Paediatric orthopaedic surgery is wide-ranging in scope and complexity. Many patients have coexisting conditions, including cerebral palsy and neuromuscular diseases. Cerebral palsy presents a wide spectrum of motor dysfunction. Preoperative assessment must be guided by associated comorbidities and particularly evaluate respiratory function and any associated cardiac disease. Patients with muscular dystrophy presenting for major orthopaedic or spinal surgery have a high risk of morbidity and mortality, which must be discussed preoperatively; inhalational agents must be avoided due to the risk of rhabdomyolysis. Patients with conditions including osteogenesis imperfecta and arthrogryposis must be carefully managed and meticulously positioned for surgery. Major orthopaedic and spinal surgery can be accompanied by a significant risk of bleeding. Multimodal analgesic strategies, including the use of local anaesthetic blocks, should be used. Scoliosis may be congenital, acquired or idiopathic. Adolescent children with idiopathic scoliosis are often otherwise fit and healthy. In contrast, patients with acquired neuromuscular scoliosis often have significant comorbidities, particularly poor cardiorespiratory function, epilepsy and poor nutrition. Elective postoperative ventilation is frequently required. Intraoperative neuromonitoring is employed to detect and prevent potential spinal cord injury. Total intravenous anaesthesia is required for robust neuromonitoring of motor pathways, and muscle relaxation must be avoided intraoperatively.