This study addresses a crucial gap in the knowledge of normative spinal growth in children. The objective of this study is to provide detailed and accurate 3D reference values for global and segmental spinal dimensions in healthy children under the age of 11. Radiographic spine examinations of healthy children conducted to rule out scoliosis were reviewed in four scoliosis referral centers in North America. All consecutive children aged three to eleven years old with EOS biplanar good quality x-rays, but without diagnosed growth-affecting pathologies, were included. Postero-Anterior and Lateral calibrated x-rays were used for spine 3D reconstruction and computation of vertebral body height and spine length. Median and interquartile range were calculated from cross-sectional data. Smooth centiles growth curves for 3D True Spinal Length (3DTSL) between T1 and S1, as well as for mid-vertebral heights of T5, T12 and L3, where fit and calibrated from data using the Lambda-Mu-Sigma method (GAMLSS package for R). This method automatically selects the best performing distribution from a familly of choices. Tables of centiles were then predicted from the computed models for selected ages. A total of 638 full spine examinations from asymptomatic patients were reconstructed in 3D, 397 in girls and 241 in boys. Medians and interquartile ranges were calculated for 3DTSL (T1-S1): 285 (24) mm, 314 (26) mm and 349 (31) mm, and for selected vertebral heights T5: 10 (1) mm, 11 (1) mm and 12 (1) mm, T12: 13 (2) mm, 14 (1) mm and 16 (2) mm, and L3: 14 (1) mm, 16 (2) mm and 18 (2) mm, respectively for the 3–6, 6–8 and 8–11 age groups. Centile curves ready for clinical use of the 3DTSL (T1-S1) and of the vertebral heights of T5, T12 and L3 as a function of age were derived for the 5, 10, 25, 50, 75, 90 and 95th centiles. In general, boys presented linear relationships between spinal dimensions and age, and girls presented more diverging trends with increased variance for older ages. Accordingly curves for boys follow the Normal distribution whereas those for girls follow the original Box-Cox-Cole-Green distribution. Model diagnostic tests (normally distributed residuals, adequate wormplots and |Z statistics| < 2) confirmed adequacy of the models and the absence of significant misfit. Accurate reference values were derived for spinal dimensions in healthy children. Spinal dimension charts showed that the spinal lengths and vertebral heights changed relatively constantly across the age groups closely resembling WHO total body height charts. The reference values will help physicians better assess their patients' growth potential. It could also be used to predict expected spinal dimensions at maturity or changes in pathologic conditions as well as to assess the impact of growth friendly interventions in the correction of spinal deformities

In orthopaedic oncology surgical precision is important and intraoperative imaging is often necessary. CAS may enhance precision and provide continuous 3D imaging without radiation. The goal of this work is to report our experience with CAS.

Since 2006 we used CAS (Stryker) in 26 patients with a bone tumour: 11 chondrosarcomas, three osteosarcomas, seven osteochondromas and five miscellaneous. Twelve lesions were located in the femur, six in the pelvis, five in the lower leg and three in the upper extremity. In 18 cases a tumour was excised, in six of these a prosthesis was placed. In eight cases a curettage was done. In 23 cases the navigation was image-based (CT and/or MRI based) and in three cases image-less (no image-preparation necessary preoperatively).

CAS was successfully employed in 23 cases. In three cases the procedure was aborted. In two cases, both in the ulna, we were unable to reconstruct the exact dimensions and in one case (image-less) the tracker was to far away from the work-field. There were no complications related to CAS. Mean precision is 0.5 mm. The time CAS takes is about 15 minutes during the procedure (7–60). In the eight curettages it proved helpful. We did not measure radiation time. In the six resections were tumour-prostheses were placed it was really helpful in rotation and length determination. In three of these, image-less navigation was performed (all distal femur). In osteochondroma resections it is helpful in four of seven cases. All surgical margins were adequate in the resections; after curettage, all MRI controls at three months did not show residual tumour. Oncology follow-up is too short yet; there was one local recurrence after two years in a parosteal osteosarcoma.

We conclude that CAS can be our navigator in orthopaedic oncology; it is successful in providing precision and continuous 3D imaging. The indication area needs further study.

Objectives. The development of tibiofemoral angle in children has shown ethnic variations. However this data is unavailable for our population. Methods. We measured the tibiofemoral angle (TFA) and intercondylar and intermalleolar distances in 360 children aged between two and 18 years, dividing them into six interrupted age group intervals: two to three years; five to six years; eight to nine years; 11 to 12 years; 14 to 15Â years; and 17 to 18 years. Each age group comprised 30 boys and 30 girls. Other variables recorded included standing height, sitting height, weight, thigh length, leg length and length of the lower limb. Results. Children aged two to three years had a valgus angulation with a mean TFA of 1.8° (. sd. 0.65) in boys and 2.45° (. sd. 0.87) in girls. Peak valgus was seen in the five- to six-year age group, with mean TFAs of 6.7° (. sd. 1.3) and 7.25° (. sd. 0.64) for boys and girls, respectively. From this age the values gradually declined to a mean of 3.18° (. sd. 1.74) and 4.43° (. sd. 0.68) for boys and girls, respectively, at 17 to 18 years. Girls showed a higher valgus angulation than boys at all age groups. Conclusion. This study defines the normal range of the TFA in south Indian boys and girls using an easy and reliable technique of measurement with a standardised custom-made goniometer. Cite this article: Bone Joint Res 2013;2:155–61

Background. Surgical treatment of AIS includes several purposes such as arrest deformity progression through a solid fusion, obtain a permanent correction of the deformity and others. Objectives. To evaluate the improvement of sagittal spinopelvic parameters and clinical outcomes in patients with adolescent idiopathic scoliosis 2 years after corrective surgery. Methods. Radiological and clinical data of 134 consecutive scoliosis patients including 11 boys and 124 girls with the average age of 15.37 years, with AIS Lenke 1, 2, 3, 4, 5 or 6 were included in this retrospective study with 2-year follow-up. Whole spine anterior/posterior and lateral Xray, CT scan and MRI were taken preoperatively, immediately after surgery, at 3 months and 2 years after corrective surgery. Radiological parameters were evaluated and compared pre and post operatively. Result. In coronal plan, significant reduction was observed in main curve, proximal curve and distal curve P<0.001, 2 years after corrective surgery. Meanwhile, the translation of apex vertebra decreased p<0.001. But sagittal profile of the patients did not show obvious changes such as LL, TK. The pelvic parameters indicated that PI was 50.6 degrees, PT was 13.8, SS was 37.0 and TPA was 47.5 degrees preoperatively. Vertebral body height increased dramatically just after surgery and showed further in the last follow up. Conclusion. The changes in coronal plan was significant 2 years after correction surgery for AIS patients and were not correlated with restoration of sagittal profile. Conflict of interest. None. Sources of funding. None

Introduction. The management of pathologic fractures (PF) following osteomyelitis (especially acute subtype) has not been widely investigated. This is challenging due to the infection-induced destructive process causing bone architecture defects. Therefore, this study aims to assess a stepwise treatment plan for the acute incidence of PF in long bone following pediatric acute Hematogenous osteomyelitis(AHO) (the most common mechanism in children). Method. This case series was conducted in a tertiary pediatric center. Patients with fracture incidence within the first 10 days after AHO diagnosis were included. Patients’ characteristics were retrospectively reviewed. Result. Nine patients (7 boys, involved bone: the femur(4), tibia(3), Radius(1), and Ulna(1)) were included, with a mean age of 52.56±66.18 months (7-216) and a follow-up time of 11.62±3.61 years (6.5-16 years). The etiology in all patients was hematological(Methicillin-resistant Staphylococcus aureus). Our stepwise treatment plan was as follows:. 1. Intravenous antibiotics until ESR<20, then oral to ESR<5. 2. Debridemnt surgery was performed if abscesses were detected. 3. Fracture type determined initial fixation: external fixation (4 patients, 2 unions) or casting (2 patients, both unions). 4. If the union was not obtained, internal fixation (with (2 patients) or without (2 patients) bone graft) was applied (all obtained union). 5. Circular external fixation was applied if the union was not obtained or leg length discrepancy occurred (1 case). A mean of 3.2 surgical procedures (1-6) was required to control the infection, and 1.4 surgical procedures (0-4) were required to obtain union. Except for one patient who died of septic shock, all other patients (88.8%) reached complete recovery (average length of hospital stay of 19.2 days (5-35).), and the union was obtained (the average union time of 17.25 months(4-36)) without long-term sequelae of osteomyelitis. Conclusion. The outcome of the stepwise plan in this study suggests that acute PF following AHO in pediatrics can be managed efficiently

Background. The advent of EOS imaging has offered clinicians the opportunity to image the whole skeleton in the anatomical standing position with a smaller radiation dose than standard spine roentgenograms. It is known as the fifth modality of imaging. Current NICE guidelines do not recommend EOS scans over x-rays citing: “The evidence indicated insufficient patient benefit in terms of radiation dose reduction and increased throughput to justify its cost”. Methods. We retrospectively reviewed 103 adult and 103 paediatric EOS scans of standing whole spines including shoulders and pelvis for those undergoing investigation for spinal deformity in a tertiary spinal centre in the UK. We matched this against a retrospective control group of 103 adults and 103 children who underwent traditional roentgenograms whole spine imaging at the same centre during the same timeframe. We aimed to compare the average radiation dose of AP and lateral images between the two modalities. We utilised a validated lifetime risk of cancer calculator (. www.xrayrisk.com. ) to estimate the additional mean risk per study. Results. In the Adult EOS Group (AEG) the mean estimated effective dose of AP was 0.08 mSv (0.04–0.15) and Lateral 0.06 mSv (0.03–0.14). Conversely in the Adult Roentgenograms Group (ARG) the mean AP was 0.49 mSv (0.15–1.88) and Lateral was 0.29 mSv (0.07–1.20). In the Paediatric EOS Group (PEG): the mean dose of AP was 0.07 mSv (0.02–0.21) and Lateral 0.04 mSv (0.02–0.11). Conversely Paediatric Roentgenograms Group (PRG) had a mean dose in AP of 0.37 mSv (0.03–5.92) and in lateral of 0.17 mSv (0.03–0.44). The percentage differences were: ARG:AES AP 613%, ARG:AES Lat 483%, PPG:PEG AP 529%, PRG:PEG Lat 425%. Mean difference 513%. The additional lifetime cancer risk for AEG was 1 in 176056 for males and 1 in 138696 for females, compared to ARG 1 in 31596 for males and 1 in 24894 for females. In PEG that was 1 in 58207 for boys and 1 in 33367 for girls, compared to PRG 1 in 11860 for boys and 1 in 6797 in girls. Differences in additional lifetime risk of cancer per scan: ARG:AES Male 557%, Female 557%, PRG:PEG Male 491%, Females 491%. Conclusion. Standard plain film imaging of the whole spine requires approximately five-times higher doses of radiation compared to dual planar EOS scans. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in both children and adults. There is approximately 5-fold increase in risk of cancer for all groups with roentgenograms over EOS. We directly challenge the NICE guidance and recommend EOS dual planar imaging in favour of plane roentgenograms for investigation of spinal deformity

Introduction. Hip dysplasia is the most common congenital deformity of the musculoskeletal system. This is a pathology that brings the hip joint from subluxation to dislocation. Frequency of hip dysplasia − 16 children per 1000 newborns. Materials and Methods. Diagnostic methods of research are X-ray inspection which is necessarily carried out at internal rotation (rotation) of an extremity as lateral rotation of a hip on the radiograph always increases an angle of a valgus deviation of a neck. Surgical treatment is performed in the subclavian area of the femur. An external fixation device is applied and a corrective corticotomy is performed, and valgus deformity and anteversion are eliminated. The duration of treatment is 2.5–3 months. Results. Frequency of hip dysplasia − 16 children per 1000 newborns. We perform about 30 operations a year, including 60% girls and 40% boys. In addition, valgus deformity can be traced -. - in cerebral palsy. - after polio. - at progressing muscular dystrophies. - tumor in the area of the epiphyseal cartilage. At insufficient stability in a hip joint at insufficiently expressed roof of an acetabulum of rotational deformation of a neck of a hip, for prevention of a coxarthrosis and normalization of a ratio of articular ends operation detorsion-varying subvertebral corticotomy of a femur is shown. Conclusions. The operation is minimally invasive, with accesses of 5–6 mm, anatomical and topographical features are taken into account, which will eliminate damage to tissues, nerve trunks and the circulatory system

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

Objectives. The aim of the current study was to assess whether calcaneal broadband ultrasound attenuation (BUA) can predict whole body and regional dual-energy x-ray absorptiometry (DXA)-derived bone mass in healthy, Australian children and adolescents at different stages of maturity. Methods. A total of 389 boys and girls across a wide age range (four to 18 years) volunteered to participate. The estimated age of peak height velocity (APHV) was used to classify children into pre-, peri-, and post-APHV groups. BUA was measured at the non-dominant heel with quantitative ultrasonometry (QUS) (Lunar Achilles Insight, GE), while bone mineral density (BMD) and bone mineral content (BMC) were examined at the femoral neck, lumbar spine and whole body (DXA, XR-800, Norland). Associations between BUA and DXA-derived measures were examined with Pearson correlations and linear regression. Participants were additionally ranked in quartiles for QUS and DXA measures in order to determine agreement in rankings. Results. For the whole sample, BUA predicted 29% of the study population variance in whole body BMC and BMD, 23% to 24% of the study population variance in lumbar spine BMC and BMD, and 21% to 24% of the variance in femoral neck BMC and BMD (p < 0.001). BUA predictions were strongest for the most mature participants (pre-APHV R. 2. = 0.03 to 0.19; peri-APHV R. 2. = 0.05 to 0.17; post-APHV R. 2. = 0.18 to 0.28) and marginally stronger for girls (R. 2. = 0.25-0.32, p < 0.001) than for boys (R. 2. = 0.21-0.27, p < 0.001). Agreement in quartile rankings between QUS and DXA measures of bone mass was generally poor (27.3% to 38.2%). Conclusion. Calcaneal BUA has a weak to moderate relationship with DXA measurements of bone mass in children, and has a tendency to misclassify children on the basis of quartile rankings. Cite this article: B. K. Weeks, R. Hirsch, R. C. Nogueira, B. R. Beck. Is calcaneal broadband ultrasound attenuation a valid index of dual-energy x-ray absorptiometry-derived bone mass in children? Bone Joint Res 2016;5:538–543. DOI: 10.1302/2046-3758.511.BJR-2016-0116.R1

Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery. Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013. 62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy). Echocardiography data were available for 68 procedures. Echo revealed a median left ventricular (LV) shortening fraction (SF) of 29% (range: 7–44). 34% of boys (23/68) had abnormal SF <25%, 48% (31/65) showed dyskinesia and 22% (14/64) had LV dilatation. CMR was routinely performed on 35 patients. Of those who underwent CMR, median left ventricular ejection fraction (LVEF) was 52% (range: 27–67%), 71% of boys (25/35) had dyskinesia. Echocardiography shortening fraction (SF) correlated significantly with CMR LVEF (r. s. = 0.67; p<0.001). Increasing severity of dyskinesia on CMR correlated with reduced CMR LVEF (r. s. = −0.64; p<0.001) and reduced echo SF (r. s. = −0.47; p = 0.004). Although functional echocardiography and CMR data tended to correlate in 35 DMD boys who underwent both imaging modalities nine (26%) had discrepant results. Seven (20%) had evidence of dysfunction on CMR (LVEF < 55%) not detected on echocardiography (SF ≥ 27%); in two cases echocardiogram measured worse function than CMR. Based on multi-disciplinary risk assessment, surgery was considered too high risk in 23 out of 67 (34%) cases. In 21 cases (91%) this was due to underlying cardiomyopathy. The highest risk among older boys assessed for spinal surgery; 21 out of 43 (49%). Of 19 boys undergoing spinal surgery, six (32%) experienced complications: two wound infections; three patients required readmission to intensive care; one patient died in the post-operative period with acute heart failure

Aims. Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018. Methods. Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed. Results. Data were extracted from the clinical records of 32 children diagnosed with Perthes’ disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period. Conclusion. The results of this case review demonstrate a variation of care provided to children in the UK with Perthes’ disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes’ disease. Cite this article: Bone Joint Open 2020;1-11:691–695

Background: Slipped capital femoral epiphysis (SCFE) is an important orthopaedic problem which emerges in early adolescence. Not clearly identified factors in the growth zone of proximal femur produce slip in which the femoral head remains in the acetabulum and femoral shaft rotates outwards and backwards. This occurs usually in one but occasionally in both hips. As we assumed that in Department of orthopaedic surgery in Ljubljana half of Slovenian adolescent population with SCFE was treated, we could calculate epidemiological data for SCFE for whole Slovenian population. Patients and Methods: In retrospectively study we analysed patients treated operatively at Department of orthopaedic surgery in Ljubljana between 1.1.1970 and 31.12.2006. The data about sex, age and side of the slips were collected. We calculated average age at occurance, ratio boys to girls, and predominance of left or right side. For determination of SCFE incidence in Slovenia, we used the attack rate method which is the sum of annual incidences of SCFE in age interval when the slips occur calculated for each one-year group. Results: There were 224 patients, 126 boys and 98 girls presenting with SCFE between 1970 and 2006 treated in Department of orthopaedic surgery in Ljubljana. The average age of boys was 12.9 and the age of girls 11.6 years (range: 8–16 years). On the average the age was 11.3 years. Slipped capital femoral epiphysis appeared more frequently on the left side (58%) than on the right side (31%). In 11% of cases the slips were bilateral. Incidence per 1000 adolescents extrapolated to Slovenian population (attack rate method) was 0,796 ‰ for boys, 0,667 ‰ for girls and 0,734 ‰ for entire endangered population. Yearly incidence of SCFE was thus 0,089 ‰ for boys and 0,073 ‰ for girls. Discussion: Epidemiological data for SCFE in Slovenia are comparable to those found in Sweden and is difficult to compare with other countries, where different statistical methods were used. Risk of getting SCFE in critical period for boys is 1:1265 and for girls: 1:1499. Risk for whole critical population is 1:1362. It is interesting that our study showed marked increase in the number of boys with SCFE in recent years. Boys to girls ratio has changed from 1:1 in years 1970 to 1994 (Zupanc in sod. 2002) to 1,29:1 in our study

The Acetabular Index and the Physeal Angle of the proximal femur are a radiographic assessment of the morphology of the acetabulum and the proximal physis, respectively. Their values to decrease with age and it remains unknown whether any correlation exists between them or if weightbearing has any influence. X-rays belonging to 30 infants (60 hips), 4 boys and 26 girls, were studied between 2003 and 2006, measuring the Acetabular Index (AI) and the Femoral Proximal Physeal Angle (PPA). Measurements were taken using a goniometer (error ± 1°). All the cases had ultrasound scans at 4 months of age, with alpha angles smaller than 50° (Graf type IIa) and cephalic coverage between 33% and 50%. Anteroposterior hip X-rays were taken at 3 months (pre-weightbearing) and 4–10 months (post-weightbearing). Statistics: t-Test and correlation. The AI was 21.5° (19.5° boys, 21.8° girls) pre-weightbearing and 20.9° (20.8° boys, 21° girls) post- weightbearing. The PPA was 76.5° (75.9° boys, 76.6° girls) pre-weightbearing and 74.9° (75.5° boys, 74.8° girls) post-weightbearing. AI and PPA decreased pre- and post- weightbearing, 2′8% and 2′1% respectively. The decrease was considered significant in the PPA (p = 0.02), especially in girls (p = 0.009), and not significant in the IA. Differences were found between sexes: the AI increased in boys (+6.3%) and decreased in girls (−8.3%), and the PPA decreased in both boys (−0.5%) and girls (−2.3%). The side had no influence. No relevant correlation was found between AI and PPA, both pre- (r = − 0.15, p = 0.27) and post- weightbearing (r = − 0.24, p = 0.07). We did not find any relevant correlation between IA and PPA values, neither previous to weightbearing, nor in the months after weightbearing occurs. The measured angles suffered a decrease after weightbearing but the only significant decrease was in the PPA

Introduction: Previous studies have reported controversial associations between exercise and neck or shoulder pains in adolescents. In this study we evaluated the relationships between physical activity or sedentary activities and neck or occipital pain (NOP) or shoulder pain (SP) in a representative sample of adolescents. Methods: The study population consisted of adolescents belonging to the Northern Finland Birth Cohort 1986 (n=5993). Associations of physical activity level, total sitting time, and different kinds of sedentary activities with NOP and SP were analyzed at 15–16 years of age using logistic regression. “Reporting NOP and SP” (not seeking medical help) and “Consultation for NOP and SP” were assessed separately in girls, but were combined in boys because of low prevalence of “Consultations”. Results: Almost half of the girls and one third of the boys reported NOP or SP, and 5% of girls and 2% of boys reported “Consultation for NOP or SP” during the past six months. High level of physical activity associated with increased prevalence of both “Consultation for NOP” and “Consultation for SP” in girls, but not in boys. Prolonged sitting was associated with high prevalence of NOP and SP in girls, and NOP in boys. Of various sedentary activities, TV watching and reading books associated with NOP in girls, whereas playing or working with a computer associated with NOP in boys. In girls, TV watching also associated with “Reporting SP”. Discussion: Both prolonged sitting and high level of physical activity seem to be related to NOP and SP among adolescents

Introduction: The values of Q angle in a child’s knee cover a wide range. Frequently its extreme values are responsible for complaints or the appearance of some pathological conditions( e.g. chondromalacia, recurrent dislocation of patella etc). Material and Methods: The Q angle has been measured in both lower limbs of 1955 children aged 7–12 (1017 boys and 938 girls). Cases of children with a history of previous fractures on lower limbs or major orthopedic or neurological disorders have been excluded. Eighty one per cent of children have had the right foot as their prominent one, the 14.8% of children have had the left foot as their prominent one, and the 4.2% of children have had no difference between their limbs. Results: For the children aged 7–8, the values of Q angle have been measured to range from 11.30±7.4 degrees in left limb to 11.52±7.4 degrees in right limb in boys, while in girls they ranged from 11.05±7.2 to 11.20±6.9 respectively. For the ages 9–10, the values ranged from 11.30±7.8 degrees in left limb to 11.38±7.2 degrees in right limb in boys, while in girls they ranged from 11.02±7.7 to 11.51±7.1 respectively. For the ages 11–12, the values of Q angle ranged from 11.72±8.8 degrees in left limb to 11.56±8.3 degrees in right limb in boys, while in girls they range from 11.87±8.3 to 12.06±8.4 respectively. There has been no difference between the right and left lower limbs in all ages and both sexes. There has been no difference between the boys and girls in both lower limbs in all ages. As girls are growing up the Q angle is increasing in both lower limbs ( P< 0.01), whereas boys have no difference in their limbs while they are growing up. Children with their prominent right limb have performed increased Q angle in both lower limbs( P< 0.05). Regarding boys, the more Bone Mass Index (BMI) has been increased, the more the Q angle has been decreased ( P< 0.001). Conclusion: We conclude that in children aged 7–12, the Q angle 1) frequently appears increased values, 2) performs no difference between both lower limbs, and 3) has negative correlation with BMI in boys

Background. The pattern of appearance of secondary ossification centers in the elbow has been based on historical studies and is popularly referred to with the mnemonic CRITOL. However the six secondary ossification centers can be variable in their presentation and pose a challenge in assessment of children with elbow injuries. Furthermore limited studies available in the current literature have reported an aberration to the sequence of appearance especially with the ossification centers of trochlea and olecranon. Aims. The aim of the study was to evaluate the relative sequence of appearance of secondary ossification centers for the trochlea and olecranon. Methods. Children between 8 and 10 years of age who had radiographs of elbow following trivial trauma between July 2013 and Feb 2015 were identified using the hospital PACS database. Cases with radiographic markers of significant trauma ie. fat pad sign, displaced fracture were excluded. Anteroposterior and lateral views of elbow were reviewed for the presence of the six ossification centers. Results. A total of 114 radiographs were reviewed of which 51 were boys and 63 were girls with a mean age of 9.03 years (±0.59). 60 radiographs were of right elbow and 54 were of the left elbow. The capitulum, radial head and medial epicondyle ossification centers were present in all patients. Both trochlea and olecranon ossification centers were noted in 51/114 (44.7%) children. 12/114 (10.5%) of the children were noted to have trochlea ossification center with no olecranon ossification center. Of these 12 children 7 were boys and 5 were girls. On the other hand 19/114 (16.7%) of the children had an olecranon ossification center but without a trochlea ossification center. Amongst these 7 were boys and 12 were girls. Discussion and Conclusions. The results of this limited cross sectional study demonstrate that the CRITOL sequence may not followed in 16.7% of cases and more so in girls. Historical studies were based on conventional radiographs. However the current digital radiographs with image enhancement tools help in accurate identification of relatively small ossification centers which may not be apparent on conventional radiographs. The current study has helped to quantify the violators to CRITOL sequence. Level of Evidence. Level III (Cross-sectional study among non-consecutive patients)

Aims. The Ponseti method is an effective evidence-based treatment for clubfoot. It uses gentle manipulation to adjust the position of the foot in serial treatments towards a more physiological position. Casting is used to hold the newly achieved position. At first, the foot resists the new position imposed by the plaster cast, pressing against the cast, but over time the tissues are expected to adapt to the new position and the force decreases. The aim of this study was to test this hypothesis by measuring the forces between a clubfoot and the cast during treatment with the Ponseti method. Patients and Methods. Force measurements were made during the treatment of ten idiopathic clubfeet. The mean age of the patients was seven days (2 to 30); there were nine boys and one girl. Force data were collected for several weeks at the location of the first metatarsal and the talar neck to determine the adaptation rate of the clubfoot. Results. In all measurements, the force decreased over time. The median (interquartile range) half-life time was determined to be at 26 minutes (20 to 53) for the first metatarsal and 22 minutes (9 to 56) for the talar neck, suggesting that the tissues of the clubfoot adapt to the new position within several hours. Conclusion. This is the first study to provide objective force data that support the hypothesis of adaptation of the idiopathic clubfoot to the new position imposed by the cast. We showed that the expected decrease in corrective force over time does indeed exist and adaptation occurs after a relatively short period of time. The rapid reduction in the forces acting on the foot during treatment with the Ponseti method may allow significant reductions in the interval between treatments compared with the generally accepted period of one week

Introduction. Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. Materials and Methods. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed. Results. The mean age at surgery was 13 years (range, 9–14). The mean body weight was 43.3 kg (range, 30–66). There were five mid-shaft fractures, one proximal third and one distal third. There were Four type A fractures, two type B and one type C. Four patients had road traffic accidents while three had direct trauma. The mean preoperative haemoglobin concentration 12.5 g/dl (range 11.3–13 g/dl). No blood transfusion was needed intraoperatively or postoperatively. The operative time averaged 122 minutes, and the mean hospital stay was one (range 1–4 days). The patients reported no pain at a mean of 1.5 weeks (range, one-three weeks). All fractures united at a mean of 8.7 weeks (range 6–12 weeks). No wound healing problems nor deep infections happened. The knee joint range of motion was full in all patients at six weeks postoperatively. There was no mechanical irritation from the inserted plate. At the final follow-up, all fractures united without malalignment nor length discrepancy. Conclusions. External fixator-assisted internal fixation of pediatric femoral fractures would facilitate the accuracy and control of fracture reduction and allow minimally invasive percutaneous osteosynthesis. Our study has shown a decrease in operative time, and an accompanying reduction in length of inpatient stay, prolonged need for analgesia and post-operative rehabilitation

Nachemson (1996), drawing upon the theses of Sahlstrand (1977) and Lidström (1988), articulated the view there are more girls than boys with progressive AIS for the following reason. The maturation of postural mechanisms in the nervous system is complete about the same time in boys and girls. Girls enter their skeletal adolescent growth spurt with immature postural mechanisms – so that if they have a predisposition to develop a scoliosis curve, the spine deforms. In contrast boys enter their adolescent growth spurt with mature postural mechanisms so that they are protected from developing a scoliosis curve. There is evidence that postural sway improves with age in boys and girls until about 10 years of age after which it is similar between the sexes (Hirashawa 1973, Odenrick and Sandstedt 1984) findings which need further evaluation. We term Nachemson’s concept the neuro-ossesous timing of maturation (NOTOM) hypothesis. It may have an evolutionary basis through natural selection towards sexual and skeletal development during adolescence being earlier in girls and later in boys. The NOTOM hypothesis suggests a treatment to prevent progression of late-juvenile idiopathic scoliosis, early-AIS, and some secondary scolioses based on delaying the onset of puberty used therapeutically in girls with idiopathic precocious puberty (IPP, Grumbach and Styne 1998). The proposal is to administer a gonadorelin analogue which in the pituitary down-regulates the receptors to hypothalamic gonadotropin-releasing hormone (GnRH) causing a fall in both luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which in turn causes a fall in oestrogens and androgens, and thereby delays or stops menarche and slows bone growth – as in girls and boys with IPP (Galluzzi et al 1998). Expert scrutiny of this therapeutic proposal is currently in progress

Abstract. Objective. To assess the prevalence of acetabular retroversion in patients presenting with Slipped Upper Femoral Epiphysis using both validated radiological signs and CT-angle measurements. Methods. A retrospective review of all cases involving surgical management for acute SUFE presenting to the Royal Children's Hospital, Melbourne were assessed from 2012–2018. Pre-operative plain radiographs were assessed for slip angle, validated radiological signs of retroversion (post wall/crossover/ischial spine sign) and standardised post-operative CT Scans were used to assess cranial and mid-acetabular version. Results. 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 females and 60 boys, with an average age of 12.7 years (range 7.5–16.6 years). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. 82% patients underwent pinning in situ (PIS) with subcapital realignment surgery (SRS) performed in 18% (slip angles >75°). Contralateral prophylactic hip PIS was performed in 72 patients (87%). On the slip side, 68% of patients had 1 or more radiological signs of retroversion in the slipped hip, with 60% on the contralateral side. The mean cranial and mid-acetabular version measurements were −8°(range −30 – 8°) and 10.5°(range −10 – 25°), respectively. Conclusions. Acetabular retroversion is rare in the normal population with studies reports ranging from 0–7%. This study showed an increased prevalence of 68% in SUFE patients, which is likely to be a primary anatomical abnormality, subsequently increasing the shear forces across the proximal femoral growth plate due to superior over-coverage. The resulting CAM lesion from SUFE in combination with the pincer lesion due to retroversion can lead to premature hip impingement and degeneration. Further larger studies are required to assess if acetabular retroversion is a true risk factor, and its role in helping guide management including prophylactic pinning. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project