European Paediatric Surgeons' Association Survey on the Management of Hirschsprung Disease.

Aim This study aims to define patterns of Hirschsprung disease (HD) management. Methods An online questionnaire was sent to all European Paediatric Surgeons' Association (EUPSA) members. Results A total of 294 members (61 countries) answered (response rate: 61%). DIAGNOSIS: All respondents perform rectal biopsies (61% rectal suction [RSBs], 39% open full-thickness), 96% contrast enema, and 31% anorectal manometry. At RSB, 17% take the most distal biopsy 1 cm above the dentate line, 34% take 2 cm, 30% take 3 cm, and 19% take > 3 cm. Rectal biopsy staining's are hematoxylin/eosin (77%), acetylcholinesterase (74%), calretinin (31%), S100 (2%), nicotinamide adenine dinucleotide-tetrazolium reductase (2%), succinate dehydrogenase (1%), and neuron-specific enolase (1%). A total of 85% respondents recognize entities including hypoganglionosis (69%), intestinal neuronal dysplasia (55%), and ultrashort segment HD (50%). SURGERY: Pull-through (PT) is performed at diagnosis by 33% or delayed by 67% (4 months or > 5 kg). Awaiting definitive surgery, 77% perform rectal irrigations, 22% rectal dilatation/stimulations, and 33% perform a stoma. The preferred type of PT is the Soave approach (65%), performed with transanal technique by 70% respondents. If symptoms persist after PT, most opt for conservative approach (enemas/laxatives = 76%; botulinum toxin = 27%), 30% would redo the PT. Total colonic aganglionosis: PT is performed in neonates (4%), at 1 to 6 months (29%), 6 to 12 months (37%) or older (30%). If required, a stoma is sited in the ileum (31%), according to intraoperative biopsies (54%), macroscopic impression (13%), and radiology (2%). Duhamel PT is performed by 52%, Soave by 31%, and Swenson by 17%. Overall, 31% would perform a J-pouch. Conclusions Most aspects of HD management lack consensus with wide variations in obtaining a diagnosis. Transanal Soave PT is the most common technique in standard segment HD. Guidelines should be developed to avoid such variability in management and to facilitate research studies.

International Survey on the Management of Congenital Diaphragmatic Hernia.

AIM: This study aims to define patterns in the management of congenital diaphragmatic hernia (CDH). METHODS: A total of 180 delegates (77% senior surgeons) from 44 (26 European) countries completed a survey at the 2014 European Pediatric Surgeons' Association meeting. RESULTS: Overall, 34% of the surgeons work in centers that treat < 5 cases of CDH/y, 38% work in centers that treat 5 to 10 cases/y, and 28% work in centers that treat > 10 cases/y. Overall, 62% of the surgeons work in extra corporeal membrane oxygenation (ECMO) centers and 23% in fetal surgery centers. Prenatal work up and delivery: 47% surgeons request prenatal magnetic resonance imaging, 53% offer karyotyping, 22% perform a fetal intervention, 74% monitor head-to-lung ratio, and 55% administer maternal steroids. Delivery is via cesarean section for 47% surgeons, at 36 to 38 weeks for 71% surgeons, and in a tertiary care center for 94% of the surgeons. POSTNATAL MANAGEMENT: A total of 76% surgeons report elective intubation, 65% start antibiotics preoperatively, and 45% administer surfactant. In case of refractory hypoxia, 66% surgeons consider ECMO with a variable course. Parenteral feeding is started preoperatively by 56% of the surgeons. Only 13% of the surgeons request contrast studies preoperatively to rule out malrotation.

Outcome of right-sided diaphragmatic hernia repair: a multicentre study.

AIM: Right-sided congenital diaphragmatic hernia (R-CDH) occurs in 14 to 25% of all CDH cases. The current literature comparing the outcome of R-CDH vs left CDH (L-CDH) is inconsistent, with some studies reporting higher and others lower mortality in R-CDH compared to L-CDH. The aim of our multicentre study was to analyse characteristics and outcome of R-CDH. METHODS: We retrospectively reviewed the medical records of 178 consecutive infants with CDH who underwent surgical repair of CDH at three European tertiary pediatric surgical centres from three different countries between 2000 and 2009. The analysis focused on demographic data, morbidity and mortality in R-CDH compared with L-CDH. RESULTS: Out of a total of 178 children, 32 (18.0%) right-sided and 146 (82.0 %) left-sided cases of CDH were identified. Prenatal diagnosis was made in 8 R-CDH vs 67 L-CDH (25.0 vs 45.9%, p = 0.030). Median gestational age in R-CDH was 39 weeks (range 29-42 weeks) and 39 weeks in L-CDH (range 28-43 weeks, p = 0.943). Median birth weight in R-CDH was 3233 g (range 905-4480 g) and in L-CDH was 3060 g (range 1065-5240 g, p = 0.184). Major associated anomalies were present in 19 R-CDH vs 46 L-CDH (59.4 vs 31.5%, p = 0.003). Extracorporeal membrane oxygenation (ECMO) was required in 3 R-CDH vs 19 L-CDH (9.4 vs 13.0%, p = 0.571). A diaphragmatic patch was used in 13 R-CDH and 59 L-CDH (40.6 vs 40.4%, p = 0.982). Fundoplication for GERD was required in 1 R-CDH and 19 L-CDH (3.1 vs 13.0 %, p = 0.109). No significant differences were observed in recurrence rate (9.4 vs 8.9%, p = 0.933). Postoperative mortality rate was significantly higher in R-CDH compared to L-CDH (21.9 vs 8.2%, p = 0.023). In R-CDH, prenatal diagnosis and patch repair correlated with mortality by univariate regression (p = 0.005 and p = 0.019). CONCLUSION: This multicentre study shows that prenatal diagnosis and patch repair were associated with an increased mortality rate in R-CDH. However, the morbidity following repair of R-CDH was not significantly different from that in L-CDH in survivors.

International survey on the management of necrotizing enterocolitis.

AIM: The aim of this study is to define patterns in the management of necrotizing enterocolitis (NEC). METHODS: A total of 80 delegates (81% senior surgeons) from 29 (20 European) countries completed a survey at the European Pediatric Surgeons' Association 2013 annual meeting. RESULTS: Overall, 59% surgeons work in centers where>10 cases of NEC are treated per year. DIAGNOSIS: 76% surgeons request both anteroposterior and lateral abdominal X-rays, which are performed at regular intervals by 66%; 50% surgeons also request Doppler ultrasonography; most frequently used biochemical markers are platelets (99% of surgeons), C-reactive protein (90%), and white cell count (83%). Laparoscopy is performed for diagnosis and/or treatment of NEC by only 8% surgeons. Overall, 43% surgeons reported being able to diagnose focal intestinal perforation preoperatively. Medical NEC: medical NEC is managed by surgical and neonatal teams together in most centers (84%). Most surgeons (67%) use a combination of two (51%) or three (48%) antibiotics for more than 7 days, and keep patients nil by mouth for 7 (41%) or 10 (49%) days. Surgical NEC: In extremely low-birth-weight infants (< 1,000 g) with intestinal perforation, 27% surgeons opt for primary peritoneal drainage (PPD) as definitive treatment. Overall, 67% think that peritoneal drainage is important for stabilization and transport. At laparotomy, treatments vary according to NEC severity. About 75% surgeons always close the abdomen, and 29% leave a patch to prevent compartment syndrome. POSTOPERATIVE MANAGEMENT: Infants are kept nil by mouth for 5 to 7 days by 46% surgeons, more than 7 days by 42%, and less than 5 days by 12% surgeons. Most surgeons (77%) restart infants on breast milk, 11.5% on aminoacid-based formulas, and 11.5% on hydrolyzed formulas. Most surgeons (92%) follow-up NEC patients after discharge, up to 5 years of life (56%) and 65% surgeons organize a neurodevelopmental follow-up. CONCLUSIONS: Many aspects of NEC management are lacking consensus and surgeons differ especially over surgical treatment of complex cases and postoperative management. Prospective multi-center studies are needed to guide an evidence-based management of NEC.

International survey on the management of esophageal atresia.

INTRODUCTION: Because many aspects of the management of esophageal atresia (EA) are still controversial, we evaluated the practice patterns of this condition across Europe. METHODS: A survey was completed by 178 delegates (from 45 [27 European] countries; 88% senior respondents) at the EUPSA-BAPS 2012. RESULTS: Approximately 66% of respondents work in centers where more than five EA repairs are performed per year. Preoperatively, 81% of respondents request an echocardiogram, and only 43% of respondents routinely perform preoperative bronchoscopy. Approximately 94% of respondents prefer an open approach, which is extrapleural in 71% of respondents. There were no differences in use of thoracoscopy between Europeans (10%) and non-Europeans (11%, p = nonsignificant). Approximately 60% of respondents measure the gap intraoperatively. A transanastomotic tube (90%) and chest drain (69%) are left in situ. Elective paralysis is adopted by 56% of respondents mainly for anastomosis tension (65%). About 72% of respondents routinely request a contrast study on postoperative day 7 (2-14). Approximately 54% of respondents use parenteral nutrition, 40% of respondents start transanastomotic feeds on postoperative day 1, and 89% of respondents start oral feeds after postoperative day 5. Pure EA: 46% of respondents work in centers that repair two or more than two pure EA a year. About 60% of respondents opt for delayed primary anastomosis at 3 months (1-12 months) with gastrostomy formation without esophagostomy. Anastomosis is achieved with open approach by 85% of respondents. About 47% of respondents attempt elongation of esophageal ends via Foker technique (43%) or with serial dilations with bougies (41%). Approximately 67% of respondents always attempt an anastomosis. Gastric interposition is the commonest esophageal substitution. CONCLUSION: Many aspects of EA management are lacking consensus. Minimally invasive repair is still sporadic. We recommend establishment of an EA registry.

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.

Effects of sodium hydroxide exposure on esophageal epithelial cells in an in vitro ovine model: implications for esophagus tissue engineering.

BACKGROUND: Esophagus tissue engineering holds promises for esophageal replacement after severe caustic injuries. The aim of this study was to determine whether viable esophageal epithelial cells could be isolated from an esophagus exposed to varying concentrations of alkali with regard to number, viability, and morphology during in vitro culture. METHODS: Ovine esophagi were exposed to phosphate-buffered saline 2.5%, 15%, or 25% sodium hydroxide (NaOH). The effect of NaOH concentrations on epithelial damage was assessed histologically. Esophageal epithelial cells were then isolated, and cell count and viability were investigated. Finally, cell number, viability, and morphology of esophageal epithelial cells were determined for 24 days of in vitro culture. RESULTS: Histologic analysis showed a progressive destruction of the epithelium proportional to increasing NaOH concentrations. Esophagi treated with phosphate-buffered saline and 2.5% NaOH showed significantly higher viable cell counts after isolation and culture in comparison with those treated with 15% to 5% NaOH. CONCLUSION: The evidence presented in this study indicates that epithelial biopsies from an esophagus exposed to low concentrations (2.5%) of NaOH will still yield large numbers of viable cells suitable for tissue engineering applications. In cases of exposure to higher concentrations (15%-25%), alternative cell sources for epithelial regeneration, such as stem cells, will be necessary for tissue engineering applications.

Colorectal carcinomas in children: an institutional experience.

PURPOSE: Colorectal carcinoma (CRC) is a rare malignancy in children. Due to its rarity this disease is seldom suspected in children and adolescents suffering from abdominal symptoms. Therefore, diagnosis is often delayed. The aim of the present study was to raise attention to this diagnosis and to present three very special cases of CRC in children treated at our department. METHODS: Patients' charts of all children treated at our department with colorectal carcinomas between 2000 and 2010 were analyzed. RESULTS: In the last 10 years three cases of CRC have been treated. The first patient was diagnosed a colon carcinoma following treatment of appendicitis, while the colon carcinoma could be resected without a recurrence. The genetic analysis demonstrated a high microsatellite instability. Subsequently, 4 years later, the patient developed an inoperable astrocytoma leading to the final diagnosis of a Turcot's syndrome. The second patient developed a colon carcinoma as a true second malignancy 10 years following an osteosarcoma. The third patient was diagnosed primarily with multiple metastases of a carcinoma of the descending colon. All three patients died 7, 8 and 11 years, respectively, following diagnosis. CONCLUSION: Albeit colon carcinomas in children are exceedingly rare, this diagnosis has to be considered in cases of unclear abdominal pain. Early recognition combined with radical surgery represents the mainstay of treatment of this disease in children.

Treatment algorithm for complex injuries of the foot in paediatric patients.

BACKGROUND: Complex injuries of the foot in the paediatric population present difficult treatment challenges. While standardised protocols exist for the adult population to achieve an optimal result in the treatment of such injuries, therapy in paediatric patientsmust be managed without a firm treatment algorithm. METHODS: Medical records of all patients with a complex trauma of the foot treated at our Department over a period of 13 years were evaluated. A complex trauma of the foot was defined using the scoring system developed by Zwipp et al. (1997).24 Treatment and outcome were analysed. Additionally, our treatment algorithm of complex injuries of the foot in paediatric patients is presented. RESULTS: Twenty-nine patients were included in the study (79%m; 21% f, average age 12.1 years, ranging 2­16 years). Traffic accidents were the most common mechanism (n = 14; 48.3%), followed by a fall from a height in five patients (17.2%). Lawnmower injuries were found in another 3 patients (10.3%) and other mechanisms of injury in 7 patients (24.2%). The mean score according to Zwipp et al. (1997)24 was 5.8 points (range 5­8 points). While closed fractures were diagnosed in 20 (69%) patients, 9 patients (31%) presented open fractures. Operative intervention was necessary in 24 patients (82.8%). Fracture stabilisation could be realised using K-wires in 13 cases (54.2%), screws in 3 cases (12.5%) and plate fixation in 1 case (4.2%). Combined techniques including external fixation were applied in another 7 (29.1%) cases. The mean time between injury and latest follow-up examination was 5.7 years (range 13 months to 13 years). The mean functional outcome was 47.6 (29­56) points for the OAFQ, 15.1 (0­69) points for the FFI and 82.3 (59­100) points for the AOFAS Score. DISCUSSION: To regard the maxims in treating complex injuries and open fractures in the growing skeleton we developed a simple treatment algorithm for complex foot injuries in order to provide preservation of the soft tissue envelope, avoidance of infection, restoration of the axis and the articular surface. CONCLUSION: A complex trauma of the paediatric foot is a rare and challenging injury. Avoidance of infection, preservation of the soft tissue envelope and fracture healing will provide good functional outcome despite the severity of trauma. Long time follow-up is essential to detect complications.

Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children.

BACKGROUND AND PURPOSE: Ulnar nerve injury may occur after pinning of supracondylar fractures in children. We describe the outcome and compare the rates of iatrogenic injuries to the ulnar nerve in a consecutive series of displaced supracondylar humeral fractures in children treated with either crossed pinning or antegrade nailing. METHODS: Medical charts of all children sustaining this fracture treated at our department between 1994 and 2009 were retrospectively reviewed regarding the mode of treatment, demographic data including age and sex, the time until implant removal, the outcome, and the rate of ulnar nerve injuries. RESULTS: 503 children (55% boys) with an average age of 6.5 years sustained a type-II, type-III, or type-IV supracondylar fracture. Of those, 440 children were included in the study. Antegrade nailing was performed in 264 (60%) of the children, and the others were treated with crossed pins. Iatrogenic ulnar nerve injury occurred in 0.4% of the children treated with antegrade nailing and in 15% of the children treated with crossed pinning. After median 3 (1.6-12) years of follow-up, the clinical outcome was good and similar between the 2 groups. INTERPRETATION: Intramedullary antegrade nailing of displaced supracondylar humeral fractures can be considered an adequate and safe alternative to the widely performed crossed K-wire fixation. The risk of iatrogenic nerve injury after antegrade nailing is small compared to that after crossed pinning.

Pisotriquetral arthrodesis for pisotriquetral instability: case report.

A 22-year-old professional downhill mountain bike rider developed increasing posttraumatic pisotriquetral instability. To preserve full function of the pisiform bone, we performed pisotriquetral arthrodesis using a Herbert screw. Ten months after the splint was removed, the patient was free of symptoms and returned to professional downhill mountain biking without limitations. This uncommon method seems to be a feasible treatment strategy and can be recommended in high-demand patients.

Evaluation of fractures in children and adolescents in a Level I Trauma Center in Austria.

BACKGROUND: Injury represents a major concern for children and adolescents worldwide. It is estimated that 10% to 25% of all pediatric injuries will result in fractures. This study aimed to analyze the epidemiology, gender distribution, age, and circumstances of fractures in childhood in a Level I Trauma Center in Austria. METHODS: Children managed with fractures between December 2004 and October 2006 were prospectively evaluated. Patients were divided into four age groups: infants (<1 year), preschool children (1-6 years), school-aged children (6-14 years), and adolescents (>14 years). RESULTS: The study included 3,339 patients younger than 19 years, who presented with 3,421 fractures. There was a male predominance (61.3%, n = 2,096). Girls (38.7%, n = 1,325) had a lower mean age at presentation of 8.2 years (boys, 9.8 years). An increase in the incidences of fractures was observed until a peak of 11 years in girls and 12 years in boys. A majority of fractures occurred in sports facilities (34.7%), followed by those at home (17.6%) and outdoors (16.7%). The most frequent mechanisms were falls on level surface (41.9%), falls from a height <3 m (23.2%), and involuntary contact with persons or objects (18.2%). The most common fractures were those of the distal radius (15.3%), followed by those of the finger (14%) and distal forearm fractures (8%). CONCLUSION: As the Department of Pediatric Surgery in Graz serves as the referral center at least for nearly all major pediatric fractures in the Austrian state of Styria, mechanisms and patterns of major fractures in this study can serve as the basis for state-wide pediatric injury prevention efforts. These prevention strategies should not aim to reduce the level of exposure but should increase the risk awareness and encourage children and their parents to use necessary precautions.

Post-traumatic coxa vara in children following screw fixation of the femoral neck.

BACKGROUND AND PURPOSE: The rare displaced fractures of the femoral neck in children need accurate reduction and rigid fixation. The implants commonly used for internal fixation in children are pins or screws. We evaluated the long-term outcome in children who sustained fractures of the proximal femur that were treated by screw fixation. PATIENTS AND METHODS: All 22 children (mean age 12 (5-16) years) with fractures of the femoral neck that were treated with screw fixation (mean 2.4 (1-3) screws) at our department between 1990 and 2006 were evaluated. For measurement of outcome, the Harris hip score (HHS) was used and the development of post-traumatic coxa vara was assessed from the difference in the neck-shaft angle postoperatively and at the latest follow-up examination, after mean 4 (2-15) years. RESULTS: A loss of reduction was observed in 12 patients. There was a statistically significant correlation between the HHS and the changes in the neck-shaft angle. INTERPRETATION: Loss of reduction was found in more than half of the children. Screw fixation cannot be recommended for the treatment of femoral neck fractures in children due to a substantial number of post-traumatic coxa vara.

Single-port appendectomy in obese children: an optimal alternative?

INTRODUCTION: The aim of this study was to evaluate our experience with single-port appendectomy (SPA) in obese children. METHODS: From January 2003 to June 2009, 94 SPA (65 women and 29 men, mean age of 12.4 years) were performed in children with appendicitis. Sixty-five of these patients were found to have normal weight, whereas 29 were obese. Patients' records were evaluated regarding operative time, intra- and post-operative complications, initiation of oral intake and histopathological findings. RESULTS: There was no significant difference in operative time between obese and normal weight patients. In the obese group, one wound healing disturbance was documented. In the normal weight group, there were one post-operative bleeding and one wound infection. There was no difference with regards to the introduction of feeds following appendectomy between the groups. Histological examinations revealed 15 normal, 32 acute, 21 phlegmonous, 20 chronic and two perforated cases of appendicitis, three neurogenic appendicopathies and one case of enterobius vermicularis related appendicitis. CONCLUSIONS: Our results indicate that the advantages of single-port appendectomy in the evaluation of the peritoneal cavity, the minimal rate of intra-operative incidents with this technique and superior cosmetics validate this alternative approach of minimal access appendectomy in obese children.

Fractures of the talus--differences between children and adolescents.

BACKGROUND: Fractures of the talus represent serious injuries of the foot skeleton. The most significant complications include osteonecrosis and posttraumatic malalignment with subsequent arthritis. The aim of our study was to compare treatment and outcome of fractures of the talus between children and adolescents. METHODS: From 1990 to 2005, 24 patients (18 male, 6 female) presented with 25 fractures of the talus. The medical records were reviewed retrospectively. Follow-up was performed by radiographical grading, and the functional outcome was measured using the Foot-Function-Index. RESULTS: Nine patients were 12 years of age or younger, and 15 patients presenting 16 talar fractures were older than 12 years. Although most fractures of the talus in children younger than 12 years were classified as Marti-Weber type I and II fractures, more than two thirds of the fractures in patients older than 12 years were Marti-Weber type III and IV fractures. Two thirds of the patients younger than 12 years were treated nonoperatively, whereas nonoperative treatment was possible in only three talar fractures in adolescents. No necrosis at follow-up (mean period, 3.2 years; range, 7 months to 8.4 years after end of treatment) was detected in children (<12a), whereas five patients older than 12 years developed persisting necrosis. CONCLUSION: Even though there is no apparent difference in the cause of the trauma leading to fractures of the talus, adolescents present with more severe fractures of the talus compared with children younger than 12 years. In addition, we did not observe persistent osteonecrosis in patients younger than 12 years old, and the outcome is favorable in most cases irrespective of the mode of treatment.

Analysis of 347 kindergarten-related injuries.

While it has been shown that non-parental child care is associated with a reduced risk for unintentional injuries, a considerable number of accidents in kindergartens do result in severe injuries. We have collected data on the behavioral and environmental aspects of accidents that occurred in kindergartens in Austria with the aim of determining possible prevention measures. Included in the study were all kindergarten-related injuries (347) from among 21,582 pediatric trauma cases treated in a 22-month period in Graz, Austria. Kindergarten-related injuries that were treated during the same period at six participating hospitals located throughout Austria were used for comparison. A questionnaire was completed at first attendance, and additional information was achieved by interviews with the parents and kindergarten teachers. Only the 347 kindergarten accidents that occurred in Graz were analyzed in detail. Half of the injuries occurred in an outdoor environment (outside), even though most of the time was spent indoors. Boys were more frequently involved in accidents than girls (male:female=3:2). We identified seasonal and circadian differences, with most children being injured during the first 2 months of attendance (September and October), during the first 3 days of the week (Monday to Wednesday) and in the hour before and after lunch, respectively. Of the 347 accidents analyzed, 24% resulted in serious injury, and injuries occurring outdoors were more severe than those occurring indoors. Most parents felt that the accidents were unpreventable (47%), while 18% stated that improved supervision may have prevented the accident. Kindergarten accidents in Austria still result in a significant number of severe injuries. Kindergarten injuries were related to gender, season, time of day and location. Our results indicate the necessity of a continuous child safety training program that involves the participation of all teachers in day-care functions.

Early complications of the Nuss procedure for pectus excavatum: a prospective study.

The Nuss procedure is a minimally invasive method for the correction of pectus excavatum, with several centers reporting its successful application. Complications related to the Nuss procedure are not uncommon and life-threatening complications have been reported. This study focuses on the incidence and management of complications in a series of 167 children and adults with funnel chest corrected by Nuss procedure. Guidelines and strategies to avoid the most common and typical complications are proposed. All patients with funnel chest, operated between April 2000 and 2006 were evaluated prospectively. Our surgical approach involved the submuscular insertion of the pectus bar under right-sided thoracoscopic control. The bar was secured in most cases with one stabilizer on the right side on the underlying rib to prevent bar displacement. Postoperative pain was primarily managed by epidural catheters. All data in the patient report forms was prospectively entered in a database. All complications were documented and classified into major or minor complication. A major complication was noted, if an organ injury occurred or if a significant surgical intervention became necessary. A minor complication was documented, if either an endoscopy or an evacuation of fluid or gas from the thorax by puncture were necessary. One hundred and sixty seven patients (136 males and 31 females) with a mean age of 16.3 (range 5-40 years) were included in this study. Major complications occurred in seven patients (4.2%) and consisted of one intraoperative heart perforation, one piercing of the liver with the trocar, bar infections (n = 2) and significant bar displacement (n = 3). Minor complications were seen in 122 patients (73.1%) and consisted of breakage of wires used to secure the lateral stabilizer plate (n = 48), pleural effusions (n = 28), intraoperative rupture of the intercostal muscle (n = 15), pericardial tears without clinical significance (n = 7) and lung atelectasia (n = 4). Major complications related to the Nuss procedure were rare but preventable and could mainly be attributed to the learning curve. Most minor complications can be avoided by changing the technique, e.g. fixation of the bar and the stabilizer onto the underlying rib, use of PDS cords instead of metal wires to fix the bar and the stabilizer, entrance into and exit of the thorax medial to the rim of the pectus excavatum, etc. Some complications are related to the technique, such as minor pleural effusion or remaining gas in the thorax. Clear guidelines in regard to the technique are presented to prevent the majority of complications and thereby shorten the learning curve.

Galeazzi lesions in children and adolescents: treatment and outcome.

UNLABELLED: A Galeazzi fracture is defined as a fracture of the radius associated with dislocation of the distal radioulnar joint. Treatment in children and adolescents is usually possible with closed reduction and casting. The objective of this retrospectively designed study was to describe all Galeazzi lesions treated at our department during a 3-year period. One hundred ninety-eight patients with displaced fractures of the radius alone or both bones of the forearm were reviewed. In 26 (13%) cases, a Galeazzi lesion was found and these patients formed the study group. Outcome was assessed using the Gartland-Werley score. Eight of 26 (31%) fractures were recognized initially and classified as a Galeazzi lesion. Casting after fracture reduction was possible in 22 patients. Thirteen patients were treated with immobilization in a below-elbow cast and nine with an above-elbow cast. Four patients were treated operatively. The results were excellent in 23 cases and good in three cases. In cases of distal forearm fractures, a possible Galeazzi lesion should be considered. However, proper reduction of the radius with concomitant reduction of the distal radioulnar joint and cast immobilization provides good to excellent outcome even if the Galeazzi lesion is primarily not recognized. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Pin tract infection with external fixation of pediatric fractures.

BACKGROUND: This study aimed to evaluate the incidence and severity of pin tract infections in a series of pediatric trauma patients. METHODS: All pediatric trauma patients with external fixation who were treated at our institution between 1998 and 2003 were included. The charts of 30 children (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were reviewed. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). Pin tract infections were graded using the Dahl classification. Bacterial cultures were obtained in case of drainage from the pin site. RESULTS: In 18 (48%) of 37 external fixations, no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. Most infections were mild or moderate, whereas only 3 (9%) severe deep infections were noted (grade 5). Six (17%) infections healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal of a pin. CONCLUSIONS: Pin tract infection occurred in half of the patients who were treated with external fixations. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization.

School accidents in Austria.

The aim of this study was to obtain information about the mechanisms and types of injuries in school in Austria. Children between 0 and 18 years of age presenting with injuries at the trauma outpatient in the Department of Pediatric Surgery in Graz and six participating hospitals in Austria were evaluated over a 2-year prospective survey. A total of 28,983 pediatric trauma cases were registered. Personal data, site of the accident, circumstances and mechanisms of accident and the related diagnosis were evaluated. At the Department of Pediatric Surgery in Graz 21,582 questionnaires were completed, out of which 2,148 children had school accidents (10%). The remaining 7,401 questionnaires from peripheral hospitals included 890 school accidents (12%). The male/female ratio was 3:2. In general, sport injuries were a predominant cause of severe trauma (42% severe injuries), compared with other activities in and outside of the school building (26% severe injuries). Injuries during ball-sports contributed to 44% of severe injuries. The upper extremity was most frequently injured (34%), followed by lower extremity (32%), head and neck area (26%) and injuries to thorax and abdomen (8%). Half of all school related injuries occur in children between 10 and 13 years of age. There are typical gender related mechanisms of accident: Boys get frequently injured during soccer, violence, and collisions in and outside of the school building and during craft work. Girls have the highest risk of injuries at ball sports other than soccer.