A new parameter for the management of positional plagiocephaly: the size of the anterior fontanelle matters.

PURPOSE: The rate of positional plagiocephaly has increased since guidelines for the prevention of sudden infant death have led to the recommendation of positioning infants on their back during sleeping. Therapy includes repositioning, physiotherapy, and helmet therapy. To date, there is no consensus on the treatment of positional plagiocephaly. Therefore, it was the goal of this study to compare the results of physiotherapy and helmet therapy and to investigate if the size of the anterior fontanelle can be used as an additional parameter for the indication of the helmet therapy. METHODS: We enrolled 98 infants with a diagonal difference of 7 mm or more and plagiocephaly classified as Argenta II or more. Patients were grouped into infants with a small anterior fontanelle (< 25mm2) and infants with a large anterior fontanelle (≥ 25mm2). The patients were observed for at least 18 months. Sixty-eight patients were treated with repositioning and physiotherapy, whereas 30 infants received helmet therapy. RESULTS: The remolding rate was significantly higher with the helmet therapy than with physiotherapy. In patients with a small fontanelle, a lower spontaneous remolding rate was seen pointing to their lower correction potential. Especially in these patients, plagiocephaly was reduced significantly more quickly with the helmet treatment than with physiotherapy, so that they may benefit from the helmet due to their otherwise reduced spontaneous remolding capacity. CONCLUSION: The helmet therapy led to a faster reduction of the asymmetry than physiotherapy in this study. In patients with a small anterior fontanelle and therefore lower remolding potential, the helmet treatment was more effective than physiotherapy.

Closed reduction and immobilization of displaced distal radial fractures. Method of choice for the treatment of children?

PURPOSE: The therapy of distal radial fractures in children is expected to be as non-invasive as possible but also needs to deliver the definite care for gaining optimal reduction and stabilizing the fracture. Therefore, closed reduction and immobilization is competing with routine Kirschner wire fixation. The aim of our study was to investigate if closed reduction and immobilization without osteosynthesis can ensure stabilization of the fracture. METHODS: We chose a retrospective study design and analyzed 393 displaced distal radial fractures in children from 1 to 18 years with open epiphyseal plates studying medical files and X-rays. The Pearson's χ (2) test was applied. Statistical analysis was performed using IBM SPSS Statistics 20.0. Statistical significance was set at an alpha level of P = 0.05. RESULTS: Of these studied fractures 263 cases were treated with closed reduction and immobilization. Only 38 of these needed secondary interventions, 28 of these underwent reduction after redisplacement and ten patients received secondary Kirschner wire fixation. The last follow-up examination after 4-6 weeks revealed that 96.4% of fractures initially treated with closed reduction and immobilization were measured within the limits of remodeling. 104 of the studied fractures were treated with cast immobilization alone when displacement was expected to correct due to remodeling. Here 22.1% of patients needed secondary reduction. Furthermore, primary Kirschner wire fixation was performed in only 25 children with unstable fractures and only one received further treatment. Interestingly, operative reports of primary closed reduction revealed that repeated maneuvers of reduction as well as residual displacement are risk factors for redisplacement. CONCLUSION: For the treatment of displaced distal radial fractures in children closed reduction and immobilization can be considered the method of choice. However, for cases with repeated reduction maneuvers or residual displacement we recommend primary Kirschner wire fixation to avoid redisplacement. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

[Strategies in the treatment of supracondylar fractures of the humerus in children - proven and controversial]. / Behandlungsstrategien bei der suprakondylären Humerusfraktur im Kindesalter - Bewährtes und Kontroverses.

Elbow fractures are the 2nd most frequent fractures in children. Their therapy needs high expertise. Particularly an adequate analgesic therapy as well as an efficient and differentiated non-surgical or surgical therapy depending on the fracture type needs to be chosen. Secondary damage, especially growth disturbances, has to be prevented. Type I fractures can be managed conservatively with a cast. The crossed percutaneous pin fixation after open or closed reduction is the typical and most frequent surgical treatment option in supracondylar humeral fractures in children. Another good treatment option for supracondylar fractures type II to IV after closed reduction is the elastic-stable intramedullar nailing (ESIN). It is a minimally invasive treatment away from the fracture zone, which allows immediate free movement of the extremity. An immobilisation in a cast is therefore not necessary. That are the most possible effects (opinion of the authors) of the ESIN method, but discussed controversial in the literature. Especially neurovascular concomitant injuries require a differentiated treatment strategy to prevent long-term damage and should only be carried out in a specialised paediatric surgery unit. Long-term complications of supracondylar fractures are limitations in range of motion, nerval palsies, disturbances of growth, as well as cubitus varus (30 %) and valgus (3-7 %). These last ones often result from an insufficient initial anatomic reduction. The aim of the therapy should in any case be a patient-orientated treatment with the expected quickest recovery time and lowest long-term complications. Therefore supracondylar fractures should be treated only by a specialised paediatric trauma team, which can provide all non-surgical and surgical treatments. The spontaneous correcture is only seen in the sagittal view in young children between 6-7 years of age.

Children and adolescents with ureteropelvic junction obstruction: is an additional voiding cystourethrogram necessary? Results of a multicenter study.

PURPOSE: The incidence of ureteropelvic junction obstruction (UPJO) and concomitant vesicoureteral reflux (VUR) ranges from 14 to 18 %. Therefore, different guidelines recommend a voiding cystourethrogram (VCUG) to identify cases of VUR early in the diagnostic process. Aim of this multicenter study was to reassess the incidence of concomitant VUR and the need for additional VCUG in a large cohort of patients with UPJO. Furthermore, we asked for clinical objectives that defined the need for VCUG with the intention of minimizing radiation exposure and the need for invasive diagnostic procedures. METHODS: Medical records for 266 patients (69 girls, 197 boys) with UPJO were analyzed retrospectively. Data were obtained on gender, clinical symptoms, results of pre- and postnatal ultrasound, VCUG and 99(m)Technetium-MAG3 (MAG3) scan. They were correlated with the incidence of concomitant VUR. RESULTS: One hundred and seventy-eight patients (67 %) underwent VCUG. Concomitant VUR was detected in 13 patients. Dilating VUR (dVUR) was observed in 11 patients. In our study, the overall incidence of a concomitant VUR was 7.3 %. In cases of proven VUR, we observed a positive predictive value for female gender, ureteral dilatation, renal insufficiency, and recurrent urinary tract infections (UTI). But there was no correlation between concomitant VUR and the severity of hydronephrosis. CONCLUSIONS: Our data suggest that the low incidence of concomitant VUR in cases of UPJO does not justify the routine use of VCUG as a routine diagnostic tool. Especially, ureteral dilatation and recurrent UTI have a positive predictive value for concomitant VUR.

[Femoral shaft fractures in children]. / Femurschaftfrakturen im Kindesalter.

Femoral shaft fractures in children represent 1.5% of all fractures in childhood. Up to the age of 4 years, conservative treatment in a hip spica or short-term overhead traction is the therapy of choice. Femoral shaft fractures between the age of 5 and 16 years should be treated surgically. In over 90% of these cases elastic stable intramedullary nailing (ESIN) is the premier treatment option. Additional end caps can be used for unstable fractures and in length discrepancy. The external fixator and the locking plate are reserved for fractures with severe soft tissue injuries, vascular problems and some specific situations mentioned later on. By adhering to these standards good results can be achieved with a low complication rate.

Early and long term outcome in children with esophageal atresia treated over the last 22 years.

BACKGROUND: The survival of infants born with esophageal atresia (EA) is > 90% at present. The purpose of this study was to evaluate early complications and long term outcome in children with EA treated at our institution. METHODS AND PATIENTS: Retrospective analysis of 111 children with EA undergoing repair of EA or tracheoesophageal fistula (TEF). Assessment of early and intermediate complications as well as long term morbidity and mortality. RESULTS: Primary anastomosis was performed in 90 (81%) and secondary anastomosis in 7 patients (6%). Gastric transposition was carried out in 14 children (13%). The postoperative mortality was 14/111 (12.6%) and could be estimated by the Spitz classification. At the age of 10 years, 33 patients (72%) were swallowing without problems, 39 children (85%) were eating at least most of the time with pleasure but 19 children (41%) had a body weight less than the 25 (th) percentile. Staged repair by gastric transposition resulted in the least amount of motility dysfunction. Long-term respiratory morbidity was high. CONCLUSION: The survival of children with EA has improved in the last two decades. For risk assessment the Spitz' classification is valid. Long term gastrointestinal and respiratory morbidity remains high. In children with long-gap EA gastric transposition performed as a staged procedure has satisfactory results and seems superior to techniques preserving the native esophagus.

Urinalysis in children with epididymitis.

BACKGROUND: The aim of this study was to examine the diagnostic and therapeutic yield of urine tests in epididymitis in children. Recently, urine examination in prepubertal epididymitis has been described as having little value for diagnostic or treatment. Yet, although urine cultures are often sterile, in clinical practice prepubertal boys with epididymitis are often treated with antibiotics. MATERIAL AND METHODS: A retrospective analysis of all boys with 1-episode epididymitis presenting to a single institution over a 5-year-period was performed. Results of laboratory tests (blood, urine) were collected. RESULTS: We found 151 consecutive patients. In 93 cases (62%), results of urine examinations were available. Only 1 patient (1%) showed bacteriuria in urine sediment, while urine culture in this patient was sterile. Urine cultures were done in 6 of 97 patients treated in hospital (6%), and all cultures were sterile. Surgical exploration was performed in 7 patients (5%); in 6 of them epididymal cultures were taken intraoperatively with negative microbiological results. CONCLUSION: In our group of children with epididymitis, almost all urine tests (urinalysis, urine culture) were negative. Epididymitis in prepubertal boys seems to be mostly idiopathic, and positive microbiological findings are rare. Antibiotic treatment in this age group should only be done in cases with positive urine tests.

[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.

[Elastic stable intramedullary nailing (ESIN) of supracondylar fractures of the humerus in children]. / Die elastisch-stabile intramedulläre Nagelung (ESIN) der suprakondylären Humerusfraktur im Kindesalter.

Supracondylar fractures are the most common elbow lesions in children. The standard procedure for displaced fractures has up to now been crossed-wire osteosynthesis. A new option is elastic stable intramedullary nailing (ESIN). We retrospectively reviewed the results of all supracondylar fractures that were treated in our department from 2000 to 2005 by the ESIN technique with the aim to provide evidence of advantages and disadvantages of this method. The mean age of the 60 patients included in the study (27 female, 33 male) was 5.9 years (range 1-12 years). Most patients presented with type II fractures (85%), 10% sustained a type III fracture and 5% the most displaced type IV. All patients were treated with the ESIN technique and underwent clinical and radiological follow-up examinations during the next 3-5 months. Average duration to implant removal was 100 days. All patients achieved free range of movement of the affected elbow. No visible malpositions, pseudarthrosis or nerve lesions were observed, in comparison to the conventional surgical technique (crossed-wire osteosynthesis) with up to 19% for these complications. Furthermore, due to the excellent stability of ESIN, the patients do not need a cast and movement is encouraged immediately. Our good experiences encourage us to continue applying the ESIN technique.

Fetal urinary bladder rupture and urinary ascites secondary to posterior urethral valves. A case report.

Megacystis is a typical prenatal sonographic finding in cases of lower urinary tract obstruction. Urinary bladder perforation represents a rare complication in this condition. We report on a boy with in utero bladder perforation and urinary ascites secondary to posterior urethral valves. The pre- and postnatal therapy is described and the current literature is reviewed.

Late obstruction after subureteral collagen injection.

We present a case with distal ureteral obstruction after a single subureteral collagen injection. Postnatally, the girl presented with bilateral vesicoureteral reflux (VUR). At one year of age, a bilateral subureteral collagen injection was carried out. Postoperatively, the girl was followed up regularly and showed no pathological findings. But three years later, hydronephrosis with a distal ureteral obstruction on the right side was found. An ureteral reimplantation was performed on that side and the histological finding was a ureteral stenosis, consisting of collagen with a knotty sclerosis and a histiocytic and granulomatous reaction. This is the first case with a late obstruction at the ureteral orifice three years after a single collagen injection. We found an inflammatory reaction against the collagen, which led to a sclerosis of the implant. Further surveillance of patients after subureteral injections should focus on this kind of complication.

Functional imaging for determination of nephroblastoma: an obligatory diagnostic program.

In Europe, 1.7 % of children with predicted nephroblastoma undergo neoadjuvant chemotherapy without being correctly diagnosed. It is necessary to reduce the number of misdiagnoses. In a girl who was referred to our institute with the diagnosis of nephroblastoma of the right kidney, DMSA scan revealed a hypertrophic compensation of the contralateral nephropathy in the lower part. Functional imaging studies of the kidney should be performed in patients in whom the type of pathology of a suspect mass in the kidney region is unclear, including a careful scrutiny of the MRI scan.

[Child abuse]. / Kindesmisshandlung.

Child abuse is most often diagnosed by an emergency doctor on call who sometimes "feels" more than knows what he is confronted with. He should nevertheless always take a medical history and make a physical and radiological examination. X-ray imaging and an ophthalmologic retinal examination are the most important diagnostic steps. Typical findings are multiple and/or dorsal rib fractures, complex skull fractures, physeal fractures, all fractures within the first 12 months, multiple fractures in different localisations and stages of healing, all injuries with uncommon distributions, all patterned bruises, immersion burns, intramural hematoma and every unexplained loss of consciousness. The first step towards victim protection is always the removal of the abused child from its caregivers by admitting it to hospital, as 95% of all cases of reported child abuse take place within the child's family.

Surgical complications in the treatment of Wilms' tumor.

We present our data on the treatment of Wilms' Tumor (WT) with an emphasis on both the positive effect and the adverse effect of preoperative chemotherapy with regard to surgical intervention. From 1980 to 2000 70 children were treated. 57 % received preoperative chemotherapy (ChTx) and 43 % were operated on primarily. 75 % of the tumors responded to ChTx with significant shrinkage of the size. After preoperative ChTx 54 % of the cases were regrouped as stage I, whereas after primary operation 46 % of the patients were grouped as stage I, thus indicating a downstaging with preoperative ChTx. In 8 % of the patients with preoperative chemotherapy intraoperative complications occurred with a rupture of the tumor in 1 case. In contrast, there were intraoperative complications in 25 % of the patients with a primary operation with rupture of the tumor in 3 cases. 1 child (1.5 %) was treated with chemotherapy who did not have a Wilms' tumor but a benign nephroma (CMN). 3 cases had a clear cell sarcoma (CCSK) and in one case histology revealed a rhabdoid tumor (MRTK). In one case of CCSK only histology of the metastases disclosed the correct diagnosis. The rate of postoperative complications such as ileus was the same for both groups. Irrespective of the known adverse effects such as changing tumor histology, which may affect the correct staging, and the remaining risk of an initial inadequate treatment, our data show that the regimen of preoperative chemotherapy as proposed by the SIOP study should not be abandoned. However, the relatively small number of our patients does not allow a significant statement to be made but confirms the results of past SIOP studies.

Tubularized incised plate (TIP) urethroplasty (Snodgrass) in primary hypospadias repair.

In the past TIP urethroplasty became a preferred technique for distal hypospadias repair, and subsequently gained worldwide popularity and acceptance. The procedure gives good functional results and a cosmetic appearance that is superior to that obtained by flip-flap or onlay preputial flap repairs. In addition, this procedure is associated with a fairly low rate of complications. From 06/2000 to 04/2004 we performed 100 primary TIP urethroplasties in patients with distal hypospadias. The age of the patients at the time of surgical correction was 16 months to 10 years with a mean of 41.4 months. All patients underwent the procedure under general anesthesia supplemented by additional pain management with a penile block anesthesia or caudal anesthesia. The surgical technique is described. During follow-up (23.5 months) we observed 2 types of complications: formation of a urethrocutaneous fistula (5 pts., 5 %) and formation of meatal stenosis (17 pts., 17 %) with a steady decrease with no stenosis formation in the last 8 months of this series. A key point might be the length of the dorsal incision of the urethral plate which should not touch the dorsal lip of the anticipated neomeatus. There were no other complications, and the cosmetic results were good in all cases.