[Posttraumatic growth disturbances of the distal radius in childhood]. / Posttraumatische Wachstumsstörungen am distalen Radius im Kindesalter.

BACKGROUND: Fractures of the distal radius in childhood are frequent but rarely lead to relevant growth disturbances. OBJECTIVE: The experiences of a pediatric trauma center over 15 years are exemplarily presented and discussed. MATERIAL AND METHODS: Osteotomies of the distal radius were selected and the clinical and radiological findings were recorded and analyzed. RESULTS: Posttraumatic growth disturbances were corrected in 10 cases with a median age of 13 ½ years. In six cases an iatrogenic cause was also possible. In two cases callus distraction with secondary palmar plate osteosynthesis was used for consolidation. In eight cases primary ad hoc corrections were carried out using palmar plate osteosynthesis (six with iliac crest and two with allogeneic grafts). In five cases the distal ulnar growth plate was also addressed. During follow-up breakage of one plate was registered. After an average of 31 months postoperatively, 9 children had full range of motion (ROM) and in 1 case there was an extension deficit of 10o. CONCLUSION: It is important to evaluate the cause of the mostly partially inhibiting growth disturbances to draw preventive conclusions. From a clinical perspective the visible deformity is given priority and the pain and functional limitations are less relevant. The indications for corrective surgery must include the age of the patient, remaining growth potential, size and localization of the growth plate bridge, the deformity and the individual wishes of patients and parents. In most cases a full correction is possible with palmar plate osteosynthesis and an iliac crest graft. External fixation and callus distraction is an alternative in cases where the correction is more extensive. The distal ulnar growth plate should be controlled concerning further growth potential before hardware removal.

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.

[Shaft fractures of the lower limb in adolescents]. / Frakturen im Schaftbereich der unteren Extremität bei Adoleszenten.

Shaft fractures of the lower extremities are rare during adolescence. Conservative treatment is no longer used for the upper leg and the significance is declining for the lower leg, as only minor axis deviations and malrotations of the shaft are acceptable and conservative therapy is associated with severe impairments in the daily routine; however, conservative treatment is still an option for femoral fractures in children < 3 years of age and for stable fractures of the lower leg. Various osteosynthesis procedures can be used depending on the body weight and epiphyseal maturation. Elastic stable intramedullary nailing is the first choice, followed by solid adolescent femoral or tibial nailing for higher body weights and external fixation for open or multifragmentary fractures. Plate osteosynthesis is an established alternative. Following correct surgical treatment, all fractures have movement and at least partial load-bearing stability and the results are satisfactory. Regular controls are recommended up to the end of the growth period.

[Diaphyseal and metaphyseal femoral fractures in childhood]. / Dia- und metaphysäre Femurfrakturen im Kindesalter.

Femoral fractures in childhood are rare and are usually the result of severe trauma. Conservative treatment (overhead extension, hip spica cast) can be used in children up to 3 years of age and beyond that elastic stable intramedullary nailing (ESIN) is the method of choice. The prognosis is very good if the surgical technique is adequate. In adolescents > 50 kg in body weight solid nails implanted via the greater trochanter are an alternative (adolescent lateral femoral nail, ALFN). External fixators and plate osteosynthesis are indicated in special situations. Femoral neck fractures are very seldom seen in this age group. Besides Kirschner (K)-wires and screw osteosynthesis a special pediatric hip plate is available in this situation. In the distal metaphysis mostly stable fractures occur in disabled children, which can usually be treated conservatively. In addition, pathological fractures occur in juvenile bone cysts and complex injuries in adolescents, which need stabilization by descending ESIN or with plates. At the distal growth plate relevant growth disturbances are possible.

Elastic stable intramedullary nailing (ESIN) of pediatric metacarpal fractures: experiences with 66 cases.

INTRODUCTION: Elastic stable intramedullary nailing (ESIN) is the first-choice surgical technique for stabilizing various pediatric diaphyseal and selected metaphyseal fractures of the long bones. This technique has increasingly been applied in fractures of the small bones. Here, we report experiences with ESIN in displaced fractures of the metacarpals in children. PATIENTS AND METHODS: Retrospective data analysis of metacarpal fractures in children stabilized by ESIN in three pediatric trauma centers between 2003 and 2009. Indication for intervention was total displacement or axial deviation >10 degrees in the frontal plane and/or >30 degrees in the sagittal view. RESULTS: A total of 66 cases of metacarpal fractures (51 right hand and 12 left hand) treated by ESIN were found in 63 children (mean age 13.3 years; range 4.0 to 16.1) over the study period. Of these, 55 fractures affected metacarpal 5, 6 fractures affected metacarpal 4, 3 fractures affected metacarpal 1, and 2 fractures occurred at metacarpal 2. Mean operating time was 21 minutes (range 5 to 54), titanium elastic nails were used with a diameter of 1.5 mm (n = 23), 2.0 mm (n = 42), and 2.5 mm (n = 1). Single ESIN implantation was performed in 63 cases; in 3 cases, two nails were implanted. Eleven patients received additional immobilization due to nondisplaced additional fractures of the phalanx (n = 2) or for analgetic treatment (n = 9). Five complications were registered (7.6%). In two cases recurrent fracture dislocation occurred, one of them requiring revision of the osteosynthesis. In other two cases irritation of the extensor tendons occurred, one of them requiring secondary tendon plasty. One persisting cutaneous hyposensibility after ESIN of a metacarpal 5 fracture was reported. All fractures healed uneventfully and metal removal was performed after a mean of 92 days (range 31 to 104). After a mean follow-up of 26 months (range 2 to 74), all patients had full range of movement and cosmetic results were described as good and satisfactory by all patients. CONCLUSION: ESIN of the metacarpals is a safe, minimally invasive, and technically easy option in displaced fractures that warrant surgical intervention achieving excellent long-term results. Complications occurred when technical aspects to obtain stability were neglected or tendons and nerves of the hand had been injured. Stabilizing fractures of metacarpal 1 is technically challenging when compared with fractures of metacarpals 2 to 5.

Delayed healing of forearm shaft fractures in children after intramedullary nailing.

BACKGROUND: In displaced and unstable forearm shaft fractures, elastic stable intramedullary nailing represents the current treatment of choice. Delayed healing has been observed in single cases, but the incidence of healing disturbances remains unclear. METHODS: Retrospective analysis of all patients with forearm shaft fractures and open epiphyseal plates, treated with elastic stable intramedullary nailing between 2000 and 2004 in 5 pediatric trauma units, was conducted. Evaluation of cases with insufficient consolidation 90 days after osteosynthesis was performed. RESULTS: Ten (1.9%) of 532 cases showed delayed healing. Mean age (12.3 years), part of open fractures (30%), and part of open reductions (60%) were clearly higher than in a nonselected collective; the ulna was concerned in 70%. One refracture, 1 local soft tissue infection, and 1 small sequestration were found. In 5 children, nails were extracted with (2x) or without (3x) local surgical intervention. In the other 5 children, the nails were left in place. All fractures healed within 13 months posttrauma without relevant functional restrictions. CONCLUSIONS: Delayed healing is possible especially in open fractures or open reduced fractures of the ulna in older children, but healing takes place up to 13 months. Therefore, no change of treatment principles is necessary. Protection of ulna periost has to remain in the center of surgical focus. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

[Osteosynthesis in proximal forearm fractures in children]. / Osteosynthesen am proximalen Unterarm im Kindesalter.

OBJECTIVE: Closed reduction and fixation of displaced proximal radial neck or ulnar fractures with elastic stable intramedullary nailing (ESIN); prevention of circulatory disturbances and functional deficits following open reduction. INDICATIONS: Proximal radial neck fractures > 45 degrees displacement (< 10 years of age) or > 20 degrees (> 10 years of age); proximal extraarticular ulnar fractures > 10 degrees malalignment; combination injuries (Monteggia fracture, Monteggia-equivalent injury). CONTRAINDICATIONS: Minimally displaced or undisplaced fractures. SURGICAL TECHNIQUE: Radius: distal implantation of the nail; touching and fixation of the proximal fragment with the tip of the nail, if need be following digital or percutaneous partial reduction (Kirschner wire); definitive reduction by torsion of the nail. Ulna: distal implantation of a prebent nail; the prebent curve is placed opposite to the malalignment. POSTOPERATIVE MANAGEMENT: Functional treatment, no additive immobilization, no physical therapy. RESULTS: 78-87% very good and good functional results.

State-of-the-art treatment of forearm shaft fractures.

As the treatment of pediatric forearm shaft fractures has changed extensively over the past 30 years, it is worth discussing the current treatment modalities in these fractures. The recommendations are based on an ongoing evaluation of treatment procedures, problems, complications, and final results going back to 1976. Between 1976 and 1985, the 95.9% of fractures that were treated conservatively were tainted with bad functional results because a significant proportion healed with malalignment. The introduction of elastic-stable intramedullary nailing (ESIN) initiated a definitive change and the opportunity to stabilize unstable fractures with a less invasive method. Apart from some technical problems, the functional results of ESIN are very satisfactory. The external fixator is a good treatment for open, comminuted, or special distal dia-metaphyseal fractures in older children and adolescents. Therefore, we currently have a variety of methods to treat forearm shaft fractures in children using primary definitive fracture care (PDFC). The differentiated use of conservative and surgical measures should minimize final functional sequelae. A well-tried algorithm for this fracture region is outlined.

What must we respect in articular fractures in childhood?

Articular fractures in children are rare and occur mainly in the elbow and ankle joint. Condylar fractures of the humerus, olecranon fractures, medial malleolar, and transitional fractures of the distal tibia are the commonest, though there is an increasing incidence of avulsion fractures of the intercondylar tibial eminence. Conservative treatment is recommended in articular displacements of less than 2 mm, but dislocation of more than 2 mm is a commonly accepted indication for surgery. Although this widely accepted guideline is based on clinical results, it is not scientifically proven. In addition, it is unknown whether there is any difference in the outcome for articular fractures if there is a step or gap, if the joint is weight-bearing or not, or the joint is immobilized or mobilized post-operatively. In experiments with rats, rabbits, and sheep, some clues have suggested that exact reconstruction of the chondral surface, fixation with compression of the fragments, and early continuous passive motion are advantageous. A prospective clinical study with a pre- and postoperative MRI scan is needed, in weight-bearing and non-weight bearing joints to show the factors influencing the outcome of these injuries.

Treatment decision, method of osteosynthesis, and outcome in radial neck fractures in children: a multicenter study.

To determine whether closed elastic-stable intramedullary nailing (ESIN) of radial neck fractures in children is accepted as standard procedure with satisfactory results, a prospective multicenter case collection study was conducted. Sixty-six cases from 12 departments were analyzed during 2 years. Thirty-six fractures of Judet 1 or 2 grade (54.5%) were treated without reduction; all of these fractures showed good to excellent results. Thirty fractures of grade 3 or 4 needed a closed (25 [37.9%]) or open reduction (5 [7.6%]), and 74% of them had good to excellent results. Osteosynthesis was carried out in 26 of the reduced fractures (23 ESIN, 3 Kirschner wire fixation). Using ESIN, 78% of the results were good to excellent. Seven children developed significant restrictions of pronation/supination, including three of the five open reduced fractures. ESIN has found wide acceptance, and the results are satisfactory. Restricted use of open interventions may be the key to improving results.