Surgical treatment of posterior cruciate ligament lesions does not cause growth disturbances in pediatric patients.

PURPOSE: The aim of the present study was to describe epidemiology, management and outcome of pediatric and adolescent patients with posterior cruciate ligament (PCL) injuries. METHODS: Sixteen patients of less than 18 years of age with 7 PCL avulsion fractures and 9 PCL tears were included over a 10-year period. Trauma mechanism, additional injuries and treatment methods were analyzed. Follow-up examination included range of motion and ability to perform squats. Pedi-IKDC and Lysholm score were obtained and posterior shift was measured in kneeling view radiographs and compared to the contralateral side. Patients were grouped into pediatric patients with open physes at the time surgery and adolescent patients with closing or closed physes. In case of open physes, growth disturbances were assessed. RESULTS: Six of the treated patients (median age 12.5 years, range 10-13) had open physes at time of surgery. Five of those sustained avulsion fractures and treatment consisted of open reduction and screw fixation in four cases and graft reconstruction in one case. One patient sustained a PCL tear and underwent graft reconstruction. Follow-up at a median of 71.5 months (range 62-100) did not reveal any growth disturbances. Median Pedi-IKDC was 71.9 (range 51.7-92.1), median Lysholm score was 81.5 (range 66-88) and median posterior shift difference was 2.5 mm (range 0-11). The remaining 10 patients (median age 16 years, range 14-17) had closing/closed physis at the time of operation. Two patients presented with avulsion fractures treated with open reduction and screw fixation and 8 patients sustained PCL tears treated with graft reconstruction. At a median follow-up of 69.5 months (range 11-112), median Pedi-IKDC was 86.8 (range 36.8-97.7), median Lysholm score was 84.0 (range 45-95) and median posterior shift difference was 4 mm (range 0-15). CONCLUSIONS: In our small number of pediatric patients with PCL injuries, open reduction and epiphyseal screw fixation of displaced avulsed fractures and steep tunnel drilling in case of PCL reconstruction did not cause growth disturbances. Nevertheless, long-term functional impairment should be expected and close follow-up has to be recommended. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Outcome following excision of the radial head in children with open physes for impaired elbow motion.

BACKGROUND: Only few reports have described the outcome of pediatric patients following radial head resection. Therefore, the aim of the present study was to assess clinical and radiologic outcome of patients with open physes following resection of the radial head. MATERIALS AND METHODS: Skeletally immature patients treated with resection of the radial head were included. Range of motion (ROM) of the elbow joint was compared with preoperative values. Grip strength, pronation and supination strength, and carrier angle were compared with the unaffected side. Radiographs were assessed for signs of arthrosis, radial migration, and perifocal ossification. Disabilities of the Arm, Shoulder and Hand and Mayo Elbow Performance scores were obtained. RESULTS: The study included 7 patients (mean age, 11 years), 5 with post-traumatic and 2 with congenitally impaired elbow joint motion. Mean follow-up was 47 months. Pronation/supination ROM improved significantly (P = .018). Extension/flexion ROM did not improve significantly (P = .122). Although grip strength (P = .027) and pronation strength (P = .028) of the affected side were significantly lower compared with the contralateral side, supination strength did not differ significantly (P = .176). The carrying angle was increased in 3 patients. Significant radial migration occurred (mean, 3 mm; standard deviation [SD], 3 mm; P = .018). Arthrosis was found in 3 patients. The mean Disabilities of the Arm, Shoulder and Hand score was 16.1 (range 8.8-30.8; SD, 10.1) and mean Mayo Elbow Performance Score was 88 (range, 70-100; SD, 12). CONCLUSIONS: Radial head excision may be considered for selected patients with open physes in cases of severe impairment of pronation/supination. However, sequelae such as radial migration, arthrosis, and elevation of the carrying angle should be expected.

Medial patellofemoral ligament (MPFL) reconstruction in combination with a modified grammont technique leads to favorable mid-term results in adolescents with recurrent patellofemoral dislocations.

PURPOSE: The aim of the present study is to present the outcome of a cohort of adolescent patients with trochlear dysplasia and elevated tibial tuberosity trochlear groove (TTTG) distance suffering from recurrent patellar dislocation. Treatment consisted of medial patellofemoral ligament (MPFL) reconstruction and a modified Grammont procedure. METHODS: MRI examinations were obtained pre- and postoperatively. Trochlear dysplasia was classified according to Déjour, and TTTG was measured on MRI. The Tegner Activity Scale and the Kujala Knee Score were assessed preoperatively and at follow-up. The Kujala Knee score and the IKDC 2000 knee score were documented at follow-up (median 50, range 20-61 months; SD 16.6). RESULTS: Seven knees of six patients (median age 16.5 years, range 14-17 years) with trochlear dysplasia and elevated TTTG distance (median 17 mm, range 16.1-21.9 mm; SD 2.8) were treated. Trochlear dysplasia was classified as Déjour type A in 1, type B in 5, and type C in 1 knee. The Kujala Knee Score significantly increased from values of 55 (range 17-88; SD 25.9) to 94 (range 73-100; SD 9.1) at follow-up (p = 0.028). TAS improved from preoperative 2 (range 0-7; SD 2.5) to 5 (range 4-9; SD 1.8) at follow-up (p = 0.034). Median IKDC 2000 Knee Score at follow-up was 89 (range 61-100, SD 13.4). No re-dislocations were encountered. CONCLUSION: In selected adolescents with recurrent patellofemoral instability, MPFL reconstruction in combination with a modified Grammont technique yields excellent functional outcome and could, therefore, help to avoid major procedures, such as osteotomies. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Balloon kyphoplasty and percutaneous fixation of lumbar fractures in pediatric patients.

PURPOSE: Type A fractures of the spine requiring operative stabilization are rare injuries in the pediatric population. Current reports have demonstrated the safety of the combination of balloon kyphoplasty and minimal invasive management of thoraco-lumbar fractures in adults. There is no information about the efficacy of this approach in managing pediatric vertebral fractures. METHODS: The aim of the present study was to report the outcome of a small series of children with A fractures of the lumbar spine treated with the combination of the abovementioned techniques. RESULTS: Three male patients without neurological deficits aged 11, 12 and 14 years were treated with fractures located at L1, L1/L2 and L2/L3, respectively. In total, six kyphoplasties were performed (monolateral in 4 vertebrae, bilateral in one vertebra). Neither cases of cement leakage nor intra- or postoperative complications were noted. Minimally invasive kyphoplasty and stabilization led to a significant improvement of the sagittal index of all five treated vertebrae which could be maintained at follow-up (14, 19 and 20 months postoperatively). CONCLUSION: This study is the first one to present an excellent outcome of children with type A fractures treated with a combination of balloon kyphoplasty and percutaneous stabilization.

The influence of brace immobilization on the remodeling potential of thoracolumbar impaction fractures in children and adolescents.

PURPOSE: Different treatment methods including immediate mobilization with or without brace, bed rest or immobilization using thoracolumbosacral orthosis have been applied for stable compression fractures of the pediatric spine. The aim of this study was to evaluate the influence of bracing on the remodeling capacity of pediatric thoracolumbar type A 1.2 impaction fractures. Additionally, the prevalence of pain and functional disabilities were assessed. METHODS: All children treated conservatively between 2000 and 2011 with impaction fractures of the thoracolumbar spine (A 1.2) were included and re-invited for a clinical [including VAS 0-100, Oswestry disability index (ODI)] and radiological follow-up examination. Changes of the sagittal index (SI) at the time of the accident, the latest control visit and at the follow-up examination were analyzed. RESULTS: Seventy-two patients with a mean age of 12 years (1.8-18 years) and a total number of 133 fractured vertebrae were included. The mean SI at the time of injury was 0.76 (range 0.45-0.94, SD 0.08); 34 patients with 67 fractured vertebrae were included in the follow-up examination after a mean of 7.9 years (2.4-13.1 years). The mean SI of the 67 affected vertebrae at follow-up significantly increased to 0.92 (range 0.74-1, SD 0.06). The initial treatment regimen (brace vs no brace) did not influence the remodeling capacity. More than half of the patients (n = 18, 53 %) complained about occasional back-related pain which was not associated with the remodeling process. The mean ODI was 5.8 (range 0-26, SD 6.6) and the mean VAS of the re-evaluated patients was 87 (range 53-100, SD 14). CONCLUSIONS: A significant remodeling capacity of thoracolumbar vertebral impaction fractures sustained in childhood is demonstrated. Bracing does not seem to influence the long-term outcome of these injuries. More studies have to be performed to define the role of bracing in these fractures.

The pediatric knee: diagnosis and management of ligament injuries.

In the last few decades, sports injuries in pediatric and adolescent athletes have increased dramatically, with ∼ 38 million young athletes participating in organized sports annually in the United States. Starting at the age of 2 years, an increase of the incidence of knee injuries until adulthood with a peak at 6 and at 13 years of age has been observed. Due to a physiologic laxity of the ligaments, ligament injuries are uncommon in these patients, but they are getting more frequent. In the growing knee, open physis are the points of minor resistance. Therefore apophyseal injuries of the pediatric knee are more common. Diagnostics and treatment of ligament injuries of the pediatric and adolescent knees are challenging. This article presents an overview of ligament injuries in the pediatric and adolescent knee, their diagnostic work-up, and their treatment in the growing patient.

Diagnosis and treatment of apophyseal injuries of the pelvis in adolescents.

An avulsion fracture occurs when the growth plate of an apophysis is injured due to a sudden and forceful contraction of the attaching musculotendinous unit. Usually it is adolescents who sustain these injuries, and a significant male preponderance has been found. Even though apophyseal fractures have been described in a variety of locations, the apophyses of the pelvis and hip are more prone to these injuries. Due to their rarity, avulsion fractures of the pelvis are often misdiagnosed. Additionally, patients can present late, and other pathologies are suspected initially. In most acute cases conservative treatment is successful. However, some cases require operative intervention. To plan an optimal treatment regimen, it is important to be familiar with the typical pathomechanism, the typical clinical findings, and the most commonly applied imaging modalities of these injures. The present review analyzes the currently available literature on the most frequently encountered apophyseal injuries of the pelvis in adolescent patients. Some case examples are also presented.

Injuries in physically disabled children.

Disability is a condition or function that is judged to be significantly impairing relative to the usual standard of an individual or group. The spectrum of musculoskeletal disabilities in children is immense and varied. Musculoskeletal disabilities are congenital or acquired; they affect a child partially or generally and can occur as a permanent or transient disability.Although injuries still represent a major concern for children and adolescents worldwide, studies focusing on injuries in physically disabled children are lacking. To detect musculoskeletal injuries, radiographs are frequently required. In disabled children the radiographic findings can detect the skeletal injury but also can present special radiographic findings of the underlying disease.This review offers an overview of different musculoskeletal disabilities and their related injuries as well as characteristic findings on radiographs.

Comparison of two treatment eras and sonographic long-term outcome of blunt splenic injuries in children.

UNLABELLED: The treatment of blunt splenic injuries (BSI) has undergone a significant shift away from an operative approach to a conservative treatment regimen in the last decades. Data concerning long-term follow-up of children sustaining BSI are largely confined to telephone surveys. Children treated with BSI over a 33-year period were analyzed. In order to describe the changing treatment, patients were divided into two groups: group I included children treated between 1977 and 1999; group II children treated between 2000 and 2009. Additionally, patients treated nonoperatively between 2000 and 2009 were invited for a sonographic follow-up examination. In group I 81 patients and in group II 89 patients were treated. An increase of male patients from 69 to 88 % was observed, comparing the two eras. While children treated in the earlier period were 8.8-years-old mean (range 1 to 15), the patients treated between 2000 and 2009 were older (mean 10.4 years, range 1 to 17). Between 1977 and 1999, 79 % of the patients were treated nonoperatively. This rate considerably increased to 94 % in the second era. Follow-up examination was performed with a mean age of 6 years (range 1 to 11 years) post-injury. In 79 % of the cases, the spleen healed without sonographic long-term sequelae. In the remaining 21 % of the patients, a scar formation could be demonstrated. CONCLUSION: We were able to confirm that the majority of children sustaining BSI can be safely treated conservatively.

Beneficial Perioperative Aspects Favor the Use of Percutaneous Crossed Pinning over Antegrade Nailing in Pediatric Supracondylar Fractures-A Retrospective Comparative Study.

(1) Background: Displaced supracondylar humeral fractures in pediatric patients can be treated by either antegrade nailing (AN) or percutaneous crossed pinning (PCP). The aim of this study was to compare the intra- and perioperative management, complications and outcome of AN and PCP. (2) Methods: This retrospective study enrolled 271 individuals (median age 5 years, IQR 4-7 years) who underwent AN (n = 173) or PCP (n = 98). Patient history was analyzed for incidence of nerve injuries, postoperative treatment, postoperative malrotation, time of hospital stay, time to implant removal and revision rate. Operative procedures were investigated for duration and radiation exposure. (3) Results: PCP was associated with a significantly lower radiation exposure (dose area product: PCP mean 20.1 cGycm2 vs. AN mean 34.7 cGycm2, p < 0.001; fluoroscopy time: PCP mean 1.1 min, range 0.1-8.1 min, vs. AN mean 1.5 min, range 0.1-7.1 min, p < 0.001), duration of surgery (PCP mean 32.2 min vs. AN mean 48.3 min, p < 0.001) and time to implant removal (PCP mean 37 days vs. AN mean 113 days, p < 0.001). Cast removal was performed earlier in the AN group (PCP mean 30.2 days vs. AN mean 20.4 days, p < 0.001) and there were fewer iatrogenic nerve lesions (PCP: 24% vs. AN: 8%, p < 0.001). (4) Conclusions: In the investigated study population, the analyzed parameters seem to favor the use of PCP. The advantages of AN should be weighed against its drawbacks. For special indications, AN remains a relevant technique in supracondylar fracture treatment, and surgeons should be familiar with this procedure.

Standalone Axial Malrotation after Pediatric Supracondylar Fracture Does Not Seem to Be an Indication for Immediate Postoperative Revision Surgery.

Rotational spurs as evidence for post-surgical malrotation are frequently observed when treating pediatric supracondylar humeral fractures (SCHFs). This study aimed to investigate the long-term outcome of a pediatric cohort with unrevised axial malrotation and to discuss the indication for revision surgery. Postoperative radiographs of children treated for SCHFs over eight years were retrospectively analyzed. Children with radiological signs of malrotation (von Laer malrotation quotient) were invited for a follow-up clinical and radiological examination. Among 338 treated children, 39 (11.5%) with a mean age of 5.3 years (range 1.8-11.7 years) showed radiological signs for postoperative malrotation and were not revised and therefore invited to participate in the study. Twelve patients (31%) with a mean age of 11.3 years (range 8.8-13.8 years) took part in the follow-up examination after a mean of 7.1 years (range 5.4 to 11.3 years). The mean postoperative van Laer malrotation quotient was 0.15 (range 0.11-0.2). At follow-up, the range of motion of the elbow joint was not significantly different compared to the contralateral side. Apart from the humeral ulnar angle (p = 0.023), there were no significant differences in the radiological axes. The Flynn criteria were excellent and good in 90% of the cases. The mean was 1.7 points indicating excellent subjective results. Standalone postoperative malrotation did not lead to an adverse long-term outcome in a small cohort of pediatric patients with SCHFs and did not indicate immediate postoperative revision surgery. However, further investigations with larger cohorts should verify whether additional criteria such as stability of the osteosynthesis and signs for increasing valgus or varus displacement in the follow-up radiographs should get more importance in decision making.

Does Calcium Phosphate Cement Kyphoplasty Cause Intervertebral Disk Degeneration in Adolescents?

OBJECTIVE: Balloon kyphoplasty with polymethylmethacrylate (PMMA) represents the standard procedure for the treatment of thoracic and lumbar type A compression fractures. However, an increased degeneration in adjacent intervertebral disks following PMMA kyphoplasty has been demonstrated in elderly patients. Calcium phosphate cement (CPC) appears to be superior to PMMA for the intravertebral stabilization in younger patients. It remains unkown whether CPC kyphoplasty causes degeneration of adjacent disks in adolescents. DESIGN: Seven adolescents with thoracolumbar spine fractures underwent kyphoplasty at a mean age of 14.5 years (range 10-18). At a mean follow-up of 3.7 years (range 1 to 4.8) postoperatively, 3.0 Tesla magnetic resonance imaging (MRI) of the spine was performed to assess intervertebral disk degeneration by quantitative T2 relaxation maps and subjective ratings using modified Pfirrmann scores. A total of 56 intervertebral disks was analyzed. Initial computed tomography (CT) examinations served as basis to assess the severity of adjacent endplate injuries in terms of articular step-offs. RESULTS: Initial imaging detected 18 thoracolumbar vertebral body fractures of which 9 were treated with CPC kyphoplasty. Quantitative follow-up MRI revealed signs of degeneration in 10 (17.9%) of the examined 56 intervertebral disks, 7 of them adjacent to a previously fractured vertebral body. Signs of disk degeneration were significantly higher in caudal endplates with articular step-offs larger than 5 mm compared to fractured vertebral bodies without endplate step-offs. CONCLUSIONS: Quantitative MRI follow-ups did not suggest CPC-related intervertebral disk degradations following thoracolumbar kyphoplasty in adolescents, but indicated disk alterations correlating to adjacent endplate fracture severity.

The epidemiology of fractures in infants--Which accidents are preventable?

INTRODUCTION: In children, fractures have a huge impact on the health care system. In order to develop effective prevention strategies exact knowledge about the epidemiology of fractures is mandatory. This study aims to describe clinical and epidemiological data of fractures diagnosed in infants. METHODS: A retrospective analysis of all infants (children<1 year of age) presenting with fractures in an 11 years period (2001-2011) was performed. Information was obtained regarding the location of the fractures, sites of the accident, circumstances and mechanisms of injury and post-injury care. RESULTS: 248 infants (54% male, 46% female) with a mean age of 7 months presented with 253 fractures. In more than half of the cases skull fractures were diagnosed (n=151, 61%). Most frequently the accidents causing fractures happened at home (67%). Falls from the changing table, from the arm of the care-giver and out of bed were most commonly encountered (n=92, 37%). While the majority of skull fractures was caused from falls out of different heights, external impacts tended to lead to fractures of the extremities. 6 patients (2%) were victims of maltreatment and sustained 10 fractures (2 skull fractures, 4 proximal humeral fractures, 2 rib fractures, and 2 tibial fractures). CONCLUSION: Falls from the changing table, the arms of the caregivers and out of bed caused the majority of fractures (especially skull fracture) in infants. Therefore, awareness campaigns and prevention strategies should focus on these mechanisms of accident in order to decrease the rate of fractures in infants.

Video-game-assisted physiotherapeutic scoliosis-specific exercises for idiopathic scoliosis: case series and introduction of a new tool to increase motivation and precision of exercise performance.

BACKGROUND: It is important to monitor how patients with juvenile and adolescent idiopathic scoliosis comply with their physiotherapeutic scoliosis-specific exercises (PSSE). Physiogame, a newly developed video game using the Game-Trak 3D interactive game controller, combines correct PSSE performance with gaming. It tracks the position of the working limb in 3D space during the exercises as participants aim to hit certain targets and avoid others, and gives direct feedback by stopping the game if the working limb leaves the target 3D space, which is chosen to secure the corrective position according to the Schroth method. Physiogame records the quality and frequency of the exercises performed. We aimed to investigate the influence of this tool on motivation to perform regularly and, correctly, and with self-assessment of performance quality. METHODS: This case series included 8 consecutive patients with idiopathic scoliosis (thoracolumbar 7, lumbar 1), ages 7-13 years, all female and treated according to SOSORT guidelines; the COBB angle of primary curve at the start of brace therapy was 22-34°. In addition to Full Time Rigid Bracing (FTRB, Cheneau) and PSSE (Schroth), the participants were to perform two standardized Schroth exercises (muscle cylinder in standing position, mainly addressing the thoracic curve, and in side-lying position, mainly addressing the lumbar curve) with video game assistance every day for 6 months. The development (first to last month) of the following parameters was analyzed with descriptive methods: the actual training time to assess motivation, the ratio of the actual playing time versus total playing time to assess exercise improvement, and self-assessment of quality of performance. RESULTS: The average number of sessions with Physiogame was 217 per study participant (range 24 to 572, the study protocol targeted at least 180); actual training time decreased from 79 to 52 min (first to last month). Actual playing time increased from 73% of the total playing time to 83% (first to last month), and positive hits per second from 0.33 to 0.56. Self-assessment increased from "good" to "very good". The curve angles (°Cobb) were maintained over the study period (upper thoracic mean -1.3°, median -1°; lower thoracic mean 3°, median 2°; lumbar mean 0.5, median 0). CONCLUSIONS: The improvement we saw in exercise performance, is thought to result primarily from the direct given feedback during the game, as the exercises themselves were already familiar to the patients. The synchronous recording of actual training time allows evaluation of Schroth therapy for idiopathic scoliosis, since both prescribed training time and actual training time are captured. No comparable tool was found in literature.

The impact of arterial vessel injuries associated with pediatric supracondylar humeral fractures.

BACKGROUND: Pediatric supracondylar humeral fractures are regularly complicated by vascular compromise. However, the treatment regimen for pulseless hands with good capillary refill time is discussed controversially. The aim of the present study was to present our treatment strategy in a series of children sustaining supracondylar humeral fractures associated with impaired peripheral blood flow. METHODS: Medical charts of all children sustaining supracondylar humeral fractures treated between 1995 and 2009 were reviewed. Treatment and the course of patients with impaired peripheral blood flow were evaluated. Patients were invited for a follow-up examination. RESULTS: Forty of 499 patients sustaining a supracondylar humeral fracture presented with peripheral pulselessness. Two children underwent immediate vascular surgery. In the remaining 38 patients, the fracture was reduced, followed by a re-evaluation of the peripheral circulation. Twenty-four of those patients had normal peripheral pulse and capillary refill time, and no further therapy was necessary. Fourteen patients had a persisting absent peripheral pulse after fracture reduction. While in 4 of those patients-including 3 patients with prolonged peripheral capillary refill time-vascular surgery was performed, 10 patients were successfully treated with "watchful waiting." At follow-up of 3.5 years (range, 2-6 years), the performed diagnostic workup including capillary refill time and blood pressure was without pathologic findings in all patients. CONCLUSION: Our data suggest that blood flow often recovers following reduction of supracondylar fractures with impaired peripheral vascularization. In cases of a "pink pulseless hand" (absent peripheral pulse and good peripheral capillary refill time), "watchful waiting" instead of immediate surgical exploration might be a treatment option. However, further studies with more patients have to be conducted to formulate a recommendation for the treatment of these severe injuries. LEVEL OF EVIDENCE: Therapeutic study, level V.

Computed tomographic scan in head trauma: what is the rational in children?

Traumatic brain injury (TBI) is the consequence of external forces that traumatically injure the brain. Closed head injury is common in children and is estimated to result in 650,000 to 1 million emergency department visits annually with approximately 7,400 deaths in the United States. Mild TBI is the most common form of closed head injury and constitutes 80 to 90% of all the TBI. Cranial computed tomography (cCT) is performed in usually more than 50% of the patients, thus, resulting in an extreme overuse with the inherent risk for inducing malignancies. The purpose of this article is to review current approaches, recommendations, and guidelines on pediatric head trauma with special emphasis on cCT. Therefore, after an overview on classification and TBI scores, diagnostic imaging, and management rules for clinical important TBI, as well as own experience including remarks on cCT technique will be discussed.