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Background Childhood fractures can have a significant impact on the daily lives of families affecting children’s normal activities and parent’s work. Wrist fractures are the most common childhood fracture. The more serious wrist fractures, that can look visibly bent, are often treated with surgery to realign the bones; but this may not be necessary as bent bones straighten in growing children. The children’s radius acute fracture fixation trial (CRAFFT) is a multicentre randomised trial of surgery versus a cast without surgery for displaced wrist fractures. Little is known about how families experience these wrist fractures and how they manage treatment uncertainty. This study aimed to understand families’ experience of this injury and what it is like to be asked to include their child in a clinical trial. Methods Nineteen families (13 mothers, 7 fathers, 2 children) from across the UK participated in telephone interviews. Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Results Our findings highlight parents’ desire to be a good parent through the overarching theme “protecting my injured child”. To protect their child after injury, parents endeavoured to make the right decisions about treatment and provide comfort to their child but they experienced ongoing worry about their child’s recovery. Our findings show that parents felt responsible for the decision about their child’s treatment and their child’s recovery. They also reveal the extent to which parents worried about the look of their child’s wrist and their need for reassurance that the wrist was healing. Conclusion Our findings show that protecting their child after injury can be challenging for parents who need support to make decisions about treatment and confidently facilitate their child’s recovery. They also highlight the importance of providing information about treatments, acknowledging parents’ concerns and their desire to do the right thing for their child, reassuring parents that their child’s wrist will heal and ensuring parents understand what to expect as their child recovers.

Perthes disease is an idiopathic avascular necrosis of a juvenile hip. Although 2010 marked a century since it was first described, the aetiology remains unknown. It is suggested that adverse socioeconomic circumstances may be a key precipitant. This work describes recent studies that explore the disease epidemiology. Descriptive studies include a case register from Merseyside, hospital discharge data from Scotland, analysis of the world’s largest community disease register (General Practice Research Database [GPRD]) and a systematic review of incidence. Analytical studies include a nested case-controlled study in the GPRD and a hospital case-controlled study. The studies demonstrated a striking north–south divide in the UK incidence of Perthes disease, similar to that seen in many adult diseases. There was a sustained fall in disease frequency in all studies, with a narrowing of the north–south divide. There was a strong association with area deprivation, independent of living in an urban environment. Internationally, equatorial regions were unaffected by disease and northern Europe had the highest incidence, which was primarily a function of race although latitude was an independent predictor. Individual characteristics associated with the disease were congenital anomalies of the genitourinary tract and a structural abnormality of arterial calibre. Despite a falling incidence, Perthes disease remains an important cause of child morbidity and exemplifies socioeconomic inequalities. A deprivation-related exposure, acting early in development, appears critical. The aetiological factor in Perthes disease remains elusive but it is likely that unravelling this enigma may unlock additional secrets pertaining to the developmental origins of this and other diseases.

Background Displaced paediatric supracondylar humeral fractures pose a significant risk of neurovascular injury and consequently have traditionally been treated as a surgical emergency. Recently, the need for emergency surgery has been questioned. We wished to analyse our experience at a large UK tertiary paediatric trauma centre. Methods A retrospective case note review was performed on patients with Gartland Grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. We divided children into those treated before 12 h (early surgery) and after 12 h (delayed surgery). Analysis was undertaken using Fisher’s exact test. Results Of the 137 patients, 115 were included in the study; median time-to-surgery was 15:30 (range 2:45–62:50); thirty-nine children were treated before 12 h and 76 patients after. In the early surgery group, three children (7.7 %) developed a superficial pin-site infection, four children (10.3 %) required open reduction, five children (12.8 %) sustained an iatrogenic nerve injury, and two children (5 %) required reoperation. In the delayed surgery group, one child (1.3 %) had a superficial pin-site infection, four children (5.3 %) required open reduction, seven children (9.2 %) sustained an iatrogenic nerve injury, and two children (2.6 %) reoperation. Bivariate analysis of our data using Fisher’s exact t test revealed no statistically significant difference between early and delayed surgery groups with regard to infection rates ( p  = 0.1), iatrogenic nerve injury ( p  = 0.53) or need for open reduction ( p  = 0.44). Conclusion Our results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis. These results indicate that patient transfer to a specialist paediatric centre, often with consequent surgical delay, is a safe management option and also negates the obligation to carry out these procedures at night.

Solute concentration and soluble dye studies inferring that preferential flow accelerates field-scale contaminant transport are common but flux measurements quantifying its impact are essentially nonexistent. A tile-drain facility was used to determine the influence of matrix and preferential flow processes on the flux of mobile tracers subjected to different irrigation regimes (4.4 and 0.89 mm h(-1)) in a silt loam soil. After tile outflow reached steady state either bromide (Br; 280 kg ha(-1)) or pentafluorobenzoic acid (PFBA; 121 kg ha(-1)) was applied through the irrigation system inside a shed (3.5 x 24 m). Bromide fluxes were monitored at an irrigation rate of 4.4 mm h(-1) while PFBA fluxes were monitored at an irrigation rate of 0.89 mm h(-1). At 4.4 mm h(-1) nearly one-third of the surface-applied Br was recovered in the tile line after only 124 mm of irrigation and was poorly fit by the one-dimensional convective-dispersive equation (CDE). On the other hand, the one-dimensional CDE fit the main PFBA breakthrough pattern almost perfectly, suggesting the PFBA transport was dominated by matrix flow. Furthermore, after 225 mm of water had been applied, less than 2% of the applied PFBA had been leached through the soil compared with more than 59% of the applied Br. This study demonstrates that the methodology of applying a narrow strip of chemical to a tile drain facility is appropriate for quantifying chemical fluxes at the small-field scale and also suggests that there may be a critical input flux whereby preferential flow is initiated.

Rupture of extensor pollicis longus (EPL) tendon is a recognised complication following volar plate fixation of distal radius fractures, usually from attrition caused by prominent screws. We sought to identify the screw holes in some of the most commonly used plates which may precipitate tendon injury. Three fixed-angle volar locking plates were sequentially positioned into 18 cadaveric arms. A wire was passed through each of the holes in the plates using a locking guide and the dorsal relationships noted. Each plate had specific 'high-risk' holes which directed the wire towards the EPL groove. The central screw holes appeared mostly implicated in EPL injury. Awareness of 'high-risk' holes and appropriate minor alterations in surgical technique may consequently decrease the incidence of EPL irritation and rupture.

A ‘torus’ (Greek for ‘bulge’ often seen at the base of Greek columns) fracture, or a ‘buckle’ fracture of the wrist, is one of the most common minor injuries seen in a Paediatric Emergency Department. Many centres will recommend cast immobilisation, discharge, follow-up, and repeat imaging. Is that the best way? Perry DC et al [Lancet 2022; 400: 39–47. DOI:https://doi.org/10.1016/S0140-6736(22)01015-7] and the PERUKI research network have published a beautifully pragmatic, properly powered, randomised, open, equivalence study which compared pain and function in children with a distal radial torus fracture offered a soft bandage and immediate discharge and no follow-up with those receiving a more traditional management of rigid immobilisation and follow-up. They recruited 965 children (aged 4–15 years) presenting with a distal radius torus fracture (with or without associated ulnar fracture) from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using a web-based randomisation software. Treating clinicians, participants, and their families could not be blinded to treatment allocation. Exclusion criteria included multiple injuries, greenstick fractures, diagnosis at more than 36 hours after injury, and inability to complete follow-up. The primary outcome was pain at 3 days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. Secondary outcomes that were proxy reported for participants younger than 8 years and self-reported by participants aged 8 years and older were: functional recovery using Patient Report Outcomes Measurement System (PROMIS Bank version 2.0) Upper Extremity Score for Children Computer Adaptive Test, which was collected at baseline, 3, and 7 days, and 3 and 6 weeks and health-related quality of life using the EuroQol 3-level EQ-5DY (EQ-5DY-3L), which is a child-friendly version of the EQ-5D-3L. During the eighteen months recruitment period, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 586 (61%) were boys. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group vs 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was –0·10 (95% CI –0·37 to 0·17) and–0·06 (95% CI –0·34 to 0·21) in the per-protocol population. Essentially, this trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. There were no safety concerns. So, it appears that this form of de-escalation the treatment of children with a torus fracture of the distal radius is appropriate. These results will be incorporated into the next updated UK National Institute for Health and Care Excellence guideline with an aim to rationalise the overuse of healthcare resources. This is another example of how a well-organised research network delivers a simple answer to a simple question. Congratulations to the researchers for such a well-constructed study.

Background The epidemiology of transient synovitis is poorly understood, and the aetiology is unknown, although a suggestion of a viral association predominates. Purpose This population-based study investigated the epidemiology in order to formulate aetiological theories of pathogenesis. Patient and methods Cases in Merseyside were identified between 2004 and 2009. Incidence rates were determined and analysed by age, sex, season and region of residence. Socioeconomic deprivation scores were generated using the Index of Multiple Deprivation, allocated by postcode. Poisson confidence intervals were calculated and Poisson regression was used to check for trends. Results Two hundred and fifty-nine cases were identified over 5.5 years. The annual incidence was 25.1 (95 % CI 22.1–28.5) per 100,000 0–14 year-olds. Male to female ratio was 3.2:1 (p < 0.001). Mean age at presentation was 5.4 years (95 % CI 5.0–5.8), which demonstrated a near-normal distribution. No relationship was identified between seasonality and incidence (p = 0.64). A correlation was identified with socioeconomic deprivation in Merseyside: incidence rate ratio 1.16 (95 % CI 1.06–1.26, p < 0.001), although further analysis within the subregion of Liverpool did not confirm this finding (p = 0.35). Conclusions The normal distribution for age at disease presentation suggests a specific disease entity. The absence of seasonality casts some doubt on the popular theory of a viral aetiology. The absence of a consistent socioeconomic gradient in both Merseyside and Liverpool challenges a previous suggestion of an association with Perthes’ disease. This paper provides ecological evidence that may challenge existing aetiological theories, though transient synovitis remains an enigma.

Perry and Perry test hypotheses about dynamic conflicts and defenses associated with narcissistic personality disorder (NPD), and examine the stability of the narcissistic interpersonal style over two to five years of follow-up. Result shows that NPD features were positively associated with the psychodynamic conflicts of rejection of others, ambition-achievement, dominant goal, resentment over being thwarted by others, and counterdependence.

The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol. In this randomised controlled equivalence trial we included 965 children (aged 4–15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395. Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was –0·10 (95% CI –0·37 to 0·17) and–0·06 (95% CI –0·34 to 0·21) in the per-protocol population. This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. UK National Institute for Health and Care Research.