Experimental studies of lateral stress to transverse fractured femora treated with external fixation

As part of a postmortem research project 9 beagle femora were dynamically tested by means of three-point bending. The test device was a spring driven impactor with an impact velocity of 3 m/s. Maximum bending force, deflection and force-deflection history were documented. After the impact transverse fractures were observed in 6 specimens, while another 3 specimens showed short oblique fractures. The fractured femora were treated realistically with external fixation (triax monotube) and again loaded on the impactor. After this treatment of the specimens and dynamic loading comminuted fractures occurred. In 7 cases all 4 pins were distorted. While there was only a small difference between the mean bending force of 751.01 N before and 729.54 N after treatment, a significant difference in terms of deflection and bending stiffness showed with p = 0.0039 for both parameters. This experimental result means that in cases of transverse fractures caused by ventral force only 9.6 % of the initial bending stiffness is obtained after stabilization with external fixation. Considering the fact that the use of external fixation protracts the time to bone consolidation of transverse fractures, this method cannot be designed as the therapy of choice.

[Multiprobe FISH for enhanced prediction of recurrent bladder cancer]

The early detection of recurrent urothelial cancer is a great challenge for both urologists and pathologists. Cytology is a sensitive and highly specific tool for the diagnosis of high-grade bladder cancer and carcinoma in situ, but is not reliable in low-grade tumors. Therefore, cystoscopy has remained the gold standard for surveillance after resection of bladder cancer. Recent data suggest that multi-target fluorescence in situ hybridization (FISH) can markedly improve the sensitivity of urinary cytology. The goal of this study was to investigate the utility of the recently developed FISH assay Uro-Vysion for the prediction of recurrence during surveillance. 134 bladder washes obtained during a negative follow-up cystoscopy from 127 patients were analyzed. Positive cytology was strongly associated with subsequent recurrence, emphasizing the importance of conventional cytology for bladder cancer surveillance. A positive UroVysion FISH test significantly predicted recurrence when cases with rare tetraploic cells were considered as negative. Taken together, both cytology and FISH help to better determine the risk of bladder cancer recurrence in order to establish more individualized follow-up schemes.

[Improved continence after Pena operations in anorectal abnormalities]

Studies investigating the functional outcome after operative treatment of high and intermediate forms of anal and rectum atresia have shown better results for the Pena procedure than for other forms of pull-through procedures. Follow-up with three-dimensional vector volume manometry of patients operated on according to Pena and matched controls demonstrated a significant improvement in the radial asymmetry index over the years and must be interpreted as a maturation process of the continence organ on a critical level.

[Is primary would closure in septic pediatric surgery contraindicated?]

Since 1994, 25 children have been treated for abscesses of the soft issue. After the incision, a complete debridement was done, followed by implantation of a collagen sponge containing gentamicin and primary wound closure. Only two relapse were seen, which had to be re-opened.

Proteus syndrome associated with a sacrococcygeal teratoma; a rare combination

We report on an 5-year-old boy with a Proteus syndrome known since his second year of life. Hidden in a lipomatous tumor we excised a sacrococcygeal teratoma which must have been present since birth. This is the first case, out of about 50 published Proteus cases, of a patient with Proteus syndrome and sacrococcygeal teratoma.

Bioresorbable pins and screws in paediatric traumatology

Bioresorbable implants are suited to the treatment of joint and shaft fractures in children. These conclusions were drawn from clinical and experimental investigations at the University of Heidelberg. Since 1990 13 fractures, including 5 medial malleolus fractures, 2 retropatella flake fractures, 1 metacarpal fracture, 2 lateral condyle, 2 epicondyle fractures and a secondary dislocated forearm fracture were treated with BIOFIX pins. 11 of these cases were without complications. There was one case of infection, and due to material failure the stability was insufficient in one case. In a post-mortem study torsional fractures were produced in femora of children between 5 and 15 months. The fractures were then fixed with one resorbable screw and put under torsional loading until the bone refractured. The post-fixation force (torsional) amounted to 77% of the original fracture force, and the degree of rotation at fracture was post-fixation 84% of the original. The stability of bioresorbable screws in the treatment of femoral spiral fractures in children can therefore be confirmed.

Ileitis hyperplastica follicularis Golden: surgical or conservative treatment?

The authors report on four cases of Golden's syndrome, a rare disease with unknown etiology and controversial therapy. The first two 7-year-old boys had gastrointestinal bleeding; their hemoglobin levels were 7.0 g% and 7.3 g%, respectively. A blood transfusion was required. Both patients underwent gastroscopy and rectoscopy, and no source of bleeding was found. Biopsies were taken during laparotomy, after terminal ileotomy in case one and coecotomy in the other. Bowel resection was not necessary in either case. The third and fourth boys (5 and 6 years old, respectively) were treated conservatively with parenteral nutrition; blood transfusion was not necessary. All four patients recovered within several days. Control colonoscopies 6 months later showed normal mucosa. The authors discuss their diagnostic and therapeutical regime, stressing that in their experience, this rare disease does not require surgical intervention.

[Neutropenic typhlitis: a frequently missed complication of aplasia-inducing tumor therapy with a possible association to the combination of etoposide with high-dose cytosine-arabinoside]

Neutropenic typhlitis (NPT) was observed in 4 of 5 adult patients with acute leukemia treated with etoposide (VP16; 100 mg/m2/d for 6 days) and high-dose cytosine-arabinoside (HD ARAC, 2 g/m2 twice daily for 6 days) in a period of 11 months. One additional patient developed NPT after combination therapy with amsacrine (mAMSA, 120 mg/m2/d for 5 days) and etoposide (80 mg/m2/d for 5 days) during the same period. These 5 cases of NPT meant a drastic rise in the incidence of NPT at our institution, where a careful retrospective review of the charts of the 128 adult patients with leukemia treated during the preceding 5 years revealed only one case of NPT. Nonsurgical treatment led to recovery in all cases. No recurrence of NPT was observed during 3 further courses of aplasia with the use of selective (2 patients) or complete (1 patient) bowel decontamination. Etoposide may potentiate the gastrointestinal toxicity of high-dose cytosine-arabinoside with a higher incidence of NPT.

A biomechanical study of bicycle helmets' effectiveness in childhood

The authors present the results of a series of impact tests on pedal cycle helmets. 10 helmets were tested using a drop test under three different test conditions: Left frontal/temporal from 1 m, right frontal/temporal from 1.5 m and left occipital from 1 m. Impact force and the acceleration of the headform's centre of gravity in three axes were measured. As a result of the authors' field research on pedal cycle helmets in Australia the 1.5 m drop height was considered to be more representative of a "real" accident than the less severe 1 m height fall. The range of resultant maximal accelerations, 1 m drop height, was 81 g to 193 g; 1.5 m drop height 122 g to 209 g. In comparison a fall without helmet from 0.5 m produced a maximal resultant acceleration of 282 g. Head injury criteria values were for 1 m drops between 201 and 630; from 1.5 m 547 to 1078; and without helmet from 0.5 m 906. The individual helmets are compared on these figures and their merits discussed.

Late-onset 3 beta-hydroxysteroid dehydrogenase deficiency with virilization induced by a large ovarian cyst

A midpubertal girl presented with secondary amenorrhea and a rapidly progressive deepening of her voice as the only signs of virilization. Diagnostic work-up yielded an extremely elevated plasma testosterone (289 ng/dl), low estradiol (29 pg/ml) levels and a large solitary cyst of the right ovary, which was totally removed. Pathohistology was in keeping with a granulosa cyst with mild luteinization. Normalization of testosterone (to 27.3 ng/dl) and estradiol (to 62 pg/ml) and resumption of regular menses after 2 months clearly indicated an autonomous function of the cyst. A malignant tumor was unequivocally excluded. Basal and ACTH stimulated levels of adrenal androgens pointed to a late-onset 3 beta-hydroxysteroid dehydrogenase deficiency, which per se is known to induce polycystic ovarian changes, but to date has never been described to be accompanied with a large and autonomous follicular cyst.

[Morphometric analysis of the vascular tree of fetal tubular bones in an experimental model]

The area of interest for the longitudinal growth is the distal growth plate. In a postmortem study we were interested in changes of the epiphyseal vascular length density after fracture and surgical therapy of foetal and neonatal femora (25th to 40th post conceptional weeks). We formed three groups of equal size. Group A (25 femora) was the control group. In group B and C we performed fractures in the middle third of the femora, in group C the femora was operated with a plate afterwards. A microangiography of all femora occurred and after plastination transparent slices were produced. In this manner we could study the epiphyseal vessels in the growth plate. Using image analyses we could show that vascular density of the epiphyseal growth plate could be verified only through fracture but not by surgical therapy. The integrity of the distal epiphyseal vascular architecture is the aim after all.

Does lateral bending lead to bowing fracture in an infantile lower arm?

In a postmortem study on 50 lower arms of fetuses of the 25th week of gestation and newborn we performed three-point bending experiments to find out the stability of the lower arm after bending to the resulting fracture. Lower arms with intact soft tissue show an elastic behavior when bent from the side until fracture occurs. Applying the loading deflection diagrams we could classify the fractures into three types which differ significantly by means of bending moment, maximal deflection per unit length, and force required.

Inflammatory cellular infiltrates in melanocytic nevi

We examined 1,054 melanocytic nevi [137 (13%) simple lentigines, 158 (15%) junctional nevi, 337 (32%) compound nevi, and 422 (40%) dermal nevi] for the presence of lymphohistiocytic infiltrates. The following criteria were evaluated: age and sex of the patient, location, histological type, horizontal and vertical diameter, increase of melanocytes in the basal layer of the epidermis, increase of melanophages in the papillary dermis, melanin content of keratinocytes, and melanin content of nevus cells. Lymphohistiocytic infiltrates were measured semiquantitatively; their presence within the center, in the lateral margins, or both was also determined. The results were analyzed statistically by means of chi-square tests and univariate and multivariate analyses. We found that 824 lesions (78%) were associated with a lymphohistiocytic infiltrate; whereas 230 (22%) were not. This infiltrate was weak in 273 cases (33%), moderate in 411 cases (50%), pronounced in 130 cases (16%), and very strong in 10 cases (1%). Multivariate analyses revealed that the only criteria associated with the presence of lymphohistiocytic infiltrates were the increase of melanocytes in the basal layer and the vertical thickness in compound nevi. All other parameters were statistically insignificant. We conclude that melanocytic nevi with a junctional hyperplasia of melanocytes--i.e., mostly early stages such as simple lentigines, junctional nevi, and superficial compound nevi--are often associated with a moderate to pronounced cellular stromal reaction. Their presence may reflect the appearance of antigens on proliferating melanocytes. It may also represent a stromal reaction to necrotic tumor cells and keratinocytes within the dermoepidermal junction. These findings rule out any relationship to an increase of melanin pigment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Concurrent vascular injuries in fractures in childhood]

Ten-year-analysis of blood vessel lesions present in eleven children with bone fractures revealed two major localizations: 1. In the lower extremity we observed vascular lesions in both open and closed fractures of femur and tibia. In cases with (complete) ischemia emergency operation had to be performed. 2. In the upper extremity the prevalent fracture localization was the supracondylar fracture of the elbow. Incomplete ischemia present in fractures with severe dislocation (Felsenreich III) could be salvaged by closed reposition and transcutaneous fixation by means of Kirschner wires. In those few cases open reposition was necessary, both exposure of vessels and fixation of the fracture was possible when medial incision was performed. Postoperative evaluation of patients included angiography (DSA) and ultrasound (Doppler).

Rare ovarian tumors in childhood

Between 1972 and 1990 44 patients with ovarian tumors were treated at the Department of Pediatric Surgery of the University of Heidelberg. 27 patients (61%) suffered from tumor-like lesions: neonatal, pubertal (functional) cysts, and cysts in case of syndromes. 17 genuine tumors were found (39%): 8 germ-cell tumors, 7 cystomas respectively cystadenomas and 2 tumors of the gonadal stroma. Malignancy has been observed only in two cases: 1 malignant teratoma and 1 malignant granulosa-theca-cell tumor. 2 tumor-like lesions were caused by syndromes: Albright-McCune-Sternberg- and Stein-Leventhal syndrome: Treatment of uncommon tumors depends on their size, hormonal activity, on the syndromes with which they are associated, and on the tumor status.

[Diagnosis and therapy of chronic rupture of the fibular ligament in children]

74 children with ruptures of lateral ligaments of the ankle were treated surgically between 1979 to 1986. In ten cases we found chronical ligament changes. In these cases periostal flap modified after Kuner was performed. The follow up of our patients showed good results in all, thus we could show that the periostal flap was effective. As the functional conservative ligament rupture therapy increases the periostal flap plastic in the case of children with chronical ligament changes is indicated.

[Severe injuries of the cervical spine in childhood, an interdisciplinary consideration]

Since 1976 in the department of pediatric surgery in Heidelberg we treated five fractures of the cervical spine with luxation, three patients demonstrated a high spinal lesion with tetraplegia. During the past five years eight subluxations were hospitalised. In this paper we relate the various injury mechanisms and fracture forms; especially the typical lesions of the altanto-axial region are discussed. The importance of modern imaging techniques, including NMR, as well as the age- and situation-dependent therapy are detailed. Based on a case report on a four year old boy with upper cervical spine lesion and tetraplegia medical nursing and logistic problems are discussed. Incentives of intensive care albeit limited, in pediatric surgical and pediatric anaesthesiological departments, not specialised in the management of tetraplegia, are pointed out.

[Surgical protocol and intraoperative considerations in interventions on the testis]

The surgical treatment of incompletely descended of the testes depends on the type of the undescended testis, the age of the patient, and the time of treatment. In a few years' time new techniques of autotransplantation may solve the problem of repositioning the testes in the scrotum. Exact knowledge of possible malformation of the testes and epididymis is essential for the paediatric surgeon. Torsion of one testicle with possible autoimmune impact involving the healthy testicle requires immediate exploratory surgery and treatment according to age. Paediatric carcinoma of the testes is rather rare, whereas treatment and prognosis vary with the histological type. Accurate classification and cooperation with a centre for paediatric oncology are essential.

[Disorders of vascularization following fracture of the ankle joint in children]

In the Department of Paediatric Surgery of the University of the Heidelberg, 64 children were admitted during five years to the hospital after an ankle fracture. 12 children showed a typical fracture of the growth plate (v. Laer). All 12 were not older than 12 years. The problem of this typical form of fracture is that even careful accurate treatment may be followed by growth problems of the tibial malleolus. A microangiographic postmortem study using plastinated shetts (v. Hagens) showed a normal distribution of vascularity of the ankle joint. The vascular damage after fracture and the damage of the local vascularity in the area at the growth plate after surgical treatment are comparable.

[Disorders of vascularization in para-epiphyseal groove humeral fractures and their clinical significance for the growing skeleton]

We analysed retrospectively 50 humerus fractures in the vicinity of elbow joint and 40 fractures of the proximal humerus with respect to possible injuries of the vessel pattern of the epiphyseal plate. The normal vessel pattern of the epiphyseal plate was examined postmortem on 8 foetus and newborns up to 6 months. We plastinated the affected regions and could compare symmetry of the vessel pattern in the epiphyseal plates as well as therapeutic consequences, especially after injuries of the elbow joint. Vascular disturbances in the case of young children, i.e. by fractures of the lateral oder medial condyle are undoubtedly seen. A fish-tail deformity can be a complication. By older children with mature epiphyseal plate we could not register any complications. In such cases we are interested in restoring the joint stability by refixation.

[Lichen sclerosis et atrophicus as a cause of acquired phimosis--circumcision as a preventive procedure against penis cancer?]

From January to December 1985, circumcision for acquired phimosis was performed at our department in 140 boys with a median age of 4 3/4 years. The histological examination of the prepuce revealed the existence of lichen sclerosus et atrophicus (LSA) in 6 cases, e.g. 4.3% of all circumcisions performed. The striking frequency of this chronic inflammatory epithelial change and the often cited connection between the existence of LSA and the development of penile cancer during adulthood as well as the well-known tendency towards the incidence of recurrent phimosis in LSA patients support the claim for total circumcision in these cases.

[Cantrell's syndrome]

Congenital diaphragmatic hernia is associated with a high mortality, especially when combined with other defects. The unusual repeated combination of the same congenital abnormalities by a number of patients and the fact that during embryonic life these organs develop from the mesoderm implies the existence of a specific syndrome. This article summarises the available clinical data and reports on three cases with Cantrell's syndrome, showing different pattern of congenital defects such as: 1) supraumbilical abdominal wall defects; 2) a defect of the lower sternum; 3) a deficiency of the anterior diaphragm; 4) a defect in the diaphragmatic pericardium; 5) congenital intracardiac defects.

[Implantation technic of a peritoneal dialysis catheter in infancy and childhood]

Since 1979 the continuous ambulatory peritoneal dialysis (CAPD) is used even in childhood. Practical management and tolerance of this method over a longer period are dependent on the compatibility of the chosen catheter material, the implantation technique and the exact introduction in catheter care with sac changing. The used variant of the classical Tenckhoff-catheter with spiral end and individually fitted cuffs has proved to be reliable. The left-sided paramedian incision is the preferred operative access. The transrectal position of the catheter guarantees its cranio-caudal course and placement of the spiral in the minor pelvis. The standardisation of surgical procedure in all details is an essential assumption for the improvement of long-term catheter function.

[Peculiarities of juvenile vertebral fractures and dislocations of the cervical vertebrae]

In addition to diagnostic and therapeutic problems of the bony spine injuries in childhood, questions of the participation of the growth plate arise and indicate the following treatment. In the last decade we treated 23 spine injuries, resulting after fall from height. Most of the cases showed single to multiple compression fractures of the anterior spine followed in a descending frequence by the lateral compression fractures, the disconnection ot the epiphyseal plate of the axis and the actual luxation fractures with injury of the stratum germinativum. In contrast to the prognostic favourable impression fractures with a spontaneous correction, luxation fractures with or without paraplegia must be repositionned and stabilized.

[Fractures and cartilage injuries of the knee joint in children]

In the last decade we treated and followed up 48 children in the Department of Paediatric Surgery in Heidelberg with fractures and cartilaginous injuries of the knee joint. In 13 cases we could see severe osseous injuries localised at the epiphyseal plate. With decreasing frequency, the following conditions occurred: avulsion fractures of the intercondylar eminence, fracture of the tibia head in children, fractures of the patella and avulsions of the tuberositas tibiae. Furthermore, we report about the special problems of foreign bodies incorporated in the knee joints of children, particularly if sewing needles are involved.

[Delivery planning and interdisciplinary management of large coccygeal teratomas]

Prenatal sonographic screening and a growing experience of examiners with regard to possible congenital malformations such as large coccygeal teratomas have induced the request for an early interdisciplinary consultation between obstetrician, human geneticist, paediatric surgeon, neonatologist and psychologist. It should aim at a careful information and counselling of the parents with regard to the mode of delivery and possibilities of operative management. The prerequisites for far sighted planning and performance of delivery are demonstrated by the example of large coccygeal teratomas. The availability of equipment, facilities and manpower at the time of delivery guarantees a course of delivery at reduced risk and is, together with the psychological guidance of the parents, a basic element of optimal care for the newborn.

[Problem of fracture of the radius head in the child]

Guidelines for the choice of conservative or operative treatment of fractures of the proximal radius are derived from a study comprising 21 children. Postoperative complications and long-term failures are specifically stressed. True intraarticular fractures of the radial head are rarely observed in children. Major problems arise in the treatment of comminuted fractures of the radial head associated with dislocation of the elbow, since these show the worst prognosis. Displaced marginal fractures below 3 mm are suited for early functional treatment using conservative procedures. 18 patients suffered a fracture of the radial neck type III and IV (Judet). Despite low failure rates of the operative therapy, we have recently been refraining from the operation.

[Fractures in the elbow joint area in childhood and adolescence]

73 cases of elbow joint fractures were treated in our Dep. of Paediatric surgery over a period of 10 years. Most of the fractures in the region of the distal humerus are localized at the ulnar epicondyle and the radial condyle. At the proximal forearm the radial head and the radial collum fractures are dominant in respect to olecranon fractures. Only two cases involved a comminuted fracture of the distal humerus. Due to the fact that only a small number of cases involving a fracture of the radial epicondyle after a luxation of the elbow were registered, it is possible that we paid no attention to this kind of fractures. An early functional therapy in the case of segmental fracture of the radial head must be emphasized among the 11 cases with a conservative treatment. Another 3 cases with a radial head fracture, type Judet III, should be mentioned, because they were treated without reposition but were spontaneously redressed. The operation procedure and the late results by 62 patients are discussed with the results of other examiners. As expected the comminuted fractures of the distal humerus and the radial head had a bad prognosis. Functional relevant dislocations were rare. Only in one case after a conservative treatment of a lateral condyle fracture a development of a valgus position with a pseudarthrosis after a secondary dislocation was observed. In more than 90% of our cases we could achieve a complete anatomical reposition with good to very good functional results.

[Lateral ligament ruptures of the upper ankle joint in children]

This report about 44 cases of fibular ligament lesions compares the results of two series of 22 cases, one investigated from 1978 to 1981 and the other from 1981 to 1983. Introduction of a special holding device in 1981 has resulted in more objective diagnostics. To prevent false indications for surgery the displacement under stress need to be compared with the healthy ankle. If there is 8 degrees difference an operation is indicated in children. Following the example of adult traumatology the introduction of a longitudinal epifibular incision and new techniques employed in ligament surgery have clearly improved the results of treatment.

Response ofScolytus multistriatus (Coleoptera: Scolytidae) to α- and δ-multistriatin in Switzerland

Laboratory bioassays and field tests demonstrated that a Swiss population ofS. multistriatus responded much more strongly to α- than to δ-miltistriatin in combination with 4-methyl-3-heptanol and α-cubebene. High concentrations of brevicomin appeared to replace α-multistriatin in evoking a response byScolytus species, but this effect can be explained by the fact that the brevicomin was contiminated with small amounts of α-multistriatin. Frontalin, another bicyclic ketal, showed no biological activity. Field tests indicated thatS. pygmaeus aggregates to the same attractant mixture asS. multistriatus. S. scolytus also responded preferentially to this mixture, but the relative amounts of α-multistriatin to 4-methyl-3-heptanol do not appear to be as important as forS. multistriatus.

[Micromelic type of spondylo-meta-epiphyseal dysplasia (author's transl)]

A 3 6/12 years old girl with micromelic type of spondylo-meta-epiphyseal dysplasia combined with hepatosplenomegaly and muscular hypotonia is described.

[The importance of scintimetry in the differential diagnosis of roentgenological areas of increased "translucence" in the skeleton of children (author's transl)]

A random selection of lesions representing osteolytic bone processes was evaluated with the "region-of-interest" technique in order to determine whether scintimetry can be helpful in the differential diagnosis of such processes in children. Bone tumours with structural densification, as well as osteomyelitides, were reviewed for comparative purposes. It was found that scintigraphy of the skeleton, while supplying additional and clinically quite interesting information, does not make any substantial contribution to the differential diagnostic clarification of roentgenological translucence in the skeleton of children.