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

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

Introduction. Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Methods. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined. Results. Between January 2019 and August 2023, 50 MPFL reconstructions were performed in 37 children using partial thickness quadriceps autograft. Patient age at time of surgery ranged from 5 to 17 years (median age 13 years). The technique was utilised for a variety of indications including recurrent traumatic and habitual patellofemoral instability, fixed dislocations, and revision MPFL reconstruction. Conclusion. Partial thickness quadriceps tendon autograft can be used safely to primarily reconstruct the medial patellofemoral ligament in paediatric population, including those children with open growth plates. It also has utility in revision cases following previous failed hamstring MPFL reconstruction. We have noted that the younger the child, the more distal to the physis lies the femoral point of isometricity, rendering this a safe and reproducible treatment in this age group. Use of this technique has increased in our unit as we have observed that patients seem to be satisfied with their clinical and functional outcomes with a low incidence of short- and medium-term complications

Purpose of study. To review the treatment and outcomes of paediatric pelvic ring injuries in the UK. Methods and results. We performed a retrospective review of all pelvic fracture admissions to an English paediatric major trauma centre (MTC) from 2012 to 2016. A total of 29 patients were admitted with pelvic ring injuries with a mean age of 11 years (4- 16yrs). Road traffic accident was the mechanism in majority (72%), followed by fall from height (24%). Femoral shaft fracture was present in 5 (17%), head injury in 5 (17%), chest injuries in 5 (17%) and bladder injury in one child. 48% patients needed surgical procedures for fractures or associated injuries. We differentiated injuries according to the classification system of Torode and Zeig. 17% were Type A, 3% Type B, 48% Type C and 31% Type D. Almost all (93%) patients were treated conservatively. 51% of patients were allowed to mobilize full weight bearing after a period of bed rest. Non-weight bearing mobilization was recommended for fractures extending into the acetabulum, sacral fractures, unstable fracture patterns or associated fractures (neck of femur, femoral shaft and tibial shaft). Surgical fixation occurred in two patients. Both of these patients had significantly displaced Type D fractures. Only 44% of patients were back to sports at six months. Conclusions. Pelvic ring injuries are rare within the paediatric population and are associated with a high incidence of concomitant injury and significant functional morbidity. Their treatment should involve a multidisciplinary approach, which includes specialist in the care of pelvic trauma

Background. Fractures of the scaphoid are uncommon in the paediatric population. Despite their rarity a significant number of children are referred to the fracture clinic for a suspected scaphoid fracture. The aim of this study is to report on the incidence and pattern of injury of the paediatric scaphoid fracture and present a new classification. Methods. An analysis of all paediatric scaphoid fractures treated in the Royal Hospital for Sick Children, Edinburgh (age up to 14 years old) over a five year period. The case notes, radiographs and were applicable MRI scan for these patients were reviewed. The clinical information recorded included the dominant hand, mechanism of injury, clinical features on examination, type of cast and length of period, stiffness following cast removal and evidence of delayed or non union. Each radiograph was analysed independently and fracture classified according to a new classification system. Results. 56 patients out of the eight hundred and thirty eight (6.7%) referred were identified who had a confirmed diagnosis of a scaphoid fracture on both clinical and radiological assessment. This group consisted of 39 males (70%) and 17 females (30%). The average age of incidence in males was 12.2 years (range 11 to 13 years) and females was 10.3 years (range 9 to 10 years). There were no scaphoid fractures seen in males below the age of 11 years and in females below the age of 9 years. The commonest type of injury was a distal pole fracture (33 patients). One patient sustained a proximal pole fracture and went onto develop a non-union. Conclusions. Scaphoid fractures in children have distinct epidemiological features. The majority involve the distal third of the scaphoid and heal with conservative treatment. The use of a new classification system specific to the paediatric population is beneficial when determining the optimal management of this type of injury

Introduction. No previous studies have attempted to measure parental satisfaction and service quality in regards to paediatric orthopaedic service inpatient care. We performed a prospective observational study to assess parental satisfaction with the level of service provided for paediatric orthopaedic inpatient care in our unit. Methods. We employed the validated Swedish parent satisfaction questionnaire to generate parental satisfaction data from 104 paediatric orthopaedic hospital inpatients between August 2009 and May 2010 (49 elective and 55 trauma paediatric orthopaedic admissions, median age range 2–6 years). Questions focused on eight domains of quality: Information on illness, information on routines, accessibility, medical treatment, care processes, staff attitudes, parent participation and staff work environment. Scores generated were a percentage of the maximum achievable for that quality index, for example 100% would correspond to a parent awarding all questions for that index the highest possible score. Results. Overall combined scores for the care indices were highest for parent's perception of ‘medical treatment’ (95%) and ‘staff attitudes’ (95%). The medical treatment index includes questions regarding staff member's skill and competence. Lowest scores corresponded to the index' information routines' (86%). Conclusion. Information routines applies to parental awareness of ward rounds, to whom questions should be directed and which doctors/nursing staff are responsible for their child's care. Lower scores in relation to this index were substantiated by comments from relatives requesting greater information provision. The types of information parents required was routinely provided suggesting that retention rather than lack of information is the main issue. Provision of information pamphlets tailored to common injuries or elective procedures might prove an effective method for improving this aspect of care and increasing overall parental satisfaction with paediatric orthopaedic inpatient service

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit. An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended. Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment). We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100). Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment. Level of evidence: IV (case series)

A retrospective analysis of all paediatric patients admitted to Camp Bastion Role 3 between June 2006 and March 2013 was conducted from the UK trauma database. Patient demographics, mechanism of injury, anatomical distribution of injury and treatment are described. Two hundred and ninety eight children were admitted, 225 males with a median age of 9 years old. The highest number of cases (78) was recorded in 2011. Overall there were 55 fatalities (85.6% male). Most injuries were by IED (68% of cases) with 74% requiring operative intervention. Seventy-four percent of casualties had three or more anatomical regional injuries. Whilst the most commonly injured region was the lower limb (78%), head injuries were seen in 41%, abdominal injuries in 48% and thorax injuries in 44%. Debridement (including amputations) (59.4%) and laparotomy (30.6%) were the commonest operations performed. Sixty percent of cases were in theatre within one hour of arrival. Amongst survivors the mean ISS score was 17 and amongst fatalities 43; NISS 22 and 51; RTS 5.45 and 2.91. Paediatric blast injuries represent a significant burden to medical facilities in contemporary conflict. Whilst limb injuries predominate, the proportion of head and torso injuries is higher than seen in adult blast injuries

To analyse the management of open paediatric tibial fractures treated at a children's Major Trauma Centre (MTC), comparing fixation methods, union and complications. We retrospectively identified all patients admitted to RMCH with an open tibia fracture between 2008 – 2016. Demographics, mechanism, inpatient stay and follow-up management were reviewed. There were a total of 44 patients, with an average age = 10 years (3–15). 93% of cases were caused by road traffic accidents, commonly pedestrian versus car. Older children were more likely to sustain higher grade injuries, requiring increased length of stay. 35 patients had primary / delayed wound closure, 1 patient required fasciotomies and 4/44 needed skin grafts and/or flap. 7 patients were treated in plaster, 9 by elastic nailing, 15 had mono-lateral fixators and 12 with circular frame. The average number of surgeries = 3 (1–7) with older children having increased risk of revision surgery. Monolateral fixators were the most common primary fixation method (n=15), however 60% required revision to ring fixator due to displacement or delayed union. The main risk factor for displacement was inadequate fracture reduction in theatre, as well as those fracture patterns involving butterfly fragments. Union (defined as RUST score = 3 on >3 cortices) was achieved in all patients (ave 6 months). Delayed union was associated with higher grade injuries, those treated with elastic nails demonstrated the longest union time (ave 7.3 months). 21/44 (47.7%) patients had complications, with pin site infection being the most commonly seen. 18% patients suffered a major complications needing further surgery. Various fixation methods can be successfully used to treat these fractures. They demonstrate a high complication rate and often require multiple surgeries, with union taking an average of 6 months. Mono-lateral fixators demonstrate a high revision rate, particularly if the fracture is not well reduced

Background:. The outcomes of open tibial fractures in a paediatric population are reported. Methods:. A retrospective analysis of consecutive cases, classified by the Gustilo-Anderson system, over the last 8 years was undertaken. The outcomes recorded were time to union, non-union, infection rates and re-operation rates. Results:. There were 60 open tibial fractures; 8.3% grade 1, 10.0% grade 2, 38.3% grade 3a, 36.7% grade 3b, and 6.7% grade 3c. There were 19 females and 41 males with a median age of 12 years. The time to first debridement was within 24 hours in 95% of patients. External fixation was used definitively in 62.7% with internal fixation next (13.6%). The mean time to union was 4 months. There was a 10.0% non-union and a 1.7% deep infection rate. Thirty percent needed re-operation: soft tissue procedures (6.7%); malaignment (5%); delayed union (5%) and infection (3.3%). All fractures united at final follow-up. There was no statistical difference between the methods of fixation on non-union rate. Conclusion:. Open tibial fractures in the paediatric population demonstrate a high union and low deep infection rate as compared to the adults. The findings support the recommendations from current BOA/BAPRAS standards on the management of these injuries

Kirschner wires are commonly used in paediatric fractures, however, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. Bioabsorbable pins that remain in situ and allow definitive closure of skin at the time of insertion could provide such advantages. Three concurrent studies were performed to assess the viability of bioabsorbable pins across the growth plate. (1) An epidemiological study to identify Kirschner wire infection rates. (2) A mechanical assessment of a bioabsorbable pin compared to Kirschner wires in a simulated supracondylar fracture. (3) The insertion of the implants across the physis of sheep to assess effects of the bioabsorbable implant on the growth plate via macroscopic, pathohistological and micro-CT analysis. An infection rate of 8.4% was found, with a deep infection rate of 0.4%. Mechanically the pins demonstrated comparable resistance to extension forces (p=) but slightly inferior resistance to rotation (p=). The in vivo component showed that at 6 months: there was no leg length discrepancy (p=0.6), with micro-CT evidence of normal physeal growth without tethering, and comparable physeal width (p=0.3). These studies combine to suggest that bioabsorbable pins do not represent a threat to the growth plate and may be considered for physeal fracture fixation

Purpose. To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. Method. A retrospective review was conducted identifying patients from our trauma database. Inclusion criteria were age (4–17 years) and open lower-limb trauma. Outcome measures included time to soft tissue coverage, surgical techniques, trauma impact scores, health-related quality of life, union and complication rates. Results. We identified 26 patients. 24 patients had open tibia fractures including 10 patients with bone loss. In 9 patients primary skin closure was achieved by acute shortening. 17 patients required soft tissue coverage including 14 free vascularised muscle flaps (89% within 48 hours). The surgical techniques applied were: circular fine wire frame (16), external fixateur (5) and open reduction internal fixation (5). Median follow up time was 8 (3–45) months. The trauma impact scores showed one in three patients were at risk of PTSD. All fractures went on to unite over a median time of 4.2 (2–9) months. No deep infections occurred. Conclusion. All our patients had limb salvage, fracture union and near normal levels of physical scores in the short term. Close psychological follow up is advisable to minimise the risk of PTSD

The aim of this study was to produce estimates of specificity and predictive value of presenting symptoms and signs of paediatric bone cancer, a rare and frequently misdiagnosed condition, to aid clinical decision-making in primary care. A systematic literature review plus questionnaire to primary care physicians were carried out to determine frequency of bone cancer symptoms in both cancer and the benign conditions as which cancer is misdiagnosed. Literature sources – Ovid MEDLINE (1950-May 2008), EMBASE (1980-May 2008) and AMED (Allied and Alternative Medicine) (1985-May 2008). Literature review methods – We included systematic reviews, cohort studies or case series (where n ≥ 10), reporting frequency of symptoms and signs at initial presentation, as originally recorded in case notes or observed by the authors, in subjects aged 0–18 years. Disease incidence data was taken from retrospective and prospective studies from 1980 onwards which recorded incidence over a defined time period, in a large pre-defined population within Europe, North America or Australia. Questionnaire respondents – 32 general practitioners and paediatric Accident & Emergency physicians throughout Scotland and England. Positive predictive values (PPVs) for bone cancer symptoms range from 0.003 to 0.034% (percentage of children presenting with symptom who have cancer). Specificity (percentage of children without cancer who do not have the symptom) varies considerably between symptoms and ranges from 24% (tenderness) to 95% (weight loss). Specificity can be improved by looking for combinations of symptoms. Weight loss and fever are the features with both highest specificity and highest PPV. Bone cancer symptoms, even those with high specificity for cancer, have low positive predictive value. We suggest that diagnosis based on initial presentation to primary care is intrinsically difficult and that delay in diagnosis is not unreasonable if it is to make use of time as a diagnostic aid

Background. To compare quality of life during treatment in children and adolescents with tibial fracture treated with either a definitive cast or Ilizarov frame. Methods. A prospective, longitudinal cohort study was undertaken. Patients aged between 5 and 17 years with tibial fractures treated with a cast or Ilizarov frame were recruited. Health-related quality of life was measured during treatment using the Paediatric Quality of Life Inventory. Results were analysed based on time from injury. Statistical analysis was undertaken using a Kruksal-Wallis test. Results. Twenty patients with casts and 28 with Ilizarov frames were included. Median treatment time was two (1–4) months for casts and four (2–9) months for frames. A significant improvement was found in the child reported physical domain in both treatment groups based on time from application (<60 days vs. >60 days, frame: p<0.0001, cast: p=0.027). There was no significant difference in reported scores between treatment groups at the same time point. There were no differences in the child reported psychosocial domain scores at any time point or between treatment groups. Conclusion. There is no difference in health-related quality of life during treatment between patients treated for tibial fracture using a cast or an Ilizarov frame. Level of evidence. II

Lateral-entry wiring (LEW) for displaced supracondylar humeral fractures (SHFs) has been popularised internationally. BOAST guidance suggests either LEW or crossed wires; the latter has reported lower risk of loss of fracture reduction –we explore technical reasons why.

We reviewed 8 years of displaced SHFs in two regional centres. Injuries were grouped using the Gartland Classification, with posterolateral or posteromedial displacement assessment for Gartland 3 injuries. We identified any loss of fracture reduction, and reviewed intra-operative imaging to identify learning points that may contribute to early rotational displacement (ERD).

345 SHFs were included, between 2012 and 2020. Gartland 2 (n=117) injuries had a 3.42% risk. ERD. Gartland 3 crossed wirings (n=114) had a 6.14% risk of ERD, with those moving all being posterolaterally displaced. Gartland 3, posterolaterally displaced LEW (n=56) had a 35.7% risk of ERD. Gartland 3, posteromedially displaced LEW (n=58) had a 22.4% risk of ERD. All injuries with ERD except 3 had identifiable learning points, the commonest being non-divergence of wires, or wires not passing through both fracture fragments.

LEW requires divergent spread and bicolumnar fixation. Achieving a solid construct through this method appears more challenging than crossed wiring, with rates of ERD 3–5× higher. Low-volume surgeons should adhere to BOAST guidelines and choose a wiring construct that works best in their hands. They can also be reassured that should a loss of position occur, the risk of requirement for revision surgery is extremely low in our study (0.3%), and it is unlikely to affect long term outcomes.

Background. Temporary hemiepiphysiodesis using 8 plate guided growth has gained widespread acceptance for the treatment of paediatric angular deformities. This study aims to look at outcomes of coronal lower limb deformities corrected using temporary hemiepiphysiodesis over an extended period of follow up. Methods. A retrospective analysis was undertaken of 56 children (92 legs) with coronal plane deformities around the knee which were treated with an extraperiosteal 2 holed titanium plate and screws between 2007 and 2015. Pre and post-op long leg radiographs and clinic letters were reviewed. Results. The mean age was 11.9 years (range 3 to 16) with a mean angular deformity of 12.3 degrees (5.1 to 33.5). The mean rate of correction was 0.8 degrees per month. Isolated distal femur correction occurred at a mean rate of 0.6 degrees per month (0.2 to 1.4) and isolated tibia at a rate of 0.5 degrees per month (0.0 to 1.7). Children treated with concurrent treatment of both femur and tibia corrected at a rate of 1.4 degrees per month (0.1 to 2.7). Similar rates of correction occur in children aged 10 and over compared to those younger than 10 (0.8 degrees per month compared to 0.7). We also saw similar rates of correction with extended follow up. The average rate of correction over the first 9 months post op was 0.8 degrees compared to 0.6 degrees over the following 10 months. Conclusion. This study is the largest long term follow up of 8 plate hemiepiphysiodesis which highlights the rate of correction in all age groups. Implications. With this knowledge surgeons can make a more informed decision regarding placement of hemiepiphysiodesis plates and length of time required for correction of angular deformities. It may also lead to consideration of alternative, more powerful techniques if the rate of correction is insufficient. Conflict of Interest: None declared

Neurological examination in children presenting with upper limb fractures is often poorly performed. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our own hospital and performed a further 3 month clinical review to detect any resulting change in practice. In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination. Following introduction of the guideline, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. Introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

The upper age limit for Paediatric Orthopaedic referrals and admissions has recently been increased from 14 to 16 years. This has many benefits but will change the volume of cases as well as influencing both case mix and the resources required. We analysed the operations and admissions in our department for the year preceding and succeeding the change in age limit in order to evaluate the impact on the service. Our outcome measures were number of trauma and elective cases treated, time spent operating, case mix and cost to the service. Admission and operative logs for the aforementioned years were analysed to obtain number of admissions, length of stay and operative intervention as well as time in theatre. National reference data from Information Services Division Scotland was used in order to get accurate costs for theatre time and inpatient stays in our hospital. Results showed an increase in total number of cases from 438 per year to 499. Trauma cases increased from 133 (30.4%) to 202 (40.5%). Of these, 35 (17.3%) were over 14 years. The number of children over 14 years which had an operation, doubled from 51 to 102. Hours spent operating increased from 681.25 to 830.25. The percentage time operating on those aged over 14 increased from 13.2% to 23.8%. Theatre costs increased by £148005 (21.9%) to £822442.50. The change in age limit has significantly increased case variety and numbers. This has significant financial implications and as such needs adequately resourced to ensure high quality clinical care

Background. Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications. Method. Retrospective review of 51 paediatric (<16 years) oncology patients undergoing primary (1 °) EPFR (minimally/noninvasive) between 06/1994 and 01/2006. Exclusions: 1 patient with 5cm extension without medical intervention and 5 patients with incomplete data. Results. There was a negative relationship between age at 1 ° operation and EPFR lengthening (p = 0.03). Mean lengthening for all (including revision) EPFR was 3cm (range 0–13.05). 28 (64%) patients were lengthened a mean 4.8cm at a mean 7 procedures each. 18 were not lengthened, of which 12 were deceased at last followup and 1 had undergone amputation. Lengthening of secondary prostheses contributed a mean 3.7cm to limb length. 2 tertiary implants were lengthened noninvasively by 1.2cm (3 lengthenings) and 1.275cm (5 lengthenings). 16 of 21 failed 1 ° femoral components had been lengthened. The 21 implants underwent a mean 4.2 lengthenings in comparison to mean 1.3 lengthenings in the 28 that did not fail. Number of 1 ° prosthetic lengthenings was positively related to risk of component failure (p = 0.035) and total number of complications (p = 0.049). Complication rate was also related to total lengthening of 1 ° prosthesis (in cm) (p = 0.004). There was a statistically insignificant (p = 0.059) trend towards increased infection rate with higher number of minimally invasive lengthening procedures. Complications were commoner in those undergoing lengthening (mean 3 vs 1.75 in non-lengthened prostheses). Number of lengthenings correlated with number of complications (p = 0.001). Total lengthening of distal EPFR correlated with incidence of knee fixed flexion deformity (FFD)(p = 0.034). Median lengthening was 3cm in those with FFD and 0cm in those without (p = 0.019). Open lengthening procedures caused 6 complications: 2 deep & 3 superficial infections and recurrent subluxation requiring acetabuloplasty in a proximal replacement. Summary/Conclusions. The inverse relationship between age at 1 ° operation and lengthening is expected if the aim of offsetting limb length discrepancy during growth is being achieved. Lengthening is associated with increased complications (particularly infection and FFD) and femoral component failure, suggesting that lengthening procedures are implicated in the cause of some complications. 5 infective complications after lengthening were theoretically avoidable if noninvasive growers were used

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.