Search

Townes-Brocks syndrome (TBS) is characterized by a spectrum of malformations in the digits, ears, and kidneys. These anomalies overlap those seen in a growing number of ciliopathies, which are genetic syndromes linked to defects in the formation or function of the primary cilia. TBS is caused by mutations in the gene encoding the transcriptional repressor SALL1 and is associated with the presence of a truncated protein that localizes to the cytoplasm. Here, we provide evidence that SALL1 mutations might cause TBS by means beyond its transcriptional capacity. By using proximity proteomics, we show that truncated SALL1 interacts with factors related to cilia function, including the negative regulators of ciliogenesis CCP110 and CEP97. This most likely contributes to more frequent cilia formation in TBS-derived fibroblasts, as well as in a CRISPR/Cas9-generated model cell line and in TBS-modeled mouse embryonic fibroblasts, than in wild-type controls. Furthermore, TBS-like cells show changes in cilia length and disassembly rates in combination with aberrant SHH signaling transduction. These findings support the hypothesis that aberrations in primary cilia and SHH signaling are contributing factors in TBS phenotypes, representing a paradigm shift in understanding TBS etiology. These results open possibilities for the treatment of TBS.

Purpose Fractures of the lateral condyle of the humerus in children are a common injury. If displaced or unstable they may require surgical reduction and fixation with Kirschner wires (K-wires). K-wires are placed using either an open or closed technique. The decision to bury or leave the ends extending through the skin is surgeon-dependent and based on factors including post-operative infection risk, bony union and ease of wire removal. Methods We performed a systematic review and meta-analysis of non-buried versus buried K-wires for lateral condyle elbow fractures in children in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A comprehensive search strategy included Medline, Embase and CINAHL via NICE Evidence from database inception to June 2017. Two authors independently reviewed, included or excluded articles, extracted data and assessed for quality with the ROBINS-I tool. We performed direct comparison meta-analysis for all adverse events, post-operative infection and failure of bony union. Results Three studies were analysed comprising of 434 participants. There was a significantly reduced relative risk of adverse events in the non-buried group, equating to approximately 45% reduced risk (RR 0.55, 95% confidence interval 0.34 to 0.88). There were no significant differences in risk of post-operative infection or failure of bony union. All three cost-analyses in the included studies observed savings with non-buried K-wires. Conclusion Non-buried K-wires for lateral condyle elbow fractures convey a lower risk of adverse events and may be more cost-effective compared with buried K-wires. Non-buried K-wires do not appear to increase the risk of infection or failure of bony union. These findings are limited by a high risk of bias due to inherent methodological flaws in the design of included studies.

Developmental dysplasia of the hip (DDH) is the most common skeletal developmental disease. However, its genetic architecture is poorly understood. We conduct the largest DDH genome-wide association study to date and replicate our findings in independent cohorts. We find the heritable component of DDH attributable to common genetic variants to be 55% and distributed equally across the autosomal and X-chromosomes. We identify replicating evidence for association between

Background Many patients with X-linked hypophosphataemic rickets (X-LHPR) demonstrate significant lower limb deformity despite optimal medical management. This study evaluates the use of guided growth by means of hemi-epiphysiodesis to address coronal plane deformity in the skeletally immature child. Methods Since 2005, 24 patients with X-LHPR have been referred to our orthopaedic unit for evaluation. All patients had standardised long leg radiographs that were analysed sequentially before and after surgery if any was performed. The rate of correction of deformity was calculated based on peri-articular angles and diaphyseal deformity angles measured at regular intervals using Traumacad software. Clinical records were reviewed to obtain relevant clinical and demographic details. Statistical analysis was performed using SPSS 23 (SPSS Inc., Chicago, IL, USA). Results The indication for surgical intervention was a mechanical axis progressing through Zone 2 or in Zone 3 despite one year of optimised medical treatment. The 15 patients underwent 16 episodes of guided growth (30 limbs, 38 segments) at a mean age of 10.3 years. In four limbs, surgery has only taken place recently; and in three limbs, correction is ongoing. Neutral mechanical axis was restored in 16/23 (70%) limbs: six improved and one limb (one segment) required osteotomy for residual deformity. The mean rate of angular correction per month was 0.3° for the proximal tibia and 0.7° for the distal femur. Patients with ≥ 3 years of growth remaining responded significantly better than older patients (p = 0.004). Guided growth was more successful in correcting valgus than varus deformity (p = 0.007). In younger patients, diaphyseal deformity corrected at a rate of 0.2° and 0.6° per month for the tibia and the femur, respectively. There has been one case of recurrent deformity. Patients with corrected coronal plane alignment did not complain of significant residual torsional malalignment. Serum phosphate and alkaline phosphatase levels did not affect response to surgery. Conclusions Guided growth is a successful, minimally invasive method of addressing coronal plane deformity in X-LHPR. If coronal plane deformity is corrected early in patients with good metabolic control, osteotomy can be avoided.

Background: Developmental dysplasia of the hip (DDH) is a common, heritable condition characterised by abnormal formation of the hip joint, but has a poorly understood genetic architecture due to small sample sizes. We apply a novel case-ascertainment approach using national clinical audit (NCA) data to conduct the largest DDH genome-wide association study (GWAS) to date, and replicate our findings in independent cohorts. Methods: We used the English National Joint Registry (NJR) dataset to collect DNA and conducted a GWAS in 770 DDH cases and 3364 controls. We tested the variant most strongly associated with DDH in independent replication cohorts comprising 1129 patients and 4652 controls. Results: The heritable component of DDH attributable to common variants was 55% and distributed similarly across autosomal and the X-chromosomes. Variation within the GDF5 gene promoter was strongly and reproducibly associated with DDH (rs143384, OR 1.44 [95% CI 1.34-1.56], p=3.55x1022). Two further replicating loci showed suggestive association with DDH near NFIB (rs4740554, OR 1.30 [95% CI 1.16-1.45], p=4.44x10-6) and LOXL4 (rs4919218, 1.19 [1.10-1.28] p=4.38x10-6). Through gene-based enrichment we identify GDF5, UQCC1, MMP24, RETSAT and PDRG1 association with DDH (p

Previous studies have identified clinical and demographic risk factors for recurrence in the treatment of idiopathic clubfoot (congenital talipes equinovarus). Evertor muscle activity is not usually considered amongst them. This study aimed to evaluate whether recurrence could be predicted by demographic, clinical and gait parameters. From a series of 103 children with clubfeet, 67 had completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic and 29 with non-idiopathic deformities. The mean age was 3.2 years (2.1 to 6.3). Primary correction was obtained in all 38 children (100%) with an idiopathic deformity, and in 26 of 29 patients (90%) with a non-idiopathic deformity. Overall, 60 children (90%) complied with the abduction brace regime. At a mean follow-up of 31.4 months (24 to 62), recurrence was noted in six children (15.8%) in the idiopathic and 14 children (48.3%) in the non-idiopathic group. Significant correlation was found between poor evertor activity and recurrence in both groups. No statistically significant relationship was found between the rate of recurrence and the severity of the initial deformity, the age at the time of treatment, the number of casts required or the compliance with the brace. After correction of idiopathic and non-idiopathic clubfoot using the Ponseti method, only poor evertor muscle activity was statistically associated with recurrence. The identification of risk factors for recurrent deformity allows clinicians to anticipate problems and advocate early additional treatment to improve muscle balance around the ankle. Cite this article: Bone Joint J 2014;96-B:1264–8.

Normal development is not an exact science. Children progress in a variety of ways without falling outside the normal range. This applies to the shape of their legs and feet, as well as the onset and development of their gait pattern. Deviation from parents' expectations may lead to considerable anxiety and medical consultation. It is essential to identify the important pathological diagnoses amongst the array of normal variants to facilitate early intervention and optimise outcomes.

The paediatric skeleton differs from that of an adult in that the bones are more elastic and they contain growth plates (physes). Physeal injuries affect the growth plates of children and adolescents. A basic understanding of the anatomy and physiology of the physis is mandatory in order that injuries to the growth plate can be managed effectively. Salter and Harris described a classification for physeal injuries based on radiographic findings. The system predicts the prognosis for any given injury and guides treatment choice. The goal of treatment is to achieve and maintain an acceptable reduction of the fracture without compromising the germinal layer of the growth plate. A comprehensive understanding of remodelling potential related to patient age and site of injury is essential and influences treatment. Occasionally, malunion and growth arrest can occur. The management of these complications ranges from simple observation to complex deformity correction. The clinician should know how to avoid such complications but also know how to recognize them should they occur.

OBJECTIVE: Screening for hip dysplasia is controversial. A previous randomized controlled trial revealed that adding universal or selective ultrasound to routine clinical examination gave a nonsignificant reduction in rates of late presenting cases, but with higher treatment rates. This study assesses differences in outcome at skeletal maturity for the 3 newborn screening strategies in terms of radiographic markers of acetabular dysplasia and early degenerative change and avascular necrosis (AVN) secondary to neonatal treatment. METHODS: From the initial trial including 11 925 newborns, a population-based sample of 3935 adolescents was invited for follow-up at age 18 to 20 years. A standardized weight-bearing anteroposterior view was obtained. The outcomes evaluated were the radiographic findings of dysplasia (center-edge angle, femoral head extrusion-index, acetabular depth-width ratio, Sharp’s angle, subjective evaluation of dysplasia) and degenerative change (joint-space width). Signs of AVN were documented. RESULTS: Of the 3935 subjects invited, 2038 (51.8%) attended the maturity review, of which 2011 (58.2% female patients) were included: 551, 665, and 795 subjects from the universal, selective, and clinical groups, respectively. Rates per group of positive radiographic findings associated with dysplasia or degenerative change varied depending on radiographic marker used. No statistically significant differences were detected between groups. No AVN was seen. CONCLUSIONS: Although both selective and universal ultrasound screenings gave a nonsignificant reduction in rates of late cases when compared with expert clinical programs, we were unable to demonstrate any additional reduction in the rates of radiographic findings associated with acetabular dysplasia or degenerative change at maturity. Increased treatment rates were not associated with AVN.

Background Neurofibromatosis 1 (NF1) is an autosomal dominant disorder with various skeletal abnormalities occurring as part of a complex phenotype. Tibial dysplasia, which typically presents as anterolateral bowing of the leg with subsequent fracture and nonunion (pseudarthrosis), is a serious but infrequent osseous manifestation of NF1. Over the past several years, results from clinical and experimental studies have advanced our knowledge of the role of NF1 in bone. On the basis of current knowledge, we propose a number of concepts to consider as a theoretical approach to the optimal management of tibial pseudarthrosis. Methods A literature review for both clinical treatment and preclinical models for tibial dysplasia in NF1 was performed. Concepts were discussed and developed by experts who participated in the Children's Tumor Foundation sponsored International Bone Abnormalities Consortium meeting in 2011. Results Concepts for a theoretical approach to treating tibial pseudarthrosis include: bone fixation appropriate to achieve stability in any given case; debridement of the "fibrous pseudarthrosis tissue" between the bone segments associated with the pseudarthrosis; creating a healthy vascular bed for bone repair; promoting osteogenesis; controlling overactive bone resorption (catabolism); prevention of recurrence of the "fibrous pseudarthrosis tissue"; and achievement of long-term bone health to prevent recurrence. Conclusions Clinical trials are needed to assess effectiveness of the wide variation of surgical and pharmacologic approaches currently in practice for the treatment of tibial pseudarthrosis in NF1. Level of evidence Level V, expert opinion.

Introduction The aim of this study was to define the clinical indications and demographic characteristics of patients undergoing open reduction for developmental dysplasia of the hip (DDH), and determine the proportion due to preventable failures of contemporary clinical screening and early management. Methods Case notes were reviewed of consecutive primary open reductions performed for non-teratologic hip dislocation at the Great Ormond Street Hospital for Children over a five-year period. Forty-eight patients (64 hips) were suitable for inclusion. A telephone survey confirmed selective hip ultrasonography screening protocols were employed in all maternity hospitals in our referral base. Results There were no cases of open reduction for unilateral DDH following Pavlik treatment commenced by six weeks of age, highlighting the importance of early detection and treatment. Eleven cases (23%) may have been avoided by appropriate implementation of existing selective ultrasonography screening protocols. Thirty-four cases (71%) presented after four months of age, suggesting open reduction is associated with late diagnosis rather than failure of primary management. None of these patients had neonatal hip ultrasonography and only 12% (4 patients) had a risk factor that should have triggered a scan. Conclusions Compared with published results, the contemporary screening practices in our referral base are failing to eliminate late presenting DDH and the need for open surgical reduction. Changes in strategy and implementation are required to significantly improve screening efficacy.

Venous thromboembolism (VTE) is widely understood to be an important cause both of morbidity and mortality in hospital inpatients. This has led to the development of guidelines for the management of VTE prophylaxis in adults by the national institute for Health and Clinical Excellence. In acknowledgement of the importance of this issue, there are government incentives in the form of Commissioning for Quality and innovation payments that are dependent on the performance of hospital trusts in certain quality indicators, such as risk assessment for VTE in the adult patient.

Early detection of the child with developmental dysplasia of the hip (DDH) allows treatment to be commenced promptly, with potentially fewer requirements for surgical intervention and a better final outcome. Clinical examination has been the mainstay of early detection but the introduction of ultrasound examination provided the possibility for greater sensitivity. The ideal process for detection is still a subject of debate, with surveillance practices varying both between and within countries. Most screening programmes attempt to find a balance between missing a dislocated hip and overtreatment of ultrasonographic findings. This chapter considers the evidence related to screening programmes for DDH and looks at the efficacy of each method of detection, the risks of a screening programme and the question of whether late presentation of developmental dysplasia is a preventable occurrence.

The evidence for the best treatment of acute physeal injuries is based mainly on epidemiologic studies, retrospective reviews, and expert opinion (LoE IV/V).

Background Congenital indifference to pain with anhidrosis (CIPA) is a rare hereditary neuropathy, which is associated with defective sensation to noxious stimuli and autonomic dysfunction. The objective of the study was to report on the orthopaedic manifestations of this condition and provide an evidence-based approach for management. Methods Retrospective review of 14 consecutive patients with CIPA referred to a single tertiary centre. Mean age of diagnosis was 2.5 years (range 0.5 to 11 years). Results Patients presented with a range of orthopaedic problems including fractures, infections, growth disturbance, joint subluxation and Charcot joints affecting the limbs and spine. Conservative treatment with closed reduction and cast immobilisation was satisfactory for stress fractures of the lower extremity and Charcot joints. Posterior instrumented correction of scoliosis was associated with a high-risk of infection requiring reoperation for debridement and removal of posterior instrumentation. Growth disturbance leading to leg-length discrepancies were managed with shoe raises and corrective osteotomies. Aspiration and cultures may be used to differentiate between acute fracture and infection. Conclusions Preventative treatment strategies with appropriately padded shoe-wear, gait and posture modification, parental education regarding environmental thermoregulation, and behavioural support are essential for improving prognosis and reducing long-term complications.

Failure of the enlarged and deformed anterolateral portion of the femoral head to roll into the acetabulum during abduction alters hip joint mechanics. The resultant hinge abduction is associated with pain, and the patient often has restricted movement. A valgus osteotomy removes the deformed portion of the femoral head away from the weight-bearing area and ensures there is pain-free congruent range of movement around the weight-bearing position. The concomitant improvement in lever arm function and leg length results in a better gait pattern. In immature patients, abolition of hinge abduction allows the lateral acetabular ossification center to grow more normally.

Developmental dysplasia of the hip (DDH) is a leading cause of disability in childhood and early adult life. Clinical and sonographic screening programmes have been used to facilitate early detection but the effectiveness of both screening strategies is unproven. This article discusses the role for screening in DDH and provides an evidence-based review for early management of cases detected by such screening programmes.We performed a literature review using the key words 'hip dysplasia,' 'screening,' 'ultrasound,' and 'treatment.'The screening method of choice and its effectiveness in DDH still needs to be established although it seems essential that screening tests are performed by trained and competent examiners. There is no level 1 evidence to advise on the role of abduction splinting in DDH although clinicians feel strongly that hip instability does improve with such a treatment regime. The definition of what constitutes a pathological dysplasia and when this requires treatment is also poorly understood.Further research needs to establish whether early splintage of clinically stable but sonographically dysplastic hips affects future risk of late-presenting dysplasia/dislocation and osteoarthritis. There is a need for high quality studies in the future if these questions are to be answered.

Guiding growth by harnessing the ability of growing bone to undergo plastic deformation is one of the oldest orthopaedic principles. Correction of deformity remains a major part of the workload for paediatric orthopaedic surgeons and recently, along with developments in limb reconstruction and computer-directed frame correction, there has been renewed interest in surgical methods of physeal manipulation or ‘guided growth’. Manipulating natural bone growth to correct a deformity is appealing, as it allows gradual correction by non- or minimally invasive methods. This paper reviews the techniques employed for guided growth in current orthopaedic practice, including the basic science and recent advances underlying mechanical physeal manipulation of both healthy and pathological physes.

Although there is much in the literature regarding pin site infections, there is no accepted, validated method for documenting their state. We present a system for reliably labelling pin sites on any ring fixator construct and an easy-to-remember grading system to document the state of each pin site. Each site is graded in terms of erythema, pain and discharge to give a 3-point scale, named "Good", "Bad" and "Ugly" for ease of recall. This system was tested for intra- and inter-observer reproducibility. 15 patients undergoing elective limb reconstruction were recruited. A total of 218 pin sites were independently scored by 2 examiners. 82 were then re-examined later by the same examiners. 514 pin sites were felt to be "Good", 80 "Bad" and 6 "Ugly". The reproducibility of the system was found to be excellent. We feel our system gives a quick, reliable and reproducible method to monitor individual pin sites and their response to treatment.

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.

Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing. The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-α) and appears to impair the blood supply of bone. Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.

We present a 10-year-old boy with a partial absence of or a hypoplastic right trapezius. At present, his only concern is shoulder asymmetry. No family history of significance and no history of trauma exist. His radiographs confirm changes in bony anatomy secondary to the altered balance of muscle forces on the skeleton. We have not identified any other clinical report of a partial or total absence of the trapezius although it has been defined in cadaveric cases. Similarly, some papers have described an absence of trapezius in combination with other abnormalities. In these cases, an abnormal blood supply has been described in contrast to the normal neurovascular anatomy identified in the cadaveric cases with partial absence. If this patient develops painful disability, the Eden-Lange procedure may be an appropriate treatment as for patients with spinal accessory nerve palsies.

Developmental dysplasia of the hip affects 1-3% of newborns.1 2 w1-w3 A registry based study showed that it was responsible for 29% of primary hip replacements in people up to age 60 years.3 The effectiveness of screening programmes aimed at early detection varies according to their organisation, methods of ascertainment, and diagnostic criteria.1 4 5 w4 Delay in diagnosis means that more complex treatments with higher failure rates will be required, so early diagnosis and prompt, appropriate treatment are essential. We describe the diagnosis, management, and screening controversies for hip dysplasia and provide a framework for early assessment, based on the available literature, including studies with level 1 evidence. #### Summary points The term refers to a spectrum of pathology, ranging from mild acetabular dysplasia with a stable hip through more severe forms of dysplasia, often associated with neonatal hip instability, to established hip dysplasia with or without later subluxation or dislocation. The condition used to be known as congenital dislocation of the …

A questionnaire was sent to all members of the British Society for Children's Orthopaedic Surgery and the Werkgroep Kinder Orthopaedie to identify points of agreement/disagreement on the management of the acute unstable slip of the upper femoral epiphysis and to compare these European results with those from a similar North American survey. Sixty-five per cent responded. Overall, both countries evaluated cases similarly and believed in their urgent management. Sixty-six per cent did not reposition the slip. Significant differences were observed in attitude towards single screw usage, prophylactic pinning and metalwork removal both between the two countries and in comparison with North America.

Botulinum toxin acts at neuromuscular junctions close to muscle motor points and is used to help manage spastic upper-limb deformities. To develop a system allowing clinicians to identify optimal injection sites by an easily reproducible technique, forearm flexor muscles were dissected in 20 formalin-preserved human limbs. Motor points for flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis and pronator teres were (1) identified, (2) related to a reference grid based on lines (proximal, distal, lateral, medial and diagonals) drawn between forearm anatomical landmarks, and (3) defined in terms of their percentage distances along the established grid lines.

Osteofibrous dysplasia is an unusual developmental condition of childhood, which almost exclusively affects the tibia. It is thought to follow a slowly progressive course and to stabilise after skeletal maturity. The possible link with adamantinoma is controversial and some authors believe that they are part of one histological process. We retrospectively reviewed 16 patients who were diagnosed as having osteofibrous dysplasia initially or on the final histological examination. Their management was diverse, depending on the severity of symptoms and the extent of the lesion. Definitive (extraperiosteal) surgery was localised ‘shark-bite’ excision for small lesions in five patients. Extensive lesions were treated by segmental excision and fibular autograft in six patients, external fixation and bone transport in four and proximal tibial replacement in one. One patient who had a fibular autograft required further excision and bone transport for recurrence. Six initially underwent curettage and all had recurrence. There were no recurrences after localised extraperiosteal excision or bone transport. There were three confirmed cases of adamantinoma. The relevant literature is reviewed. We recommend extraperiosteal excision in all cases of osteofibrous dysplasia, with segmental excision and reconstruction in more extensive lesions.

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.

Summary points Cerebral palsy describes a heterogeneous group of permanent disorders of movement and posture which are attributed to non-progressive disturbances in the developing fetal or infant brain and cause limitations in activity. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior; epilepsy; and secondary musculoskeletal problems.1 Worldwide, cerebral palsy is the commonest cause of motor disability in childhood, with an incidence of 2-3 per 1000 live births,2 3 4 increasing to 40-100 per 1000 live births in premature babies and those of very low or low birth weight.5 As cerebral palsy is a permanent disabling condition it is a major consumer of healthcare resources in developed countries. The motor disorder results from centrally …

The management of intra-articular calcaneal fractures remains controversial with strong arguments supporting both conservative and operative management. This study assesses the results of open reduction and internal fixation (ORIF) of displaced intra-articular fractures of the calcaneum in two independent centres where the indications for operative management had been strictly defined.Forty-seven patients (51 fractures) who had sustained such injuries underwent an ORIF performed by one of the senior surgeons using the technique described by Eastwood et al. [JBJS 75-B(1993)189] All of the fractures were assessed by plain X-ray and CT scan and graded according to the Sanders classification [Clin. Orthop. 290(1993)97]. Patients were assessed at a minimum of 2 years post-surgery both clinically and with a standardised questionnaire based on that described by Kerr et al. [Injury 27(1996)35]. The mean age at operation was 42 and 50 years for the two centres, and the mean follow-up was 44 months. Seventy-six per cent of the patients were male. Eighty-eight per cent of the injuries were due to a fall from a height. Fifteen patients had contralateral foot/ankle injuries. Thirty-four of 46 patients were in employment at the time of the injury, 24 of these were in physical jobs and 20 sustained their injury whilst at work.Overall, the satisfaction rate was 90%. Ninety-four per cent of patients in work returned to work at a median of 6 months. Bilateral injuries were associated with a significantly poorer outcome as were those with heel pad pain. Delay to operation greater than 14 days was associated with a higher infection rate. Smoking was not related to infection rate.

We have developed a clinical method for the graphic recording, analysis and planning of treatment of leg-length discrepancy during growth. Initially, the clinically determined discrepancy is plotted against the chronological age yearly, and then in late childhood at six-monthly intervals. CT and measurements of skeletal age are made in middle and late childhood to confirm the clinical findings. In a prospective study in 20 children, we observed that only eight had a linear increase in discrepancy. The observed pattern of increase was therefore used to estimate the mature discrepancy. Epiphyseodesis reference slopes were used to determine the most appropriate time and type of epiphyseodesis. In all children, the leg-length discrepancy at maturity was within 1 cm of the predicted amount. Changes in discrepancy due to leg lengthening or correction of deformity were also plotted graphically. We conclude that the clinical graphic method is simple to use, takes into account the varying patterns of discrepancy, and minimises radiation dosage.

Context A “missed” case of congenital hip dislocation (CDH) can be a disaster for the patient and the outcome may be poor. Considerable resources are expended on screening programmes to identify appropriate cases early but a recent change in terminology to developmental dysplasia of the hip (DDH) and a realisation that neonatal hip maturation is poorly understood has made it difficult to know who should be screened and why. Starting point Neonatal hip screening is well established although some experts feel that the effectiveness of clinical let alone ultrasound screening programmes is unproven. Several European countries undertake population screening, while selective screening occurs in 93% of UK units. K Holen and colleagues recently reported (J Bone Joint Surg 2002; 84-B: 886–90) a prospective randomised trial of just over 15 500 newborn babies in which they compare universal and selective screening programmes. With a follow-up of 6–11 years, one late-detected hip dysplasia was seen in the universal group compared with six in the selective group (not statistically significant). These investigators found, on the background of an excellent clinical programme, no additional benefit from universal screening and thus advocate selective screening. Where next The aims of a screening programme must be defined, then evaluated. A consideration of costs can never take into account family pain and distress. The results of the universal screening programme in Coventry, UK, are impressive and significantly better than results from other UK centres. If the Coventry results are the gold standard, then it is necessary to work out how this can be achieved elsewhere rather than worry about whether it is unachievable.

Background Adolescent posteriorly displaced physeal injuries of the medial clavicle are uncommon. Up to 50% of conservatively treated patients remain symptomatic, and late surgery is hazardous. Stability is rarely achieved with closed or open reduction alone, and internal fixation is usually required. Previously described options for fixation achieve stability of the medial clavicle by securing it to the intact epiphysis. Because the epiphyseal fragment is small, fixation is achieved using sutures or wires. This relies on the size and structural integrity of the medial fragment, which in our experience can be variable. We hypothesized that a novel technique of operative stabilization of these injuries, which does not require fixation to the epiphyseal fragment and uses no metalwork, is safe and effective in treating these injuries. Materials and methods The operative technique involves suturing the medial clavicle to the anterior platysmal and periosteal layer using absorbable sutures passed through drill holes in the medial clavicle. Patients were assessed clinically an average of 9 months after surgery. Results We treated 7 patients with this method. There were no intraoperative complications. All patients were pain-free and symptom-free and had a full range of movement at follow-up. All patients had returned to their preinjury level of sports. Conclusions We recommend this technique for treating these uncommon injuries. It is simple, safe, and reproducible and it produces good results.

To report the prevalence of qualitative radiographic findings for femoroacetabular impingement (FAI) and associations among them and to characterize the inter- and intraobserver variability of these interpretations.This study is part of an institutional review board-approved population-based prospective follow-up of 2081 of 4006 (participation rate, 51.9%) young adults (874 [42.0%] male participants, 1207 [58.0%] female participants; mean age, 18.6 years) who took part in a randomized hip trial on developmental dysplasia of the hip. All participants gave informed consent. Two pelvic radiographs were obtained. Pistol-grip deformity, focal femoral neck prominence, and flattening of the lateral head, all suggestive of cam-type impingement, and the posterior wall sign, excessive acetabular coverage, and crossover sign, all suggestive of pincer-type impingement, were assessed subjectively by an experienced radiologist. To assess inter- and intraobserver agreement, images from 350 examinations were read independently twice by two observers.Cam-type deformities were seen in 868 male and 1192 female participants, respectively, as follows: pistol-grip deformity, 187 (21.5%) and 39 (3.3%); focal femoral neck prominence, 89 (10.3%) and 31 (2.6%); and flattening of the lateral femoral head, 125 (14.4%) and 74 (6.2%). Pincer-type deformities were seen in the same numbers of male and female participants, respectively, as follows: posterior wall sign, 203 (23.4%) and 131 (11.0%); and excessive acetabular coverage, 127 (14.6%) and 58 (4.9%) (all P.001, according to sex distribution). The crossover sign was seen in 446 (51.4%) and 542 (45.5%) of the male and female participants, respectively (P = .004). There was a high degree of coexistence (odds ratio [OR]2) among most FAI findings. Interobserver agreement was good to very good (κ = 0.74-0.84) in rating cam- and pincer-type findings. Intraobserver agreement was moderate or good (κ = 0.49-0.80) for all findings for both observers.Overall, radiographic FAI findings are quite common in a population of healthy young adults, especially in males, with a high degree of coexistence among most findings (OR2).

♦ The child’s foot is very supple but when injuries do occur conventional imaging is not as valuable as it should be because of the late ossification. Accessory centres of ossification complicate matters♦ Transchondral fractures are not easily seen on conventional x-rays♦ Lawnmower injuries (shredding of the forefoot) should have a slightly more tissue-preserving approach than in adults♦ Lacerated tendons in the hindfoot need repairing if foot growth is to be normal.

♦ Developmental dysplasia of the hip represents a spectrum of hip pathology with or without hip instability♦ Controversy continues regarding the relative roles of clinical and ultrasound screening programmes♦ Early diagnosis and prompt, appropriate treatment is important♦ All treatment methods risk compromising the vascularity of the developing femoral head♦ Residual dysplasia may require an aggressive surgical approach.

♦ Damage to the physis may lead to slowing or angulation of growth, especially if a bone bar forms♦ Fractures involving the physis may be difficult to diagnose on x-ray♦ The Salter–Harris classification is commonly used♦ Fixation of fractures should not cross the physis if it can be avoided♦ Partial growth arrest may be best treated with a complete epiphysiodesis followed by reconstruction.