[Posttraumatic complications after pediatric ankle injuries]. / Posttraumatische Komplikationen am kindlichen Sprunggelenk.

Ankle sprains are common injuries in childhood and are generally harmless. However, fractures of the ankle joint are rare, but complications (persistent rotational or axial deformity, alteration of growth of the distal tibia or fibula, or joint deformity) can lead to serious problems during growth. The clinical relevance of growth disturbances at the distal tibia or fibula depends on the age at the time of fracture more than on the fracture type, severity of dislocation, or interponated material in the fracture gap. Both stimulation and inhibition of growth are possible. Inhibition of growth at the distal tibial growth plate regularly leads to varus deformity and shortening. This is of clinical importance as this type of growth disturbance is the most common. Valgus deformity is rare, mostly due to persistent axial deviation of an insufficiently reduced fracture. Transitional fractures always occur at the time of growth plate closure; thus, growth disturbances do not play a role. Transitional fractures could be overlooked or treated insufficiently, leading to a step or gap of the joint surface.

The Baumann procedure to correct equinus gait in children with diplegic cerebral palsy: long-term results.

Although equinus gait is the most common abnormality in children with spastic cerebral palsy (CP) there is no consistency in recommendations for treatment, and evidence for best practice is lacking. The Baumann procedure allows selective fractional lengthening of the gastrocnemii and soleus muscles but the long-term outcome is not known. We followed a group of 18 children (21 limbs) with diplegic CP for ten years using three-dimensional instrumented gait analysis. The kinematic parameters of the ankle joint improved significantly following this procedure and were maintained until the end of follow-up. We observed a normalisation of the timing of the key kinematic and kinetic parameters, and an increase in the maximum generation of power of the ankle. There was a low rate of overcorrection (9.5%, n = 2), and a rate of recurrent equinus similar to that found with other techniques (23.8%, n = 5). As the procedure does not impair the muscle architecture, and allows for selective correction of the contracted gastrocnemii and soleus, it may be recommended as the preferred method for correction of a mild fixed equinus deformity.

[General considerations in the management of paediatric injuries]. / Allgemeine Gesichtspunkte zur kindorientierten Behandlung von Verletzungen.

This report discusses the differences between the paediatric and adult musculoskeletal system. Consideration is given to preventive measures and the epidemiology and aetiology of fractures in relation to the developmental milestones in children. The principles of growth disturbances (overgrowth or growth arrest) and their management are presented. Pitfalls in diagnosis and different treatment options for paediatric fractures are discussed. Doctor-patient communication at different stages of growth and the importance of respecting the opinion of the child in management planning is emphasised.

Propulsive function during gait in diplegic children: evaluation after surgery for gait improvement.

Seventeen patients with diplegic cerebral palsy were assessed by clinical examination and three-dimensional gait analysis before and after surgery to improve gait. Selection of surgical procedures was according to a fixed set of selection criteria. The average postoperative follow-up was 3.8 years (range, 2.6-5.7 years). Clinical examination revealed an improved range of motion for the ankle and no reduction in the power grade at the hip, knee and ankle after surgery. Kinematic parameters showed improved knee extension in stance and significant changes towards a normal ankle motion pattern postoperatively. Kinetic evaluation demonstrated that most of the total power during walking was generated at the hip, with the ankle contributing a small part. After surgery, patients walked faster with an increased power generation at the hip during first double support and at the ankle during push off. Power generation at the hip in stance is pointed out to be an important mechanism for propulsion during walking.

Flexible intramedullary nailing for the treatment of unicameral bone cysts in long bones.

BACKGROUND: Unicameral bone cyst is characterized by its tenacity and risk of recurrence. Pathological fracture is common and is often the presenting symptom. The objective of the present study was to evaluate the results of flexible intramedullary nailing for the treatment of a unicameral bone cyst with or without a pathological fracture. METHODS: Flexible intramedullary nailing for the treatment of a unicameral bone cyst was performed in thirty-two patients. Thirty of these patients presented with a pathological fracture; twenty-four were managed immediately with intramedullary nailing, and the other six had been managed conservatively at other clinics before they were referred to our department. The remaining two cysts were detected incidentally. The cyst was located in the humerus in twenty-one patients, in the femur in nine, and in the radius in two. The mean age of the patients at the time of surgery was 9.8 years, and the mean duration of follow-up was 53.7 months. Radiographic evaluation was performed according to the criteria of Capanna et al., and the cyst was classified as completely healed, healed with residual radiolucency (osteolysis), recurred, or having no response. RESULTS: The healing period ranged from three to 105 months. Fourteen cysts healed completely, and sixteen healed with residual radiolucent areas visible on radiographs. There was recurrence of two cysts that had healed with residual radiolucency. All of the cysts in the present study responded to treatment. A change of nails was necessary in nine patients, as the nails had become too short after bone growth. No major complications were observed. CONCLUSIONS: Flexible intramedullary nailing provides early stability, which allows early mobilization and thus obviates the need for a plaster cast and decreases the prevalence of the most common complication: a pathological fracture. This method of treatment also allows for an early return to normal activity.

Reconstruction of part of the distal tibial growth plate with an autologous graft from the iliac crest.

We describe the reconstruction of a defect of the medial malleolus which was the result of an accident in a ten-year-old child. A graft from the iliac crest, with the apophyseal cartilage and perichondrium, was used for reconstruction of the medial malleolus, the growth plate and the adjacent metaphyseal defect, respectively. The soft-tissue defect was covered with a free scapular flap with microvascular anastomosis. Three years after the injury stability of the ankle is excellent with adequate growth of the reconstructed epiphyseal plate.

Elastic stable intramedullary nailing for unstable femoral fractures in children: preliminary results of a new method.

BACKGROUND: Many femoral fracture patterns in children cannot be stabilized sufficiently by intramedullary nailing only. Such fractures may require additional cast bracing or cerclage wiring after nailing. To overcome this problem, pediatric Ender nails that can be interlocked were designed to achieve better fracture stabilization. METHOD: Seventeen children (age, 2.5 to 15 years) were treated with this method for unstable traumatic fractures of the femur. The average follow-up period was 11.8 months. RESULTS: All fractures healed within 4 weeks in the mean. There were no major complications. CONCLUSION: This new method prevents shortening and axial deviation of the fractured femur. Start of postoperative mobilization and increase of weight-bearing is mainly determined by the child.

Implantation of a soft-tissue expander before operation for club foot in children.

Primary skin closure after surgery for club foot in children can be difficult especially in revision operations. Between 1990 and 1996 a soft-tissue expander was implanted in 13 feet before such procedures. Two were primary operations and 11 were revisions. A standard technique was used for implantation of the expander. Skin augmentation was successful in 11 cases. There was failure of one expander and one case of wound infection. Sufficient stable skin could be gained at an average of five weeks. Primary skin closure after surgery was achieved in 12 cases. We conclude that soft-tissue expansion can be used successfully before extensive surgery for club foot. The method should be reserved for revision procedures and for older children. The technique is not very demanding, but requires experience to achieve successful results.

[Pediatric scaphoid fractures--treatment and prognosis]. / Kindliche Skaphoidfrakturen--Behandlung und Prognose.

From 1990 to 1994, we treated 28 children aged eight to fourteen years, with a scaphoid fracture. In eight of them, the initially suspected fracture could not be verified by X-ray earlier than two weeks after the injury. Eleven more patients--after false initial suspect of fracture--were discharged after two weeks without any complaints and negative X-ray control. These were not included in the series. Patients with radiologically evident fracture or clinically typical history and symptoms of scaphoid fracture--even without positive X-ray--were treated by below-elbow-thumb spica-cast for two weeks. After that period, all patients went for repeated clinical and radiological examination. All children with radiologically visible fracture or continuous, typical complaints underwent cast fixation for another four weeks. Symptom-free patients without radiological evidence of fracture were discharged. One displaced fracture was reduced and stabilized with a screw. In follow-up examination after six to forty months, all fractures showed good radiological consolidation, four patients reported occasional pain on straining the wrist. Scaphoid fractures in children seem to be more difficult to diagnose than to treat. Nondisplaced or slightly displaced fractures can be treated easily with plaster cast. Fractures that show dislocation of more than 1 mm should undergo open reduction and stabilization by a screw.

[Femoral neck fractures in childhood]. / Schenkelhalsfrakturen im Kindesalter.

In a retrospective multicenter study we followed-up 30 fractures of the neck of the femur in children aged 11 years (1.5-15 years) for 4.8 years (0.5-20.0 years). It is the aim of this study to analyse factors possibly related to outcome, like age at injury, type of fracture, interval between injury and treatment, method of stabilization and postoperative interval until full weight bearing. At follow-up subjective parameters (pain, weather sensitiveness), clinical parameters (range of motion, claudication, leg length discrepancies) and radiological parameters (hip series) were investigated and medical charts and roentgenograms were reviewed using a standardized protocol. 29 of 30 children (96.7%) have sustained displaced fractures. Non-operative treatment has been applied in 4 children. 26 femoral neck fractures (type I: 1, type II: 8, type III: 17) were stabilized by internal fixation using screws and/or pins. Following non-operative treatment one child suffered a coxa vara and another child suffered a avascular femoral head necrosis in combination with coxa vara and leg length shortening of 4 cm. Following operative treatment 9 of 26 children (34.6%) suffered a avascular femoral head necrosis and 3 children (11.5%) suffered a coxa vara. In 6 of 26 children (23%) we observed leg length discrepancies > 2 cm. We were not able to demonstrate any significant follow-up result differencies between the groups of children who have sustained type II or type III fractures, or between the groups of children aged < 10 years when compared to children aged > 10 years, or between the group of children who were operated on within 6 hours after the accident when compared to the group of children operated > 6 hours after the accident. We observed no significant follow-up result differences between the groups of children who had different intervals between operation and full weight bearing. Operative fracture management remains the treatment of choice in the majority of displaced femoral neck fractures in children. However, in our limited study we were not able to demonstrate any significant follow-up result differences between the group of children treated by immediate open reduction and internal fixation (interval injury - operation < 6 hours) when compared to children who had been operated > 6 hours after the injury.

[High arched forefoot--pes cavus metatarsus congenitus. A case report]. / Der Vorfusshohlfuss--pes cavus metatarsus congenitus. Ein Fallbericht.

This is a rare congenital deformity. Because of it's typical aspect the name "pes cavus metatarsus congenitus" was given. Complete operative correction is easily done.

[Bicycle accidents of children]. / Fahrradunfälle bei Kindern.

Bicycles are funny and stimulating sport and play tools for children but riding a bicycle brings also a lot of risks. The most frequent causes of injuries, the accident patterns, the seriousness and patterns of injuries were examined by means of two investigations of 823 children injured in bicycle accidents. The safety consciousness of children and parents was evaluated as well. Three sources of danger were found to be the most frequent causes of accidents: "the agent" (bicycle), "the environment" (situations) and "psychodynamic risk factors" (behaviour). Prevention measure for all three sources of danger will be discussed. The use of bicycle helmets as simple, cheap and efficient protective measure is recommended in particular.

[Results of conservative treatment of ligament lesions of children's ankle joint--a prospective study]. / Ergebnisse der konservativen Behandlung von Bandläsionen des kindlichen Sprunggelenkes--Eine prospektive Studie.

There is disagreement in the literature about the ideal treatment of ligamentous injuries of the ankle in children. We examined the results of controlled conservative treatment by means of a prospective study in 28 children, each with a fresh ligamentous ankle injury. In all patients the supinatory talus tilt was between 7 and 15 degrees as compared with the noninjured side. The children were treated with a plaster cast for 6 weeks. The results of the present study were compared with results of two other earlier investigations from our department. In one group the patients had been treated not uniformly conservatively for 1-5 weeks. In another group, patients were treated by operative ligamentous repair (5, 8). At the follow-up examination 82% of the children of the present study showed ligamentous stability, which is approximately the same percentage as it was found in operatively treated children (84%), but lies significantly higher than in inconsequentially conservatively treated patients (74%), (p greater than 0.05). 50% of the children in the present study complained about some discomfort, a number that is significantly higher than that found after operative treatment (30%), (p greater than 0.05). We assume that conservative treatment of fibular ankle lesions is justified in children with supinatory talus tilts between 7-15 degrees as compared with the noninjured side. Ligamentous stability can be expected in 80% of the patients.

Influence of superoxide dismutase on staphylococcal arthritis--a histological and biochemical investigation using an experimental animal model.

The effect of superoxide dismutase (SOD) on staphylococcal arthritis has not been successfully evaluated to date. A suitable animal model has been developed to investigate a possible correlation. Using 16 rabbits divided into four groups, we injected the knee joints of two groups with Staphylococcus aureus and the other two with NaCl. One group in each of the two treatment groups was also injected with SOD. Blood samples and samples of joint fluid were taken at 12 hour intervals. Lipids were measured in plasma and joint fluid. The joints were examined macroscopically and microscopically using a scoring system to quantitate the deterioration of joint structures. Lipid peroxide concentrations measured in plasma differed in each of the groups, with higher values found in animals with septic arthritis compared with controls. The estimations made of lipid peroxide in joint fluid also displayed extreme variability, with the highest values found in animals with Staphylococcal arthritis treated with SOD. Histological examination also verified that the infected joints injected with SOD showed significantly more inflammation, a higher amount of bacteria in the joint cavity, and more distinct joint damage than joints injected only with bacteria. The mechanisms responsible for this SOD effect remain to be determined.

Septic arthritis--an experimental animal model useful in free oxygen radical research.

An experimental animal model for bacterial joint inflammation has been tested. Using 16 rabbits divided into 4 groups, we injected knee joints of two groups with Staphylococcus aureus and the other 2 with NaCl. One group in each was also injected with superoxide dismutase (SOD). A technique was developed which allowed frequent standardized aspirations of the joints carried out through the patella tendon. By this means, we aspirated 16 joints 112 times over 72 h, obtaining estimates of the activity of intra-articularly injected SOD. TBA-reactive substances (TBARS) measured in joint fluid and plasma were different in each of the groups, with the highest values found in animals with septic arthritis treated with SOD. Leucocyte and differential blood cell counts were checked at 12 hour intervals.

[Therapy of persistent dislocation of the radius head in children]. / Die Therapie der persistierenden Radiusköpfchenluxation bei Kindern.

In contrast to the Monteggia-fracture the chronical condition of the luxation of radial capitulum in infants represents a serious clinical problem. Uncertainties concerning the etiology are documented by numerous methods of treatment. Due to the results in 8 infants which were operated on because of persistent luxation of radial capitulum (some of them remained untreated at their parents request) therapy and prognosis of this rare consequence of the injury in infants are to be discussed.

Staphylococcal arthritis--effects of superoxide dismutase on infected knee joints of rabbits.

The effect of SOD on staphylococcal arthritis has not been successfully evaluated to date. We developed an animal model to investigate the correlation. Using 16 rabbits divided into four groups, we injected two groups with staphylococcus aureus and the other two with NaCl. One group in each was also injected with SOD. The presence of SOD activity in untreated and infected knee joints of rabbits over a period of 72 hours showed no significant difference. TBA-reactive substances (TBARS) measured in joint fluid and plasma did differ in each of the groups, with the highest values found in animals with septic arthritis treated with SOD. This finding corresponded especially with the histological investigation. Joints of infected animals intra-articularly injected with SOD also showed histologically significantly more inflammation, a higher amount of bacteria in the joint cavity, and more distinct joint damage than joints injected only with bacteria. The mechanisms responsible for this SOD effect remain to be determined.

[Results following surgical treatment of ligament ruptures of the ankle joint in children]. / Ergebnisse nach operativer Behandlung von Bandrupturen am kindlichen Sprunggelenk.

A follow-up study was done in 49 children one to five years after surgical repair of traumatic rupture of the fibular ligaments of the ankle joint. Surgery has been performed when the unstable ankle joint showed radiologically a difference in the supinatory subluxation of more than 7 degrees in comparison to the opposite side. 30 children were free of complaints and showed identical stability of both ankle joints. Further eleven patients had minor complaints but the ankle joints were stable, clinically and radiologically. Four patients without complaints had a slightly differing weakness of the ankle joint. Further four patients had substantial complaints. Three of them also showed radiologically instability of the joint. Ruptures of the fibular ligament in childhood are not infrequent. Early operative treatment obviously gives better results when compared with those of conservative plaster cast therapy. The radiologically confirmed difference in supinatory subluxation of the traumatised ankle joint in comparison to the other side provides an excellent parameter for the indication to surgery.