Purpura fulminans (PF) is a severe clinical manifestation of Neisseria meningitides infection that is associated with high mortality rates in children. Survivors are frequently left with debilitating musculoskeletal sequelae. There is a paucity of reports on the musculoskeletal pathology of purpura fulminans. We report on a 2-year-old boy with purpura fulminans due to meningococcemia. The child developed distal gangrene in both the upper and lower limbs. Amputations were done for both lower limbs. Histological examination of the amputated specimens showed an inflammatory process and features of osteonecrosis. The latest follow-up at the age of 6 years showed a right knee valgus due to asymmetrical growth arrest of the proximal tibia. PF and its complications are challenging to treat and may require a multidisciplinary approach to improve patient’s functional ability.

Femoral neck stress fractures are rare in children. To the best of our knowledge, the tension type stress fracture has been reported only twice in the English language literature. We report on a five years follow-up of a 10-year-old boy with this injury which was initially missed. The fracture healed after screw fixation. We highlight the importance of considering stress fracture as a differential diagnosis in a child with chronic hip pain. A careful physical examination and the appropriate imaging will avoid missing the diagnosis.

The optimisation of blood pressure management is critical in managing hypotensive episodes in patients with spinal cord injury. Improper handling of this preventable factor will negatively impact the patient recovery prognosis. A 42-yearold man was admitted for a complete spinal cord injury after fell from height. He developed subacute neurological deterioration unrelated to the mechanical instability but due to multiple episodes of hypotension occurring one month after the initial injury. After proper management of blood pressure, his deterioration was halted and no further progression. Spinal cord haemodynamics play an important role in mediating the onset of subacute post-traumatic ascending myelopathy. Better education and awareness on Subacute Post-traumatic Ascending Myelopathy (SPAM) especially to the junior healthcare providers are important to hinder this rare but avoidable condition.

Introduction: The guided growth technique is an alternative to corrective osteotomy for treating angular deformities of the extremities. It has the advantage of being minimally invasive and is effective in a growing child. This study reports on the outcome of guided growth technique using a plate in correcting knee angular deformities. Materials and methods: We conducted a retrospective study of children with angular deformity of the knee treated by the guided growth technique from January 2010 to December 2015 in a tertiary centre. The guided growth technique was done using either the flexible titanium plate (8-plate) or the 2- hole reconstruction plate. Correction of deformity was assessed on radiographs by evaluating the mechanical axis deviation and tibiofemoral angle. The implants were removed once deformity correction was achieved. Results: A total of 17 patients (27 knees) were evaluated. Twenty-two knees (81.5%) achieved complete correction of the deformity. The median age was 4.0 (interquartile range 3.0-6.0) years and the median Body Mass Index (BMI) was 26.0 (25.0-28.0). There were 7 unilateral and 10 bilateral deformities with different pathologies (14 tibia vara, 3 genu valgus). The median rate of correction was 0.71° per month. One patient (1 knee) had screw pull-out and two patients (4 knees) had broken screws in the proximal tibia. Three patients (5 knees) failed to achieve complete correction and were subsequently treated with corrective osteotomies. Out of five patients (8 knees) who were followed-up for at least 12 months after removal of hardware, two had rebound deformities. No permanent growth retardation occurred in our patients. Conclusion: Our outcome for guided growth to correct knee angular deformity was similar to other studies. Guided growth is safe to perform in children below 12 years old and has good outcome in idiopathic genu valgus and Langeskiold II for tibia vara. Patients should be observed for recurrence until skeletal maturity following implant removal.

Introduction: To compare the anxiety levels demonstrated by children during cast removal procedure between oscillating saw vs cast shear methods. Material and methods: A randomised prospective study of 102 children (mean age 8.3 ± 3.5 years) with fractures involving upper or lower limbs. Children undergoing removal of cast were divided into 2 groups; either by an oscillating saw or a cast cutting shear. The level of anxiety was assessed by recording the heart rate with a portable fingertip pulse oximeter before, during and after removal of the cast. Objective assessment was performed by documenting the fear level on Children’s Fear Scale (CFS). Results: There was a significant increase in the heart rate of children during cast removal while using the oscillating saw compared to cast shear (p<0.05). The noise level produced by the saw exceeded 80 dB (mean 103.3 dB). The fear level was significantly lower in the cast shear group (p<0.05). Conclusion: The noise produced by the oscillating saw was associated with an increased anxiety level in children undergoing cast removal. Cast shear is a simple and inexpensive instrument that can be used for cast removal in overly anxious children.

Tardy ulnar nerve palsy is a known complication of cubitus valgus. The options for treating the ulnar neuropathy include anterior nerve transposition or neurolysis. We report on an 11-year-old boy who had a tardy ulnar nerve palsy due to cubitus valgus resulting from a non-union of a lateral condyle fracture of the humerus. Anterior transposition of the ulnar nerve was not done after the closing wedge osteotomy of the distal humerus. The close wedge osteotomy relieved the tension on the nerve and not transposing the ulnar nerve anteriorly prevented an iatrogenic nerve injury. The patient had no restriction with activities of daily living at the six years follow-up although neurological recovery was incomplete.

Percutaneous pinning after closed reduction is commonly used to treat supracondylar fractures of the humerus in children. Minor pin tract infections frequently occur. The aim of this study was to prevent pin tract infections using a rubber stopper to reduce irritation of the skin against the Kirschner (K) wire following percutaneous pinning. Between July 2011 and June 2012, seventeen children with closed supracondylar fracture of the humerus of Gartland types 2 and 3 were treated with this technique. All patients were treated with closed reduction and percutaneous pinning and followed up prospectively. Only one patient, who was a hyperactive child, developed pin tract infection due to softening of the plaster slab. We found using the rubber stopper to be a simple and inexpensive method to reduce pin tract infections following percutaneous pinning.
Bone Wires

Introduction: Conventional Chest Physiotherapy (CCPT) remains the mainstay of treatment for sputum mobilization in patients with productive cough such as bronchiectasis and “Chronic Obstructive Airway Disease” (COPD). However CCPT is time consuming requires the assistance of a physiotherapist and limits the independence of the patient. Mechanical percussors which are electrical devices used to provide percussion to the external chest wall might provide autonomy and greater compliance. We compared safety and efficacy of a mechanical chest percusser devised by Formedic Technology with conventional chest percussion. Methods: Twenty patients (mean age 64years) were randomly assigned to receive either CCPT or mechanical percussor on the first day and crossed over by “Latin square randomisation” to alternative treatment for 6 consecutive days and the amount of sputum expectorated was compared by dry and wet weight. Adverse events and willingness to use was assessed by a home diary and a questionnaire. Results: There were 13 males and 7 females, eight diagnosed as bronchiectasis and 12 COPD. The mean dry weight of sputum induced by CCPT (0.54g + 0.32) was significantly more compared with MP (0.40g + 0.11); p-value = 0.002. The mean wet weight of sputum with CCPT (10.71g + 8.70) was also significantly more compared with MP (5.99g + 4.5); p-value < 0.001. There were no significant difference in adverse events and majority of patients were willing to use the device by themselves. Conclusion: The mechanical percussor although produces less sputum is well tolerated and can be a useful adjunct to CCPT

Objective: The aim of this study was to evaluate the role of polymerase chain reaction (PCR) in the diagnosis of spinal tuberculosis after 2 weeks of preoperative anti tuberculosis treatment and to compare PCR to the Lwenstein Jensen Culture (LJC) and histopathological examination (HPE) methods. Methods: Twenty five patients were included in this study. Sixteen patients were diagnosed and treated for spinal tuberculosis based on clinical and radiological evidence. Nine patients were controls. The LJC me
Orthopaedic

The cases of nine patients with unicameral bone cysts were reviewed from two orthopaedic centres. In one hospital, five patients received serial steroid injections, and at the other hospital four patients were treated conservatively following fractures. In the steroid injection group, three cases were in the proximal femur and two in the proximal humerus. The five steroid injection patients showed radiological evidence of cyst healing within six months of treatment. Subsequently four of the patients showed a satisfactory radiological outcome after a year and complete resolution after 2 years. In the conservative group, all four cases were in the proximal humerus. Persistent cystic lesions were observed in all four patients and two was complicated by another fracture within six months.