Introduction

We present a single surgeon series of 20 modified Dunn osteotomies without surgical dislocation of the femoral head for slipped upper femoral epiphysis (SUFE).

Introduction

Paediatric hip fracture accounts for less than one percent of paediatric fractures. Previous studies report complication rates between 20 and 92%.

Introduction: Approximately 5% of grade III supracon-dylar fractures are associated with vascular compromise. Following closed reduction and K wire stabilisation 60% of childrens surgeons in UK would adopt a policy of observation providing the hand is well perfused. We have retrospectively compared 2 groups of patients to determine whether observation or exploration leads to the best outcome.

Materials and Methods: Over a 7 year period 18 patients were identified with pulseless pink hands. Management following reduction and K wire fixation was at the discretion of the admitting consultant. 10 Patients were managed expectantly and 8 patients had immediate exploration of the vessel.

Results: Of 10 patients managed by observation, 3 had secondary exploration of the vessel and one patient has developed forearm claudication. Although a palpable radial pulse was present in all cases by 3 months it had returned within 24hrs (suggesting spasm of the artery) in only 3 patients.

In 6 of 8 primarily explored brachial arteries the vessel was observed to be tethered to the fracture site.

Following release, in 6 of 8 cases the radial pulse had returned within 24hrs. Satisfactory radiological reduction of the fracture does not preclude vessel entrapment.

In 8 cases there was an associated median nerve palsy. All of these cases were found to have an anatomical obstruction to the brachial artery.

Conclusions: In the majority of cases absent pulse is due to vessel entrapment. Long term perfusion of the forearm is due to collateral circulation. Providing a near anatomical reduction is achieved observation for 24 hours would seem reasonable course of action. If the pulse has not then returned further imaging (arte-riograme/MRA) may be advisable. If there is associated nerve palsy immediate exploration is warranted

Aim: To propose new guidelines in the management of supracondylar fractures treated by percutaneous Kirschner wires.

Subjects and Method: We audited 62 children with displaced, unstable supracondylar fractures of the humerus, which were fixed with Kirschner wire over a period of 2 years. The fractures were classified according to the Wilkins modification of the Gartland system. 10% were type II and 90% type III. The protocol followed was that all unstable fractures that required closed or open reduction must be stabilised with Kirschner wires of adequate thickness used in a crossed configuration and supplemented with back slab. They were then followed up mostly weekly, often with multiple check X-rays until 3 weeks, and for wire removal at 3 weeks. The parameters studied are level of surgeon, adequacy of intra operative reduction, re operation rate, adequacy of intra operative X-rays, out of hour operations, number of post operative X-rays, number of follow ups and any complications.

Results:

Two patients had re operation because of poor intra operative reduction which were performed by junior grade surgeon without supervision during out of hours.

Conclusions: Unnecessary radiation can be avoided by obtaining adequate intra operative X-rays and avoiding check X-ray as no fracture had displaced at follow up. New guidelines proposed: 1. Patients with no N-V complications can wait till the morning trauma list. 2. All intraoperative X-rays to be reviewed by consultants before discharging home. 3. 3 weeks appointment for wire removal can be set at one week clinic follow up with out X-ray.

Aim: To propose new guidelines in the management of supracondylar fractures treated by percutaneous Kirschner wires

Subjects and Method: We audited 62 children with displaced, unstable supracondylar fractures of the humerus, which were fixed with Kirschner wire over a period of 2 years. The fractures were classified according to the Wilkins modification of the Gartland system. 10% were type II and 90% type III. The protocol followed was that all unstable fractures that required closed or open reduction must be stabilised with Kirschner wires of adequate thickness used in a crossed configuration and supplemented with back slab. They were then followed up mostly weekly, often with multiple check X-rays until 3 weeks, and for wire removal at 3 weeks. The parameters studied are level of surgeon, adequacy of intra operative reduction, re operation rate, adequacy of intra operative X-rays, out of hour operations, number of post operative X-rays, number of follow ups and any complications.

Results:

Two patients had re operation due to poor intra operative reduction which were performed by junior grade surgeon without supervision during out of hours.

Conclusions: Unnecessary radiation can be avoided by obtaining adequate intra operative X-rays and avoiding check X-ray as no fracture had displaced at follow up.

New guidelines proposed:

Patients with no N-V complications can wait till the morning trauma list.

Introduction and Aims: The appropriate duration of antibiotic therapy in children suffering from acute haematogenous osteomyelitis (AHO) and acute septic arthritis (SA) has not been clearly established by clinical trials. In recent years there has been a tendency to shorter courses of both intravenous and oral therapy, but evidence is currently limited as to the efficacy of short duration antimicrobial therapy. .

Method: This study was conducted in two phases.

A retrospective study of 71 children in which we investigated the duration of both intravenous and oral antimicrobial therapy in relation to recurrent disease and side effects.

Results: Duration of antibiotics in the retrospective study varied from two to 28 days with a median duration of 4.5 days. Duration of the oral phase of antibiotic therapy varied from two to 10 weeks with a median value of 4.7 weeks. The recurrence rate, requiring admission or an additional operative procedure was 1.4%. There were no long-term sequelae.

In the prospective study the duration of intravenous and oral antibiotics has been successfully reduced in the majority of patients, without any increase in the need for surgical procedures, re-admission or evidence of chronic osteomyelitis. However, in 26% of patients, the duration of the IV phase of antibiotic therapy was electively increased, because of clinical signs, suggestive of inadequate response. To date recurrent/chronic disease has only been seen in patients judged clinically to have an inadequate response to short-term therapy and who received a longer course of IV antibiotics.

Conclusion: Shorter courses of antimicrobial therapy in children with acute haematogenous osteomyelitis and acute septic arthritis, are safe and effective with a low incidence of recurrent disease. However clinical judgment is required to identify those children who require longer courses of both intravenous and oral therapy in order to eradicate the disease during the primary presentation. Further study is required to identify with greater certainty the profile of children who require longer courses of therapy than the emerging standard, three weeks IV/three weeks oral.