Purpose

The decision to undertake prophylactic pinning to prevent contralateral slipped upper femoral epiphysis (SUFE) remains controversial; we hypothesised that the grade of initial SUFE could predict the grade of a second SUFE and risk of poor outcome.

We present a review of our Specialist Physiotherapy clinic for normal physiological variations of the lower limb (SPNV) clinics, demonstrating them to be clinically effective and cost effective.

Children with normal variation of rotational profile and limb angulation present much anxiety to parents and primary care. Providing consultation: to eliminate significant pathology and reassure families, is an important service that a Paediatric Orthopaedic department provides. In our tertiary referral department we have a Specialist Physiotherapy led clinics into which primary care practitioners refer children with whom there are concerns about lower limb development variation.

The (SPNV) Clinic was first set up by a Consultant and Senior Physiotherapist in 1999. The aim of the clinic was to reduce the waiting times for incoming referrals but ensuring they are seen in an appropriate environment by an experienced health care professional. Clinics are run by Senior Specialist Physiotherapists, alongside Consultant clinics who are available for advice and direction. This provides security for the physios, the Trust and the patient.

Over 15 years there have been more than 4000 patient visits to this clinic. Over 80% were new patient visits. 70% of these visits were discharged in one or two reviews. 97.4% of new referrals were discharged without subsequent review by an orthopaedic surgeon. The most common conditions reviewed were Genu valgum (25%), Genu Varum (16%), intoeing (17%) and flexible flat feet (11%).

The clinic has proven to be cost effective as well in drawing in up to £500,000 revenue into the trust in a single year. The department has been approached by other trusts to assist in the implementation of similar clinics.

We present this review of the patients, as a template for supporting the work of Paediatric Orthopaedic Departments. This service has facilitated the streamlining of our Consultant Paediatric Orthopaedic clinics.

Tropical pyomyosistis is an uncommon condition in the United Kingdom. Early diagnosis and appropriate treatment are crucial for a good outcome. We had seen 13 cases in our previously published series from 1998 to 2009. This is an update showing a significantly increased incidence from 2010 to 2016.

A retrospective review of all cases of pelvic pyomyositis in our centre from January 2010 to April 2016 was undertaken from case notes and radiology reports. All children with clinical and radiographic evidence of pyomyositis were included. Since our previous publication we had changed our practice to get an MRI scan in all children who presented with a limp, fever and raised inflammatory markers, and had no effusion in the hip ultrasound scan.

We identified 24 children with a mean age of 7 years (range, 1 week to 14 years). MSSA (Methicillin-Sensitive Staphylococcus aureus) was the most common cultured organism (n=8). Median hospital stay was 9 days (3 to 12). Obturator internus was the most common muscle affected. All patients had appropriate antibiotics with 2 patients requiring surgical drainage of abscesses. The majority of children (n=22) showed a complete recovery with antibiotics only.

Incidence of pyomyositis has increased dramatically in our population and early diagnosis can result in a good outcome. We recommend MRI scan in all patients who present with a clinical picture of septic arthritis of the hip but with no effusion.

The aim of this study is to discuss the results of intramedullary devices in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique.

30 patients with isolated Judet III and IV fractures were included in this retrospective study. The method of reduction was reviewed. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow score.

Intramedullary K wires were used in 10 patients and blunt tipped TENS nails in 20 patients. The complications seen were radiocapitellar joint penetration-6 cases at mean 4.87 weeks, redisplacement − 6, radial epiphyseal sclerosis − 5 and heterotopic ossification − 1 case. The functional result was good to excellent in 24 of 30 cases(80%). The mean Oxford Elbow score was 44.32. The mean follow-up was 40.11 months.

Intramedullary K wires may result in radiocapitellar joint penetration. Blunt tipped devices should not be used as purely fixation devices as they may not prevent redisplacement. Minimal redisplacement does not affect the functional outcome.

Regular follow-up until atleast 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be closely followed up and given a guarded prognosis.

A retrospective review of patients with spinal growing rods in a single institution. Demographic data including age at first surgery, diagnosis, pre- and post-operative cobb angles from erect standardised radiographs were collected. The type of construct used i.e. spine to rib or spine to spine was noted along with the type of growing mechanism used (magnetic or cassette). Any complications were collated for each technique.

Our results include 26 patients who had growing rod insertion, 12 in the spine - spine group and 14 in rib - spine group. Pre-operative cobb angles of 71 and 78 degrees respectively with a correction to 36 and 35 degrees. Mean age at surgery was 63 months in spine to spine group and 67 months in rib to spine group. Spine to spine group had 2 proximal pull out of hooks and the rib spine group had one pull out of hook.

The correction achieved by the new technique is comparable to the spine – spine constructs. Complications are seen in both groups. The perceived benefit of the new technique is the proximal spine is not violated so there is a reduced risk of mass fusion. The canal and pedicles are not included proximally, so there will be no effect on the growing diameter of the canal. Biomechanically the construct is more robust and should allow greater control of the curve. Further follow up and analysis of this new technique is warranted.

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 use of serial casting in the management of early onset scoliosis (EOS) has been well described. Our aim was to evaluate outcomes of plaster jacket therapy in patients with EOS from a tertiary referral centre.

A retrospective review of hospital records and PACS images of 27 patients to identify patients treated with serial casting over a five year period. The primary outcome measure was the need for surgical intervention, with change in Cobb angle used as a secondary outcome measure

Mean age at presentation was 14 months (range 10 – 42), including 14 male and 13 female patients, with an average follow-up of 34 months. Curves were categorised according to aetiology: 16 idiopathic, 6 syndromic, 3 congenital and 2 neuromuscular curves. The mean Cobb angle at diagnosis was 43.7° (range 22 – 115) and mean rib vertebral angle difference (RVAD) was 22.2° (8 – 70). Duration of treatment was 9.9 months (range 3 – 27), with an average of two plaster jacket changes per child. At the time of review, patients fell into one of three groups. Group one (10 patients) failed conservative treatment due no improvement in Cobb angle (mean 48.4° compared with pre-op 53.9°, p value 0.55) and either had insertion of growing rods or had been listed for this procedure, at a mean age of 51.8 months. Group two (12 patients) had a mean Cobb angle of 38.9° pre-treatment which improved to 23.5° (p value <0.05) and were either treated in a brace or had discontinued treatment. The mean RVAD at initial diagnosis was 36.6° in group 1 compared with 13.8° in group 2 (p<0.05). All patients in group one requiring surgical treatment had an RVAD of greater than 20°. Serial casting is on-going for five patients (group three). Complications occurred in 30% of patients including pressure sores, chest infection and respiratory compromise requiring intubation.

Current NICE guidance recognises that serial casting ‘rarely corrects scoliosis’ but recommends it may be used ‘to allow growth before a more permanent treatment is offered’. In our experience, serial casting did not allow any patients with a progressive scoliosis (determined by an RVAD of greater than 20°), to reach a single definitive fusion. However serial casting appeared to halt to curve progression until the child was suitable for the insertion of a growing rod system.

Aims:

To assess the success rate of closed reduction after failing Pavlik harness for treatment of DDH.

Objective

There is mounting evidence to suggest a vascular insult is responsible for Perthes' disease, and it is suggested that this may have long-term implications for the vascular health of affected individuals. This study sought to use ultrasound measures to investigate vascular structure and function in children affected by Perthes' disease.

Aim

Debate remains over the optimal treatment for severe unstable SCFE. AVN is the principle problem; current thinking suggests this can be minimized by emergent reduction and fixation within 24 hours. If emergent treatment is not possible, open osteotomy with a variable delay of 10–21 days has been advocated. We present our experience of delayed intracapsular cuneiform osteotomy (ICO)

Purposes of study

Evaluation of the pre-operative documentation of neurovascular status in children presenting with Gartland Grades 2 and 3 supracondylar fractures and the development of an Emergency Department Proforma.

Background

The association between idiopathic scoliosis and intrinsic abnormalities of the spinal cord are well known. MRI is the most sensitive imaging modality available to diagnose an intraspinal anomaly. The use of a routine ‘screening MRI’ prior to scoliosis correction is controversial.

Objective

The relationship between the index (2D) to ring finger (4D) is one of the most commonly studied anthropometric measures, which is believed to offer insight into early growth and the foetal environment. This study aimed to determine the relationship between the 2D:4D ratio and the risk of Perthes' disease in children.

Background

Tension band epiphysiodesis for lower limb length discrepancy in children Planned physeal growth arrest (epiphysiodesis) for the treatment of limb length discrepancy (LLD) in growing children is a well described treatment modality in the literature. We describe our experience of temporary epiphysiodesis using a tension band technique with the “8-plate” in the treatment of LLD in growing children.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Purpose

To evaluate the efficacy of Kocher's criteria to differentiate between transient synovitis and septic arthritis in children.

Aims

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

Opinions about the treatment of Perthes' disease vary widely. However there is no disagreement about the need for containment during fragmentation stage to create an optimum biomechanical environment for remodelling of femoral head. Types of containment may vary. Younger children do well irrespective of the method of containment. Older children usually require surgical containment. The present study was aimed at evaluating the results of different methods of surgical containment in different age group and identifying specific factors that alter the final outcome and prognosis.

107 cases were reviewed retrospectively. 21 cases were excluded due to lack of records. 86 hips were available for clinical and radiological evaluation. 31 patients were under 7 years and required Varus osteotomy (VO). 55 patients were above 7 years. VO was performed in 30 hips and Shelf containment was done in 25. Case notes were reviewed for demographic details, surgical details and clinic letters. Radiographs were reviewed for Herring's grading, Stulberg staging, containment indices, centre edge angle, lateral pillar height, Mose index, neck shaft angle and shelf width.

In all patients, there was an improvement in pre-operative symptoms and summated range of motion, especially abduction. Good functional and radiological outcome was seen in age group < 7 years. In older children, outcome was good to satisfactory with Herring grade B. Stulberg grading worsened with advancing age and Herring grade C, irrespective of the method of containment. Persistence of varus neck shaft angle and trochanteric overgrowth were significant problems with VO. Although all containment indices improved with Shelf group, Stulberg grading remained poor in most patients.

The lateral pillar classification and age strongly correlate with final outcome. Herring group C had the least favourable result. Stulberg staging remained poor in older children irrespective of the method of containment.

Displaced fractures of the radial neck in children can lead to limitation of elbow and forearm movements if left untreated. Several management techniques are available for the treatment of radial neck fractures in children. Open reduction can disturb the blood supply of the soft tissue surrounding the radial head epiphysis and is associated with more complications.

We report our experience of treating 14 children between the age of 4 and 13 years, who had severely displaced radial neck fractures (Judet type 111 and 1V). 12 patients were treated with indirect reduction and fixation using the Elastic Stable Intramedullary Nail (ESIN) technique, (3 with assisted percutaneous K-wire reduction) and 2 had open reduction followed by ESIN fixation of the radial head fragment. This method reduces the need for open reduction and thus the complication rate. Three patients had associated fractures of the same forearm which was also treated surgically at the same time. We routinely immobilised the forearm for two weeks and removed the nail in all cases in an average of 12 weeks. We had no complication with implant removal.

All 14 patients have been followed up for average of 28 months. One patient (7%) developed asymptomatic avascular necrosis (AVN) of the head of radius. Thirteen patients (93%) had excellent result on final review. One patient had neuropraxia of the posterior interosseous nerve which recovered within 6 weeks.

In conclusion we advocate ESIN for the closed reduction and fixation of severely displaced radial neck fractures in children. It remains a useful fixation method even if open reduction is required and allows early mobilisation.

Aim: The purpose of the study was to report the outcome of Flexible elastic nailing for femoral shaft fractures in children

Materials and Methods: Sixty-three femoral shaft fractures in 62 children treated with titanium flexible elastic nailing over a 10 year period (1998–2007). There were 44 boys and 18 girls aged 7.4 to 15.6 yrs (mean 11.2 yrs). Their body weight ranged from 22 to 64.80 kg (mean 40.99 kg). The right side was involved in 36 and the left in 27 children (including 1 bilateral fracture). The mechanism of injury varied from Road traffic accidents (RTA) in 42, Sports in 2 and Falls in 18 children. The proximal third shaft was involved in 3, middle third in 50 and distal third in 10 children. The fracture pattern varied from Transverse in 28, Oblique in 21, Spiral in 12 and Comminuted in 2 children.

Results: All fractures united with a mean union time of 15 weeks (range 6 to 30 weeks). The average follow-up was 72 weeks (range 52–104 weeks). Outcome assessment using the Titanium Elastic Nailing (TEN) Score showed 63% excellent, 32% satisfactory and 5% poor results. The minor complications varied from transient knee stiffness in 8 children, prominent nail ends in 7 children, extensor lag in 2 children, and acceptable facture angulation in 2 children. The major complications were fracture malunion, non-union, delayed union in 1 child each and re-fracture at different level in one child. The mean leg length discrepancy after union was 8mm (range 0–13 mm). There were no cases of infection. This method of treatment provided stable fixation, early mobilization and discharge.

Conclusion: We found that good surgical technique with attention to surgical details resulted in 95% excellent to satisfactory outcome.

Introduction: There is a paucity in the literature regarding the long term outcome of children with septic hips. Often, there is a delay in diagnosis which may lead to complications such as growth arrest, deformity and leg length discrepancy. We investigated the outcome of these patients and report the observed complications.

Methods: We performed a retrospective review of all children who underwent arthrotomy and washout for septic arthritis of the hip over a ten year period. Patients were identified from hospital databases and the coding department. Medical records were reviewed and data including demographics, method of presentation, laboratory investigations and outcome were recorded.

Results: We analysed the records of 70 patients who underwent formal arthrotomy and washout of their septic hip. Two patients had bilateral washouts (n = 72 hips). There were 36 (51%) female patients. 24 patients were under 1 year of age at presentation, with 11 of these in the neonatal period.

Temperature data was available for 48 patients, with a mean of 38.2 degrees Celsius at presentation. The mean ESR was 55.8. 28 patients (40%) grew an organism on culture of the hip fluid. The most common organism was Staphylococcus Aureus (64% of positive cultures).

66% (n=16) of patients in the < 1 year old group developed complications relating to growth arrest and leg length discrepancy. Seven of these patients (43%) underwent further surgery to correct deformity at a later date. In contrast, only 4.3% of patients in the > 1 year old group developed complications. The mean delay to surgery in patients who developed complications was 6.3 days with a mean delay to surgery of 3.1 days in patients who did not develop complications (p = 0.03, student’s T-Test).

Discussion: Paediatric Septic Arthritis remains a complex issue for both the patient and the surgeon. We have demonstrated that an increased delay in patients undergoing washout can lead to increased complications although this predominantly affects patients under 1 year of age. This can be explained by the lack of clinical signs in a < 1 year old child. Clinicians should have a high index of suspicion of septic arthritis in patients with features of sepsis with an unknown cause.

Gradual correction of periarticular deformities has necessitated the application of external fixators to accomplish the task. By contrast, such deformities when treated by acute correction are most often stabilised using internal fixation. Hemi-epiphyseal arrest, by stapling or transphyseal screw is a disadvantage by being an irreversible process which has to be delayed until later childhood. This study describes the preliminary results of using an alternative internal device which corrects angular deformity by acting as a tension band on one side of the growth plate.

Twenty nine consecutive patients with significant coronal plane deformities in the lower limb were treated using the guided growth technique. This was accomplished through the extra-periosteal application of a 2-hole plate and screws (the 8-plate, Orthofix SRL, Verona). The plate was left in-situ and the patient monitored at regular intervals until the desired correction of the mechanical axis was accomplished. Plate removal was undertaken if the child was not skeletally mature at completion of treatment.

Eighteen males and 11 females completed treatment and had their plates removed. The age of patients ranged from 5 to 14 years (average 11.5 years). There were 23 patients with genu valgum deformity with an average deformity of 9.8 degrees, and 6 patients with genu varum deformity with an average deformity of 29.9 degrees. The follow up period averaged 12.5 months from plate removal. The average duration of correction was 15.8 months. The overall rate of correction was 0.87 degrees per month. Two complications were recorded: plate migration in one patient and deep infection in another patient. We had one case of rebound deformity.

The guided growth technique using the 8-plate is a simple and safe procedure for the treatment of lower limb angular deformity which produces temporary physeal arrest.

Primary pyomyositis is increasing in incidence in the western world. Although a commonly encountered condition in the tropics it was not described in the USA until 1971 and the UK until 1998. The reason for the increasing incidence is not understood.

Typically pyomyositis affects the muscles around the hip and may present in a variety of ways to orthopaedic or general surgeons – occasionally leading to unnecessary operative intervention. We sought to identify the experience gained, of this condition, within a UK paediatric tertiary referral unit.

A retrospective review of cases of pyomyositis, from our institution, since 1998 was undertaken to identify demographics, presentation, diagnosis and management. Thirteen cases of pyomyositis were identified. Obturator internus was most commonly affected (n = 7). Trauma was implicated in three cases and group A staphylococcus was cultured in nine cases. Male:Female ratio ~ 3: 2. Initial working diagnosis at presentation was septic joint in eight cases, appendicitis in three cases and soft tissue abscess in two cases. Ten cases settled with antibiotics alone. One diagnostic retroperitoneal exploration was performed which may have been avoided with greater preoperative awareness of this condition. On reflection, all cases were identified by CT or MRI.

To our knowledge, this is the first UK series of pyomyositis, reflecting its increasing incidence in the western world. Its presentation is similar to other common paediatric surgical emergencies, yet its management is very different – often not requiring surgery. A greater awareness of this emerging condition is therefore essential to both general and orthopaedic surgeons in order to prevent misdiagnosis and unnecessary surgical intervention.

Elastic stable Intramedullary nailing (ESIN) is a method of treating femoral fractures in older children.

The purpose of this study is to report our results over a 9 year period. Between 1998 and 2007, 62 children with femoral shaft fracture were managed at our institution with flexible titanium nailing. There were 44 boys and 18 girls with a mean age of 12.4 years (range 6 to 16 years). The mechanism of injury varied from RTA, falls and sports. The right side was involved in 41 and the left in 23. Two children had bilateral fractures. The fracture was in the proximal one third in 3, middle third in 51 and the distal third of the diaphysis in 8 children. The fracture pattern varied from transverse in 33, oblique in 15, spiral in 10 and comminuted in 4 patients. 11 children had associated injuries and 2 had mild osteogenesis imperfecta and another 3 sustained pathological fractures (fibrous dysplasia - 1 patient; simple bone cyst -1 patient; aneurismal bone cyst – 1 patient). The surgical procedure was retrograde except in one child with a mid third oblique fracture where this technique failed and hence an ante grade insertion was performed.

All fractures united at an average follow-up of 18 months (range 12–24 months). The mean union time was 3.8 months (range 1.2 to 7.2 months). All patients were followed until the implant was removed and the mean insertion to removal interval was 13 months (5 to 29 months). The complications noted in our series were knee discomfort with stiffness (8 patients), pain from prominent nails (2 patients), malunion (1 patient), delayed union (1 patient), peri-prosthetic fracture (1 patient). There were no cases of infection.

In conclusion, the results of our series showed that Elastic stable Intramedullary nailing gives satisfactory outcome in management of femoral shaft fractures in children.

Aim: To assess whether use of the Pavlik harness for the management of developmental dysplasia of the hip (DDH) can safely be discontinued without weaning.

Method: The study group comprised babies diagnosed with DDH at the Royal Liverpool Children’s hospital over a 10 year period, between January 1995 and August 2004. The decision to instigate treatment with a Pavlik harness was based upon the Graf grade. We used Graf IIB or worse as our treatment threshold for the use of the Pavlik harness. In our practice the harness was removed when the hips were ultrasonographically and clinically normal, without a period of weaning.

Results: There were 368 hips (273 babies) for analysis, 178 cases of unilateral DDH (128 left hips and 50 right hips) and 95 bilateral cases. Mean age at diagnosis was 59 days (range 1 – 187 days) with twenty-six patients presenting late after the usual 120 day time limit. Treatment with the Pavlik harness was successful in normalising 323 hips (87.8%). The Pavlik harness was unsuccessful in reducing 45 dislocations (12.2%). Patients were followed-up for a mean of 4.1 ± 2.7 years with no deterioration of acetabular indices on plane radiographs, according to the Tonnis classification. There were 4 hips with possible grade I avascular necrosis. To date there have been no cases of late dysplasia.

Conclusions: Although many units remove the harness after a period of gradual weaning, practice is varied. Since we did not encounter any negative outcome despite not weaning we conclude that that weaning is unnecessary.

Aim: To assess the effectiveness of a physiotherapist led normal variant clinic for children.

Method: The study comprised all children presenting to the physiotherapy clinic at the Royal Liverpool Children’s hospital between January 2000 and January 2006. The clinic is run by two specialist physiotherapists alongside a consultant led Orthopaedic clinic, providing support as required. Physiotherapy staff are able to request and interpret radiographs and order blood tests independently. The numbers of patients, the range of conditions seen in the clinic, and the outcome of the consultations recorded in the practitioner case-notes were examined for the purpose of this study.

Complete data was available for the full period under review except for the year 2003.

Results: During the five year study period 1594 children were seen, a mean of 318 patients annually (range 267–387). The age distribution of patients was 33.1% (527) under the age of 2, 38.9% (620) 2–5 years, 19.3% (307) 5–10 years and 8.8% (140) 10–16 years. The most common conditions seen were genu valgum 28.7% (458), genu varum 18.4% (293), in-toeing 14.7% (234) and toe walking 6.0% (96). Most patients (94.7% n=1509) were managed independent of consultant supervision by the physiotherapist. A minority of patients required consultant review in the clinic (4.2% n=67). Fewer still were referred to another medical clinic (1.1% n=18).

Conclusions: Children with a spectrum of orthopaedic conditions can be appropriately managed by a trained physiotherapist independent of consultant input.

Aim: To demonstrate that the conservative management of meralgia paraesthetica in children is effective.

Method: Clinic case-notes of the senior author (CB) were retrospectively searched between January 1997 and February 2007 to identify cases of meralgia paraesthetica. Sixteen cases were discovered in fourteen patients, 6 right, 6 left, and 2 bilateral. Four patients had had previous pelvic surgery and two combined pelvic and femoral osteotomy for developmental dysplasia of the hip. One underwent bilateral pinning for slipped upper femoral epiphyses. Clinical symptoms were assessed subjectively. All patients were initially managed conservatively with NSAIDs and counselled to avoid tight fitting clothing across the waist. If symptoms had failed to settle at follow-up a local anaesthetic/steroid injection was administered to the site of maximal tenderness. Surgical decompression was performed for intractable cases.

Results: There were 10 females and 4 males, with a mean age of 13.6 years (8–17). Mean follow-up was 15 months (1–50).

Eleven cases (68.8%) improved with conservative management and a further three cases improved following a local anaesthetic/steroid injection. Two cases (12.5%) who did not improve with these measures underwent surgical decompression with subsequent improvement in symptoms. No side effects were reported from the either the steroid injection or surgical decompression.

Conclusions: There is no current evidence supporting the management of meralgia paraesthetica in children. In adults, this elusive diagnosis is managed conservatively to good effect. This retrospective study demonstrates that conservative management is also effective in paediatric patients. In those cases where symptoms prove intractable, surgical decompression produces clinical improvement.

Purpose of Study: To discuss on Clinical presentations, Investigations, Histopathology, Differential diagnosis and Treatment options based on a series of six Lipoblastomas that we encountered in our paediatric orthopaedic practice.

Materials and Methods: This series consists of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006. Mean age 17 months. Mean follow up was 26 months. The youngest was a six month old infant with a swelling on his right instep. The second patient was a three year old girl who presented with a limp and swelling in her foot, the third patient was an 18 month old boy with a swelling on the dorsum of his left forearm, fourth patient had a swelling of his left thigh and two patients had swellings in their back. They were investigated appropriately with MRI, CT or USG and surgical excision planned accordingly.

Results: Male to female ratio was 5:1. Age groups; 2 patients were of less than 12 months of age, another two of them was between 12 to 24 months and the last two were under 36 months at the time of diagnosis. Anatomically three patients had swellings in the lower limb, 2 had swellings over dorsum of their trunk one patient had a forearm swelling.

Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up.

Discussion: Lipoblastomas are uncommon, benign tumour of embryonal mesenchymal cells. It is a rare tumour but occurs mostly during infancy and early childhood. It most often presents on the extremities, back, head and neck.

Histology: cellular neoplasm composed of lipoblasts in different stages of maturation and fine vascular network, with well defined septa.

Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading.

These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported.

Differential diagnosis includes myxoid liposarcoma, welldiffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.

Conclusion: All patients were originally thought to have simple lipomas or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour and is rarely encountered in orthopaedic training. It is important that we orthopaedic surgeons be aware that lipoblastoma is in fact the most likely diagnosis of a fatty lump in a child of less than two years of age. Lipoblastomas needs through imaging and if possible cytogenetic evaluation for accurate diagnosis before surgery because complete surgical resection is mandatory to prevent a likely local recurrence.

Aprotinin has been shown to reduce blood loss in a number of surgical specialities. Patients with Duchenne Muscular Dystrophy (DMD) bleed more during surgical procedures than patients without this condition. The aim of this study was to evaluate the effect of aprotinin in reducing blood loss in scoliosis correction surgery in patients with DMD.

A retrospective analysis of case notes was performed. Thirty two patients diagnosed with DMD who underwent surgical correction for scoliosis over the last 25 years were included. All patients underwent posterior spinal fusion and instrumentation, between the levels T3 and L3. All procedures were carried out by the same lead surgeon. Patient age, body weight, length of procedure, and estimated blood loss were recorded. Blood loss as a percentage of total circulating volume was calculated and compared between patients who had not received aprotinin (seven patients), and those who did (25 patients). Blood loss as a percentage of total circulating volume in the group of patients with aprotinin (range 37% – 107% mean 67%) was significantly lower (P< 0.05) than the group without aprotinin (range 67% – 157% mean 111%). There was found to be no statistically significant relationship between blood loss and length of procedure. There was no statistically significant difference in the duration of the procedure between the two groups of patients. Despite the small number of patients this study shows a beneficial effect for aprotinin in reducing blood loss during scoliosis correction surgery in patients with DMD.

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.

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.

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.

The practice of regular radiological follow-up of infants with a positive family history of developmental dysplasia of the hip is based on the widespread belief that primary acetabular dysplasia is a genetic disorder which can occur in the absence of frank subluxation or dislocation. We reviewed all infants who were involved in our screening programme for developmental dysplasia of the hip, between November 2002 and January 2004, and who had a normal clinical and ultrasound examination of the hip at six to eight weeks of age, but who, because of a family history of developmental dysplasia of the hip, had undergone further radiography after an interval of 6 to 12 months. The radiographs of 89 infants were analysed for signs of late dysplasia of the hip and assessed independently by three observers to allow for variability of measurement. There were 11 infants (11%) lost to follow-up.

All the patients had normal radiographs at the final follow-up and none required any intervention. We therefore question the need for routine radiological follow-up of infants with a positive family history of developmental dysplasia of the hip, but who are normal on clinical examination and assessment by ultrasound screening when six to eight weeks old.

Background: In times of blood shortage, the department of health plan to cancel elective surgery requiring more than 2 units of blood cross matching preoperatively. We assessed the use of blood products in scoliosis surgery and identified factors increasing the need for post operative blood transfusion.

Methods: Prospective data collection. Forty four patients underwent corrective spinal surgery between January 2003 and June 2004. Numbers of units of blood cross matched pre operatively and transfused post operatively were calculated. Subtype of scoliosis and surgical approach were also identified.

Results: All patients were cross matched 6 units of blood pre operatively, total of 264 units. Only 133 units were actually transfused, giving an overall 50.4 % product use rate. All syndromic patients were transfused blood irrespective of surgical approach. Idiopathic patients who had a one stage anterior approach did not require transfusion. Idiopathic patients were transfused a mean of 2.4 units and 2.9 units for one stage posterior and 2 stage approaches respectively. Syndromic patients were transfused a mean of 2.5 units, 5.8 units and 4.2 units for one stage anterior, one stage posterior and 2 stage procedures respectively.

Conclusion: The department of health published a paper on contingency planning for the shortage of blood products (1). In times of shortage, those surgeries requiring preoperative cross matching of more than 2 units will be cancelled first. Therefore, not only is it important to reduce the waste of blood products from a cost perspective, but also to cross match appropriately to avoid unnecessary cancellation if blood shortages occur. Surgical approach and underlying diagnosis need to be identified when cross matching patients for corrective scoliosis surgery. Idiopathic scoliosis patients only require 2 units of blood cross matching preoperatively. Patients with syndromes require 2–6 units depending on the surgical approach. A prospective validation trial has been implemented to validate our retrospective findings.

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.

Aim: To investigate the versatility of ßexible intramedullary nails (FIN) in the surgical treatment of forearm fractures in children. Methods: 28 children were treated using FIN for displaced forearm fractures over a period of 5 years. There were 18 boys and 10 girls. The mean age was 11.5 years and the mean follow up were 7.9 months. Two nails were used one each for radius and ulna. 12 children were operated for unstable displaced fractures, 14 were operated after failed initial reduction and 2 were operated for open fractures. 16 were nailed by closed method, 12 had mini open technique in cases of failed initial closed reduction. The nails were removed on an average of 6–8 months. Results: All the children achieved bony union in excellent position. The average time for union was 5.6 weeks. All but 2 patients had full range of movements and none had any functional difþculty. 3 children had transient hypo aesthesia in the area of superþcial radial nerve distribution and one child developed compartment syndrome which needed fasciotomy. There were no long term sequel. Conclusions: Use of FINs in paediatric forearm fractures should be encouraged when surgical intervention is needed. They are axially and rotationally stable. They are safe to introduce and remove at a later date. Their ßexibility allows remodelling of the fracture and growth of the long bones.

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.

Aims: This study shows the efþcacy of The Pavlik harness for the treatment of Development Dysplasia of hip (DDH) using ultrasonographic monitoring. Methods: Between 1995–2000 we treated 149 dysplastic hips in 117 babies. According to the Grafñs classiþcation 90 were dysplastic type IIB, IIC, IID hips; 59 were dislocated Type IIIA, IIIB and IV hips. Babies were regularly monitored using ultrasound unto 26 weeks and radiographs up to 5 years in dislocated hips for bony roof angle. Results: The average full time harness treatment was 12.2 (range 6–20) weeks, average follow up was 55 (range 30–90) months. The harness failed to reduce 14 hips (9.5% of total hips). Two cases continue to show a small femoral ossiþc nuclei at 30 months follow up. The hips showed no signiþcant difference in acetabular index from the normal values at follow up radiographs. Conclusions: We conclude that using this protocol, successful initial treatment of DDH with the Pavlik harness appears to restore normal development of the hip.

This study shows the efficacy of The Pavlik harness for the treatment of Development Dysplasia of Hip using ultrasonographic monitoring. Between March 1995 and February 2000 we treated 149 dysplastic hips in 117 babies. According to the Graf’s classification 90 were dysplastic type IIB, IIC,IID hips; 59 were dislocated Type IIIA, IIIB and IV hips.

Babies were regularly monitored using ultrasound until the age of 26 weeks and radiographs there after for bony roof angle. The Pavlik harness was abandoned if there was persistent dislocation of hip at the end of 3 weeks of treatment. The average full time harness treatment was 12.2 ( range 6–20 ) weeks. The average follow up was 55 ( range 30–90 ) months.

The harness failed to reduce 14 hips ( 9.5 % of total hips). These required arthrogram and closed or open reductions. Late presentation beyond 12 weeks and a higher grade on the Graf’s classification reduces the success rate of the pavlik harness treatment. Two cases continue to show a small femoral ossific nuclei at 30 months follow up. The hips treated successfully showed no significant difference in acetabular index from the normal values at follow up radiographs.

We conclude that using our protocol, successful initial treatment of Developmental Dysplasia of Hip with the Pavlik harness appears to restore normal development of the hip. We continue to monitor patients by regular radiological surveillance up to 3 years in dysplastic hips and 5 years in unstable and dislocated hips.

Introduction: It is commonly believed that markedly increased femoral anteversion is a primary abnormality and a consistent feature of hip dysplasia. It is also considered to be one of the main factors leading to redislocation. Apart from limited cadaveric studies, the true normal range of anteversion in infants is largely unknown. We measured femoral anteversion in infants using ultrasound. We are presenting our results measuring the femoral anteversion in both normal and DDH hips.

Methods and materials: Anteversion measurements are taken at the time of routine ultrasound screening for Developmental Dysplacia of Hip. This method was previously validated. We measured femoral anteversion in 76 infants with normal hips. We measured femoral ante-version in 27 hips with DDH. The mean femoral ante-version in normal babies is compared to the value in the babies with hip dysplasia using unpaired t-test.

Results: The mean value of femoral anteversion in normal babies in our series was 46.75° with 95% reference interval of 36.34° to 57.17°. The mean femoral anteversion in dysplastic hips was 50.39° with a 95% reference interval of 34.88° to 65.89°. The difference between normal and dysplastic hips was statistically significant (p value −0.0095 and 95% CI of 6.36° to 0.90°). This showed a small increase of femoral anteversion in the dysplastic hips.

Conclusion: We established reference ranges of femoral anteversion in normal and dysplastic hips. Our series showed only a small increase of femoral anteversion in the dysplastic hips. We showed that the markedly increased femoral anteversion was not a primary abnormality in hip dysplasia.

Introduction: Atlanto-axial rotatory fixation is a rare condition which occurs more. commonly in children than in adults. The terminology can be confusing and the condition is also known as. ‘ atlanto-axial rotatory sub-luxation’ and ‘atlanto-axial rotary dislocation’ . Rotatory fixation is the preferred term however , as in most cases the fixation occurs within the normal range of rotation of the joint and by definition therefore the joint is neither subluxed nor dislocated. Atlanto-axial rotatory fixation is a cause of acquired torticollis. Diagnosis can be difficult and is often delayed. The classification. system proposed by Fielding in 1977 is most frequently used and will be discussed in detail. Given that this classification system was devised in the days before CT, as well as the fact that combined atlanto-axial and atlanto-occipital rotatory subluxation is omitted from the classification, we propose a modification to the classification of this rare but significant disorder.

Methods and Results: The radiological findings in six cases of atlanto-axial rotatory fixation will be illustrated, including a case with associated atlanto-occipital sub-luxation. The pertinent literature will be reviewed and a more comprehensive classification system proposed. The imaging approach to diagnosis and the orthopaedic approach to management will be discussed.

Conclusion: In general, children who present with a traumatic torticollis should be treated conservatively with cervical collar and anti-inflammatory medication for one week. Those children whose torticollis fails to resolve after one week require aggressive investigation by ‘dynamic’ computed tomography to assess whether the joint is fixed. If however there is a history of significant trauma then immediate radiological assessment is advised. This approach will avoid over-investigation and over-treatment yet will still detect atlanto-axial rotatory fixation early enough to achieve a good outcome.

The surgical treatment of Perthes’ disease by femoral or innominate osteotomy is not as effective in those over the age of eight years as it is in the younger child. This has prompted the search for other types of management in those who are older. The preliminary results of the use of a lateral shelf acetabuloplasty for such cases have shown encouraging results at two years. The concern with such an operation is that it might interfere with the growth of the outer aspect of the acetabulum and so prejudice the long-term outcome. We describe a review at maturity of 26 children presenting with early disease after the age of eight years who were treated by lateral shelf acetabuloplasty. The results suggest that the outcome is improved; 22 of 27 hips were rated as Stulberg groups 1 to 3. Poor results occurred in children, particularly girls, presenting with Group-4 disease over the age of 11 years.