[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.

[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.

Simple traumatic elbow dislocations; benefit from early functional rehabilitation: A systematic review with meta-analysis including PRISMA criteria.

INTRODUCTION: Elbow dislocation is the second most frequent joint dislocation after shoulder dislocation. They have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed.The purpose of this systematic review and meta-analysis was to review the literature and analyze the evidence of early functional rehabilitation. METHODS: A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified and evaluated in a stepwise approach. Of these publications 29 met the inclusion criteria of the authors and described simple elbow dislocations in 5765 patients.Data from the studies and subgroups included were initially categorized descriptively in conservative and surgical primary therapies, in immobilizing (immobilization lasting 2 weeks or longer) and free-functional follow-up treatments, and those data were then extracted from each subgroup in absolutes. We then pooled these numbers into descriptive statistics to ensure their comparability. We determined the success rates from the numbers of excellent and good results of the specific used outcome scores. RESULTS: The effect estimate of the conservative therapy's success rate was 84% and for surgical treatment 80% (P < .0001). The difference between the immobilizing treatment (78% success rate) and early-function therapy (83% success rate) was significant (P = .002).In a subgroup analysis the success rate of conservative and immobilizing therapy was 79%, of conservative and early-functional therapy 91%, of surgical and immobilizing groups' was 77% and of the surgical and early-functional therapies was 93%. The difference among the 4 treatment options was significant (P < .0001), as were differences between the 2 conservative groups (P < .0001) and between the 2 surgical groups (P = .044). DISCUSSION: Conservative therapy is the dominant therapy. Regardless of the primary therapy chosen in simple elbow dislocations: early functional follow-up care seems to be superior to immobilizing therapy with a duration more than 2 weeks.

[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.

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.

[Pale and pulseless hand after luxation of the left elbow in a 9­year-old boy]. / Blasse und pulslose Hand nach Luxation des linken Ellenbogens bei einem 9­jährigen Jungen.

BACKGROUND: Luxation of the elbow occurs around the age of 7 years instead of a supracondylar humeral fracture. The most common complication is a fracture of the medial epicondyle of the ulna in the sense of a bony avulsion of the ligament. There are only few case reports regarding collateral injuries of the brachial artery. All authors have described this complication as being very rare. CASE REPORT AND LITERATURE SEARCH: This article reports the case of a 10-year-old boy, who suffered a dorsal luxation of the left elbow. After reduction the left hand was noticeably pale and cold. The diagnostics showed a complete rupture of the brachial artery, associated with a dislocated fracture of the medial epicondyle of the ulna. In addition to the case report, the available literature concerning traumatic rupture of the brachial artery in pediatric elbow dislocation was evaluated. RESULTS: Because of the results of the clinical examination and the Doppler examination with a lack of blood flow in the brachial artery of the left arm, computed tomography angiography was directly performed. The result was a complete interruption of the brachial artery at the level of the left elbow. The brachial artery rupture was treated using a local vein graft from the brachial vein. The fracture of the medial epicondyle of the ulna was treated by open reduction and an osteosynthesis with Kirschner (k) wires was performed. DISCUSSION: The clinical suspicion of an injury of the brachial artery justifies a rapid diagnostic investigation by CT angiography and an open vascular intervention as the only possibility to recreate a sufficient blood flow.

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.

[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.

Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents-A systematical review and meta-analysis.

BACKGROUND: Fractures of the proximal humerus in patients under the age of 18 years show a low incidence; existing clinical studies only comprise small patient numbers. Different treatment methods are mentioned in the literature but a comparison of the outcome of these methods is rarely made. Up to now, no evidence-based algorithm for conservative and operative treatment is available. The aim of this systematic review with meta-analysis was therefore to gather the best evidence of different treatment methods and their associated functional outcome, complication rates, rates of limb length discrepancies and radiological outcome. METHODS AND FINDINGS: The OVID database was systematically searched on September 30th in 2016 in order to find all published clinical studies on the subject of proximal humerus fractures of patients ≤18 years. Exclusion criteria were previously defined. The Coleman Methodology Score was used to evaluate the quality of the single studies. 886 studies have been identified by the search strategy. 19 studies with a total of 643 children (mean age: 11.8 years) were included into the meta-analysis with a mean Coleman Methodology Score of 71 ± 7.4 points. 18 of the 19 studies eligible for inclusion were retrospective ones, of the best quality available (mean follow-up ≥ 1 year, mean follow-up rate ≥ 65%). 56% of the patients were male. Proximal humerus fractures were treated conservatively in 41% and surgically in 59% of the cases (Elastic Stable Intramedullary Nailing (ESIN): 31%; K-wires: 20%; 8% other methods, e.g. plate osteosynthesis, olecranon traction). The overall success rate (good/excellent outcome) for all treatment methods was 93%. The success rate of ESIN (98%) and of K- wire fixation (95%) was significantly higher (p = 0.01) than the success rate of conservative treatment options (91%). A subgroup analysis of severely displaced fractures (Neer grade III/IV, angulation ≥ 20°) resulted in a change of success rates, to the disadvantage of conservative treatment methods (conservative treatment 82%, ESIN 98%, K-wires 95%; p < 0.001). Complication rates did not differ to a significant extent. 9% of the complications occurred in the patients treated by K-wire fixation, 8% if a conservative treatment option was chosen and 7% in the fractures that were stabilized by ESIN. A change from a one-nail technique to a two-nail technique reduced the complication rate of ESIN significantly. Follow-up X- rays without residual deformity could be found in 96% of the patients treated by ESIN, a rate which was higher than in the patients treated conservatively (93%) or by K-wire fixation (88%). The rate of arm length discrepancies at final follow- up was lower if the fractures were stabilized by ESIN (4%) than if they were treated conservatively (9%) or by K-wires (19%). An evaluation of age-dependent treatment options was performed. CONCLUSIONS: By performing this meta-analysis an evidence-based treatment algorithm could be introduced to treat the fractures according to the severity of displacement and according to the patient's age. For severely displaced fractures ESIN is the method of choice, with the best clinical and radiological outcome.

Interprofessional approach for teaching functional knee joint anatomy.

Profound knowledge in functional and clinical anatomy is a prerequisite for efficient diagnosis in medical practice. However, anatomy teaching does not always consider functional and clinical aspects. Here we introduce a new interprofessional approach to effectively teach the anatomy of the knee joint. The presented teaching approach involves anatomists, orthopaedists and physical therapists to teach anatomy of the knee joint in small groups under functional and clinical aspects. The knee joint courses were implemented during early stages of the medical curriculum and medical students were grouped with students of physical therapy to sensitize students to the importance of interprofessional work. Evaluation results clearly demonstrate that medical students and physical therapy students appreciated this teaching approach. First evaluations of following curricular anatomy exams suggest a benefit of course participants in knee-related multiple choice questions. Together, the interprofessional approach presented here proves to be a suitable approach to teach functional and clinical anatomy of the knee joint and further trains interprofessional work between prospective physicians and physical therapists as a basis for successful healthcare management.

Complications after surgical management of distal lower leg fractures.

BACKGROUND: Osseous healing of distal lower leg fractures can be prolonged and is often associated with wound healing problems because of the marginal soft - tissue and vascular supply in this area. Postoperative complications are frequent, and according to the literature, open reduction and plate fixation is thought to be associated with higher complication rates. The objective of this study was to evaluate the most common postoperative complications following intramedullary nailing or plate osteosynthesis of distal lower leg injuries with a focus on combined tibio-fibular fractures. The outcomes of patients with and without complications associated the two surgical techniques were compared. METHODS: During a 5-year period, all surgically treated distal tibiofibular fractures were retrospectively collected from the clinical database and were evaluated for the presence of postoperative complications which included compartment syndrome, wound infection, delayed union and non-union, synostosis and rotational malalignment. Postoperative complications were reviewed and correlated with patient risk factors. RESULTS: A total of 199 patients were included in the study, and 75 complications were reported. The majority of complications were associated with closed fracture types treated with intramedullary nailing, delayed union being the most frequent. For open fractures, surgical treatment with plate fixation had a complication rate of 12% compared with 25% after intramedullary nailing. DISCUSSION: In general, distal lower leg fractures are associated with a high risk of postoperative complications. Distal diaphyseal tibial fractures that have been treated with intramedullary nailing devices have a higher risk of delayed union or non - union. CONCLUSION: Plate fixation in distal metaphyseal fractures has a higher risk of problems related to wound healing and postoperative wound infections.

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.

Biomechanical comparison of different external fixator configurations for stabilization of supracondylar humerus fractures in children.

BACKGROUND: Currently, closed reduction and percutaneous pinning are considered the treatment of choice for displaced supracondylar humerus fractures. However, indications exist for the use of external fixation with Schanz screws. In this in vitro study, we evaluate the biomechanical properties of a new variation for external fixation and compare them to an established construct. METHODS: Twenty distal cadaver humeri (10 pairs) were allocated to 2 groups. The humeri of the first group were fixed by an external fixator consisting of Schanz screws and an oblique K-wire inserted from the distal radial cortex of the humerus, those of the second group were fixed by a new variation with the oblique K-wire inserted from the distal ulnar cortex of the humerus. Displacement and stiffness in static loading in internal and external rotation, as well as in extension and flexion were evaluated and compared. FINDINGS: The variation of the external fixator of the second group proved to be statistically significantly superior to the variation of the first group in internal rotation loading (p>0.05). In sagittal loading conditions and external rotation loading, the variations were equally stable (p>0.05). There was no significant effect of the samples' bone density on displacement and stiffness values in any direction of loading. INTERPRETATION: In cases of pediatric supracondylar humerus fractures when an external fixator is used for osteosynthesis, the insertion of an additional ulnarly inserted anti-rotation K-wire should be preferred to a radially inserted one as it reduces secondary displacement of the distal fragment.

The Lumbar Spine as a Dynamic Structure Depicted in Upright MRI.

Spinal canal stenosis is a dynamic phenomenon that becomes apparent during spinal loading. Current diagnostic procedures have considerable short comings in diagnosing the disease to full extend, as they are performed in supine situation. Upright MRI imaging might overcome this diagnostic gap.This study investigated the lumbar neuroforamenal diameter, spinal canal diameter, vertebral body translation, and vertebral body angles in 3 different body positions using upright MRI imaging.Fifteen subjects were enrolled in this study. A dynamic MRI in 3 different body positions (at 0° supine, 80° upright, and 80° upright + hyperlordosis posture) was taken using a 0.25 T open-configuration scanner equipped with a rotatable examination bed allowing a true standing MRI.The mean diameter of the neuroforamen at L5/S1 in 0° position was 8.4 mm on the right and 8.8 mm on the left, in 80° position 7.3 mm on the right and 7.2 mm on the left, and in 80° position with hyperlordosis 6.6 mm (P < 0.05) on the right and 6.1 mm on the left (P < 0.001).The mean area of the neuroforamen at L5/S1 in 0° position was 103.5 mm on the right and 105.0 mm on the left, in 80° position 92.5 mm on the right and 94.8 mm on the left, and in 80° position with hyperlordosis 81.9 mm on the right and 90.2 mm on the left.The mean volume of the spinal canal at the L5/S1 level in 0° position was 9770 mm, in 80° position 10600 mm, and in 80° position with hyperlordosis 9414 mm.The mean intervertebral translation at level L5/S1 was 8.3 mm in 0° position, 9.9 mm in 80° position, and 10.1 mm in the 80° position with hyperlordosis.The lordosis angle at level L5/S1 was 49.4° in 0° position, 55.8° in 80° position, and 64.7 mm in the 80° position with hyperlordosis.Spinal canal stenosis is subject to a dynamic process, that can be displayed in upright MRI imaging. The range of anomalies is clinically relevant and dynamic positioning of the patient during MRI can provide essential diagnostic information which are not attainable with other methods.

Outcome and risk factors in children after traumatic cardiac arrest and successful resuscitation.

INTRODUCTION: Prospective collected data of the TraumaRegister DGU(®) were analyzed to derive survival rates and predictors for non-survival in the children who had suffered traumatic cardiorespiratory arrest. Different time points of resuscitation efforts (only preclinical, in the emergency room (ER) or preclinical+ER) were analyzed in terms of mortality and neurological outcome. METHODS: The database of the TraumaRegister DGU(®) comprising 122,742 patients from 1993 to 2013 was analyzed. The main focus of this survey was on the paediatric group defined by an age ≤ 14 years who could be compared to adults. Different statistical analysis (univariate and multivariate analysis, logistic regression) were performed with mortality as the target variable. Differences between the paedatric group and adults were analysed by Fisher's exact test. RESULTS: Data after preclinical and/or ER resuscitation from 152 children and 1690 adults were analyzed. A good or moderate outcome (GOS 5+4) was found in 19.4% of the children's group compared to 12.4% of the adults (p=0.02). Analysis of the GOS 5+4 subgroups after preclinical resuscitation only revealed that these outcomes were achieved by 19.4% of the paediatric group and 13.2% of the adults (p=0.24), after ER-only resuscitation by 37.0% of the children and 19.6% of the adults (p=0.046), and after preclinical and ER resuscitation by only 10.9% of the children compared to 2.5% of the adults (p=0.006). Taking only survivors into account, 84.8% of the children and 62% of the adults had a GOS 4+5. The highest risk for mortality in the logistic regression model was associated with preclinical intubation, followed by GCS 3, blood transfusion and severe head injury with AIS ≥3 and ISS. CONCLUSIONS: CPR in children after severe trauma seems to yield a better outcome than in adults, and appears to be more justified than the current guidelines would imply. Resuscitation in the ER is associated with better neurological outcomes compared with resuscitation in a preclinical context or in both the preclinical phase and the ER. Our children's outcomes seem to be better than those in most of the earlier studies, and the data presented might support algorithms in the future especially for paediatric resuscitation.

Biomechanical evaluation of a new technique for external fixation of unstable supracondylar humerus fractures in children.

BACKGROUND: Closed reduction and percutaneous pinning is regarded as the treatment of choice for unstable supracondylar humerus fractures, but there are cases in which the use of external fixation is preferable. OBJECTIVE: The aim of this study was to investigate whether the method of external fixation could be considered as a stable alternative to percutaneous pinning and whether there was a difference in stability between two different external fixator constructs. METHODS: Eighteen synthetic humeri were allocated to three groups of six bones each. The specimens of group 1 were fixed by crossed pinning, those of group 2 by a new variation of an external fixator and the specimens of group 3 by an established variation of it. Osteotomy displacement was measured under static loading in internal and external rotation, as well as in extension and flexion. RESULTS: The external fixators proved to be significantly more stable than crossed pinning in sagittal loading. In internal rotation loading the new variation of the external fixator showed the best results. CONCLUSIONS: In case of fractures that can't be replaced by closed reduction the new variation of external fixator should be preferred to the established variation or open reduction and crossed pinning.

Biomechanical testing of an innovative fixation procedure to stabilize olecranon osteotomy.

UNLABELLED: For the treatment of distal humerus an approach involving olecranon osteotomy is frequently preferred as it offers a clearer view, especially in cases of complex intraarticular fractures. It is however associated with the high risk of osteotomy-related complications such as nonunion, delayed healing, implant failure and migration of wires. The aim of the present study was to evaluate the stability of different new procedures that stabilize olecranon osteotomy compared with conventional tension band wiring. We hypothesize that the new implants provide equivalent stability as the conventional tension band wiring. To test the hypothesis 27 biomechanically evaluated synthetic ulnae were osteotomized and stabilized with either the application of tension band wiring, the Olecranon Hook LCP (Synthes, Switzerland), or the Olecranon Osteotomy nail (Synthes, Switzerland). Loading was performed providing a tensile load to simulate the tensile force applied by the triceps muscle. Cyclic force-controlled loading was performed at 300 alternating forces between 10N and 500N at a speed of 200N/sec. An ultrasound-based system measured displacement to an accuracy of 0.1 mm. Statistical analysis showed significantly less displacement in the Olecranon Hook LCP and Olecranon Osteotomy nail groups compared with tension banding. Comparison of plate and nail yielded no differences in stability. Biomechanical testing did however show significantly higher stability for newer fixation methods for olecranon osteotomies compared with the frequently applied technique of tension band wiring. Whether the use of these implants will also lower complication rates remains to be evaluated in future clinical studies. LEVEL OF EVIDENCE: Basic Science Study, Biomechanical Study.