[Long-term results following fracture of the femoral neck in children]. / Dlouhodobé výsledky po zlomenine krcku stehenní kosti u detí.

PURPOSE OF THE STUDY: This retrospective study was designed to evaluate the severity and nature of long-term sequelae of femoral neck fractures in children in relation to the strategy and technique of therapy. MATERIAL: The study included 15 patients with a fracture of the femoral neck who, at the time of injury, had an opened proximal physis. The average age at the time of injury was 11.5 years (range, 4 to 16.3 years). There were eight boys and seven girls. Twelve children suffered injury due to a fall varying in gravity, two were knocked down by a vehicle, and one was injured as a co-driver in a car accident. The group involved no type I fracture, six type II, seven type III and two type IV fractures, as classified by the Delbet and Colonna system. METHODS: All children were operated on within an average of 4.1 days after injury. The delay was caused by a late referral from an outside hospital or was due to associated complications.However, the majority of fractures were treated within 24 hours of injury. Surgery was carried out from the anterolateral approach. Miniarthrotomy was performed in 11 patients to remove hematoma and decompress the intra-articular space. The methods of stabilization included Kirschner's wires in four children, compressive osteosynthesis using lag screws inserted extraphyseally in 10 children and the combination of both methods in one child. No plaster of Paris spica or traction was applied after surgery. RESULTS: The long-term results were evaluated at a minimum of 5 years after injury. The average follow-up was 9 years and 11 months, with the range from 5 years and 1 month to 15 years and 5 months, and 12 patients were involved. Six had a type II and six had a type III fracture. Ten patients were treated by arthrotomy. Stabilization of the fracture was performed with lag screws in nine children and Kirschner's wires in three patients. Both subjective and objective findings were evaluated by the modified Rattlif criteria. Concerning pain, eight (67 %) children had excellent outcomes, three (25 %) reported good outcomes and only one (8 %) had a poor outcome. The activity following injury was subjectively evaluated as excellent by 11 (92 %) patients and as good by one (8 %) patient. None of the patients was noticeably limited in their activity, as compared with the pre-injury state. Objective findings were based on X-ray images and the range of hip motion. No or minimal radiographic changes were found in five (42 %) patients and were assessed as excellent outcomes. A good outcome, i. e., a spherical head with a moderate neck deformity, was achieved in five (42 %) patients. A poor outcome, i. e., avascular necrosis free of revitalization, but with collapse, on X-ray images was recorded in two (16 %) patients. The values for the range of motion and limb-length discrepancy were excellent in eight (67 %), good in two (16.5 %) and poor in two (16.5 %) patients. Poor objective and subjective findings were recorded in the patients who had not undergone miniarthrotomy. DISCUSSION: A comparison with the literature data showed that the occurrence of each fracture type was in agreement with the reports of other authors. The finding of a higher frequency of type I fractures can be explained by a pathological slip due to hormonal changes. The opinions on treatment of these fractures have developed to the view that surgery is necessary in the early post-injury period, preferably with the use of compressive osteosynthesis or Kirschner's wires. However, subsequent immobilization in a plaster cast spica is not necessary. The subjective and objective findings were not exactly correlated due to differences in patients' age and different intervals between injury and treatment. CONCLUSIONS: The authors recommend early surgery and stabilization by compressive osteosynthesis or Kirschner's wires, together with miniarthrotomy in order to decompress the articular space.

[Complications of internal fixation by a short proximal femoral nail]. / Komplikace osteosyntézy krátkým proximálním femorálním hrebem.

PURPOSE OF THE STUDY: The article presents analysis of complications of the treatment of unstable fractures of the proximal femur by the proximal femoral nail (PFN Synthes). MATERIAL: Between October 1997 and October 2003, 239 patients were treated for unstable fractures of the proximal femur, 89 men and 150 women, average age 71 years. The minimum follow-up was 12 months. Unstable was considered a fracture in which it was impossible to restore by reduction the medial support -- the Adams' arch, i. e. the region below the lesser trochanter in subtrochanteric fractures. Prevailing in the group of patients were unstable pertrochanteric fractures (AO 31 A2.1, A2.2) that occurred in 55 % of patients, per-subtrochanteric fractures (AO 31 A2.3) accounted only for 26 % and subtrochanteric fractures (AO 31 A3.3) for 19 %. RESULTS: The fracture healed in 95 % of patients within 6 months and in 98 % of patients within 9 months. There were 29 intraoperative complications recorded in 19 patients (12 %). This category included also intraoperative technical difficulties. Only 9 patients (4 %) were reoperated on. Early postoperative complications occurred in 16 patients (8 %) requiring reoperation in 7 cases. Six late postoperative complications occurred in 3 patients. DISCUSSION: Intramedullary implants for internal fixation of the proximal femur tolerate higher static and several times higher cyclical loading as compared to DHS types of implant. As a result the fracture heals even without the primary restoration of the medial support. The implant temporarily compensates the function of the medial column. When this function is not restored in a limited period of time, the internal fixation, although correctly performed, fails. The main cause of complications are technical mistakes or failure to observe the proper surgical technique. CONCLUSION: The most frequent mistake is reduction with the persisting varus position or distraction in the fracture line, incorrect placement of the screw in the femoral neck or the nail in the femoral shaft, wrong choice of the length of the screws, unnecessary hesitation in solving the defect in the course of the treatment. Forced insertion of the implant may cause additional damages to the skeleton. PFN is a quality implant for the treatment of unstable pertrochanteric and subtrochanteric fractures of the femur. The number and severity of complications may be reduced by the observance of proper principles of reduction and exact surgical technique.

[Personal experience with injuries of the flexor tendons of the hand]. / Nase zkusenosti s poranením slach flexoru ruky.

PURPOSE OF THE STUDY: The study presents a retrospective evaluation of a group of 198 patients with 242 acute injuries of tendons of flexors of the hand in the period between 1995-1999. Evaluation covers the outcomes of the primary treatment as compared to the secondary reconstruction surgery--mainly in zone II after Kleinert. MATERIAL: The followed up group (242 injuries of flexor tendons) consisted of 79% of men and of 21% women. Hundred-and-twelve patients (46%) had the flexor tendon affected in zone II. METHODS: According to anatomical location the injuries were classified into five zones after Kleinert. Primary treatment in zone I consists in suture or reinsertion (after Bunnell), in zones II-V in suture. Primary treatment was performed within 24 hours, postponed primary treatment within 10 days. The surgery is performed by autraumatic suture in the operating theatre under strictly aseptic conditions. In case of the injury of the superficial and deep flexor we always treated both. At the same time suture or reconstruction of pulleys of flexor tendon sheaths was performed. The total number of reconstruction surgeries was 31 (re-suture, re-insertion, tenolysis, one- or two-step transplantation by means of tendon of the long palmar muscle); of this in zone I six surgeries, in zone II nineteen, in zone III two, in zone IV three and in zone V one surgery. RESULTS: The results are evaluated after the accomplished physical therapy according to the range of motion on the basis of the so called Louisville system based on the deficit of flexion and extension. In zones I, III, IV and V the result was excellent or good in 90% of patients after primary surgery and in 80% of patients after secondary operation. After primary suture in zone II excellent or good results were achieved in 80% of patients, after reconstruction surgery only in 63% of patients. DISCUSSION: The results show in accordance with all cited authors that the primary treatment provides a far better final effect of the treatment of flexor tendons of the hand than the reconstruction surgery, even though precisely performed. CONCLUSION: Treatment of the flexor tendons of the hand should be performed as soon as possible with a full comfort for the patient (operating theatre, total or local anesthesia) as well as for the surgeon (assistance, perfect suture material). Reconstruction surgery is considerably less successful. In all zones after the primary surgery excellent or good results are at least by 10%, in zone II even by 16%, more frequent than in the secondary surgery.

[The contribution of the virology laboratory to the diagnosis of neuroinfections]. / Príspevek virologické laboratore k diagnostice neuroinfekcí.

The authors summarizes the results of a virological examination in 1231 patients with neuroinfections hospitalized in 1973-1984 at the Infectious Diseases Clinic in Plzen. The virological diagnosis contributed towards the elucidation of the aetiology in 62.4% of the patients. In the aetiology participated the virus of tick-borne encephalitis in 28.2%, the virus of epidemic parotidis in 15.8% and a group of enteroviruses in 14.9%. The participation of other viral agents was small.