Musculoskeletal tuberculosis (TB) in infants has non-specific clinical presentations and its radiographic appearance is like pyogenic osteomyelitis. Five children at the age of one-year-old presented with localized swellings of the lower limb with reduced movement of the affected limb after two weeks of symptoms. None of the family members had a history of pulmonary TB and all patients had received Bacille Calmette- Guerin (BCG) vaccination at birth. Radiographs revealed well-defined radiolucent metaphyseal bone lesions with reactive periosteal thickening. Two patients had metaphyseal distal femur lesions, two patients had metaphyseal proximal tibia lytic lesion while 1 patient had a lesion over the distal tibia extending close to the physeal plate. Surgical intervention was carried out and samples were sent for TB PCR and culture where all had PCR positive with 3 patients grew Mycobacterium bovis. Oral antituberculous therapy were commenced and will be completed after 12 months. In Malaysia, neonates are BCG immunized at birth as part of the national childhood immunization programme to reduce the spread of pulmonary TB and extrapulmonary TB. The gold standard for checking strain type is by TB PCR testing and culture. Huang et al reported that the commonest sites of bone involvement are the extremities especially the lower limb (60%) and the average delay in diagnosis was 8 months. A high index of suspicion of TB osteomyelitis should be considered in infants who develop localised chronic symptoms and discrete swellings on the extremities and TB cultures should be sent to assess the strain type.

It is generally recommended that treatment of clubfoot should be initiated as soon as possible after birth. This study was conducted to review on the long-term outcome between starting treatment before one month of age or after that age. This is a retrospective study on babies with clubfoot treated in University Malaya Medical Centre from 2013 to 2017. 54 babies (35 boys and 19 girls) were divided into two cohorts, Group 1 that had treatment before the age of one month, and Group 2 that had treatment after one month old. Of the 54 babies, with 77 clubfoot treated during the period, our outcome showed that the mean number of cast change for both groups were not significant. The duration assessed for these babies were at least of 5 years of follow up. 15 from group 1 and 20 from group 2 were assessed. 19 patients dropped out of the study cohort due to lost contact or relocated. The rate of relapsed after treatment were compared. 4 foot in Group 1 relapsed while 3 foot in Group 2 relapsed which shows not statistically significant. 2 were treated with tibialis anterior transfer while the rest were successfully treated with repeated Ponseti method. Treating CTEV using Ponseti method starting after one month was not associated with higher rate of relapse in the long-term outcome. Babies with neonatal conditions and families who decided to observe confinement practices will be able to delay treatment knowing that they can expect similar favourable outcomes.

INTRODUCTION: Congenital radio ulnar synostosis causes a lot of parental distress in cultures were eating with hands is common. We treated, synostosis which are fixed in pronation of more than 10 degrees. METHODS: proximal ulna osteotomy and distal end radius osteotomy was performed. the forearm was rotated to get 60 degree true supination of forearm. We documented the technical difficulties faced in achieving correction and union. 58 forearm surgeries were studied for following details – duration of surgery, ease of correction, stability after osteotomy, need for fixation, cast complications, time for union, and finally parent reported outcome. RESULTS : 16 children with bilateral deformity and 26 children with unilateral deformity participated. Children of age 2.2 to 18 years participated in our study. Duration was 30 to 48 min in age<7years while 48 min to 90mins in > 7 years. Children older than 10years required shortening achieve correction. Stability after the osteotomy and need for fixation was related to distance between osteotomies, with age less than 7 years and gap >18cm being stable in AE cast only. Time to union was prolonged in 12 children <7 years age and 4 cases of age > 12 years who underwent plate fixation for osteotomy fixation. CONCLUSIONS: This study reflects our learning curve with this method of correcting the deformity. The RU rotational osteotomy is safe and effective method. However certain points like age of correction, size of synostosis, degree of correction, stability after correction should be kept in mind while performing the surgery.

Background: Review of the published articles does not show any study done to see if children with torus fracture are with Vitamin D deficiency. The aim of this study was to determine association of inadequacy of Vitamin D level with torus fracture and its predictors in children in Karachi Pakistan.
METHODS:All patients with torus fracture included in this cross-sectional study, were below 13 years of age and managed non-operatively with below elbow cast.Pro forma was made including demographic data (age, gender, nutritional status) and exposure to sunlight, dietary habits, kind to apparel and type of accommodation they were living at. All participants underwent measurement of serum vitamin D level. We also got Vitamin D level done for mothers of lactating participants.

Results:Out of 558 children presented to emergency department with upper limb fractures, 190 had torus fracture with mean age of 6.0 ± 4.2 years. 93 (48.94%) in pre-school group, 59 (31.05%) in school and 38 (20%) were breast fed. malnourished were 72 (37.89%), out of which 32 (44.44%) had first-degree malnutrition.
Vitamin D level was insufficient in 55 (28.94%) patients. We found 86(45.26%) as Vitamin D deficient and only 52(27.36%) participants had Vitamin D within normal range. we found that vitamin D level is not significantly related with age, gender, type of accommodation and different fabric types.
Conclusion:Torus fracture in children is significantly associated with Vitamin D deficiency, with common predictors including nutritional status, maternal Vitamin D level for lactating mothers and duration of exposure of sunlight.

Interlocked cannulated balde plate for proximal femoral osteotomy in paralytic hip dislocation
— Introduction. Hip subluxation is common in the ambulatory patient, but it is very common in the nonambulatory patient. Hip Subluxation will develop in 50% of quadriplegic CP patients. 50% to 75% of dislocated hips will become painful. Treatment is based on radiologic assessment with the Reimer Migration percentage.
— To avoid complications of Conventional 90°blade plate in children with neurological diseases, due to bone fragility such as, a wrong direction or movement of the blade in the neck of the femur, pulled out of blade and increase prominent of plate under the skin and soft tissue irritation, we introduce our new plate.
— The aim of introducing new system. We assumed that this new system would offer significant advantages over existing systems, including more stable fixation and an easier and safer learning curve for trainees.
— Key wards: Interlocked, cannulated, balde plate, femoral, osteotomy, paralytic, hip, dislocation
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— Materials and methods
Between March 1, 2019 and April, 2022, 30 proximal femoral osteotomies were performed in 25 children and adolescents. There were 13 boys and 17 girls with a mean age
of 7 years and 9 months (range of 3–17 years) and a mean weight of 22.7 kg (range 11–66 kg).
Mean follow-up was 9 months (SD range 4–20 months).

Results

All children were followed to bony union with no hip recurrent dislocation in fellow up 2 years
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Introduction: Osteochondritis dissecans (OCD) remains a relatively uncommon condition in the paediatric population. Its aetiology is unknown, but trauma is a predisposing factor. OCD affects the weightbearing aspect of the knee in those with an open physis. Management strategies range from conservative to more invasive treatments such as microfracture or open fixation. Methods: Retrospective analysis of OCDs treated at a tertiary centre over a 5-year period (2017-2022). Data showing demographic, aetiology of injury, pre-op imaging, as well as intra-operative findings were collected. Post operative resolution of the OCD on MRI imaging along with range of motion and improvement of pain were the primary outcome measures. Results: 26 patients were surgically treated. 13 underwent fixation with 7 undergoing microfracture alone. Two patients had diagnostic arthroscopies showing healed OCDs intraoperatively. 71% of patients were reviewed within one month of their procedure and all reported reduction in pain and did not have symptoms of instability. There was no clinically significant difference in the range of movement achieved in those that underwent microfracture or fixation. Patients achieved on average of 126 degrees of flexion by three months. 16 patients had a post operative MRI at 12 months after intervention, all showed significant improvement in size of the lesion, with no significant difference between those who underwent fixation or microfracture. Conclusion: Osteochondritis Dissecans (OCD) is an important differential in juveniles with knee pain. Both microfracture and fixation showed improvements in pain and stability in the assessed population.

Introduction:According to the WHO, poliomyelitis has been virtually eradicated,despite this,a middle-aged patients still suffer the long-term sequelae of this disease,With skeletal growth,leg shortening,soft tissue contractures and foot deformities often develop in poliomyelitis.Treatment strategies require consideration of several factors, including the instability from muscle imbalance, the presence of knee and hip contractures or poor soft tissue conditions from previous surgery.The goal of orthopaedic surgical treatment is to obtain a painless and stable lower limb.Patients and methods: Eleven patients with combined fixed flexion knee deformity, equinus ankle,cavus foot and limb shortening. were initially treated with a distal femoral osteotomy for lengthening and extension of distal femur, gradual correction of the flexed knee, gradual correction of equinus and foot osteotomy for the cavus simultaneously with ilizarov. The Patients were evaluated preoperatively and postoperatively radiographically by assessing the femoral tibial angle, mPDFA, limbs discrepancy, Meary’s angle, tibial insole angle and calcaneal inclination angle. Results: At a mean follow-up of 36 months ,The mean mPDFA angle changed from 73.45° to 94.3°. The mean calcaneal inclination angle improved from .35° to 18° and Meary’s angle from 20 to 5°. 10 of 12 patients had sufficient improvement in stable leg stance without hand to thigh support.Conclusion: The presence of a major handicap such as these deformities following Poliomyelitis should be treated to promote or improve gait.This technique allows simultaneous correction not only of the flexion knee deformity, but also of limb discrepancy and foot deformity which improve the function and the patient can be made brace free.

Introduction: Calcaneal lengthening osteotomy was first described by Dillwyn Evans in 1975. Its aim is to lengthen the foot's lateral column to re-align the along axis of the talus with that of the first metatarsal on both anteroposterior and lateral radiograhic views.
Surgical Tip: After performing the osteotomy a trapezoidal bone graft is inserted after distracting the osteotomy. Prior to distraction a retrograde K wire should be inserted across the calcaneocuboid joint to avoid its subluxation, stopping just distal to the osteotomy. Distracting the osteotomy is quite demanding and there are several ways to do this. Either using 2 osteotomes on each side of the osteotomy or a laminar spreader. Both these methods cause some crushing of cancellous bone on the opposing surfaces of the osteotomy. These instruments also leave very little space for insertion of the bone graft, which frequently slips out during removal of the used instrument. The one method described which leaves the area for graft insertion completely free is the use of 2 K wires, one in each fragment to pull the osteotomy apart. But these wires usually tend to bend and therefore diminish the power of distraction. The "Caspar Cervical Distractor" proved successful in preserving straightness of the K wires and making distraction in a more controlled manner. This is because distraction is done with the device flush with the outer cortex of each fragment, leaving ample space for graft insertion.

Hip fractures in the young, healthy population are rare and often the result of high-energy trauma. A previously healthy 17-year-old patient presented to our institution with a 5-week history of left hip and knee pain in the absence of any trauma. Pelvic radiograph revealed a subacute left femoral neck fracture. He subsequently underwent surgical fixation and made an uneventful recovery. Further endocrine evaluation revealed isolated vitamin D deficiency to be the likely underlying cause for this fracture. Multiple previous opportunities were missed to identify the cause for this patient's symptoms. An intracapsular fracture in a young adult requires early recognition and prompt anatomical reduction. This case emphasises the need to maintain a high index of suspicion for atraumatic fractures in healthy adolescents with unexplained joint pain. Further endocrine and metabolic investigations are warranted, and isolated vitamin D deficiency must be considered as a potential causative factor.

Introduction: Aneurysmal bone cyst is a benign cystic lesion with still unknown etiology. The lesion may be with locally aggressive character. The occurrence in children poses a problem of diagnosis and management. Materiels and methods: We conducted a retrospective, descriptive and analytical study of 22 cases of aneurysmal bone cysts, during a 16-year period from 2005 to 2021. Results: The sex ratio in our work was 1.20 in favor of the male sex; the average age was 9 years with extremes ranging from 2 to 15 years. The location on the skeleton is mainly represented by the femur followed by the location on the humerus; tibia and metacarpus, half of the bone cysts studied were located on the metaphysis. The aneurysmal bone cysts in our series was discovered in trauma cirumstances associated or not with a bone fracture, followed by bone pain and swelling. Radiological exploration was performed by standard radiographs, CT scan and magnetic resonance imaging. All cases of aneurysmal bone cysts were confirmed by bone biopsy. Therapeutic management consisted on curettage of the cyst and placement of a graft, associated in 18 cases with osteosynthesis. The average follow-up was 19.5 months; only one case of recurrence was noted in our series; no other complications occurred. conclusion: The good managment of Aneurysmal bone cyst needs good knowledge by the clinician to performe needed explorations, the most important of which is the biopsy and antoomopathological confirmation before any therapeutic decision.

To determine the functional outcome of cast manipulation in idiopathic congenital dislocated knee in new born to 3month old child”.

ABSTRACT
Objective: To determine the functional outcome of the manipulation and casting & to know the earliest age limit when surgical intervention can be avoided in Congenital Dislocated Knee.
Methods: This Prospective study was carried at Jinnah Postgraduate Medical Centre Karachi, Pakistan from January 2014 to December 2017.The patients with Idiopathic, Type II & III Congenital Knee Dislocations (CDK), in newborn to three months were managed by serial manipulation and Casting with and without per Cutaneous Quadriceps Tenotomy (PCQT).
Results: At 26 months median follow-up, out of 32 knees of 23 patients, 29(90.62%) behaved Excellent and 2(6.25%) behaved good. Average 4 casts required, to achieve >1200 flexion, stable knees with negative Drawers test in 96.87% Knees. The required number of casts increased from 3 to 5 as age increased from one day to one month & above, moreover 7 knees of 3 patients, who got treatment initiated after 3 weeks of birth also required PQCT.
Conclusion: The CDK is easy to reduce without significant manipulation time, when treatment is started within 24 hours of birth. With increasing age from hours to four weeks, the manipulation takes more time to reduce and required more number of cast to maintain reduction. After three weeks of age, CDK often require an addition procedure of PCQT.
Key words: Casting, Congenital, Dislocation, Knee, Manipulations, Per Cutaneous Tenotomies.

Introduction:There is a paucity of literature documenting CAI in the paediatric population. We present two cases of CAI in a 13 and a 10 year old patient. Unlike typical adult aetiology,the cause of instability was defunctioning lateral ligamentous complex as a consequence of bony avulsion of the tip of the fibula.Methods:Both patients sustained a twisting injury to the ankle.The force was sufficient to cause an avulsion fracture of the tip of the fibula.The fractures failed to unite. The non union defunctioned the (ATFL) with consequent CAI.At initial clinical assessment, MRI was requested in both cases.Case 1:10 year old girl.The MRI scan showed a ruptured ATFL with small bony avulsion. The CFL and (PTFL) were intact. Due to the small size of the avulsed fragment fixation was not possible.A Modified Gould-Brostrom procedure was undertaken which facilitated a repair of the avulsed fragment using two G2 (dePuy-Mitek) anchor sutures.Case 2:13 year old girl.The MRI arthrogram confirmed an intact ATFL and calcaneofibular ligament (CFL). The ligaments remained in their anatomic attachment to the non united bony fragment of the fibula. Having failed non-operative treatment.The fracture was fixed with two headless screws and was immobilised in plaster for 6 weeks.Results Case 1,post operatively the instability symptoms settled completely.The patient returned to normal activities. Case 2,the fracture healed without complication.Patient returned to normal activity with no impairment.The symptoms of instability settled completely.Conclusions Recognising and understanding the aetiology of CAI in children along with timely appropriate intervention will avoid long-term problems and improve quality of life.