Altering hip biomechanics

Altering the rate of femoral head healing

Forced rest and activity modification dictated by surgery

Increased blood flow to the area

The load-relieving effect of varus angulation

A significant correlation exists between the amount of varus angulation obtained at surgery and the Stulberg outcome at maturity

A significant number of patients obtain Stulberg class I or II hips following proximal femoral varus osteotomy

A varus angulation of 20–25° is recommended

For lateral pillar group C, a higher postoperative neck–shaft angle (less varus angulation) is associated with a greater probability of obtaining a Stulberg class I or II outcome

Surgery may lead to a significant limb length discrepancy

Account for less than 1% of fractures in children

Physeal arrest occurs in approximately 40% of cases

Interposed periosteum is an indication for open reduction

Metaphyseal screw fixation is the preferred method of treatment

Account for between 6% and 9% of physeal fractures

Adduction of the foot is required to stretch the medial soft tissues

Children managed with boots and bars had an increased recurrence of deformity than did those managed with ankle–foot orthosis

The Denis Browne boots and bar (DBB) is very well tolerated

The Pirani score quantifies the severity of clubfoot and is a reliable prognostic of outcome

With the Ponseti technique, about 8% of idiopathic clubfeet require further surgical treatment after a percutaneous tenotomy.

The pull-off theory suggests that lateral humeral condylar fractures are avulsion fractures.

The push-off theory postulates that these fractures are the result of a force directed upwards and outwards along the radius

They are the most common paediatric elbow fracture

They represent 12–20% of paediatric elbow fractures.

They typically occur in children aged approximately 6 years

A Milch type I fracture is a Salter–Harris type IV fracture

A Milch type II fracture is characterised by a fracture line that courses lateral to the trochlea and into the capitulotrochlear groove

Lateral condylar fractures present clinically with severe deformity and neurovascular compromise

Milch is of little use in determining fracture management and is largely of historical interest

Milch type I fractures extend into the apex of the trochlea

A varus force on the elbow may assist in visualising the fracture fragment

In general, three pins should be used for fixation to reduce the chance of pin failure and fracture re-displacement

Lateral approach is generally preferred

Surgical management usually consists of open reduction and smooth pin fixation

With open reduction, all dissection should be posterior to avoid damaging the blood supply to the distal fragment and risking osteonecrosis

Cubitus valgus deformity is caused by lateral physeal arrest

Cubitus valgus is a much less common complication than a cubitus varus deformity

Cubitus varus deformity is most common in nondisplaced and minimally displaced fractures

Non-union is most common in patients treated non-surgically

Ulnar nerve palsies typically present early

Complications occur in nearly 1 in 6 patients

Female gender and older age are isolated predictors of a complication

Implant related fractures are less likely to occur when using a DCP

The most common complications are pain or irritation from the plate

The risk of implant-related fracture is higher with ulnar plating

Aetiological theories include altered haemodynamics with venous obstruction causing increased interosseous pressure and cyst formation

Follow-up x-rays demonstrate that the growth plate moves away from the cyst as the child grows

Multiple steroid injections are usually required to achieve healing

Recurrence or persistence of the cyst after surgical curettage and bone grafting occurs in approximately 30–45% of cases

When fractures do occur, they generally involve the growth plate

Allows for selective correction of the contracted gastrocnemius and soleus

Disrupts the muscle architecture

Has a high rate of over-lengthening

Has a high recurrence rate

Its use for correction of a mild fixed equinus deformity in children has been abandoned

Clear established guidelines for management exist

Gustilo grade III open fractures in children have been shown to have a better outcome than adults

Monolateral external fixation is currently the most commonly used method of stabilisation for these injuries

Studies have shown good remodelling potential following tibial malunion

The use of a programmable circular external fixator has a high rate of complications

Concerning the management options of this bone lesion, which option is the most appropriate?

The lesion can be managed with observation and serial radiographs

Any surgery undertaken should involve using autograft bone

It is necessary to remove structural bone from the outer cyst wall

Internal fixation lessens the risk of additional surgery

When performing curettage plus bone grafting, it is often necessary to use adjunctive materials, such as phenol or liquid nitrogen to prevent recurrence

Dislocation rate is reported as 12%

In general, THA should be avoided because of concerns with dislocation, infection and early prosthetic failure

Heterotopic ossification occurs in 20% of hips

Revision rates of 30% have been reported at 5 years

Most common complication of THA is periprosthetic hip fracture

As a general rule, bones remodel better close to the knee and far from the elbow

Girls are affected twice as often as boys

Most authors recommend accepting any displacement in Salter–Harris type I or II injuries more than 48 hours old.

Physeal fractures account for up to 70% of all paediatric fractures

Salter–Harris type I accounts for 20% of all physeal injuries

They account for 5% of all paediatric fractures

Cervicotrochanteric fractures (type III also known as basicervical fractures) are the most common fracture in children

Delbet classification describes three types of fracture based on the anatomical location of the fracture line

They are frequently associated with life-threatening injuries

Transcervical fractures (type II) constitute the least common of the hip fractures

Coxa vara, defined as a femoral neck–shaft angle of <120°, is the most common complication of hip fractures in children

Decompression of intracapsular haematoma is a routine part of the surgical procedure after reduction and fixation have been completed

Osteonecrosis is usually diagnosed radiographically within 3 months of injury

Physis-sparing fixation methods, such as those using transphyseal smooth wires and screws placed up to the metaphyseal femoral neck but not across the physis, are preferred

Yearly radiographic surveillance for 3 years post-surgery is recommended for displaced fractures in younger children

For a triple osteotomy concentric hip reduction is a prerequisite

Pemberton osteotomy is a complete osteotomy that hinges through the triradiate cartilage

The periacetabular osteotomy allows extensive acetabular reorientation, including medial and lateral displacement

The primary indication of a Chiari osteotomy is a painful, subluxated hip without the possibility of congruent reduction in a patient older than 8 years of age

Triple osteotomy is generally indicated for older children and adolescents

They are caused by symmetric activity of the adductors, abductors and internal and external rotator muscles

If the hip develops more than 30% subluxation, varus shortening osteotomy is recommended

It results in pelvic obliquity and pelvic rotation

The child with a windblown hip may have a ‘pseudo-Galeazzi’ sign

It usually affects totally involved non-ambulatory children with severe spasticity

Lateral hemiepiphysiodesis around the knee for the treatment of adolescent Blount disease is more effective for patients with an age >14 years

A distal femoral valgus deformity is almost universally present

There is decreased internal tibial torsion

There is increased femoral anteversion

Guided growth using 8 plate tension band is best utilised for recurrent deformity

Following development of femoral nerve palsy the harness should be abandoned

Is a common complication following use of a Pavlik harness

Is diagnosed late

It is strongly predictive of failure of treatment

Smaller patients are at increased risk of femoral nerve palsy

Asymmetric skinfolds are a common finding with unilateral hip dislocation

Hip clicks indicate significant hip pathology

With each hip examination, a one-time-only Barlow and Ortolani test should be performed to minimise the risk of cartilage damage.

With the Ortolani test, the examiner attempts to dislocate the hip

With the Barlow test, the examiner attempts to reduce a dislocated hip