[Malpractice in the treatment of diaphyseal fractures in children - experience of the Arbitration Office of the Northern German Medical Boards]. / Fehler bei der Behandlung diaphysärer Frakturen der langen Röhrenknochen bei Kindern - Erfahrungen der norddeutschen Schlichtungsstelle.

BACKGROUND: Statistics of the Arbitration Office of the North German Medical Boards for extrajudicial claim resolution show that nearly 30 % of all panel proceedings confirm medical malpractice. In proceedings concerning fractures in children the percentage rises to 63 % with significant differences in various fracture localisations. METHODS: Between 2000 and 2011 the Arbitration Office dealt with 272 panel proceedings regarding the fracture treatment in children. In this study 83 proceedings concerning the treatment of diaphyseal fractures of the long bones are evaluated. RESULTS: The claims were related to the following specialities (p = number of proceedings, m = number of malpractices): orthopaedics/traumatology p = 46, m = 38; general surgery p = 17, m = 21; paediatric surgery p = 16, m = 13; anaesthesia p = 1, m = 1; general practitioner p = 2, m = 2. In 7 cases concerning obstetrics (4) and paediatrics (3) no malpractices could be established. In 5 cases two facilities/doctors were included in the same proceeding. On 17 occasions, 2 errors were made that were unrelated to each other. The overall frequency of malpractice was 69 % with no significant differences between the involved facilities. The diaphyseal fracture locations were: humerus p = 5, m = 2; radius and/or ulna (Monteggia fractures excluded): p = 29, m = 20; femur p = 29, m = 20; tibia (with or without fracture of the fibula): p = 20, m = 14. In conservative fracture treatment the following negligent adverse events were confirmed: severe skin lesions owing to either plaster extension or removal of the cast (11), omitted or insufficient reduction followed by consolidation in intolerable malposition (8), no inducement of corrective measures after consolidation in intolerable displacement (11). Following malpractices in the surgical treatment were classified as: no indication for surgical treatment (2), no osteosynthesis in spite of clear indication (3), technical failures in primary osteosynthesis (16), technical failures in repeated osteosynthesis (4), aspiration pneumonia due to missed intubation (1). The applied methods of osteosynthesis were intramedullary nailing, mainly ESIN p = 24, m = 12; plate p = 24, m = 5; fixateur externe p = 7, m = 5. The results of maltreated diaphyseal fractures were altogether moderate: transitional impairment due to delayed or repeated therapeutic measures with prolonged fracture healing, no functional loss 70 %, slight deformation of the forearm, minimal loss of mobility 21 %, remarkable deformation of the forearm with considerable impairment of mobility, especially pronation/supination, deformation of the radio-ulno-carpal joint unit 7 %. DISCUSSION: There are three main categories in the maltreatment of diaphyseal fractures: 1) Omission of fracture reduction with or without internal stabilisation in cases of relevant axial deviation by unjustified expectation of "spontaneous correction". 2) Omission of fracture reduction in cases of unmotivated or neglected secondary displacement. 3) Technical failures in performing of osteosynthesis resulting in instability or the creation of intolerable malposition requiring re-osteosynthesis. The high number of plate osteosyntheses in our series (44 %) is not representative for the general treatment of children's fractures in Germany. Most cases of plate osteosynthesis are related to corrective measures with clear indication. In nine casuistic representations the errors in treatment are explained. CONCLUSION: The evaluation of malpractice in the treatment of diaphyseal fractures in children confirms the consensus: correct assessment of fracture type, early adequate treatment and fracture control, early corrective measures after insufficient primary reduction or secondary dislocation, lead to fracture healing without any anatomic or functional deficiency. Reverse argument: fracture healing leading to anatomic and/or functional loss gives a very probable indication of malpractice.

[Malpractice in the treatment of fractures and dislocations of the elbow joint in children--experience of the arbitration office of the North German Medical Boards]. / Schlichtungsverfahren bei Kindern mit Frakturen und Luxationen des Ellenbogengelenks--Erfahrungen der norddeutschen Schlichtungsstelle.

BACKGROUND: Statistics of the arbitration office of the North German Medical Boards show that 30% of all panel proceedings confirm medical malpractices. In panel proceedings concerning the treatment of fractures in children, the percentage rose to 60% with significant differences in the individual fracture localisations. METHODS: Between the years 2000 and 2010, the arbitration office dealt with 257 panel proceedings regarding the fracture treatment of children. This study evaluates the decisions of 53 proceedings concerning the treatment of fractures and dislocations of the elbow joint. RESULTS: All cases except one concerned the following surgical specialities: 1. orthopaedics/traumatology, n = 14; 2. general surgery, n = 13; 3. paediatric surgery, n = 5. On 7 occasions 2 treatment facilities were involved in the same proceeding. The following types of fractures/dislocations were present (each with the number of proceedings [p] and the confirmed malpractices [m]): fracture of the radial humeral condyle and transcondylar Y-fractures, p = 12, m = 11; fracture of the ulnar epicondyle, p = 2, m = 2; sole dislocation of the radial head as well as in combination with Monteggia lesion, p = 19, m = 17; displaced fracture of the radial head and radial neck, respectively, p = 8, m = 4; fractures of the olecranon, p = 3, m = 2; fracture of the coronoid processus, p = 1, m = 1; dislocations and dislocation fractures of the elbow joint without Monteggia lesion, p = 8, m = 5. DISCUSSION: 42 of these cases (79 %) confirmed malpractice of which 27 (64%) resulted in permanent restriction of the elbow joint mobility. Due to the diversity of injuries, the types of treatment errors were also very variable. In most cases the treatment errors were initiated through the false interpretation of X-ray findings which resulted in false and inadequate therapy measures, for example, the overlooked and not reduced dislocation of the radial head. Three transcondylar Y-fractures were missed on both the X-ray findings and during the operation. In cases where the dislocation of the radial head was not diagnosed in the first instance but operated on within four months (n = 3), a satisfactory result was still achieved. However, if the operation took place at a later time (in our cases 9 months to 8 years after the injury, n = 14) there was no improvement achieved and in many cases the elbow joint mobility deteriorated significantly. In three cases of dislocation of the elbow joint, an intraarticular entrapment of the disjointed ulnar epicondyle was overlooked and therefore not corrected which resulted in deleterious effects on the joint movement. There were five cases with a dislocation combined with a displaced fracture of the radial neck (Mason IV). This fracture was insufficiently reduced/stabilised on two occasions and in one instance the reconstruction of the disrupted joint ligaments was not carried out which resulted in permanent instability of the elbow joint and subluxation. In five casuistic representations the final decision of the arbitration board on the basis of expert reports is illustrated. CONCLUSION: From a traumatological point of view, the elbow region of a child constitutes a distinct problem zone due to the rarity and diversity of the fractures and dislocations in this area. Relevant experiences in diagnostics and therapy of injuries in this region cannot always be expected. Every doctor who happens to come across a case in which a child suffers from such injuries should be responsible for the timely referral to a treatment facility that has the relevant experience to treat such cases.

[Malpractice in the treatment of supracondylar humeral fractures in children - experience of the arbitration office of the Northern German Medical Boards]. / Fehler bei der Behandlung suprakondylärer Humerusfrakturen bei Kindern - Erfahrungen der Norddeutschen Schlichtungsstelle.

INTRODUCTION: Arbitration offices ("Schlichtungsstellen") in Germany are expert panels for the extrajudicial resolution of malpractice claims. The performance of arbitration panel proceedings ("Schlichtungsverfahren") is based on the German medical and insurance jurisdiction. In Germany, and in the United States likewise, malpractice claims involving children concern in most cases fracture treatment followed by appendicitis. Out of 242 panel proceedings with the background of fracture treatment in children malpractice was confirmed in 144 cases (60%). The overall ratio: number of confirmed malpractices to number of all proceedings is 30%. There are remarkable differences between the natural occurrence of the different fracture localisations and the fracture localisation related claims. This ratio amounts for example: clavicula 7 : 1, forearm 2 : 1, femur 1 : 5, elbow region (articular) 1 : 5, humerus supracondylar 1 : 3. METHOD: 32 arbitration panel proceedings concerning alleged malpractice in the treatment of supracondylar humeral fractures in children were evaluated in regards to diagnosis of fracture type and degree of dislocation, conservative and operative fracture treatment, complications, and malpractice related permanent disabilities. RESULTS: In 20 cases (63%) malpractice was confirmed. The different failures could be classified in: 1) Incorrect interpretation of the X-ray findings, classified as fractures without or with minimal displacement, no reduction, healing with intolerable dislocation; n = 3. 2) Insufficient closed or open fracture reduction, stabilisation and healing with intolerable dislocation; n = 10. 3) Correct primary closed or open reduction, unstable osteosynthesis (loss of pin fixation of the ulnar epicondylus), secondary postoperative rotatory dislocation, cubitus varus; n = 3. 4) Delayed detection of a compartment syndrome of the forearm, no or delayed fasciotomy; n = 3, in two cases resulting in severe Volkmann's contracture. 5) Extensive skin necrosis caused by uncontrolled tourniquet under operation. All malunited fractures, except one, led to cubitus varus, often combined with a restriction (extension/flexion) of the mobility of the elbow joint. No cubitus valgus was found in our series. In eight cases a cubitus varus was treated by valgus osteotomy later on. In other cases this procedure was planned. Adverse events which could not be proven as caused by malpractice, included fracture consolidation in minimal tolerable displacement, n = 3; delayed recurrence of the normal mobility of the elbow joint, n = 2; traumatic cubitus varus caused by primary damage of the humero-ulnar epiphysis, n = 3; pin track infection, n = 1; nerve injuries, n = 10. The concomitant nerve injuries concerned: n. medianus 3, n. ulnaris 2, n. radialis 1, nn. radialis and ulnaris 3, nn. medianus and ulnaris 1. In all these cases the claim was based only or together with other reproaches on the nerve injury, but in no case could a malpractice be confirmed. However it should be mentioned that in some cases a iatrogenic nerve injury could not be excluded definitively. Therefore we always recommend the exploration and documentation of the function of the arm nerves at admittance and immediately after treatment. The applied methods of osteosynthesis were pin fixation, crossed or unilateral radial, n = 30; radial screw, n = 1; elastic stable intramedullary nailing fixation (ESIN), n = 1; fixateur externe (reoperation), n = 1. In no case the method of osteosynthesis was proven as inapplicable or as the cause for the adverse event. Permanent disabilities were considered to be slight in 12 cases (deficient mobility of the elbow joint) and severe in two cases (Volkmann's contracture). Physiotherapy was not found to be beneficial for the restitution of normal mobility of the elbow joint after supracondylar fracture. In at least 7 cases painful physiotherapy was applied, although the X-ray films clearly demonstrated the displaced fracture as the cause of the restricted mobility. In 5 casuistic representations of adverse events after treatment of a supracondylar humeral fracture, the final decision of the arbitration board on the basis of expert reports is illustrated. CONCLUSION: The results are discussed in order to avoid mistakes in the treatment of supracondylar humeral fracture in children. The appropriate treatment requires exact assessment of the degree and direction of the fracture dislocation, clear definition of the cases in which active treatment, i.e. closed or open reduction and stabilisation, is obligatory, and experience in the operative treatment. A beginning compartment syndrome of the forearm should be detected early by the initial symptoms and immediately treated by fasciotomy.

[Malpractice in the diagnosis and treatment of the slipped capital femoral epiphysis]. / Fehler bei der Diagnostik und Behandlung der Epiphyseolysis capitis femoris.

INTRODUCTION: Expert commissions (Gutachterkommissionen) and arbitration offices (Schlichtungsstellen) in Germany are expert panels for the extrajudical resolution of malpractice claims. The performance of arbitration panel proceedings ("Schlichtungsverfahren") is based on the German medical and insurance jurisdiction. METHOD: 39 arbitration panel proceedings concerning supposed malpractice in the diagnosis and treatment of slipped capital femoral epiphysis were evaluated in regard to the involved clinics and physicians and, respectively, the medical specialties, type of slippage (acute or chronic), malpractice and the disabilities caused by malpractice. RESULTS: In 28 cases (72 %) the malpractice was confirmed, the average of confirmed failures in all proceedings being about 30 %. The failures could be classified as misdiagnosis followed by inadequate treatment and failures in operative treatment. Minor and moderate permanent disabilities due to malpractice remained in 8 cases, severe permanent disability resulted in 14 cases due to osteonecrosis of the femoral head. DISCUSSION: The results are discussed with regard to the avoidance of mistakes in diagnosis and treatment and the problems of medical assessment.

[Humeral shaft fracture in childhood]. / Die Oberarmschaftfraktur im Kindesalter.

In a collective study of twelve surgical clinics 222 diaphyseal fractures of the humerus in children were examined. 159 children were checked up two to 14 years after the accident. Priority was given to conservative treatment: Désault or Gilchrist dressing (24%), arm cast (34%), extension (29%), change from primary extension to secondary dressing or cast (27%), osteosynthesis (10%). Late results were excellent in 85%, whereas in 15% minor anatomical lesions persisted, such as axial deviations, but without functional impairment. There were eight transitory primary nerve lesions (3.6%), seven concerning the radial nerve, one the ulnar nerve. The individual therapeutic procedure depends on the age of the child and on the pattern of the fracture. Operative treatment is indicated in open fractures, in cases of polytraumatism, and in fractures with uncontrolled major axial deviation.

[Treatment of Monteggia fracture in children]. / Die Behandlung der Monteggia-Fraktur beim Kind.

Described in this paper is a therapeutic concept by which to cope with Monteggia's fracture in childhood. It is based on experience obtained from 72 cases with injuries of that kind and their evaluation in a group study. Therapeutic approach to the individual case was determined by the following criteria: age of infant, localisation and shape of ulnar fracture, reducibility of capitulum radii, and accompanying injuries requiring treatment on the same arm. The need for surgical stabilisation of ulnar fracture was found to increase along with growing age of the affected child. High-stability anatomic reduction of the ulnar fracture proved to be a prerequisite for safe stabilisation of the radial capitulum. Close reduction has proved to be sufficient in many instances. Open reduction and internal fixation were found to be necessary in cases in which an ulnar fracture was irreducible or instable and/or a radial head was not reducible. Minimal osteosynthesis and plaster cast is considered to be an optional therapy for younger children, whereas ulnar stabilisation by means of plates is preferred for children in somewhat advanced age of childhood. The radial head may be fixed by trans-articular Kirschner's wire (WITT) or primary reconstruction of the annular ligament, using a strip of biceps or triceps tendon, or adaptation around the collum radii and ulna of the proximal radio-ulnar joint by means of a sling of Dexon or Vicryl suture.

[Monteggia fracture in childhood]. / Die Monteggiafraktur im Kindesalter.

In a collective study the late results of 72 Monteggia fractures in children are presented. Early and sufficient treatment achieved excellent results in all these cases. The misdiagnosed dislocation of the radial head was the only cause of unsatisfactory outcome. Persistent dislocation of the radial head however did not lead to major functional impairment of the elbow in most cases. A therapy related classification of the Monteggia fracture is recommended, which includes 1. age, 2. Ulna fracture: reducible or irreducible, stable or unstable retention, 3. radial head dislocation: reducible or irreducible, stable or unstable retention, 4. additional lesions at the same arm.

[Isolated dislocation of the radius head in childhood]. / Die isolierte Luxation des Radiusköpfchens im Kindesalter.

In a collective study 24 isolated dislocations of the radial head in children were analysed. Early diagnosis was made in only 13 cases, delayed diagnosis in 11 cases one week to 18 months after the injury. Closed reduction was impossible in all cases of delayed diagnosis. Early detection of the lesion led to excellent late results without exception. The final results after operative treatment of the 11 children with delayed diagnosis were good in only two cases, 6 were poor and 3 were unsatisfactory. The functional lesions after delayed treatment were caused by persistent dislocation or subluxation, deformity of the radial head, and humeroradial arthrosis.

[Physical therapy within the scope of fracture treatment in children. Recommendations of the Traumatology in Childhood Study Group]. / Physiotherapie im Rahmen der Frakturbehandlung bei Kindern. Empfehlungen der Arbeitsgemeinschaft für Traumatologie des Kindesalters.

Physiotherapeutic follow-up treatment is required only in exceptional cases of fractures in childhood. Physiotherapeutic indications are justified for fractures with months of immobilisation, multiple fractures, fractures accompanied by soft-tissue defects and nerve injuries, vertebral fractures, fractures and craniocerebral trauma, and fractures entailing the risk of bone necrosis. Passive exercises are not at all indicated.

[Therapy of vesicoureterorenal reflux in childhood--report of 10 years' experience with Lich-Gregoir antireflux-plasty]. / Zur Therapie des vesikoureterorenalen Refluxes im Kindesalter--10-Jahre-Erfahrungsbericht mit der Antirefluxplastik nach Lich-Gregoir.

In a ten years period 186 extravesical antireflux operations (Lich-Gregoir) were performed in 145 children. Indications, surgical technique, postoperative complications, reflux recurrence, and pyelonephritis are described and discussed with regard to the literature. In 66 children followed up for more than 4 years there were 6 cases (9%) with persisting pyelonephritis. No postoperative ostium stenosis occurred. The authors prefer the extravesical approach because of its relative easy operative technique, its safety in removing the reflux, and the avoidance of operative manipulations at the ostium, which may cause postoperative ostium stenosis.

[Selective proximal vagotomy in stenosing and penetrating duodenal ulcer]. / Die selektiv-proximale Vagotomie beim stenosierenden und penetrierenden Ulcus duodeni.

In duodenal ulcer with complete pyloric stenosis selective proximal vagotomy in connection with either pyloric dilatation or duodenoplasty is generally indicated. Pyloroplasty may still be considered as an acceptable alternative drainage procedure. In high risk patients with pyloric stenosis, especially in the very old, truncular vagotomy with an adequate drainage is the operation of choice because of its low operative trauma. Penetrating ulcers are treated by selective proximal vagotomy only. Postoperative pyloric stenosis occurs rarely and should be managed by secondary pyloroplasty or pyloric dilatation.

[Revision operations following vagotomy]. / Revisionsoperationen nach Vagotomie.

Recurrent duodenal ulceration after highly selective vagotomy is best managed by antral gastric resection and gastroduodenostomy (BI). In cases of gastral localisation of the recurrent ulcer and in cases with high postoperative acidity a 2/3 partial gastrectomy (BI) should be performed. Revagotomy after highly selective vagotomy is not feasable in most cases. Pyloric stenosis after highly selective vagotomy occurs in about a percentage of 2 and can be easily corrected by secondary pyloroplasty or duodenoplasty. In very rare cases of severe postvagotomy dumping and postvagotomy diarrhoea the interposition of an antiperistaltic jejunal segment can be practised. Persisting postvagotomy dysphagia may require pneumatic dilatation of the cardia or operative revision of the oesophago-cardiac region. A case of ulcerocancer in a pyloric ulcer primarily treated by truncal vagotomy and pyloroplasty is reported.

[Late results of osteosynthesis in forearm fractures in childhood (author's transl)]. / Spätergebnisse nach Osteosynthesen von Unterarmschaftfrakturen im Kindesalter.

This is a collective study of 16 surgical clinics of the GDR, undertaken to evaluate the results of osteosynthesis in forearm fractures in childhood. Out of 401 patients who underwent surgery 327 (81.6%) could be followed up. In 86% there were good results and bad ones in only 4.4%. The causes of failure were analysed.