Journal of Bone and Joint Surgery-british Volume, Jun 1, 2005
Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simul... more Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simulated transverse fractures of synthetic composite bones. Methods: Steel and titanium nails (3mm diameter) were individually used in pairs of divergent configuration to study torsion, cantilever bending (anteroposterior and lateral), and axial loading properties of adolescent synthetic composite tibiae model (10mm diameter). Properties of the intact bone, simulated fresh fracture with nails and simulated healing fracture with nails were studied. Instron 4303 universal testing machine was used to study axial loading. Applying fibreglass layers around the fracture with epoxy resin simulated fracture healing with callus formation. Results: Steel and titanium nails maintained good alignment of fracture fragments. Both the nails demonstrated very poor stability of fresh fractures in torsion loading. Steel nail/bone construct was 57% stronger than Titanium nail/bone construct under similar testing conditions during fracture healing (p 50% that of intact bone. Axial stiffness of both nails was more than bending or torsion stiffness implying that fracture fragments play a significant role in the stability of the fracture. Although both types of nail/bone constructs demonstrated similar stiffness results in fresh and healing fractures, steel nails performance was statistically better than Titanium nails in all loading tests (p Conclusion: Fractures fixed with either type of flexible nails should be supplemented with splints or plaster for a short duration until callus formation. Flexible nails should be used with caution in comminuted fractures, over weight patients since they may not provide adequate stability or allow early mobilization. Additional research with cadaver bones may provide further insight into the performance of the flexible nails.
Introduction: Children are inevitably casualties in wars. They are treated variously by local doc... more Introduction: Children are inevitably casualties in wars. They are treated variously by local doctors and foreign surgeons working for military and Non-Governmental Organisations. The basic principles of surgical treatment of war wounds are the same as for adults, but there are specific differences in injury pattern and the response to injury that must be borne in mind. Method: Casualties under sixteen years age with extremity trauma caused by missiles or blast admitted to a British military field hospital during the latest Gulf War were evaluated. The date, time and method of wounding were recorded and ICRC Wound Scores calculated. The details of surgical treatment prior to admission, and further surgical management described. Case studies were used to illustrate particular considerations relevant to paediatric trauma. Results: The records for sixteen wounded children were available for analysis. Their ages ranged from three to fifteen years. The method of injury falls into three phases, gun-shot wounds during the mobile attack, shell fragment wounds during the seige of urban areas and blast/fragment injuries from small munitions from the period following active fighting. Blast/fragment wounds typically affected multiple body areas. Half the patients had received surgical treatment before reaching the hospital, either at civilian hospitals, forward military surgical units or both. None of this surgery was strictly “life or limb-saving”. Amputations performed prior to admission were in the proximal tibia and followed the long posterior flap pattern appropriate to an adult amputation for vascular disease regardless of the level of injury. Several had primary closure of war wounds. After admission, four patients required plastic surgical procedures, two had ophthalmic surgery, one had a laparotomy and one had a facial reconstruction procedure in addition to surgery for extremity trauma. One child with fragment wounds was undergoing treatment for acute lymphoblastic leukaemia. Conclusion: A military hospital must be prepared to treat children during war-time. Multi-system injury patterns are common and require multidisciplinary care. When possible children should be transferred to a facility with specialist care available for primary surgery. The effects of injury and treatment on future growth should be given more consideration.
AimsThe aim of this study was to determine the consensus best practice approach for the investiga... more AimsThe aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.MethodsA Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. St...
AimFractures are the second commonest presentation of non-accidental injury (NAI) in children. Ap... more AimFractures are the second commonest presentation of non-accidental injury (NAI) in children. Approximately one third of abused children will present to Acute Trauma Services (ATS) with fractures. Any cases of suspected child maltreatment should be referred to Safeguarding Services for follow-up, as outlined by Trust Guidelines. Our aim was to examine the referral of children with suspicious fractures to safeguarding and assess if cases with high risk of abuse are being missed by ATS.MethodA comprehensive literature review identified commonly cited indicators of abuse. Inclusion criteria included age less than 18 months seen in A&E or Fracture Clinic with a long bone fracture. Patient notes were analysed to identify occurrence of these risk factors and findings cross-referenced with Safeguarding Services' records to verify whether high-risk patients were detected. The origin of each referral was also noted.ResultsThe cohort consisted of 28 patients, nine had records with Safegu...
Introduction: Limp in a child is a common presentation to the emergency department. Most patients... more Introduction: Limp in a child is a common presentation to the emergency department. Most patients have no serious pathology. However, it is important not to miss specific problems and delay treatment. We therefore established a limping child protocol in conjunction with the emergency department, which was implemented in 2003. We aimed to assess our performance against agreed standards; 100% investigated as per protocol, and 100% admitted or seen in the next fracture clinic. Methods: We examined all emergency department case notes of children aged less than 14 years old who presented with a lower limb problem over a 1 year period. Patients diagnosed as having soft tissue injuries or fractures were excluded. We were left with 58 patients. Information concerning investigations and disposal from the emergency department was sought from the case notes and the hospital computer system. Results: Average age was 5.1 years. The protocol was followed correctly in only 21% of cases. 33% were followed-up incorrectly, and 22% received no documented follow-up. Discussion: There was poor compliance in the emergency department. Incomplete investigations, follow-up and documentation were the main problems. Up to one quarter of serious pathology may have been missed. We attribute these problems to high staff turn over and poor awareness of the protocol. We have introduced changes to improve our performance.
The Annals of The Royal College of Surgeons of England, 2006
INTRODUCTION The aim of this study was to investigate the degree of contamination of a surgeon... more INTRODUCTION The aim of this study was to investigate the degree of contamination of a surgeon's hand following use of chlorhexidine gluconate or alcohol gel as disinfectants. MATERIALS AND METHODS In this prospective, randomised trial, orthopaedic surgeons were allocated to one of two different hand-washing protocols using a randomisation table. The hand-washing protocol dictated that all surgeons should wash for 5 min with chlorhexidine for their first case. Thereafter, the surgeon was randomised to wash for 3 min with either alcohol gel or chlorhexidine. At the end of each procedure, the gloves of each surgeon were carefully removed and the fingertips from each hand were placed on an agar plate. The number of bacterial colonies present after 24 h and 48 h of incubation were recorded for each agar plate by a microbiologist blinded to the washing protocol used. RESULTS Overall, 41 procedures and 82 episodes of hand washings were included in the study. Two episodes were discarde...
Journal of Bone and Joint Surgery-british Volume, 2013
Aim Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiot... more Aim Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome. Method Since 2010, 38 feet in 31 patients have been treated. Diagnosis of CVT is confirmed with a stress radiograph. The underlying conditions are diverse. The technique involves serial passive stretches and plaster of Paris casts. Once the talo-navicular joint is judged to be reduced, the joint if fixed with a percutaneous pin under local anaesthetic and an Achilles tenotomy performed. Post-operative treatment is as per the Iowa technique with night-time bracing and an AFO for ambulant patients. Results There have been no major complications and no complete relapses. The result was compromised in 6 patients at the beginning of the series by omission of talo-n...
Background: There are no clearly defined guidelines for the management of distal radial physeal i... more Background: There are no clearly defined guidelines for the management of distal radial physeal injuries. We aimed to identify the risk factors for patients with distal radial physeal trauma for the risk of deformity, physeal closure, and revision procedure and develop a predictive model. Methods: The retrospective study included patients less than 16 years old with displaced distal radial physeal injuries treated between 2011 and 2018 across five centers in the United Kingdom. Deformity was defined as a volar angulation of >11°, dorsal angulation of >15°, a radial inclination of <15° or >23°, or positive ulnar variance. Presence of a bony bar spanning the physis was considered physeal closure. Results: This study comprised of 479 patients. In that, 32 (6.6%) patients had a second procedure. Also, 49 (10.2%) patients had closure of physis, and 28 (6%) patients had deformity at the end of follow-up. The occurrence of deformity had a strong correlation with age (p = 0.04) ...
Paediatric septic arthritis, osteomyelitis and pyomyositis are infrequent diagnoses in general or... more Paediatric septic arthritis, osteomyelitis and pyomyositis are infrequent diagnoses in general orthopaedic practice. However, when they present they require early diagnosis and expeditious treatment to prevent sepsis and long-term morbidity. This is challenging as the early stages of each disease can closely mimic more common and often less significant pathologies. Here we aim to address the diagnostic challenges encountered in paediatric acute musculoskeletal infection and identify when urgent surgical intervention is required. In particular we cover which key symptoms and signs should be identified in the initial clinical assessment and how blood tests and imaging can help guide diagnosis, including the use of clinical predictive algorithms. We also discuss theories regarding disease pathogenesis and how different causative organisms can lead to a wide variety of clinical presentations. Finally we present up-to-date clinical evidence regarding treatment, whether this be via surger...
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2013
This baby boy had been diagnosed antenatally to have femur-fibula-ulna complex by fetal medicine ... more This baby boy had been diagnosed antenatally to have femur-fibula-ulna complex by fetal medicine colleagues. He was the first child of a non-consanguineous couple. The left femur was short, the contralateral radius and ulnar were short and his right hand had three digits. The rest of his examination was normal. I did not know the prognosis, risk …
♦ Myelomeningocoele is a congenital failure of neural tube development♦ Hydrocephalus is a common... more ♦ Myelomeningocoele is a congenital failure of neural tube development♦ Hydrocephalus is a common association♦ Multidisciplinary management is important♦ An alteration in neurological status requires further investigation♦ Beware the insensate skin♦ A supple plantigrade foot aids independence.
Journal of Bone and Joint Surgery-british Volume, Jun 1, 2005
Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simul... more Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simulated transverse fractures of synthetic composite bones. Methods: Steel and titanium nails (3mm diameter) were individually used in pairs of divergent configuration to study torsion, cantilever bending (anteroposterior and lateral), and axial loading properties of adolescent synthetic composite tibiae model (10mm diameter). Properties of the intact bone, simulated fresh fracture with nails and simulated healing fracture with nails were studied. Instron 4303 universal testing machine was used to study axial loading. Applying fibreglass layers around the fracture with epoxy resin simulated fracture healing with callus formation. Results: Steel and titanium nails maintained good alignment of fracture fragments. Both the nails demonstrated very poor stability of fresh fractures in torsion loading. Steel nail/bone construct was 57% stronger than Titanium nail/bone construct under similar testing conditions during fracture healing (p 50% that of intact bone. Axial stiffness of both nails was more than bending or torsion stiffness implying that fracture fragments play a significant role in the stability of the fracture. Although both types of nail/bone constructs demonstrated similar stiffness results in fresh and healing fractures, steel nails performance was statistically better than Titanium nails in all loading tests (p Conclusion: Fractures fixed with either type of flexible nails should be supplemented with splints or plaster for a short duration until callus formation. Flexible nails should be used with caution in comminuted fractures, over weight patients since they may not provide adequate stability or allow early mobilization. Additional research with cadaver bones may provide further insight into the performance of the flexible nails.
Introduction: Children are inevitably casualties in wars. They are treated variously by local doc... more Introduction: Children are inevitably casualties in wars. They are treated variously by local doctors and foreign surgeons working for military and Non-Governmental Organisations. The basic principles of surgical treatment of war wounds are the same as for adults, but there are specific differences in injury pattern and the response to injury that must be borne in mind. Method: Casualties under sixteen years age with extremity trauma caused by missiles or blast admitted to a British military field hospital during the latest Gulf War were evaluated. The date, time and method of wounding were recorded and ICRC Wound Scores calculated. The details of surgical treatment prior to admission, and further surgical management described. Case studies were used to illustrate particular considerations relevant to paediatric trauma. Results: The records for sixteen wounded children were available for analysis. Their ages ranged from three to fifteen years. The method of injury falls into three phases, gun-shot wounds during the mobile attack, shell fragment wounds during the seige of urban areas and blast/fragment injuries from small munitions from the period following active fighting. Blast/fragment wounds typically affected multiple body areas. Half the patients had received surgical treatment before reaching the hospital, either at civilian hospitals, forward military surgical units or both. None of this surgery was strictly “life or limb-saving”. Amputations performed prior to admission were in the proximal tibia and followed the long posterior flap pattern appropriate to an adult amputation for vascular disease regardless of the level of injury. Several had primary closure of war wounds. After admission, four patients required plastic surgical procedures, two had ophthalmic surgery, one had a laparotomy and one had a facial reconstruction procedure in addition to surgery for extremity trauma. One child with fragment wounds was undergoing treatment for acute lymphoblastic leukaemia. Conclusion: A military hospital must be prepared to treat children during war-time. Multi-system injury patterns are common and require multidisciplinary care. When possible children should be transferred to a facility with specialist care available for primary surgery. The effects of injury and treatment on future growth should be given more consideration.
AimsThe aim of this study was to determine the consensus best practice approach for the investiga... more AimsThe aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.MethodsA Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. St...
AimFractures are the second commonest presentation of non-accidental injury (NAI) in children. Ap... more AimFractures are the second commonest presentation of non-accidental injury (NAI) in children. Approximately one third of abused children will present to Acute Trauma Services (ATS) with fractures. Any cases of suspected child maltreatment should be referred to Safeguarding Services for follow-up, as outlined by Trust Guidelines. Our aim was to examine the referral of children with suspicious fractures to safeguarding and assess if cases with high risk of abuse are being missed by ATS.MethodA comprehensive literature review identified commonly cited indicators of abuse. Inclusion criteria included age less than 18 months seen in A&E or Fracture Clinic with a long bone fracture. Patient notes were analysed to identify occurrence of these risk factors and findings cross-referenced with Safeguarding Services' records to verify whether high-risk patients were detected. The origin of each referral was also noted.ResultsThe cohort consisted of 28 patients, nine had records with Safegu...
Introduction: Limp in a child is a common presentation to the emergency department. Most patients... more Introduction: Limp in a child is a common presentation to the emergency department. Most patients have no serious pathology. However, it is important not to miss specific problems and delay treatment. We therefore established a limping child protocol in conjunction with the emergency department, which was implemented in 2003. We aimed to assess our performance against agreed standards; 100% investigated as per protocol, and 100% admitted or seen in the next fracture clinic. Methods: We examined all emergency department case notes of children aged less than 14 years old who presented with a lower limb problem over a 1 year period. Patients diagnosed as having soft tissue injuries or fractures were excluded. We were left with 58 patients. Information concerning investigations and disposal from the emergency department was sought from the case notes and the hospital computer system. Results: Average age was 5.1 years. The protocol was followed correctly in only 21% of cases. 33% were followed-up incorrectly, and 22% received no documented follow-up. Discussion: There was poor compliance in the emergency department. Incomplete investigations, follow-up and documentation were the main problems. Up to one quarter of serious pathology may have been missed. We attribute these problems to high staff turn over and poor awareness of the protocol. We have introduced changes to improve our performance.
The Annals of The Royal College of Surgeons of England, 2006
INTRODUCTION The aim of this study was to investigate the degree of contamination of a surgeon... more INTRODUCTION The aim of this study was to investigate the degree of contamination of a surgeon's hand following use of chlorhexidine gluconate or alcohol gel as disinfectants. MATERIALS AND METHODS In this prospective, randomised trial, orthopaedic surgeons were allocated to one of two different hand-washing protocols using a randomisation table. The hand-washing protocol dictated that all surgeons should wash for 5 min with chlorhexidine for their first case. Thereafter, the surgeon was randomised to wash for 3 min with either alcohol gel or chlorhexidine. At the end of each procedure, the gloves of each surgeon were carefully removed and the fingertips from each hand were placed on an agar plate. The number of bacterial colonies present after 24 h and 48 h of incubation were recorded for each agar plate by a microbiologist blinded to the washing protocol used. RESULTS Overall, 41 procedures and 82 episodes of hand washings were included in the study. Two episodes were discarde...
Journal of Bone and Joint Surgery-british Volume, 2013
Aim Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiot... more Aim Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome. Method Since 2010, 38 feet in 31 patients have been treated. Diagnosis of CVT is confirmed with a stress radiograph. The underlying conditions are diverse. The technique involves serial passive stretches and plaster of Paris casts. Once the talo-navicular joint is judged to be reduced, the joint if fixed with a percutaneous pin under local anaesthetic and an Achilles tenotomy performed. Post-operative treatment is as per the Iowa technique with night-time bracing and an AFO for ambulant patients. Results There have been no major complications and no complete relapses. The result was compromised in 6 patients at the beginning of the series by omission of talo-n...
Background: There are no clearly defined guidelines for the management of distal radial physeal i... more Background: There are no clearly defined guidelines for the management of distal radial physeal injuries. We aimed to identify the risk factors for patients with distal radial physeal trauma for the risk of deformity, physeal closure, and revision procedure and develop a predictive model. Methods: The retrospective study included patients less than 16 years old with displaced distal radial physeal injuries treated between 2011 and 2018 across five centers in the United Kingdom. Deformity was defined as a volar angulation of >11°, dorsal angulation of >15°, a radial inclination of <15° or >23°, or positive ulnar variance. Presence of a bony bar spanning the physis was considered physeal closure. Results: This study comprised of 479 patients. In that, 32 (6.6%) patients had a second procedure. Also, 49 (10.2%) patients had closure of physis, and 28 (6%) patients had deformity at the end of follow-up. The occurrence of deformity had a strong correlation with age (p = 0.04) ...
Paediatric septic arthritis, osteomyelitis and pyomyositis are infrequent diagnoses in general or... more Paediatric septic arthritis, osteomyelitis and pyomyositis are infrequent diagnoses in general orthopaedic practice. However, when they present they require early diagnosis and expeditious treatment to prevent sepsis and long-term morbidity. This is challenging as the early stages of each disease can closely mimic more common and often less significant pathologies. Here we aim to address the diagnostic challenges encountered in paediatric acute musculoskeletal infection and identify when urgent surgical intervention is required. In particular we cover which key symptoms and signs should be identified in the initial clinical assessment and how blood tests and imaging can help guide diagnosis, including the use of clinical predictive algorithms. We also discuss theories regarding disease pathogenesis and how different causative organisms can lead to a wide variety of clinical presentations. Finally we present up-to-date clinical evidence regarding treatment, whether this be via surger...
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2013
This baby boy had been diagnosed antenatally to have femur-fibula-ulna complex by fetal medicine ... more This baby boy had been diagnosed antenatally to have femur-fibula-ulna complex by fetal medicine colleagues. He was the first child of a non-consanguineous couple. The left femur was short, the contralateral radius and ulnar were short and his right hand had three digits. The rest of his examination was normal. I did not know the prognosis, risk …
♦ Myelomeningocoele is a congenital failure of neural tube development♦ Hydrocephalus is a common... more ♦ Myelomeningocoele is a congenital failure of neural tube development♦ Hydrocephalus is a common association♦ Multidisciplinary management is important♦ An alteration in neurological status requires further investigation♦ Beware the insensate skin♦ A supple plantigrade foot aids independence.
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Papers by Philip Henman