Alastair W. Murray

Microbiological characteristics of acute osteoarticular infections in children

This study aimed to describe the microbiological characteristics of acute septic arthritis (SA) and osteomyelitis (OM) in children. Cases of children (0-15 years) with SA/OM were identified through a retrospective search of hospital discharge codes over a six-year period. In addition, a systematic literature search and meta-analysis of studies reporting culture results of children with SA/OM was performed. In our retrospective chart review, we identified 65 cases of OM and 46 cases of SA. The most frequently cultured organisms in both conditions were Gram-positive cocci, primarily Staphylococcus aureus. On admission, most patients had a normal white blood cell count (WCC) but elevated C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR). Bacteraemia was associated with a longer mean length of hospitalization for both infections. Considering our results and the meta-analysis, we found low rates of culture-positivity in cases of clinically confirmed infection. In SA, articular fluid was culture-positive in 42.49% [95% confidence interval (CI) 28.39-57.23]. In OM, intra-operative samples were culture-positive in 52.65% (95% CI 30.54-74.22). Bacteraemia was detected in 23.91% (95% CI 8.40-44.24) of children with SA and 21.48% (95% CI 10.89-34.47) with OM. Despite appropriate sampling, a positive microbiological diagnosis is often lacking in paediatric acute osteoarticular infection using standard culture-based methods. This highlights the need for validation and use of more sensitive diagnostic methods, such as PCR.

Do children who in-toe need to be referred to an orthopaedic clinic?

The objective of this study was to investigate the outcome of in-toeing referrals to a paediatric orthopaedic department. Two hundred and two patients referred to the Royal Hospital for Sick Children, Edinburgh between July 2005 and March 2008 were retrospectively reviewed. Increased femoral anteversion and internal tibial torsion formed the majority of diagnoses. The median age of referral was 4 years. No patient in the audit period required surgery. Eighty-six percent of children were discharged after their first visit. No significant pathology was identified in the 14% reviewed. Management and outcome for these children were not affected by referral to the orthopaedic clinic.

Enhanced detection services for developmental dysplasia of the hip in Scottish children, 1997–2013

Background Developmental dysplasia of the hip (DDH) remains common. If detected early, DDH can usually be corrected with conservative management. Late presentations often require surgery and have worse outcomes. Objective We estimated the risk of undergoing surgery for DDH by age 3 years before and after the introduction of enhanced DDH detection services. Design Retrospective cohort study. Setting Scotland, 1997/98–2010/11. Patients All children. Methods Using routinely collected national hospital discharge records, we examined rates of first surgery for DDH by age 3 by March 2014. Using a difference in difference analysis, we compared rates in two areas of Scotland before (to April 2002) and after (from April 2005) implementation of enhanced DDH detection services to those seen in the rest of Scotland. Results For children born in the study period, the risk of first surgery for DDH by age 3 was 1.18 (95% CI 1.11 to 1.26) per 1000 live births (918/777 375). Prior to April 2002, the risk of surgery was 1.13 (95% CI 0.88 to 1.42) and 1.31 (95% CI 1.16 to 1.46) per 1000 live births in the intervention and non-intervention areas, respectively. In the intervention areas, from April 2005, this risk halved (RR 0.47; 95% CI 0.32 to 0.68). The risk remained unchanged in other areas (RR 1.01; 95% CI 0.86 to 1.18). The ratio for the difference in change of risk was 0.46 (95% CI 0.31 to 0.70). Conclusions The implementation of enhanced DDH detection services can produce substantial reductions in the number of children having surgical correction for DDH.

Principles of Fracture Care

In childhood, bone has certain characteristics that are quantitatively different from those of the adult. First, the modulus of elasticity is relatively high and the thick periosteal sleeve adds further resistance to complete fracturing. Hence buckle (torus) and greenstick fractures are relatively common, although they may be more extensive than plain radiographs suggest. Second, it should be appreciated that bone tends to give way before ligament in the prepubertal child: apophyses and other bony points of soft tissue attachment avulse before the tendon ruptures or the ligament tears.

Trends in surgery for developmental dysplasia of the hip before and after introduction of improved detection pathways: a population-based cohort study, Scotland 1997–2014

Abstract Background Developmental dysplasia of the hip diagnosed in early infancy ( Methods For all children born in Scotland in April 1997 to March 11, we compared the risk of surgery for developmental dysplasia of the hip by age 3 years (follow up to March, 2014). We compared risks for children born before and after implementation of improved detection pathways. Under usual care in Scotland, all babies undergo clinical examination of the hip (Ortolani and Barlow tests) by a non-specialist examiner as part of the examinations done at birth and 6–8 weeks. Babies with positive findings and those with risk factors for developmental dysplasia of the hip are referred for further investigation. Two areas of Scotland (NHS Lothian and Fife) independently introduced improved detection pathways between April 2002 and March 2005, employing a specialist physiotherapist and paediatrician, respectively, to increase awareness of the condition, train staff undertaking newborn hip examinations, and improve access to expert hip examination and ultrasound scans. We used a logistic regression model of first surgery for developmental dysplasia of the hip by age 3 as recorded in national hospital discharge records on an area by period interaction to estimate the difference in difference. Findings Among 777 375 live births in Scotland in April 1997 to March 2011, 918 children underwent first surgery for developmental dysplasia of the hip by age 3 years (1·18 per 1000 live births, 95% CI 1·11–1·26). The risk of surgery for babies born in the post-introduction period (April 2005 to March 2011) compared with the pre-introduction period (April 1997 to March 2002) halved in the intervention areas (NHS Lothian and Fife combined) but remained unchanged elsewhere in Scotland (ratio for the difference in change of risk 0·46, 95% CI 0·31–0·70). Interpretation Implementation of enhanced detection pathways can substantially reduce late diagnosis of developmental dysplasia of the hip and associated requirement for surgical correction. Current models of care based on non-specialist clinical hip examination are associated with unacceptably high rates of late diagnosis. Funding DAM is funded by a Wellcome Trust intermediate clinical fellowship (and Beit fellowship) (201492/Z/16/Z). JRM is funded by a Medical Research Council clinician scientist fellowship.

Pretibial subcutaneous soft tissue lesions presenting to a paediatric orthopaedic clinic

Pretibial swellings in children usually represent erythema nodosum which exhibits characteristic skin changes. Three cases of pretibial subcutaneous lesions are presented which had no skin involvement or bony abnormalities on plain radiographs. At initial presentation, concerns of malignancy were raised but these lesions were ultimately diagnosed as granuloma annulare, fat necrosis and subcutaneous infection. In combination with clinical assessment and plain radiographs, MRI proved invaluable in reaching diagnosis and excluding neoplasia. Biopsy was only required in one case in this series after MRI. A tissue diagnosis, however, remains mandatory if there is any doubt over the nature of such lesions.