Who performs neonatal hip assessment: is there a cause for concern?

OBJECTIVE: The UK falls behind other European countries in the early detection of developmental dysplasia of the hip (DDH) and screening strategies differ for early detection. Clinical detection of DDH is challenging and recognised to be dependent on examiner experience. No studies exist assessing the number of personnel currently involved in such assessments.Our objective was to review the current screening procedure by studying a cohort of newborn babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual. METHODS: This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020. Record of each initial baby check was obtained from BadgerNet. Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records. RESULTS: 1037 babies were examined by 65 individual examiners representing 9 different healthcare professional groups. The range of examinations conducted per examiner was 1-97 with a median of 5.5 examinations per person. 49% of individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. Of the six babies (0.48%) treated for DDH, one was picked up on neonatal assessment. CONCLUSION: In a system where so many examiners are involved in neonatal hip assessment, the experience is limited for most examiners. Currently high rates of late presentation of DDH are observed locally, which are in accordance with published national experience. The potential association merits further investigation.

How Critical is Patient Positioning in Radiographic Assessment of the Hip in Cerebral Palsy When Measuring Migration Percentage?

BACKGROUND: Migration percentage (MP) is an accepted method of assessing lateral displacement of the femoral head in children with cerebral palsy (CP). Difficulty in positioning of patients for pelvic radiography remains a concern for the reliability of the MP. METHODS: This 2-part quantitative study examined 100 anteroposterior pelvic radiographs for children with CP. Fifty were from a region that had a positioning protocol for hip surveillance of children with CP and 50 images were from a region without. Images were assessed for acceptability of position in relation to hip abduction/adduction and/or pelvic rotation.Ten images deemed Acceptable or Borderline from the region with no protocol were then randomly selected. MP was measured on 2 separate occasions by 5 children's orthopaedic surgeons and statistically analyzed for intrarater and interrater reliability. RESULTS: There was no statistically significant difference in the acceptability of images between the 2 regions with 60% to 66% of the images meeting the criteria outright. When allowances were made for slight variation of abduction/adduction within 5 degrees, 74% to 80% of the images were acceptable.Reliability was variable with limits of agreement between 4.96% and 15.15%. Observers more familiar with the software measuring package had higher reliability within and between occasions. Variability within and between observers decreased as MP increased. CONCLUSIONS: Poor positioning did not appear to be the main reason for the variation in reliability of MP. Repeat measurements were reliable although standardized technique, training, and familiarity with software measuring programmes did influence outcomes.

Variation in physical development in schoolboy rugby players: can maturity testing reduce mismatch?

OBJECTIVES: This study set out to pursue means of reducing mismatch in schoolboy rugby players. The primary objective was to determine whether application of previously reported thresholds of height and grip strength could be used to distinguish those 15-year-old boys appropriate to play under-18 school rugby from their peers. A secondary objective was to obtain normative data for height, weight and grip strength and to assess the variation within that data of current schoolboy rugby players. DESIGN: Cross-sectional cohort study. SETTING: 3 Scottish schools and 'Regional Assessment Centres' organised by the Scottish Rugby Union. PARTICIPANTS: 472 rugby playing youths aged 15 years (Regional Assessment Centres) and 382 schoolboys aged between 12 and 18 years (three schools). OUTCOME MEASURES: Height, weight and grip strength. RESULTS: 97% of 15-year-olds achieved the height and grip strength thresholds based on previous reported values. Larger mean values and wide variation of height, weight and grip strength were recorded in the schoolboy cohort. However, using the mean values of the cohort of 17-year-olds as a new threshold, only 7.7% of 15-year-olds would pass these thresholds. CONCLUSIONS: Large morphological variation was observed in schoolboy rugby players of the same age. Physical maturity tests described in earlier literature as pre-participation screening for contact sports were not applicable to current day 15-year-old rugby players. New criteria were measured and found to be better at identifying those 15-year-old players who had sufficient physical development to play senior school rugby.

Serious neck injuries in U19 rugby union players: an audit of admissions to spinal injury units in Great Britain and Ireland.

OBJECTIVES: To obtain data regarding admissions of U19 rugby players to spinal injury units in Great Britain and Ireland and to compare this with a recent peak in presentation in Scotland. To assess the current state of data collection and subsequent analysis of serious neck injuries. To analyse the mechanism of injury in this group of at-risk players. DESIGN: Retrospective case series. PARTICIPANTS: Spinal injury units in Great Britain and Ireland. OUTCOME MEASURES: Annual frequency of serious neck injuries. Analysis of injury types, neurological deficit and mechanism of injury. RESULTS: 36 Injuries were recorded. 10 Of these occurred in Scotland since 1996 of which six have occurred in the past 4 years. This compared with 14 in Ireland over the same period. 12 Cases were traced in England and Wales since 2000; records were not available before this date. No prospective collation of data is performed by the home unions and inconsistency of data collection exists. The mean age was 16.2 years. 16 Of the 36 admissions had complete neurological loss, 9 had incomplete neurological injury and 11 had cervical column injury without spinal cord damage. The mechanism of injury was tackle in 17 (47%), scrum in 13 (36%), two each due to the maul and collision, and one each due to a kick and a ruck. Some degree of spinal cord injury occurred in 92% of scrum injuries (61% complete) and 53% of tackle injuries (29% complete). CONCLUSION: U19 rugby players continue to sustain serious neck injuries necessitating admission to spinal injury units with a low but persistent frequency. The recent rate of admission in Scotland is disproportionately high when the respective estimated playing populations are considered. While more injuries were sustained in the tackle, spinal cord injury was significantly more common in neck injury sustained in the scrum (p<0.001). No register of catastrophic neck injuries exists despite repeated calls over the past three decades, and a study such as this has not been reported before. Data collection of this serious category of injury is incomplete and very variable across the home unions, as a consequence a large proportion of the serious neck injuries that have occurred in U19 players over the past 14 years have not been analysed. Rigorous data collection and analysis have to be established so that problem areas of the game such as scrum engagement and the tackle can be made safer.

Two cases of neurofibromatosis presenting with a foot deformity.

Two children presented with an isolated foot and ankle deformity. Examination in each suggested a plexiform neurofibroma although this diagnosis had not been considered before referral. Diagnosis of neurofibromatosis type 1 was confirmed by MRI scanning and on investigation both patients were proved to have widespread disease. One had a plexiform neurofibroma encasing the aorta and oesophagus. Both cases remain under observation and have not undergone surgery for their disease. Neurofibromatosis can present with isolated foot and ankle deformity and when such a diagnosis is suspected thorough investigation is important in a condition in which unsuspected widespread disease may exist.

Risk of periprosthetic fracture after anterior femoral notching.

BACKGROUND: Notching of the anterior femoral cortex in distal femoral fractures following TKR has been observed clinically and studied biomechanically. It has been hypothesized that femoral notching weakens the cortex of the femur, which can predispose to femoral fractures in the early postoperative period. We examined the relationship between notching of the anterior femoral cortex during total knee replacement (TKR) and supracondylar fracture. PATIENTS AND METHODS: Postoperative lateral radiographs of 200 TKRs were reviewed at an average of 9 (6-15) years postoperatively. 72 knees (41%) showed notching of the anterior femoral cortex. Notches were classified into 4 grades using the Tayside classification as follows. Grade I: violation of the outer table of the anterior femoral cortex; grade II: violation of the outer and the inner table of the anterior femoral cortex; grade III: violation up to 25% of the medullary canal (from the inner table to the center of the medullary canal); grade IV: violation up to 50% of the medullary canal (from the inner table to the center of the medullary canal) and unclassifiable. RESULTS: The interobserver variability of the classification system using Cohen's Kappa score was found to be substantially reliable. 3 of the 200 TKRs sustained later supracondylar fractures. One of these patients had grade II femoral notching and the other 2 showed no notching. The patient with femoral notching sustained a supracondylar fracture of the femur following a simple fall at home 9 years after TKR. INTERPRETATION: There is no relationship between minimal anterior femoral notching and supracondylar fracture of the femur in TKR.

A simple modification of the Pavlik harness for unstable hips.

The Pavlik harness has been used in the treatment of developmental dysplasia of the hip for almost 60 years. During this time there has been little in the way of modification of the original design. In clinical practice it has an established role, but it is recognized to be less effective in more unstable hips, which are often associated with marked acetabular dysplasia. The authors present a simple modification that proved successful in three hips that were not stabilized in a Pavlik harness applied in the usual fashion.