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Includes bibliographical references (leaves 28-31).

Background: In paediatric trauma, measured increase in prevertebral soft tissue thickness on a lateral cervical spine (C-spine) X-ray is interpreted as swelling, raising suspicion of C-spine injury1,2 . Defining swelling in absolute measurements is cumbersome – children’s sizes vary. Evidence for potentially more consistent tools measuring soft tissue thickness as a ratio of vertebral body width is lacking. Clinical decision rules should be based on best available evidence to minimize patient harms and improve health outcomes. This study determined whether consistent, measurable ratios exist for use as simple diagnostic tools in assessing paediatric soft tissue swelling and C-spine injury. Methods: A pragmatic quantitative retrospective cross-sectional study randomly sampled C-spine trauma X-rays taken at a South African children’s hospital. Seventy-one un-intubated X-rays from 85 controls were used to identify normal ratios. The authors measured vertebral bodies and soft tissue at each level, created all possible ratios, then chose the two least variable – one for the upper and one for the lower C-spine. Twenty cases aided in determining diagnostic accuracy for C-spine injury. Results: Mean soft tissue at the second cervical vertebral level (c2) was 38% of the seventh vertebra (C7) (95%CI:34-41.9%, SE:2.0%, variance:2.5%). Mean c6 soft tissue was 65.6% of C7 vertebra (95%CI:61.9-69.3%, SE:1.9%, variance:2.3%). In diagnosing C-spine injury, a Receiver Operating Characteristic (ROC) curve calculation gave an empirical optimal cut-point of 53.9% and 74.4% respectively. Using practical cut-offs of 55% at c2 and 75% at c6 yield specificities of 93.8% (95%CI:84.8-98.3%) and 81.8% (95%CI:70.4-90.2%), with negative predictive values of 90.9% (95%CI:81.3-96.6%) and 91.5% (95%CI:81.3-97.2%) respectively. Conclusions: Consistent and specific ratios exist in the upper and lower paediatric C-spine. Both ratios have extremely poor sensitivities and positive predictive values and so are poor screening tools, but can aid in ruling in injury in patients with clinical suspicion. Level of evidence: Diagnostic Level III

Background: According to the World Health Organization (WHO), Traumatic Brain Injury (TBI) will become the third largest cause of global disease by the year 2020. Despite its astonishing numbers, TBI remains a silent or even forgotten epidemic with significant paucity in epidemiological data. TBI in developing countries represents a disproportionate burden of disease and data are lacking regarding the unique demographics in South Africa to design and implement focused prevention programmes. A valuable tool to assess the severity of TBI is the use of Computer tomography (CT). CT also is the main imaging modality to provide rapid identification and information for the management of children with TBI. CT scanning utilises ionising radiation and as an imaging modality poses risk to the patient. In order to guide decision protocol/algorithm, various Clinical Decision Rules (CDRs) have been established in High Income Countries. These protocols, including the need for CT scan might differ in a Medium/Low Income setting. Methodology: This is a prospective, single centre cohort study. Data were collected over an 18-month period (1 August 2015 - 31 January 2017). Children under the age of 13 years (n=3007) presenting to RCWCH after sustaining a head injury were included. Various epidemiological data were collected. A Road Safety Questionnaire was also used to evaluate safety knowledge of health care workers. Three different CDRs were compared to the standard of practice in RCWCH. A final analysis of demographics, mechanism of injury, radiology outcome, safety analysis and evaluation of a comparison of local protocol compared to the other CDRs was performed using descriptive statistics. Results: The mean age of paediatric patients presenting after a head injury was 4.6 years. There was a significant male predominance (66%) and almost two thirds of all children were of pre-school age. Falls (53%; n=1601) represented the most common mechanism of injury across all age groups, followed by road traffic related injuries (RTI) (29%; n=864), struck by or against an object (9%; n=279) and injuries as a result of interpersonal violence (8%; n=230). Within the subset of RTI (n=864) only 6 passengers were appropriately restrained, with 142 unrestrained and 56 passengers transported on the back of a goods vehicle. In the under 3-yearold age group, only 1 patient was appropriately transported in a car seat, with 51 unrestrained and 6 transported on the back of a goods vehicle. Pedestrian related injuries were by far the largest group of RTI (70%) with 50% of these under the age of 5 years. Intentional injuries inflicted by an adult were most common (34%) in the pre-verbal (under 2 years old) group. Interpersonal violence among minors (assault with a brick or stone) constituted 52% of intentional injuries. Eight firearm related injuries were recorded. Appliances and iron gates that were not correctly installed were additional causes of injury. CT scans were obtained according to the RCWCH protocol in 59% of cases and 34% showed an abnormal result. The sensitivity (98%) and specificity (93%) while using the standard of practice protocol was better than the 3 CDRs developed in High Income Countries. Analysing our Road Safety Questionnaire there appears great room for improvement regarding awareness of road safety guidelines and legislation. Conclusion: The performance of the current RCWCH CT scan protocol appears appropriate in our setting although there is some room for improvement using the strengths of the other CDRs. Valuable insight regarding the epidemiology of TBI in our setting has been highlighted. Of specific importance is the large proportion of very young children at risk of injury by all mechanisms of injury, particularly pedestrian-related injuries, unrestrained passengers and interpersonal violence among minors. Important gaps in knowledge about current recommendations for road safety were identified by the questionnaire. As long as these issues are not appropriately addressed through enhanced injury prevention programmes, children will continue to carry the heavy burden of TBI morbidity and mortality.

The Ponseti technique of manipulation and casting is reported to have almost eliminated the need for extensive soft tissue release in the treatment of idiopathic clubfoot. This technique of treatment has however not been universally adopted and results of treatment vary significantly between treatment centres. Furthermore, surgical decision making in the treatment of clubfoot is currently largely based on clinical findings as opposed to radiographic parameters. The Ponseti method of manipulation and casting was introduced at our institution in 2002, prior to which we used the Kite method. Both prior to, and following the introduction of Ponseti casting, surgical decision making was based on pre-operative radiology, and intra-operative clinical assessment. We propose to determine the impact on this change of plastering technique on the rate of major surgery performed primarily in our patients with idiopathic clubfoot. We also aim to determine whether or not pre- operative radiographs have any bearing on the surgery performed on these patients.

Includes summary., Includes bibliographical references (leaves 47-50)., Rudimentary ulnar polydactyly is one of the most common congenital hand anomalies. These are conventionally treated by suture ligation in the neonatal period or by formal excision, when the child is one year of age. For the last three years, the Congenital Hand Unit at Red Cross Children’s Hospital has used vascular clip ligation as an alternative method of treatment for rudimentary ulnar polydactyly, based on the same principle as suture ligation, but with less associated complications. A study was performed at the unit, where two hundred and nineteen supernumerary digits were treated over a two-year period. The digits were ligated using a vascular clip, as an outpatient procedure.