[Do paediatric and adult surgeons follow different approaches to physeal fractures?]

INTRODUCTION

The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS).

METHODS

62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases.

RESULTS

Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis.

DISCUSSION

There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

Children and adolescents with posttraumatic shoulder instability benefit from arthroscopic stabilization

INTRODUCTION

Traumatic dislocation of the shoulder in childhood is rare, accounting for only 0.01% of all injuries in this age class. However, literature does contain indications that post-traumatic instabilities and re-dislocations occur with more than average frequency in children and adolescents.

MATERIAL AND METHODS

This study describes the technique and results of arthroscopic stabilization of the shoulder joint before the completion of growth. Over a period of four years, seven patients were treated prior to reaching skeletal maturity. Five patients were treated by means of arthroscopically assisted labral refixation using suture anchor systems.

RESULTS

Arthroscopic labral refixation for post-traumatic shoulder instability could be carried out using the same surgical procedure as in adults. Clinical follow-up was undertaken after 12 to 48 (average 26) months using modified Constant-Murley and Rowe scores. Instability, re-dislocations and postoperative impairment of mobility did not occur after arthroscopic treatment, with an average Constant score of 92 points (Rowe score >95 points).

CONCLUSION

This study demonstrated that this technique can be used successfully in children and young people prior to skeletal maturity. Considerable experience in adult shoulder reconstruction promises excellent results in children and adolescents, too. There was no evidence of growth disturbance or biodegradation-associated problems in this group of children and adolescents. Delay of labral refixation until adulthood is therefore not indicated.

Magnetic Resonance Relaxometry at Low and Ultra low Fields

Nuclear magnetic resonance (NMR) and magnetic resonance imaging (MRI) are ubiquitous tools in science and medicine. NMR provides powerful probes of local and macromolecular chemical structure and dynamics. Recently it has become possible and practical to perform MR at very low fields (from 1 μT to 1 mT), the so-called ultra-low field (ULF) regime. Pulsed pre-polarizing fields greatly enhance the signal strength and allow flexibility in signal acquisition sequences. Improvements in SQUID sensor technology allow ultra-sensitive detection in a pulsed field environment.In this regime the proton Larmor frequencies (1 Hz - 100 kHz) of ULF MR overlap (on a time scale of 10 μs to 100 ms) with "slow" molecular dynamic processes such as diffusion, intra-molecular motion, chemical reactions, and biological processes such as protein folding, catalysis and ligand binding. The frequency dependence of relaxation at ultra-low fields may provide a probe for biomolecular dynamics on the millisecond timescale (protein folding and aggregation, conformational motions of enzymes, binding and structural fluctuations of coupled domains in allosteric mechanisms) relevant to host-pathogen interactions, biofuels, and biomediation. Also this resonance-enhanced coupling at ULF can greatly enhance contrast in medical applications of ULF-MRI resulting in better diagnostic techniques.We have developed a number of instruments and techniques to study relaxation vs. frequency at the ULF regime. Details of the techniques and results are presented.Ultra-low field methods are already being applied at LANL in brain imaging, and detection of liquid explosives at airports. However, the potential power of ultra-low field MR remains to be fully exploited.

Consecutive bilateral proximal tibial fractures after minor sports trauma

INTRODUCTION

Fractures of the proximal tibia are infrequent during childhood and adolescence. However, intra-articular fractures, growth plate separations and metaphyseal fractures do appear.

CASE REPORT

An obese adolescent male suffered from consecutive bilateral fractures of the tibia within 6 months of each after minor sports trauma. On the left side, the injury presented as a epiphyseal separation of the Salter-Harris I type; on the right side, as a transitional two-plane fracture. Both injuries were treated by percutaneous screwing and healed without any signs of posttraumatic growth disorder.

DISCUSSION

Although proximal tibial injuries are rare, they frequently seem to appear bilaterally after inadequate trauma. A causal connection to morphological changes prior to physeal closure can be assumed.

Growth disturbances of the distal tibia after physeal separation--what do we know, what do we believe we know? A review of current literature

PURPOSE

Although they are the most frequent physeal separations of the lower limb, epiphyseal separations (Salter I and II) of the distal tibia are rare injuries, peaking in adolescence. Generally they are considered lobe benign fractures with a low rate of complications. However, in the literature, concrete statements on the incidence of fracture-associated growth disturbances are infrequent and inconsistent, even contradictory.

MATERIALS AND METHODS

A review of textbooks, classical references and recent literature was performed to identify the available evidence on distal tibia physeal separations.

RESULTS

A review of the literature showed that most authors agree that conservative, nonoperative treatment is the preferred treatment. But opinions differ on almost all essential fundamentals of treatment. Neither the potential for growth-associated spontaneous correction of posttraumatic axis deviations nor the tolerable degree of axial deviations are evaluated homogenously. Opinions also vary greatly concerning the frequency of posttraumatic growth disturbances, the influence of the mechanism of injury and the amount of primary axial deviation. The most consistent statement in the literature is that poor results of both closed and open reduction lead to an increasing number of growth disturbances, which may include the assumption that not only trauma but operative procedures, too, can be the reason for restrictive physeal plate disturbances.

CONCLUSIONS

There are two major deficiencies in most of the reviewed literature. The first is that the numbers of cases reported in each article are low due to the rarity of the injury. The second deficiency is that many studies report "physeal injuries" but do not clearly distinguish physeal separations (Salter I and II) from epiphyseal fractures (Salter III and IV) and transitional fractures, all involving the physeal plate, but in completely different ways with completely different prognoses. A prospective multicenter study is taking place.

[Conservative treatment of fractures of the long bones during the growth phase]

In the treatment of fractures of the long bones in children and adolescents, surgical and conservative methods are not mutually exclusive alternatives; rather, each can complement the other in the overall treatment strategy. Many operative procedures, such as fixation of juxtaarticular, metaphyseal fractures, need to be supplemented by conservative procedures, such as immobilization by means of casts. We refer to methods that are performed without anaesthesia and do not involve the implantation of osteosynthetic foreign material as conservative. These are: immobilization with no further treatment, plaster wedging, and functional treatment options. The indications for purely conservative treatment strategies are basically different for articular and nonarticular fractures. Whereas in the case of articular fractures only the nondisplaced fractures are treated by conservative methods, in the case of nonarticular (shaft) fractures those involving a degree of displacement, as long as it is not too pronounced to allow the integration of spontaneous corrections, can also be treated conservatively.

Enhanced alpha 1(I) mRNA expression in frozen shoulder and dupuytren tissue

The purpose of this study has been to investigate collagen I and III synthesis during the fibrosing stage of frozen shoulder and Dupuytren samples in comparison to normal capsule tissue. - By using the quantitative PCR significantly increased levels of alpha 1(I) mRNA transcription in samples of frozen shoulder (p = 0.016) and Duypuytren (p = 0.041) could be demonstrated, whereas alpha 2(I) and alpha 1(III) chains have shown the same mRNA levels as in normal capsule tissue. - Despite an enhancement of alpha 1(I) mRNA transcription in frozen shoulder and Dupuytren samples the intracellular precursor procollagen I and extracellular mature collagen I was detected immunohistochemically in reduced levels. - The structural alteration of collagen I assembly might be caused by disturbed post-translation from the polypeptide chains into the triple helices procollagen I though alpha 1(I) mRNA transcription was significantly increased and alpha 2(I) mRNA transcription was in normal range. Fibroblasts might release high quantities of free alpha 1(I) polypeptide chains or (alpha 1(I)) 3 homotrimer into the extracellular space during the fibrosing stage of frozen shoulder and Dupuytren disease. - In all samples neither differences of alpha 1(III) mRNA transcription nor differences of immunohistochemical staining intensity of collagen III could be seen. This might result from apoptosis of myofibroblasts in the final phase of the fibrosing processes. - The stimulating effect of insulin-like growth factor type I (IGF-I) to induce fibrosis in connective tissue such as scarlet is known. In all patients suffering from frozen shoulder and Dupuytren disease the serum IGF-I level was in a normal range and the IGF-I receptor - (IGFR-I) mRNA transcription in the samples was also in the same level compared with normal capsule tissue.

[Intraoperative radiation exposure in elastic stable intramedullary nailing (ESIN) during the growth period. Observations in 162 long bone shaft fractures]

BACKGROUND

The increase of intraoperative radiation exposure in intramedullary techniques of osteosynthesis is recognised and accepted in adults especially in interlocked nailing. In contrast data about fluoroscopy times in elastic stable intramedullary nailing (ESIN) in children and adolescents are hardly available.

MATERIAL AND METHOD

Operation records of 162 surgical procedures (8.6% humerus, 43.8% forearm, 32.7% femur, 14.8% lower leg) of a 3-year period were evaluated retrospectively. The mean age was 6.1 years in femoral shaft fractures, nearly similar in forearm and lower leg fractures (8.7 and 7.9 years, respectively) and 12.4 years in patients with humeral shaft fractures.

RESULTS

Mean operation (OP) and fluoroscopy times (FL) were increased in humeral fractures (58.1 min OP, 1.62 min FL), at a medium level in forearm fractures (35.2 min OP, 1.06 min FL) and femoral fractures (42.3 min OP, 1.27 min FL) and shortest in lower leg fractures (29.6 min OP, 0.69 min FL).

CONCLUSION

Our results and literature analysis show that optimal technical conditions, especially the use of a pulsed image intensifier and well-trained theatre staff, are able to reduce intraoperative radiation load.

[Distraction osteogenesis for adjusting humeral length difference due to premature closure of the proximal growth plate in a simple bone cyst]

Complications after pathological fractures of simple bone cysts of the humerus are refracture, cyst recurrence, and in rare cases premature closure of the physeal plate with resulting shortening of the arm. Length discrepancies of the lower limbs beyond physiological limits need early compensation in children as well as adults to avoid interference with the pelvis and spine. However, surgical treatment of length differences of the humerus is usually cosmetic, because even considerable discrepancies do not lead to functional deficits. We report the long-term course of a complicated bone cyst of the proximal humerus and resolving a severe length difference of 7 cm by distraction osteogenesis in a young adult. The cause of the premature physeal closure and the primary therapeutical concept are discussed.