[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]. / Die Behandlung der proximalen Humerusfraktur im Kindes- und im Jugendalter : Konsensusbericht der Sektion Kindertraumatologie der DGU.

BACKGROUND: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature. METHODOLOGY: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this. RESULTS: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X­ray images in 2 planes (true AP and Y­images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X­ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks). CONCLUSION: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Proximal humeral fractures in children - controversies in decision making.

BACKGROUND: Proximal humeral fractures in children are rare and usually treated non-operatively, especially in children younger than ten. The decision between operative and non-operative treatment is mostly based on age and fracture angulation. In the current literature, diverging recommendations regarding fracture angulation that is still tolerable for non-operative treatment can be found. Besides, there is no consensus on how fracture angulation should be determined. This study aimed to determine whether leading experts in pediatric trauma surgery in Germany showed agreement concerning the measurement of fracture angulation, deciding between operative and non-operative treatment, and choosing a treatment modality. METHODS: Twenty radiographs showing a proximal humeral fracture and the patient's age were assessed twice by twenty-two senior members of the "Section of Pediatric Traumatology of the German Association for Trauma Surgery". Experts determined the fracture angulation and chose between several operative and non-operative treatment modalities. The mean of individual standard deviations was calculated to estimate the accuracy of single measurements for fracture angulation. Besides Intra-Class Correlation and Fleiss' Kappa coefficients were determined. RESULTS: For fracture angulation, experts showed moderate (ICC = 0.60) interobserver and excellent (ICC = 0.90) intraobserver agreement. For the treatment decision, there was fair (Kappa = 0.38) interobserver and substantial (Kappa = 0.77) intraobserver agreement. Finally, experts preferred ESIN over K-wires for operative and a Gilchrist over a Cuff/Collar for non-operative treatment. CONCLUSIONS: Firstly, there is a need for consensus among experts on how fracture angulation in PHFs in children should be reliably determined. Our data indicate that choosing one method everybody agrees to use could be more helpful than using the most sophisticated. However, the overall importance of fracture angulation should also be critically discussed. Finally, experts should agree on treatment algorithms that could translate into guidelines to standardize the care and perform reliable outcome studies. LEVEL OF EVIDENCE: III.

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.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study.

OBJECTIVES: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy. MATERIALS AND METHODS: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years). RESULTS: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92). CONCLUSIONS: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. / Bildgebung bei Kindern und Jugendlichen intraoperativ, bei ausgewählten Frakturen und im Verlauf nach konservativer und operativer Behandlung : Teil 2 der Ergebnisse einer bundesweiten Online-Umfrage der Sektion Kindertraumatologie der Deutschen Gesellschaft für Unfallchirurgie.

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair. METHODS: An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons. RESULTS: Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks. DISCUSSION: The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed. CONCLUSION: Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

[Imaging after trauma in clinics and practice for children and adolescents : Part 1 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. / Bildgebung nach Unfall in Klinik und Praxis bei Kindern und Jugendlichen : Teil 1 der Ergebnisse einer bundesweiten Online-Umfrage der Sektion Kindertraumatologie der Deutschen Gesellschaft für Unfallchirurgie.

BACKGROUND: The indication for radiography should strictly follow the ALARA (as low as reasonably achievable) principle in pediatric and adolescent trauma patients. The effect of radiation on the growing sensitive tissue of these patients should not be disregarded. QUESTION: The Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) wanted to clarify how the principle is followed in trauma care. METHODS: An online survey was open for 10 weeks. Target groups were trauma surgeons, pediatric surgeons, general surgeons, and orthopedic surgeons. RESULTS: From Nov. 15, 2019, to Feb. 29, 2020, 788 physicians participated: branch office 20.56%, MVZ 4.31%, hospital 75.13%; resident 16.62%, senior 38.07%, chief 22.59%. By specialist qualification, the distribution was: 38.34% surgery, 33.16% trauma surgery, 36.66% special trauma surgery, 70.34% orthopedics and trauma surgery, 18.78% pediatric surgery. Frequency of contact with fractures in the above age group was reported as 37% < 10/month, 27% < 20/M, 36% > 20/M. About 52% always request radiographs in 2 planes after acute trauma. X-ray of the opposite side for unclear findings was rejected by 70%. 23% use sonography regularly in fracture diagnosis. In polytrauma children and adolescents, whole-body CT is never used in 18%, rarely in 50%, and standard in 14%. DISCUSSION: The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. CONCLUSION: Comparing the results of the survey with the consensus findings of the SKT recently published in this journal, persuasion is still needed to change the use of radiography in primary diagnosis.

[Successful laparoscopic robot-assisted surgical treatment of bilateral ureterosciatic hernias (Lindbom's hernia) and pelvic kidney]. / Erfolgreiche laparoskopische roboterassistierte operative Therapie bei beidseitigen ureteroischialen Hernien (Lindbom's Hernie) und Beckenniere.

Ureterosciaic hernia is a rarely described pathology that represents a diagnostic and therapeutic challenge for the treating physician. In this case report, we present a patient with symptomatic bilateral ureteroschial hernias and a pelvic kidney on the left. The definitive surgical treatment of the hernias was performed in the robotic-assisted laparoscopic technique.This is the second case describing bilateral intestinal sciatic hernia, in combination with its diagnosis and robotic surgical repair.In this paper we present the fourth known case of a robotic approach to the surgical treatment of ureterosciaic hernia with detailed presentation of diagnostic and therapeutic measures, as well as postoperative results and literature research on this rare pathology.

Greenstick fractures of the proximal metaphyseal tibia: a retrospective multicenter study on the outcome after non-surgical or surgical treatment and the occurrence of posttraumatic tibia valga.

PURPOSE: This study investigates the occurrence of (progressive) posttraumatic valgus deformity after proximal metaphyseal greenstick fractures of the tibia in young children, and whether non-surgical or surgical treatment influences the outcome. METHODS: A retrospective multi-center study was conducted including surveys and X-rays of patients < 12 years of age with a fracture of the proximal tibia. In patients with greenstick fractures, the medial proximal tibia angle (MPTA; defined as the angle of the tibial axis and the joint-line of the knee) was measured at trauma, short-term follow-up (st-FU), and long-term FU (lt-FU) as defined for the 2 groups of non-surgically and surgically treated patients. RESULTS: Of a total of 322 fractures, 91 were greenstick fractures. Of these, 74 were treated non-surgically and 17 were treated surgically. The mean MPTA at trauma of non-surgically treated patients was 91.14°, and of surgically treated patients was 95.59° (p = 0.020). The MPTA in non-surgically treated patients significantly increased from the timepoint of trauma to st-FU (92,0°; p = 0.030), and lt-FU (92,66°, p = 0.016). In surgically treated patients, the MTPA improved after trauma to st-FU (94.00°; p = 0.290), and increased again to lt-FU (96.41°; p = 0.618). CONCLUSION: Progressive valgus deformity after greenstick fractures of the proximal tibia occurred in both non-surgically and surgically treated patients. In non-surgically treated patients, this was of statistical, but not clinical significance. In surgically treated patients, progressive valgus was observed after metal removal for an unknown reason. Therefore, surgery for proximal greenstick fractures of the tibia in this age group has only limited effect and may be indicated only in selected cases. Further studies are needed to explain the responsible mechanisms. LEVEL OF EVIDENCE: III, retrospective analysis.

[Clavicle shaft fractures in childhood and adolescence : Consensus report of the Pediatric Traumatology Section of the German Society for Trauma Surgery]. / Claviculaschaftfrakturen im Kindes- und Jugendalter : Konsensusreport der Sektion Kindertraumatologie in der Deutschen Gesellschaft für Unfallchirurgie.

INTRODUCTION: Clavicle shaft fractures are among the most common fractures in childhood and adolescence. In the past they were almost exclusively treated conservatively but in recent years there has been an increase in surgical treatment. Nevertheless, exact recommendations for the choice of diagnostics and for the treatment regimen do not yet exist. MATERIAL AND METHODS: Therefore, our aim was to develop a consensus within the 7th scientific working meeting of the section for pediatric traumatology in the German Society for Trauma Surgery based on expert opinion. RESULTS: Single-plane radiographic imaging is considered the gold standard diagnostic tool. Children younger than 10 years are primarily treated conservatively, and the type of immobilization is secondary. In girls older than 12 years and boys older than 14 years, fractures dislocated by more than the shaft width and shortened by > 2 cm should be treated by open reduction and stabilized by osteosynthesis, followed by free-functional follow-up treatment. CONCLUSION: In addition to X­rays, diagnostics using ultrasound must be further established. Treatment continues to be primarily conservative, but surgical treatment is also important, especially in adolescents. If the indications are correct, a good outcome can be expected regardless of the choice of treatment.

Management of juvenile and aneurysmal bone cysts: a systematic literature review with meta-analysis.

PURPOSE: Numerous approaches to the management of juvenile and aneurysmal bone cysts (ABC) are described in the specialist literature together with discussion of the associated healing and recurrence rates. Since there is currently no evidence-based treatment standard for these conditions, the aim of this systematic literature review with meta-analysis was to examine the different management approaches, evaluate the corresponding clinical outcomes and, as appropriate, to formulate a valid treatment recommendation. METHODS: A systematic search on OVID Medline® based on a pre-existing search strategy returned 1333 publications. Having defined inclusion and exclusion criteria and analysis of the relevant full texts, 167 publications were included in the descriptive analysis and 163 in the meta-analysis. For this purpose, different subgroups were created, based on the type of cyst and the therapeutic procedure. Those subgroups were then analysed in relation to their healing rates, the number of recurrences and complication rates. RESULTS: For aneurysmal bone cysts, both surgical removal and Doxycycline injection lead to excellent outcomes (98% healing) and low recurrence rates (6% and 11% resp.). Curettage (91% healing), including its combination with autologous cancellous bone graft (96% healing), showed very good healing rates but higher recurrence rates (22% and 15%, resp.), which were however improved by preoperative selective arterial embolization. A critical view must be taken of radiotherapy (90% healing) and the injection of alcohol (92% healing) because of their high complication rates (0.43/cyst and 0.42/cyst, resp.). In the management of juvenile bone cysts, surgical interventions like curettage and cancellous bone graft (87% healing) are far superior to non-surgical approaches (51% healing), furthermore, the application of autologous cancellous bone graft reduced the recurrence rate (3% recurrence) compared to curettage alone (20% recurrence). In subgroup analysis, treatment by ESIN was found to produce excellent outcomes (100% healing), though the patient collectives were small. CONCLUSION: Surgical procedures to treat aneurysmal bone cysts appear to be the method of choice whereby Doxycycline injection may be an alternative. A surgical approach should be preferred in the treatment of juvenile bone cysts.

The Impact of Anatomical Predisposition and Mechanism of Trauma on Dislocation of the Patella: A Retrospective Analysis of 104 Cases.

BACKGROUND: The aim of this study was to determine whether traumatic dislocation of the patella is provoked by the presence of predisposing factors and examine the role of the mechanism of injury. METHODS: Cases diagnosed with dislocation of the patella and covered by the workers' compensation program were identified and classified as traumatic based on insurance regulations. We examined predisposing factors (e.g., frontal axis, torsional deviation, trochlear dysplasia, patella alta) in case groups based on age at dislocation and trauma mechanism. Retrospective cohort study, level of evidence III. RESULTS: Our sample size comprised 104 cases, consisting of 54 children and 50 adults. The most common mechanism of injury in children and adults was rotational trauma. Only 20% of the children and 21% of the adults exhibited no relevant predisposing factors. Group specifically, falls accounted for the highest number of cases exhibiting none of the defined anatomical predisposing factors. Children are more frequently affected by predisposition-related dislocations than adults. CONCLUSION: The proportion of predispositions is high. A fall, direct impact, or rotational trauma can be viewed as an adequate mechanism of trauma. For successful treatment, it is paramount to analyze the exact mechanism of the trauma and address any underlying predispositions.

[X-ray diagnostics of fractures in childhood and adolescence-Consensus report of the scientific working group of the pediatric traumatology section of the German Society for Trauma Surgery (DGU)]. / Röntgendiagnostik bei Frakturen im Kindes- und Jugendalter ­ Konsensusbericht des Wissenschaftlichen Arbeitskreises der Sektion Kindertraumatologie der DGU.

For decades projection radiography has been the standard in the diagnostics of fractures and injuries, including patients in childhood and adolescent; however, each examination with X­rays should also be based on an individual assessment of the benefits and risks. The pediatric traumatology section of the DGU has developed a consensus paper on various aspects of imaging for diagnostics and assessment of progression, on setting options for intraoperative imaging, on X­ray imaging of the opposite side, on polytrauma and computed tomography (CT), on postoperative radiological checks and the use of sonography after an accident.

[U-shaped fractures of the sacrum-what is the correct treatment? : A presentation of three cases]. / U-Frakturen des Os sacrum ­ Wie therapiert man richtig? : Eine Präsentation dreier Fälle.

BACKGROUND: Sacral U­shaped fractures are rare but severe injuries. Due to the resulting spinopelvic dissociation they are highly unstable. Reduction and stabilization are usually required and decompression may be necessary due to frequent concomitant neurological injuries. In the literature there is no consensus with respect to the selection of the surgical approach. CASE PRESENTATIONS: After a road traffic accident an 18-year-old woman suffered a U-fracture of the sacrum type II according to Roy-Camille and was treated with bilateral double sacroiliac screw osteosynthesis and sacral laminectomy. A 76-year-old man with a U­fracture type I according to Roy-Camille after falling down the stairs was treated by lumbopelvic fixation. A 24-year-old man with U­fracture type II according to Roy Camille after a road accident was treated with triangular vertebropelvic stabilization and sacral laminectomy. For all patients the outcome was good. CONCLUSION: Surgical treatment is necessary, with minimally invasive techniques offering advantages over open surgery. A distinction must be made between lumbopelvic fixation and posterior pelvic ring fixation. Multiple aspects must be taken into consideration of the indications when selecting the surgical technique.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist. OBJECTIVE: The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients. MATERIAL AND METHODS: Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process. RESULTS: Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients. CONCLUSION: Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures.

BACKGROUND AND PURPOSE: Unstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate. PATIENTS AND METHODS: The analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n = 957 with vs n = 4,542 without). Furthermore, the subgroups with secondary surgery (n = 713 vs n = 1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n = 24 vs n = 219). Calculated odds ratios were adjusted for potential confounders. RESULTS: Patients treated by CC/EF were younger (45 ± 20 vs 62 ± 24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3 mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p < 0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02-1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06-20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation. INTERPRETATION: Primary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use.

Pelvic fractures in severely injured children: Results from the TraumaRegister DGU.

Injuries in the pelvic region in children and adolescents are very rare and often associated with a high energy trauma. Aim of this prospective multicenter study was, by analyzing the data from the TraumaRegister Deutsche Gesellschaft für Unfallchirurgie (TR-DGU), to evaluate any correlation between the severity of pelvic fractures and resulting mortality in different age groups.These study findings are based on a large pool of data retrieved from the prospectively-setup pelvic trauma registry established by the German Trauma Society (DGU) and the German Section of the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) International in 1991. The registry provides data on all patients suffering pelvic fractures within a 14-year time frame at any 1 of the 23 level 1 trauma centers contributing to the registry. The analysis covers 4 age groups ranging from 0 to 17 years, covering different factors regarding pelvic fractures and their treatment.We identified a total of 9684 patients including 1433 pelvic fractures in children aged ≤17 years. Those patients were divided into 4 subgroups according to the patients' age (groups A-D) and according to the fracture severity (group 1 =  Abbreviated Injury Scale (AIS) score pelvis ≤2, and group 2 = AIS pelvis ≥3). The mortality in group 1 was 8.8% with a RISC (Revised Injury Severity Score) II of 8.6%, standard mortality rate (SMR) of 1.02 and 7.2% in group 2 with an RISC II of 9.9% (SMR 0.73). In pelvic factures of Type A (Tile classification of pelvic fractures), an SMR of 0.76 was recorded, in Type B fractures the SMR was 0.65, and in Type C fractures 0.79. Severe pelvic injuries (AIS pelvis ≥2) were associated with a higher rate of whole body computer tomograph (CT) scans (1-5 years: 80%, 6-10 years 81.8%, 11-14 years 84.7%, and 15-17 years 85.6%). The rate of pelvic surgery rose with the pelvic injury's severity (AIS 2: 7.6%, AIS 3: 35%, AIS 4: 65.6%, AIS 5 61.5%). We observed higher rates of preclinical and initial clinical hypotension defined as Riva-Rocci (RR) <90 mmHG) as well as of preclinical fluid application in all age groups. The presence of a pelvic injury was associated with a higher rate of severe abdominal injuries with an AIS of ≥3 (25.1% vs. 14.6%) and of severe thorax injuries with an AIS≥3 (43.6% vs. 28.6%).We have been able to analyze an enormous number of pelvic fractures in children and adolescents including different age groups by relying on data from the TR-DGU. Mortality seems to be associated with the severity of the pelvic injury, but is lower than the RISC II score's prognosis.

Efficacy of Thoracolumbar Bracing in Spinal Immobilization: Precise Assessment of Gross, Intersegmental, and Segmental Spinal Motion Restriction by a 3D Kinematic System.

BACKGROUND: Various diseases of the spine are treated by immobilization via orthoses, although detailed evidence on the efficiency of orthotic bracing remains elusive. The present study sought to investigate the impact of 3 different orthoses on spinal immobilization using 3-dimensional (3D) kinematic measurements. METHODS: Twelve healthy volunteers performed different motion tasks, including trunk flexion/extension and bilateral trunk bending. Movements were performed under 4 different conditions: 1) without orthosis, 2) while wearing a 3-point hyperextension brace (HB), 3) while wearing a custom-made semirigid orthosis (SO), and 4) while wearing a custom-made rigid orthosis (RO). Spinal motion was analyzed using a 3D optical motion capture system assessing regional, intersegmental, and segmental range of motion (ROM). RESULTS: Assessment of spinal motion was successfully accomplished in all subjects. Overall, orthoses significantly reduced spinal motion compared with no bracing. RO caused the greatest restriction of regional, intersegmental, and segmental spinal motion among all orthoses. For flexion/extension, the mean percentage decreases between T3 and L5 in full active ROM with HB, SO, and RO compared with no orthosis were 38%/30%, 48%/47%, and 51%/55%, respectively (P ≤ 0.05). Lateral bending was impaired by 28%, 44%, and 70%, respectively (P ≤ 0.05). Assessment of lateral bending revealed greater immobilization by SO and RO compared with HB (P ≤ 0.05). CONCLUSIONS: The present 3D kinematic system allows for precise assessment of spinal motion. Custom-made orthoses cause superior restriction on gross spinal motion compared "off-the-shelf" orthoses. If orthotic bracing is indicated, design, comfort, and patient compliance need to be carefully considered to guarantee successful therapy.

[Differences in the outcome of seriously injured children depending on treatment level]. / Unterschiede im Outcome schwerverletzter Kinder in Abhängigkeit von der Versorgungsstufe.

INTRODUCTION: Many publications, mainly from other countries, suggest that the treatment of seriously injured children might be better in specialised paediatric trauma centres than in general trauma centres. Data from Germany are not available yet, but those from abroad were used for the recommendations made by the German Association for Trauma Surgery (DGU) on the topic of paediatric trauma in the "White Paper on Trauma Care". The goal of this study was to analyse whether the outcome of severely injured children is dependent on treatment level and on the availability of a paediatric surgeon based on the given data. MATERIALS AND METHODS: Data from the "TraumaRegister DGU" between 2002 and 2012 were used. Children aged 1-15 years treated during the period 2002-2012 were included. Severity had to reach a minimum Injury Severity Score (ISS) of 9 and the treatment had to involve a stay at an Intensive Care Unit. Patients with an ISS ≥9 who died were also included to take into consideration children with particularly severe injuries. RESULTS: Hospitals without a paediatric surgeon transferred the patients significantly more frequently (p < 0.001). Mean hospital stay was shorter in centres with a paediatric surgeon, with slightly longer median stays at an Intensive Care Unit. Hospitals without a paediatric surgeon performed slightly more frequent surgical interventions on injured children (barely significant at p = 0.045). The death rate and the calculated Revised Injury Severity Classification (RISC) II prognosis were the same with or without the presence of a paediatric surgeon. No difference was found in the Glasgow Outcome Score (GOS) between the group with and the group without involvement of a paediatric surgeon. DISCUSSION: Overall, the medical care of seriously injured and polytraumatised children in Germany is good at all levels of treatment whether a paediatric surgeon is involved or not.

Classification and Outcome of Fracture-Dislocation of the Cuneiform Bones.

Fractures and dislocations of the cuneiform bones are rare injuries to the midtarsal foot. The injury severity is often unclear, and the prognostic factors are unknown. The purpose of the present study was to characterize our insights of the diagnostics, therapy, and fracture patterns. We questioned whether the number of involved cuneiform bones and the type of injury would affect the clinical outcome. With this information, we aimed to develop a classification system for injuries of the cuneonavicular joint. Five patients who had sustained complex fracture-dislocation of the cuneiform bones were prospectively registered, underwent surgery, and were followed. We reviewed the published data and found 47 reports that included 55 patients to improve the informative value of our study. The injury mechanisms and therapy were evaluated, and the postoperative limitations and pain were assessed. The clinical outcome was correlated with the number of involved cuneiforms and the fracture/dislocation pattern. Direct trauma was associated with isolated fracture, and indirect injury was associated with isolated dislocations. Occasionally, these injuries were overlooked on conventional radiographs, and closed reduction frequently failed. The number of cuneiform bones involved and the type of injury were shown to affect the clinical outcome. We devised an easily applicable classification system for injuries to the cuneiform bones using this information. All cases were classified as isolated fractures (1), isolated dislocations (2), or fracture-dislocations (3) involving 1 (A), 2 (B), or 3 (C) cuneiform bones. The classification system we propose will facilitate a better understanding of the fracture patterns at the cuneonavicular joint line and is a good prognostic tool that requires validation in clinical settings.

Proximal humeral fracture treatment in adults.

Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.