[Kirschner wire osteosynthesis for fractures in childhood: bury wires or not? : Results of a survey on care reality in Germany]. / Kirschner-Draht-Osteosynthese bei Frakturen im Kindesalter: Drähte versenken oder nicht? : Ergebnisse einer Umfrage zur Versorgungsrealität in Deutschland.

INTRODUCTION: Kirschner wire osteosynthesis is considered to be the standard technique for surgical fixation of displaced supracondylar humeral and distal radial fractures in children. The Kirschner wires can be left exposed or buried under the skin. Advantages of the epicutaneous technique are, e. g. the efficiency (cost, effort) and the possibility for wire removal without the necessity of a second anesthesia. On the other hand, there is a concern about higher infection rates as well as traumatization of the children due to externally visible wires. METHODS: A web-based survey of members of the DGU, DGOU, DGOOC, and the pediatric traumatology section of the DGU (SKT) was performed to evaluate current treatment concepts in Germany. The pros and cons for each technique were recorded and the need for a clinical study was examined. In addition, a cost analysis was performed for both methods. The results from the literature are summarized and discussed. RESULTS: A total of 710 questionnaires were evaluated. The majority of the respondents were trauma surgeons working in a hospital (80%). The buried technique was superior in both fracture groups (supracondylar humeral fractures 73% and distal radius fractures 69%), whereas a relevant difference could be found depending on the profession. The main reason for the subcutaneous technique was anxiety or observed higher infections using the epicutaneous technique. CONCLUSION: In Germany, the majority of wires are buried under the skin due to a fear of higher infection rates. In addition, other influencing factors such as pain and traditional approaches play a significant role. With respect to the results in the literature as well as a possible improvement of efficiency and avoidance of a second anesthesia, a multicentric clinical study seems necessary in the future to compare both techniques.

[Transitional fractures : Epiphyseal injuries in adolescence]. / Übergangsfraktur : Epiphysenverletzungen im Adoleszentenalter.

The so-called transitional fractures describe articular fractures in adolescents with partial closure of the epiphyseal growth plate. This shows a specific stereotype fracture pattern, which can be differentiated into biplane, triplane I and triplane II fractures depending on the involvement of the metaphysis and the number of fragments. The diagnostics and therapy can differ from fractures where the epiphyseal growth plate is still open. The main focus for surgical treatment is the reconstruction of the articular surface whereas relevant growth disturbances no longer need to be feared when the epiphysis has already begun to close.

[Growth behavior after femoral shaft fractures: feasibility of patient therapy targets]. / Wachstumsverhalten nach Oberschenkelschaftfrakturen: Umsetzbarkeit von Patiententherapiezielen.

BACKGROUND: The treatment of femoral shaft fractures has increasingly become a domain of surgical therapy. On the one hand the possibilities of spontaneous correction of shaft axis deviation and rotation are limited and on the other hand leg length differences are often observed as a result of shaft fractures, which can lead to relevant consequences for spinal and pelvic statics. OBJECTIVES: Is there a benefit from the increasing trend towards surgical therapy and what treatment options are currently available for the treatment of femoral shaft fractures? MATERIAL AND METHODS: Analysis of treatment recommendations and a literature search of the last decades. RESULTS AND DISCUSSION: Newly developed implants currently provide a variety of methods for osteosynthesis for each age group and each fracture type. This allows a better fracture, weight and age adjusted retention of fractures with increased stability and a lower risk of post-traumatic leg length differences. Secondary effects are prompt mobilization and reintegration in the social environment of patients and hence a better achievement of their own therapeutic goals.

Triplane fractures: do we need cross-sectional imaging?

INTRODUCTION: Diagnosis of Triplane fractures remains difficult in common practice. Aim of the study was the evaluation of the fracture pattern and the benefit of cross-sectional imaging in classification of Triplane-fractures. MATERIAL AND METHODS: A total of 27 pediatric patients treated for ankle fractures were identified from patient charts. Radiographic images of epiphyseal fractures (X-rays and additional cross-sectional imaging) were blinded evaluated by 13 observers to answer a specific questionnaire regarding type or fracture and treatment suggestion. RESULTS: There were seven Triplane-I and eight Triplane-II fractures. The other physeal ankle fracture group consisted of four patients with a Twoplane-fracture, five Salter-and-Harris (SH) II, one SH-III, and two SH-IV fracture. Accuracy of classification improved considerably depending on the experience of the observer in pediatric trauma care. Surgeons specialized in pediatric trauma care classified correctly with conventional X-rays in 48.1 % of all cases presented versus 31.5 % appropriate diagnosis by younger fellows. Accuracy in exact specification of Triplane-fractures was comparable lesser in younger fellows (31.1 vs. 22 %). Cross-sectional imaging improved classification of all fractures in both groups (75.6 % specialized vs. 47.3 % non specialized). Whereas availability of cross-sectional imaging improved treatment recommendation in specialized surgeons this benefit was not detectable for the doctors without specialization. Evaluation of fracture pattern showed a relatively stereotypical fracture pattern in Triplane-II fractures, whereas Triplane-I fractures were more variable. CONCLUSION: The additional information of cross-sectional imaging seems helpful for any physician in finding the right classification of a pediatric ankle fracture. However, the additive information appears especially viable for experienced surgeons to suggest the appropriate treatment.

[Distal humerus fractures in children]. / Distale Humerusfrakturen beim Kind.

Fractures of the distal humerus belong to the most common injuries of the upper arm in childhood. Most frequently occurring is the supracondylar fracture of the distal humerus. In these cases and in the second most common epicondylar fractures, the metaphysis is affected and these fractures are therefore extra-articular. They have to be distinguished from articular fractures regarding therapy and prognosis. The growth potential of the distal epiphysis is very limited as is the possibility of spontaneous correction so that major dislocations should not be left uncorrected. Unstable and especially dislocated articular fractures must be anatomically reconstructed employing various osteosynthetic techniques, mostly combined with immobilization. Insufficient reconstruction, growth disturbance and non-union can result in axial deformities, such as cubitus valgus and varus, restriction of motion, pain and nerve palsy.

[Proximal tibial fractures]. / Frakturen der proximalen Tibia.

Only 1-4% of all long bone fractures in children involve the proximal tibia. To evaluate these fractures appropriately, it is mandatory to differentiate between articular fractures and metaphyseal fractures. Articular fractures of the proximal physis are rare and include Salter Harris type III and IV injuries. The reconstruction of the articular surface is the fundamental goal of therapy. Injuries of the anterior crucial ligament which typically appear as an avulsion of the tibial spine and the avulsion fracture of the tibial tubercle apophysis can involve the articular surface. Dislocated fractures should be reduced and stabilized. Extraarticular fractures include Salter Harris type I and II fractures. Other types of metaphyseal fractures are the complete fracture, the compression fracture and the bending fracture of the proximal tibia. Care should be taken while treating bending fractures, especially a valgus deformity must be excluded. Due to unequal growth stimulation during remodelling, a progressive valgus deformity frequently develops. Small deformities in the sagittal plane can be compensated by spontaneous remodelling during further growth. Dislocated fractures should be reduced and stabilized by K-wires. The retention of bending fractures by a compression plate or external fixator for medial compression might be more beneficial.

[Pelvic injuries in childhood and adolescence: Retrospective analysis of 5-year data from a national trauma centre]. / Beckenverletzungen im Kindes- und Jugendalter: Eine retrospektive Analyse eines überregionalen Traumazentrums über 5 Jahre.

BACKGROUND: Pelvic fractures are uncommon injuries in paediatric trauma patients because of specific anatomical features. Due to the low incidence there is no standardized therapeutic algorithm. MATERIAL AND METHODS: This retrospective review evaluates paediatric pelvic fractures of a Level I Trauma Centre over 5 years. In addition, we compared the data with adult pelvic fractures and reviewed the literature. A total of 37 pelvic fractures (≤16 years) were documented, with an incidence of 9.9% in the child with multiple injuries. The most common injury mechanisms were traffic accidents, followed by falls from heights. RESULTS: Type A injuries occurred in 50% (type B: 16%, type C: 27%, acetabular injuries: 11%). Osteosynthesis was performed in nine cases. Therapeutic intervention was necessary in three cases of haemodynamically relevant bleeding; 97% of all children had associated injuries (mean ISS: 38). CONCLUSION: Our data showed some differences to the literature. Pelvic fractures are predictors for high injury severity. Despite similar fracture pattern, in contrast to adults most injuries could be treated non-operatively. In unstable or dislocated fractures open reduction and stabilization must be performed.

[Calcaneal fractures in childhood: a retrospective survey and literature review]. / Frakturen des Kalkaneus im Kindesalter : Eine retrospektive Untersuchung und Literaturübersicht.

Calcaneal fractures (CF) are uncommon injuries in childhood; most data concerning CF originate from studies of adult trauma. In a retrospective analysis, we evaluated CF in children treated in our department over the last 5 years. In addition, we reviewed the current literature concerning the mechanism of injury, diagnostics, and complications after conservative and operative treatment. In addition, we evaluated the diagnosis and treatment of CF in children and adolescents in another five pediatric trauma centers in Germany by the help of a questionnaire. The data for the last 5 years (48 fractures) and in the current literature confirm that CF remain uncommon in childhood. Regarding the mechanism of injury, fracture pattern, and diagnosis, specific differences between pediatric and adult patients exist. Treatment strategies and recommendations are still inconsistent. In extraarticular and nondislocated fractures, conservative treatment does not seem problematic. But in intraarticular fractures with dislocation of the joint, operative treatment with anatomic reduction is advised in order to avoid long-term consequences.

[Therapeutic relevance of magnetic resonance imaging in joint injuries in children]. / Therapeutische Relevanz der Magnetresonanztomographie bei Gelenkverletzungen im Kindesalter.

AIM: In this retrospective study, we assessed whether the use of MRI in children provides additional, therapeutically relevant information to assist in the diagnosis of joint injuries. In addition, we determined whether the usefulness of this approach is dependant on age of the child and localisation of the trauma. METHOD: MRI of 45 children aged between 3 and 16 years were analysed independently by four different investigators (two radiologists, two trauma surgeons) and assessed for their therapeutic relevance. RESULT: MRI of the knee (n=18) gave additional information in 11 patients (61%) and led to a change in the recommended therapy involving arthroscopy in seven patients (39%). MRI of the ankle (n=21) provided additional information in 12 patients (57%) and the decision for further therapy was influenced in six patients (29%), however, the indication for surgery was not influenced. The diagnosis of injuries of the elbow (n=6) was changed in four patients (67%), but the therapeutic decision was not influenced. CONCLUSION: MRI additional to conventional x-ray provides relevant information on the therapeutic procedure to be used for the knee, whereas for the ankle and the elbow MRI it rarely delivers additional information relevant to therapeutic decision making.