[Isolated fracture of the lesser trochanter-What age-related differences are important?] / Die isolierte Trochanter-minor-Fraktur ­ Worauf muss man in Abhängigkeit vom Patientenalter achten?

Isolated fractures of the lesser trochanter are very rare injuries. This case report describes the age-related differences based on two cases. A 13-year-old girl suffered an avulsion fracture of the lesser trochanter while sprinting. The patient received conservative treatment with pain-adapted partial weight bearing as tolerated using crutches with the goal of full weight bearing after 6 weeks. After 3 months she could return to the preinjury functional level without impairments. A 55-year-old woman also suffered an isolated fracture of the lesser trochanter, which was a pathological fracture due to a breast cancer metastasis. The cause of an isolated fracture of the lesser trochanter in adults is assumed to be the sign of an underlying malignant disease, until this has been disproven.

Cuboid nutcracker fracture in children: Management and results.

INTRODUCTION: Compression fractures of the cuboid bone in children and adolescents are rare. Fracture morphology, associated lesions, treatment options and long-term outcomes of this very rare injury are published in a few case reports. This study with review of the literature aims to support the understanding of fracture pattern and optimize pathways of decision making. MATERIAL AND METHODS: A retrospective two-center study was performed in a patient cohort treated between 2001 and 2016. All patients aged less than 18 years who sustained a cuboid fracture were included. Age, gender, mechanism of injury, fracture morphology, amount of displacement, associated injuries, and therapy were analyzed. In the follow-up (FU), the AOFAS Midfoot Scale was investigated. RESULTS: Fractures of the cuboid bone were diagnosed in 7 boys and 9 girls. The mean age of the patients was 10 years (range: 2.2-16.1 years). According to the classification of Fenton we detected 11 (69%) type 2, 2 (12%) type 3 and 3 (19%) type 5b fractures. Other fracture types according to Fenton were not observed. All children under 10 years sustained a type 2 fracture. Open reduction and internal fixation was performed in 5 (31%) patients. Bone grafting was not necessary. FU was performed in 14/16 patients on average after 9 years (mean; range: 1.4-16.2 years). The mean AOFAS Midfoot Scale at FU for extra-articular type 2 fractures was 100 points, whereas in intra-articular fractures (Type 3) and fractures associated with mid-tarsal disruption (type 5b) worse results were found (95 and 66 points, accordingly). CONCLUSION: This rare injury shows inhomogenous morphologies and offers different treatment approaches. Extra-articular Fenton type 2 lesions are the most common type of cuboid fracture in children (69%). A potential loss of length of the lateral column must be considered. In contrast to adults, type 1, 4, and 5a fractures were not found in our cohort of children and adolescents. Lower scores of the AOFAS Midfoot Scale were found with either intra-articular involvement or associated midfoot lesions.

Avulsion fracture of the lesser trochanter in adolescents.

INTRODUCTION: Avulsion fractures of the lesser trochanter in adolescents are rare. They are a result of a sudden and forceful contraction of the iliopsoas muscle. Functional results in the medium term after non-operative treatment are unknown. Therefore we aimed to report these in the present study. MATERIALS AND METHODS: A retrospective two-center study was performed in a case series treated between 2011 and 2017. All adolescents with an acute avulsion fracture of the lesser trochanter were included. Age, gender, mechanism of injury, fracture side, amount of displacement, and therapy were analyzed. In the follow-up, the Harris Hip Score (HHS), the sports level, the power of flexion in the hip, and signs of an ischio-femoral impingement (IFI) were investigated. RESULTS: An avulsion fracture of the lesser trochanter was diagnosed in 4 boys and 1 girl. The mean age of the patients was 13.8 years (range: 13-15 years). We observed 2 type II and 3 type III fractures. The patients received similar non-operative treatment. Follow-up was performed at a mean of 4.9 years (range: 3.5-6.2 years) after injury. All patients returned to competitive sports. The Harris Hip Score (HHS) was 100 out of 100 points. History and provocation test concerning an IFI were negative in all patients. CONCLUSION: Our study shows excellent results with non-operative treatment in acute avulsion fractures of the lesser trochanter in a case series of five adolescents. All patients returned to competitive sports. In our opinion, acute avulsion fractures of the lesser trochanter should be treated non-operatively.

[Changes in the patient population with proximal femur fractures over the last decade : Incidence, age, comorbidities, and length of stay]. / Veränderung der Patientenklientel mit hüftgelenknahen Femurfrakturen in der letzten Dekade : Inzidenz, Alter, Nebenerkrankungen und Liegezeiten.

BACKGROUND: Over the last decade, the percentage of people >65 years has increased from 16.6% to 20.7%. In industrialized countries, the annual incidence in people >65 years with a proximal femur fracture is about 600-900 per 100,000 population. The incidence will increase by 3-5% per year. Guidelines advocate early surgery as soon as possible but within 24 h. External quality control requires surgical treatment within 48 h. In this study, the changes in the patient population with proximal femur fractures and their treatment during the last decade were investigated. METHODS: From 2005-2014, data of all patients ≥65 years with proximal femur fractures were recorded. The patients were treated in a level 1 trauma center certified by the German Society for Trauma Surgery. The evaluation was carried out by means of descriptive statistics. RESULTS: In all, 2093 patients with proximal femur fractures (1164 trochanteric neck fractures and 929 femoral neck fractures) were evaluated. The annual increase in the percentage of patients was 1.5-2%. Over the decade, the percentage of patients increased by 20% and the average age increased by 2 years. There were no changes in comorbidities or case mix index during the investigation period. Despite the increase of the preoperative waiting times, a decrease in the total length of stay was found. DISCUSSION: The increase in the number of patients, as well as the requirements of the guidelines and external quality control are relevant challenges for the hospitals. More human and material resources (e. g., surgical capacity) are needed. The increase in the age of the patients, their comorbidities, and medication must be taken into account, e. g., in the context of geriatric orthopedic trauma centers.

Number of positive radiographic findings in pediatric trauma patients.

PURPOSE: Conventional radiography is frequently performed in pediatric patients in whom fractures and dislocations are suspected. However, until now, the rate of positive findings of the most commonly performed radiographic examinations in pediatric patients is unknown. The aim of this study was to evaluate the number of positive findings in the 20 most frequently requested standard radiographic examinations in pediatric patients in a level 1 trauma center systematically. METHODS: A transversal cohort study was conducted at a level 1 trauma center in Germany (2008-2014). In a statistical pre hoc analysis, a sample size of 200 images of each standard radiograph was determined. The picture archiving and communication system (PACS) was searched for radiographic examinations in patients under 18 years. RESULTS: The following fracture rates for the investigated 20 most common examinations were found: 70.5% clavicle, 54.5% forearm, 53% wrist, 41.5% elbow, 30.5% lower leg, 20% hand, 18.5% finger, 12.5% toe, 12% forefoot, 11.5% ankle, 9% shoulder, 6.5% patella, 5.5% foot, 4% knee, 2% conventional rib series, 1.5% lumbar spine, 1% Towne view, 0.5% skull, 0% cervical spine, and 0% odontoid. Differences in the mean age of analyzed pediatric trauma patients in correlation to different standard radiographs were found. CONCLUSIONS: In our study, a relevant amount of different standard radiographs revealed a low fracture rate. Therefore, indications for X-ray should be checked properly and alternative procedures should be discussed with the patient and the parents. Clinical decision rules should be developed and pathways have to be implemented to minimize radiation exposure, waiting time, and costs.

Outcome after operative treatment of proximal humeral fractures in elderly patients.

BACKGROUND: The proximal humeral fracture (PHF) (5 %) of the elderly is the third most common fracture after proximal femoral and distal radius fractures. Proximal femoral fractures often lead to a loss of autonomy. OBJECTIVES: The aim of this study is to show how PHF changes the patient's autonomy and the coping with everyday life as well as which factors influence the outcome 1 year (y) after surgery. MATERIALS AND METHODS: Data of 62 patients with surgical treatment of a PHF ≥ 60 y was prospectively collected. With a telephone interview Short Form (SF) 12 (physical and mental health; PH, MH), Barthel Index (BI), range of motion, pain, and satisfaction was observed after 3 and 12 months. The dependence of outcome on different factors was investigated. RESULTS: The mean age was 73.3 y (median 73, 60-94). Mortality after 3 months was 3 % and after 1 y 11 %. The PH before the injury (47.9) was significantly better than after 3 months (37.1) and after 1 y (42.6). The MH showed no difference. The BI before the injury (92) was significantly better than after 3 months (86), but the same after 1 y (91). After 1 y > 50 % were able to abduct and flex the arm > 90°. More than two-thirds were able to perform everyday life activities for body care and nutrition after 1 y. Approximately, 73 % of the patients had little or no pain, and 84 % were satisfied with the result after 1 y. Good score values before the fracture resulted in better outcome. Higher severity in fracture led to a higher level of pain. DISCUSSION: A surgically treated PHF in the elderly does not lead to a relevant impairment in quality of life. Despite the lack of complete retrieval of range of motion patients achieve a good to very good result in coping with everyday life.

Pediatric trauma care with computed tomography--criteria for CT scanning.

Trauma centers, trauma management concepts, as well as integration of whole-body computed tomography (CT) reduced mortality significantly. The accuracy of a trauma care algorithm with emergency CT in children was evaluated. Data of 71 children with emergency CT were recorded retrospectively. In addition to epidemiological data admission date, kind of CT scan, mechanism of injury, missed diagnoses, injury severity score (ISS), admission to and time on intensive care unit (ICU), and time of hospitalization were observed. The algorithm for CT scanning was based on mechanism of injury, pattern of injury, and altered vital signs. Sixty-nine percent of the children reached the ER during on-call service hours. A percentage of 32.4 received a whole-body scan and 67.6 % a cranial scan. The mean ER ISS was 9.9 points (1-57). Children have different trauma mechanisms compared to adults. A percentage of 33.8 of the children had relevant trauma related findings in the CT scan. In 2 children, (2.8 %) 3 diagnoses (2.2 %) were initially missed. After reevaluation of the CT data, all diagnoses were identified. Thus, the accuracy of our algorithm in children was 100 %. In children, our algorithm detected all injuries, but only one third of the children had relevant trauma related findings in the CT scan. In order to reduce radiation exposure but preserve the advantages of CT, a new algorithm was developed with more flexibility taking the child's age and mental status more into account as well as clinical findings. The mechanism of injury itself is not anymore an indication for CT scanning.

Triplane Fracture of the Distal Fibula.

This is a case report of a 14-year-old girl with a triplane fracture of the distal fibula. The fracture showed displacement and was treated by open reduction, internal fixation, and 5 weeks of external immobilization. The follow-up 5 months after injury yielded an excellent clinical result. Triplane fractures are also seen in locations other than the growth plate of the distal tibia. Due to the occurrence close to the end of the growth period, the potential for growth deformity is negligible. There has been no previous report of a transitional fracture in this location.

Induction of orthotopic rat adrenomedullary neoplasia by intraadrenal pheochromocytoma cell transplantation.

We aimed to establish a technically feasible, easily reproducible model of orthotopic adrenomedullary neoplasia. Male rats received adrenal injection of rat pheochromocytoma cells infected with the Escherichia coli gene for beta-galactosidase (lac Z). Each of 10 animals was perfused 7 or 24 days after tumor cell injection; 5 animals of each group were injected with cyclosporin. Animals without tumor cell injection served as controls. Tumor cells were identified and characterized in frozen sections by histochemical and immunohistochemical methods. Immunosuppressed animals had enlarged adrenals 7 days after tumor cell injection. In the rats without immunosuppression the adrenals seemed unaltered despite microscopic demonstration of tumor cells. After 24 days tumors had developed in all animals, weighing 50 times more than normal adrenals in animals with immunosuppression, and 9 times more in animals without immunosuppression. Intraadrenal catecholaminergic tumor cells could be identified by beta-galactosidase expression. No animal showed systemic spread. Generation of adrenomedullary neoplasia by intraadrenal pheochromocytoma cell transplantation is easily reproducible and technically feasible. This model allows simultaneous study of neoplastic and normal adrenal tissues (e.g., regarding their response to drugs intended for diagnostic and therapeutic purposes). The decreased tumor growth in animals without immunosuppression is presumably due to the high number of intraadrenal immunocompetent cells.