SPECIALTY SUMMARIES

360

ROUNDUP
Childrens orthopaedics
Conservative treatment still

functional perspective the overall re-

complete data, the research team

stabilisation and although it seems

OK in paediatric clavicular

sults were superb for most patients,

were able to include data from over

logical that this would extend to

fractures x-ref

although shortening was associated

100 children (206 lower limbs). The

children, there is surprisingly little

There has recently been an about

with poor clinical outcome scores

computer-generated kinematic data

evidence to support operative stabili-

turn undertaken by adult trauma

(Oxford Shoulder Score, cosmetic

suggested that examination ndings

sation following shoulder disloca-

surgeons with clavicular fracture xa-

and overall satisfaction scores). In

were erroneous in around 25% of

tion in children. Given the rarity of

tion becoming a more widespread

this series, the long-term functional

lower limbs, leaving a sample of 158

the diagnosis, it is hardly surprising

and accepted treatment, although

and clinical outcomes were excellent

limbs with pronounced inversion of

that there is little published in the

the pendulum is starting to swing

for the majority of adolescents with

the patella. The researchers identied

literature, however, a multicen-

the other way again with a number

clavicular fractures. The results of this

a subgroup of around three quarters

tre study has been undertaken

of studies now showing conicting

paper do not support a change in

of these patients (n = 117) who

by researchers in Thessaloniki

results. Despite the rekindling of

practice and conservative manage-

exhibited excessive femoral neck an-

(Greece) and Herne (Germany)

interest in adult clavicular fractures

ment should remain the mainstay

teversion. Amazingly, of these, only

as a comparative prospective cohort

there has been no real renewed inter-

of management forfracturesof

56% exhibited excessive hip internal

series (level II evidence) to identify

est in childrens fracture xation. Re-

theclaviclein this age group.

rotation, with the remainder due

the outcomes of adolescentpatients

Femoral anteversion not

to excessive pelvic rotation or hip

(age 15 to 18 years) with a rst time

shoulder dislocation.3 The study

searchers in Lrenskog (Norway)

set out to establish if conservative

the usual suspect in patellar

muscular contraction. The research-

treatment is still appropriate for the

inversion x-ref

ers argue, quite reasonably, that an

team identied 72 patients of whom

majority of childrens clavicular frac-

Femoral morphological abnor-

internally rotated patellar gait is not

60% were treated operatively and

due only to excessive femoral neck

40% non-operatively. Patients were

anteversion and that in their series

treated with identical rehabilitation

the combination of internal hip rota-

protocols, and clinical outcomes

tion and pelvic rotation was equally

were established with the Rowe

to blame in many cases.

score at 12, 24 and 36 months. The

turning their beady eyes to possible

Shoulder dislocation best

differences in recurrence rates were

new associations with proximal

treated with an operation

marked with a higher than 70%

femoral abnormalities. One of the

x-ref

most widely accepted of these sup-

There has been much interest

positions is the association between

in stratifying shoulder dislocation

femoral neck anteversion and patel-

recurrence rates with conservative

lar mal-tracking. Many clinicians ac-

treatments over the past decade,

cept femoral rotational abnormality

such that patients likely to suffer

as the cause of patellar mal-tracking,

recurrent dislocation can be identi-

and particularly inturned patel-

ed early and undergo stabilisation

lar gait. This is, however, accepted

surgery prior to the development of

without much evidence. A study

the sequelae of recurrent dislocation

team in Paris (France) undertook a

(such as Hill-Sachs lesions, Bankart

study of 188 spastic diplegic children,

lesions and SLAP lesions, to name

tures.1 The study team reviewed all

clavicular fractures occurring at their
institution over a two-year period
in adolescents (aged 10 to 18 years)
and identied the patients using
electronic records. The research team
reviewed records and radiographs to
classify fracture patterns, displacement and shortening. Clinical
outcomes were assessed with the
Oxford Shoulder score and the
QuickDASH scores, along with specic and general satisfaction scores.
The study team were able to review
the records of 185patients (mean age
14 years) with an overwhelming majority of midshaft (93%) undisplaced
(62.2%) fractures. Just nine fractures
underwent operative xation (and
all of these were displaced midshaft
fractures). It is surprising that given
the low operative rate, just one
patient developed nonunion. From a

malities (particularly cam and pincer

deformity of the hip joint and abnormal neck morphology) have become
the height of orthopaedic fashion.
Clinicians and radiologists alike are

all with cerebral palsy. The research

just a few). The general thrust of

team undertook clinical examina-

current adult literature is that the

tion and kinematic 3D gait analy-

younger the patient the more likely

sis. Although not all patients had

they are to benet from operative

Bone & Joint360 | volume 3 | issue 4 | august 2014

failure rate in the conservative group

and just 13% in the operative group.
A total of 38 shoulders in the surgical
group and 27 shoulders in theconservativegroup could be completely
evaluated. From the conservativegroup, 19 patients (70%) suffered
a recurrence of the instability whereas in thearthroscopicgroup, ve
patients (13%) suffered a recurrence
of the instability. Unsurprisingly,
these results strongly mirror the evidence for adult patients and it would
seem sensible for these patients to
undergo arthroscopic stabilisation in
the same way that adults do.

Perthes disease results in

Physiotherapy little benet in

outcome in either group. This useful

isolated and combined disease.

poorer quality of adult life

supracondylar fractures x-ref

study demonstrates no advantage of

Radiological outcomes were also

LeggCalvPerthes disease

There are precious few ran-

physiotherapy over no treatment for

satisfactory with improvement of the

(LCP) is an idiopathic condition

domised controlled trials in

children following a supracondylar

tibiotalar angle to 120 (90 to 152)

of the femoral head which is as-

paediatric orthopaedic surgery so it

fracture of the humerus. Given the

and calcaneal pitch angles to 4 (-13

sociated with idiopathic necrosis

was with some excitement that we

added health economic burden of

to 22). There were three patients

of the femoral head. While the

read a report of a clinically relevant

physiotherapy and poorer short-

requiring subsequent further surgery

aetiology and best method of treat-

randomised controlled trial from

term outcomes, we would tend to

for planovalgus free and two who

ment have been heavily studied

researchers in Seattle (USA).5 Their

agree with the authors here at 360,

required a later pantalar release. This

(although hardly resolved), there

study was designed to establish

that patients received no benet

paper certainly supports the concept

is little known about the longer-

the role (if any) of physiotherapy in

involving either return of function or

of limited midfoot releases as the

term outcomes of Perthes disease,

restoring function after a paediatric

elbow motion from a short course of

best initial surgical option in CVT.

and specically the quality-of-life

supracondylar fracture. The study

physical therapy.

There were no cases of talus AVN

ramications for sufferers of LCP are

team randomised their patients to no

Congenital vertical talus

seen in this series and those patients

unknown. Authors from Upp-

treatment or physiotherapy follow-

addressed at the midtarsal

who required further surgery were

sala (Sweden) have studied the

ing treatment of their supracondylar

joint x-ref

addressable with a peri-talar release.

longer-term consequences of LCP

fracture and included

in adulthood within the Swedish

all patients sustaining a

general population.4 The study

supracondylar fracture

team used a population of 145

between the ages of ve

patients, all diagnosed with LCP at

and 12 years. Patients

their centre and undertook a pro-

treated with both plaster

spective longitudinal cohort study.

immobilisation and per-

Patients were followed using qual-

cutaneous pinning were

ity-of-life questionnaires (EQ-5D),

included in the study

physical activity scales (IPAQ) and

and outcomes were as-

an attention decit hyperactivity

sessed using a combina-

disorder (ADHD) self-reporting tool

tion of self-assessment

(ADHD self-reporting checklist).

of activity levels; the

In addition, prospective records

ASK-p (Activities Scale

of details of soft-tissue injuries or

for Kids-performance

fractures requiring medical care

version) score, anxiety

were also recorded. These results

scores and movement assessment

were compared with normal values

by a blinded physiotherapist. The

from the general Swedish popula-

study cohort consisted of 61 patients

tion. The reported cohort consisted

who were randomised to one of the

of 145 patients (of whom 116 had

two treatment modalities and then

complete responses) and were

assessed for upper limb performance

established to have signicantly

at weeks 1,9,15 and 27 following

lower quality-of-life scores than the

injury. The two intervention groups

Swedish general population (as

consisted of either six sessions of

measured by the EQ-5D) in both

standardised hospital-based special-

the VAS and dimensions portions

ist physiotherapy or no treatment.

of the score. Interestingly, the

The ASK-p scores (primary outcome

researchers established that over

measure) were signicantly better

a quarter of the study population

in the no-therapy group at nine and

had scores suggestive of ADHD,

15 weeks after injury (p = 0.02 and

and there was a strong correlation

0.01, respectively), however, this dif-

between impaired EQ-5D scores

ference had normalised by 27 weeks

and higher ADHD indices. Despite

with no differences in performance

impaired quality-of-life scores, over

of activities of daily living or time to

90% of study patients had moder-

return to sports. Objective blinded

ate or high physical activity scores

assessment of range of elbow move-

and the authors comment that this

ment did not show any differences

may be in part associated with the

at any time points, and severity

aetiology of LCP disease.

of injury was not associated with

Congenital

vertical talus (CVT) can

Certainly a paper with food for

thought in a rare condition.

be a challenging condi-

Single-sitting DDH surgery

tion to diagnose and

worth the effort

treat. Rarely amenable

Late diagnosis of developmental

to conservative treat-

dysplasia of the hip (DDH) poses

ment the condition

challenges for surgeons, patients

is also uncommon,

and carers. Often associated with

making decision making

cerebral palsy, later onset DDH is

complex. Patients usu-

often bilateral and treatment can

ally require a pan-talar

often interrupt schooling and reha-

release which has been a

bilitation for the patient. Surgeons in

staple accepted treatment

Izmir (Turkey) aimed to establish

for many years. Surgeons

if a staged approach or combined

in Paris (France) have

bilateral procedure yielded best

been using an alternate,

outcomes for patients with bilateral

less signicant surgical approach

DDHdiagnosed after walking age.7

for over 35 years, just releasing the

Outcomes were assessed with a com-

midtarsal joint.6 This rare condition

bination of radiological (acetabular

is reported in a lifetime series of 31

index) and clinical outcomes. The

complex foot reconstructions in 21

study group consisted of 24 prospec-

patients. The surgical team treated

tive patients split into two different

31 feet over 32years of which around

groups, with 12 treated with each

half (15feet) were isolated CVT

method (bilateral procedures or a sin-

and the remainder were associ-

gle unilateral procedure). Follow-up

ated with other conditions (usually

was to just over 4.5years and there

arthrogryposis or a neuromuscular

were no signicant differences in any

disorder). The feet were relatively

of the outcome measures between

severe with a mean tibiotalar angle

groups including clinical and

of 150 and calcaneal pitch of -19 (

radiological outcome measures. The

-72 to 4). The French surgical team

inference from this paper is that the

used a reproducible surgical tactic

clinical and radiological outcomes

undertaking midfoot capsulotomies

are identical between unilateral and

(at the talo-navicular and calcaneo-

bilateral simultaneous procedures. If

cuboid joints) in combination with

outcomes are the same and bilateral

Achilles tendon and extensor tendon

hips can be addressed at a single

tenotomies. Outcomes as assessed

sitting, then it would seem best to

by the Adelaar score were good in

do so, minimising disruption to the

around three quarters of feet, with

patient and carers without compro-

no detectable differences between

mising outcomes.

Bone & Joint360 | volume 3 | issue 4 | august 2014

25

Cubitus valgus associated

tions. Outcome measures were

from small clinical series, however,

of the shoulder in adolescents. J Pediatr Orthop

with simple elbow dislocation

specically designed to establish the

this series does make the interest-

2014;34:421-425.

Simple elbow dislocation is

rate (or otherwise) of longer-term

ing observation that on occasion

4. Hailer YD, Haag AC, Nilsson O. Legg-calv-

relatively common in children and

deformity and therefore carry-

clinically relevant valgus can occur

perthes disease: quality of life, physical activity, and

may be associated with a capitellar

ing angle (as compared with the

following simple elbow dislocation.

behavior pattern. J Pediatr Orthop 2014;34:514-521.

or trochlear fracture (making it a

uninjured side) and the Mayo elbow

It would be nice to see a larger series

5. Schmale GA, Mazor S, Mercer LD,

complex dislocation) and these are

performance score were used to

reported, and with eight authors one

Bompadre V. Lack of benefit of physical therapy

widely recognised to be associated

assess patients clinically in the longer

could be tempted to wonder what

on function following supracondylar humeral

with cubitus varus and valgus in

term. Outcomes were assessed

contribution each has had to a paper

fracture: a randomized controlled trial. J Bone Joint

later life. For this reason patients are

at a little over two years of mean

reporting just 11 patients!

Surg [Am] 2014;96-A:944-950.

usually followed-up long term. There

follow-up and all patients achieved

is, however, little evidence informing

good or excellent results according

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to follow-up. Almost universally

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(10 to 20) when compared with

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