with cerebral palsy who had had a de-rotation osteotomy between the periods of 2000 – 2005, who had also had a pre and post operative gait analysis, assessment of anteversion, muscle charting and hip range of movements. There were 12 patients [17 hips, 5 bilateral] 5 male 7 female with an average age of 13. Seven were diplegic, two hemiplegic and three had asymmetric diplegia. Data was assessed using SPSS 13.0. As the data was found to be normally distributed the Fisher exact test and the Spearman’s Co-relation Coefficient was used.

Results: Of the 17 limbs operated, preoperative femoral anteversion was 20–60 degrees [mean: 45] and post op femoral anteversion was 0–35[mean: 15]. Of these 7 hips had persistent internal rotation gait on gait analysis. None of these patients with persistent internal rotation had any hip capsular contractures, and there was no significant change in abductor power after surgery. On testing the hypothesis it was found that there is no relationship between weak hip abductors and persistent internal rotation. [Fisher exact test: p value: 0.8, r = −0.07]

Conclusion: Weak abductors may not be a cause of persistent internal rotation following de-rotation osteotomy. Weak abductor power is not a contraindication to de-rotation osteotomies and do not affect outcome of surgery.

Purpose: Some patients with Cerebral Palsy who had a de-rotation osteotomy performed for correction of excessive anteversion had persistence of internal foot progression even after the surgery. The aim of this study was to see if there is any relationship between significant abductor weakness [less than Grade III: MRC] and persistence of internal foot progression.

Methods: We included all ambulatory patients with cerebral palsy who had had a de-rotation osteotomy between the periods of 2000 – 2005, who had also had a pre and post operative gait analysis, assessment of ante-version, muscle charting and hip range of movements.

There were 12 patients [17 hips, 5 bilateral] 5 male 7 female with an average age of 13. Seven were diplegic, two hemiplegic and three had asymmetric diplegia. Data was assessed using SPSS 13.0. As the data was found to be normally distributed the Fisher exact test and the Spearman’s Co-relation Coefficient was used.

Results: Of the 17 limbs operated, preoperative femoral anteversion was 20–60 degrees [mean: 45] and post op femoral anteversion was 0–35[mean: 15]. Of these 7 hips had persistent internal rotation gait on gait analysis. None of these patients with persistent internal rotation had any hip capsular contractures, and there was no significant change in abductor power after surgery.

On testing the hypothesis it was found that there is no relationship between weak hip abductors and persistent internal rotation. [Fisher exact test: p value: 0.8, r = -0.07]

Conclusion: Weak abductors may not be a cause of persistent internal rotation following de-rotation osteotomy. Weak abductor power is not a contraindication to de-rotation osteotomies and do not affect outcome of surgery.

Aim: To report the clinical and radiological outcome of intramedullary fixation following corrective femoral diaphyseal derotational osteotomy, particularly in children with cerebral palsy.

Methods: We conducted a retrospective study of all femoral diaphyseal derotational osteotomies with Trigen antegrade intramedullary fixation (TAN system, Smith & Nephew) from April 2005 to June 2006. There were 9 patients with 14 affected limbs. The diagnosis was spastic diplegia in 8 of the 9 children, of whom 5 underwent the osteotomy as part of multilevel surgery.

Results: The mean age at surgery was 13.7 years (Range 11.2 – 17.3 years). The mean preoperative femoral anteversion was 43.6 degrees (Range 30 – 50 degrees) with the mean internal & external rotation being 61.6 (Range 50 – 70) & 8.3 (Range 0 – 20) degrees respectively. The average follow-up period was 9.5 months (Range 1.5 – 15 months). All patients mobilised with crutches in an average of 5 days (Range 3 – 12 days) and full weight bearing was achieved by 65 days (Range 45 – 150 days). Marked improvement in gait was noted in all children with postoperative mean internal & external rotation being 42.9 & 52.6 degrees respectively. There have been no instances of avascular necrosis or postoperative complications to date. Correction was maintained at the final follow up in all children with good bony union by 8 – 12 weeks.

Conclusion: The key to the success of femoral derotational osteotomy for correction of excessive femoral anteversion in children lies in achieving correction and early mobilisation. Intramedullary fixation following diaphyseal derotational osteotomy in children is a safe, effective, cosmetic and reliable procedure with rapid bony union, attributable to biological fixation and early mobilisation. Good early results have been obtained in children with cerebral palsy undergoing this procedure as a part of multilevel corrective surgery.

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Materials and Methods: We analysed the case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate techinique between April of 2005 and August 2006. A total of 18 limbs in 12 patients underwent this procedure. Preoperative and post operative flexion deformity was measured using a goniometer. All measurements were made by the senior surgeon.

Results: The mean age of the patients was 12.8 years (range between 9–16)

Mean follow up time for the patients after they had undergone the procedure was 8.5 months (range 3 – 15). The Mean correction achieved – 16.15 degrees (range 5 – 40)

Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date. We also present technical tips in the 8-plate anterior femoral hemi-epiphyseodesis procedure.

Purpose of study: The majority of children with cerebral palsy suffer from fixed flexion contractures of their knees. Procedures commonly used to correct these deformities include hamstring releases, anterior femoral hemi-epiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are unpopular because of the risk of permanent physeal closure. Soft tissue procedures are usually only partially effective, with a high recurrence rate. We present our initial experience of correcting of knee flexion deformities using the 8-plate technique which uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Method: The case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate technique between April 2005 and August 2006 were analysed. A total of 18 limbs in 12 patients underwent this procedure. The pre- and post-operative flexion deformity was measured with a goniometer.

Results: The mean age of the patients was 12.8 years (range 9–16) and the mean follow up was 8.5 months (range 3–15). The mean correction achieved was 16.15 degrees (range 5–40)

Conclusions: This is a simple technique with a learning curve of 1 case and with few complications to date. All patients in our series have shown sustained gradual correction. We also present technical tips in the use of the 8-plate for anterior femoral hemi-epiphyseodesis.

Aim: To evaluate our initial experience using the Ponseti method for the treatment of clubfoot.

Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study.

The standard protocol described by Ponseti was used for treatment.

Mean period of follow up was 12 months (6– 30 months).

Evaluation was by the Pirani club foot score.

Results: Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity.

Average number of casts required were 6.

Tenotomy was required in 80% of feet.

At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.

Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations.

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

Aim: The aim of this study was to evaluate management of non-articular distal tibial fractures.

Materials & Methods: Between January 2000–December 2004, we treated 25 children with a non-articular distal tibia fracture. All fractures were isolated high velocity injuries (11-Road traffic accidents; 14-Sports injuries) without neurovascular compromise. Only 2 out of 25 were open (grade I) fractures. There were 19 males and 6 females aged 7–16 years (average 11.4 years). On radiography, the fracture patternsvaried from transverse-7 patients, spiral-8 patients, short oblique-7 patients, and communited-3 patients.16 patients had an associated fibula fracture. 20 of the 25 fractures were primarily treated in a cast while the remaining 5 were primarily treated by external fixator (3-Orthofix; 2-Ilizarov) as closed reduction was unstable. The average period in cast/external fixator was 8.4 weeks and the average follow-up 6.2 months.

Results: On early follow-up, 8 of the 20 fractures (40%) that were initially treated in a cast needed intervention (plaster wedging-5; external fixator-3) because of displacement/angulation of the fracture. 7 (28%) of the 8 fractures needing intervention were short oblique fractures. There was no correlation between open injury/associated fibula fracture and displacement/angulation.

Conclusion: Short oblique fractures had a high failure rate with cast treatment. We recommend close monitoring with weekly radiographs for cast treated fractures or alternately primary external fixation of unstable, short oblique fractures.

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.

Aim : To evaluate our initial experience using the Ponseti method for the treatment of clubfoot .

Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score.

Results : Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average nuber of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.

Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations.

Introduction: The purpose of this study was to evaluate the predictors of outcome of hip reconstruction in cerebral palsy and to review the trend in recovery over five years following operations.

Methods: 39 reconstructions in 22 patients [mean age 9.9 SD 2.1] with a mean follow up of 4.7 years were reviewed retrospectively. Information regarding diagnosis, preoperative function and symptoms, details of operation and the postoperative status were retrieved from the clinical records. Preoperative, postoperative and yearly follow up radiographs were reviewed to document acetabular index, Rimmer’s migration percentage (MP) and CE angle. 17 patients underwent simultaneous bilateral hip reconstruction. Femoral osteotomy was performed in all cases in the primary hip and in 17 cases in second hip. Acetabuloplasty was performed in 18 patients in the worst hip and only in 5 cases in the second hips.

Results: The mean preoperative MP in the worst hip was 81%. This improved to 30.7%. In the second hip it improved from 38% to 12.2%. The follow up measurements of the acetabular indices, MP and CE angle had a significant correlation with the postoperative measurements (p< 0.05). In 18 patients hip pain improved and in 14 patients sitting tolerance improved. Perineal hygiene improved in 7 patients following the operation. Graphs of trends in the MP and CE angle are presented. There was no correlation between preoperative presence of pelvic obliquity and post operative outcome. There was no significant difference in outcome in the groups of patients based on open reduction at the time of surgery.

Discussion and Conclusions: The final outcome of the reconstruction can be predicted consistently from the first postoperative radiograph. The quality of reduction at the time of operation is of paramount significance in ensuring long-term survival of the reconstruction.

Introduction Most proximal humeral fractures are treated conservatively. However, treatment for the severely displaced fractures (Neer’s grade IV) is more challenging. This is especially in the adolescent age group where the remodelling potential is reduced. We report on our 8-year experience of fixing severely displaced proximal humeral fractures in children using ESIN.

Method Between 1996 and 2003, we treated 14 children (7 metaphyseal and 7 epiphyseal fractures) using ESIN. 11 were completely displaced and 12 were caused by high energy forces. Our indications included unstable fracture with severe displacement (> 2/3 shaft diameter), age above 12 years and multiple injuries/polytrauma. Manipulation of the fractures and the operative technique is described. Post-operatively, the arm is kept in a sling for 2 weeks. All patients were reviewed on a monthly basis until clinical and radiological healing. Following the removal of the nails, the patients are only discharged when they demonstrate full pain-free range of movement.

Results The double nail technique was used in the first 2 cases and a single nail was used for the subsequent 12 cases. The fracture was reduced by open technique in 1 case. In another, the nail was inserted antegrade. Time from injury to surgery was 2.4 days. The mean operation time was 65 minutes and hospital stay 2.1 days. Time to clinical healing (complete pain-free range of movement) was 2.4 months and radiological healing 3.2 months. All nails were removed by 6 months. Shoulder and elbow range of movement returned to normal at 3.5 and 3.2 months. Complications included 4 cases of elbow stiffness due to nail prominence and 1 case of nail breakage during removal. 1 patient had 10 degrees of varus and in 2 other patients, 5 degrees of varus and 1 cm of shortening and 1.5 cm of shortening respectively. At the final follow-up (14.6 months), all patients had symptom free full range of movement.

Conclusion ESIN is a valid treatment for the severely displaced proximal humeral fractures in the adolescence. It avoids lengthy and awkward immobilization and allows early post-operative mobilization. The single nail technique proved to be adequate to maintain alignment and allow fracture healing, keeping the invasiveness of the procedure to a minimum.

Introduction ESIN is an established method of treatment of long bone fractures in children, which has been in regular use in our institution since 1996. We report on our 7-year experience of using ESIN for the treatment of long bone fractures in children.

Method 92 fractures were nailed (26 femoral, 12 tibial, 17 humeral and 37 forearm). The average age was 12 years (7–15) and average follow-up 15 months. Main indications included unstable and severely displaced fractures, failure of conservative treatment and polytrauma or head injury. Data collection included mechanism of injury, fracture configuration, treatment delay, operation time and technique, length of hospital stay, rehabilitation, healing, nail removal and complications.

Results 49% of fractures were caused by road traffic accidents. All were diaphyseal apart from 14 proximal humeral fractures. The average surgery delay was 7 days and operation time 78 minutes. Open reduction was performed in 3 femoral, 1 humeral and 18 forearm fractures. Single nailing was used for the proximal humeral and forearm fracture. The average hospital stay was 5.8 days, ranging from 12 days for femoral to 2 days for forearm fractures. Clinical healing was achieved at 3.5, 4.3, 2.4 and 2.1 months respectively for femoral, tibial, humeral and forearm fractures.

The commonest complication (25%) was skiin irritation around the entry site, which invariably resolved after implant removal. Delayed union occurred in 2 femoral and 2 tibial fractures (all healed following bone marrow injection). 2 tibial fractures mal-united and 1 tibial fracture was complicated with compartment syndrome. The average nail removal time was 9 months. The nails could not be removed in 4 cases.

Conclusion ESIN is minimally invasive and has a low complication rate. It avoids the lengthy immobilization of conservative treatment, and the surgical trauma of plating without the association of refractures or nerve damage. We believe it represents a valid option in the treatment of long bone fractures.

Aims: We reviewed 100 paediatric lateral condylar fractures of the elbow treated with k-wire þxation. We compared the complication rates of wires left percutaneous versus wires buried beneath the skin. Methods: 68 patients had wires left percutaneous and 32 patients had their wires buried. Fractures were classiþed as displaced or undisplaced. Lengths of time for Ôwires in situñ, limb immobilisation and follow up were recorded. All complications of treatment and outcomes were recorded. Results were analysed using Chi-square tests. Results: Buried k-wires stayed in situ longer than percutaneous wires (average 6.7 versus 4.9 weeks). Fracture types along with mean lengths of immobilisation and follow up were similar for both groups. In the Ôburiedñ group 6 (19%) patients wires migrated through the skin although only 1 (3%) case became infected. 1 (3%) patient developed an uncomfortable heterotrophic ossiþcation. In the Ôpercutaneousñ group 20 (29%) patients developed wire infection and/or granulation tissue requiring treatment. 3 (4%) of these cases severely compromised treatment. Delayed union requiring re-operation occurred in 1(1%) patient. Conclusion: Burying the wires after open reduction and þxation of lateral condylar fractures signiþcantly (p=0.0026) reduces the incidence of infection and overgranulation associated with the wires.

Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans.

We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers’ assessments were compared using the paired Student’s t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs.

We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures.

Introduction; Distal tibial physeal fractures are the commonest cause of growth arrest and deformity secondary to failure to achieve and maintain an accurate reduction. Our study compared assessment of displacement and screw placement using X-ray alone compared to CT scans. Methods; 62 consecutive fractures over a 4 year period were used. Displacement was measured on 18 Salter Harris III and IV fractures by 7 surgeons separately using X-rays alone. These measurements were compared to those made from the CT scans. Screw placement was drawn onto tracings of outlines of of single cuts of CT scans by 4 surgeons seperately for all 62 fractures using X-rays alone. This was repeated one week later using the CT scans. Ideal screw placement was considered to perpendicularly bisect the fracture line. Differences between the ideal and observer measurements were analysed using the paired t-test. Results; The surgeons were incorrect in determining whether there was more or less than 2mm of displacement in 33.3 Ð 50% of cases (mean = 38.9%) . There was a statistically signiþcant difference (p < 0.0001) in accuracy of screw insertion point and direction between using X-rays and Ct scans for all surgeons and fracture types. Conclusions; We recommend that CT scans are essential for accurate pre-operative assessment of distal tibial physeal fractures.

Aim: To evaluate the initial experience of using the Ponseti Method in the management of idiopathic clubfoot and to identify learning curve problems.

Materials and Methods: A retrospective analysis undertaken of 57 feet in 39 patients with CTEV treated by the Ponseti method. The standard protocol described by Ponseti was followed. Pirani’s clubfoot score was used to assess the deformity and the results of treatment. The follow-up in the study ranged from 3 months to 35 months. Denis Brown splints were used full-time for 3 months and at night for 1 year.

Results: 47 out of 57 feet had good results with no evidence of recurrence. 10 feet had recurrence and underwent further surgery. If compliance was poor with the Denis Brown splints or if there was a severe initial deformity there was an increased risk of recurrence. 20% had problems with the plaster of Paris cast and the foot slipped out of the Denis Brown splint in 14%. It was noted there were 2 cases of bruising and swelling associated with the removal of the cast and the application of Denis Brown boots which had not previously been reported.

Conclusion: This is only a preliminary study and therefore the long-term outcome cannot be assessed. It was noted that attention to detail and appropriate regular follow-up is important in achieving satisfactory results.

Introduction

Distal tibial physeal fractures are the commonest cause of growth arrest and deformity secondary to failure to achieve and maintain an accurate reduction. Our study compared assessment of displacement and screw placement using X-Ray alone compared to CT scans.

Method

Sixty-two consecutive fractures over a four-year period were used. Displacement was measured on 18 Salter Harris III and IV fractures by seven surgeons separately using X-rays alone. These were compared to measurements from the CT scans. Screw placement was drawn onto outlines of single cuts of CT scans by four surgeons for all 62 fractures using X-Rays alone. This was repeated one week later using the CT scans. Ideal screw placement was considered to perpendicularly bisect the fracture line. Differences between the ideal and observer measurements were analysed using the paired t-test.

Results

The surgeons were incorrect in determining whether there was more or less than 2mm of displacement in 33.3 – 50% of cases (mean = 38.9% ). There was a statistically significant difference (p < 0.0001) in accuracy of screw placement between using X-Rays and CT scans for all surgeons.

Conclusions

We recommend that CT scans are essential for accurate pre-operative assessment of distal tibial physeal fractures.