Background: Non-Accidental Injury (NAI) in children has significant burden on the society and is a social stigma. It is imperative that the orthopaedic surgeons are aware of the recent developments in diagnosing and managing NAI. Aim: The purpose of the study is to perform a literature review and provide an update on the NAI injuries to the orthopaedic surgeons. Seventy eight papers were selected for the review. Conclusion: Our study has shown the wide variation across the globe in definition, epidemiology, diagnostic measures, protocol and policy measures. It also highlights the difficulty in diagnosis and management of these injuries under a stressful environment and the need for multidisciplinary approach.

There is a wide range of foot disorders and deformities in children. While most of them are benign, some of the foot deformities may require operative intervention and/or a prolonged period of treatment. We will discuss the most common of these disorders: clubfoot, congenital vertical talus, calcaneovalgus deformity, metatarsus adductus, flexible flatfoot, tarsal coalitions and cavus foot.

The management of slipped upper femoral epiphysis is controversial and evolving as insight into the condition develops. Loder introduced the concept of slip stability and demonstrated a strong association between poor outcome and instability. Almost half of patients with unstable slip developed femoral head osteonecrosis. This has been influential in surgeons' choice of treatments. Some surgeons have adopted a minimal intervention approach such as pinning in situ or gentle reduction and pinning whereas others advocated an urgent open reduction and stabilisation of slip using various surgical techniques. In this review we analysed the influence of various interventions, timing of surgery and severity of the slip on the outcome of unstable slip.

BACKGROUND:Several aspects of slipped capital femoral epiphysis (SCFE) treatment remain controversial. Loder's work has been instrumental in changing our understanding and approach to the management of the condition when he introduced the concept of "slip instability" and showed that avascular necrosis (AVN) developed in 47% of unstable slips but none of the stable slips. As the two types of SCFE behave differently in terms of presentation, progress and complications, we approached them as two different conditions to highlight these differences. This paper focuses on treatments of stable SCFE. MATERIALS AND METHODS:An extensive literature search was carried out from multiple databases. One thousand six hundred and twenty-three citations were screened. Three hundred and sixteen full publications were obtained for further scrutiny. Fifty-eight studies (2262 hips) were included in the review. These studies evaluated 6 interventions. AVN was chosen as a surrogate for bad outcome. Secondary outcomes were chondrolysis (CL), femoro-acetabular impingement (FAI), osteoarthritis (OA) and patients' reported outcomes. The latter were pooled when they met our predefined criteria. RESULTS:The type of surgical intervention was an important risk factor. Pinning in situ (PIS) was associated with the lowest AVN rate (1.4%). Moreover, the CL, FAI and OA rates were relatively low in patients who underwent PIS. These were not translated into high patient satisfaction rates among these patients, with only 47% reporting an "excellent" outcome. In contrast, 87% of patients who underwent Ganz surgical dislocation reported an "excellent" outcome. The Ganz surgical dislocation was associated with an AVN rate of 3.3%; double that observed in pinning in situ. CONCLUSION:Pinning in situ is the best treatment for mild and moderate stable slip. Ganz surgical dislocation gives higher patient satisfaction for severe stable slip but the risk of AVN is doubled compared with pinning in situ. Devices that allow continued growth may be better than standard screws. LEVEL OF EVIDENCE:Level III.

Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity.

PURPOSE:The purpose of this study was to evaluate the magnetic resonance imaging (MRI) and clinical results of arthroscopic repair of isolated subscapularis tears at 24 months' follow-up.METHODS:We prospectively followed up 20 patients with isolated subscapularis tears treated with arthroscopic repair with suture anchors in a 3-year period (January 2006 to December 2008) at our institution. Clinical examination of the patients and functional scores (Constant and University of California, Los Angeles [UCLA] scores) were obtained preoperatively and at 6 months, 12 months, and 24 months postoperatively. MRI and routine radiographs were obtained to evaluate the repair at the last follow-up.RESULTS:Of the patients (mean age, 42 years; age range, 31 to 56 years), 19 (95%) had complete follow-up. Constant and UCLA scores improved significantly after the repair at all postoperative examinations. The Constant score gained 39.7 points to a mean of 81 points (range, 61 to 95 points) at last follow-up, and the UCLA score improved from 16 points to 32 points (range, 25 to 35 points). Of the shoulders, 13 had a concomitant lesion of the long head of the biceps; 12 were treated with biceps tenodesis. At last follow-up, there were 2 retears detected by both MRI and examinations (positive belly-press and liftoff tests). Seventeen patients were satisfied with their results at 24 months postoperatively.CONCLUSIONS:Arthroscopic repair of isolated subscapularis tendon tears is an effective technique with good-to-excellent clinical and functional results.LEVEL OF EVIDENCE:Level IV, therapeutic case series.

Aneurysmal bone cysts (ABCs) are rare benign bone tumours. Scapula is a very rare location, and the relative literature is sparse. The purpose of this study is to present a case of a giant aggressive scapular aneurysmal bone cyst in a child. A 7-year-old boy presented to our hospital with pain and a palpated mass on the right scapula. Imaging studies (radiographs computed tomography scintigraphy) were indicative of aneurysmal bone cyst. We performed curettage and bone grafting after the diagnosis was set by pathological examination through a posterior shoulder approach. Five years later, the patient has only residual signs of the lesion on radiographic control without signs of recurrence.

Lower leg oedema after trauma may cause various degrees of pain, disability and delay in patient recovery. In this prospective randomized study, we hypothesized that venotonic drugs had no effect in clinical outcome of patients with ankle sprain.

Background: There are only a few studies with long-term follow-up of distal clavicular injuries in children and their treatment is not clearly defined. The purpose of our study is to suggest a new classification system according to the fracture pattern and the degree of the displacement, to evaluate the long-term follow-up and also to propose an algorithm for treatment.Methods: We conducted a retrospective study from 1983 to 2008. Seventy-five children and adolescents, age ranging from 3 to 16 years (46 > 8 years), were treated in our department. We classified all these injuries into five groups according to the fracture pattern and into subgroups according to the displacement of the bony particles: greenstick fractures as group I, transverse fractures as group II, oblique fractures as group III (IIa and IIIa: undisplaced, IIb and IIIb: displaced), comminuted fractures as group IV and true dislocation of the acromioclavicular joint as group V. Sixty-three patients were treated conservatively, while 12 sustained surgical treatment.Results: Fifty-nine patients were re-examined after 2-18 years. All the patients included in groups I, IIa and IIIa had no loss in the motion of their shoulder. Seven of the 29 patients in groups IIb, IIIb, IV and V appeared to have minor loss of motion. A constant score was noted in 52 patients and the results were excellent. None of the patients complained of limitations in daily activities, while five patients, who were treated conservatively, complained of visible prominence at the fracture site. One of them had a clavicular duplication, while another patient treated surgically complicated with coracoclavicular synostosis.Conclusion: The aforementioned proposed classification of these injuries is based on the fracture pattern and is simple, leading to decision making concerning therapy of these injuries. The functional results after a distal clavicle fracture will be excellent, either after conservative or surgical treatment. Older patients (>8 years) from groups IIb, IIIb, IV and V, with greater displacement, could be treated surgically to have better cosmetic results. Crown Copyright (C) 2010 Published by Elsevier Ltd. All rights reserved.

Avulsion fibular head fractures are rare. There is only one reference of bilateral fibular fractures after epileptic seizure. We aim to present the mechanism and the treatment of this rare injury. We present the case of a 30-year-old woman who was hit by a car on the anteromedial side of both knees. Clinical and radiographic control showed bilateral fibular head fractures. Knee instability was not found at both knees and MRI did not show any concomitant ligament ruptures. Bone bruises of both medial condyles found in MRI explain the mechanism of this injury. The patient was treated conservatively with functional knee braces for 6 weeks allowing full range of motion, but otherwise mobilised as normal without any support. Six weeks after the trauma, there were no symptoms while the fractures sites had united completely after 6 months. One year postinjury the patient was free from symptoms.

We report a case of a closed tibiotalar dislocation without an associated malleolar fracture, in the presence of medial malleolar hypoplasia, treated with closed reduction and surgical repair of the deltoid ligament, followed by cast immobilization. Postreduction radiographs, before open repair of the deltoid ligament, revealed an Elise test ratio of 0.43. The ruptured superficial and deep portions of the deltoid ligament and the anterior ankle capsule were primarily repaired with suture, after which cast immobilization and non-weight bearing were used before physiotherapy and rehabilitation. Two years after the injury, the patient was pain free with a full range of ankle motion, and there were no signs of residual instability or early osteoarthritis. Subjective clinical testing using a valid health measurement instrument revealed an excellent clinical outcome. Based on our experience in this case, closed ankle dislocation in the presence of a hypoplastic medial malleolus and stress manipulation evidence of medial instability indicates the need for primary repair of the deltoid ligament. Level of Clinical Evidence: 4 (The Journal of Foot & Ankle Surgery 48(6): 690.e13-690.e17, 2009)

We present a 40-year-old man, manual worker, who sustained a right hand injury, after a fall on his outstretched hand. Initial diagnosis was isolated pisiform fracture, documented with the conventional carpal views and a conservative treatment was applied by using a cast. Three months after the trauma episode, the patient presented at hospital outpatient’s clinic with symptoms of ulnar neuropathy. The fracture had been already united, according to the signs of callus formation in plane radiographs. Nerve conduction studies confirmed the ulnar nerve’s neuropathy and a decision of surgical exploration of Guyon’s canal was made. Intraoperatively, we found that pisohamate ligament was ruptured and an acquired aberrant fibrous band was the main cause of ulnar nerve compression. The patients’ symptoms were promptly receded after the resection of the pisohamate ligament band. At one-year follow-up, no recurrence of symptoms was reported and the patient was successfully returned to his priory to injury occupation .