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Introduction: Low bone mineral density (BMD) is prevalent in children with cerebral palsy, increasing fracture risk and compromising an optimal bone health trajectory through the lifespan. Zoledronate is increasingly used to improve the BMD, however, no randomized trial has evaluated the ef- fect. We performed a multi-center, randomized, controlled, double-blind trial to evaluate the effect of zoledronate in children with non-ambulant cerebral palsy.Patients and methods: Two doses of placebo or zoledronate were infused at a 6-month interval. Dual X-ray absorptio- metries of the lumbar spine and lateral distal femur were done at baseline and 12months and the BMD Z-score changes were calculated. Growth was monitored using weight, bone age, pubertal staging, knee–heel length and blood biomarkers.Results: Twenty-four participants were randomized and completed the study. Ten were treated with placebo. The fourteen participants in the zoledronate group experienced BMD Z-score gains of +0.8 SD at the lumbar spine and + 0.3 to +1.7 in the three regions of the lateral distal femur. Three of four gains were significantly different from the placebo group. Moderate to very severe influenza-like symptoms were common in the zoledronate group, but only after the first dose. Lasting side effects including growth changes were not encountered.Conclusion: Zoledronate significantly increases BMD in children with cerebral palsy in 1year without affecting growth. First-dose side-effects were common and consider- able. Studies into lower first doses and long-term outcomes are needed.

Background and purpose — Temporary hemiepiphysiodesis for growth modulation in skeletally immature patients is a long-known technique. Recently the use of tension-band devices has become popular. This study compares 2 tensionband implants (eight-Plate and FlexTack) regarding their effects on the growth plate. Animals and methods — 12 pigs in 2 equally sized groups (A and B) were investigated. The right proximal medial tibia was treated with either eight-Plate or FlexTack. The left tibia of the same pig was treated with the opposite implant. After 9 weeks all implants were removed. Animals in group B were then hosted for another 5 weeks. Histomorphometric analysis of the growth plate was carried out after 9 and 14 weeks, respectively. Radiographs were taken at implantation, removal, and after 14 weeks. Results — Both tension-band devices achieved a statis- tically significant and clinically relevant growth inhibition, whereas the effect appeared to be more distinct after the use of FlexTack. Implant-related complications or physeal damage was not observed. After implant removal, rebound phenomenon was radiologically observed in all cases. The growth plates treated with eight-Plate showed a paradox reversal of the zonal distributions, with an increase of the proliferative zones at the previously arrested medial aspect of the physis and a decrease laterally. Interpretation — Both eight-Plate and FlexTack proved to be appropriate devices for growth-guiding treatment. The radiographic evaluation showed a change in angular axes after treatment with each implant, while the correction appeared to be faster with FlexTack. The paradox cartilaginous reaction observed after removal of the eight-Plate might be a histopathological correlate for rebound phenomenon., Finanziert durch den Open-Access-Publikationsfonds der Westfälischen Wilhelms-Universität Münster (WWU Münster).

Background: Patient Reported Outcome Measures (PROM) after resection of tarsal coalitions are sparse. This cross-sectional study evaluates the outcome after resection of tarsal coalitions in children using the validated Oxford Foot and Ankle Questionnaire (OxAFQ).Methods: Tarsal coalition patients between 5-16 years of age from Aarhus University Hospital (Denmark) and The Royal London Hospital (United Kingdom) were included. The patients were identified using patient and theatre register. All patients and proxies filled in the PROM: OxAFQ-C and OxAFQ-proxy respectively. The scores were calculated within each domain and reported as means (95% confidence intervals). Talocalcaneal coalitions were compared to calcaneonavicular coalition with regard to OxAFQ score and re-operation rate.Results: 27 patients and their proxies returned 54 questionnaires in total regarding 36 feet. Mean time from surgery to filling of the questionnaire was 25 (21-30) months. The relative mean OxAFQ score was higher in the School and Play and Emotional domain than the Physical domain, p = 0.007. The OxAFQ scores and re-operation rates were similar for both coalitions, p=0.63.Conclusion: The OxAFQ PROM showed more encouraging results in playing or emotional health status than the physical health status. The outcome for both types of coalitions is similar.Level of Evidence: IV.

Femoral fractures in children are not common injuries, and the treating physicians should master non-operative and operative treatment options. Non-accidental injury is frequently seen in children below two years of age. In this review, we describe a range of techniques for treatment of the injuries, and the current treatment trends and matters of discussion are early spica casting, age and weight guidance for use of flexible and rigid intramedullary nails. We advocate early consultation with a tertiary care centre for guidance and planning of the best treatment modality.

Background and purpose ��� Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation. Methods ��� We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities. Results ��� Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016. Interpretation ��� The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.

INTRODUCTION: Genu valgus is a condition characterised by a lateral shift of the knee's mechanical axis. The deformity can be characterised using clinical examinations and long hip-knee-ankle (HKA) angles, but it is unclear how these investigations correlate with each other. Our aim was to examine the correlation between clinical and radiographic measurements of the lower extremities in children.METHODS: A total of 49 children between 5.9 and 16.7 years of age who had been referred with genu valgum deformity were included. They all had their intermalleolar (IM) distance measured and a standardised anterior-posterior radiograph of the lower extremities taken. IM distance was adjusted for the mean tibial and femoral length to adjust for differences in leg length. We calculated the Spearman's rank correlation coefficient to study the reliability between radiographs and clinical examinations.RESULTS: We found no correlation between clinical IM distance and the HKA angles. Spearman's rho for comparison between adjusted clinical IM distance measurements and HKA angles on radiographs was found to be 0.36.CONCLUSIONS: We found a poor correlation between clinical examinations and HKA angles as data were corrected for leg length. More studies are needed to provide clear recommendations for following children with malalignment.FUNDING: none.TRIAL REGISTRATION: The study was registered with the Danish Data Protection Agency.