Child abuse is an essential discussion within society and poses many challenges. The international literature describes patient and family based risk factors and suspicious injuries. We have created a protocol for the identification and investigation of children with suspected non-accidental injuries. The paediatric orthopaedic ward experiences many children being delayed in the ward once fit for discharge. This study aimed to quanitify those delayed discharges and describe the demographics and risk factors for abuse within the local population.

After obtaining ethics clearance, we conducted a retrospective review of records from the Teddy Bear Clinic, as well as admission records. The study examined demographic characteristics, family, injury characteristics and referral to Child Welfare. The delay of discharge from hospital was quantified and was compared to those characteristics.

Records were collected from 1 January 2015 to 31 December 2021. Seventy-nine complete records were included. There were 40 males and 39 females with an average age of 20 months. 75.9% were under 36 months old. 94.1% of the cases sustained lower limb fractures. Fifty-two cases had a delayed discharge. The delay ranged from 1 to 233 days. There was an association between an age less than 36 months and delayed discharge. There were no significant correlations between caregiver characteristics and delayed discharge. The later the completion of investigations, the more likely there would be a delay. There was also a significant correlation between referral to Child Welfare and delayed discharge.

Children under 36 months on this remain at highest risk for non-accidental injury. Delayed discharge was associated with age less than 36 months, upper limb fractures and referral to Child Welfare.

Despite the delayed discharge, most children returned to the same home environments

Aims

Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures.

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

Background and Aims:

In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients.

Introduction:

Blount's disease can be defined as idiopathic proximal tibial vara. Several etiologies including the mechanical theory have been described. Obesity is the only causative factor proven to be associated with Blount disease.

Varus deformity is also a clinical feature of rickets and 31% of children with vitamin D deficiency rickets presented with varus deformities to the local Metabolic Bone clinics. The aim of this study is to assess if there is an association between vitamin D and Blount's disease. We hypothesize that children with Blount disease are more likely to be vitamin D deficient.

Introduction

Oral factor Xa inhibitors have recently been licensed for use as thromboprophylaxis in arthroplasty surgery. Phase IV trials have proven there efficacy in DVT/PE prevention with comparable rates in major adverse events, including major bleeding. We examined whether the introduction of rivaroxoban, an oral factor Xa inhibitor, increased total blood loss in patients undergoing primary arthroplasty surgery.

Aim: One of the issues of metatarsophalangeal joint (MTPJ) replacements is that they do not restore full range of movement (RO M). However, full RO M is not needed for functional walking. The aim of this study was to measure the difference between the functional and maximum ROM of the first metatarsophalangeal joint.

Materials & Method: The functional and maximum ROM of 32 MTPJs in 16 normal adults were measured with a video imaging system. The system first measured the ROM as the subject walked past the camera. It then measured the ROM as standing maximum extension tests were performed.

Results: During functional walking tests the mean ROM was 37.9 degrees (SD 12.2). During maximum standing extension tests the mean ROM was 64.9 degrees (SD 11.3). Therefore the functional walking ROM was only 58% of the maximum standing extension ROM, with a mean difference of 27 degrees. A paired t-test comparison showed P< 0.0001.

Discussion: MTPJ arthroplasty has previously been criticised because it does not restore full RO M. However, the results of this study suggest that the functional movements required in normal gait are significantly less than what can be maximally achieved in clinical standing extension tests. Therefore arthroplasty can be a suitable treatment if it can provide an adequate functional RO M.

Conclusion: The results of this study show that the functional range of movement required for walking is only 58% of the maximum extension ROM of the first MTP joint. Therefore, MTP joint replacements do not need to restore maximum extension, as normal gait can be achieved without this.

We present the early results of 36 primary total elbow arthroplasties using the Acclaim prosthesis. The Acclaim prosthesis was used in 46 primary total elbow arthroplasties between July 2000 and August 2002. All operations were performed or directly supervised by the two senior authors (IAT and JKS). There were 32 females and 14 males. The mean age at surgery was 64 years (range, 34–93). The underlying pathology was rheumatoid arthritis in 39, osteoarthritis in five and post-traumatic arthritis in two. The early results of 36 cases are presented at a minimum follow-up of two years. Patients were assessed using the American Shoulder and Elbow Surgeons patient self assessment form and the range of movement of the elbow measured. The Wrightington method was used for radiographic analysis of lucencies. There was good relief of pain and range of movement improved. The mean preoperative pain score was 8.1 and decreased to 2.1 at latest follow up. The mean disability score increased from 34.2 to 66.1. The mean overall satisfaction rating following surgery was 9.3 on a visual analogue scale from zero to ten. The mean range of flexion increased from 83^oto105^o. The mean flexion gain was just over 10^o and the mean extension gain was just over 12^o. There were 11 cases of intraoperative fracture of the humeral condyle. One of these fractures failed to unite and required revision to a linked prosthesis because of persistent instability. There was one case of deep infection. There were three cases of ulnar neuropathy, one of which resolved. There was no evidence of loosening. The Acclaim total elbow arthroplasty gives good symptomatic relief and improvement in function according to the American Shoulder and Elbow Surgeons patient self assessment form. These early results are encouraging but the frequency of intra-operative fractures is of some concern.

The aim of this study was to establish the consensus of opinion amongst trauma surgeons for the management of displaced supracondylar fractures of the humerus in children.

We carried out a postal questionnaire involving 130 orthopaedic surgeons with an interest in paediatric trauma. They were identified as being members of the British Society for Children’s Orthopaedic Surgery.

We received a response rate of 65%. One third of respondents believe that in uncomplicated fractures, reduction should occur within 6 hours of injury and one half felt that ‘pulseless’ fractures should be treated in the same time frame. 60% said they would explore a pulseless arm after midnight, but only 20% would reduce and stabilise uncomplicated fractures. 82% of surgeons stabilise displaced grade III fractures with K wires, of these, the majority would use a‘crossed’ configuration. If after stabilisation the arm remained pulseless, only 16% said they would explore the brachial artery immediately, 23.5% would seek a vascular opinion and 60.5% of surgeons would observe for 24 hours. If the arm remained pulseless but pink after 24 hours, the majority of surgeons would continue to observe and rely on collateral circulation for distal perfusion.

The majority of surgeons would stabilise displaced supracondylar fractures as soon as possible but not after midnight unless the arm was pulseless. If the hand remained pink but pulseless, most felt that continued observation beyond 24 hours was acceptable.

We compare the management and outcome of two management stratergies for the perfused but pulseless hand following stabilisation of grade III supracondylar fractures in children.

For this study we looked at 15 patients treated in two centres (all treated by the senior author) between 1995 and 2004. The patients were designated to group I if the pulseless hand had been observed or group II if they underwent immediate exploration. Data collected included time to surgery, neurological deficit, time to return of pulse and subsequent symptoms of forearm claudication. All patients were seen at week 1,3 and followed for at least 6 months post surgery. Radiographs were reviewed to determine the adequacy of reduction of the fracture.

The mean age of patient was 3.8 years. Median time to surgery was 6 hours. 6 children had evidence of anterior interosseus nerve palsy. 12 cases were reduced anatomically, 3 had minimal fracture gap. Of the 8 patients in group I (observation) 2 had secondary exploration and one developed claudication symptoms. All had palpable radial pulse at 3 months.6 of the 7 patients in group II (exploration) were seen to have brachial artery tethering, 2 with median nerve entrapment. 5 of them had subsequent return of radial pulse within 24 hours.

Satisfactory radiological reductionof the fracture does-not exclude vessel or nerve entrapment. We would advocate early exploration of the artery if the pulse does not return within 24 hours.

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function.

No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%).

In the 40 years since Smith and Robinson described the anterior approach to decompress and fuse the cervical spine, generally acceptable clinical results have been reported though few papers include any form of detailed outcome assessment. More recently Snyder and Bernhardt have described an anterolateral disc-preserving approach to treat cervical radiculopathy that does not entail vertebral artery exposure. We describe our experience of this procedure.

Surgery was performed on 40 patients ( 21 male, 19 female, mean age 41 years). Functional outcome was assessed by the Neck Disability Index (NDI), return to usual work status, patient subjective satisfaction rating, and by standard VAS. Radiographic evaluation was performed looking at the following parameters: neutral films – maintenance of interbody disc height/diameter ratio R and degree of kyphosis/lordosis: dynamic films – degree of movement maintained at operated motion segment.

At an average follow up of 20 months(range 6 – 36) the mean NDI had fallen from 45% to 10% .Mean neck pain score was 2 (pre op was 7), average arm pain score 1 (pre op was7). 93% of patients had returned to work, 85% to their original occupation at an average of 11 weeks. Patient satisfaction scores were: 85% very satisfied, 5 % satisfied, 5% unsatisfied and 5% very unsatisfied. Radiologically it was possible to preserve intervertebral body disc height and motion in some patients whilst others lost some height and motion. A minority fused spontaneously.

ACFID is associated with clinical functional outcome scores comparable with those reported in the literature for alternative procedures. Bone graft donor site morbidity is avoided and radiological results show that preservation of useful motion at the operated disc is possible.