[LiLa classification for paediatric long bone fractures. Intraobserver and interobserver reliability]

Identification of a novel three-column classification for double-column die-punch fractures of the distal radius

The present study aimed to classify double-column die-punch fractures of the distal radius according to imaging data, and to evaluate their clinical features. A retrospective analysis of imaging data derived from 498 patients diagnosed with a double-column die-punch fracture of the distal radius was performed. The fractures were divided into those with middle-column avulsion with fracture of the radial-column articular surface (type I), those with middle-column collapse with fracture of the radial-column articular surface (type II), those with middle-column collapse with fracture of epiphysis of the radial column (type III) or mixed-type fractures (type IV). The intra- and inter-observer consistency between assessors was analyzed with kappa statistics. The patients with double-column die-punch fractures of the distal radius were followed up. There were 21 cases of type I fracture, 135 cases of type II fracture, 130 cases of type III fracture and 212 cases of type IV fracture. The intra-observer kappa coefficient ranged from 0.810–0.861, whereas the inter-observer kappa coefficient range was 0.830–0.876, with high consistency. Following 13 months of follow-up, the patients were assessed for functional recovery of the wrist and hand using the Gartland-Werley scoring system. The analysis indicated that in 95.78% of the patients, wrist function was rated as excellent or good (n=477), while in 4.22% of patients it was rated as fair (n=21), mainly due to the development of post-traumatic arthritis of the wrist following inappropriate therapy. All of the cases were type IV and type III fractures. These data demonstrated the application of a novel classification system named the Three-Column Classification, used to classify double-column die-punch fractures of the distal radius. This method reflected the mechanisms and severity of the fractures, conforming to the principle of AO fracture classification. Furthermore, it exhibited high consistency and may provide reference values for clinical diagnosis, treatment and prognostic evaluation.

Elastic Stable Intramedullary Nailing for Treatment of Pediatric Femoral Fractures; A 15-Year Single Centre Experience

Objective:

To analyze outcomes of treatment and complications in children treated with elastic stable intramedullary nailing (ESIN) due to femoral fracture.

Methods:

From May 2002 until May 2018 case records of 103 patients (76 male and 27 female), with median age of 9 (range, 3-17) and follow-up of 92 months, who underwent ESIN because of displaced femoral fracture were retrospectively reviewed. The patient’s information including age, sex, side involved, trauma mechanism, type of fracture, associated injuries, neurovascular status, complications, operation time, duration of hospital stay, time to implant removal were analyzed. The surgical procedure implied a reposition of bone fragments and osteosynthesis with titanium elastic nails introduced through an incision over the lateral and medial border of the distal femoral metaphysis.

Results:

All patients achieved complete radiographic healing at a mean of 8.5 (range, 5-15) weeks. Nine (8.49%) postoperative complications were recorded: three entry site skin irritation, two cases of valgus angulation and one case of nail protrusion, re-fracture, Varus angulation and delayed union. All complications, except case of re-fracture and one valgus angulation, were treated conservatively, with no long term consequences for the patients. Two patients were re-operated. After removal of nails all patients recovered complete function of the extremity, without long term consequences.

Conclusion:

The ESIN for treatment of femoral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. Because of the excellent objective and subjective results, the operative stabilization of femoral fractures with ESIN should be recommended to all pediatrics patients

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF. Patients and methods - We included children and adolescents (0-17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs. Results - Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures. Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents. Interpretation - The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.

[Growth behavior after epiphyseal plate injury: importance of "watertight" osteosynthesis]

BACKGROUND

The frequency figures for epiphyseal plate injuries of long bones given in the literature are inexact and they probably occur with a frequency of 15% of all fractures of the growing skeleton. In order to be able to give correct figures in the future a classification system, such as the LiLa classification should be used, which does not attempt to be oriented to an assumed growth prognosis but is oriented to therapy and makes a strict differentiation between shaft and joint fractures. For epiphyseal joint fractures a differentiation must be made between those where the epiphysis is still open and those where the epiphysis has begun to close, in order to be able to incorporate all epiphyseal joint fractures and differentiate them from epiphyseal shaft fractures (epiphysiolysis).

CLINICAL ASPECTS

The growth prognosis encompasses stimulatory and inhibitory growth disorders as well as spontaneous correction of residual axial deviations. The prognosis is fundamentally dependent on the biological age of the patient by fracture, on the localization in the skeleton and the localization in the segment because the growth components of epiphyses are asymmetrically distributed in the segment. Stimulatory growth disorders in the actual growth phase < 10 years of age are the obligatory growth disorders which lead to overgrowth of the section of the skeleton affected. In an age over 10 years they lead to an also obligatory premature closure of adjacent or affected epiphyses which is expressed as a slight shortening. Asymmetrical stimulations are most common in the upper extremities following intra-articular fractures of the radial condyle as the obligatory growth disorder at this site. Asymmetrical stimulation is rare in the lower extremities after extra-articular metaphyseal valgus fractures of the proximal and distal tibia. Asymmetrical premature closure of the epiphysis in the upper extremities is rare in contrast to partial stimulation with less than 5% after extra-articular fractures of the distal radius and proximal humerus. Conversely, asymmetrical inhibitory growth disorders are found significantly more often in the lower extremities after extra-articular and intra-articular fractures of the distal femur, proximal tibia and distal tibia between 50% and 20%. "Spontaneous corrections" of residual axial deviations and side to side shifts after epiphyseal shaft fractures occur reliably without resulting in growth disorders, provided the patient is young enough.

THERAPEUTIC TARGETS

In cases of displacement the aim of therapy in epiphyseal shaft fractures is to reconstitute age-related and tolerable axes. For displaced epiphyseal joint fractures the aim is to reconstruct the joint surfaces. The basic principles of an efficient and targeted diagnostics and the therapeutic options for diminishing the clinical sequelae of growth disorders are discussed.

CONCLUSION

No growth disorders, which are to be expected as a result of every epiphyseal injury, can primarily be therapeutically avoided; however, better foundations can be achieved to reduce the clinical sequelae of growth disorders. Therapy can only follow the differentiation into shaft and joint (and not an assumed growth prognosis) and should integrate a scientifically proven and reasonable spontaneous correction for the patient. A classification must achieve a therapy-related uncoupling of the epiphyseal injuries into shaft and joint fractures.

Modification of elastic stable intramedullary nailing with a 3rd nail in a femoral spiral fracture model - results of biomechanical testing and a prospective clinical study

Background

Elastic stable intramedullary nailing (ESIN) is the standard treatment for displaced diaphyseal femoral fractures in children. However, high complication rates (10-50%) are reported in complex fractures. This biomechanical study compares the stiffness with a 3rd nail implanted to that in the classical 2C-shaped configuration and presents the application into clinical practice.

Methods

For each of the 3 configurations of ESIN-osteosynthesis with titanium nails eight composite femoral grafts (Sawbones®) with an identical spiral fracture were used: 2C configuration (2C-shaped nails, 2 × 3.5 mm), 3CM configuration (3rd nail from medial) and 3CL configuration (3rd nail from lateral). Each group underwent biomechanical testing in 4-point bending, internal/external rotation and axial compression.

Results

2C and 3CM configurations showed no significant differences in this spiroid type fracture model. 3CL had a significantly higher stiffness during anterior-posterior bending, internal rotation and 9° compression than 2C, and was stiffer in the lateral-medial direction than 3CM. The 3CL was less stable during p-a bending and external rotation than both the others. As biomechanical testing showed a higher stability for the 3CL configuration in two (a-p corresponding to recurvation and 9° compression to shortening) of three directions associated with the most important clinical problems, we added a 3rd nail in ESIN-osteosynthesis for femoral fractures. 11 boys and 6 girls (2.5-15 years) were treated with modified ESIN of whom 12 were ‘3CL’; due to the individual character of the fractures 4 patients were treated with ‘3CM’ (third nail from medial) and as an exception 1 adolescent with 4 nails and one boy with plate osteosynthesis. No additional stabilizations or re-operations were necessary. All patients achieved full points in the Harris-Score at follow-up; no limb length discrepancy occurred.

Conclusion

The 3CL configuration provided a significantly higher stiffness than 2C and 3CM configurations in this biomechanical model. These results were successfully transmitted into clinical practice. All children, treated by 3CL or 3CM according to the individual character of each fracture, needed no additional stabilization and had no Re-Do operations. As a consequence, at our hospital all children with femoral diaphyseal fractures with open physis are treated with this modified ESIN-technique.