Comparison of the Reliability of Three Scoring Systems Used to Decide Whether to Apply Cement in Hip Arthroplasty Among Fracture Patients and the Effect of Surgical Experience: The Spotorno, Dorr, and Canal Flare Indices.

BACKGROUND: No consensus has been reached regarding the best index to decide whether to use cement during hip replacement surgery. Therefore, this study compared the reliability of three frequently used scoring systems. The secondary purpose was to evaluate the effect of surgical experience on the decision to use cement. METHODS: Anteroposterior radiographs of 60 hips were assessed by four orthopedic surgeons and four orthopedic residents. The observers were asked to make measurements using the Spotorno criteria, the Dorr index, and the canal flare index, and to decide whether to use a cemented or cementless femoral stem. The same X-rays were sent to all participants, in a different order, 4 weeks later, for a second evaluation. The SPSS software (version 24.0) was used for the statistical analysis. Intraobserver agreement was determined for all observers via the intraclass correlation coefficient (ICC), and interobserver reliability was calculated using the weighted kappa (κ) statistic. RESULTS: The average age of the patients were 73.1 ± 12.1 years. Thirty-three (55%) patients were female and thirty-two (53.3%) had fractures on the right side. Intraobserver agreement was "excellent" for all participants according to the Spotorno criteria. The canal flare index had the lowest intra-observer agreement. The highest interobserver agreement was found using the Spotorno criteria. CONCLUSION: The intra- and interobserver reliabilities of the Spotorno criteria were higher than those of the Dorr index and the canal flare index. The Spotorno criteria was more useful for deciding between cemented and un-cemented hip arthroplasty.

Posterior tibial slope of the knee measured on X-rays in a Turkish population.

PURPOSE: Posterior tibial inclination of the knee joint should be considered during anterior cruciate ligament reconstruction and total knee replacement surgery. This inclination is called the posterior tibial slope (PTS) angle. The PTS differs among populations and the aim of this study was to determine the mean PTS in a Turkish population. METHODS: PTS was measured retrospectively on lateral knee X-rays (n = 1024). The angle between the line connecting the anterior and posterior points of the lateral tibial plateau and the tibial longitudinal axis was taken as the PTS angle. Intra- and inter-observer agreement regarding the measurements on 20 X-rays were checked. RESULTS: The mean PTS angle for the entire cohort was 8.36 ± 3.3° (range: 2.1-18.7°); it was 8.57 ± 3.4° (range: 2.3-17.4°) in men and 8.16 ± 3.2° (range: 2.1-18.7°) in women. Although no significant correlation was detected between PTS and age, PTS was higher in men than in women. CONCLUSION: The increasing number of total knee replacement surgeries has increased the need for studies on implant mismatch. In this study, reference PTS values were determined for a Turkish population. It may be beneficial to use patient-specific implants in some cases.

Computed tomography evaluation of the iliac crest apophysis: age estimation in living individuals.

Determination of the ossification properties of the iliac apophysis is important not only in the clinical evaluation of patients undergoing orthopedic surgery but also in age estimation studies for forensic purposes. The literature includes both anthropological and radiological (conventional radiography, ultrasonography, and magnetic resonance imaging modalities) investigations of the different staging systems used for these purposes. In this study, we assessed the utility of computed tomography (CT) of the iliac crest apophysis in estimating forensic age. CT scans of the iliac crest apophysis of 380 patients (187 females, 193 males, and 10-29 years of age) were evaluated according to the four-stage system. Further subclassification did not give data properly due to the reference length measurement of the iliac wing with CT. Thus, in our series, stage 2 was first seen in 12 years of age and stage 3 in those 14 years of age in both sexes and on both sides of the pelvis. Stage 4 was first seen in 17 years of both sexes but only on the right side; on the left side, it appeared in females 18 years of age and in males 17 years of age. Present data was found consistent with previous pelvic radiographic findings. First seen ages for stage 2 and 3 are 12 and 14 years respectively which presented valuable information for legally important age thresholds. However, disadvantages of CT, including high-dose radiation exposure to gonads, the difficulty of evaluating the iliac crest, and the age boundary of 17 years, could make this method infeasible, as compared with hand wrist and pelvic radiographic methods. CT of the iliac crest has probably a greater utility where preexisting CT scans of the pelvic region are available, and it may be considered as a supportive method for age-estimation purposes.

Medial percutaneous hemi-epiphysiodesis improves the valgus tilt of the femoral head in developmental dysplasia of the hip (DDH) type-II avascular necrosis.

BACKGROUND AND PURPOSE: Avascular necrosis (AVN) is a major cause of disability after treatment of developmental dysplasia of the hip (DDH), leading to femoral head deformity, acetabular dysplasia, and osteoarthritis in adult life. Type-II AVN is characterized by retarded growth in the lateral aspect of the physis or by premature lateral fusion, which produces a valgus deformity of the head on the neck of the femur. We investigated the effect of medial percutaneous hemi-epiphysiodesis as a novel technique in the treatment of late-diagnosed type-II AVN. PATIENTS AND METHODS: 9 patients (11 hips) with a diagnosis of type-II AVN who underwent medial percutaneous hemi-epiphysiodesis after the surgical treatment for DDH were included in the study. 10 patients (12 hips) with the same diagnosis but who did not undergo hemi-epiphysodesis were chosen as a control group. Preoperative and postoperative articulotrochanteric distances, head-shaft angles, CE (center-edge) angles, and physeal inclination angles were measured. The treatment group underwent medial hemi-epiphysodesis at a mean age of 8 years. The mean ages of the treatment group and the control group at final follow-up were 14 and 12 years respectively. The mean duration of follow-up was 5.7 years in the treatment group and 8.3 years in the control group. RESULTS: Preoperative articulotrochanteric distance, head-shaft angle, and functional outcome at the final follow-up assessment were similar in the 2 groups. However, preoperative and postoperative CE angles and physeal inclination angles differed significantly in the treatment group (p < 0.05). The final epiphyseal valgus angles were better in the treatment group than in the control group (p = 0.05). The treatment group improved after the operation. INTERPRETATION: Medial percutaneous epiphysiodesis performed through a mini-incision under fluoroscopic control is a worthwhile modality in terms of changing the valgus tilt of the femoral head.

Analysis of the factors affecting school attendance in pediatric fractures.

OBJECTIVE: This study aimed to examine the average duration of school absence according to the type of fracture and the factors affecting the duration of absence in children who had difficulty going to school after an acute orthopedic injury. METHODS: Patients between the ages of 6 and 17 who applied to the emergency department of our hospital and were treated for orthopedic trauma during a teaching period between September 2022 and December 2022 were examined. This study was designed prospectively. All school-aged patients with upper or lower extremity fractures requiring hospitalization or outpatient treatment were included in this study. Information about school absences and school starting dates were recorded at the outpatient clinical presentations of these patients. RESULTS: A total of 126 patients were included in this study. The mean age of the patients was 11.7 (range=6-17) years. The gender ratio was determined as F/M=20/106. The average time absent from school was 14.7 (range=2-61) days. Distal radius fractures were the most common upper extremity fractures; the mean time away from school was 7.9 days. In lower extremity fractures, lateral malleolar fracture was the most common complaint, and the mean duration of absence was calculated as 21.8 days. The periods of absence were mainly determined by the family or the child. CONCLUSION: One of the critical findings in this study was that rest periods were primarily determined by the parents and/or the child and not by the physician. The need to use crutches and/or transportation difficulties were other reasons for the absence. For these reasons, teachers and school management should be sensitive to the adverse effects of absenteeism on the child's success and provide facilitating support and home education opportunities when necessary. LEVEL OF EVIDENCE: Level II, Prognostic study.

Analysis of the factors affecting pain level during K-wire removal among pediatric elbow fractures.

Our aim was, to analyze the reasons for possible increased pain during the removal of the Kirschner wires from the elbows of children. From February 2021 to December 2021, 573 patients with elbow fractures were treated. In total, 150 patients were analyzed prospectively. No action was taken to reduce pain during the removal of Kirschner wires. The pain status of the patients was evaluated according to the Wong-Baker FACES Pain Rating scoring system (WBAS), the Numeric Rating Scale (NRS) for the pain system and the pulse and oxygen saturation measured by the pulse oximeter on the finger. Measurements were performed before, during, immediately after and 30 min after the procedure. There were 119 patients with a diagnosis of supracondylar humerus fracture and 31 patients with a diagnosis of lateral condyle fracture. The mean age of treated patients was 7.1 years (1-15 years). Of the patients, 93 were boys and 57 were girls. In the measurements made according to the sex difference, it was determined that there was a statistically significant increase in the WBAS scores measured both before the procedure ( P = 0.032) and during the removal ( P = 0.017), and also in the pulse measurements taken 30 min after the removal in girls ( P = 0.034). A statistically significant difference was found in both the WBAS score during removal ( P = 0.025) and the NRS scores 30 min later ( P = 0.048) in the procedures performed on the right elbow. We found a statistically significant increase in the pain parameters we evaluated in girls, right extremity fractures, the group over 8 years old and when both parents were with the child during the K-wire removal procedure. In light of these findings, physicians should consider the above-mentioned conditions before starting the procedure to ensure a less painful and positive experience.

Management of tibial non-unions with Masquelet technique after failed previous treatment options for Grade III open fractures.

BACKGROUND: Non-union is a serious complication of open tibial fractures. This case series investigates the efficiency of the induced membrane technique in patients with tibial exposed non-union. METHODS: Eleven consecutive male patients with non-union after an open tibia fracture were enrolled into the study. The mean age of the patients was 40.7 (25-63). Induced membrane technique described by Masquelet was performed. Operative treatment with a temporary polymethylmethacrylate cement spacer to induce membrane formation followed by spacer removal and bone grafting at 7.35 (6-10) weeks were performed. Time to union, time to full weight-bearing, and any complications were evaluated. RESULTS: The average follow-up period of patients was 24.6 (13-40) months after the second stage. The mean length of bone defects after radical debridement was 51 mm (25-98). Fracture healing was observed in 9 patients (81%). The mean time needed to obtain bony union healing was 8.1 (8-12) weeks after second stage of surgery. Patients were allowed to full weight bearing as tolerated at 12 weeks. Two patients were failed to obtain bony union and infection control. One patient had below knee amputation due to persistant infection. Vascularized bone graft was performed for other patient due to the inability to obtain bone union. CONCLUSION: The induced membrane technique is a reliable and reproducible treatment modality for tibial non-unions after failed open fracture treatment. However, it is unpredictable to obtain bony union and control of infection in initial infected non-unions with a large bone defect.

Analysis of the factors affecting mortality after non-traumatic major lower extremity amputations.

OBJECTIVE: The aim of this study was to evaluate the prognostic factors affecting mortality after major lower extremity amputations in patients with diabetes mellitus and peripheral vascular disease. METHODS: For this retrospective study, 484 patients (345 male, 139 female) who were previously diagnosed with diabetes mellitus and peripheral vascular disease and underwent first-time nontraumatic major lower extremity amputations between January 2008 and January 2021 were included. The mean age of the patients was 64.2 ± 13.8 (20-114). In 32.4% of patients, peripheral vascular disease was the underlying cause, whereas diabetes mellitus was responsible for the etiology in 67.6% of patients. About 68.8% of patients had below-knee amputations, whereas 2.9% had bilateral below-knee amputations, 27.1% had above-knee amputations, and 1.2% had hip disarticulation performed. Gender, age, amputation level, amputation etiologies, Charlson comorbidity index, need for blood transfusion, and laboratory findings such as hemoglobin, platelet, albumin, erythrocyte sedimentation rate, C-reactive protein, sodium, potassium, and neutrophil to lymphocyte ratio levels were recorded preoperatively and at the time of discharge. Patients were grouped as died ≤1 month, ≤3 months, ≤6 months, and ≤12 months or alive. RESULTS: Advanced age, female gender, high Charlson comorbidity index, blood transfusion requirement, proximal amputation level, preoperative low platelet, preoperative low albumin, and parameters such as low hemoglobin, low erythrocyte sedimentation rate, high sodium, low platelet, low albumin, high C-reactive protein, and high neutrophil to lymphocyte ratio at time of discharge were seen to have a statistically significant effect on mortality at 1 month, 3 months, 6 months, and 12 months postoperatively. Preoperative high C-reactive protein had a statistically significant effect on mortality at 1 and 3 months postoperatively, whereas low C-reactive protein had a statisti cally significant effect on mortality at 6 months postoperatively. High potassium at the time of discharge was associated with mortality at 6 and 12 months postoperatively. CONCLUSION: This study has shown us that mortality rates are affected by modifiable parameters at the time of discharge such as hemoglo bin, sodium, potassium, platelet, and albumin, and normalization of these parameters before discharge could reduce the rates of mortality in the postoperative period. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

Can titanium elastic nail be safely used for paediatric subtrochanteric femur fractures?

In this study, we aimed to show that subtrochanteric femur fractures, an uncommon type of fracture in the paediatric age group, can be treated with titanium elastic nailing (TEN). We reviewed the patients treated with TEN in the paediatric age group with subtrochanteric femur fractures who had been treated at the Orthopaedics and Traumatology Clinic of Izmir Tepecik Research and Training Hospital between January 2011 and December 2016 retrospectively. All fractures were fixed by retrograde nailing with supracondylar entry following reduction. Patients' demographics as well as data such as fracture type, fracture level, time of operation, reduction type, time to union, shortness, additional fixation, duration of additional fixation, Flynn scores and reduction loss were evaluated. The 20 patients included in our study were followed up for at least 1 year, had an age range of 54-173 months (mean, 104 ± 31.82 months) and were operated within 2-11 days after fracture. All patients had fracture union and only three patients had union with an angulation of less than 5°. None of the patients had limb length inequality. Fourteen patients underwent reoperation, all of these were routine operations for implant removal and no patients required reoperation for complications. We think that paediatric subtrochanteric femur fractures can be treated by TEN fixation using the proper technique, with a limited invasive intervention.

Pediatric Forearm Refracture with Intramedullary Nail Bending In Situ: Options for Treatment.

In this study, we present the case of a nine-year-old male patient who had initially presented to the emergency department with a right both-bone forearm fracture. He was treated with closed reduction and long-arm casting. The cast was applied for six weeks and then replaced with a short-arm cast for two weeks. The patient returned with a both-bone forearm refracture one and a half months after the removal of the cast. Surgical treatment was initiated and an intramedullary nail fixation was applied. The patient sustained a new trauma five months postoperatively. The condition was diagnosed to be a refracture of the both-bone forearm with an intramedullary nail in situ. Closed reduction was performed, but an acceptable level of reduction was not achieved. Subsequently, intramedullary nails were replaced with new nails. At the one year follow-up, the patient was observed to have a full range of motion and reported no pain or muscle weakness.

Viewing arthrography images affects treatment preferences for Legg-Calvé-Perthes disease among medical professionals.

OBJECTIVES: We explored how experience of arthrography affects treatment preferences for Legg-Calvé-Perthes disease (LCPD) patients. We also examined changes in surgical procedure preferences after examining arthrography images. In addition, we analysed the effect of experience with arthrography on treatment and surgical modality preferences. METHODS: A case-based questionnaire was completed by 26 participants. Information on age, symptoms, hip range of motion (ROM), and extremity length differences were provided for eight LCPD cases. Based on these data and roentgenography images of the cases, the respondents were questioned regarding diagnostic, treatment, and surgical preferences. A slide was shown of arthrography images of each case and the same questions were asked to determine any changes in treatment preferences. The participants were divided into arthrography-experienced (Group 1, n = 16) and -inexperienced (Group 2, n = 10) groups to determine differences in treatment preferences in association with experience. RESULTS: After the participants had examined the arthrography images, a significant decrease in the number of additional examination requests was observed (p < 0.001). A significant group difference was also found in the rate of change of preference in diagnostic modality (p < 0.001).After arthrography images were examined, the tendency towards a preference for surgery increased in all participants. However, no significant difference between the experience groups was observed (p = 0.193). In addition, after arthrography images were examined, there was an increased tendency towards a preference for femoral valgisation and Salter osteotomy among participants who chose surgical treatments (p = 0.408). The treatment preferences difference between the two experience groups were not significant, and nor was the preference regarding surgical procedures (p = 0.999). CONCLUSIONS: Previous studies have shown that arthrography is useful for planning treatment and informing decisions regarding surgical modality for LCPD. However, no study has explored changes in treatment preferences after viewing arthrography images. This study explored such changes in choices regarding the diagnostic method and treatment modality. Our study showed that experience with arthrography decreased the preference for additional diagnostic tests (p < 0.001). Experience of arthrography increased the preference for surgery, though not significantly (p = 0.193).

Physiological periostitis in a 2.5-month-old baby.

Periosteal reaction has different etiologies in early infancy. Physiological periostitis is a well-documented X-ray finding seen in both preterm and term babies aged between 1-6 months and can easily be misdiagnosed as child abuse or pathological periostitis. Here, we present a 2.5-month-old infant admitted with a history of fever, swollen right upper arm after vaccination and X-rays findings revealing periosteal reactions on both sides of the humeri, radii, tibiae and femora. Initial diagnosis was child abuse or congenital syphilis. Due to the normal physical findings and normal serological-biochemical data, physiological periostitis was diagnosed. Physiological periostitis should also be considered in patients with periosteal reactions of the long bones in infants aged between 1-6 months.

Is open reduction necessary for pediatric T-condylar fractures of the humerus?

The aim of this study was to investigate the outcomes of closed reduction and percutaneous pinning (Kirschner wire fixation) as a less invasive method for the treatment of pediatric T-condylar fractures of the humerus compared with open reduction and pinning. Among pediatric patients who were diagnosed with T-condylar fractures of the humerus between 2010 and 2017, those who underwent closed reduction and percutaneous pinning were retrospectively evaluated. The surgical technique used was to restore joint alignment through closed reduction and then to insert a pin parallel to the joint surface to stabilize the intercondylar fracture. Then, the supracondylar fracture was fixed with crossed pins. At 1-year follow-up, rotation, angulation, and joint range of motion were evaluated. Patient satisfaction was assessed subjectively using the visual analogue scale. Early and late postoperative Baumann angles were measured. All patients were male, and the mean age was 10.8 ± 4.6 years. The mean follow-up duration was 16.5 ± 7.2 months, and the mean union duration was 7.4 ± 2.3 weeks. None of the patients had any rotational deformities, but two had 5° of varus, one had 5° of valgus, two had a flexion contracture of 10°, and one had a flexion contracture of 40°. The only complication observed was a pin-tract infection, which developed in one patient. The mean visual analogue scale score was 9.25 ± 1. In pediatric patients with T-condylar humerus fractures, closed reduction and percutaneous pinning may be a good alternative to open reduction and pinning, because it is less invasive and does not cause additional complications.

Arthroscopically assisted percutaneous osteosynthesis of lateral tibial plateau fractures.

BACKGROUND: The aim of our study was to evaluate the results of lateral tibial plateau fractures treated with arthroscopically assisted percutaneous osteosynthesis (AAPO). METHODS: Twenty-one patients (14 men and 7 women) with a mean age of 41 years underwent AAPO to repair low-energy Schatzker I-III tibial plateau fractures. Under pneumatic tourniquet, we reduced and fixed the fracture with 1 or 2 subchondral cannulated screws. Accompanying lesions included 10 meniscus tears, which we partially excised in 9 patients and repaired in 1 patient. On the second postoperative day, patients began range-of-motion exercises. We encouraged partial and full weight-bearing by the sixth and tenth weeks, respectively. The mean follow-up period was 38 (range 12-96) months, and we evaluated the patients using Rasmussen's clinical and radiologic criteria. We used a t test for statistical analysis. RESULTS: There were 13 excellent (62%), 6 good (28%) and 2 fair (10%) clinical results, and 11 excellent (52%), 7 good (33%) and 3 fair (14%) radiologic results. We observed mild or moderate arthritic changes in 5 patients (24%). There were no infection or wound problems, but we removed hardware in 4 patients. CONCLUSION: Arthroscopically assisted treatment of lateral tibial plateau fractures yields satisfactory results and can be accepted as an alternative and effective method for the treatment of low-energy tibial plateau fractures.

Evaluation of clinical and radiographic outcomes of complete subtalar release in clubfoot treatment.

BACKGROUND: We evaluated patients with unilateral clubfoot deformity who were treated by complete subtalar release according to Simons' criteria and assessed the correlation between clinical and radiographic results. METHODS: Eleven patients underwent a complete subtalar release through a Cincinnati incision. Evaluation included a questionnaire and clinical and radiographic examination. RESULTS: Mean follow-up was 12 years 8 months. The radiographic measurement differences in the diagnostic angles between normal feet and clubfeet were not significant. Shortening of the talus and the navicular bone was significant. The talar dome was flattened in seven patients and was flattened, sclerotic, and irregular in one. Flattening of the talar head was detected in eight patients, irregularity in one, and deformity and sclerosis in one. Six patients had deformity in the talonavicular joint. The navicular bone was wedge shaped in nine patients and subluxated dorsally in seven. The talar head was congruent with the navicular bone semilunar in normal feet; this relation was not detected in patients treated for clubfoot. CONCLUSION: Radiographic changes, such as flattening of the talar, a wedge-shaped navicular bone, dorsal navicular migration, irregularity, and lack of congruence of the talonavicular joint, can be encountered postoperatively in clinically and cosmetically healthy patients. These changes may be caused by the nature of the disease, correcting manipulations or casting, or surgical techniques. Although complete subtalar release is an effective procedure for satisfactory clinical results, maintenance of anatomical configuration, but not normal anatomical development of tarsal bones, can be achieved with this method.

Optimum Screw Configuration for the Fixation of Sanders Type IIC Tongue-Type Fractures? A Biomechanical Study.

BACKGROUND: The minimally invasive technique (percutaneous screw fixation) is one of the options for treating tongue-type IIC fractures successfully. The aim of this study was to assess the biomechanics of four different screw configurations used for the fixation of tongue-type IIC calcaneal fractures. METHODS: Identical osteotomies, recapitulating a type IIC injury, were created in synthetic calcaneus specimens using a saw. The specimens were randomly assigned to one of the four fixation groups (n = 7 per group): two divergent screws, two parallel screws, two parallel screws plus one screw axially oriented toward the sustentaculum tali, and three parallel screws. A load test was performed on all of the groups, and the specimens were then tested using offset axial loading until 2, 4, and 5 mm of fracture displacement occurred. RESULTS: Mean force values for the three-parallel screw construct at 2-, 4-, and 5-mm fracture displacements were found to be significantly higher compared with those for the other groups. CONCLUSIONS: The use of a three-parallel screw construct seems to provide more stability in the treatment of tongue-type IIC fractures.

Is pin configuration the only factor causing loss of reduction in the management of pediatric type III supracondylar fractures?

OBJECTIVE: Closed reduction with percutaneous pinning is the treatment of choice for displaced supracondylar humerus fractures in children. In addition to configuration of pin fixation, many factors have been attributed to loss of reduction (LOR). The aim of the present study was to review potential factors that contribute to loss of reduction in the closed management of type III pediatric supracondylar fractures. METHODS: Treatment of 87 patients with type III supracondylar fractures was reviewed to determine factors associated with loss of reduction; 48 patients were treated with lateral pinning and 39 with crossed-pinning after closed reduction. Outcome parameters included radiographic maintenance of postoperative reduction. RESULTS: Lateral or crossed-pin configuration, pin spread at fracture site, pin-spread ratio (PSR), and direction of coronal displacement of the fracture were not associated with LOR. A significant difference (p = 0.01) was found between LOR rates of patients with medial wall communication and LOR. CONCLUSION: Medial wall communication is a contributing factor to LOR in the management of type III supracondylar fractures. Cross-pinning should be preferred when medial wall communication is present, to provide more stable fixation. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Are the Appropriate Use Criteria for the management of pediatric supracondylar humerus fractures useful in clinical practice?

The aim of this study was to evaluate our treatment modalities in pediatric supracondylar humerus fractures according to the recently published Appropriate Use Criteria (AUC) by the American Academy of Orthopaedic Surgeons. A total of 991 patients with supracondylar humerus fractures were included. After reviewing medical records, 38 different clinical scenarios described in the AUC were observed. Of the 991 patients, 127 were type I, 423 were type II, and 405 were type III fractures according to the Gartland classification. The AUC was appropriate for 100% of type I, only 25 (5.9%) of type II, and 389 (96.0%) of type III fractures. Overall, the total appropriateness rate was 54.5%. We concluded that application of the AUC is useful but burdensome and that AUC provides important guidance especially for rarely encountered urgent clinical scenarios.

[The frequency and distribution of fractures in children presenting to the emergency service]. / Acil servise kirik nedeniyle basvuran çocuk hastalarda kiriklarin siklik ve dagilimi.

OBJECTIVES: We investigated the frequency and distribution of childhood fractures seen at the emergency service of Tepecik Education and Research Hospital, Izmir, Turkey. METHODS: This prospective study included fractures of 1,706 children (992 boys, 714 girls; age range 0 to 14 years) who presented to the emergency department on even-numbered days. Data forms including information about characteristics of the patients and fractures were filled in for each case. Age and sex of the patients, date and time of fractures together with mechanism, site, and type were recorded. RESULTS: The most frequent ages for fractures were 7 (9%) and 3 (8%) years for boys, and 4 (9%) and 5 (8.5%) years for girls. The most common cause was domestic accidents (53%), followed by school (22%), traffic (17%), and sport (8%) accidents. Fractures occurred most frequently in summer (35%) especially in July, followed by autumn (24%), winter (21%), and spring (20%). The most frequent time intervals of presentation were between 16 and 20 hours (32%) and between 20 and 24 hours (25%). The most common site of involvement was the distal radius (26%), followed by the elbow (19%), forearm (17%), hand-foot (12%), clavicle (9%), tibia (7%), and the femur (6%). The humerus (1%) was the least affected site. Treatment included conservative methods in 84%, and surgical methods in 16%. CONCLUSION: In our area, child fractures generally result from falls in summer and spring months and at play hours and are generally treated with conservative methods. Distal radius fractures are the most frequent and, inconsistent with the relevant literature data, occur at younger ages.

[Combination of direct and indirect reduction techniques in periarticular complex knee fractures]. / Diz çevresi parçali kiriklarinin direkt ve indirekt redüksiyon teknikleriyle eszamanli olarak tedavisi.

BACKGROUND: We evaluated the efficiency of treatment of comminuted intraarticular fractures of the knee, involving direct reduction and rigid fixation for articular components, and indirect reduction and biological fixation for metaphyseal-diaphyseal components. METHODS: Twelve patients (9 males, 3 females; mean age 46 years; range 22 to 71 years) with distal femoral (n=6) and proximal tibial (n=6) intraarticular fractures were included. There were seven closed and five open fractures. Intraarticular fractures were fixed directly through a lateral parapatellar incision; while comminuted metaphyseal-diaphyseal fractures were indirectly reduced and internally fixed with biological fixation methods. The patients were evaluated clinically and radiographically. Intraarticular bone and soft tissue changes were evaluated by conventional and three-dimensional computed tomography. The results were assessed according to the HSS (Hospital for Special Surgery) criteria. The mean follow-up was 43 months (range 15 to 78 months). RESULTS: All fractures healed without any refractures, implant failures, or infections. The mean time to full weight-bearing was 25.5 weeks for tibial, and 24 weeks for femoral fractures. Leg length discrepancy occurred in all the patients with femoral fractures (1-2 cm), and in two patients with tibial fractures (1 cm). One patient with a femoral fracture had a valgus deformity of 10 degrees. According to the HSS criteria, the results were good in five cases, and moderate in one case for tibial fractures; good in one case, moderate in four cases, and poor in one case for femoral fractures. Tomographic evaluations showed articular congruity in all the cases without any signs of loose bodies. CONCLUSION: Combination of indirect and direct reduction techniques is an effective method for the treatment of comminuted intraarticular knee fractures.