Introduction: Despite early screening, infants continue to present late ( > 4 months) with DDH. The impact of late diagnosis is significant. Established DDH causes significant morbidity and may have major medicolegal implications.

Aim: To review the incidence of late presenting DDH nationally for a single year and assess the patterns of referral. To identify the reasons for the late presentation of DDH in the presence of early clinical screening.

Methods: In a retrospective study all cases of late DDH presenting in 2004 were identified using inpatient database. Patient records were retrieved and data collected.

Results: Fifty nine cases of DDH were diagnosed at greater than 4 months. There was an additional 26 cases of isolated acetabular dysplasia treated at greater than four months.

The mean age of diagnosis was 14.6 months (range 4–72). Many of the late referrals had risk factors for DDH.

Conclusion: Despite routine clinical screening at birth and six weeks, children continue to present with late DDH. This represents a significant workload for our tertiary unit.

Introduction: This retrospective study examined the clinical characteristics, radiological findings, management, and functional outcome in 34 rehabilitated patients who presented with traumatic central cord syndrome.

Methods: Between 1994 and 2004 a total of 34 patients with central cord syndrome were admitted to the National Spinal Injuries Unit. There were 29 men and 5 women. The mean age was 56.1 years (15 to 88). The mean follow up time was 4.9 years. Patients were divided into three groups by age, < 50 years (10 patients), 50–70 years (16 patients), and > 70 years (8 patients). The American Spinal Injury Association (ASIA) system recorded the motor and sensory scores, of upper and lower limbs, on admission, discharge and during rehabilitation. Patients underwent radiological investigation that included plain film, CT, and MRI of the cervical spine.

Results: The mechanism of injury was a fall in 58.8%, road traffic accident in 35.2% and other in 6%. Alcohol was a contributing factor in 32.4% of cases. Seven patients had a spinal fracture. The cervical spine was involved in 5 cases with the remaining 2 cases involving the thoracic spine. Seventy percent of patients received intravenous steroids. Over half (53%) of the patients had some degree of cervical spondylosis while cord changes were seen in almost all of the patients (79.4%). In the majority of cases (70.4%) the affected level was C3/4. Disc herniation was present in one third of cases (33.2%). The mean upper limb ASIA score on admission was 7.6, on discharge was 12.4 and at follow up was 20.2. A similar pattern was also observed in the lower limb with scores of 12.1, 13.7, and 20.5 respectively. Sensory loss also improved with time. 88.2% of those admitted required urinary catheterization, with 23.5% being discharged to the National Rehabilitation Hospital with a catheter in situ. Surgical decompression was performed in 7 cases. The remainder of patients wore a Miami-J cervical collar.

Conclusion: As was shown in the original paper by Schneider et al (1954), hyperextension of a degenerative cervical spine was the predominant mechanism of injury. The return of lower limb function precedes that of upper limb, with autonomic function recovering in the majority of cases.

Discussion: In this study patients in the younger age groups had better recovery of function and had fewer complications. The original paper by Schneider et al. stated that conservative treatment was most appropriate, however, in this review surgery was performed in specific cases such as those with cord compression secondary to disc herniation. Alcohol was a significant contributing factor.

Introduction: Recent data from the UK suggests that the incidence of osteomyelitis in the paediatric population is declining. However, the incidence in the Scandic countries has risen in the late eighties and nineties. We undertook to examine the epidemiology of osteomyelitis presenting to a paediatric teaching hospital in an Irish urban setting.

Patients and Methods: We undertook a retrospective review to identify patients admitted over a twenty-five year period with a diagnosis of osteomyelitis. Patients were identified from hospital records, theatre log-books and a departmental database. Demographic data was collected, as were details of the infected bony structure, treatment required and organism cultured.

Results: A total of 291 patients were admitted over a twenty-four year period, from 1977 to 2000.

A marked reduction in osteomyelitis was noted over the twenty-four year incidence of the study. In addition, a shift in the causative organism was noted from an incidence of H Influenzae in the 70’s of up to 30%, to less than 5% in the 90’s. The treatment regime changed markedly over the course of the study period, with a significantly reduced duration of hospital stay reflecting the move away from protracted periods of hospitalisation.

Conclusion: A marked fall in osteomyelitis has occurred in the paediatric population. This may be due to improved living conditions and the introduction of H Influenzae vaccinations. The duration of hospital stay has declined markedly and the introduction of newer imaging modalities has aided diagnosis, allowing early aggressive intervention. However, as osteomyelitis is becoming increasingly rare, a higher index of suspicion is required, particularly from non-specialists who are more likely to be the first to encounter these patients.

Introduction: Complete spinal cord injury patients demonstrate an initial rapid lower limb bone mineral density loss.^1,2; Reports suggest an increase incidence of lower limb fractures in such patient.³ Such injuries place an additional burden on patients undergoing rehabilitation.

Aims: This prospective study was established to assess whether disuse osteopenia contributes to increased incidence of lower limb fractures in patients following complete spinal cord injury. We compare this cohort to patients who attained mobility after their spinal cord injury.

Methods: We prospectively reviewed 128 patients (107 male; 21 female) treated in our unit, a Tertiary Referral Spinal Trauma Unit. All patients presented between January 1994 and July 2002. There were 66 patients 958 male; 8 female) who initially presented to this unit and subsequently attained mobility either while in hospital or during rehabilitation. Both groups were comparable in age and sex profiles.

Results: The mean length of follow-up was 58 months for patients with complete neurology and 64 months for those who attained mobility. There were 4 lower limb fractures in the group of patient with complete neurology. Two patients sustained supracondylar femoral fractures with one requiring operative intervention, while 2 patients with mid-shaft tibia/fibula fractures were treated conservatively.

Conclusions: Previous papers have shown that patients with complete neurology after spinal injury undergo disuse osteopenia. We report an increase incidence of lower limb fractures in patients with complete neurology compared to patients initially presenting with neurology but attaining full mobility. This difference is statistically significant, (p< 0.05).

Breech presentation is historically associated with an increased incidence of hip Dysplasia (6.6%–9.6%), but the effect of vaginal breech delivery on the development of hip dysplasia is unknown. In the Irish Republic, the proportion of breech presentations delivered by caesarean section is now over 90%. If the mechanical trauma of vaginal delivery is a significant event in the aetiology of DDH in breech presenters, caesarean section should be protective. We tested this hypothesis by a prospective study in infants presenting in the breech position who were delivered by caesarean section, during the 2002 calendar year.

There were 108 infants in the breech position at the time of delivery during this period; all but two of these (excluded from the study) were delivered by caesarean section. 50 were male and 56 were female. The mean duration of pregnancy at delivery was 37 weeks. An initial examination was performed in all cases within the first 48 hours postpartum, and treatment in a Pavlik harness commenced where there was clinical instability. Standardised AP and BIR views of the pelvis were taken at 4 months after birth, in all 106 cases. The acetabular index (AI) was measured on both sides.

There was only one case of hip dislocation at birth (bilateral dislocation in a first-born female infant). In 7 cases the initial examination was suspicious for instability, and patients were treated in Pavlik harness; in five of these cases another recognised risk factor (first-born female, family history) was also present. Two of these cases were found to have evidence of instability at 4 months, and underwent treatment by closed reduction and spica casting. For the entire group, the mean acetabular index (212 hips) was 23 degrees (range 17 to 36 degrees). Among those with signs suggestive of instability, the mean AI was 28 degrees. Only one patient had an AI > 30 degrees. Among those with no other risk factors, the mean AI was 22 degrees (range 17 to 28).

Our prospective study suggests that the incidence of DDH is markedly lower in breech presenters delivered by caesarean section (< 3%) that that reported for breech presenters as a whole. The three patients in our group with DDH had other risk factors present. We conclude that caesarean section may be protective for the development of DDH in infants who present in the breech position.

The number of skate related injuries has seen a resurgence in the western world with almost 51000 patients in 1999 presenting to US hospitals with a skateboard related injury, almost 90% of these being male and almost 70% of these are orthopaedic related injuries. Protection , particularly wrist guards, elbow pads, knee pads and recognized helmets are all necessary in protecting the young child against orthopaedic injuries. However despite these physical barriers little training or supervision exists in adequately educating children as to the dangers of these devices. Having observed an increased number of referrals to our Accident and Emergency Dept with fractures sustained whilst roller-blading and skateboarding we set about prospectively evaluating the epidemiology and nature of such injuries. 100 successive referrals to the orthopaedic service as a result of roller/skate injuries were evaluated. Childs age, sex, time using apparatus, mechanism of injury, and whether the injury occurred in a dedicated skatepark or on the street was recorded. Whether the child was wearing any form of protective gear and what type was also recorded. The type of fracture and its treatment and follow up was evaluated. All results were recorded on standard excel spreadsheets and statistical analysis was performed using Instat statistics (Graphpad USA 2002). The Male to female ratio in street injuries was 1:1, whereas in ramp injuries 4:1. 60 injuries occurred on the street whereas 40 occurred whilst using the ramps. The mean age was 11.4yrs. The mean length of time using rollerblades/skateboards was 20 and 19 months for street and ramps respectively. The number of children wearing some form of protective gear shows only 20 children out of the 100 studied wore gear, of these 15 wore helmets only. The treatment initiated shows almost 80% of ramp related injuries required formal manipulation under general anaesthesia or open reduction and internal fixation, where as only 25% of street fractures required this form of treatment, The usage of ramps demonstrates an increased relative risk of 4.26 (95% CI 3.5–5.1) This study shows that skateboards and rollerblades still constitute a major component of childhood fracture admissions. Only 20% of children use some form of protective gear whilst skating, this needs to be addressed on a national level. The wearing of helmets whilst protecting the child against head injury do not prevent serious orthopaedic injuries. Wrist guards should be worn by all children skating as the fall onto outstretched hand still remains a childs defensive mechanism when thrown off balance. Almost 75% of all fractures involve the wrist or the forearm. We urge better education and a tighter supervision of children whilst skating. Dedicated skateparks should only be used by experienced and older children and they should at least be supervised during their first attempts at using the parks, 85% of ramp injuries occurred during first or second time users. A child using a skatepark particularily for the first time is three times more likely to sustain a fracture, and almost 4 and a half times more likely to require definitive surgical treatment of this fracture. This constitutes a huge orthopaedic burden as well as it’s associated morbidity and financial costs to the health service. Children should be encouraged to use limb protectors as well as helmets whilst skating and should be supervised more closely during their initial attempts.

A retrospective study was undertaken in our unit to investigate any change in osteomyelitis trends in the last ten years (1991-2001). These results were then compared to 3 previous studies conducted by our unit on childhood osteomyelitis, 1977-1979 45 cases(O’Brien et al)1, 1980-87 (84 cases) and 1988-1991 (54 cases).

149 patients were identified from hospital discharge database with a diagnosis of osteomyelitis between 1991 and 2001. 136 fully completed charts were discovered and included in the study. 22 children did not fulfil the criterion for the diagnosis of acute or subacute osteomyelitis and were excluded. Cellulitis was the actual diagnosis 18/22 cases, leukaemia or other neoplasm in 4/22 cases. 28% of the children 32/114 had acute haematog-enous osteomyelitis with classical signs and symptoms the remaining 72% fell into the subacute osteomyelitis category as described by Gledhill. Table 1 shows the comparison between the 4 studies.

89% of patients underwent 3 phase bone scanning, and 90% of these were positive. Blood cultures were performed in 87% of patients and were positive in 8.5%, 2 patients being positive and symptomatic of Nesseria meningitis, 4 Staph aureus, 2 Strep Pneumonia, 1 staph epidermidis and 1 E.Coli. As compared to previous 3 studies no case of haemophilus influenza type B was encountered. Aspiration was performed in 22 patients and 18 demonstrated bacteria, the two commonest pathogens were Staphylococcus aureus 66% and epider-midis 16%. 8 patients underwent surgical debridement or drilling if clinically septic or because of failure to improve despite medical treatment.

Initial antibiotic treatment comprised of i.v. penicillins and oral fucidin in 92% of patients, the remainder receiving cephalosporins as favoured by physicians or erythromycin if history of hypersensitivity. Antibiotics arethen tailored to clinical picture or culture results. Table 2 shows the changing duration pattern of antibiotic administration.

There were four cases of complications, 2 cases of chronic osteomyelitis and 2 cases of limb shortening both around the knee joint.

Our results correlate well with other authors. Surgery has an ever-decreasing role in the management of osteomyelitis, with conservative antibiotic management and splintage being the treatment of choice. Subacute osteomyelitis is an ever-increasing entity as reflected in other studies. The incidence of osteomyelitis presenting to our unit has fallen to 2.34 per 10000 per yea. A possible explanation may lie in altered host pathogen interactions, increased host resistance, the frequent administration of broad-spectrum antibiotics in general practice. Increased population wealth as experienced in Ireland in the last 8 years may also have a role.

The pathophysiology of discogenic low back pain is poorly understood. The morphological changes occurring in disc degeneration are well documented but unhelpful in determining if a particular degenerate disc will be painful or not.

Herniated intervertebral disc tisssue has been shown to produce a number of pro-inflammatory mediators and cytokines. No similar studies have to date been done utilising disc material from patients with discogenic low back pain.

The aim of this study was to compare levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and Prostaglandin E2 (PGE2) in disc tissue from patients undergoing discectomy for sciatica with that from patients undergoing fusion for discogenic low back pain.

Tissue from 50 patients undergoing discectomy for sciatica and 20 patients undergoing fusion for discogenic low back pain was cultured and the medium harvested for subsequent analysis using an enzyme linked immunoabsorbent assay method. Statistical analysis of the results was performed using the Mann-Whitney test.

Disc specimens from both experimental groups produced measurable levels of all three mediators. Mean production of IL-6, IL-8 and PGE2 in the sciatica group was 26.2±75.7, 247±573 and 2255±3974 respectively. Mean production of IL-6, IL-8 and PGE2 in the low back pain group was 92±154, 776±987 and 3221±3350 respectively (data = mean production pg/ml ± 1 standard deviation).

There was a statistically significant difference between the levels of IL-6 and IL-8 production in the sciatica and low back pain groups (p< 0.006 and p< 0.003 respectively).

The high levels of pro-inflammatory mediator production found in disc tissue from patients undergoing fusion for discogenic LBP may indicate that nucleus pulposis pro-inflammatory mediator production is a major factor in the genesis of a painful lumbar disc. This could explain why some degenerate discs cause LBP while other morphologically similar discs do not.

Acute haematogenous osteomyelitis remains a significant cause of morbidity in the paediatric population. The clinical presentation has changed, however, over the last number of decades. The typical picture of established osteomyelitis is less commonly seen. Children more often present with a less fulminant picture.

The treatment of acute haematogenous osteomyelitis remains controversial. Antibiotic therapy, initially intravenous, then orally, is the gold standard. Hover, the role of surgery is unclear. Some centres, particularly in North America treat 25–40% of patients surgically.

We present our experience with acute haematogenous osteomyelitis in children over a three year period. The total number of patients was forty-five. The mean age was 6.1 (range 6 months to thirteen years). The most common isolated organism was Staphylococcus Aureus. The mode of treatment was intravenous antibiotics for two weeks, or until clinical, and laboratory evidence of improvement, and the oral antibiotics for six weeks. No patients required surgical interventioin. All patients made a satisfactory recovery.

We conclude that the treatment of acute haematogenous osteomyelitis in the paediatric population should consist of antibiotic therapy only, and that there is no place for surgery.

We have reviewed 59 patients with injury to the spinal cord to assess the predictive value of the sparing of sensation to pin prick in determining motor recovery in segments which initially had MRC grade-0 power.

There were 35 tetraplegics (18 complete, 17 incomplete) and 24 paraplegics (19 complete, 5 incomplete), and the mean follow-up was 29.6 months. A total of 114 motor segments initially had grade-0 power but sparing of sensation to pin prick in the corresponding dermatome. Of these, 97 (85%) had return of functional power (≥ grade 3) at follow-up. There were 479 motor segments with grade-0 power but no sparing of sensation to pin prick and of these only six (1.3%) had return of functional power. Both of the above associations were statistically significant (chi-squared test, p < 0.0001).

After injury to the spinal cord, the preservation of sensation to pin prick in a motor segment with grade-0 power indicated an 85% chance of motor recovery to at least grade 3.

The transiliac method of leg lengthening uses a modification of Salter's innominate osteotomy. The bone graft increases the length of the hemipelvis distal to the sacro-iliac joint. Leg-length inequality in 23 patients was treated by this method with an average gain in length of 2.8 cm (2.0 to 3.5). Apart from one residual femoral nerve palsy there were no notable complications. The facility to redirect the acetabulum allowed by the technique, may be useful in cases of potential hip instability or acetabular dysplasia.

Seventy-seven children admitted with a provisional diagnosis of acute osteomyelitis over a three year period have been reviewed. Acute haematogenous osteomyelitis was confirmed in 45 of these patients whose ages varied from three days to 14 years with a mean of 6.2 years. All patients were treated with intravenous fusidic acid and cloxacillin with splintage for three weeks followed by oral antibiotics for a further period of six weeks. Only seven patients required operation. One patient had recurrence of infection; all other patients were cured with no evidence of chronic osteomyelitis. It is suggested that surgical drainage of acute haematogenous osteomyelitis is seldom needed and that high intravenous doses of antibiotics in combination with splintage are adequate treatment in most cases.