The aims of this study were i) to see if there is an association between poorly applied plasters and redisplacement of paediatric forearm fractures, and ii) to define reliable radiographic measurements to predict redisplacement of these fractures. The two radiographic measurements which were assessed were Cast Index and Padding Index which are a guide to plaster moulding and padding respectively. The sum of these was termed as the Canterbury Index. Case records and radiographs of 142 children who underwent a manipulation for a displaced fracture of forearm were studied. Angulation, translation displacement, Cast index and Padding index were measured on radiographs. Redisplacement was seen in 44 cases (32.3%). The means and 95 % Confidence intervals for cast index and padding index were 0.87 (0.84, 0.90) and 0.42 (0.39, 0.62) in the redisplacement group whereas were 0.71 (0.69, 0.72) and 0.11 (0.09, 0.12) in the group with no redisplacement respectively. Initial displacement, Cast index, Padding index and Canterbury Index were significantly greater in the redisplacement group (p< 0.005). No statistically significant difference was seen for age, fracture location, initial angular deformity and seniority of the surgeon. We suggest that Cast Index > 0.8, Padding Index > 0.3 and Canterbury Index > 1.1 are significant risk factors for redisplacement of conservatively treated paediatric forearm fractures

In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown. A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student t-tests and Fisher's exact tests for continuous variables. During the pandemic period, ED visits for orthopaedic trauma decreased compared to pre-pandemic levels by 23% (1370 vs 1790 patients) and operative treatment decreased by 28% (283 vs 391 patients). There was a significant decrease in the number of operative cases per day in lockdown Stage 1 (1.25 pandemic vs 1.90 pre- pandemic; p < 0 .001) and Stage 2 (1.65 pandemic vs 3.03 pre-pandemic; p< 0.001) but no difference in operative case number during Stage 3 (2.18 pandemic vs 2.45 pre-pandemic; p=0.35). Significant differences were found in MOI and AL during Stage 1 (p < 0 .001) and Stage 2 (p < 0 .001) compared to pre-pandemic. During Stage 1 and 2, playground injuries decreased by 95% and 82%, respectively; sports injuries decreased by 79% and 13%, and trampoline injuries decreased 44% and 43%, compared to pre-pandemic. However, self-propelled transit injuries (bicycles/skateboards) increased during Stage 1 and Stage 2 by 67% and 28%, respectively compared to pre- pandemic. During lockdown Stage 3 there were no differences in MOI nor AL. There were no significant differences in injury severity in any lockdown stage compared to pre-pandemic. COVID-19 lockdown measures significantly reduced the burden of operative paediatric orthopaedic trauma. Differences in volume, mechanism and pattern of injuries varied by lockdown stage offering evidence of the burden of operative trauma related to specific childhood activities. These findings will assist health systems planning for future pandemics and suggest that improvements in safety of playgrounds and self-propelled transit are important in reducing severe childhood injury requiring operative intervention. For any figures or tables, please contact the authors directly

Introduction. The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children. Materials & Methods. A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for. Results. There were 17 cases, in 15 patients, in our case series where calcium sulphate synthetic bone graft was used. The average patient age was 12.0 years (range 5 years – 17 years). Indications for use included likely infection (12), possible infection (3), and 2 elective finger cases (enchondroma and osteotomy). The humerus was the most common target site (5), followed by the femur (4), tibia (3), calcaneum (2), finger (2) and metatarsal (1) also included. There were positive intra-operative microbiology samples for eleven cases (Staphylococcus aureus and Staphylococcus epidermidis). Antibiotics were used in all cases except the elective finger surgery, and choice ranged between vancomycin, gentamicin, or a combination of both. Two patients required return to theatre for management of ongoing deep infection, although one case was later deemed to be non-infective osteomyelitis. Seven patients had undergone debridements prior to the definitive one with calcium sulphate (5 without Calcium Sulphate, 2 with Calcium Sulphate). Three patients experienced wound issues in the form of discharge/leakage, all were managed with dressings and did not require return to theatre. Conclusions. Calcium Sulphate synthetic bone graft, with addition of antibiotics, is an efficacious treatment in the paediatric population and is not associated with any major complications. Wound discharge should be observed for, and patients/parents warned about this, but only as per the adult population

Introduction. Hip arthrodiastasis for paediatric hip conditions such as Perthes disease is growing in popularity. Intended merits include halting the collapse of the femoral head and maintaining sphericity by minimising the joint reaction force. This can also be applied to protecting hip reconstruction following treatment of hip dysplasia. Our aim was to assess functional outcomes and complications in a cohort of paediatric patients. Materials and Methods. A retrospective single-surgeon cohort study was performed in a University teaching hospital from 2018–2021. Follow-up was performed via telephone interview and review of patient records. Complications, time in frame and functional scores using the WOMAC hip score were recorded. Results. Following review, 26 procedures were identified in 24 patients. Indications included 16 cases of Perthes disease, 4 following slipper upper femoral epiphysis, 3 avascular necrosis, and single cases following infection, dysplasia and a bone cyst. Pre-treatment WOMAC scores averaged 53.9, improving to 88.5 post-removal. Pin site infections were encountered in 11 patients, all treated with oral antibiotics. Two patients required early removal of frame due to pin loosening. Average time in frame was 3.9 months. Conclusions. This series displays how hip arthrodiastasis can be used to manage paediatric hip conditions. Complex reconstructions may be required in patients with severe deformity following perthes disease, DDH or SUFE. The use of arthrodiastasis in these patients aims to protect the reconstruction and potentially improve outcomes. A dedicated team of specialist nurses, physiotherapists and psychologists are crucial to the treatment program

Patellofemoral instability (PFI) is a common cause of knee pain and disability in the paediatric population. Patella alta, lateralised tibial tubercle, medial patellofemoral ligament (MPFL) deficiency, genu valgum and trochlear dysplasia are well known risk factors. A prospective database was created including patients referred through our physiotherapy pathway following first-time patella dislocation. Patella alta and lateralisation of the tibial tuberosity was treated with a Fulkerson-type tibial tubercle osteotomy(TTO). Medial patellofemoral ligament was reconstructed using quads tendon autograft pull-down technique. A modified Sheffield protocol was used postoperatively allowing weightbearing in a hinged knee brace. Forty patients were identified with 8 patients having bilateral presentations. Male to female ratio was 12:28 with an age range of 4–17 years. Eight patients had congenital PFI, five patients acquired PFI through traumatic patella dislocation and twenty-seven patients developed PFI from recurrent dislocations. Structural abnormalities were found in 38(95%) of patients. Patella alta (Caton-Deschamps index >1.2) was identified in 19(47%) patients, genu valgum in 12(30%) patients, increased tibial tubercle-trochlear groove distance(TT-TG>20mm) was present in 9(22.5%) patients and persistent femoral anteversion(> 20 deg) in 7(17%) patients. Eight patients were treated with TTO and MPFL reconstruction, three patients with MPFL reconstruction alone and five patients had guided growth for genu valgum correction. Ten patients are awaiting surgery. No postoperative patients had recurrence of PFI at their latest follow up. PFI is a common problem in the adolescent paediatric population with identifiable structural abnormalities. Correcting structural pathology with surgery leads to predictable and safe outcomes

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs. Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures. We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons). We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs. Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures. We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons). We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries

Olecranon fractures are common injuries representing roughly 5% of pediatric elbow fractures. The traditional surgical management is open reduction and internal fixation with a tension band technique where the pins are buried under the skin and tamped into the triceps. We have used a modification of this technique, where the pins have been left out of the skin to be removed in clinic. The purpose of the current study is to compare the outcomes of surgically treated olecranon fractures using a tension-band technique with buried k-wires (PINS IN) versus percutaneous k-wires (PINS OUT). We performed a retrospective chart review on all pediatric patients (18 years of age or less) with olecranon fractures that were surgically treated at a pediatric academic center between 2015 to present. Fractures were identified using ICD-10 codes and manually identified for those with an isolated olecranon fracture. Patients were excluded if they had polytrauma, metabolic bone disease, were treated non-op or if a non-tension band technique was used (ex: plate/screws). Patients were then divided into 2 groups, olecranon fractures using a tension-band technique with buried k-wires (PINS IN) and with percutaneous k-wires (PINS OUT). In the PINS OUT group, the k-wires were removed in clinic at the surgeon's discretion once adequate fracture healing was identified. The 2 groups were then compared for demographics, time to mobilization, fracture healing, complications and return to OR. A total of 35 patients met inclusion criteria. There were 28 patients in the PINS IN group with an average age of 12.8 years, of which 82% male and 43% fractured their right olecranon. There were 7 patients in the PINS OUT group with an average age of 12.6 years, of which 57% were male and 43% fractured their right olecranon. All patients in both groups were treated with open reduction internal fixation with a tension band-technique. In the PINS IN group, 64% were treated with 2.0 k-wires and various materials for the tension band (82% suture, 18% cerclage wire). In the PINS OUT group, 71% were treated with 2.0 k-wires and all were treated with sutures for the tension band. The PINS IN group were faster to mobilize (3.4 weeks (range 2-5 weeks) vs 5 weeks (range 4-7 weeks) p=0.01) but had a significantly higher complications rate compared to the PINS OUT group (6 vs 0, p =0.0001) and a significantly higher return to OR (71% vs 0%, p=0.0001), mainly for hardware irritation or limited range of motion. All fractures healed in both groups within 7 weeks. Pediatric olecranon fractures treated with a suture tension-band technique and k-wires left percutaneously is a safe and alternative technique compared to the traditional buried k-wires technique. The PINS OUT technique, although needing longer immobilization, could lead to less complications and decreased return to the OR due to irritation and limited ROM

Survival of sepsis has been documented worldwide, but little is documented about the long-term health outcomes of multifocal sepsis from acute musculoskeletal infection - the first study of its kind in New Zealand. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1. st. January 2002 to 31. st. December 2017 with a musculoskeletal focus of infection were identified from hospital coding data. Notes review from discharge to present day determined survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. Seventy patients were studied. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Long-term survival was favourable with no recorded deaths after discharge. Recurrence/chronic infection occurred in 23%, a mean of 1.1 year after discharge. Growth disturbance occurred in 18%, a mean of 3 years after discharge. The hip joint and proximal femur have the worst complications. Children under 2 years are most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years after discharge. Health-related quality of life scores were on par with normative data. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with long hospital stay and multi-organ complications. Māori and Pasifika children, those under two and those involving the proximal femur/or hip are most at risk. Other outcomes are favourable with no evidence of chronic lung disease or poor quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

Thoracolumbar injury classification systems are not used or researched extensively in paediatric population yet. This systematic review aims to explore the validity and reliability of the two main thoracolumbar injury classification systems in the paediatric population (age ≤ 18). It also aims to explore the transferability of adult classification systems to paediatrics. The Thoracolumbar Injury Classification System (TLICS) published in 2005 and the AO Spine published in 2013 were assessed in this paper because they both provide guidance for the assessment of the severity of an injury and recommend management strategies. A literature search was conducted on the following databases: Medline, EMBASE, Ovid during the period November 2020 to December 2020 for studies looking at the reliability and validity of the TLICS and AO Spine classification systems in paediatric population. Data on validity (to what extent TLICS/ AO Spine recommended treatment matched the actual treatment) and reliability (inter-rater and intra-rater reliability) was extracted. There is an “almost perfect validity” for TLICS. There is a “strong association” between the validity of TLICS and AO Spine. The intra-rater reliability is “moderate” for TLICS and “substantial” for AO Spine. The intra-rater reliability is “substantial” for TLICS and “almost perfect” for AO Spine. The six studies show a good overall validity and reliability for the application of TLICS and AO Spine in pediatric thoracolumbar fractures. However, implication of treatment and anatomical differences of the growing spine should be explored in detail. Therefore, AO Spine can be used in absence of any other classification system for paediatrics

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system. A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded. For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?. Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care

This study aimed to identify long-term physical and psychosocial health outcomes in children with overwhelming musculoskeletal sepsis. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1st January 2002 to 31st December 2017 with a musculoskeletal focus of infection were identified. A medical notes review was completed to determine survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. 70 patients were identified over 15 years. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Recurrence/chronic infection affected 23%. Growth disturbance affected 18%. The hip joint and proximal femur suffered the worst long-term complications. Children under 2 years most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent acquired brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years (SD 4.5, range 2– 18 years) after discharge. Health-related quality of life scores were on par with normative data. All patients who underwent pulmonary function tests had normal results. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with multi-organ complications for some children. Māori and Pasifika children are most at risk. Children under 2 years and those with proximal femur and/or hip involvement are most likely to have chronic musculoskeletal sequelae and permanent disability. Other outcomes are favourable with no evidence of chronic lung disease or mean reduced quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience. Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction. 77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’. The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences

The requirement for the peer support groups were born out of concern for the psychological wellbeing of the paediatric patients and to assess if this would improve their wellbeing during their treatment. Groupwork is a method of Social Work which is recognised as a powerful tool to allow people meet their need for belonging while also creating the forum for group members to empower one another. Social Work meet with all paediatric patients attending the limb reconstruction service in the hospital. The focus of the Medical Social Worker (MSW) is to provide practical and emotional support to the patient and their parent/guardian regarding coping with the frame. Some of the challenges identified through this direct work include patient's struggling with the appearance of the frame and allowing peers to see the frame. The peer support group aims to offer its attendees the opportunities to engage with fellow paediatric patients in the same position. It allowed them to visually identify with one another. We wanted to create a safe space to discuss the emotional impact of treatment and the frames. It normalises the common problems paediatric patients face during treatment. We assisted our participants to identify new coping techniques and actions they can take to make their journey through limb reconstruction treatment more manageable. Finally, we aimed to offer the parents space to similarly seek peer support with regard to caring for a child in treatment. All paediatric patients were under the care of the Paediatric Orthopaedic Consultant and were actively engaging with the limb reconstruction multi-disciplinary team (MDT). The patient selection was completed by the MDT; based on age, required to be in active treatment, or their frames were removed within one month prior to the group's commencement. Qualitative data was collected through written questionnaires and reflection from participants in MSW sessions. We also used observational data from direct verbal feedback from the MDT. In the first group, parents gave feedback due to participants age and completed written feedback forms. For our second group, initial feedback was collated from the participants after the first session to get an understanding of group expectations. Upon completion, we collected data from both the participants and the parents. Qualitative and scaling questions gathered feedback on their experience of participating in the group. We held two peer support groups in 2022:One group for patients aged between 3–6 years in January 2022 across two sessions, which was attended by four patients. The second group for young teenage patients aged between 11–15 years in April 2022 across four sessions, which was attended by five patients. The written feedback received from group one focused on eliciting the participant's experience of the groupwork. 100% of participants identified the shared experience as the main benefit of the groupwork. 100% of participants agreed they would attend a peer support group again, and no participant had suggestions for improvement to the group. Feedback did indicate that group work at the beginning of treatment could be more beneficial. In relation to the second group, 60% of the paediatric patients and their parents returned the questionnaires. All of the parent's feedback identified that it was beneficial for their child to meet peers in a similar situation. They agreed that it was beneficial to meet other parents, so they could get support and advice from one another. On a scale between 1 and 5, 5 being the highest score, the participants scored high on the group work meeting their expectations, enjoyment of the sessions, and the group work was a beneficial aspect of their treatment. All respondents would strongly recommend groupwork to other paediatric patients attending for limb reconstruction treatment. Overall, the MDT limb reconstruction team, found the peer support group work of great benefit to the participants and their parents. The MSW team identified that during a period on the limb reconstruction team, when a high number of patients were in active treatment, the workload of the MSW also increased reflecting this activity. Common issues and concerns were raised directly to MSW (particularly from group two) regarding numerous difficulties they experienced trying to cope with the frame. The group work facilitators created a space where the participants could get peer support, share issues caused by the frame, hear directly from others, and that they too experience similar feelings or issues. Collectively, they identified ways of coping and promoting their own wellbeing while in treatment. The participants in group two, subsequently created a group on social media, to be able to continue their newly formed friendships and to continue to update one another on their treatment journeys. The participants self-requested another group in the future. This was facilitated in November 2023, the facilitators sought more feedback from all participants and their parents after this session. These findings will contribute towards the analysis for the presentation. Peer support groupwork was presented at the hospital's foundation day and has been well received by senior management in the hospital, as a positive addition to the limb reconstruction service. The focus of the MDT in 2024, is to further develop and facilitate more peer support groups for our paediatric patients

Purpose:. Non-contiguous spinal injury can add significant complexity to the diagnosis, management and outcome in children. There is very little in the paediatric literature examining the nature, associated risk factors, management and outcomes of non-contiguous spinal injuries. The objective is to determine the incidence and clinical characteristics of non-contiguous spinal injuries in a paediatric population. The secondary objective is to identify high risk patients requiring further imaging to rule out non-contiguous spinal injuries. Methods:. All children up to 18 years of age with a spinal injury, as defined by ICD-09 codes at one paediatric trauma hospital were included (n=211). Data for patient demographics, mechanism of injury, spinal levels involved, extent of neurologic injury and recovery, associated injuries, medical complications, treatment and outcome were recorded. Results:. Twenty five (11.8%) out of 211 patients had non-contiguous spinal injuries. The mean age was 10.7 years. The most common pattern of injury was a double thoracic non-contiguous injury. 16% of cases of NCSI were initially missed, but with no clinical deterioration due to the missed diagnosis. Associated injuries occurred in 52% of patients with NCSI. Twenty-four percent of patients with multiple non-contiguous spinal injuries had a neurologic injury compared to 9.7% in patients with single level or contiguous injuries (p=0.046). Conclusions:. There is a high incidence of children with multiple non-contiguous spinal injuries who are more likely to suffer neurological injuries compared to patients with single level or contiguous spinal injuries. Patients with a single level spinal injury on existing imaging and a neurological injury should have entire spine lateral radiographs to exclude non-contiguous injuries. In patients without neurologic injury and a single spinal fracture, radiographs showing at least 7 levels above and below the fracture should be performed. All children with spinal injury should have associated injuries carefully excluded

This study was performed at Assiut University, Assiut, Egypt. Anterior distal femoral hemiepiphysiodesis (ADFH) using intra-articular plates for the correction of paediatric fixed knee flexion deformities (FKFD) has two main documented complications: postoperative knee pain and implant loosening. This study describes a biomechanical analysis and a preliminary report of a novel extra-articular technique for ADFH. Sixteen femoral sawbones were osteotomized at the level of the distal femoral physis and fixed by rail frames to allow linear distraction simulating longitudinal growth. Each sawbone was tested twice: first using the conventional technique with medial and lateral parapatellar eight plates (group A) and then with the plates inserted in the proposed novel location at the most anterior part of the medial and lateral surfaces of the femoral condyles with screws in the coronal plane (group B). Gradual distraction was performed, and the resulting angular correction was measured. Strain gauges were attached to the plates, and the amount of strain (and equivalent stress) over the plates was recorded. This technique was then applied to 9 paediatric FKFDs of different aetiologies. The preoperative FKFD and the amount of subsequent angular correction were measured. The amount of angular correction was higher in group B at 5, 10-, and 15-mm of distraction (p<0.001). The maximum and overall stresses measured throughout the distraction process were higher in group A (p<0.001). The mean FKFD improved from 24 ± 9° preoperatively to 9 ± 7° after 10 ± 3° months (p<0.001). The correction rate was 1.81 ± 0.65° per month. During ADFH, the fixation of the eight plates in the coronal plane at the anterior part of the femoral condyles may produce greater correction and lower stresses over the implants as compared to the conventional technique. Preliminary results from our initial series seem to support the effectiveness of this technique with respect to the degree of angular correction achieved

Abstract. Objectives. Epiphysiodesis is a commonly used treatment for lower limb angular deformities. However, in recent years, distal tibial growth modulation using ‘eight plates’ or screws has emerged as an alternative treatment for paediatric foot and ankle disorders, such as CTEV. Our objective was to assess the efficacy of distal tibial modulation in correcting various paediatric foot and ankle disorders. Methods. This retrospective study analysed 205 cases of paediatric foot and ankle disorders treated between 2003 and 2022, including only cases where the eight plate or screw was fixed on the anterior surface of the distal tibia. Our aim was to measure post-operative changes in dorsiflexion, the distal tibial angle, and the tibiocalcaneal angle by examining clinical records and radiology reports. Results. We identified nine cases (nine feet) meeting the full inclusion criteria, comprising seven cases of CTEV, one case of arthrogryposis, and one case of cavovarus foot. The cohort consisted of five male and four female patients, with a mean age of 10 years and 9 months at the time of surgery. Seven cases involved the left tibia, and two cases involved the right tibia. The mean time between pre-operative X-ray to surgery was 168 days, and the mean turnaround time between surgery and post-operative X-ray was 588 days. A mean change in the distal tibial angle of 4.33 degrees was noted. However, changes in dorsiflexion were documented in only one case, which showed a change of 13 degrees. Notably, our average distal tibial angle was significantly lower than reported in the literature, at 4.33 degrees. Additionally, some studies in the literature used the Oxford Ankle Foot Questionnaire for Children to assess pre- and post-operative outcomes, but it is important to note that it is validated only for children aged 5 to 16. Furthermore, most cases reported an improved tibiocalcaneal angle except for an anomaly of 105 degrees. We assessed satisfactory patient outcomes using patient notes. Out of the 6 procured notes, one has been discharged. The rest are still under yearly or 6-monthly review and are at various stages, such as physiotherapy, removing the eight plate, or requiring further surgery. The most common presentations at review are plantaris deformity and pain. Conclusions. Our study suggests that distal tibial growth modulation can be an effective treatment option for selected paediatric foot and ankle disorders. However, due to the limited number of cases in our study, the lack of documentation of changes in dorsiflexion, and a lack of pre- and post-operative outcomes using a standardised method, further research is needed to investigate this procedure's long-term outcomes and potential complications. 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

Our study seeks to determine whether characteristics of radiographs taken post-reduction of a forearm fracture can indicate future risk of refracture or loss of reduction. We hypothesize that reducing forearm fractures too precisely may be counterproductive and provide less benefit than reductions left slightly offset prior to cast immobilization. We conducted a retrospective review of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. Percent fracture displacement, location, orientation, comminution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Patients treated with closed reduction were reduced from a mean displacement of 29.26±36.18% at an angulation of 22.67±16.57 degrees to 7.88±9.07% displacement and 3.89±6.68 degrees angulation post-reduction. Patients developing complications including a loss of reduction or refracture were found to have post-operative radiographs with a lower percent displacement (0.50±1.12) than those not developing complications (8.65±9.21)(p=0.0580). Post-reduction angulation (p=1.000), average reduction in angulation (p=1.000) and average reduction in displacement percent(p=0.2102) were not significantly associated with development of complications. Percent displacement of radial shafts was seen to be the most important metric to monitor in post-operative radiographs for patients undergoing closed reduction of a forearm fracture. We theorize a slight displacement provides greater surface area for osteoblastic expansion and callus formation leading to a decreased risk of refracture or loss of reduction. While our sample size precludes our ability to measure the ideal amount of post-reduction displacement for optimal healing, our results demonstrate that some degree of shaft displacement is required for optimal healing conditions

Introduction. Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and deformity correction within our service. This consecutive series illustrates the advantages and complications associated with the use of this device, and describes a novel technique modification for antegrade intramedullary lengthening nails. Materials & Methods. A retrospective cohort review was performed of patient outcomes after treatment with the Fitbone nail at two tertiary referral limb reconstruction services (one adult, one paediatric) between January 2021 to December 2023. Aetiology, indications, initial and final LLD, use of concomitant rail assisted deformity correction (ORDER), removal time and healing index were assessed. Complications of treatment were evaluated and described in detail, alongside technique modifications to reduce the rate of these complications. Results. 21 nails (18 femoral, 2 tibial, 1 humeral) were inserted in 6 adult and 13 paediatric patients. Post-traumatic and congenital/developmental LLD were the most common indications for surgery in the adult and paediatric cohorts respectively. ORDER was employed in 11 cases (9 femurs and 2 tibias). Treatment goals were achieved in all but one case. Complications included superficial infection, locking bolt migration, periprosthetic fracture and component failure. Seven patients required unplanned returns to theatre. Conclusions. The Fitbone nail is an established option for intramedullary limb lengthening, however its use in the UK has been relatively limited compared to the PRECICE until 2021. Our data helps to define its place for limb lengthening and complex deformity correction in both adult and paediatric patients, including in humeral lengthening and retrograde femoral insertion across an open physis. We have identified important potential risks and novel techniques to simplify surgery and avoid complications

Abnormal patella height has been found to be one of the main reasons for abnormal contact between patella and trochlear groove leading to patellar instability in children. Many methods have been described to diagnose patellar instability but most of them are justified only in adults. The reason being incomplete ossification in the paediatric population. These methods have been divided into direct and indirect methods. We analysed the MRI scan of knee of 57 children between 12–14 years of age with no previous diagnosis of patellar instability. Patients with a diagnosis of patellar instability, previous surgery on the knee or trauma and poor MRI scan were excluded from the study. We used Insall -Salvati Index (ISI), Caton-Deschamp Index (CDI) and Patella-Trochlear Index (PTI) and compared the results. We found that 40% of measurements by CDI and 41% by ISI showed patella alta in patients with normal patella height. 10% of patients in PTI readings had value suggestive of abnormal patella height. We concluded that PTI is a more reliable index to be used in children as it uses the length of articular surface and does not rely on bony landmarks. Studies done show PTI is a more reliable and accurate method of measuring patella height