Search

Background: Developmental dysplasia of the hip (DDH) is a common disorder of atypical hip development. Pelvic osteotomy (e.g., according to Salter, Pemberton or Dega) may be indicated for children with DDH at walking age. The most popular postoperative treatment is a hip spica cast. Alternative postoperative options include abduction braces and non-weightbearing protocols combined with physical therapy. The aim of this systematic review was to determine the most effective form of postoperative treatment after unilateral pelvic osteotomy in children with DDH in terms of clinical and radiological outcomes and complications. Methods: A systematic review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines and registered in the international prospective register of systematic reviews. Articles were selected from PubMed, Embase and Cochrane databases. The quality of all (non-)randomized included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results: The search strategy yielded 3524 articles. Fourteen articles with 367 total hips were included in this review. A total of 312 hips were treated with spica casts, 49 with abduction braces and 6 with non-weightbearing protocols. The quality of evidence was moderate (MINORS, 3–12 points). All types of postoperative treatments had good clinical outcomes overall, without secondary displacement of the osteotomy. Clinical outcomes for spica casts were reported according to McKay's criteria in 135 hips, with 123 excellent and 12 good results. Clinical outcomes for abduction braces showed satisfaction for all parents (49 of 49). The radiological outcome was overall well preserved with any postoperative treatment. There was a higher complication rate with the use of hip spica casts, including avascular necrosis, pain complaints and superficial infections. Conclusion: This systematic review showed no benefit of postoperative spica casts compared with abduction braces and avoidance of weightbearing after simple pelvic osteotomy for residual DDH. [ABSTRACT FROM AUTHOR]

Background. During the treatment of unstable hips in developmental hip dysplasia (DDH), the position of the femoral head must be assessed in spica cast (SC) after reduction. A transinguinal sonographic technique (TIT) to the hip joint has been previously described in the literature. The aim of this study is to evaluate the agreement among TIT and MR to identify hip reduction. Methods. From 2016 to 2019, 14 consecutive newborns (10 female, 4 males) with a mean age of 2.97 ± 1.29 months were treated with closed reduction in SC. A total of 4/14 children had bilateral unstable DDH. Out of 18 hips, there were 8 hips type IV and 10 hips type IIIA, according to Graf. SC were changed monthly and hips were checked both with TIT and MR, looking for persistent dislocation. Results. Overall, a mean of 2.61 SC/hip (mode = 3) was accomplished, accounting for 47 procedures, with 46 reduced hips and 1 dislocated hip: TIT and MR always agreed on the same result (47/47; Cohen k = 1, CI95 1.00 to 1.00). Conclusions. The inguinal ultrasound technique described by van Douveren showed perfect agreement with MR and might be considered a reliable alternative to check the position of the femoral head during the conservative treatment of hip dysplasia in spica cast. [ABSTRACT FROM AUTHOR]

Background: Developmental dysplasia of the hip (DDH) is a common disorder of atypical hip development. Pelvic osteotomy (e.g., according to Salter, Pemberton or Dega) may be indicated for children with DDH at walking age. The most popular postoperative treatment is a hip spica cast. Alternative postoperative options include abduction braces and non-weightbearing protocols combined with physical therapy. The aim of this systematic review was to determine the most effective form of postoperative treatment after unilateral pelvic osteotomy in children with DDH in terms of clinical and radiological outcomes and complications. Methods: A systematic review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines and registered in the international prospective register of systematic reviews. Articles were selected from PubMed, Embase and Cochrane databases. The quality of all (non-)randomized included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results: The search strategy yielded 3524 articles. Fourteen articles with 367 total hips were included in this review. A total of 312 hips were treated with spica casts, 49 with abduction braces and 6 with non-weightbearing protocols. The quality of evidence was moderate (MINORS, 3–12 points). All types of postoperative treatments had good clinical outcomes overall, without secondary displacement of the osteotomy. Clinical outcomes for spica casts were reported according to McKay’s criteria in 135 hips, with 123 excellent and 12 good results. Clinical outcomes for abduction braces showed satisfaction for all parents (49 of 49). The radiological outcome was overall well preserved with any postoperative treatment. There was a higher complication rate with the use of hip spica casts, including avascular necrosis, pain complaints and superficial infections. Conclusion: This systematic review showed no benefit of postoperative spica casts compared with abduction braces and avoidance of weightbearing after simple pelvic osteotomy for residual DDH.

Ammar K Alomran,1 Hadeel Almulhim,2 Shahad Alabdulqader,2 Danah S Almutairi,2 Danah F Alrusayyis,2 Sarah A Althwaiqb,2 Arwa Alumran3 1Orthopedics Department, Imam Abdulrahman bin Faisal University, College of Medicine, Dammam, Saudi Arabia; 2College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia; 3Health Information Management and Technology Department, Imam Abdulrahman bin Faisal University, College of Public Health, Dammam, Saudi ArabiaCorrespondence: Hadeel Almulhim, Tel +966501407070, Email 2170006025@iau.edu.saBackground: Hip spica tables are widely used among pediatric orthopedic surgeons to maintain the hip position during cast application and drying processes for a better outcome. Locally customized spica tables can be a significant concern if their limitations significantly interfere with the quality of care.Objective: This study aims to explore the current practice of pediatric hip spica table application among hospitals in the GCC countries and report comprehensive data that help surgeons enhance their practice.Methods: This is a cross-sectional study on pediatric orthopedic surgeons using a self-administered Online Questionnaire. The respondents were grouped as those using locally customized tables, where further information about the material and characteristics were collected, and those using company manufactured tables. Both groups answered analytical questions related to their current practice of hip spica tables.Results: Sixty-three surgeons completed the survey. More than half the physicians in this study are using locally customized spica tables (n= 41, 65%). Compared to company-manufactured tables, locally customized tables were associated with a higher rate of difficulties when taking an X-ray, when the patient weighs more than 50.0 kg, and with anesthesia, although not statistically significant.Conclusion: Obtaining a good quality spica table at a suitable price is a primary obstacle pediatric orthopedic surgeons face. This study shows no statistically significant difference between locally customized and company-manufactured tables regarding the outcomes and that spica tables have room for development to optimize their utilization.Keywords: spica tables, pediatric orthopedics, spica cast, developmental dysplasia of the Hip, DDH, fractures

There remains a lack of high-quality evidence on the treatment of pediatric femur shaft fractures. Therefore, treatment choices may still be based on personal preference of treating surgeons. To gain insight in considerations regarding treatment options, we conducted a survey among Dutch trauma and orthopedic surgeons. This survey was conducted in 2020, regarding treatment considerations for closed femoral shaft fractures in children in different age and weight groups. One hundred forty-two surgeons were included in the analysis. 31% of participating surgeons considers surgical fixation in children of 2–4 years old, compared to 83% in children of 4–6 years old. In terms of weight, 30% considers surgery in children of 10–15 kg, compared to 77% considering surgery in children weighing 15–20 kg. While most surgeons find traction and spica cast suitable options for children younger than 4 years, a minority also considers these treatment modalities for children older than 4 (traction: 81% versus 19%, spica cast 63% versus 29% respectively). 33% of surgeons considers ESIN under 4 years of age, compared to 88% in children older than 4. An age of 4 years and a weight of 15 kg seem to be cut off points regarding preference of non-surgical versus surgical treatment of closed femoral shaft fractures. There is a wide range of ages and sizes for which treatment options are still being considered, sometimes differing from the national guideline. This questions guideline adherence, which may be due to a lack of available high-quality evidence. • Almost all trauma and orthopedic surgeons take both age and size in consideration when deciding on treatment of pediatric closed femur shaft fractures. • An age of 4 and a weight of 15 kg seem to be cut off points regarding preference of non-surgical versus surgical treatment of closed femoral shaft fractures. • Although the identified turning points of 4 years old and 15 kg are in accordance with the national guideline, the wide range of ages and sizes for which some treatment options are still being considered might imply a limited adherence to this guideline. [ABSTRACT FROM AUTHOR]

Introduction: Bilateral femoral fractures in children (BFFC) are an uncommon condition. Only a few cases were reported in the literature. The frequency and outcome in low-setting facilities are unknown. This study aims to describe our experience in managing BFFC. Patients and Methods: A 10-year ongoing study spanning from 2010 to 2020 was held in a level-1 paediatric facility. We included all cases of BFFC on a bone-free disease with at least 10 months of follow-up time. Data were collected and analysed with statistical software. Results: A total of eight patients with ten BFFC were collected. It involved mainly boys (n = 7/8) with median age of 8 years. Mechanism of injury were a road traffic accident (n = 4), a fall from height (n = 3), and been crushed by a falling wall (n = 1). Associated injuries were frequent (n = 6/8). Patients were managed nonoperatively with spica cast (n = 5) and by elastic intramedullary nails (n = 3). After 6.11 years of mean follow-up time, all fractures healed. The outcome was excellent and good in 7 cases. One patient sustained knees stiffness. Conclusion: Non-operative management of BFFC showed satisfactory outcomes. Early surgical care must be developed in our low-income settings to reduce in-hospital stay and encourage early weight-bearing.

Purpose: Titanium elastic nail (TEN) is a good option for femoral shaft fractures in school-age children, whereas a spica cast is favored for younger patients. We aimed to compare these treatment modalities in a group of children aged three to six years. Methods: 34 patients aged 3–6 years with an isolated closed femoral shaft fracture treated with TEN or one-leg spica cast immobilization were retrospectively assessed. Age, gender, weight, mechanism of injury, hospital stay time, bone union time, radiographic shortening, malunion, and complications were compared between the treatment groups. Results: 16 (47.1%) patients who were treated with TEN (Group T) and 18 (52.9%) patients with spica casting (Group S) were included with a mean of 51 (24–94) months follow-up. The mean age was 4.98 years and statistically similar between both groups (mean, 5.2 vs. 4.8 years; p = 0.234). The patients in Group T were heavier (mean, 19.3 vs. 17.2 kg; p < 0.001) and were more likely to have a higher-energy mechanism of injury (p = 0.006). The mean late femoral shortening of Group S patient's was 6.5 ± 3.5 mm and significantly higher than Group T, which was 2.0 ± 2.9 (p = 0.050). However, effective late femoral shortening rates were not statistically different between groups (p = 0.347). Malunion was seen in six (33.3%) patients in Group S, whereas none of the patients in Group T had malunion at the last follow-up examination and were statistically different (p = 0.011). Conclusion: Our study identified radiographic evidence favoring TEN over spica cast immobilization in treating preschool-age children with an isolated femoral shaft fracture in terms of malunion. [ABSTRACT FROM AUTHOR]

Introduction: Bilateral femoral fractures in children (BFFC) are an uncommon condition. Only a few cases were reported in the literature. The frequency and outcome in low-setting facilities are unknown. This study aims to describe our experience in managing BFFC. Patients and Methods: A 10-year ongoing study spanning from 2010 to 2020 was held in a level-1 paediatric facility. We included all cases of BFFC on a bone-free disease with at least 10 months of follow-up time. Data were collected and analysed with statistical software. Results: A total of eight patients with ten BFFC were collected. It involved mainly boys (n = 7/8) with median age of 8 years. Mechanism of injury were a road traffic accident (n = 4), a fall from height (n = 3), and been crushed by a falling wall (n = 1). Associated injuries were frequent (n = 6/8). Patients were managed nonoperatively with spica cast (n = 5) and by elastic intramedullary nails (n = 3). After 6.11 years of mean follow-up time, all fractures healed. The outcome was excellent and good in 7 cases. One patient sustained knees stiffness. Conclusion: Non-operative management of BFFC showed satisfactory outcomes. Early surgical care must be developed in our low-income settings to reduce in-hospital stay and encourage early weight-bearing. [ABSTRACT FROM AUTHOR]

Background. During the treatment of unstable hips in developmental hip dysplasia (DDH), the position of the femoral head must be assessed in spica cast (SC) after reduction. A transinguinal sonographic technique (TIT) to the hip joint has been previously described in the literature. The aim of this study is to evaluate the agreement among TIT and MR to identify hip reduction. Methods. From 2016 to 2019, 14 consecutive newborns (10 female, 4 males) with a mean age of 2.97 ± 1.29 months were treated with closed reduction in SC. A total of 4/14 children had bilateral unstable DDH. Out of 18 hips, there were 8 hips type IV and 10 hips type IIIA, according to Graf. SC were changed monthly and hips were checked both with TIT and MR, looking for persistent dislocation. Results. Overall, a mean of 2.61 SC/hip (mode = 3) was accomplished, accounting for 47 procedures, with 46 reduced hips and 1 dislocated hip: TIT and MR always agreed on the same result (47/47; Cohen k = 1, CI95 1.00 to 1.00). Conclusions. The inguinal ultrasound technique described by van Douveren showed perfect agreement with MR and might be considered a reliable alternative to check the position of the femoral head during the conservative treatment of hip dysplasia in spica cast.

Mohamad S Yasin, Mohammed S Alisi, Yazan S Hammad, Omar Q Samarah, Freih O Abu Hassan Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, JordanCorrespondence: Mohamad S Yasin, Department of Special Surgery, Division of Orthopedics, School of Medicine, The University of Jordan, Amman, Jordan, Email msyasin82@gmail.comPurpose: Closed reduction (CR) is a standard treatment for developmental dysplasia of the hip (DDH) after failed conservative treatment. After CR, the affected hip is held in the reduced position by a spica cast that typically extends below the knee (long). Above knee (short) spica cast is an alternative technique utilized by some pediatric orthopedic surgeons. We aimed to compare short versus long spica cast after CR in terms of success rate and complications.Methods: Patients who underwent CR with short or long hip spica cast over a 3-year period (2016– 2019) were evaluated for the success (sustainability of the reduction) and complications. The acute and long-term success were recorded retrospectively. Acute success was defined as concentric reduction of the hip confirmed by intraoperative arthrogram and immediate postoperative CT scan. Long-term success was defined as maintained reduction at 12 months’ post reduction.Results: Forty-seven patients were included in our study. Long spica casts were used in 24 patients and short ones in the remaining 23. The overall acute and long-term success rates were 83% and 66%, respectively. The acute success rate of long spica was 87.5%, while short spica achieved 78.2%. On the long term, the success rate of short spica was higher than long one (73.9% vs 58.3%). Cox regression analysis showed that the type of cast (short vs long spica) was not correlated with acute success (P = 0.405), long-term success (P = 0.263), residual dysplasia (P = 0.405), or avascular necrosis (P = 0.053).Conclusion: CR in DDH is an important line of management in the younger patient population and can save them an invasive open surgery later in life. A short leg spica could represent an easier and likely as successful alternative to the traditional long spica. More prospective future research is needed to validate our observational findings.Level of Evidence: III.Keywords: DDH, spica cast, closed reduction, hip, dysplasia

Objective: To review current literature on treatment of closed femoral shaft fractures in children of 2–10 years old, with subgroup analysis of children aged 2–6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. Methods: We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2–10 years of age. Subgroup analysis of children aged 2–6 years was performed. Results: Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15–2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82–2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03–0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02–47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05–0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05–69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). Conclusion: Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2–10 years of age. Level of evidence: 3. [ABSTRACT FROM AUTHOR]

Closed reduction followed by spica casting is a conservative treatment for developmental dysplasia of the hip (DDH). Magnetic resonance imaging (MRI) can verify proper closed reduction of the dysplastic hip. Our aim was to find prognostic factors in the first MRI to predict the possible outcome of the initial treatment success by means of ultrasound monitoring according to Graf and the further development of the hip dysplasia or risk of recurrence in the radiological follow-up examinations. A total of 48 patients (96 hips) with DDH on at least one side, and who were treated with closed reduction and spica cast were included in this retrospective cohort study. Treatment began at a mean age of 9.9 weeks. The children were followed for 47.4 months on average. We performed closed reduction and spica casting under general balanced anaesthesia. This was directly followed by MRI to control the position/reduction of the femoral head without anaesthesia. The following parameters were measured in the MRI: hip abduction angle, coronal, anterior and posterior bony axial acetabular angles and pelvic width. A Graf alpha angle of at least 60° was considered successful. In the radiological follow-up controls, we evaluated for residual dysplasia or recurrence. In our cohort, we only found the abduction angle to be an influencing factor for improvement of the DDH. No other prognostic factors in MRI measurements, such as gender, age at time of the first spica cast, or treatment involving overhead extension were found to be predictive of mid-term outcomes. This may, however, be due to the relatively small number of treatment failures. [ABSTRACT FROM AUTHOR]

BackgroundThe Tübingen splint was initially developed for the treatment of stable developmental hip dysplasia (DDH). Later on, some authors expanded its include for the treatment of unstable DDH, but there remain some controversies in the literature. This study aims to compare the outcome between stable and unstable DDH treated with a Tübingen splint.MethodsEpidemiological data and ultrasonographic data of all infants diagnosed with DDH and initially treated with a Tübingen splint at our institution between May 2017 and February 2020 were assessed retrospectively. We divided the population into stable and unstable hips using the Graf classification. Age at treatment initiation, duration of treatment, complications, and radiological outcome between 12 and 24 months were investigated.ResultsWe included a total of 45 patients (57 hips) affected by DDH treated with the Tübingen splint. Treatment has been successful in 93% of stable hips and only 40% of unstable hips. Radiological outcome at 1-year follow-up significantly correlated with initial Graf classification (p < 0.001).ConclusionThe Tübingen splint is a safe and effective treatment for stable hips, nevertheless, for unstable hips, closed reduction, and spica cast remains the gold standard.

PurposeThis study aims to compare radiographic outcomes and complication rates of immobilization with an abduction pillow to spica casting for postoperative care after a hip reconstruction with varus derotational proximal femur osteotomy (VDRO) with or without pelvic osteotomy for children with cerebral palsy (CP).Methods233 children (1–18 years old) diagnosed with CP that underwent VDRO with or without pelvic osteotomy were identified, of which 188 patients were immobilized with a spica cast and 45 were immobilized with an abduction pillow, based on surgeon preference. 123 (65%) in the Spica group and 21 (47%) in the pillow group had pelvic osteotomies. Demographic data and complication rates were collected. Radiographic parameters, including anatomic medial proximal femoral angle (aMPFA), acetabular index (AI) and migration percentage (MP), were measured for each patient at the completion of surgery, six weeks post-operatively, and one year post-operatively.ResultsThere was not a statistically significant difference in BMI (p = 0.285), gender distribution (p = 0.984), or median follow-up time (p = 0.314) between groups. Rates of complications were consistent among groups with no differences in instances of delayed unions (p = 0.10), subluxations (p = 0.55), infection (p = 0.71), or non-unions (p = 0.10). There was no statistically significant difference in number of patients with an ideal aMPFA, AI, or MP (p = 0.44, p = 0.19, p = 1.00) at one year post-operatively.ConclusionsImmobilization with an abduction pillow is a safe and effective alternative to hip spica casting following hip reconstruction.

Closed reduction followed by spica casting is a conservative treatment for developmental dysplasia of the hip (DDH). Magnetic resonance imaging (MRI) can verify proper closed reduction of the dysplastic hip. Our aim was to find prognostic factors in the first MRI to predict the possible outcome of the initial treatment success by means of ultrasound monitoring according to Graf and the further development of the hip dysplasia or risk of recurrence in the radiological follow-up examinations. A total of 48 patients (96 hips) with DDH on at least one side, and who were treated with closed reduction and spica cast were included in this retrospective cohort study. Treatment began at a mean age of 9.9 weeks. The children were followed for 47.4 months on average. We performed closed reduction and spica casting under general balanced anaesthesia. This was directly followed by MRI to control the position/reduction of the femoral head without anaesthesia. The following parameters were measured in the MRI: hip abduction angle, coronal, anterior and posterior bony axial acetabular angles and pelvic width. A Graf alpha angle of at least 60° was considered successful. In the radiological follow-up controls, we evaluated for residual dysplasia or recurrence. In our cohort, we only found the abduction angle to be an influencing factor for improvement of the DDH. No other prognostic factors in MRI measurements, such as gender, age at time of the first spica cast, or treatment involving overhead extension were found to be predictive of mid-term outcomes. This may, however, be due to the relatively small number of treatment failures.

Children younger than 18 mo with developmental dysplasia of the hip (DDH) were treated with reduction and spica cast. X-Ray, computed tomography or magnetic resonance imaging (MRI) was used to evaluate reduction effectiveness. This study explored the hip medial ultrasonography method and anatomic structure sonograms. Twenty-eight children with DDH were enrolled. A total of 51 hips (24 left hips /27 right hips) were measured, including 30 affected hips and 21 normal hips. Various indices, including femoral head diameter (DIA), triradiate cartilage-femoral distance (TFD), acetabular-femoral distance (AFD) and ilium-femoral distance (IFD), were measured in the acetabular median coronal plane of ultrasound and the median coronal plane of MRI. The intra-group correlation coefficients for DIA, TFD, AFD and IFD were 0.968 (95% confidence interval: 0.917-0.985), 0.959 (0.929-0 976), 0.923 (0.869-0.955) and 0.950 (0914-0.971), respectively. Hip medial ultrasound and MRI exhibited good consistency. It is feasible to use hip medial ultrasound to evaluate the reduction of DDH in infants and children after spica cast. [ABSTRACT FROM AUTHOR]

Purpose: The position of the femoral head in spica cast after the reduction of developmental dysplasia of the hip (DDH) should be examined and followed up closely and regularly. The study aimed to use the transgluteal ultrasonography approach for this purpose and compare its accuracy with the results of CT scan, which is the most commonly used modality. Methods: Twenty-three patients with an average age of 20–21 months were examined for 1 year after the reduction of DDH, both closed and open. Ultrasonography and CT scan were performed on the patients on the same day, and the results were interpreted by different radiologists. Transgluteal ultrasonography in spica cast was performed while the legs were abducted, internally rotated, and flexed. A blanket was placed under the patient to elevate the cast. Results: Thirty cases of proper reduction (81%) and 7 cases of dislocated hip (19%) were reported in transgluteal ultrasonography, and 29 cases of proper reduction (78%) and 8 cases of dislocated hip (22%) were reported in the CT scan. The rate of agreement between the results of ultrasonography and CT scan was 91%. Conclusion: Transgluteal ultrasonography can be used as an excellent modality to examine the position of the femoral head in relation to the posterior rim of the acetabulum in spica cast. The position of the femoral head can be viewed properly needless of perineal opening in the cast. Thus, transgluteal ultrasonography can replace the CT scan to assess the position of the femoral head. Sonography does not expose patients to radiation and does not require sedation. [ABSTRACT FROM AUTHOR]

Background: Surgical hip joint reconstruction may be the method of choice for children and adolescents with developmental dysplasia of the hip (DDH), as well as neurogenic dislocation of the hip (NDH) and Legg–Calvé–Perthes disease (LCPD). Following pelvic surgery, immobilization using a spica cast is considered to be the gold standard, despite the fact that casting may cause complications, such as hygienic problems, skin lesions, neurological deficits, and rigidity of the adjacent joints. An alternative for postoperative immobilization is a foam splint. The purpose of this randomized controlled trial was to compare spica cast and foam splint immobilization after hip reconstruction in children and adolescents with DDH, NDH, and LCPD. Methods: In a prospective randomized clinical trial, children and adolescents (age: 4–14 years), who received hip reconstructive surgery (osteotomy of the ilium and proximal femur, open reduction, soft tissue techniques) for DDH, NDH, and LCPD were included. Patient recruitment, group allocation, surgery, and aftercare were carried out in a department for orthopaedic surgery in Central Europe. Standardized questionnaires SF-36 (Short Form-36), EQ-5D (Euro Quality of Life 5D and CPCHILD (Caregiver Priorities and Child Health Index of Life with Disabilities) were gathered before, six, and twelve weeks after surgery from each patient. Group one received a spica cast and group two a foam splint for a period of six weeks postoperatively. There was no difference in surgical treatment. Results: Twenty-one out of thirty planned patients were enrolled in the study. One patient had to be excluded because of a lack of compliance. All quality of life (QOL) scores showed a significant reduction at the 6-week follow-up compared to the preoperative assessment. After twelve weeks, the scores came back close to the preoperative values. A significant reduction was seen in the spica cast group pre- vs. postoperatively for the variables CPCHILD (81% vs. 64%, p = 0.001), EQ-5d (65% vs. 45%, p = 0.014), and SF-36 (85% vs. 74%, p = 0.004). The corresponding values for the foam splint group also presented a reduction for all scores, but without statistical significance. Complications occurred in five cases. Conclusions: Recent retrospective studies suggest that foam splint immobilization after hip reconstruction surgery is a safe and feasible method, promising fewer complications compared to spica casting. The preliminary results of this prospective randomized clinical trial show an improvement of the scores when using a foam splint compared to the conventionally used spica cast. Benefits for the patients may be fewer adverse events and no need to undergo a second round of anaesthesia for recasting. Data suggest higher patient and caretaker satisfaction in the foam splint group.

Objective: There is little data defining safe transport protocols for spica-casted children. A single earlier study demonstrated the presence of a body cast alters kinematics and injury metrics during simulated side-impact crashes. Since then, the National Highway Transportation Safety Administration (NHTSA) proposed a new side-impact test protocol for evaluating child restraints. This test is more severe than the earlier tests, as it simulates an impact with a door intruding into the occupant space. As no currently available child restraint system (CRS) able to accommodate a spica-casted child has been evaluated using these updated testing criteria, the objective of this study was to evaluate current restraint options in simulated side-impact collisions using an anthropomorphic test device (ATD) modeled after a 3-year-old.Methods: Four commercially available CRSs able to accommodate a spica-casted Q3s side-impact ATD were selected for testing. Side-impact testing was performed using casted and uncasted ATDs in compliance with the NHTSA proposed side-impact test. High-speed photography and ATD instrumentation were used to measure selected injury criteria.Results: HIC15 values were highest in CRSs with less robust side wings, such as the Merritt WallenburgTM (HIC15 = 1,373), which allow for the occupant to interact with the intruding door panel. Head contact with the door panel was found to correspond with high resultant neck peak force. Pelvic acceleration magnitudes were greatest for the uncasted tests. Casted tests with a CRS that included an armrest were associated with greater torso rotation in the frontal plane with the left shoulder moving toward the door panel.Conclusions: The presence of a spica cast alters injury metrics in side-impact testing. Spica specific child safety seats are not yet optimized for side-impact with door intrusion. This is due to a lack of adequate side cushion wings, which may place both casted and uncasted occupants at increased likelihood for injury through head contact with an intruding door. Additional work is needed to improve the safety of CRSs for both casted and uncasted children in side-impact collisions. [ABSTRACT FROM AUTHOR]

Background: The ideal treatment of femoral shaft fracture in children is defined as one that controls alignment and length, is comfortable for child and convenient for family and causes the least psychological impact possible. Aims and Objective: The current study was designed to evaluate outcomes prospectively in the first year following treatment of a diaphyseal femoral fracture in children between five and ten years of age treated randomly either by intramedullary titanium elastic nailing or by traction followed by spica cast. Materials and Methods: Out of 48 cases selected according to inclusion/exclusion criteria 6 patients were lost to follow up. Among the rest of 42 patients, 23 were treated by intramedullary titanium elastic nailing and the other 19 conservatively by surface traction. The patients were evaluated at the regular interval of 2, 4, 6 and 8th week post operatively and thereafter every month. Results: There was a significant difference (p< 0.001) in terms of mean hospital stay and mean weight bearing between the two study groups. The findings of outcome and maintenance of reduction, time taken for the evidence of union to appear, the range of movements, the time when weight bearing can be allowed, the functional return of the limb, the rate of complications and the number days of hospital stay were comparable to similar studies conducted earlier. Conclusion: The study concludes that closed pediatric femoral shaft fractures within the ages of 5-10 years can be treated successfully by any methods of traction followed by spica cast or intramedullary titanium elastic nailing. However, because of shorter immobilization period and earlier ambulation, internal fixation with titanium elastic nailing is recommended as the better choice to treat this fracture in school going children.

Developmental dysplasia of the hip (DDH) describes a broad spectrum of developmental abnormalities of the hip joint that are traditionally diagnosed during infancy. Because the development of the hip joint is a dynamic process, optimal treatment depends not only on the severity of the dysplasia, but also on the age of the child. Various imaging modalities are routinely used to confirm suspected diagnosis, to assess severity, and to monitor treatment response. For infants younger than 4 months, screening hip ultrasound (US) is recommended only for those with risk factors, equivocal or positive exam findings, whereas for infants older than 4-6 months, pelvis radiography is preferred. Following surgical hip reduction, magnetic resonance (MR) imaging is preferred over computed tomography (CT) because MR can not only confirm concentric hip joint reduction, but also identify the presence of soft-tissue barriers to reduction and any unexpected postoperative complications. The routine use of contrast-enhanced MR remains controversial because of the relative paucity of well-powered and validated literature. The main objectives of this article are to review the normal and abnormal developmental anatomy of the hip joint, to discuss the rationale behind the current recommendations on the most appropriate selection of imaging modalities for screening and diagnosis, and to review routine and uncommon findings that can be identified on post-reduction MR, using an evidence-based approach. A basic understanding of the physiology and the pathophysiology can help ensure the selection of optimal imaging modality and reduce equivocal diagnoses that can lead to unnecessary treatment. [ABSTRACT FROM AUTHOR]

Background: Fractures of the hip in children are rare , although it have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). The Objective: Our objectives is to present a rare type of injuries presented to our hospital . and to discuss the type of treatment we did , and the outcome after 2 year fallow up , with discussion of other treatment options . Material and methods : Over a period of 2 years from January - 2008 to December- 2009 we have treated displaced fractures by early anatomical reduction, internal fixation and immobilization in a spica cast to try to reduce these complications. The Result : We have reviewed 6 patients who had a displaced nonpathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (4 to 11). They returned for examination and radiography at a mean follow-up of 2.1 year. Each patient had been treated by early (24 hours) closed or open reduction with internal fixation and all of them had immobilization in a spica cast. [ABSTRACT FROM AUTHOR]

A 4 months and half female child come to our attention for congenital dislocation of the left hip, previously treated in another hospital with abduction bracing, without satisfactory results. After progressive longitudinal bilateral traction, closed reduction under general anesthesia was performed and a spica cast was applied in the so-called human position. The patients remained in the spica cast for 6 weeks and then the plaster cast was renewed in narcosis for another 6 weeks. Once the second cast has been removed left femoral nerve palsy was detected. Orthopaedic treatment was interrupted and in 3 months the nerve completely recovered, while the hip was still stable. We followed the child regularly since then, she is now five years old, she is totally asymptomatic, X-rays shows a residual acetabular dysplasia, with no sign of avascular necrosis.

Background: Magnetic resonance imaging (MRI) of the hips is being increasingly used to confirm hip reduction after surgery and spica cast placement for developmental dysplasia of the hip (DDH).Objective: To review a single institutional experience with post-spica MRI in children undergoing closed or open hip reduction and describe the utility of MRI in directing the need for re-intervention.Materials and Methods: Seventy-four patients (52 female, 22 male) who underwent post-spica hip MRI over a 6-year period were retrospectively reviewed. One hundred and seven hips were included. Data reviewed included age at intervention, gender, type of intervention performed, MRI findings, the need for re-intervention and the interval between interventions. Gender was compared between the closed and open reduction groups via the Fisher exact test. Age at the first procedure was compared via the Wilcoxon rank test. Rates of re-intervention after closed and open reduction were calculated and the reasons for re-intervention were reviewed.Results: The mean age at the time of the first intervention was 16.4 months (range: 4 to 63 months). Mean age for the closed reduction group was 10.5 months (range: 4-24 months) and for the open reduction group was 23.7 months (range: 5-63 months), which was significant (P-value <0.0001). Of the 52 hips that underwent closed reduction, 16 (31%) needed re-intervention. Of the 55 hips that underwent open reduction, MRI was useful in deciding re-intervention in only 1 (2%). This patient had prior multiple failed closed and open reductions at an outside institute.Conclusion: Post intervention hip spica MRI is useful in determining the need for re-intervention after closed hip reduction, but its role after open reduction is questionable. [ABSTRACT FROM AUTHOR]

Purpose Paediatric femur fractures are commonly encountered and often successfully managed with spica casting. Despite spica casting's long history there is little formal guidance for optimal outcomes and no consolidation of existing literature. The purpose of this study is to review the available literature regarding the use of spica casting for the management of paediatric diaphyseal femur fractures. Methods The PubMed database was queried for all research articles including the phrase "spica". A total of 788 abstracts were reviewed for relevance to the current study. Data was extracted from all available research studies which specified tolerance for fracture angulation or shortening in the cast. Additionally, all articles describing alternative materials, methods for spica application, and complications of spica casting were reviewed. Results In all, 106 articles were found relevant to the management of diaphyseal femur fractures in the paediatric population. The aggregated, accepted fracture shortening decreased from 16 mm to 18 mm before age ten years to 12 mm to 14 mm after puberty. Aggregated, accepted angulation decreased from 14° to 16° varus/valgus and 18° to 22° pro/recurvatum before age two years, to 6° to 8° and 10° to 12° by puberty, respectively. The overall reported complication rate was 19.6%, with the most common complication being skin compromise in 8.2% of patients, followed by unacceptable angulation at the fracture site in 4.2% of patients and excessive limb shortening in 1.9% of patients. Conclusions This article reviews the available spica casting literature and compiles the available data. Spica casting offers a safe, effective means for definitive management of paediatric diaphyseal femur fractures. Future research identifying the rate and pattern of remodelling as it relates to angulation and shortening at various patient ages, particularly beyond the aforementioned norms, would be valuable to identify true biological tolerances versus accepted expert opinion. [ABSTRACT FROM AUTHOR]

Background: Most orthopedic surgeons prefer spica cast immobilization in children for 4 to 12 weeks after surgical hip reconstruction in children with developmental hip dysplasia. This challenging treatment may be associated with complications. Studies are lacking that focus on early mobilization without casting for postoperative care after hip reconstruction.Methods: Twenty-seven children (3.4±2.0 years), including 33 hips with developmental hip dysplasia (DDH) and dislocation of the hip (Tönnis grade 1 to 4), who underwent hip reconstruction (Dega acetabuloplasty, varisation-derotation osteotomy and facultative open reduction) were retrospectively included in this study. Postoperatively the patients were placed in an individual foam shell with 30 degrees of hip abduction, hip extension, and neutral rotation. Early mobilization physiotherapy was performed within the first few days after the surgery under epidural anaesthesia. Full weight bearing was allowed after 3-4 weeks. All children received a clinical examination and radiographic evaluation before and after surgical intervention. The follow-up period was 12.3±2.9 months.Results: On average, the postoperative acetabular index decreased significantly from 36.9 to 21.7 degrees and the center-edge angle increased from 9.9 to 28.6 degrees. All hips had reached Tönnis grade 1 at the time of the last follow-up. No complications such as dislocation of the bone wedge, avascular necrosis of the acetabulum or femur, lack of non-union, or nerve injury, were reported.Conclusions: In this cohort study, hip reconstruction was successful according to clinical and radiographic outcome parameters after early mobilization without cast therapy. Early mobilization may be used as an alternative treatment option after hip reconstruction in DDH. [ABSTRACT FROM AUTHOR]

Purpose Spica casting of femoral shaft fractures is standard practice for young children. In 1983, Dr. Rang published an illustration demonstrating that radiographs can be misleading when measuring femoral fracture shortening. Today, fluoroscopy is used to determine shortening after closed reduction and spica casting. This paper aims to determine the accuracy of fluoroscopy when measuring 25 mm of shortening in a femur fracture sawbone model. Methods Magnification, elevation and angulation were evaluated using a femur fracture sawbone model with a fixed overlap of 25 mm. Two C-arm machines used in clinical practice were studied: the OEC 9900 Elite GE C-arm and the Fluoroscan InSight mini C-arm. Results The OEC 9900 Elite GE C-arm demonstrated a 1.75 × magnification. The Fluoroscan InSight mini C-arm demonstrated a 2.5 × magnification. An 11% and a 17% magnification with elevation of the femur to 8 cm occurred using the OEC 9900 Elite GE and the Fluoroscan InSight mini C-arm respectively. Changing the tube angulation from 0° to 60° resulted in a 36% and 16% change in measured femur fracture shortening on the OEC C-arm and Fluoroscan mini C-arm respectively. Conclusion C-arm images are inaccurate. When measuring 25 mm of shortening of a paediatric femur fracture, each machine has a unique amount of magnification that should be determined and accounted for in clinical practice. Elevation of the femur above the C-arm receiver and angulation of the femur further increase the inaccuracies when measuring 25 mm of fracture shortening. Images perpendicular to the fracture are most accurate. [ABSTRACT FROM AUTHOR]

Background: The ideal treatment of femoral shaft fracture in children is defined as one that controls alignment and length, is comfortable for child and convenient for family and causes the least psychological impact possible. Aims and Objective: The current study was designed to evaluate outcomes prospectively in the first year following treatment of a diaphyseal femoral fracture in children between five and ten years of age treated randomly either by intramedullary titanium elastic nailing or by traction followed by spica cast. Materials and Methods: Out of 48 cases selected according to inclusion/exclusion criteria 6 patients were lost to follow up. Among the rest of 42 patients, 23 were treated by intramedullary titanium elastic nailing and the other 19 conservatively by surface traction. The patients were evaluated at the regular interval of 2, 4, 6 and 8th week post operatively and thereafter every month. Results: There was a significant difference (p< 0.001) in terms of mean hospital stay and mean weight bearing between the two study groups. The findings of outcome and maintenance of reduction, time taken for the evidence of union to appear, the range of movements, the time when weight bearing can be allowed, the functional return of the limb, the rate of complications and the number days of hospital stay were comparable to similar studies conducted earlier. Conclusion: The study concludes that closed pediatric femoral shaft fractures within the ages of 5-10 years can be treated successfully by any methods of traction followed by spica cast or intramedullary titanium elastic nailing. However, because of shorter immobilization period and earlier ambulation, internal fixation with titanium elastic nailing is recommended as the better choice to treat this fracture in school going children. [ABSTRACT FROM AUTHOR]

Background: Pediatric femur fractures are frequently encountered injuries frequently treated with spica casting. Spica casting may, however, be expensive and burdensome to patients. A possible alternative is a long leg splint. Methods: Patients aged 6 months to 5 years old who were treated for a femoral shaft fracture with a long leg splint extending above the waist were matched with a patient treated with a spica cast. Results: At the time of healing, the alignment in the spica cast group was only significantly better than the alignment of the splint group with respect to coronal angulation. [ABSTRACT FROM AUTHOR]