The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation.Aims
Methods
We present the long term outcome from children with Legg-Calves-Perthes (LCPD) treated at our unit. Patients treated for LCPD were identified retrospectively from an orthopaedic database between 1990 and 2005. Patient demographics, clinical examination, treatment and Herring classification were recorded at initial presentation and treatment. Long-term clinical and radiological follow-up was also recorded. 85 patients were identified and 4 excluded due to insufficient data giving a total of 81 patients. Of these, 58 were male and 23 female. Average age range at presentation was 6.5 years (range 1.5–14 yrs). The side affected was 34 right, 35 left, 24 bilateral giving 93 hips in total. Time between presentation and diagnosis averaged 4.7 months (range 0–48 months). In patients with recorded clinical examination 87% had reduced abduction and 88% reduced internal rotation. Treatment was largely conservative with 12 hips (13%) undergoing surgery within the first 4 years of diagnosis. Radiographs were available for 71 hips. Herring classification was A-12, B-22, C-37. Long term follow up averaged 16 years (range 10–25 yrs). Stulberg grading was available in 67 hips; Grade I 13, Grade II 21, Grade III 19, Grade IV 18 and Grade V 6. There were ongoing issues (mostly pain) in 18 hips, 5 of which required a subsequent operation. No correlation was found between abduction and Stulberg grade (p-value = 0.7). A correlation was found between delay in diagnosis of ≥6 months and the need for a subsequent operation (p-value = 0.0408). The overall trend as expected showed that a better Herring classification generally led to a more favourable Stulberg classification. Range of motion was not predictive for Stulberg grade. The need for further surgical intervention for symptoms at long term follow up was 0.05%.
The purpose of this study was to investigate whether patient age of 16 years and under is a valid “red flag” for back pain, by determining how often magnetic resonance imaging (MRI) investigations in these patients demonstrated significant pathology. This was a retrospective review of cases over a five-year period (2008–12). The radiology database was interrogated to identify all patients aged 16 and under who had undergone an MRI scan of their lumbar spine for a primary complaint of low back pain. All emergency and inpatient admissions were excluded from the study. Casenotes of each of these patients were analysed for demographics, clinical features, diagnosis and outcome. After exclusions, 98 eligible cases were identified. The age range of these patients was 2–16 years (mean age 12.63 years). The MRI scan found no abnormalities in 71.4% of cases. In the scans with positive findings, there were 8 cases of spondylolysis, 3 spondylolistheses, 9 cases of disc degeneration and 5 cases of Scheuermann's. Tumour or infection were found in only 3% of cases, (2 cases sacroilitis, 1 sacral chondroblastoma); there had been sacral or sacroiliac tenderness in each of these cases. In keeping with other recent studies, this study shows that the diagnostic yield of MRI in patients under the age of 16 with low back pain is relatively high (28.6%). However, scan findings did not significantly alter management in the vast majority of cases (97%). Serious pathology (infection or tumour) was found in only 3% of cases. We therefore suggest that an age of 16 years or less, in isolation, should not be a “red flag” indicator for low back pain. We do however advise a lower threshold for imaging in patients presenting with sacral region pain and tenderness.
The aim was to compare the efficacy of selective ultrasound-screening (SUSS) for developmental dysplasia of the hip (DDH) to clinical screening alone, by comparing outcomes in a contemporary group with those from a 40 year old cohort. This was a retrospective cohort study. The department's DDH and surgical databases were used to identify all cases of DDH, and all cases of surgery for DDH during the study period (2009–13). Patients born outside our region, and teratologic cases were excluded from analysis. The Obstetric database provided the total number of live births over the five-year period. This data was used to calculate the incidence of late-diagnosis (age over 3 months) DDH and the rate of surgery for DDH in our region. These results were compared to those of a similar study from our institution published in 1977, after the introduction of universal clinical screening. Relative risk (RR) was calculated for the two groups, and analysed for statistical significance. The incidence of late-diagnosis DDH over the recent 5-year study period was 0.66/1000 live births, compared to 0.6/1000 in the control group. The RR for late-diagnosis DDH was not significantly different between the two groups (RR 1.14, 95% CI 0.6 to 2.2). The rate of surgery for DDH was 0.86/1000, compared to 0.9/1000 live births in the control group. The RR for surgery for DDH in the current study population compared to the historic control was 0.97, but this difference was not statistically significant (95% C.I. 0.57 to 1.68; p=0.92). Despite advances in screening for DDH over the last 40 years, neither the incidence of late diagnosis DDH, nor rates of surgery for DDH in our region have changed. Whilst previous studies have demonstrated that SUSS does not eliminate late-presenting DDH, this study suggests it confers no advantage over clinical screening alone.
Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18+0–20+6 week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV. The database of the antenatal ultrasound department was interrogated for all suspected cases of CTEV on the 18+0–20+6 week USS, between August 2006 and June 2012. Terminations, stillbirths and outside referrals were excluded. Our Ponseti-service database was searched to identify all patients treated for structural CTEV between January 2007 and November 2012. Cases were excluded if the mother did not receive antenatal-care at our centre. Results from the two searches were cross-referenced, and statistical analysis performed.Aim
Method
Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information. An electronic 18 item, single response multiple-choice questionnaire was designed to investigate various aspects of the surgical management of supracondylar fractures, with particular focus on areas that remain controversial in the literature. Members of BSCOS were invited by email, on three occasions, to complete the questionnaire, which was posted on the web-based SurveyMonkey™ platform (Aim
Methods
Our aim was to compare the Wilkins'-modified Gartland classification and AO classifications of supracondylar humeral fracture with respect to: -Inter-observer reliability; Association of fracture-grade with radiological quality of reduction; Association of fracture-grade with complications. The unit database was interrogated to identify all operated supracondylar fractures between 2007–2011. Radiographs from each case were evaluated by four observers (three consultants, one trainee) and classified according to Gartland and the AO system. Inter-observer reliability was calculated using Cohen's Kappa coefficient. Radiological quality of reduction was evaluated using a new scoring system, combining the anterior humeral line, the lateral capitello-humeral angle (LCHA) and Baumann's angle, (compared to reference values). Analysis of variance (ANOVA) was performed to determine whether there was a statistically significant difference in scores between the fracture grades. Case notes were reviewed for pre- and post-operative complication, and chi-squared test performed to compare the incidence between different fracture grades.Aim
Methods
We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management. Three cases of tibia vara secondary to atraumatic slippage of the upper tibial epiphysis on the metaphysis were identified from three different centres. The case notes and imaging studies were retrospectively reviewed to distinguish common clinical and radiographic features.Introduction
Method
