[Elastic, stable intramedullary nailing of pertrochanteric femoral fractures in children (<6-8 years)]. / Elastisch-stabile intramedulläre Nagelung pertrochantärer Femurfrakturen im Kleinkindesalter (<6 bis 8 Jahre).

OBJECTIVE: Minimally invasive, sufficiently stable for movement and partial weight bearing, osteosythesis of pertrochanteric femoral fractures in children < 6-8 years using elastic, stable intramedullary nailing (ESIN). INDICATIONS: Proximal, pertrochanteric femoral fractures Delbet type IV in children < 6 years. CONTRAINDICATIONS: Comminuted fractures, femoral neck fractures. SURGICAL TECHNIQUE: By inserting three elastic titanium nails (TEN), prebent in the proximal third, retrograde into the femur, a stable 3­point support stabilizes the proximal fragment. For further improvement of stability, EndCaps can be used. POSTOPERATIVE MANAGEMENT: Partial weight bearing (sole-contact) for 4-5 weeks. X­ray controls immediately after surgery and after 4-5 weeks. No sports for 3 months. RESULTS: In our patient population we have good experience with this technique for very rare pertrochanteric fractures in children younger than 6-8 years. With minimally invasive access, exercise-stable administration can be achieved without a pelvic leg cast.

Instability of the hip after anatomical re-alignment in patients with a slipped capital femoral epiphysis.

AIMS: Several studies have reported the safety and efficacy of subcapital re-alignment for patients with slipped capital femoral epiphysis (SCFE) using surgical dislocation of the hip and an extended retinacular flap. Instability of the hip and dislocation as a consequence of this surgery has only recently gained attention. We discuss this problem with some illustrative cases. MATERIALS AND METHODS: We explored the literature on the possible pathophysiological causes and surgical steps associated with the risk of post-operative instability and articular damage. In addition, we describe supplementary steps that could be used to avoid these problems. RESULTS: The causes of instability may be divided into three main groups: the first includes causes directly related to SCFE (acetabular labral damage, severe abrasion of the acetabular cartilage, flattening of the acetabular roof and a bell-shaped deformity of the epiphysis); the second, causes not related to the SCFE (acetabular orientation and poor quality of the soft tissues); the third, causes directly related to the surgery (capsulotomy, division of the ligamentum teres, shortening of the femoral neck, pelvi-trochanteric impingement, previous proximal femoral osteotomy and post-operative positioning of the leg). CONCLUSION: We present examples drawn from our clinical practice, as well as possible ways of reducing the risks of these complications, and of correcting them if they happen. Cite this article: Bone Joint J 2017;99-B:16-21.

[Rotation or derotation osteotomy of the tibia]. / Rotations- oder Derotationsosteotomie der Tibia.

OBJECTIVE: Corrections for congenital or posttraumatic malrotation of the lower leg, considering alignment of the contralateral leg, with an osteotomy and fixation using locking compression plates (LCP). INDICATIONS: Posttraumatic deformity due to malunion. Increased tibial torsion in residual clubfoot deformity as long as the foot has been realigned. Idiopathic internal or external rotational deformity if the child is regularly tripping and falling, has psychological problems (other children making fun of the child because of the unusual gait), or is bothered by the deformity (age > 10 years, relative indication). CONTRAINDICATIONS: Rotational deformities at other levels, mainly the hip. Children under the age of 3 years due to the remodeling potential during growth. SURGICAL TECHNIQUE: Osteotomy at supramalleolar level and fixation with 3.5 mm 90° locking plate. Perpendicular osteotomy at the intersection of midshaft to distal shaft. After achieving the desired correction, fixation by a straight four-hole 3.5-mm locking plate. POSTOPERATIVE MANAGEMENT: Following fixation of the osteotomy with the four hole 3.5 mm LCP, a lower leg cast is recommended for 4-5 weeks. Applying the 3.5 mm 90° LCP allows immediate postoperative full weight bearing. Osteotomy material should be removed 1 year postoperatively. RESULTS: Assuming an uneventful postoperative course, consolidation of the fracture can be expected within 4-6 weeks. The stable fixation with locking plates provides stability without loss of correction at follow-up.

[Proximal Femoral Osteotomies with the Paediatric Hip Plate (LCP): Valgus osteotomy]. / Osteotomien am proximalen Femur mit der winkelstabilen kindlichen Hüftplatte (LCP): Valgusosteotomie.

OBJECTIVE: Proximal femoral osteotomy with stable fixation and sufficient correction. Low complication rates due to exact preoperative planning. INDICATIONS: Congenital or traumatic femoral neck pseudarthrosis. Coxa vara. CONTRAINDICATIONS: None. In severe deformities, a single femoral osteotomy may not solve the problem; thus, additional correction, e.g., a pelvic osteotomy, is required. SURGICAL TECHNIQUE: Correct planning of the correction angle. Lateral approach. Subperiosteal detachment of vastus lateralis muscle. Place guide wire on the femoral neck to judge anteversion. Insert positioning wire 5 mm distal to trochanteric physis. Insert 2.8 mm Kirschner wire in the femoral neck. Osteotomy of the femur after marking the rotation by Kirschner wires or oscillating saw. Slide LC plate over Kirschner wires. Replace Kirschner wires with screws. Reduction of the femoral shaft to the plate with bone forceps. Definitive fixation of the plate to the femoral shaft by cortex or locking screws. Readaptation of vastus lateralis muscle over the plate. POSTOPERATIVE MANAGEMENT: Partial weightbearing for 4-6 weeks depending on the age of the patient without any external fixation (e. g. cast) is possible. RESULTS: Recent studies support the authors' findings of sufficient correction and stable fixation after proximal femoral osteotomy with the LCP pediatric hip plate. Low complication rates and stable fixation.

[Acetabulum injuries in infancy and childhood]. / Acetabulumverletzungen im Kleinkindes--und Kindesalter.

In this article, the anatomical and morphological features of the acetabulum in infancy and childhood are presented. The pathology and treatment of older children and adolescents is deliberately not covered, because the fracture morphology and treatment of patients aged 13 to 15 years is based on the criteria of adult medicine. Especially in the younger child, the anatomical differences are of particular importance. The younger the child is, the more difficult the diagnosis. Therefore today, MRI examinations should be generous used, even if anesthesia is necessary. If the injured child is hemodynamic stable, anesthesia can be electively used for a more complex diagnosis. Acetabular fractures are particularly problematic in infancy because even with optimal treatment and perfect reduction growth disturbances can occur. These manifest as so-called secondary dysplasia. During treatment, care should be taken to ensure that a surgical team having experience with the infant and juvenile skeleton is available and that appropriate implants are available.

Clinical evaluation of end caps in elastic stable intramedullary nailing of femoral and tibial shaft fractures in children.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) may be complicated by the loss of reduction following push out of the nails at the entry site in unstable femoral and tibial fractures, especially in older and heavier children and following technical failures. An end cap system addressing this complication was evaluated clinically. METHODS: In a retrospective case series, 49 femoral and five tibial fractures in 54 pediatric patients treated by ESIN and end caps were documented in two European tertiary centers. End caps were used to interlock standard ESIN nails. The results were evaluated regarding difficulties in the placement and removal of the end cap system, fracture stability and healing, and return to normal activities by analyzing patient charts and X-rays. RESULTS: Fifty-three of 54 fractures were stabilized sufficiently with ESIN and end caps. Loss of reduction was observed in one patient, requiring additional surgery. Six complications were observed, five of which were not related to end caps. There were no significant leg length differences or varus/valgus deformities. A rotational difference of >10°-20° was found in one patient. Removal of the end caps and nails was rated as simple and uncomplicated in 35/37 cases. CONCLUSIONS: End caps avoided postoperative instability in the majority of pediatric patients with lower limb shaft fractures, even in heavier, older patients and those with instable fracture types. End caps, however, will not compensate for operative technical insufficiency concerning reduction or nail placement. To maximize the stability of ESIN-instrumented unstable fractures, end caps require properly placed nails.

Greenstick fractures of the middle third of the forearm. A prospective multi-centre study.

BACKGROUND: Greenstick fractures suffered during growth have a high risk for refracture and posttraumatic deformity, particularly at the forearm diaphysis. The use of a preemptive completion of the fracture by manipulation of the concave cortex is controversial and data supporting this approach are few. AIM: Aim of this study was to determine the factors which predispose to refracture and deformities, and to define therapeutic strategies. METHODS: We prospectively gathered clinical and radiographic data over a period of one year on greenstick fractures of the middle third of the forearm in children as part of a multi-centre study. Endpoint was a follow-up visit at one year. Radiographic deformity, state of consolidation at resumption of physical activities and refracture rate were analysed statistically (ANOVA, Student's t-test and Pearson's chi-square test) with regard to patient age, gender, fracture type, therapy and time in plaster. RESULTS: We collected the data of 103 patients (63 boys, 40 girls), average age 6.6 years (1.3-14.5 years), the vast majority of whom had a combined greenstick fracture of the radius and ulna. 6.7% of the patients sustained a refracture within 49 days (29-76) after plaster removal. They were significantly older (p=0.017) with a significantly higher incidence of manual completion of the fracture with radiographic signs of partial consolidation (p=0.025). Residual deformities were significantly smaller after completion of the fracture compared to reduction without completion (p=0.019) or plaster fixation alone (p<0.005). CONCLUSIONS: Completion of a greenstick fracture does not prevent refracture. Nevertheless, it diminishes the extent of secondary deformities in cases where the primary angulation exceeds the remodelling capacity. Prevention of refracture should include a routine radiographic follow-up 4-6 weeks after injury with continuation of plaster fixation in cases of partial consolidation.

ChronOS inject in children with benign bone lesions--does it increase the healing rate?

OBJECTIVE: Benign bone lesions in children although rare, can result in a pathological fracture. Although their etiology and pathogenesis are not yet entirely clear, the phenomenon of spontaneous healing is well known. Nevertheless, some benign bone lesions are unlikely to heal spontaneously due to the patient's age or high risk of fracture and deformity due to the lesion's location or size. The following study presents our results after treatment of these bone cysts with chronOS Inject. METHODS: From June 2004 to May 2007 23 patients with 24 benign bone cysts were treated with chronOS Inject, an injectable tricalcium phosphate, using a minimally invasive technique at two pediatric surgery departments. Postoperative follow-up examined bone healing, remodeling, chronOS Inject resorption and adverse effects. RESULTS: 15 males and 9 females, mean age 11 years at time of diagnosis, were treated with chronOS Inject. The humerus was affected 13 times, the femur 7 times, the tibia twice and the radius, the fibula and talus once each. Except for one case, all pathological fractures healed within five weeks post-injection. Two children had cystic residues. No severe adverse effects were seen. CONCLUSIONS: These preliminary results indicate that chronOS Inject could provide an alternative treatment for benign bone cysts that are unlikely to heal spontaneously due to the patient's age, high risk of instability or pathological fracture due to the lesion's size or location, or lesions that have already been treated several times using other methods without success.

[Bilateral post-traumatic acetabular dysplasia]. / Beidseitige posttraumatische pfannendysplasie.

Traumatic disruption of the acetabular triradiate cartilage is an infrequent injury. When it occurs in early childhood, it may lead to growth changes in acetabular morphology. The morphology of this kind of acetabular dysplasia is uniform and differs significantly from that seen in classic developmental dysplasia of the hip. We present a case of bilateral post-traumatic acetabular dysplasia, which to our knowledge has not been reported. The morphology and the symptoms of impingement and periacetabular osteotomy of the hip joint are discussed.

Report of an uncommon cluster of septic arthritis of the hip in premature newborns: three cases in a period of 3 months.

We report an uncommon cluster of this rare condition which occurred within a very short period of time in our unit. We reviewed the current literature and observed that the diagnosis is often delayed, which can have very serious consequences for the outcome. Our 3 patients have had an uncomplicated course so far and follow-up examination at almost one year was normal. A high index of suspicion for the diagnosis and early and aggressive treatment is necessary.

Quadruplication of the ureter in combination with a large ureteral cyst.

A newborn female was found to have a quadruplication of the ureter: four proximal, slim ureters opened into a large ureteral cyst and a distal monoureter opened into the bladder. Only five cases of ureteral quadruplication have been reported in the literature, one of which presented with identical pathology. These two cases may have been caused by similar, unidentified abnormal embryonic development.

Secondary radial head dislocation and dysplasia of the lateral condyle after elbow trauma in children.

We report five cases of a rare complication of childhood fractures of the elbow region. The complication consists of posttraumatic dissolution of the lateral humeral condyle followed by secondary radial head overgrowth and dislocation. The initial injuries ranged from displaced lateral condyle fractures (three patients) to a supracondylar fracture and an open elbow dislocation. Dysplasia of the lateral humeral condyle was first noted 1 to 4 years after the trauma (mean, 2.5 years) and seemed to be caused by removal of the displaced fracture fragment in one patient, and possibly by malfixation and repeated surgical procedures in the others. Because of loss of motion, ulnar nerve irritation, and cosmetic deformities, corrective osteotomies had to be performed in four patients and additional radial head removal in two patients.

Congenital pseudarthrosis of the ulna and radius in two cases of neurofibromatosis type 1.

Two children with neurofibromatosis type 1 who presented at birth with congenital pseudarthrosis of the ulna and radius are described. The patients were treated with broad resections. As a consequence, the forearms were reduced in length. The osteotomies were stabilized in one patient first with endomedullary nailing and then with a free vascularized fibular graft. In the second patient the osteotomy was stabilized by external fixation. Using these techniques, rapid and excellent healing and normal function were achieved. In contrast to the lower extremity, reduction of the length of the forearm can be accepted to a certain extent. If necessary, an extension osteotomy can be performed at a later date.

[Pseudoarthrosis in neurofibromatosis type 1]. / Pseudarthrose bei Neurofibromatose Typ 1.

Neurofibromatosis type 1 (NF1) is the most common neurocutaneous disease. The clinical manifestations are diverse. Some of the skeletal changes are most relevant to the patient. We report on 9 patients with NF1 who presented with typical pseudarthrosis. In 8 of these children the lower extremity was involved. In 2 cases lesions of both tibia and fibula were found, in one case even over long segments with a fully instable leg. One child had a complete pseudarthrosis of the radius and ulna. This report analyses the bony changes, the operations performed and the possible technical improvements to be made. The present study as well as other recent studies suggest that bony lesions should be operated early using microsurgical methods.

Growth disturbances after injuries of the proximal tibial epiphysis.

Proximal tibial epiphyseal fractures are very rare. Partial growth arrest of the physis can cause important axial malalignment in the frontal or the sagittal plane or both, with subsequent shift of the weight-bearing axis onto the injured compartment of the knee joint. To detect the exact extent of the deformity, comparative radiographs of the contralateral side in two planes using long films as well as standing whole leg orthoradiographs are desirable. Accurate measurements in our series of six patients revealed deformities in two, which required secondary surgical correction.

Tumoral calcinosis and atypical juvenile dermatomyositis: case report.

Tumoral calcinosis is a rare, benign calcification of soft tissues in periarticular areas. It can manifest as an isolated disease or as part of an underlying disorder. We report a case of a 6-year-old girl who presented with tumoral calcinosis of her left knee in association with atypical juvenile dermatomyositis. Finally, we discuss operative and non-operative treatment strategies of tumoral calcinosis in children and adults.

[Fractures near the femur head in children and adolescents]. / Femurkopfnahe Frakturen bei Kindern und Jugendlichen.

13 patients (1981-1991) between 1.5-15.5 years (average 10.2 years) with Delbet I-III fractures were analysed of the incidence of avascular necrosis. Only one (type II fracture) of our 13 patients was associated with a severe complication (Ratliff type I) of an avascular necrosis of the femoral head. This satisfactory result may be explained by our concept of immediate open reduction and minimal internal fixation of the displaced fractures.