Is cross-sectional imaging necessary for fractures of the distal lower leg in children and adolescents: results of a nationwide survey

PURPOSE

In childhood and adolescence, cross-sectional imaging, most commonly computed tomography (CT), is often performed for advanced diagnosis of joint injuries of the distal lower leg and upper ankle. Due to radiation exposure, the need for CT remains controversial, as these injuries follow stereotypies and usually have a similar course. Alternatively, the performance of magnetic resonance imaging (MRI) is also discussed. Since radiation sensitivity at this young age is much higher than in adults, an effort must be to minimize radiation exposure according to as low as reasonably achievable (ALARA) principles. The aim of this survey is to evaluate the current procedure in Germany in the diagnosis of pediatric injuries of the distal lower leg and upper ankle.

METHODS

For data collection, a survey entitled "CT in fractures of the ankle joint in childhood and adolescence: subject of the survey are injuries between 8 and 15 years of age" of the Section of Pediatric Traumatology in the German Association of Trauma Surgery was sent to all members via the distribution list of the German Society of Orthopedics and Traumatology and the distribution list of the German Society of Pediatric Surgery in a period from September 20, 2022-December 21, 2022. The survey included a total of 21 questions. Target groups were trauma and pediatric surgeons and orthopedic surgeons working in the hospital and in practice.

RESULTS

A total of 525 participants took part in the survey: ultrasound diagnostics are used by almost 25% and the Ottawa Ankle Rules by over 50% always or in most cases. A conventional x-ray is always or most often used by over 90%. CT imaging is rarely used by 88.57%, mainly for surgical planning or analysis of fracture progression. 69.9% report that their radiology department uses a pediatric protocol for CT exams; 25.71% do not know if this is the case. MRI imaging is also used infrequently by 89.33%, mostly to identify associated injuries. Overall, CT imaging is chosen by 55.62% and MRI imaging by 35.24% as the sectional imaging modality for suspected fractures; 95.05% consider sectional imaging useful for a triplane fracture, 59.24% for a two-plane fracture, 41.71% for a Salter-Harris type III/IV injury, and 8% for a Salter-Harris type I/II injury.

CONCLUSION

The survey showed that the conventional X-ray is still the gold standard. Interestingly, more than half of the respondents regularly use the Ottawa Ankle Rules, and diagnostics using ultrasound are also used by almost a quarter. Awareness of radiation protection in children exists, although a quarter of all participants do not know the extent to which their radiology department has a specific pediatric protocol for CT imaging. Cross-sectional imaging is performed on a regular basis. Regarding the actual extent of imaging, there is a clear divergence between theory and practice.

[Assessment of osteosynthesis in X-ray images]

Osteosynthesis refers to various surgical procedures, closed or open, for the treatment of fractures of any age. To document and control the osteosynthesis and the healing process X‑ray controls of the affected skeletal segment are performed during the operation and at regular intervals. To assess the quality of an osteosynthesis or to identify a complication, a comprehensive and systematic image review is useful. This includes the assessment of the restoration of the functional anatomy, the position of the material in relation to the surrounding structures, an evaluation of the stability as far as this is possible, and a control of the bone healing in a functionally correct position.

[Assessment of patellar dislocations in childhood and adolescence : Accident-related or predisposition-related?]

BACKGROUND

Numerous predisposing factors are known for patellar dislocations but the extent to which these or the trauma cause the dislocation is often unclear.

AIM

This study investigated whether the analysis of the accident mechanism and anatomical predisposition in juvenile patellar dislocations enables a conclusion as to the causality.

MATERIAL AND METHODS

Retrospective cohort study, evidence level III. In-house employers' liability insurance association (BG) cases with the diagnosis of patella dislocation in patients under 18 years were descriptively evaluated with respect to demographic and predisposing aspects as well as regarding accident information. The accident mechanisms were sorted into subgroups: direct impact, trivial trauma, fall, torsional trauma.

RESULTS

A total of 54 patellar dislocations were identified with a patient age of 14 years (range 9-18 years). A mild valgus configuration was found in 39% of the cases, on average normal torsion, a tibial tuberosity-trochlea groove (TTTG) distance of 17 mm (range 8-24mm), with 41% a high proportion of patella alta and a trochlear deformity in 57%. Only 20% of the children had no relevant predispositions. The trivial traumas showed the highest proportion of recurrent dislocations with 50% and in the other accident categories the proportion of first dislocations was >75%. In the fall cohort the rate of children without relevant predisposition was highest.

CONCLUSION

The predisposition rate in infantile patellar dislocations is high; however, falls are always significant accident events as well as medial direct impact. Torsional trauma is also a significant causative factor, unless high-grade trochlear dysplasia is present, whereas trivial traumas are not.

Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment

Background

Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate.

Methods

Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d’Aubigne and the EQ. 5D-3 L scores.

Results

Over an 11-year period (2004–14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d’Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts.

Conclusion

Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients.

Trial registration

DRKS, no. 00000488. Registered 14th July 2010 - Retrospectively registered

Spinal Orthoses: The Crucial Role of Comfort on Compliance of Wearing - Monocentric Prospective Pilot Study of Randomized Cross-Over Design

PURPOSE OF THE STUDY Various spine disorders are regularly treated by orthoses, and success of treatment depends on wearing these devices. In this study we examined the compliance, wear comfort, subjective stabilization and side effects associated with spinal orthoses using an individualized questionnaire and the Compact Short Form-12 Health Survey (SF-12). MATERIAL AND METHODS In this prospective pilot study of randomized cross-over design, twelve healthy volunteers with a mean age of 31.2 years wore three different types of orthoses, each for one week: A hyperextension brace (HB), a custom-made semirigid orthosis (SO) and a custom-made rigid orthosis (RO). The daily duration of wearing the orthosis was defined as primary endpoint; contentment was measured using an individualized questionnaire and the standardized SF-12. RESULTS In the study population calculated probability of wearing the HB and RO was between 0.2 und 38.5% (95% confidence interval). No volunteer wore the SO orthosis for the predefined time. The SO and RO each displayed high subjective stabilization, while the RO was more often associated with side effects like skin pressure marks than the SO. The need for rework due to discomfort was mainly necessary with the RO. We observed no substantial differences in feeling compression and sweating. Noteworthy, eight of 12 subjects complained of uncomfortable sternal pressure due to the upper pad of the HB. The SF-12: scores ranged from 52.1 to 48.6 on the physical (PCS), and from 53.7 to 50.8 on the mental component score (MCS), demonstrating an influence on QoL. DISCUSSION AND CONCLUSIONS The design as well as the orthosis itself influence the compliance of wearing and exert a moderate negative, but acceptable impact on QoL. The SO appeared to correlate with the best overall compromise between comfort and subjective stabilization. Further investigations are necessary in patients with spinal diseases, for whom the effect of orthosis wearing may surpass the potential discomfort. Key words: thoracolumbar spine, orthoses, SF-12 - Quality of Life - QoL, comfort, compliance.

Outcome and predictors for successful resuscitation in the emergency room of adult patients in traumatic cardiorespiratory arrest

BACKGROUND

Data of the TraumaRegister DGU® were analyzed to derive survival rates, neurological outcome and prognostic factors of patients who had suffered traumatic cardiac arrest in the early treatment phase.

METHODS

The database of the TraumaRegister DGU® from 2002 to 2013 was analyzed. The main focus of this survey was on different time points of performed resuscitation. Descriptive and multivariate analyses (logistic regression) were performed with the neurological outcome (Glasgow Outcome Scale) and survival rate as the target variable. Patients were classified according to CPR in the prehospital phase and/or in the emergency room (ER). Patients without CA served as a control group. The database does not include patients who required prehospital CPR but did not achieve ROSC.

RESULTS

A total of 3052 patients from a total of 38,499 cases had cardiac arrest during the early post-trauma phase and required CPR in the prehospital phase and/or in the ER. After only prehospital resuscitation (n = 944) survival rate was 31.7 %, and 14.7 % had a good/moderate outcome. If CPR was required in the ER only (n = 1197), survival rate was 25.6 %, with a good/moderate outcome in 19.2 % of cases. A total of 4.8 % in the group with preclinical and ER resuscitation survived, and just 2.7 % had a good or moderate outcome. Multivariate logistic regression analysis revealed the following prognostic factors for survival after traumatic cardiac arrest: prehospital CPR, shock, coagulopathy, thorax drainage, preclinical catecholamines, unconsciousness, and injury severity (Injury Severity Score).

CONCLUSIONS

With the knowledge that prehospital resuscitated patients who not reached the hospital could not be included, CPR after severe trauma seems to yield a better outcome than most studies have reported, and appears to be more justified than the current guidelines would imply. Preclinical resuscitation is associated with a higher survival rate and better neurological outcome compared with resuscitation in the ER. If resuscitation in the ER is necessary after a preclinical performed resuscitation the survival rate is marginal, even though 56 % of these patients had a good and moderate outcome. The data we present may support algorithms for resuscitation in the future.

Biomechanical investigation of a minimally invasive posterior spine stabilization system in comparison to the Universal Spinal System (USS)

Background

Although minimally invasive posterior spine implant systems have been introduced, clinical studies reported on reduced quality of spinal column realignment due to correction loss. The aim of this study was to compare biomechanically two minimally invasive spine stabilization systems versus the Universal Spine Stabilization system (USS).

Methods

Three groups with 5 specimens each and 2 foam bars per specimen were instrumented with USS (Group 1) or a minimally invasive posterior spine stabilization system with either polyaxial (Group 2) or monoaxial (Group 3) screws.

Mechanical testing was performed under quasi-static ramp loading in axial compression and torsion, followed by destructive cyclic loading run under axial compression at constant amplitude and then with progressively increasing amplitude until construct failure.

Bending construct stiffness, torsional stiffness and cycles to failure were investigated.

Results

Initial bending stiffness was highest in Group 3, followed by Group 2 and Group 1, without any significant differences between the groups.

A significant increase in bending stiffness after 20’000 cycles was observed in Group 1 (p = 0.002) and Group 2 (p = 0.001), but not in Group 3, though the secondary bending stiffness showed no significant differences between the groups.

Initial and secondary torsional stiffness was highest in Group 1, followed by Group 3 and Group 2, with significant differences between all groups (p ≤ 0.047). A significant increase in initial torsional stiffness after 20’000 cycles was observed in Group 2 (p = 0.017) and 3 (p = 0.013), but not in Group 1.

The highest number of cycles to failure was detected in Group 1, followed by Group 3 and Group 2. This parameter was significantly different between Group 1 and Group 2 (p = 0.001), between Group 2 and Group 3 (p = 0.002), but not between Group 1 and Group 3.

Conclusions

These findings quantify the correction loss for minimally invasive spine implant systems and imply that unstable spine fractures might benefit from stabilization with conventional implants like the USS.

[Femoral shaft fractures in children under 3 years old. Current treatment standard]

INTRODUCTION

Femoral shaft fractures in children are a common injury. Operative treatment is recommended for children above 3 years of age. The question of this investigation was the current clinical standard for the treatment of femoral shaft fractures in children under 3 years old.

MATERIAL AND METHODS

An e-mail questionnaire was sent to all clinics and hospital departments of the members of the German Society for Trauma Surgery and the German Society of Pediatric Surgery.

RESULTS

Out of 775 clinics and departments, 121 participated in the survey (16 %). From 2011 to 2012 overall 756 femoral shaft fractures of children 3 years and younger were treated of which 375 (50 %) were stabilized with elastic stable intramedullary nailing (ESIN), 183 (24 %) with an overhead extension, 178 (23 %) with a plaster cast and 9 (1 %) with external fixation. Finally, operative treatment was used in 51 % compared to 49 % with conservative treatment.

DISCUSSION

Obviously, operative treatment of femoral shaft fractures in children younger than 3 years is routinely used despite the fact that there is no evidential basis for this approach. There are good arguments for and against operative and conservative forms of treatment. Indications for operative treatment include multiple trauma, open fractures, body weight over 20 kg, child already free walking and lack of stable fixation with conservative treatment. To achieve more evidence for the existing recommendation of the American Academy of Orthopaedic Surgeons (AAOS) and the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, Working Group of the Scientific Medical Specialist Societies), further investigations are needed.

Minimally invasive stabilization of distal humerus fractures: a pilot study with biomechanical evaluation

BACKGROUND

Fracture of the distal humerus is a fairly rare injury and makes high demands on the treating surgeon. Prerequisites for a good outcome are anatomical reconstruction and osteosynthesis stable enough for exercises. A method permitting early restoration of function is especially important for patients with osteoporosis. The extensive surgical approach necessary for open reduction is associated with a high number of wound healing disorders and infections with a frequency of 11% being reported in the literature. Although open reduction and internal fixation in double-plating technique is unavoidable for complex intraarticular fractures, an alternative, minimally invasive and, consequently, tissue-preserving procedure is desirable for simpler fractures.

OBJECTVE

To investigate this issue further an angular stable nail system developed for the distal radius was implanted as a stabilizer and the construct tested biomechanically as part of a feasibility study.

METHODS

Distal humerus fractures were stabilized by insertion of a distal radius nail, namely, the Targon DR (Aesculap, Tuttlingen) and a K-wire. To test the hypothesis six cadaveric bones fixed in formalin were tested biomechanically for displacement, implant failure, and stiffness. Displacement was determined by means of an ultrasound-based system.

RESULTS

An average displacement of 1.6 mm ± 0.7 was recorded at a maximum compression force of 100 N in extension and an average displacement of 1.4 mm ± 0.9 in flexion. Implant failure was not observed for any of the constructs.

CONCLUSIONS

The study presented here permits the conclusion that a minimally invasive procedure is possible at the distal humerus and does ensure adequate stability. Although the nail was not specifically designed for the humerus, current findings form the basis for a promising approach that will be pursued further after modification of the nail design.

Relationship between autologous bone graft osteointegration and correction loss after antero-posterior spondylodesis of traumatic vertebral body fracture

BACKGROUND

A common method to restore the sagittal alignment and stabilize the spinal column is a dorso-ventral spondylodesis. It is assumed that correction loss after posttraumatic spondylodesis results from inadequate incorporation of the autologous iliac crest graft.

MATERIALS AND METHODS

Retrospective documentation of patients with unstable vertebral body fractures of the thoracic or lumbar spine with concomitant rupture of at least one adjacent intervertebral disk who received surgical treatment at our institution from 2000 to 2006. Followed by analysis of the computer tomography documentation of a total of 142 patients with unstable vertebral body fracture stabilized by posterior internal fixator and anterior iliac crest spondylodesis.

RESULTS

The following mean angle changes were derived from the second series of CT scans performed on average 283 days after anterior spondylodesis: vertebral wedge angle (VWA): 2.1°; segmental kyphotic angle: 4.9°; adjusted-SKA: 4.8°; sagittal index (SI): -0.04; segmental-scoliotic-angle (SSA): 0°; adjusted-SSA: 0°. Changes in VWA, both SKAs and SI postoperatively and prior to ME, were statistically significant (P<0.05). The McAfee fusion assessment of the graft showed: full fusion: cranial 64%, caudal 47%; partial fusion: cranial 20.5%, caudal 29%; lysis: cranial 8.5%, caudal 17%; graft resorption: 7%. No correlation was found between the above-mentioned angle changes and fusions grade.

DISCUSSION

The importance of radiological evidence of fusion deficiency is questionable, because the extent of fusion only has a minimal effect on correction loss.

LEVEL OF EVIDENCE

Level IV.

Management of femoral shaft fractures

Femoral shaft fractures are severe injuries and are often associated with a high impact trauma mechanism, frequently seen in multiple injured patients. In contrast an indirect trauma mechanism can lead to a complex femoral shaft fracture especially in elderly patients with minor bone stock quality. Hence management of femoral shaft fractures is often directed by co-morbidities, additional injuries and the medical condition of the patient. Timing of fracture stabilization is depended on the overall medical condition of the patient, but definite fracture fixation can often be implemented in the early total care concept in management of multiple injured patients. The treatment of choice is intramedullary fracture fixation. Further development of existing intramedullary nailing systems now offer comfortable handling and different locking options. Ipsilateral fractures of the neck and shaft are therefore facilitated in management. Then again increasing numbers of obese patient are representing a new patient group with challenging co-factors in fracture management. Sufficient preoperative planning is helpful to choose the most adequate fixation device. Correct reduction of the fracture and perioperative control of the axis and rotation is mandatory to avoid postoperative malrotation, which still represents the most frequent complication.

Radial head prosthesis after radial head and neck fractures - current literature and quality of evidence

Due to the elbow joint's complex functional anatomy, the multifragmentary nature of many fractures and concomitant destabilizing associated injuries, dislocated fractures of the radial head and neck still present a serious challenge for the orthopedic surgeon. Thorough knowledge of the elbow's anatomy and biomechanics is essential to analyze and understand the injury and plan its treatment. The aim of a differentiated therapy approach is to restore the joint's anatomy and kinetics, stable and painless joint function, and to avoid or at least delay posttraumatic joint changes. The degree of dislocation, stability of fragments, size and number of fractured joint surfaces and associated bony and ligamentous injuries (and the instability they incur) must be addressed in the therapy regimen. There are various treatment options depending on the injury's classification, i.e. a Mason I fracture is treated conservatively, while more severe injuries may require osteosynthesis and endoprosthesis. There is a lack of clear therapy recommendations based on solid evidence regarding Mason classification types III-IV. In particular expert opinions diverge and study results are inconsistent. Especially the value of radial head arthroplasty is still hotly debated. Key words: radial head fracture, radial head prosthesis, radial neck fracture, Mason classification, radial head arthroplasty, elbow injury.

Is Whole-Body Computed Tomography the Standard Work-up for Severely-Injured Children? Results of a Survey among German Trauma Centers

PURPOSE OF THE STUDY

Whole-body computed tomography is accepted as the standard procedure in the primary diagnostic of polytraumatised adults in the emergency room. Up to now there is still controversial discussion about the same algorithm in the primary diagnostic of children. The aim of this study was to survey the participation of German trauma-centres in the care of polytraumatised children and the hospital dependant use of whole-body computed tomography for initial patient work-up.

MATERIAL AND METHODS

A questionnaire was mailed to every Department of Traumatology registered in the DGU (German Trauma Society) databank.

RESULTS

We received 60,32% of the initially sent questionnaires and after applying exclusion criteria 269 (53,91%) were applicable to statistical analysis. In the three-tiered German hospital system no statistical difference was seen in the general participation of children polytrauma care between hospitals of different tiers (p = 0.315). Even at the lowest hospital level 69,47% of hospitals stated to participate in polytrauma care for children, at the intermediate and highest level hospitals 91,89% and 95,24% stated to be involved in children polytrauma care, respectively. Children suspicious of multiple injuries or polytrauma received significantly fewer primary whole-body CTs in lowest level compared to intermediate level hospitals (36,07% vs. 56,57%; p = 0.015) and lowest level compared to highest level hospitals (36,07% vs. 68,42%; p = 0.001). Comparing the use of whole-body CT in intermediate to highest level hospitals a not significant increase in its use could be seen in highest level hospitals (56,57% vs. 68,42%; p = 0.174).

CONCLUSION

According to our survey, taking care of polytraumatised children in Germany is not limited to specialised hospitals or a defined hospital level-of-care. Additionally, there is no established radiologic standard in work-up of the polytraumatised child. However, in higher hospital care -levels a higher percentage of hospitals employs whole-body CTs for primary radiologic diagnostics in polytraumatised children.

Anatomical assessment of iliac crest graft size for anterior spondylodesis

Standard procedure for monosegmental anterior spondylodesis often combines anterior stabilization with autologous iliac crest graft. Recent publications defined a minimum size of the graft as a technical specification for this procedure. The cross sectional area of the graft to be transplanted should be at least 23.9% of the cross sectional area of the vertebral bodies to be fused. We investigated whether the required minimum size of autologous graft, as identified both experimentally and clinically, is compatible with the anatomical conditions in central european patients. Computed tomography scans (n = 348) of polytraumatized patients were obtained in the course of initial diagnosis. The scans were evaluated for vertebral body size and the possible size of autologous bone graft in the region of the anterior superior iliac crest. The evaluation of 348 CT scans demonstrated that 95% of the quantified iliac crest grafts would achieve the size recommended for anterior spinal fusion between T10 and T12. In 90% of all cases the planned iliac crest graft exceeded the size limit of 23,9% between concerning the endplates T10 and L2. In 85% the planned iliac crest graft exceeded the size limit of 23,9% between T10 and L3. The recommendation to take this value into account for monosegmental anterior spondylodesis should gain in importance in clinical practice.

[Does simulator-based team training improve patient safety?]

Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

Tears of the rotator cuff. Causes--diagnosis--treatment

Rotator cuff ruptures are the most common degenerative tendon injury and occur mainly in older patients as multifactorial disorders manifesting the main symptoms of pain and restricted range of motion. Thorough clinical examination of the shoulder includes testing the function of the rotator cuff and leads to a tentative clinical diagnosis that is the prerequisite for diagnostic imaging procedures. Sonography of the shoulder gives rapid access to a very good sensitive overview of the rotator cuff. Conventional radiological imaging permits differential diagnosis since a reduced acromiohumeral interval is understood as a direct sign of rotator cuff rupture. The gold standard in imaging diagnostics is MRI because it not only delivers images of rotator cuff defects, but also permits interpretation of degenerative changes in the musculature. Significant pain relief can be achieved by conservative therapy such as analgesia, manual therapy and physiotherapeutic exercises and leads to improvements in the active range of motion. Persistent pain or progressive pain during conservative therapy are indications for surgical intervention. Arthroscopy-assisted treatment is tissue friendlier than open surgery and is today considered the standard for surgical treatment of rotator cuff rupture because of higher patient acceptance. Recent studies report that surgical rotator cuff repair leads to significant improvement in function, pain relief, and greater patient satisfaction. The principles of postoperative care after surgical rotator cuff repair are immobilization and gradual loading with passive and active exercises.

Distal tibial fractures and pilon fractures

Fractures of the distal tibia are often very severe injuries that generally occur in the context of high-energy trauma and present with significant concomitant soft tissue involvement. Open fractures and extensive destruction of the articular surfaces are important challenges to the treating surgeon. In consequence the outcome for distal meta- and epiphyseal tibial fractures depends largely on the severity of the soft tissue injury and its management. Conventionally, tibial pilon fractures require surgical intervention. Conservative treatment would only be considered in some exceptional cases, for example, inoperability of the patient. Controversial discussion of optimal surgical technique and optimal timing of surgery is ongoing. There is broad consensus that soft tissue consolidation must have first priority as this is the basis for both fracture healing and good long-term outcomes. Surgical intervention can be managed as a one-stage or multi-stage procedure to achieve internal or external fracture fixation.

Patellar fractures--a review of classification, genesis and evaluation of treatment

The patellar bone is involved in repetitive, load bearing motion sequences every day and functions as a vectorial force translator. A fracture rate of 1% of all skeletal fractures is reported and surgical treatment often required. beside a direct trauma mechanism, indirect mechanism but as well as fatigue fractures after reconstructive knee surgery are published. The fracture management is dependent on the soft tissue condition and a variety of surgical options are known. new generation of low profile plates show promising results but the conventional cerclage wiring technique with K-wires is widely preferred. best functional results with sustainable stability are biomechanically seen after a combined fixation technique using anterior cerclage wiring with cannulated screw fixation. A definite algorithm of treatment of patellar bone fractures is yet not defied but a review of classification and surgical techniques should give assistance in decision making.

Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome

INTRODUCTION

There is no consensus on optimal treatment strategy for Mason type II-IV fractures. Most recommendations are based upon experts' opinion.

METHODS

An OVID-based literature search were performed to identify studies on surgical treatment of radial head and neck fracture. Specific focus was placed on extracting data describing clinical efficacy and outcome by using the Mason classification and including elbow function scores. A total of 841 clinical studies were identified describing in total the clinical follow-up of 1264 patients.

RESULTS

For type II radial head and neck fractures the significant best treatment option seems to be ORIF with an overall success rate of 98% by using screws or biodegradable (polylactide) pins. ORIF with a success rate of 92% shows the best results in the treatment of type III fractures and seem to be better than resection and implantation of a prosthesis. For this fracture type the ORIF with screws (96%), biodegradable (polylactide) pins (88%) and plates (83%) showed the best results. In the treatment of type IV fractures similar results could be found with a tendency of the best results after ORIF followed by resection and implantation of a prosthesis. If a prosthesis was implanted, the primary implantation seems to be associated with a better outcome after type III (87%) and IV (82%) fractures compared to the results after a secondary implantation.

DISCUSSION

Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence.

LEVEL OF EVIDENCE

IV.

Autologous chondrocyte implantation in children and adolescents

PURPOSE

Autologous chondrocyte implantation (ACI) is a well-established treatment method for cartilage defects in knees. Age-related grouping was based on expression data of cartilage-specific markers. Specificities of ACI in the different populations were analysed.

METHODS

Two hundred and sixty-seven patients undergoing ACI in the knee between 2006 and 2010 were included in this analysis. Cell characteristics and expression data of cartilage-specific surface markers as CD44, aggrecan and collagen type II were statistically analysed for age association. Epidemiological data of the defined groups were compared. Course of treatment was evaluated using MRI.

RESULTS

A correlation analysis showed statistically significant associations between age and aggrecan or collagen type II expression in all patients <30 years. A cluster analysis could predict age-dependent expression of these markers separating groups with an average age of 18.1 ± 2.3 and 23.6 ± 4.2 years, respectively (p < 0.02). Discriminance analysis suggested the age border between adults and juveniles at about 20 years. There was no influence of age on cell characteristics or CD44 expression. In the 19 of 267 patients with an age ≤18 years, gender distribution was not different compared to adults, but patella was significantly more affected. Cartilage lesions were mainly caused by osteochondritis dissecans (OCD) and trauma. The Knee Osteoarthritis Scoring System in MRI reached 4.8 ± 2.3 points before, declining to 3.3 ± 2.3 points 6 and 12 months after the operation.

CONCLUSIONS

Age-related expression of cartilage-specific markers allows definition of adolescents in cartilage regenerating surgery. Chondromalacia in these patients is mainly caused by OCD or trauma.

LEVEL OF EVIDENCE

Case series, Level IV.

[Therapy of humeral shaft fractures]

Fractures of the humeral shaft are less frequent than those of the proximal humerus. The formerly recommended treatment of humeral shaft fractures was conservative according to Böhler. This still remains an adequate concept of treatment but according to a change in the technical possibilities and the demands of patients and physicians on fast restoration of function and low pain, there is a trend towards surgical stabilization of humeral shaft fractures. The implant of choice is discussed controversially and consists of various types of nails versus plating. The technique of nailing is antegrade or retrograde and depends on the localization of the fracture. In our opinion good indications for plating are combined fractures of the proximal humerus and the shaft as well as very distal humeral shaft fractures. A primary lesion of the radial nerve is no imperative indication for exploration and different studies have shown the same results for exploration after 2 or 3 months if there is no spontaneous remission.

Treatment of proximal humeral fractures - a review of current concepts enlightened by basic principles

Fractures of the proximal humerus commonly affect elderly patients. The vast majority of proximal humeral fractures result from low-energy trauma in presence of osteoporosis. Incidence of proximal humeral fractures dramatically increased over the last decades. Recent epidemiological studies expect a rather stagnant incidence. Diversity of fracture types attenuates reliability of available classification systems. Even though, predictive morphologic criteria have been detected enabling a prognostic assessment. A short or absent metaphyseal head extension and disruption of the medial periosteal hinge reliably predict ischemia of the humeral head fragment. Still, humeral head necrosis may be prevented in early reduction and fixation. The range of treatment options consists of non-operative therapy, minimal-invasive osteosynthesis, open reduction and plate fixation, intramedullary nailing and primary arthroplasty. Most proximal humeral fractures in the elderly are stable injuries and can be successfully treated by non-operative means. Operative treatment of displaced, unstable fractures should resort to the least invasive procedure providing adequate reduction and fixation stability. To date, open reduction and locking plate osteosynthesis represents the standard operative procedure in displaced three- and four-part fractures. However, a number of risk factors may promote fixation failure or impair functional outcome, most important low local bone mineral density, residual varus displacement of the humeral head, insufficient restoration of medial calcar support, humeral head ischemia and insufficient fracture reduction. Innovation of fixation techniques (e. g. angular stable locking systems and bone augmentation) will further expand indications for operative fracture treatment. Outcome of hemiarthroplasty is closely related to anatomical tuberosity healing and restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients, rotator cuff dysfunction or failure of first-line treatment. Choice of treatment should be individualized and base on careful evaluation of patient-specific, fracture-specific and surgeon-specific aspects.

Tibial shaft fractures - management and treatment options. A review of the current literature

Treatment of tibial shaft fractures is still discussed controversial. In the present study current literature was reviewed with the objective to demonstrate current recommendations concerning tibial shaft fractures. Tibial shaft fractures are often caused by high-energy trauma with severe concomitant soft-tissue injuries. Solid bone union without hypertrophy, fast mobilization and full range of motion without further soft-tissue damages are the aims of the therapy. Non-displaced tibial shaft fractures in patients with good compliance can be treated conservatively. Deep venous thrombosis, compartment syndrome, soft tissue injury and chronic regional pain syndrome are the major risks of conservative treatment and need to be required. Operative treatment can be performed with several different implants. Intramedullary nailing with a huge biomechanical stability seems to be the implant of choice. Only rare indications for plate osteosynthesis can be found. The use of external fixation has declined even though external fixation is still the implant of choice in first line treatment of multiple trauma according to the damage control principles. Open fractures with precarious blood supply and weak soft tissue covering are vulnerable to complications and remain a challenge for every treating surgeon. Reconstruction of axis, length and rotation is essential for a good outcome. The choice of technique depends on fracture localization, type of fracture, history of concomitant disorders and soft tissue damage.

[Fracture stabilization in polytraumatized children]

Polytrauma is a rare diagnosis in childhood. Even after high-energy accidents isolated injuries of the skull and brain or extremities are more common. Injury is still the most frequent cause of death in childhood in industrialized countries. The lethality of polytraumatized children is about 19%. Injuries of the extremities do not play such an important role for the survival of polytraumatized children but for the definitive outcome. The diagnostic algorithm for polytraumatized children is related to adults and includes spiral computed tomography in the emergency room. Plain radiographs are still the gold standard for the diagnostic workup of fractures. Generally therapeutic approaches in the treatment of fractures in children are often conservative. Because of the special situation in polytrauma with ICU care and the need for venous catheters, fast mobilization and positioning in bed, indications for operative treatment and definitive stabilization of fractures are required for polytraumatized children.

Surgical treatment of supracondylar humerus fractures in children

PURPOSE OF THE STUDY

Surgical techniques for the treatment of supracondylar fractures in children are repeatedly the subject of discussion. The aim of the present study was to compare experience with the technique of crossed Kirschner wires at our own hospital with current literature.

PATIENTS AND METHODS

In the period from 2000-2006 a total of 86 children aged 1.7 to 12.7 years were treated by means of crossed K-wire osteosynthesis. Follow up was conducted at an average of 32 months. Outcomes were evaluated based on von Laer's criteria.

RESULTS

Reported complications were migration of the K-wires in 7% of cases and secondary dislocation and re-operation in 4% of cases. Lesion of the radial nerve was diagnosed postoperatively in two cases. Hospital stay was 1.5 days on average. Postoperative immobilization in an upper arm splint and implant removal after 6 weeks on average. 57% of the children received physiotherapy during the course of treatment. Slight varization was found in 11% of children and an unsatisfactory range of motion in 13%. Satisfactory outcomes were recorded for 83% of patients.

CONCLUSION

K-wire osteosynthesis is associated with a low complication rate and continues to be a safe standard procedure for the stabilization of supracondylar humerus fractures. Key words: supracondylar humerus fracture, Kirschner wires, paediatric fractures.

Clavicle fractures--is there a standard treatment?

Clavicle fractures, especially of the mid third, are an injury commonly seen in clinical practice, therefore, there is constant earnest discussion of the optimal approach to therapy. Until recently clavicle fractures were solely the domain of non surgical management. Even displaced fractures have been successfully managed without surgery. However, complications have been reported after non surgical treatment, the most frequent being post-traumatic shortening of the clavicle with varying functional consequences for the shoulder joint and range of arm motion as well as pseudarthrosis, especially after more severely displaced fractures. Recent studies have now shown that outcomes after non surgical management of displaced fractures or shortening of the clavicle are worse than had been previously assumed. Surgical techniques for the stable fixation of clavicle fractures have been improved and a wider selection of implants for osteosynthesis of these fractures has become available. Although there is widespread consensus that undisplaced or minimally displaced clavicle fractures respond well to non surgical management, optimal treatment of displaced fractures or severe shortening is under scrutiny with regard to both the basic choice between non surgical or surgical management and implant selection. According to current research findings, surgical management of displaced clavicle fractures has advantages and appears to be superior to non surgical management. Intramedullary nailing has proven suitable for simple straight fractures, and plate fixation for multifragmentary fractures.

Humerus shaft fractures - where are we today?

Humeral shaft fractures account for about 1-3% of all fractures. These fractures are regarded as the domain of non-surgical management. This is certainly still the contemporary view but there is an obvious trend towards surgical stabilization. Surgical treatment of humeral shaft fractures has nonetheless been greatly facilitated by the development of new implants. In particular, a new generation of nails that general permit immediate mobilization have become available for improved management of longitudinal and multi-segmental fractures. Retrograde and antegrade nails have advantages and disadvantages and selection procedure is often based on the distal or proximal location of the fracture. Plates also offer an alternative for certain indications and have advantages at the proximal and distal shaft in particular. If there is primary lesion of the radial nerve, exploration is not very advisable, but in the absence of remission exploration can be conducted after several months with the same degree of success. Since the published literature offers no comparative studies with a high level of evidence, our statement can only be regarded as an up-to-date recommendation in the hope that future prospective randomized studies will address this issue.

Clinical outcome after surgical treatment of transitional fractures of the distal tibia in children

PURPOSE OF THE STUDY

Fractures affecting a partially closed physis are described as transitional fractures. The distal tibia is one of the most common locations for transitional fractures second only to the distal radius. Aim of this retrospective study was to evaluate the clinical and radiological results after surgical treatment of transitional fractures of the distal tibia.

PATIENTS AND METHODS

From May 2003 to March 2009 24 children (median age 14 years) received surgical treatment for transitional fractures of the distal tibia. 89% (21/24) of patients were followed up after 27.5 (range 6 to 72) months to assess functional out come (using the AO Foot and Ankle Score).

RESULTS

Nine girls and 15 boys were included in the study with the girls being younger on average (12.4 ± 0.9 vs. 14.3 ± 1.1 years, p = 0.00013). Two-plane fractures were present in 4 cases, 15 and 5 children sustained tri-plane I and II fractures, respectively. Median preoperative fracture displacement was measured at 4 mm (range 3 to 11 mm). Traumatic supination of the ankle joint during sports activities was the predominant injury mechanism (18/24 cases) followed by bicycle or motorbike accidents (6/24). A satisfactory reduction (1 mm or less) was achieved in all but one patient. In this case revision surgery was necessary to restore anatomical reduction. No perioperative complications occurred in the remaining 23 cases. Metal implants were removed upon fracture consolidation after 8.2 ± 6.7 months. At the time of follow-up none of the children were impaired in activities of daily living and there were no restrictions in sporting activity. All patients sco- red good or excellent results on the AO Foot and Ankle Score.

DISCUSSION

Surgical stabilization can be recommended as a safe and effective treatment strategy in displaced transitional fractures of the distal tibia and will lead to good or excellent mid term results.

Injury patterns in polytraumatized children and consequences for the emergency room management

INTRODUCTION

The effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of com- mon injury patterns, incidence, mortality, and consequences. The needed initial radiological imaging remains controversial and should be adapted to the expected injury pattern.

PATIENTS AND METHODS

In this retrospective study, the injury patterns of 56 polytraumatized paediatric patients (age ≤ 16 years) in the period from December 2001 to May 2009 were evaluated. All children were initially diagnosed with a whole body CT scan. The cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. The AIS (Abbreviated Injury Scale) and ISS (Injury Severity Score) were used to classify the severity of injuries in different body regions. Moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated.

RESULTS

The mean ISS was 30 ± 13 in 38 boys and 18 girls with a mean age of 10 years. The lethality was 13% and 4% in the first 24 hours. The most severe and most frequent injury was craniocerebral trauma in 89% with an AIS ≥ 3 in 80%. Surgical intervention of the head was done in 41%. Thorax injuries were found in 63% with 57% with an AIS ≥ 3 and in 11% a thoracic drainage was needed. Abdominal trauma was found in 34% (surgery 4%) with an AIS ≥ 3 in 32%. Fractures of the spine occurred in 14% (surgery 5%) with an AIS ≥ 3 in 4% and pelvic injuries were diagnosed in 16% (surgery 4%) with an AIS ≥ 3 in 14%. Injuries of the upper extremity were found in 23% (surgery 11%) with an AIS ? 3 in 5% and of the lower extremity in 32% (surge- ry 16%) with an AIS ≥ 3 in 13%.

CONCLUSION

The authors recommend a whole body CT scan in children who are potentially polytraumatized because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery. The quickest imaging with a high sensitivity is the whole body CT scan which provides the clinicians with relevant information to initiate life-saving therapy.

[Monteggia lesions in children--a clinical trial]

BACKGROUND

The Monteggia lesion is a rare injury of the elbow in children. This lesion is defined as a shaft fracture of the ulna combined with a luxation of the radial head. The primary problem in this injury is the proper diagnosis because the misalignment of the radial head is often missed. The purpose of this study was to retrospectively analyse the results after Monteggia lesions in children.

PATIENTS AND METHODS

Ten children between two and nine years of age (six boys and four girls) were clinically assessed using the Morrey score. They were treated in our department between December 1999 and October 2004.

RESULTS

The Morrey score after 54 months (min.: 26/max.: 84) had a median value of 100 points with 100 being the maximum (min.: 95/max.: 100). We found two complications, a combined lesion of the radial and ulnar nerves which completely recovered after six months. In one case a k-wire dislocated, which was removed earlier.

DISCUSSION

If the Monteggia lesion in children is correctly diagnosed and treated early enough, only good and very good results may be expected. After delayed diagnosis and treatment, the clinical results are not as good or even very poor.

[Stump forming after traumatic foot amputation of a child--description of a new surgical procedure and literature review of lawnmower accidents]

AIM

Amputation injuries in children occur in motor vehicle, farming and, importantly, lawn mower accidents. Treatment of lawn mower related injuries is complicated by gross wound contamination, avascular tissue, soft tissue defects and exposed bone. Many treatment options exist and often an adequate prosthetic supply is needed for rehabilitation. We report on an 8-year old boy who got under a ride-on lawn mower and sustained a subtotal amputation of his right foot. After initial surgery an amputation was subsequently necessary. For this, it had to be taken into account that the traumatic loss of the talus, calcaneus and parts of the cuboid bone would result in a length shortening of the right leg and so far not injured metatarsal and tarsal bones had to be sacrificed. Thus, we aimed to develop a new operation technique to optimize stump length as well as preserve tarsal bones and the possibility of limb growth.

METHOD

In order to achieve this, we performed a new stump forming operation in which we integrated uninjured tarsal and metatarsal bones. First a Lisfranc's amputation was performed and a metatarsal bone was kept aside. The talus, calcaneus as well as the cuboid bone were either completely or almost completely destroyed and were removed. The remaining cuneiform bones were transfixed by a notched metatarsal bone, thus achieving a tarsal arthrodesis, and the cartilages of the proximal joint surfaces were removed. The cartilage of the cranial and caudal navicular as well as the distal tibial joint surface was also removed and an arthrodesis between the distal tibia and the navicular bone was achieved by crossed Kirschner wires. Finally the cuneiform bones were placed inferior to the navicular bone. Further stump coverage was managed by skin and muscle flaps as well as split skin graft.

RESULT

Our patient was discharged on day 34. A fluent gait without crutches as well as sports activities were possible again as early as 6 1/2 months after the injury.

CONCLUSION

Using our stump forming technique we hope to prevent some complications of amputation injuries. Because of the intact epiphysis a bone overgrowth is hopefully prevented and growth potential is preserved and by inclusion of tarsal and metatarsal bones in the stump formation a length discrepancy is minimized.

[The percutaneous bone biopsy: in vitro study for comparison of bone biopsy needles]

PURPOSE

The aim of this study was to assess the differences in ease of use and quality of samples of several bone biopsy needles in an animal test.

MATERIALS AND METHODS

An evaluation of eight bone biopsy needles of different gauges was undertaken. With each needle, 5 biopsies of an animal bone (lumbal vertebral body of calf, pig and lamb) were performed and compared to each other. The subjective assessment of force to obtain a sample, ease of needle use and ease of sample removal were graded on a 5-point scale. Each biopsy specimen was measured before and after fixation and the gross state was evaluated. For evaluation of histopathological quality, width and degree of fragmentation were also evaluated on a scale.

RESULTS

The Somatex, Bone Marrow and Safe Cut 8 G and the Cardinal Health, Jamshidi 8 G needles were rated as being the easiest ones to use, while the Bloodline, Easy Trap 8 G and the RADI, Bonopty 15 G biopsy needles were rated as being the most difficult ones. Histological specimen quality was highest for the Somatex 8 G needles, the Cardinal Health, Jamshidi 8 G and the Bloodline, Easy Trap 8 G needles. The Inter.V, SnareLok 8 G and the RADI, Bonopty 15 G needles had the lowest yield. Furthermore, differences in length before and after fixation were recorded. The average decrease of core length after fixation was 18 %.

CONCLUSION

The bone biopsy needles tested here vary significantly in performance and quality of the histopathological specimen. Detailed knowledge of the strengths and weaknesses of different needles could facilitate the decision for the selection of an appropriate instrument.

Stabilisation of articular fractures of the distal humerus: early experience with a novel perpendicular plate system

INTRODUCTION

The treatment of fractures of the distal humerus is difficult and involves the risk of bad functional results, particularly with articular fractures or impaired bone quality. Anatomical reconstruction and stable fixation allowing early mobilisation of the elbow are the basic prerequisites for good clinical outcomes. The aim of our study was to evaluate whether the Distal Humerus Plate (DHP, Synthes), a novel, perpendicular, fixed-angle plate system, fulfils the requirements for this treatment goal.

METHODS

From 2004 to 2007, 46 consecutive patients (19 men and 21 women; mean age of 60.5 years) underwent open reduction and internal fixation with the new DHP system. Six patients were lost to follow up. The remaining 40 patients were followed up for 11 months (range 4-24 months). Follow up involved assessment of functional outcome using the Mayo Elbow Performance Score (MEPS) and Liverpool Elbow Score (LES), reduction results and complication rates. Subgroup analyses involved comparisons of younger (<60 years) to elderly (> or =60 years) patients and type C3 injuries versus other fracture patterns.

RESULTS

Only six cases received primary internal fixation, whilst 31 patients were temporarily stabilised by either external fixation or cast before ORIF could be performed. Three patients were treated for implant failure (systems other than DHP) after surgery in other hospitals. The mean time from injury to internal fixation was 7 days. Open fractures were present in 10 cases. Olecranon osteotomy was required for reduction in 35 cases. Mean operation time was 215 min. 'Good' or 'excellent' results were observed in 29/40 patients. Median MEPS and LES were 84 and 8.1 points, respectively. Mean ROM was 100 degrees. We found no significant differences in the subgroup analyses; however, there was a tendency towards better functional results in younger patients and injuries without comminution of the articular surface. Complications comprised two superficial wound infections, two cases of heterotopic ossification, one case of delayed union and five cases of transient ulnar neuropathy. Implant failure was observed twice in one patient.

CONCLUSION

Open reduction and internal fixation with the DHP system provides reliable, stable fixation allowing early functional mobilisation of the elbow joint, even in complex fractures and impaired bone quality, resulting in good outcomes for the majority of patients. The complication rate reported here is comparable to that of other implants, but the low number of implant failures is promising and warrants further investigation.

Proximal humerus fractures - current treatment options

Proximal humerus fractures represent an increasing challenge for the health system due to epidemiological changes. As estimated by a Finnish study group the number of fractures may triple by the year 2030. The majority of patients with these fractures are older than 60 years and in this population most of the proximal humerus fractures have been related to osteoporosis. Nondisplaced fractures and fractures with minimal displacement and adequate stability are usually successfully treated non-operatively. The main challenge in the operative treatment of displaced and unstable proximal humerus fractures is to achieve effective stabilization of an adequately reduced fracture to maximize the functional patient outcome. Especially in osteoporotic bone and comminuted fractures operative stabilization is challenging and the management of displaced and unstable fractures remains controversial. The most important factor for favourable results in the treatment of complex three-part or four-part humerus fractures is anatomic reduction. Minimal exposure, high primary stability, and load transfer through the implant are important for avoiding complications such as secondary dislocation, osteonecrosis, and stiffness. Recently invented implants with angular stability provide better biomechanical properties and enhanced anchorage especially in the osteoporotic bone. These implants therefore have a potential for achieving better results in the treatment of these complex injuries.

[Clinical evaluation of evidence-based criteria for CT diagnostics in the treatment of mild traumatic brain injury]

AIM

The mild traumatic brain injury (MTBI) is one of the most frequent diseases treated in emergency departments. Extensive studies addressing evidence-based treatment criteria have been published, the indication for CT scans depending on clinical symptoms appeared to be one of the critical issues. In this study, the question was raised whether or not the developed evidence-based criteria may be transferred to the patients of a German level 1 trauma centre.

PATIENTS AND METHODS

Within 2 years (2004/05) 1841 patients with a traumatic brain injury were treated, 1042 patients with a mild traumatic brain injury and with an age over 14 years were included in the study. The indication for a head CT scan was checked by criteria of a phase 3 study (New Orleans Criteria - NOC). Furthermore, the length of hospitalisation, number and character of secondary aggravation, and kind of inpatient care were analysed.

RESULTS

69.5 % of our patients were diagnosed with the help of a CT scan, according to the evidence criteria 98.8 % of the patients should have been scanned (p > 0.001). A secondary aggravation caused by a cerebral lesion was found in 3 patients without a CT scan, all of these patients would have been scanned according to the NOC (n. s.). The fraction of patients with alcohol intoxication reached 44 %, a rate that is significantly higher compared to other international studies. These patients were not as often scanned (p < 0.001) and had a shorter hospital stay (p < 0.001) compared to other patients. Duration of hospital stay was prolonged depending on the severity of the brain injury and occurrence of secondary aggravation (p < 0.001).

CONCLUSION

Summarising, the high sensitivity of the investigated evidence-based criteria (NOC) could be confirmed, but the application would not have led to a reduction of CT scans within our population.

[Management of ipsilateral femoral neck and shaft fractures]

PURPOSE

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

MATERIAL AND METHODS

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

RESULTS

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

CONCLUSION

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.

[What is the value of the whole body spiral CT in the primary radiological imaging of severely injured children?]

AIM

Whole body spiral CT scans have become a routine method in the radiological imaging of severely injured patients in emergency rooms of an increasing number of hospitals. The routine use of CT scans is, however, still discussed controversially, especially with regard to its use in children. This is mainly due to the reportedly higher level of exposure to radiation of CT scans as compared to plain radiographs. The aim of the present study was to compare the dose of exposure to radiation of a whole body CT scan to that of a plain radiograph protocol in an animal model for severely injured children.

MATERIAL AND METHODS

We chose 3 female pigs of different weights to serve as a model for children at different ages. 4 film radiation dosimeters (positioned on the eye, under the breast, paravertebrally on the thoracic spine and in the small pelvis, respectively) were implanted into every pig for each examination. Plain radiographs of the chest and the pelvis in one plane and of the skull and the complete spine in two planes were performed. The CT scan included skull, cervical spine and the whole body from the thorax to pelvis.

RESULTS

The radiation dose of CT scans was 7 times higher as compared to the X-ray protocol, but the performance of CT scans was faster (8 vs. 18 min). The radiation dose of the whole body CT scan was at about 15 mSv.

CONCLUSION

Based on our data and a review of the literature we will use whole body spiral CT scans as the preferred method in the primary radiological imaging of severely injured patients. In our opinion, the evident benefit of a reduced time of imaging in combination with superior image information outweighs the higher level of exposure to radiation.

[Emergency room management of contaminated patients]

Accidents with the risk of exposure to hazardous nuclear, biological, or chemical materials are rare. Most emergency rooms are not familiar with the management of contaminated patients after this kind of incident. There are also ambiguous cases concerning the contamination status of the patient. The medical attendance should be performed carefully and under special security arrangements until a hazard for third persons can be excluded. The security arrangements should protect both (medical) personnel and third persons. Early medical treatment combined with decontamination should be the aim. Based on the case of a contaminated patient who was brought to our emergency department after an explosion of a fog grenade with red phosphorus, we discuss our management concept and the current literature.

Locking plates in proximal humerus fractures

It is well known that proximal humerus fractures are among the three most frequent fracture types. Epidemiological invetsigations show that in people elder than 60 years the fracture of the proximal humerus is more frequent than fractures of the hip region (17). Over the last decades several techniques have been applied for treatment of proximal humerus fractures. Widely accepted is the initiation of a conservative treatment regimen for undisplaced fractures, however, the standard treatment for displaced fractures, especially three and four part fractures, is still the center of scientific debate. Many different implants have been tested and investigated, thus demonstrating lack of sufficient results. Over the last years the development of angle stable, locking implants started and clinical studies demonstrated encouraging results. In our clinic the locking proximal humerus plate and the PHILOS plate advanced to the implant of choice for treatment of displaced proximal humerus fractures. There are still cases of implant failure and humerus head necrosis, but most of these complications were caused by the fracture type and not an implant specific problem. However the overall results with these new implants are encouraging. Key words: locking plates, proximal humerus fracture, humerus, humerus fracture, PHILOS, PHP.

Ist die winkelstabile, palmare 3,5-mm-T-Platte die Lösung für dislozierte, distale Radiusfrakturen?

BACKGROUND

There are many different possibilities for the treatment of the distal radial fracture. According to evidence-based medicine there is no gold standard for the treatment of this fracture. With the development of locking plates, the spectrum of indications for plate osteosynthesis has possibly increased. The aim of our investigation was the evaluation of the clinical results after stabilisation of distal radial fractures with the locking, 3.5 mm T-LCP.

MATERIAL AND METHODS

In a retrospective study we analysed all patients with distal radial fractures treated with a 3.5 mm T-LCP between 05/02 and 05/04. The complete medical histories and X-rays were analysed and a clinical follow-up examination with the Martini score was performed.

RESULTS

76 from 93 patients (82%) could be examined for the follow-up, the average age was 59 years (17/88). According to the AO classification of Mueller and Nazarian we had 23 A-fractures, 7 B-fractures and 73 C-fractures. After reduction and plate osteosynthesis we found no secondary displacement. The median of the overall results according to the Martini score was 33 from 38 points (9/38). As far as complications were found 1 CRPS, 3 CTS, 2 pseudarthroses, 1 wound infection, 1 delayed bony union, 3 implant failures, and 1 broken plate (after a new injury). In one case the median nerve was cut during operation and a suture was performed.

CONCLUSION

According to our results the 3.5 mm T-LCP is a good implant for the stabilisation of displaced distal radius fractures if the fragments are not too small for the 3.5 mm screws. The anatomic reduction is maintained and the X-rays show very good results. Compared with other investigations we must ask ourselves if the benefit of the locking plates justifies its use as compared with non-locking (conventional) plates.

Seizure-induced muscle force can caused lumbar spine fracture

Patients suffering form epilepsy have an increased risk for fractures. Beside fractures caused by fall or accident muscles forces alone generated during tonic-clonic seizure can result in severe musculoskeletal injury. Contractions of strong paraspinal muscles can lead to compression fracture of the mid-thoracic spine. We report a patient who had suffered from a tonic-clonic seizure during early morning hours. After a cracking sound the patient woke up in a state of post-ictal disorientation, loss of urine and tongue bite. He was admitted to our facilities with the suspected vertebral fracture albeit he just reported of mild lower back pain. Native X-rays and computer-tomography scans showed instable burst fractures of L2 and L4. The fractures were stabilised with a dorsally instrumented internal fixator from L1 to L5 followed by hemi-laminectomy and ventral spondylodesis. Muscle force alone can result in severe skeletal trauma including vertebral fractures. This example emphasizes the importance of critical examination of patients after grand mal seizures. Seizures-induced injuries can appear clinically asymptomatic and can easily be overseen due to absence of trauma and post-ictal impairment of consciousness.

[Injuries of the cervical spine with Forestier's disease. Problems in the diagnostic and surgical management]

The incidence of diffuse idiopathic sceletal hyperostosis (DISH) is described in men more than 50 years old up to 25% and in women up to 15%. Even little trauma in patients with DISH often leads to injuries of the spine, especially the cervical spine. In many cases MRI is necessary to find the injury in this anatomically modified spine. It is often difficult to detect the injury by plane radiographs or even CT. Based on two cases of cervical spine fractures in patients with DISH we will describe the difficulties and specialities in the diagnostics and surgical treatment of injuries of the cervical spine in patients with DISH. In the one case we stabilized a patient with an odontoid fracture type Andersson II, the other case was a traumatic spondylolisthesis C4/C5. Both cases were treated operatively, the odontoid fracture was stabilized by a single screw, the spodylolisthesis by a ventral plate. If there are modifications in the spinal anatomy by degenerative diseases like DISH or spondylitis ankylosans, it is important to perform an intense search for injuries of the spine. In many cases MRI is indicated to detect the injury because plane radiographs and CT are not sensitive enough. For the planning of the operation it is important to meet concerns to the thick anterior longitudinal ligament and to use screws, that are long enough because the use of standard instruments is often not successful.

Halo-Fixateur - Indikationen und Komplikationen

Over the period between 06/00 and 03/03, 41 patients with different injuries of the upper cervical spine were treated by a halo fixator and were statistically recorded. The collective showed different injury patterns, 2 fractures of occiput condyles (5%), 3 Jefferson fractures (7%), 1 combined injury of the odontoid process and an atlas fracture (2%), 32 odontoid fractures (78%), 2 hanged-man-fractures Typ Effendi II (5%) and one case of pathologic fractures from the 2. to the 4. cervical vertebral body based on a plasmocytoma (2%). 31 of 41 patients could be examined for a follow up; 40 complete medical histories were well documented and could be analysed. As complications we had screw loosening in 6 cases (15%), a complete tear out of screws in 2 cases (5%). One patient took the halo away by himself two times, so after the second time surgical stabilisation was performed (2,5%). One case of intracranial penetration of a screw happened after the patient fell down in an accident with the halo (2,5%). Infection of the screw pins appeared in 4 cases (10%) and we had 2 cases of skin necrosis (5%). A second reduction after redisplacement was necessary in 8 cases (20%). 23 patients suffered from pain at the insertion of the screws (75%) and 18 patients complained of pressure in the head (58%). On the question of the comfort of this kind of therapy answered 18 patients with "intolerable" (58%), 10 patients with middle (32%) and 3 patients with tolerable (10%). Despite of the large number of different complications and the miscomfort of a halo fixator we think that there are still indications for treatment of special injuries of the upper cervical spine with a halo fixator. One important aspect is the lack of adequate alternatives even with regard to the biomechanical stability.

Spontaneous healing of pathologic humerus fracture caused by a cartilaginous tumor

Conservative treatment of pathologic fractures of the long bones have been reported very infrequently, especially when fracture is caused by an tumour. This report highlights the possibility of an nonoperative treatment of a pathologic humerus fracture caused by an cartilaginous tumour with radiographic criterions of an chondrosarcoma.

Mittelfußverletzungen im Kindesalter

Midfoot injuries of children are rare entities and often caused by high energy trauma mechanisms. Foot fractures in children may pose a diagnostic challenge but they usually have a good prognosis. In special cases computed tomography is necessary to find the right diagnosis in addition to plain X-rays. Based on two cases of midfoot injuries, a type II open Lisfranc fracture dislocation and a dislocation of a Chopart's joint, we describe the causes, diagnosis, and possibilities for treatment of juvenile midfoot injuries.

[The AO/ASIF Flexnail : A flexible intramedullary nail for the treatment of humeral shaft fractures]

BACKGROUND

The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation.

METHOD

Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score.

RESULTS

Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome.

CONCLUSION

We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.

[Congenital radial head dislocation on both sides]

Both traumatic and congenital dislocation of the radial head are very rare in childhood. It can sometimes be difficult to tell them apart in practice. In this paper therefore, we present one case and discuss the various aspects of both conditions with reference to the available literature. Traumatic dislocation of the radial head is generally easily reduced without open surgery, and an open procedure is virtually never indicated in a patient who is still growing. In contrast, specific treatment of congenital radial head dislocation is not necessary because most patients are free of pain.

[Diagnosis and treatment of the Essex-Lopresti lesion. Literature review and four case reports]

BACKGROUND

A fracture of the radial head in combination with a rupture of the interosseous membrane and lesion of the distal radioulnar joint known as Essex-Lopresti lesion is a rare injury. Usually it is caused by a high-energy trauma. Initially unrecognized distal radioulnar dislocations often show poor results.

MATERIAL AND METHOD

Four case reports are presented to discuss the trauma mechanism together with diagnostic and treatment options. Especially the accuracy of ultrasound to diagnose an interosseous membrane disruption was evaluated.

RESULTS

After an average of 35 months all patients were examined using the Morrey score and the modified score of Green and O'Brien. Initially the extent of the injury was not diagnosed in three cases. According to the score values the average results have been fair.

CONCLUSIONS

An early diagnosis is the key for the correct treatment of an Essex-Lopresti lesion based on the classification of Edwards and Jupiter. In addition to the clinical and radiological assessment ultrasound should be used to diminish the rate of unrecognized interosseous membrane disruptions.