Children's Orthopaedics Research Articles

The management of idiopathic toe walking.

The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care. An established Delphi approach with predetermined steps and degree of agreement based on a standardized protocol was used to determine consensus. The steering group members and Delphi survey participants included members from the British Society of Children's Orthopaedic Surgery (BSCOS) and the Association of Paediatric Chartered Physiotherapists (APCP). The statements included definition, assessment, treatment indications, nonoperative and operative interventions, and outcomes. Descriptive statistics were used for analysis of the Delphi survey results. The AGREE checklist was followed for reporting the results. A total of 227 participants (54% APCP and 46% BSCOS members) completed the first round, and 222 participants (98%) completed the second round. Out of 54 proposed statements included in the first round Delphi, 17 reached 'consensus in', no statements reached 'consensus out', and 37 reached 'no consensus'. These 37 statements were then discussed, reworded, amalgamated, or deleted before the second round Delphi of 29 statements. A total of 12 statements reached 'consensus in', four 'consensus out', and 13 'no consensus'. In the final consensus meeting, 13 statements were voted upon. Five were accepted, resulting in a total of 31 approved statements. In the aspects of practice where sufficient evidence is not available, a consensus statement can provide a strong body of opinion that acts as a benchmark for excellence in clinical care. This statement can assist clinicians managing children with ITW to ensure consistent and reliable practice, and reduce geographical variability in practice and outcomes. It will enable those treating ITW to share the published consensus document with both carers and patient groups.

Protocol for Surgery or Cast of the EpicoNdyle in Children's Elbows (SCIENCE).

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children's Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children's Elbows (SCIENCE) trial. Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment. At six weeks, and three, six, and 12 months, data on function, pain, sports/music participation, QoL, immobilization, and analgesia will be collected. These will also be repeated annually until the child reaches the age of 16 years. Four weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the PROMIS upper limb score at 12 months post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardians. The NHS number of participants will be stored to enable future data linkage to sources of routinely collected data (i.e. Hospital Episode Statistics).

1012 Evaluation of the ‘Clicky’ Hip in the Diagnosis of Developmental Dysplasia of the Hip (DDH)

Abstract Aim Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate the use of a ‘clicky’ hip as an indication for secondary assessment as per the British Society for Children's Orthopaedic Surgery (BSCOS) consensus statement. Method Prospective cohort study of all patients born within the catchment area of a single tertiary centre (n = 27,731) all of whom underwent a new-born and 6–8-week examination and ultrasonographic screening of the hip. Multivariate odds ratios, cumulative risk difference, were calculated in relation to DDH (Graf type IIb-IV that required treatment) for those with ‘clicky’ hip as the only abnormality on examination. Results The prevalence of pathological DDH that required treatment within our population was 5.1/1000 live births (n = 148). An abnormal examination defined only by the presence of ‘clicky’ hip had a sensitivity of 11.5% [(95%CI6.84 to 14.75) 17/148)] and a positive predictive value of 4.39% (95%CI2.82 to 6.77%) for DDH. The increase in risk of having DDH from having a clicky hip during the 6-8-week examination was 10.1% and odds ratio 3.84 (95%CI2.33 to 6.32) demonstrated a significant association (p<0.001). Conclusions This study has evaluated the role of the ‘clicky’ hip in neonatal hip screening. Clearly demonstrating a statistical association with pathological DDH and also providing important information relating to the risk and predicative value of a clicky hip, addressing the principal research need by the BSCOS consensus statement.

Consensus guidelines on the management of musculoskeletal infection affecting children in the UK.

The 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. A 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. Statements were discarded ('consensus out') if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. A total of 133 children's orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached 'consensus in', 0 'consensus out', and 11 'no consensus'. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as 'consensus in', resulting in a total of 40 approved statements. In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe.

A Delphi consensus study on the treatment of slipped capital femoral epiphysis: Considerable consensus in mild and moderate slips and limited consensus in severe slips.

The aim of this expert consensus study was to establish consensus on the treatment of different types of slipped capital femoral epiphysis and on the use of prophylactic screw fixation of the contralateral unaffected side. In this study, a four-round Delphi method was used. Questionnaires including all possible theoretical slip scenarios were sent online to 14 participants, experienced in the field of children's orthopedics and in the treatment of hip disorders in children. In-situ fixation was considered to be the first treatment choice in all types of mild slip scenarios and in moderate, stable ones. Performing in-situ fixation was not favored in moderate, unstable, and in all severe slip scenarios. In moderate to severe, unstable slip scenarios, there was consensus on the use of gentle closed or open reduction and internal fixation. Any consensus was not established in the optimal treatment of severe, stable slips. There was also consensus on the use of prophylactic screw fixation of the contralateral side in case of co-existing endocrine disorder and younger age. The establishment of consensus on the treatment of all types of slipped capital femoral epiphysis even among the experienced surgeons does not seem to be possible. The severity of the slip and stability of the slip are the primary and secondary determinants of the surgeons' treatment choices, respectively. In-situ fixation is still the preferred treatment option in several slip types. Gentle capital realignment by closed or open means is recommended in displaced, unstable slips. Prophylactic screw fixation of the contralateral side is indicated under certain circumstances. level V.

Male Versus Female Authorship in Flagship Pediatric Orthopaedic Journals From 2002 to 2021.

The evolution of female authorship in orthopaedic journals is reportedly rising, however, trends in pediatric orthopaedic publications have not been specifically studied, despite a higher proportion of female pediatric orthopaedic surgeons compared with orthopaedics at large. This study aimed to investigate trends in female first and senior authorship in 3 flagship pediatric orthopaedic journals over the past 20 years. All manuscripts from the "Journal of Pediatric Orthopaedics, Journal of Pediatric Orthopaedics Part B, and Journal of Children's Orthopaedics" from 2002 to 2021 were evaluated from Ovid MEDLINE, and the data were extracted. We utilized the sex "Application Program Interface" algorithm to determine the sex of the first and senior authors. χ 2 tests were used to analyze the demographics of the first and senior author cohorts. Fisher exact test was used to assess the trends in male and female authorship, controlling for year and journal. Of a total, 5499 individual first authors and 5794 senior authors were identified. Sex was determined for 83.5% of the authors. Female first authorship increased significantly from 2002 to 2021 (8.8% to 22.4%, P < 0.001), with women being more likely to publish as first authors in more recent years in each journal ( P < 0.001). Female senior authorship did not increase significantly over the same time period (10.8% to 12.8%, P = 0.238). There was significantly more male than female first and senior authors for all journals ( P <0.001 for both first and senior authors). While female first authorship in prominent pediatric orthopaedic journals has increased significantly from 2002 to 2021, senior authorship has remained stagnant. In addition, female pediatric orthopaedic surgeons publish at rates lower than their prevalence in the field. This study serves as a benchmark for future studies looking at sex and authorship in hopes of better understanding the underlying complex issues. Level III.

Inhibition of Toll-Like Receptor 4 Signaling Pathway Accelerates the Repair of Avascular Necrosis of Femoral Epiphysis through Regulating Macrophage Polarization in Perthes Disease.

Legg-Calvé-Perthes disease (LCPD) is still a refractory disease in children's orthopedics. With the introduction of the concept of "osteoimmunology", the immune-inflammatory mechanisms between bone and immune system have become a research focus of LCPD. However, few studies have reported on the pathological role of inflammation-related receptors such as toll-like receptors (TLRs) as well as immune cells such as macrophages in LCPD. This study was for investigating the mechanism of TLR4 signaling pathway on the direction of macrophage polarization and the repair of avascular necrosis of femoral epiphysis in LCPD. With GSE57614 and GSE74089, differentially expressed genes were screened. Through enrichment analysis and protein-protein interaction network, the functions of TLR4 were explored. Furthermore, immunohistochemistry, enzyme-linked immunosorbent assay (ELISA), hematoxylin & eosin (H&E) staining, micro-CT, tartrate-resistant acid phosphatase (TRAP) dyeing and western blotting were performed for determining the influences of TAK-242 (a TLR4 inhibitor) on the repair of avascular necrosis of femoral epiphysis in rat models. Totally 40 co-expression genes were screened as well as enriched in TLR4 signaling pathway. Immunohistochemistry and ELISA analyses certified that TLR4 facilitated macrophage polarization toward the M1 phenotype and prevented macrophage polarization toward the M2 phenotype. Besides, the results of H&E and TRAP staining, micro-CT, and western blotting showed that TAK-242 can inhibit osteoclastogenesis and promote osteogenesis. Inhibition of TLR4 signaling pathway accelerated the repair of avascular necrosis of femoral epiphysis by regulating macrophage polarization in LCPD.

The management of developmental dysplasia of the hip in children aged under three months : a consensus study from the British Society for Children's Orthopaedic Surgery.

A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children's Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed.Cite this article: Bone Joint J2023;105-B(2):209-214.

Clubfoot: an overview and the latest UK guidelines.

Clubfoot is one of the most common congenital anomalies, affecting every 1 of 1000 live births in the UK. Historically, clubfeet have been managed with a variety of conservative and operative techniques. Over the last two decades, the Ponseti serial casting method has become the gold standard of treatment. In July 2021, the British Society of Children's Orthopaedic Surgery (Gelfer et al, 2022) published a consensus statement that outlines the optimal management for clubfoot. This article provides an overview of clubfoot and a summary of the latest management guidelines.

Screening for developmental dysplasia of the hip: current UK practice and controversies

Developmental dysplasia of the hip (DDH) remains the most common musculoskeletal disorder in newborns. Although screening for DDH has existed in the UK for over 50 years, controversy and lack of consensus nationally and worldwide, continues to surround how screening is best achieved. A literature review of DDH screening publications 1990–2022 was conducted. Online publications, textbooks and websites in English language, reporting on the evolution of DDH screening were considered for inclusion. A summary of the current UK national screening programme for DDH; its criteria and methods, is included in this review. An up-to-date summary of the most recent evidence, with advantages and disadvantages of different screening strategies, is also provided. DDH screening has been identified as a top research priority in Children's Orthopaedics. Ongoing work by the British Society for Children's Orthopaedic Surgery (BSCOS) is focusing on shaping the direction of future research to answer some of the biggest yet unanswered questions regarding screening and the best way this can be conducted in the UK.

Treatment preferences of orthopedic surgeons for closed, isolated middle-third diaphyseal long bone fractures without neurovascular injury in children: A cross- sectional survey.

This study aimed to assess the treatment trends and the factors influencing the treatment methods of Orthopaedic Surgeons in closed, isolated, middle-third diaphyseal long bone fractures without any neurovascular injury in children. This was a cross-sectional electronic survey of Turkish Orthopaedic Surgeons who were active members of the Turkish Society of Children's Orthopaedics (TSCO) and still managing the children's fractures in their daily clinical practice. An initial e-mail including the electronic survey followed by three reminder e-mails was sent to 110 members, and then reminder telephone calls were made. The survey response rate was 66/110 (60%). In recent years, a definitive trend to surgical treatment was not seen 98%, 77%, 39%, and 88% of the responders in the closed humerus, forearm, femur, and tibia mid-shaft fractures, respectively. Neither the years of expertise nor the intensity of daily pediatric patients of the participants did not affect the treatment trend in any fracture scenarios. The patient's age was the most cited factor influencing the responders' decisions on whether conservative or surgical treatment would be performed in each fracture scenario. The most cited lowest age limits for surgical treatment inclosed mid-shaft fractures of the humerus, forearm, femur, and tibia, were the adolescent age group, 10-12 years, six years, and ten years, respectively. This is the first study assessing the daily clinical practice of members of TSCO in the management of closed, isolated, non- complicated middle-third diaphyseal long bone fractures in children just before the covid-19 pandemic started. A marked tendency toward surgical treatment is seen in femur mid-shaft fractures, followed by forearm mid-shaft fractures up to a certain level. The patient's age is the main determinant of the responders' decisions on the type of treatment in closed, isolated, non-complicated middle-third diaphyseal long bone fractures in children.

Oleg Alekseevich Malakhov

July 13, 2001 was the 60th anniversary of the head of the clinic for pediatric orthopedics of the Central Institute of Traumatology and Orthopedics. N.N. Priorov to the Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Professor, Academician of the Academy of Medical and Technical Sciences, Chief Orthopedist of the Moscow Health Committee, Chief Children's Orthopedic Traumatologist M3 of the Russian Federation O.A. Malakhov.

Meeting of the main pediatric orthopedic traumatologists of Russia: "Actual issues of pediatric traumatology and orthopedics"

In accordance with the Plan of the main organizational measures of the Ministry of Health of Russia for 2002 (paragraph 7.46) and the Directive of the Ministry of Health of Russia No. 594-U dated 15.04.02, on May 29-30, 2002 in Svetlogorsk (Kaliningrad Region) a meeting of the main pediatric orthopedists-traumatologists on topic "Actual issues of pediatric traumatology and orthopedics". It was organized by the State Research Institute for Children's Orthopedics. G.I. Turner (Director - Prof. Yu.I. Pozdnikin), GUN Central Research Institute of Traumatology and Orthopedics. N.N. Priorov (Director - Academician of the Russian Academy of Medical Sciences S.P. Mironov) and the Health Department of the Kaliningrad Region (Head - E.M. Krepak). The meeting was held under the patronage of the Governor of the Kaliningrad Region V.G. Egorov, who addressed the participants with a welcome address.

Yuri Ivanovich Pozdnikin

Director of the Scientific Research Children's Orthopedic Institute named after A.I. G.I. Turner (GUN) to Doctor of Medical Sciences, Professor Yu.I. Pozdnikin.

A case review to describe variation in care following diagnosis of Perthes disease

Purpose: Perthes disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged 4–9 years old, with recent statistics suggesting it affects around five per 100,000 children in the United Kingdom (UK). Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children's Orthopaedic Surgery through the James Lind Alliance's prioritisation of work to determine/identify surgical versus non-surgical management of Perthes disease. It was identified as the fourth highest priority for paediatric lower limb surgery research in 2018.

Analysis of Author Gender in the Pediatric Orthopaedic Literature from 2011 to 2020.

Orthopaedic surgery remains a male-dominated specialty. To date there has not been a focused analysis of gender in authorship within the pediatric orthopaedic literature. The electronic table of contents from 2011 to 2020 of 3 major pediatric orthopaedic journals [Journal of Children's Orthopaedics (JCO), Journal of Pediatric Orthopaedics (JPO), and Journal of Pediatric Orthopaedics Part B (JPO-B)] were reviewed. Publications were reviewed for the number of articles with at least 1 female author and the number of articles with women listed as first authors. These were compared over the 10-year study period, and by individual year of publication. Statistical analysis included a general linear model with factorial one-way anslysis of variance and Bonferroni post hoc testing. A total of 4097 articles were reviewed. In 2020, there was a significantly higher percentage of articles with a female author when compared with 2011 (64% to 42%, P=0.010). A female was listed as first author in significantly more publications in 2020 as compared with 2011 (23% to 10%, P=0.031). During the 10-year study period, the highest mean proportion of articles with at least 1 female author was seen in JPO (60%), with similar findings in JCO (55%). Significantly fewer articles in JPO-B contained a female author (37%, P=0.001). The highest percentage of publications with a female first author across 10 years was in JCO (22%), followed by JPO (20%). Significantly fewer articles with a female first author were found in JPO-B (9%, P=0.001). There is an increasing proportion of publications in the pediatric orthopaedic literature with female authors and female first authors from 2011 to 2020. In addition, there was a statistical difference in female authorship when comparing specific publications, which should be investigated further. Level IV.

The history of orthopedics and traumatology in Iasi

In Iasi, Orthopedics-Traumatology later appeared as a distinct specialty. In a first stage, orthopedics developed in surgical clinics - the period of surgical clinics (1879-1970). In each surgical clinic there were surgeons who dedicated themselves to orthopedic pathology: Radu Dimitrie, Theodor Căpățînă (Surgery I), Filimon Cicerone, Eusebiu Neagoe, Iulian Grădinaru (Surgery II), Paul Trosc (Surgery III). In 1967, at the Charity Hospital, two surgical services were carried out: The Surgery and Children's Orthopedic Clinic (Th. Economu) and the Osteoarticular Tuberculosis Clinic (A. Berneaga). Also, this year, 1970, in Iasi, the construction of a new medical unit will be completed - the Children's Hospital where the Clinic of Pediatric Surgery and Orthopedics will be moved. The Charity Hospital is disbanded and the Emergency Clinical Hospital will be established on the site of the former establishment. A second period begins - the transition period (1970-1983) - characterized by the search for optimal solutions, which involved changes and temporary until the establishment of orthopedic clinics. The newly established unit, the Emergency Clinical Hospital, was designed to include three departments: General Surgery IV (I. Jitaru), Medical Clinic (G. Popa) and an Orthopedics and Traumatology Clinic (conf. Gh. Floareș). This clinic treated all surgical pathology of orthopedics, traumatology and had didactic activity with fourth year students. The Orthopedics-Traumatology Department had 40 beds. There is also an Orthopedics-Traumatology department, with 40 beds, located in the Dr. C. I. Parhon Hospital run first by A. Berneaga and then by P. Trosc. Dimitrie Radu, Iulian Grădinaru and G. Herescu worked in this department. A new Recovery Hospital appears in Iasi. The new hospital also has an Orthopedics-Traumatology department (with 111 beds) where the orthopedics department will be transferred from Parhon Hospital. In 1983, Professor Gh. Floareș opted to move the clinic from the Emergency Hospital to the new Rehabilitation Hospital. At the Emergency Hospital there remains an Orthopedics-Traumatology Department staffed by a single doctor - Nicolae Georgescu who will develop a new team, which also have teaching activity: T. Cozma, L. Stratan, P. Sîrbu, Ovidiu Alexa, Paul Corlaci, Cezar Popescu. There are eight resident doctors (Elena Glod, Luminița Lăbușcă, Victor Pencu, G. Ghinoiu, C. Nanu, T. Bunescu, R. Malancea, L. Pacu). During this period (1992-1996) a basic A.O. course was organized in Iași. internationally, on which occasion many orthopedists are persuaded to routinely use modern means of osteosynthesis. Two more doctors come in this clinic: B. Puha, R. Asaftei, D. Cionca and A. Ciubara. After 1989, the ATOM was born: The Association of Traumatologists and Orthopedists of Moldova, congresses and postgraduate courses are organized. In 2012 the Orthopedic Clinic moved to the St. Spiridon Emergency Clinical Hospital (Prof. Ovidiu Alexa). The orthopedic clinic at the Recovery Hospital treats chronic osteoarticular pathology (prof Paul Sirbu).

Congenital Talipes Equinovarus: Results of Treatment and Are We Bracing Effectively?

The aim of this retrospective study was to assess our management of Congenial Talipes Equinovarus (CTEV) in relation to national standards published by the British Society for Children's Orthopaedic Surgery (BSCOS). A secondary aim was to evaluate if a more tailored bracing regime than advocated in the traditional Ponseti technique, would be appropriate for some cases of CTEV. One hundred and thirty-three feet in 96 patients were treated between June 2006 and January 2016. All patients were clinically assessed prospectively by the senior author at initial presentation using the Harrold & Walker classification system. A combination of the senior author's database, Elogbook and trust IT systems were used for data collection. The results of Ponseti surgical procedures such as tendoachilles release and tibialis transfer fell within the BSCOS guidelines. The rate of radical subtalar surgical release was higher than advocated (12.3%) which was partly due to the number of primary syndromal patients in the series. There was a significantly lower mean time spent in bracing of 14.3 months (95% confidence interval 14.8-19.3) compared to recommended national guidelines. There was a clinically significant difference in the lower relapse rate of female patients compared to male patients and also a higher propensity of surgical intervention in male patients. In addition, there was a statistically significant difference in both time spent in bracing, between H&W classifications and between patients who had bracing removed pre walking age or post walking age. This potentially demonstrates a more tailored bracing regime may be possible when applied to less severely affected feet and the condition may be more benign in female cases.

Answers to the CME questions on Children's Orthopaedics

Answers to the CME questions on Children's Orthopaedics

Epidemiological Determinants of Children's Orthopedic Care in Rural Central India

Background: Musculoskeletal disorders of children in rural India are often highlighted through anecdotal reports of delayed presentations. This study was conducted to identify prevalence and factors that influenced children's orthopedic care in a secondary hospital in rural Central India. Methodology: A retrospective survey was conducted to identify the prevalence of musculoskeletal disorders and delayed presentation among children at our institution from July 2011 to June 2016. Actionable epidemiological determinants were identified with the Delphi method and a prospective cohort was analyzed for delayed presentation. Results: Among 2281 children 71% presented with trauma. The incidence of delayed presentation among the trauma cases was 28%. Remaining had neuromuscular (17%), infectious (3.75%), metabolic (1.5%), congenital (3.25%), and miscellaneous (3.5%) disorders. Delayed presentation in 19 children from a prospective cohort of 100 patients showed significant association with distance traveled to reach the clinic and poor transport infrastructure in rural areas (P = 0.025) but did not differ by socioeconomic scale (SES) (P = 0.085), lack of health insurance coverage (P = 0.348) or primary indigenous treatment (P = 0.535). In this cohort, 84% belonged to middle and low-SES families, 33% had insurance coverage, 79% received primary traditional remedies and 68% traveled from distant rural locations. Conclusions: Trauma care and neuromuscular diseases constituted the bulk of musculoskeletal disorders in children in this survey from rural India. Poor transport infrastructure led to delayed presentation in the prospective cohort but lower SES, lack of health insurance, and rampant primary indigenous treatment in rural areas are likely contributory factors.