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.

Aims:

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

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)

The aim of this study is to assess the long-term results of Ethibloc (Ethnor Laboratories/ Ethicon, Norderstedt, Germany) injection in aneurysmal bone cysts (ABC).

33 patients with aneurysmal bone cysts were treated with computed tomographic (C.T) guided percutaneous injection of Ethibloc into the cyst cavity. 22 patients had Ethibloc injection as primary treatment and 11 patients had presented to us with recurrence following previous procedures including steroid injection, bone marrow injection, curettage bone grafting and various other surgical procedures. The mean follow-up was 54 (22-90) months.

Symptoms were relieved in all patients. 2 patients were lost to follow up. 18 (58%) of the 31 patients followed, had complete resolution of the lesion, 11 (35.5%) patients had partial healing (asymptomatic residual non progressive lytic areas). 2 (6.5%) patients showed recurrence in the proximal humerus during the follow-up. They are under follow-up but asymptomatic. 2 patients encountered more significant complications after the procedure.

Ethibloc injection is a relatively simple, minimally invasive alternative procedure for the treatment of ABC, and makes open operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of ABCs excluding spinal lesions as shown by this long-term follow-up study.

Aims

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

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.

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.

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.

Purpose of Study: To present the clinical features, investigations, histopathology, differential diagnosis and treatment options for lipoblastoma, based on a series of six encountered in our paediatric orthopaedic practice.

Method: The records of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006 were reviewed. Mean age was 17 months and mean follow up was 26 months.

Results: The youngest was a six month old infant with a swelling on his right instep. The second patient, a three year old girl, 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. The fourth patient had a swelling of his left thigh and two patients had swellings in their backs. Each was investigated by MRI (1), CT (1) or US (4) and surgical excision planned accordingly. There were no post operative complications. None has shown recurrence during follow-up.

Conclusions: All patients were originally thought to have simple lipomata or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour, yet lipoblastoma is the most likely diagnosis of a fatty lump in a child aged less than two. Differential diagnoses include myxoid liposarcoma, well-differentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.

Lipoblastomata need thorough imaging. Cytogenetic evaluation of tumour cells often reveals chromosomal anomalies, such as abnormalities of the long arm of chromosome 8 leading to rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended for accurate diagnosis, as clinical and radiological diagnoses can be misleading.

Lipoblastomata tend to spread locally and may recur after incomplete resection; metastatic potential has not been reported. Complete surgical resection is mandatory to prevent recurrence.

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 : 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 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: 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.

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.

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.