Introduction:There has been a recent increase in the surgical management rates of paediatric tibial fractures. However,there is a lack of consensus on indication for surgical management. Our study aims to identify various factors that affect healing in pediatric tibial fractures.

Methods:This was a single-centre, retrospective analysis of a pediatric database between 2008-2020. Patient demographics, injury characteristics, fracture characteristics, method of management and post-operative complications were noted. The Radiographic Union Scale in Tibial fractures (RUST) scores were evaluated on radiographs at weeks 4, 8 and 12. Logistic regression modelling was used to identify risk factors for non-union.

Results: 83 patients(mean age:10.7±4.11 years, M:F=46:21) were included in the study. At 4 weeks only open reduction significantly associated with higher RUST scores (p = 0.004). At 8 weeks, female sex and increasing age negatively associated with rust scores (p = 0.007 and p < 0.001)and open reduction was still associated with higher RUST scores (p = 0.004)

At 12 weeks, female sex, increasing age and ‘poor reduction’ negatively added to the model (p = 0.001, p < 0.001 and p = 0.002).The effect of open reduction on RUST scores was no longer significant at this time point.

Conclusion:Open reduction is associated with better RUST scores at 4 and 8 weeks, which may indicate quicker union. The effect is lost however at 12 weeks with outcomes comparable to other treatment types. Female sex, increasing age and poor fracture reduction are all risk factors for poor RUST scores and should therefore be treated with caution.

Introduction:
Paediatric Femur fractures under the age of 5 years are usually treated either by traction or in a hip spica. Approximately 2cm of femoral overgrowth is expected and traditional treatment is to let femur fractures heal with shortening to accommodate this.
We demonstrate how precise reduction of femur fractures results in minimal or no leg length discrepancy.

Methodology:
A series of children under 5 years with femur fractures were recruited over eight year period. All children had precise closed reduction performed under image intensifier guidance and a hip spica was applied. Hip spicas were left for six weeks.
Children had bilateral long leg x-rays to judge femoral overgrowth and leg length difference.

Results:
36 children under the age of 5 years, age ranges 6-41mth average of 26 months were recruited. 26 children had spiral midshaft femoral fractures, 10 had a proximal spiral femur fracture. Average follow-up was 37 months(13-64 months).
There was no shortening of the femur fracture on the intraoperative image intensifier films.
Most femur fractures had no overgrowth with no leg length difference on follow-up; 4 children had -0.5cm overgrowth, 1 child had 1 cm overgrowth.

Conclusion:
The precise reduction of a femur fracture means minimal or no overgrowth long-term. Therefore children can be safely discharged when fractures are healed in the expectation that they will not develop a significant leg length difference. Overgrowth may occurs in the first twelve months after a fracture. However,these small leg length differences do not correct, but are not clinically significant

Introduction: Postoperative knee pain and implant loosening can complicate anterior distal femur hemiepiphysiodesis (ADFH) using plates. Aim of the work: This is a mechanical analysis and an initial case series of a novel extra-articular technique for the management of fixed knee flexion deformity (FKFD). Methods: Sixteen femoral sawbones were osteotomized at the distal physis and fixed by rail frames to allow linear distraction. Each was tested twice: first using the conventional parapatellar plate position (group A) then with plates in the proposed novel location anteriorly on the medial and lateral surfaces of the femoral condyles, screws in the coronal plane (group B). Strain gauges were attached to the plates. Angular correction was measured. Strain (and equivalent stress) over the plates was recorded. This technique was then applied to 11 pediatric FKFDs. Results: Angular correction was higher in group B at 5, 10-, and 15-mm of lineal distraction (p<0.001). Maximum and overall stresses were higher in group A (p<0.001). Mean FKFD improved from 24 ± 8° preoperatively to 7 ± 7° after 10 ± 3° months (p<0.001). Correction rate was 1.81 ± 0.6° per month. None of the patients complained of anterior knee pain or implant loosening. One patient was overcorrected and another suffered from periarticular heterotopic ossification. Conclusion: Insertion of plates extra-articularly in the coronal plane may produce greater correction and lower stresses over the implants. Preliminary results support the effectiveness of this technique achieving angular correction and its value with implants at an extraarticular position avoiding known complications.

Obstetric brachial plexus injuries are relatively rare, but when it occurs the consequences are life altering. With a reported spontaneous recovery of 50-92%, these debilitating injuries carry with them a high risk of long term morbidity in patients without recovery. The obstetric related birth injury results in a high brachial plexus palsy which manifests long term as internal rotation contractures due to external rotator weakness. This leads to progressive bony deformities of the glenohumeral joint. Current surgical treatment involves arthroscopic and open techniques to restore external rotation and musculoskeletal mechanics. Literature outlining the best surgical methods and timing for the treatment of this internal rotation contracture and external rotation weakness is sparse. Currently no clear guidelines exist on the use of internal contracture release with or without the addition of latissimus-dorsi tendon transfer.

This retrospective case series reviewed 32 cases performed in the last 18 years. Parameters assessed included demographics, narks classification, choice of surgical treatment, timing, clinical features of OBPP, pre and post-operative range of motion.

This is the largest series and longest follow up in our setting. We found that patients had improved functional parameters who were drop arm positive with subscapular release and lattisimus dorsi transfer with mallet scores less than 16, and subscapular release only with mallet greater than 16. Clinical parameters and mallet scores are more useful at determining timing of surgery than age. We have also developed a useful flow diagram to use as an algorithm when deciding on the method of treatment.

Introduction: Cerebral palsy (CP) is a non-progressive insult of the growing brain that leads to progressive musculoskeletal deformities including hand deformities. We evaluated short term results of surgical correction of thumb-in-palm deformity in children with CP. Methods: A prospective study including 30 patients (age 4 to 12 years) with spastic CP and thumb-in-palm deformity. Pre and postoperative evaluation were done using manual ability classification system MACS, spontaneous functional analysis SFA, and dynamic positional analysis DPA of the thumb. Surgery: according to static House classification, in all types thumb web z-pasty, adductor pollicis brevis, first dorsal interosseous releases and extensor pollicis longus re-routing. In type 2 flexor pollicis brevis release was added. In type 3 metacarpophalangeal capsulodesis. In type 4 flexor pollicis brevis release and longus lengthening. Results: The average follow-up was 10.9 months. 77‰ of patients were hemiplegics and 23‰ diplegics. According to static House classification, one patient was type I, 16 patients were type 2, eight patients were type 3 and five patients were type 4. Functional improvement was statistically significant according to postoperative MACS, and SFA. Thumb position improved postoperatively according to DPA. Conclusion: Surgery yields improved short-term functional outcomes and should be based on precise clinical assessment.

The treatment of large bone defects of limbs is a serious challenge for orthopedic surgeons and patients. using the Ilizarov method has become the main treatment option for the reconstruction of bone defect. However, inevitable difficulties and complications related to bone transport technique have been reported by many authors.
The purpose of this study was to evaluate the effectiveness and complications of bone transport technique using Ilizarov method in the treatment of bone defect and correct lengthening .
Methods: The study was conducted on 350 patients who underwent bone transport procedures using Ilizarov from 2000 to 2019 at Al-thawra, Military and other hospitals. outcomes at minimum of 3 years follow-up were collected and retrospectively analyzed.
All difficulties that related to bone transport were documented according to Paley’s classification. The clinical outcomes were evaluated using Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at last clinical visit.
Results: There were 300 male and 50 females with a mean age of 40 years (range 2–70 years). The mean defect was 10 ± 5 cm, whereas single level transport in 345 cases and double level transport in 5 cases. There were 30 problems, 33 obstacles and 400 complications (370 minor and 30 major complications).
Conclusion: Bone transport is a reliable method for reconstruction of bone defects in all limbs and more for the femur and tibia and awareness of predictable complications is beneficial to prevent or early detection of the expected complication which can improve the risk-benefit balance

Introduction: In the developing countries, with limited resources, there may be no routine neonatal screening for DDH and the condition usually presents late after walking (age > 1 year). Closed reduction (CR) would be an acceptable approach so that open reduction is reserved only for the non-reducible hips. It is necessary to establish definitive success parameters and complication rates following CR for DDH. Materials: this prospective study included 30 children diagnosed as having untreated DDH. The condition was bilateral in 18 cases (36 hips) and unilateral in 12 cases with a total of 48 hips. Their ages ranged from 9 to 26 months at the time of diagnosis. Only cases of idiopathic DDH were included in this study. Methods: Under general anesthesia a percutaneous tenotomy of adductor muscles was performed. Using image intensifier, gentle CR was performed. Stability of reduction was tested avoiding excessive abduction. Plaster cast hip spica was applied with the hip in the human position. Post-reduction radiographs were obtained to ensure maintenance of adequate reduction. Results: successful stable CR was possible in 42 cases (87.5%). In five cases (10.5%) CR was possible but unstable and converted to open reduction. Re-dislocation after one week occurred in one case (2%). AVN with different grades was diagnosed in 14 cases (29%). Discussion: Gentle closed reduction can be attempted in children after walking age. Predictors of successful CR are; low station head, a well-developed acetabulum, positive telescoping test, tight adductor muscles and an easy and stable reduction.

This study aims to evaluate the management and outcomes of displaced tibia fractures in children. A retrospective study was undertaken for children up to 16 years with displaced tibia shaft fractures from January 2011-December 2021. Fractures managed in the theatre and patients who completed follow-up until fracture healing were included in the study. Treatment procedures were assessed, and hospital stays, complications and revision procedure were measured for outcomes. Seventy-four patients (75 fractures, including one re-fracture) were included in the study. Ages ranged from 2-16 years (median 11). Seven patients sustained open fractures. Tibia diaphysis was the commonest site of involvement. Forty-three patients were treated by manipulation under anaesthesia and cast. Surgical fixation was directly proportional to increasing age (p<0.05). 74% of patients were treated by fixation when age was >10 years. Three patients needed conversion of casting to surgical fixation. Complications included delayed union, pin site and surgical site infections in 5 cases. Infections were managed by antibiotics except in one patient who needed debridement. Average hospital stay was three days. The median number of follow-up x-rays was 4. The planned removal of all flexible nails and the circular frame was done between 2 and 15 months, except for one that had delayed union. All the patients underwent clinical and radiological union at the end of the follow-up. Overall, the treatment plan was dependent on the individual need of the patient and the fracture pattern. Better logistic support in the emergency department could reduce the burden on the operating theatre.

Background: Pediatric patients with peroneal tendon tears (PTT) frequently present with vague ankle pain and are a diagnostic dilemma. MRI detects peroneal tendon pathology but findings do not always correlate with symptoms. Adult studies found MRI has a positive predictive value (PPV) of around 48% for PTT. However, no published studies have correlated examination to imaging findings in children. Purpose: To determine the relationship between MRI-diagnosed PTT and clinical findings in the pediatric population. Methods: IRB approval was granted for this study. Inclusion criteria were patients <18 years of age with an ankle MRI, read by an MSK radiologist, indicating a tear of the peroneus brevis or longus tendon and underwent clinical examination of the same ankle by a pediatric orthopaedic surgeon. Congenital deformities or previous surgical intervention of the lateral ankle were excluded. Clinical examination criteria included lateral ankle pain, tenderness, or dislocation/snapping. Results: 47 patients met inclusion criteria. The majority of the positive MRI(s) (63%) demonstrated a peroneus brevis split tear. Of 47 patients with positive MRI findings, 17 had an associated positive exam and thirty had a negative exam. The PPV of MRI for PTTs with positive clinical findings was 36.2% (95% CI = 31.1% - 41.6%). There were 30 patients with false positive findings. Conclusion: Patients with MRI findings of PTT should undergo careful examination, as the PPV of MRI for clinical PTT is low. This study confirms findings in children similar to adults and demonstrates a high PTT false positive rate on MRI.

Purpose: Evaluate MRI findings of a new bone (distractional regenerate bone) after limb lengthening using transosseous osteosynthesis with the Ilizarov apparatus to address rehabilitation issues.
Methods: MRI scan was performed for 10 patients aged 25 to 37 years with subjectively low height and for 25 achondroplasia patients aged 6 to 16 years before and after lower limb lengthening using using a 1.5-T MRI unit. Different sequences of MRI - T2 tse,T2 tse fs, PD fs, Т1 fl 2d, T1 se were employed.
Results: Application of MRI was based on varied architecture of the distractional regenerate bone that appeared to be structured with trabecular bone and non-ossified zones. Non-ossified areas served a measurement to be used to assess an extent of a new bone being restructured. Quantitative assessment of the new bone being restructured after limb lengthening was offered that would be practical to determine how much weight to be maintained by the limb, if an additional fixation to be added to the limb after frame removal. If a T2 MRI image showed an area of non-ossified zone having heterogeneous hypointensive signal relative to parental bone measuring less than 30% of the total regenerate area the regenerate quality was considered to be adequate to maintain weight-bearing on the limb lengthened.
Conclusions: MRI scan was first used to evaluate the quality of distractional regenerate bone providing quantitative assessment. MRI allowed us to assess maturity of distractional regenerate bone at a higher quality level as compared with other modalities.