Aim

Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome.

Aim

Fractures are the second commonest presentation of non-accidental injury (NAI) in children. Approximately one third of abused children will present to Acute Trauma Services (ATS) with fractures. Any cases of suspected child maltreatment should be referred to Safeguarding Services for follow-up, as outlined by Trust Guidelines. Our aim was to examine the referral of children with suspicious fractures to safeguarding and assess if cases with high risk of abuse are being missed by ATS.

Aim: To present the features and management of Pyogenic myositis in children.

Method: Two boys of four and six years old presented to our hospital within 6 months. The initial presentation suggested septic arthritis of the hip with pain, pyrexia and limited hip movements. Serum inflammatory markers were significantly raised. Hip rotation, however, was not severely reduced when examined carefully. Neither case demonstrated an effusion on ultrasound of the hip joint. The diagnosis was made on magnetic resonance imaging which produced striking images. Staphylococcus aureus was isolated from blood cultures in each case.

Results: Both children settled with antibiotic treatment alone. The bacterial strain in the second case was of a type requiring combination antibiotic therapy for effective treatment.

Conclusions: Pyogenic myositis is not a common diagnosis in previously healthy children presenting with hip pain. It is a condition that has been reported more frequently recently and which should have a higher profile since it is probably under-diagnosed. Urgent magnetic resonance imaging is recommended for atypical cases of musculoskeletal infection in children. Care must be taken to prescribe antibiotic therapy appropriate to the particular bacterial strain.

Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simulated transverse fractures of synthetic composite bones.

Methods: Steel and titanium nails (3mm diameter) were individually used in pairs of divergent configuration to study torsion, cantilever bending (anteroposterior and lateral), and axial loading properties of adolescent synthetic composite tibiae model (10mm diameter). Properties of the intact bone, simulated fresh fracture with nails and simulated healing fracture with nails were studied. Instron 4303 universal testing machine was used to study axial loading. Applying fibreglass layers around the fracture with epoxy resin simulated fracture healing with callus formation.

Results: Steel and titanium nails maintained good alignment of fracture fragments. Both the nails demonstrated very poor stability of fresh fractures in torsion loading. Steel nail/bone construct was 57% stronger than Titanium nail/bone construct under similar testing conditions during fracture healing (p< 0.05) but still < 50% stiffness of intact bone. In bending tests, both types of nails showed < 10% of the stiffness of intact bone in fresh fractures (p< 0.05). Mediolateral stiffness was better than anteroposterior stiffness. In fracture healing, the bending stiffness of both types of nail/bone constructs was > 50% that of intact bone. Axial stiffness of both nails was more than bending or torsion stiffness implying that fracture fragments play a significant role in the stability of the fracture.

Although both types of nail/bone constructs demonstrated similar stiffness results in fresh and healing fractures, steel nails performance was statistically better than Titanium nails in all loading tests (p< 0.05).

Conclusion: Fractures fixed with either type of flexible nails should be supplemented with splints or plaster for a short duration until callus formation. Flexible nails should be used with caution in comminuted fractures, over weight patients since they may not provide adequate stability or allow early mobilization. Additional research with cadaver bones may provide further insight into the performance of the flexible nails.

Introduction: Controversy continues over the value of routine ultrasound hip screening and the question of whether the outcome of hips with dysplasia detected by ultrasound can be improved with treatment. Graf describes a group of infants in whom ultrasound demonstrates a hip that is in joint and centred yet severely dysplastic. These are classified as Grade 2c and are important because, although they may be clinically stable on presentation, they are at risk of progressing to dislocation.

Method: Cases were identified in which failure to recognize and/or treat Grade 2c hips lead to subluxation or dislocation of the joint. They were collected from centres where neonates had ultrasound examination of the hip as part of a selected screening program.

Results: Eight cases from four UK centres, showing deterioration in untreated Grade 2c hips. All were identified on retrospective Graf grading. Five patients underwent open reduction.

Discussion: The Graf method of hip ultrasound examination has not been widely accepted in the UK. Some authors believe that stable dysplastic hips will correct with growth and that treatment confers no specific advantage. However, an advantage of Graf’s method is that it can detect the centred, frequently ‘stable’ hip that will deteriorate in time; the Grade 2c hip. These cases illustrate the importance of recognising and appropriately managing this group of patients who will account for a proportion of late presenting cases of DDH.

Introduction: Children are inevitably casualties in wars. They are treated variously by local doctors and foreign surgeons working for military and Non-Governmental Organisations. The basic principles of surgical treatment of war wounds are the same as for adults, but there are specific differences in injury pattern and the response to injury that must be borne in mind.

Method: Casualties under sixteen years age with extremity trauma caused by missiles or blast admitted to a British military field hospital during the latest Gulf War were evaluated. The date, time and method of wounding were recorded and ICRC Wound Scores calculated. The details of surgical treatment prior to admission, and further surgical management described. Case studies were used to illustrate particular considerations relevant to paediatric trauma.

Results: The records for sixteen wounded children were available for analysis. Their ages ranged from three to fifteen years. The method of injury falls into three phases, gun-shot wounds during the mobile attack, shell fragment wounds during the seige of urban areas and blast/fragment injuries from small munitions from the period following active fighting. Blast/fragment wounds typically affected multiple body areas.

Half the patients had received surgical treatment before reaching the hospital, either at civilian hospitals, forward military surgical units or both. None of this surgery was strictly “life or limb-saving”. Amputations performed prior to admission were in the proximal tibia and followed the long posterior flap pattern appropriate to an adult amputation for vascular disease regardless of the level of injury. Several had primary closure of war wounds. After admission, four patients required plastic surgical procedures, two had ophthalmic surgery, one had a laparotomy and one had a facial reconstruction procedure in addition to surgery for extremity trauma. One child with fragment wounds was undergoing treatment for acute lymphoblastic leukaemia.

Conclusion: A military hospital must be prepared to treat children during war-time. Multi-system injury patterns are common and require multidisciplinary care. When possible children should be transferred to a facility with specialist care available for primary surgery. The effects of injury and treatment on future growth should be given more consideration.