Bado III Monteggia in children - treatment options and outcome: an ultrasound control study.

The Bado III Monteggia lesion is an uncommon fracture in children. Radial head dislocation can occur due to intra- or extra-articular fractures of the olecranon. In extra-articular ulnar fractures, heterogeneous operative methods are proposed in different case reports. The objective of this study is to determine if closed reduction of the ulnar fracture, either without osteosynthesis or by using TEN, is a safe treatment option. In a multicenter study, we retrospectively analyzed 26 children who were treated for an extra-articular proximal metaphyseal ulnar fracture with dislocation of the radial head. These patients underwent a follow-up examination after an average of four years. The investigation included a physical examination, visualization of the elbow anatomy, and specifically, the radial head retention in the joint by ultrasound. Of the 26 patients, 18 were treated by closed reduction and intramedullary osteosynthesis (TEN), 7 were treated by closed reduction and cast immobilization without osteosynthesis, and 1 child was treated by open reduction of the ulna and plate osteosynthesis. In the follow-up examination, 25 children showed an excellent outcome, as well as inapparent sonography. Although this is a retrospective study with different types of treatment, closed reduction of the ulna with or without osteosynthesis appears to be effective. We believe that the correct primary reduction is the key to an excellent long-term outcome. Regarding the invasiveness of the treatment, reduction without or with TEN osteosynthesis should be the preferred approach in extra-articular pediatric Bado III fractures.

Epidemiology and injury morphology of traumatic hip dislocations in children and adolescents in Germany: a multi-centre study.

OBJECTIVE: Traumatic hip dislocations are very rare in childhood and adolescence. The aim of this multi-centre study is to analyse the current epidemiology and injury morphology of a large number of traumatic hip dislocations in children. This can provide a better understanding of childhood hip dislocations and contribute to the development of a therapeutic approach in order to prevent long-term impacts. METHODOLOGY: This retrospective, anonymised multi-centre study included patients, aged up to 17 years, with acute traumatic hip dislocations and open growth plates. The patients came from 16 German hospitals. Exclusion criteria included insufficient data, a positive history of hip dysplasia, or an association with syndromal, neurological or connective tissue diseases predisposing to hip dislocation. An analysis was carried out on the patients' anthropometric data and scans (X-ray, MRI, CT), which were collected between 1979 and 2021. Gender, age at the time of dislocation, associated fractures, mechanism of injury, initial treatment including time between dislocation and reduction, method of reduction, treatment algorithm following reduction and all documented complications and concomitant injuries were evaluated. RESULTS: Seventy-six patients met the inclusion criteria. There were two age peaks at 4-8 years and 11-15 years. There was an increased incidence of girls in the under-eight age group, who had mild trauma, and in the group of over-eights there were more boys, who had moderate and severe trauma. Dorsal dislocation occurred in 89.9% of cases. Mono-injuries dominated across all age groups. Concomitant injuries rarely occurred before the age of eight; however, they increased with increasing ossification of the acetabulum and appeared as avulsion injuries in 32% of 11-15-year-olds. Of the 76 patients, 4 underwent a spontaneous, 67 a closed and 5 a primary open reduction. A reduction was performed within 6 h on 84% of the children; however, in around 10% of cases a reduction was not performed until after 24 h. Concomitant injuries needing intervention were identified in 34 children following reduction. Complications included nerve irritation in the form of sensitivity disorders (n = 6) as well as avascular necrosis (AVN) of the femoral head in 15.8% of the patients (n = 12). CONCLUSIONS: Traumatic hip dislocations are rare in childhood and adolescence and have high complication rates. The most severe complication, femoral head necrosis, occurred in 16% of cases. Minor injuries, especially in younger children, are enough to cause a dislocation. Posterior dislocation was more frequent and primarily occurred as a mono-injury; however, concomitant injuries must be considered with increasing age. Children continue to experience delayed reductions. The length of time until reduction, age and the severity of the concomitant injury play a role in the development of femoral head necrosis; however, this topic requires additional investigation.

A comparison of intervention and conservative treatment for angulated fractures of the distal forearm in children (AFIC): study protocol for a randomized controlled trial.

BACKGROUND: Angulated fractures of the distal forearm are very frequent lesions in childhood. Currently, there are no standard guidelines on whether these children should be treated conservatively with a cast; with reduction and a cast; or with reduction, pinning and a cast under anesthesia. Minor prospective and retrospective studies have shown that the distal physis of the forearm possesses high remodeling capacity leading to reliable correction of malalignment. The aim of this trial is to answer the question about whether operative and conservative treatment show equivocal results. METHODS/DESIGN: This is a prospective, multinational, multicenter, randomized, observer-blinded, actively controlled, parallel group trial, with 24 months of observation. The primary objective of this trial is to assess whether or not the long-term functional outcome in remodeling patients is inferior to patients receiving closed reduction and K-wire pinning. The trial should include 742 patients with acute fracture. The patients will be included in 30 medical centers in Germany, Switzerland and Austria. All patients 5 to 11 years of age presenting at the emergency department with an angulated distal fracture of the forearm will be randomized online after informed consent. The primary endpoint is the Cooney Score after 24 months. The secondary endpoint is the grade of radiological displacement at 12/24 months. DISCUSSION: Therapy of angulated fractures is a matter of intensive debate. Primary manipulation and pinning under general anesthesia is recommended in order to avoid malalignment. No major study has proven the advantage of manipulation and pinning over immobilization alone. Should remodeling appear to be a safe alternative, manipulation under general anesthesia, K-wire pinning and removal of pins could be avoided, thus sparing significant costs. TRIAL REGISTRATION: DRKS00004874 , 30 October 2013.