[X­ray of the thoracic and lumbar spine in injured children and adolescents : Incidence, fracture rates and therapeutic consequences]. / Röntgen der Brust- und Lendenwirbelsäule bei verletzten Kindern und Jugendlichen : Aufkommen, Frakturrate und Therapiekonsequenz.

INTRODUCTION: Usually, conventional radiographs are appropriate for injuries in the region of the thoracic and lumbar spine (TLS) in children and adolescents. The aim of our study was to determine the incidence of trauma-associated radiographic findings in this anatomical region and to present the therapeutic consequences. MATERIAL AND METHODS: In a retrospective cohort study (2007-2015) of a level 1 trauma center all children and adolescents (0-17 years) with a TLS-trauma, in which conventional radiographs were performed anteroposterior and lateral as the initial imaging modality, were included. RESULTS: In 396 children and adolescents conventional radiographs were performed, but only 5.6 % suffered a fracture. Conventional radiographs were performed in 188 cases of the thoracic spine, in 43 cases in the thoracolumbar junction and in 255 cases in the lumbar spine. On average, children and adolescents with fractures were 12.5 (5-17) years old. Fractures were classified as 38.7 % A1.1, 51.6 % A1.2, and 9.7 % were fractures of the transverse process. B and C fractures could not be detected. Of all fractures, 80 % were found in the mid-thoracic spine and the thoracolumbar junction. All fractures could be treated conservatively. CONCLUSION: With 5.6 % TLS-injuries in children and adolescents, the study revealed a low fracture rate in a highly radiosensitive region. With regard to an expected stable fracture morphology and the absent surgical consequences, the indication for emergency radiographs should be provided restrictively.

[Associated injuries with greater tuberosity fractures : Mechanism of injury, diagnostics, treatment]. / Begleitverletzungen bei Tuberculum-majus-Frakturen : Entstehungsmechanismus, Diagnostik, Therapie.

BACKGROUND: To date, little attention has been given to greater tuberosity fractures (GTFs) in the literature. Several mechanisms of injury are described, but few authors report that a GTF is accompanied by a high rate of often unrecognized associated injuries. OBJECTIVES: The aim was to document the incidence of dislocation, to diagnose associated injuries and, based on these, these draw conclusions about the mechanism of injury concerning GTF. PATIENTS AND METHODS: From 2007-2015 the detection of a shoulder dislocation, the fracture extent (displacement, fragments, size), associated injuries, and the surgical treatment of GTF and associated injuries were documented in 46 patients with GTF who were less than 65 years of age. After detection of associated injuries by computed tomography, magnetic resonance imaging (MRI) or arthroscopy it was decided if surgery was necessary or not. RESULTS: Shoulder dislocation was found in 46.2 % of patients with a 1-fragmentary GTF. Shoulder dislocation was found in 66.7 % of patients with a 2-fragmentary GTF and 100 % of patients with ≥3 fragments.. Typical injuries associated with dislocation were found in 90.7 %. In 52.6 % of these surgery was necessary. With or without dislocation, approximately the same prevalence of associated injuries was present (92.6 %; 87.5 %). With dislocation surgery for the associated injuries was necessary in 70.8 %; without dislocation surgery was necessary in 35.7 %. DISCUSSION: The reason for a GTF seems to be an anterior shoulder dislocation or partial dislocation. In multifragmentary GTF or GTF with dislocation surgery is necessary frequently; without dislocation surgery is necessary less frequently. Associated injuries should be searched for selectively. An arthroscopy could be performed for diagnosis and therapy. In a GTF that can be treated conservatively, an MRI should be performed.

[Reasons for proximal femoral fracture surgery delays : Analysis of the structured dialog in Rheinland-Pfalz]. / Verzögerte Versorgung hüftgelenknaher Femurfrakturen : Analyse des Strukturierten Dialogs Rheinland-Pfalz.

BACKGROUND: For the "preoperative stay" quality indicator , which is part of the external quality assurance for proximal femoral fractures (module 17/1), a tolerance range for surgery within 48 h after admission of ≤15 % is given. MATERIALS AND METHODS: The structured dialog (2014) in Rheinland-Pfalz was analyzed with respect to reasons for delaying surgery for more than 48 h after admission. RESULTS: A total of 331 cases were analyzed. In 60.7 % patient-related reasons and in 13.3 % administrative reasons were found. In 9.1 % the statements were not feasible. Due to a lack of software-related specifications in 7.3 % a wrong preoperative length of stay was generated. Wrong coding or a computer-related problem was found in 6.6 %. The most common reason for delay was the intake of an anticoagulant (25.7 %). CONCLUSION: The significance of the quality indicator "Preoperative stay" without division into whether this was administrative or patient-related must be considered critically.

[Length of hospital stay for patients with proximal femoral fractures : Influencing factors]. / Verweildauer von Patienten mit hüftgelenknahen Femurfrakturen : Beeinflussende Faktoren.

BACKGROUND: In departments of orthopedic and trauma surgery patients with proximal femoral fractures constitute the largest proportion of trauma patients. The length of stay (LOS) has economic consequences and prolonged LOS leads to a shortage in bed capacity. OBJECTIVES: In this study treatment and patient-related factors that influence the LOS of patients with proximal femoral fractures were investigated. MATERIAL AND METHODS: Treatment and patient-related data of 242 patients (age >64 years) were recorded retrospectively and included residential aspects, legal guardianship, time of admission and surgery, hospital mortality, LOS, diagnosis, comorbidities, medication, surgical treatment, general and surgical complications, intensive care therapy and American Society of Anesthesiologists (ASA) classification. RESULTS: Of the patients, one fifth came from a nursing home and were under supervised care or a healthcare proxy at the time of admission. Two thirds were admitted to hospital and operated on during on-call service periods. One half of the patients did not return to their previous domestic environment and were usually admitted to a nursing home. Patients who came from or were admitted to nursing homes, who were under healthcare supervision as well as patients who rapidly underwent surgery had a shorter LOS. Hospitalization and surgery during on-call service periods did not extend the LOS and showed a tendency towards reduction. Older age correlated with a longer LOS and surgical complications doubled the LOS. DISCUSSION: Surgical treatment during on-call service periods, short preoperative waiting times and avoidance of surgical complications shortened LOS and thus had an impact on costs and bed capacity.

[Injuries in children and adolescents in emergency services]. / Verletzungen bei Kindern und Jugendlichen im Bereitschaftsdienst.

BACKGROUND: A differentiated knowledge of trauma in children and adolescents is essential for the treatment of injured minors. The aim of this study was to present the focus of treatment in trauma emergency services. MATERIAL AND METHODS: Over a period of 2 years all acutely injured children and adolescents (n = 4784) in the emergency service were analyzed prospectively. The data were analyzed according to sex, age, date of examination, indications for x-ray imaging, diagnosis and therapy. RESULTS: Seasonal differences in the treatment spectrum were detected. In total 34.4 % of the patients presented with bruises/contusions, 23 % wounds, 19.9 % fractures, 14.9 % sprains/strains/ligament ruptures, 4.1 % craniocerebral trauma, 1.5 % dislocations, 1.1 % muscle/tendon injuries and 0.9 % burns. Of the patients 60 % underwent an x-ray examination and 8.3 % were hospitalized. Different injuries were found in the different age groups. Most fractures (25.7 %) were found at the distal forearm and most osteosyntheses (22.5 %) were also carried out at this anatomical location. CONCLUSION: Knowledge of the frequency and age dynamics is essential for competent treatment of injuries in children and adolescents. Analysis of the reality of the treatment in emergency services allows a much better evaluation of the requirements with respect to this clientele. The collected data can serve as a basis for the development of major capability foci, training concepts, treatment algorithms as well as prevention measures.

[Emergency radiographs in injured children and adolescents]. / Notfallröntgen bei verletzten Kindern und Jugendlichen.

BACKGROUND: Adequate interpretation of radiographs of injured children and adolescents is key for appropriate treatment. For the purposes of structuring in-hospital education and training, conventional radiographs obtained in the emergency department (ED) should be analyzed. MATERIAL AND METHODS: A total of 10,232 radiographs of children and adolescents (0-17 years old) were analyzed retrospectively. Data was analyzed according to sex, age, time, radiograph, and type of insurance. RESULTS: The male to female ratio was 3:2. In all, 76% of all radiographs were processed during on-call duty hours. Radiographs of the ankle were ordered most at a rate of 11%. Radiographs of the skull, wrist, finger, and ankle stood out from the sum of all radiographs and together accounted for 40%. CONCLUSION: Radiographs of injured children are analyzed predominantly during on-call duty hours. Frequently mandated radiographs should be diagnosed accurately and standard injuries should be well known. Particular attention should be directed to the typical injury patterns of the ankle joint.

[Early complication rate of fractures close to the hip joint. Dependence on treatment in on-call services and comorbidities]. / Frühkomplikationsrate bei hüftgelenknahen Frakturen. Abhängigkeit von der Versorgung im Bereitschaftsdienst und von Nebenerkrankungen.

BACKGROUND: Guidelines advocate early surgery for proximal femoral fractures so that operations are frequently performed in on-call duty times. Multimorbid patients also suffer more frequently from postoperative complications. Does on-call duty or night shift services correlate with higher postoperative complication rates and what influence do comorbidities have? PATIENTS AND METHODS: In 300 patients (> 65 years) postoperative surgical and non-surgical complications were documented and correlated with comorbidities, on-call duty and night shift service times. RESULTS: Postoperative complications were observed in 10.7 % of surgical and 62 % of non-surgical cases. Surgery in on-call duty and night shift times did not increase the postoperative complication rate. Comorbidities, age and ASA classification correlated with postoperative complications which significantly prolonged hospital stay. CONCLUSION: Surgery of proximal femoral fractures in on-call duty and night shift times is justified because postoperative complications are not increased. Comorbidities and higher age correlated with postoperative complications. Postoperative complications should be avoided because they result in prolonged hospital stay.

[Factors influencing course of hospitalization in patients with hip fractures: Complications, length of stay and hospital mortality]. / Einflussfaktoren auf den stationären Verlauf von Patienten mit hüftgelenknahen Femurfrakturen: Komplikationen, Liegezeit und Krankenhaussterblichkeit.

BACKGROUND: Time of surgery, age, sex, and co-morbidities influence the complication and mortality rate in patients with hip fractures. Patients with relevant co-morbidities, who were hospitalized at the weekend have a higher mortality rate. Complications prolong length of stay (LOS), which results in higher costs and shortage of bed capacity. OBJECTIVES: The influence of various factors on hospitalization with emphasis on complications, LOS, and clinical mortality should be observed. MATERIALS AND METHODS: Retrospectively, 242 patients with hip fractures (>64a) were observed. In addition to age and sex, time of hospitalization and surgery, intensive care therapy, hospital mortality, LOS, comorbidities, ASA, and complications were recorded. Times were assigned to the work week or the weekend or regular or on-call duty service. RESULTS: 29.8 % were hospitalized at the weekend, 66.1% on on-call duty, 24.1% were operated on the weekend, 67.4% on on-call duty. 86.3% were operated <48 h after admission. The mortality rate was 8.3%. Longer time to surgery results in more frequent intensive care therapy, prolongs the LOS, and increases overall complications. Advanced age increases mortality and LOS. A higher value of the ASA classification leads to increased mortality; co-morbidities lead to more frequent intensive care therapy. Surgical complications prolong LOS of 10.8d (86.4%). CONCLUSION: Hospitalization is influenced by age, ASA and co-morbidities as well as by time to surgery and operation in day or late and nighttime service. Early surgery and prevention of surgical complications reduce LOS.

[The DRG responsible physician in trauma and orthopedic surgery. Surgeon, encoder, and link to medical controlling]. / Der DRG-beauftragte Arzt in der Orthopädie und Unfallchirurgie. Operateur, Kodierer und Bindeglied zum Medizincontrolling.

BACKGROUND: Precise coding is an essential requirement in order to generate a valid DRG. The aim of our study was to evaluate the quality of the initial coding of surgical procedures, as well as to introduce our "hybrid model" of a surgical specialist supervising medical coding and a nonphysician for case auditing. MATERIALS AND METHODS: The department's DRG responsible physician as a surgical specialist has profound knowledge both in surgery and in DRG coding. At a Level 1 hospital, 1000 coded cases of surgical procedures were checked. RESULTS: In our department, the DRG responsible physician who is both a surgeon and encoder has proven itself for many years. The initial surgical DRG coding had to be corrected by the DRG responsible physician in 42.2% of cases. On average, one hour per working day was necessary. CONCLUSION: The implementation of a DRG responsible physician is a simple, effective way to connect medical and business expertise without interface problems. Permanent feedback promotes both medical and economic sensitivity for the improvement of coding quality.

[Treatment duration of trauma and orthopedic patients in an emergency department]. / Behandlungsdauer orthopädisch-unfallchirurgischer Patienten in der Notaufnahme.

INTRODUCTION: The majority of emergency patients are admitted to hospital via the emergency department. Overcrowding in emergency departments results in dissatisfied patients, increased complication rates, and negative medicoeconomic consequences. To overcome these problems, sufficient personnel strength should be available depending on treatment duration and the patients' characteristics. MATERIALS AND METHODS: First, trauma and orthopedic patients were classified into six categories: ABT (history, findings, and therapy), RABT (X-ray and ABT), WABT (wound care and ABT), WRABT (wound care and RABT), STAT (hospital admission), and SR (trauma life support). Furthermore, the duration of medical treatment was correlated with the physicians' educational level (specialist or physician in training after or during the common trunk period). Not included were waiting periods and nursing care measures. After analyzing the frequency of each category, the mean duration of treatment for an"average patient" was determined. RESULTS: The duration of treatment of 900 patients was recorded. The average times were 9.5 min (ABT), 13.8 min (RABT), 17.3 min (WABT), 24.5 min (WRABT), 38.4 min (STAT), and 84.2 min (SR). The frequencies for the different categories were: ABT 18.8%; RABT 50.2%; WABT 14.5%; WRABT 4.4%; STAT 10.6%, and SR 1.4%. Thus, an average duration of medical treatment of 17.6 min was calculated. Especially in the RABT category, significant differences between specialists and physicians in training were evident. In children and adolescents, the duration of treatment was 12.5 min. CONCLUSION: The duration of treatment of an average trauma and orthopedic patient depends on the level of care of the hospital and the qualification of the physician in charge. In order to avoid negative consequences of overcrowding in emergency departments, adequate personnel strength is essential. Personnel strength should be calculated based on the average duration of medical treatment of about 18 min.

Mortality after proximal femur fracture with a delay of surgery of more than 48 h.

PURPOSE: For hip fractures, guidelines require surgery as soon as possible, but not later than 48 h. Some authors observed a positive and some a negative effect of early operation on mortality rate. The aim was to evaluate the mortality rate of patients with a delay of surgery >48 h after admission, as well as influencing factors and reasons for delay. METHODS: One hundred and thirty-six patients with hip fractures (>65a) from 2007 to 2011 were included. Comorbidities, the American Society of Anaesthesiologists (ASA) classification, time of admission and surgery, and mortality were recorded up to 12 months. Reasons for delay were divided into administrative-related or patient-related. The following time intervals were observed: 48.01-72 h (2-3 days), 72.01-120 h (3-5 days), 120.01-168 h (5-7 days), 168 h (>7 days). RESULTS: 94.9 % of the reasons for delay were patient-related. The mean survival times of the first three intervals were almost the same (9.5-9.9 months) (p = 0.75). The last group had a significantly shorter survival time (7.8 months). Summarizing the first three groups, a significant shorter (p = 0.03) survival time and significantly higher (p = 0.04) 12-month mortality rate in patients with a delay >7 days was observed. The probability of death was primarily dependent on the ASA classification (p < 0.0001) and secondarily on the patient's age at the time of injury (p = 0.005). CONCLUSIONS: In hip fractures, reasons for a delay >48 h are mainly patient-related. A delay up to 7 days did not influence survival time and mortality negatively. The higher the value of the ASA classification and the older the patient was at the time of injury, the higher the mortality rate and the shorter the survival time.

[ProFI reduction of pediatric pulled elbow]. / Die ProFI-Reposition der Pronatio dolorosa infantum.

BACKGROUND: Pulled elbow is a common injury in children under the age of 5 years which is usually treated by manual reduction. Supination of the forearm is recommended as opposed to pronation or other maneuvers. The author has developed a manipulative intervention for reduction of pulled elbow in young children on the basis of the pronation technique and called ProFI reduction. PATIENTS AND METHODS: The ProFI method was performed on 41 children and the group was analyzed prospectively according to effectiveness of the ProFI repositioning. RESULTS: Among the 41 children the initial diagnosis was incorrect in 7 cases (17%) and in 11 children (27%) more than one doctor's visit was necessary to reposition successfully. Repositioning with the ProFI method was immediately successful in all cases. CONCLUSION: The application of the ProFI method as a modified pronation technique was shown to provide excellent effectiveness with respect to the patients treated.

[Posterocentral approach to the posterior tibial plateau. Reconstruction of tibial plateau fractures and avulsions of the posterior cruciate ligament]. / Posterozentraler Zugang zum dorsalen Tibiakopf. Rekonstruktion dorsaler Tibiakopffrakturen und Avulsionen des hinteren Kreuzbandes.

BACKGROUND: For surgical treatment of posterior shearing tibial plateau fractures and avulsion fractures of the posterior cruciate ligament (PCL) a posterocentral approach without dissection or separation of the heads of the gastrocnemius muscle is used. The aim of this study was an evaluation of this approach. PATIENTS AND METHODS: From 2001-2012 a total of 33 patients were surgically treated using a posterocentral approach to the dorsal knee joint. Of these patients 22 had a posterior shearing tibial plateau fracture and 11 had an avulsion fracture of the PCL. The fracture type, complications, expertise of the surgeon, fracture healing, implant position and irritation, nerve lesions, scar tissue and range of motion were documented. RESULTS: Hypesthesia around the scar, at the lateral foot and lower lateral leg were observed in one each of three patients. Despite two ventral implant infections no infection of the dorsal implant occurred. All scar tissue was without pathological findings and scar contracture was not observed. In three cases the screw tips at the anterior proximal tibia were palpable but without complaints from the patients. CONCLUSIONS: The posterocentral approach showed a low complication rate in the hands of experienced surgeons. The soft tissue cover seems to prevent implant infections.

[Proximal femoral fractures in the German external quality assurance module 17/1: reasons for delay in surgery]. / Hüftgelenknahe Femurfrakturen im Qualitätssicherungsmodul 17/1: Ursachen der verlängerten präoperativen Verweildauer.

BACKGROUND: For the quality indicator "preoperative stay" a part of the external quality assurance for proximal femoral fractures (module 17/1), a tolerance range for surgery within 48 h after admission of ≤ 15 % is given. MATERIALS AND METHODS: Over a period of 5 years all cases were analyzed with respect to reasons for delayed surgery of more than 48 h after admission. RESULTS: A total of 165 patients (16%) out of 1,036 documented cases had surgery later than 48 h after admission. Reasons were pathological bleeding, preoperative poor general condition, lack of informed consent, intake of metformin and lacking initial radiological detection of fractures. Due to a lack of software-related specifications in ten patients a wrong preoperative length of stay was generated. CONCLUSION: The significance of the quality indicator "preoperative stay" without division into whether this was administrative or patient-related must be considered critically. For fall-related fractures in hospital the time of the accident or diagnosis should be considered.

[Assessment of prehospital injury severity in children: challenge for emergency physicians]. / Präklinische Einschätzung der Verletzungsschwere bei Kindern: Herausforderung für Notärzte.

BACKGROUND: The prognosis of polytraumatized patients is dependent on the quality of emergency room (ER) management and a smooth transition from prehospital to ER therapy is essential. The accurate assessment of prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. It also helps to ensure that medical resources are immediately available. Overestimation of injury severity wastes resources and underestimation puts patients at risk. The assessment of prehospital injury severity in adults is unreliable. In children, the assessment of injury severity seems to be even more challenging. MATERIALS AND METHODS: For the comparison of the prehospital documented injury severity and injury severity diagnosed after the ER phase, the injury severity score (ISS) and trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the revised trauma score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the abbreviated injury scale (AIS). The concordance of the injury severity within different tolerances was evaluated. A tolerance of the prehospital documented injury severity of more than ± 25 % to the injury severity calculated after ER diagnostics was considered as overestimation or underestimation. The concordance of the prehospital documented diagnosed injury severity and the severity diagnosed after the ER phase of different body regions according to the AIS was evaluated. The documented mechanism of injury in the emergency physician protocol was judged as being detailed, satisfactory or poor. RESULTS: The results showed that 69 % of the children reached the ER during on-call hours. Furthermore 92 % of the children reached the ER during the daytime between 08.00 h and 20.00 h. The transportation of 25 % of the children was on a private basis. The mean ER-ISS was 10 points (range 1-57). In 42 % of cases the ISS of the emergency physician protocol within a tolerance of ± 25 % was concordant with the ER-ISS. According to this criterion in 38 % of cases an overestimation of the assessment of the injury severity of the emergency physician was found and in 20 % an underestimation. Within a tolerance of ± 75 % based on the ER-ISS, the ISS of the emergency physician protocol was concordant in more than half of the cases (52 %). Using the TRISS with a tolerance of ± 25 % a concordance was observed in 46 % of the cases. Within a tolerance of ± 50 % based on the ER-ISS the ISS calculated after ER diagnostics was concordant in 50 % of the cases. A high concordance of the prehospital and hospital injury severity was found in the region of the face (75 %). The concordance in the body regions of the head, thorax, extremities and pelvis and soft tissue ranged between 43 % and 50 % of the cases. Of the children 38 % suffered a traffic accident, 52 % a fall of less than 3 m and 10 % of more than 3 m. The mechanism of injury was documented in detail in 70 % and satisfactory in 8 %. CONCLUSIONS: The assessment of prehospital injury severity in children is unreliable. In order to evaluate injury severity the use of anatomical trauma scores alone is insufficient. The adequate documentation of the mechanism of injury implies that the mechanism of injury seems to play a relevant role in the assessment of prehospital injury severity. The unreliable assessment of the injury severity, the arrival in the ER in on-call hours and the private transport to the hospital is a challenge to the ER leader in trauma life support for children.

Mortality and quality of life after proximal femur fracture-effect of time until surgery and reasons for delay.

INTRODUCTION: Studies yield conflicting results from the effect of early surgery on mortality. Some observed a positive, others a negative and some did not find any effect of early operation. In this study, mortality and quality of life in relation to time until surgery as well as reasons for delay were observed prospectively. MATERIAL AND METHODS: Data of 138 patients (>65 years) with proximal femoral fractures and consecutive surgery were observed. Demographic data as well as mortality rate, survival time and Barthel Index up to 1 year in relation to different time frames were observed. Reasons for operative delay were divided into being administrative or patient-related. RESULTS: Three-month mortality was 10.1% and 1-years was 23.9%. Neither time from injury until hospital admission nor from injury until surgery or from hospital admission until surgery up to 48 hours had any effect on mortality and survival time. The age of patients dying in the follow-up period was significantly higher than the age of patients surviving (86.8 vs. 84.4 years). No influence of any delay in time until surgery on the Barthel Index was observed. CONCLUSION: In proximal femoral fractures, a delay of surgery up to 48 hours did not influence mortality and Barthel Index negatively, nor did other associating factors. Only the patients age at the time of injury influences mortality rate, survival time, and Barthel Index significantly. The older the patient at the time of injury; the higher the mortality rate, the shorter the survival time and the lower the Barthel Index.

[Pediatric calcaneal fracture after supination trauma: conservative therapy with an orthosis]. / Kalkaneusfraktur im Kindesalter nach Umknicktrauma : Behandlungsalternative mittels Kalkaneusfrakturorthese.

We report the case of a 12-year-old boy with a calcaneal fracture due to a simple supination trauma. As magnetic resonance imaging (MRI) showed a non-displaced extra-articular fracture no surgical treatment was necessary. A conservative therapy using calcaneal fracture orthosis with full weight bearing was carried out. Using this procedure allowed a comfortable means of movement without the need for a plaster cast immobilization or forearm crutches accompanied by a rapid return of the child to the normal daily routine.

[Avulsion fracture of the lesser trochanter]. / Traumatische Apophysenlösung des Trochanter minor.

An avulsion fracture of the lesser trochanter is a very rare injury often misdiagnosed as a muscle lesion or hip distortion. This report concerns the avulsion fracture of the lesser trochanter of a 13-year-old boy, suffered on a runway preparing for a long jump. Conservative treatment without weight-bearing was indicated for 6 weeks. Twelve weeks after the injury the patient resumed his normal sport activities.

[The mature twoplane and triplane fracture. Transitional fractures of the distal tibia combined with typical fracture patterns of adults]. / Die reife Two- und Triplane-Fraktur. Eine Kombination aus Übergangsfraktur und Erwachsenenfraktur der distalen Tibia.

Physiologic closure of the growth plate of the distal tibia occurs between the ages of 12 and 14 years in girls and 1 year later in boys. The closure of the tibial physis starts eccentrically at the ventrolateral zone of the medial malleolus extending dorsally and ends laterally. Therefore, the anterolateral zone is the last to ossify. The process of closure lasts about 18 months. During this period the growth plate loses its joint-protective function and transitional fractures may occur. The more the closure progresses the more lateral the location of the fracture. In addition to the typical transitional fractures, typical fracture patterns of adults in the ossified physis are possible due to a mature bone structure. We report two cases of transitional fractures combined with typical fracture patterns of adults due to a dorsomedial ossified physis in the distal tibia.

[Dorsomedial talocalcaneal coalition: a rare condition]. / Dorsomediale talokalkaneare Koalition: Ein seltenes Krankheitsbild.

Talocalcaneal coalitions are rare but a posterior facet talocalcaneal coalition is even rarer. There are three different types: fibrous, cartilaginous and osseous coalitions. Besides conventional x-rays computed tomography is essential for assessment of the subtarsal joint. In the absence of concomitant coalitions and foot deformity resection of the coalition is advocated due to good clinical results when there is an adequate size of the talocalcaneal joint (>50%) and without osteoarthrosis. A case of a rare posterior facet talocalcaneal coalition is reported.