Long-term functional outcomes following paediatric traumatic elbow dislocation, a clinical retrospective cohort study.

BACKGROUND: Paediatric traumatic elbow dislocation occurs in 6 per 100,000 children per year and if not treated promptly can result in a poor outcome. Despite this, the long-term clinical and functional outcome of these injuries has not been well described using modern patient-reported outcome tools. The aim of our study was present the outcome of these injuries in the long term. METHODS: Twenty children with an acute traumatic elbow dislocation who presented between February 2007 to February 2016 were included in our study. Patient demographics, management and complications were recorded from the clinical notes. Ten children had associated fractures and were managed surgically, while the remaining were managed with closed reduction and immobilisation. Functional outcomes were assessed with Kim's elbow performance score. RESULTS: The mean age was 12 years (7 -15) and follow-up was 8 years (4 - 13). There was one (5%) re-dislocation requiring surgery and one (5%) ulna nerve neurapraxia that resolved within one month. The average Kim's scores were 87.5 (65 - 100) and 77.5 (60 - 100) in the closed reduction and open reduction groups, respectively (P=0.08). 80% (16/20) reported good or excellent outcome with a Kim's score of greater than 75 points with no cases of poor functional outcome reported in our series. CONCLUSIONS: Traumatic elbow dislocations in children, with or without associated fracture, have a good long-term functional outcome with appropriate early management.

The treatment of neonatal hip dysplasia with splints in the United Kingdom: time for consensus?

PURPOSE: To understand the variation in the management of hip dysplasia identified from the United Kingdom neonatal selective screening programme. METHODS: Having been designed and tested by the research committee of the British Society for Children's Orthopaedic Surgery (BSCOS), a nationwide online survey was conducted of BSCOS members to ascertain their treatment strategies for neonatal hip dysplasia. RESULTS: There were 111 responses (60% of members), which illustrated wide variation in care. In all, 91 (over 80%) of respondents treat more than ten cases per year, yet only 61 (55%) work to an agreed protocol. A total of 90 (81%) use the Graf classification and 103 (93%) use the Pavlik harness initially. Consensus is lacking in key areas including duration of harness use, hours per day, clothing and weaning. Importantly, notable differences of opinion even exist regarding which hip pathologies need treatment. CONCLUSION: This study quantifies the wide variation in many key elements of the initial treatment of neonatal hip dysplasia in the United Kingdom. This variation appears unnecessary and unacceptable as the Getting It Right First Time programme seeks to standardize care pathways. The charitable sector has called for consensus to mitigate parental anxiety, and it has been suggested that this could allow better integration of hip dysplasia into national screening pathways. Standardized care benefits patients and represents the platform from which we can begin understanding effectiveness and optimizing outcomes. LEVEL OF EVIDENCE: Level V.

Osteofibrous Dysplasia of the Tibia in Children: Outcome Without Resection.

BACKGROUND: The proposed association between osteofibrous dysplasia and adamantinoma has led some to advocate resection of the entire lesion, which can require major subsequent reconstruction. However, this link remains unproven and there is some support in more recent literature for a less aggressive approach. This study aims to describe our experience managing pediatric tibial osteofibrous dysplasia with such an approach and to report functional outcomes in children treated thus. METHODS: A total of 28 cases of osteofibrous dysplasia in 25 patients were managed at a referral center for pediatric bone tumors with observation in the first instance, then limited surgical intervention if required to address pain and deformity. Surgery aimed to restore stability and alignment without excising the lesion. Clinical records provided basic clinical outcome measures involving walking, recreation, orthoses and school/work participation and patients provided a Musculoskeletal Tumour Society score (MSTS) where contactable. RESULTS: Mean age at presentation was 6.0 years and mean follow-up was 8.3 years. Only 8 patients required surgery. According to basic outcome measures, 13 patients were symptom-free. About 15 patients (17 cases) provided a MSTS and the mean score was 24 of 30. No transformation to adamantinoma was observed. Those who presented at a younger age and with bilateral disease more often required surgery and remained symptomatic. CONCLUSIONS: A less aggressive approach to pediatric tibial osteofibrous dysplasia achieves good functional outcomes and patient satisfaction in most cases. Surgery is required in the minority of cases. Transformation to adamantinoma was not observed in this series. We recommend patient education, clinical observation and reactive intervention if required, rather than proactive resection and reconstruction. LEVEL OF EVIDENCE: Level IV-case series.

Universal versus selective ultrasound screening for developmental dysplasia of the hip: a single-centre retrospective cohort study.

A total of 28 068 infants were studied to investigate whether universal ultrasound screening for developmental dysplasia of the hip results in fewer delayed presentations than selective screening, and whether the screening protocol affects subsequent treatment. The rate of delayed presentation was not lower with selective screening compared with universal screening but all cases of delayed presentation in this cohort were administrative errors. There were no sonographic errors (false-negatives). The treatment rate was significantly higher with universal screening but infants were treated earlier and were significantly less likely to require any surgical intervention. Those requiring surgery were less likely to require open reduction or pelvic osteotomy.

The effect of regional trauma networks on paediatric trauma care in an integrated adult service.

OBJECTIVE: Our study analyzes the impact of becoming a major trauma centre (MTC) on paediatric trauma workload in a centre outside a major city without specialist paediatric surgical services. METHODS: Paediatric 'trauma calls' presenting between 1 April 2010 and 31 March 2013 were retrospectively reviewed. As our centre became an MTC on 1 April 2012, our study population was split into 'pre-MTC' and 'post-MTC' groups. Patient demographics, mechanism of injury, patient outcome, Injury Severity Score and results of radiological investigations were recorded. RESULTS: There were 132 paediatric trauma calls, with a 72% annual increase post-MTC. More children with minor injuries, according to the Injury Severity Score, were seen post-MTC (47.5 vs. 29.6%). Although the proportion of patients undergoing a CT scanning remained static, the actual number increased and a higher proportion were normal in the post-MTC group (72.9 vs. 52.4%). This contributed to a higher proportion of patients being discharged home directly from the emergency department post-MTC (47.5 vs. 36.6%). Practice moved away from targeted CT scanning, in favour of trauma scanning post-MTC. CONCLUSION: The implementation of a regional trauma network has led to a rise in paediatric trauma cases. Paediatric trauma patients tend to be less severely injured, but the proportion undergoing CT scanning has remained the same, and these scans are more likely to be normal. A more rational approach for imaging of paediatric trauma patients is required to reduce the potentially harmful effects of exposure to ionizing radiation, and criteria for implementing trauma calls in children should be reconsidered.

Staged weaning versus immediate cessation of Pavlik harness treatment for developmental dysplasia of the hip.

Outcomes of nonoperative treatment for developmental dysplasia of the hip were compared between two centres. Eighty children in Centre A underwent staged weaning of the Pavlik harness once three consecutive weekly ultrasounds showed Graf Grade I hips, whereas in 48 children in Centre B, the harness was removed immediately. No statistically significant difference was found in the rate of reintervention (repeat harness treatment, closed or open reduction), avascular necrosis or acetabular index between the two methods, although there was a nonsignificant trend towards higher reintervention rate and lower avascular necrosis rate with immediate harness removal. Age at start of treatment significantly impacted upon initial harness success, reinterventions and avascular necrosis.

Injuries in Elite Men's Lacrosse: An Observational Study During the 2010 World Championships.

BACKGROUND: There are limited data on injuries sustained during men's lacrosse. As the sport gains popularity, practitioners will be more likely to treat lacrosse players. PURPOSE: To analyze data from the 2010 World Lacrosse Championships. STUDY DESIGN: Descriptive epidemiology study. METHODS: This was a prospective observational study of injuries reported during the 2010 World Lacrosse Championships. An injury surveillance questionnaire was completed, and data were categorized into body part injured, diagnosis, mechanism, and time of injury. RESULTS: Over 9 days, 667 players from 29 countries competed in 105 games. A total of 150 injuries were sustained by 129 individuals aged 16 to 46 years. Five times more injuries occurred during games than in training (69.3% [n = 104] vs 13.3% [n = 20]; rate ratio [95% CI] = 5.2 [4.9-5.5]), resulting in 39.5 injuries per 1000 hours played. The most frequent mechanism was contact (53.3%; n = 80), including direct impact with another player (30%; n = 45), with a stick (16.7%; n = 25), or with a ball (5.3%; n = 8). Change of direction and/or speed were the most common noncontact mechanisms (27.3%; n = 41). The most frequently reported injuries were contusions (32.0%; n = 48), sprains (22.7%; n = 34), and strains (22.7%; n = 34). The lower limb was the most injured body part (50.7%; n = 76) compared with the upper limb (23.3%; n = 35; rate ratio [95% CI] = 2.2 [2.1-2.3]). The ankle was the most injured joint (14.0%; n = 21), followed by the shoulder (10.0%; n = 15). CONCLUSION: As participation expands, health professionals may become more responsible for treating lacrosse players. Players are susceptible to a range of injuries. Familiarity with the common injury patterns could help treatment and prevention. Despite differences in rules during international competition, this study corroborates reports from North America. CLINICAL RELEVANCE: The epidemiology of men's lacrosse injuries needs to be documented and understood to effectively prevent injuries. The 2014 World Championships are to be held in Denver, Colorado (July 10-19, 2014), and it is important that practitioners treating players are aware of the differences in the international game. Publication of these data will allow for those planning lacrosse tournaments to do so more effectively.

Assessment of cup orientation in hip resurfacing: a comparison of TraumaCad and computed tomography.

PURPOSE: The orientation of the acetabular component in metal-on-metal hip resurfacing arthroplasty affects wear rate and hence failure. This study aimed to establish if interpretation of pelvic radiographs with TraumaCad software can provide a reliable alternative to CT in measuring the acetabular inclination and version. METHODS: TraumaCad was used to measure the acetabular orientation on AP pelvis radiographs of 14 painful hip resurfacings. Four orthopaedic surgeons performed each measurement twice. These were compared with measurements taken from CT reformats. The correlation between TraumaCad and CT was calculated, as was the intra- and inter-observer reliability of TraumaCad. RESULTS: There is strong correlation between the two techniques for the measurement of inclination and version (p <0.001). Intra- and inter-observer reliability of TraumaCad measurements are good (p <0.001). Mean absolute error for measurement of inclination was 2.1°. TraumaCad underestimated version compared to CT in 93% of cases, by 12.6 degrees on average. CONCLUSIONS: When assessing acetabular orientation in hip resurfacing, the orthopaedic surgeon may use TraumaCad in the knowledge that it correlates well with CT and has good intra- and inter-observer reliability but underestimates version by 12° on average.

A vast increase in the use of CT scans for investigating occult hip fractures.

BACKGROUND: Early diagnosis in neck of femur fractures has been shown to improve outcome. The National Institute for Clinical Excellence recommends if an occult hip fracture is suspected then an MRI should be performed and if not available within 24h a CT should be considered. At our centre, emergency MRI is rarely available and so CT is commonly used. OBJECTIVES: Our study aims to analyse the trends in CT use over a five year period for the diagnosis of neck of femur fractures. METHODS: Both the number of patients with a hip fracture and those undergoing a CT hip to diagnose an occult injury were identified across two district general hospitals between 2006-2007 and 2010-2011. The time from initial radiograph to CT and initial radiograph to operation were calculated. RESULTS: In 2006-2007, of 547 hip fractures, 20 CT hips were performed and 6 reported as a fractured neck of femur (30%). In 2010-2011, of 499 hip fractures, 239 CT hips were performed and 65 fractures were recognised (27%). The mean time from radiograph until CT scan was 2.0 days in 2007 and 3.2 days in 2011, which was a statistically significant difference (p<0.001). For those diagnosed using a CT scan the mean time from admission X-ray to surgery was 1.2 days in 2007 and 3.6 days in 2011. CONCLUSION: Clinicians are becoming increasingly reliant on CT for the diagnosis of hip fractures with our data suggesting further imaging is one factor that can delay time to diagnosis and theatre.

Developmental dysplasia of the hip.

The close interaction between community practitioners and young families provides an invaluable opportunity for prevention, education, support and even diagnosis in cases of developmental hip dysplasia. This article provides a brief overview of the condition, including clinical findings, screening protocols, 'hip safe' practices, and common treatments that may be encountered in the community.

Single-bone fixation of paediatric diaphyseal both-bone forearm fractures: a systematic review.

Unstable paediatric diaphyseal both-bone forearm fractures that fail conservative management are usually treated with fixation of both radius and ulna. This systematic review aimed to establish if single-bone fixation achieves results comparable to both-bone fixation and which bone should be fixed and by what method. A systematic review of the published literature was performed, searching Medline for English language studies that reported functional or radiographic outcome following single-bone fixation of either bone by any method. Eight studies met the inclusion criteria (Level of Evidence III or IV). Three studies compared single- with both-bone fixation, showing comparable functional and radiographic outcomes. Redisplacement of the radius fracture is common following fixation of the ulna, particularly with intramedullary K-wires. Flexible nails achieve better results than K-wires in intramedullary stabilisations. Outcome is good following radius fixation with plating or nailing. Plating achieves good results in either bone. Few complications are seen when the second bone was left unfixed only if reduced and stable. Single-bone fixation achieves results comparable to both-bone fixation. Fixing the radius rather than the ulna provides better outcome, regardless of the method. The second bone should only be left unfixed if reduced and stable intra-operatively.

Functional outcome following direct repair or intervertebral fusion for adolescent spondylolysis: a systematic review.

A systematic review of the literature was performed to establish whether direct repair of the pars defect or intervertebral fusion achieves better Oswestry Disability Index scores in adolescent spondylolysis or low-grade spondylolisthesis. Nine studies fulfilled the inclusion criteria, reporting a minimum total of 80 direct repairs and 108 fusions because of presumed replication of data between studies. Little statistically or clinically significant difference could be established between the two interventions. The only comparative study showed improved long-term outcome with fusion. Further well-designed prospective comparative studies are required to establish the optimum treatment for this condition.

Functional outcome following intramedullary nailing or plate and screw fixation of paediatric diaphyseal forearm fractures: a systematic review.

PURPOSE: Unstable paediatric diaphyseal both-bone forearm fractures requiring fixation have traditionally been treated with rigid internal fixation with plate and screws. Intramedullary stabilisation has grown in popularity over the last 25 years but may be associated with rotational deformity and subsequent loss of pronosupination. This systematic review aims to establish which treatment method provides better functional outcome. METHODS: A systematic review of the published literature was performed, searching Medline, Embase, Pubmed and the Cochrane Library for English-language studies comparing intramedullary nailing with plate and screws in patients less than 18 years old with both-bone diaphyseal forearm fractures. RESULTS: Seven studies met the inclusion criteria. They were all retrospective comparative studies (level III or IV). One was age- and sex-matched. Three looked specifically at older children. No study reported a significant difference in functional outcome with either treatment. CONCLUSIONS: The currently available literature shows no difference in functional outcome between intramedullary nailing and plate and screw fixation, even in older children with less remodelling potential. Intramedullary nailing may therefore be the treatment of choice for simple fracture patterns due to shorter operative time, better cosmesis and ease of removal. Plating may still have a role in more complex injuries.

The diagnostic accuracy of magnetic resonance imaging and ultrasonography in gluteal tendon tears--a systematic review.

Gluteal tendon tears are one of the many pathologies causing pain around the greater trochanter that are often labelled as trochanteric bursitis. We systematically reviewed the peer-reviewed literature to establish the accuracy of magnetic resonance imaging and ultrasonography in the diagnosis of gluteal tendon tears in patients with persistent lateral hip pain or Greater Trochanteric Pain Syndrome (GTPS). 7 studies met the inclusion criteria, comparing either imaging modality with a reference standard of surgical findings. Included studies were assessed for methodological quality using the QUADAS checklist. MRI had sensitivity of 33-100%, specificity of 92-100%, positive predictive value of 71-100% and negative predictive value of 50%. False-positives were common. High signal located superior to the trochanter had a stronger association with tears. Ultrasonography had a sensitivity of 79-100% and positive predictive value of 95-100%. The amount and quality of literature on the subject is limited and further well-designed studies are required to establish the optimum diagnostic strategy in this condition. Ultrasonography may prove to be the investigation of choice, despite requiring a skilled practitioner. The orthopaedic surgeon should liaise with an experienced musculoskeletal radiologist to best investigate and diagnose gluteal tendon tears in the clinical picture of GTPS.

Outcome in 36 elderly patients treated with the Gamma3 Long Nail for unstable proximal femoral fracture.

The results of a series of 36 elderly patients with proximal femoral fracture distal to the intertrochanteric line treated with the third generation long Gamma nail are presented. Outcome was comparable with the second generation nail in terms of 1-year mortality, length of stay, surgical complications and re-operation rate. No patients required reoperation for construct failure. Medical complications and reduction in post-operative function were relatively high in an elderly population with significant pre-existing comorbidities but 3 in 4 were independently mobile on discharge from the acute orthopaedic unit. Charlson Comorbidity Index > 5 on admission is identified as a predictor of increased mortality. The Gamma 3 Long Nail is shown to be a suitable implant for the treatment of these fractures. Little tangible benefit of this nail's new instrumentation is seen, with similar operative time to its predecessor, and more units of blood transfused.

The factors associated with prolonged inpatient stay after surgical fixation of acute ankle fractures.

In order to identify specific factors associated with prolonged inpatient stay following surgical correction of acute ankle fracture, we conducted a retrospective cohort study of patients who underwent acute ankle fracture repair, comparing length of hospital stay to the reason for delay of surgery (logistical versus clinical), type of fracture, and age. Our findings showed that delay in surgical repair beyond 24 hours following presentation to the emergency department was associated with a statistically significant overall longer length of stay, in comparison to patients who underwent surgery within the first 24 hours (P = .022). Delay due to clinical reasons statistically significantly increased the length of stay (P = .004), whereas those due to purely logistical reasons also prolonged the stay, although this association was not statistically significant in our study (P = .086). We also observed a statistically significant positive correlation between age and length of stay (P