[Injury prevention as the physician's challenge]. / Prävention von Verletzungen als ärztliche Aufgabe.

In Germany, more than 9 million individuals yearly sustain injuries and more than 30,000 fatal injuries. Based on estimations, preventive measures could avoid more than one half of all accidents and could influence the other half of the accidents such that the injuries caused are minor. The aim of an initiative of the Study Group on Injury Prevention of the German Trauma Society (DGU) is a complete inventory of all prevention programs from different expert groups in Germany. A synopsis of the gathered knowledge should serve as a basis for further interdisciplinary preventive measures. The consistent interdisciplinary orientation of this program is a special characteristic including trauma surgery, orthopedics, pediatric surgery, pediatrics, sociology, legal medicine, psychology, sports medicine, geriatrics, anesthesiology, and others. Special attention was also directed to the age groups of children/adolescents and the elderly.

[Sonographic diagnosis of supracondylar fractures of the humerus]. / Sonographische Beurteilung von supracondylären Humerusfrakturen - Retrospektive und prospektive Untersuchungen bei Kindern -

AIM: The aim of this study is to evaluate whether sonography as a primary diagnostic tool can be used for the diagnosis of supracondylar fractures of the humerus within a screening regimen. METHOD: With standardized sonography, a total of 75 children with suspected fractures of the distal humerus were investigated. The initially retrospective study (learning phase) was followed by a prospective study. All examinations were counter-checked by radiography. Supplementary to the standard sections two new sectional planes had to be added and evaluated. RESULTS: Of 65 children with fractures of the elbow, 43 had supracondylar fractures. All fractures could be visualized sonographically in the retrospective study and were diagnosed in the prospective examination. No supracondylar fracture was overlooked. Five results were falsely positive and would have been classified as undislocated supracondylar fractures type Baumann I. With the introduction of the two new sectional planes (dorsal radial and dorsal ulnar longitudinal section), rotatory deformity could be assessed. CONCLUSION: The longitudinal sections of the first compartment (standard sections) together with the two newly added dorsal radial and ulnar sections improved the diagnosis of supracondylar fractures of the humerus. The primarily unsatisfactory results could be improved by introduction of these additional sections, which are now recommended as standard sections of ultrasound application. Having acquired sufficient experience, the method can be used as a screening method for primary diagnosis and documentation of supracondylar fractures.

[Sonographic visualization of the axial level of the anal sphincters. Preliminary results in children]. / Sonographische Darstellung der axialen Ebene analer Sphinkterstrukturen aus dem digitalen Volumenscan. Erste Ergebnisse bei Kindern.

BACKGROUND: The sonographic visualization of anal sphincter structures in children through perineal sections in the sagittal and the coronary plane is unsatisfactory for the assessment of morphologic pathologies. Only the scan direction vertically to the longitudinal axis of the rectum facilitates the showing of the sphincter structures and their circumferential course. Up to now, this could only be achieved by a rectal introduction of the probe. This method has not found any acceptance with the diagnosis of children due to the necessary penetration as well as problems with orientation, resolution and time consuming preparations. METHOD: The anal sphincter structures of 10 children in the age of 2-6 years were examined. As a control group 5 children had no previous operations and a normal bowel movement. The others had previous operations due to anal atresia as well as pathological defecation. The Combison 530D (Kretz) was used. We started with the prototype of a 3D transducer that was derived from those designed for intravaginal use in gynecology. Modifications were made concerning the transducer design, the direction of the ultrasound was changed to 145 degrees forward angulation and a probe with short focus and 7.5 MHz. RESULTS: Our first investigations showed that axial levels calculated from the digitally registered volume scan permit so far not yet achieved visualization of the anal sphincter structures in children. Relevant pathomorphological findings can exactly be located. The examinations are non invasive and well accepted by children.

The Currarino syndrome--hereditary transmitted syndrome of anorectal, sacral and presacral anomalies. Case report and review of the literature.

The Currarino triad is a hereditary transmitted syndrome, originally defined by Currarino as ASP-association, consisting of an anorectal malformation, a sacral bony defect and a presacral mass. In most cases autosomal dominant transmission is suggested. In family members one or two features of the syndrome may be missing, indicating an incomplete form of this complex. We describe two unrelated girls at the age of 8 and 9 months respectively with ASP-association. Family screening in both patients showed 8 additional cases with a complete or incomplete Currarino triad, four of them being asymptomatic. A review of the literature up to 1991 revealed 48 patients with ASP-association. In more than 80% of cases, this complex is diagnosed in the first decade, whereas incomplete Currarino syndrome is diagnosed predominantly in adults. Most frequently the presacral mass in ASP-association was reported to be an anterior meningocele (47%) and a benign teratoma (40%). The number of patients with Currarino syndrome has been underestimated so far. We recommend anorectal examination, pelvic ultrasound and pelvic x-rays in all patients with a history of chronic constipation since early childhood. Positive findings should lead to further investigations such as barium enema, MRI, myelography and family screening. Close cooperation between pediatric surgeons and neurosurgeons is required to ensure adequate surgical treatment, considering both the risk of malignant degeneration as well as the risk of intraoperative nerve damage. Thus, radical excisional surgery is not obligatory in every case of Currarino syndrome.

Intraoperative vascular assessment for estimation of risk in primary closure of omphalocele and gastroschisis.

Surgical repair of anterior abdominal wall defects is often complicated by a discrepancy between the eviscerated organs and the intra-abdominal space available. Primary closure of the abdominal wall may result in increased intra-abdominal pressure and consecutive circulatory impairment. We report the results of a retrospective and consecutive prospective study evaluating the influence of different witameters on mortality and morbidity in children with gastroschitis and omphalocele. Both studies demonstrated that real-time sonographic investigations, intraoperative Doppler duplex sonography, and colour-coded Doppler sonography provide the oppurtunity to collect objective intraoperative data. Our data indicate that intraoperative vascular assessment facilitates the discrimination between infants who benefit from primary closure and those in whom a staged repair is the treatment of choice.

[Surgical strategies in thyroid gland diseases in childhood and adolescence]. / Chirurgische Strategien bei Schilddrüsenerkrankungen im Kindes- und Jugendalter.

In the Department of Paediatric Surgery of the University Hospital of Mainz and the Department of Paediatric Surgery of the University Hospital of Frankfurt/M 90 children with thyroid gland lesions were operated on between 1970 and 1988. 78 patients had benign findings and 12 had malignant tumours. The most frequent operative indication for benign lesions was the euthyroid goitre (57 patients). We found nodular goitre in 45 patients, cystic goitre in 11 patients, and diffuse goitre in only 1 patient. 20 children were suffering from hyperthyroidism (11 with Basedow's disease, 9 with autonomy) and 1 from Hashimoto's thyroiditis. Among the malignant tumours, papillary carcinomas were the most frequent (5 patients), followed by follicular carcinomas (2 patients) and C-cell carcinomas (2 patients), and 1 case each of C-cell hyperplasia, retothelial sarcoma and malignant lymphoma. The following operative interventions were necessary: Among the patients with the benign findings, 28 unilateral subtotal resections were done (17 right side and 11 left side). 24 lesions were enucleated, 24 goitres were subjected to subtotal bilateral resection; in 1 case subtotal resection on the right side and hemithyroidectomy on the left side was performed, and in one patient polresection was necessary. All the 12 patients with malignant tumours underwent thyroidectomy: In 4 cases one-step operations were done and in other 8 cases multistep operations were performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional colonic ultrasonography: normal findings of colonic motility and follow-up in neuronal intestinal dysplasia.

Three types of neuronal intestinal dysplasia (type A, type B, and combination with Hirschsprung's disease) can be distinguished. Functional assessment of the affected bowel segments can be achieved by functional colonic ultrasonography, thus providing exact parameters for further therapeutical procedure. The technique is described. Ten children with neuronal intestinal dysplasia in whom functional colonic ultrasonography was employed and results of their follow-up examinations are reported.

[Functional echo morphology of Bauhin's valve]. / Funktionelle Echomorphologie der Bauhinschen Klappe.

Following rectal irrigation, it is possible to demonstrate the ileo-caecal valve sonographically, using a right para-inguinal approach. The shape, position and motility of the valve can be evaluated. The normal valve is two to three mm. thick, similar to the colonic wall, but its lips are thickened. Two distinct mechanisms are responsible for opening the valve, the ileocolic pressure gradient and relaxation of the circular muscle round the valve. The resulting intraluminal flow can be quantified by duplex sonography. The information may be of diagnostic and therapeutic significance, particularly during childhood.

[Diagnosis and therapy of non-parasitic splenic cysts in children]. / Zur Diagnostik und Therapie nichtparasitärer Milzzysten bei Kindern.

Splenic cysts of various types are rare surgical abnormalities. The diagnostic and therapeutic procedures are discussed with special reference to the author's clinical material consisting of six children with non-parasitic cysts. Sonography and, in special cases, CT are the most important methods of examination. The desirability of conserving the spleen, while removing the cyst, is stressed.

[Modern diagnosis and therapy of traumatic hemobilia in childhood]. / Moderne Diagnostik und Therapie der traumatischen Hämobilie im Kindesalter.

The authors report on the first case of haematobilia diagnosed in childhood by means of sonography. Massive haematemesis occurred in a six-year-old boy on the 57th postoperative day after an oversewn rupture of the liver. Sonography revealed an atonic gallbladder with stratification phenomena and free floating highly reflecting coagulates, as well as pulsations and flow phenomena in an area of the size of a bean at the floor of a necrotic cavity of the liver (aneurysm). Relaparotomy was done by locating the aneurysm via sonography and performing a purse-string ligature. The high mortality rate of 10 to 20% can be reduced if the gradually evolving condition is identified at an early stage, which means that regular sonographic examinations should be conducted in the postoperative control of liver rupture. Intraoperative sonography with sterilisable sound heads enables accurate location of the source of bleeding.

[Post-traumatic radio-ulnar synostoses in childhood]. / Posttraumatische radioulnare Synostosen im Kindesalter.

This article reports on five children treated surgically during 1973-1975 for posttraumatic radioulnar synostosis. The synostoses had developed as a complication after a proximal radial fracture. Lesion of the proximal ulna plays an important part in creating such an osseous union. Another factor of equal importance is the traumatization of the tissues during surgical treatment of the fracture, especially if debris of the periosteum and fine bone fragments additionally enter into the space between radius and ulna. Formation of excess callus, and hence synostosis, is also promoted if repositioning or re-repositioning of a proximal radial fracture is effected too late. The article presents the technique of surgical treatment of proximal radioulnar synostosis with Lyodura sheathing. Follow-up examination of the five children during an observation period of five years showed good results in two children, a moderate result in one, and poor results of surgery in two cases. Improved results may be expected from further improvement of the surgical method, such as resection of the bicipital tuberosity (tuberositas radii) or from additional partial sheathing of the ulna at the side facing the radius.

[Relaparotomy in childhood]. / Relaparotomie im Kindesalter.

From 1.1.1976 to 31.12.1983 1,793 laparotomies were performed on children up to the age of 15 years at the Hospital of Pediatric Surgery, Mainz University. The incidence of acute unplanned relaparotomies was 4.6%. The most frequent indication of acute relaparotomy was postoperative obstruction due to adhesions (in 53% of all cases); burst abdomen, peritonitis, intestinal perforation, anastomotic insufficiency and secondary hemorrhage were less frequent causes of repeated abdominal procedures. 15% of all relaparotomised children underwent more than one repeat laparotomy. More than 40% of acute relaparotomies were performed on children within their first year of life. 56% of all relaparotomies had to be performed within the first four postoperative weeks, 87% within the first year. The lethality rate of acute relaparotomy was 15%. Lethality was especially high in children suffering from anastomotic insufficiency or burst abdomen; it increased with the number of relaparotomies. The significance of preoperative sonography for the diagnosis leading to acute unplanned relaparotomies is discussed and commented with examples.

Antenatal ultrasound diagnosis of congenital malformations of the urinary tract: results and criticism.

Fifty-five congenital malformations of the urinary tract (25%) were among 220 antenatally diagnosed malformations. Accuracy of diagnosis was 63.8% (44 cases); 20 infants had to be operated on. Good morphological and functional results could be obtained in 82% of the cases. Prenatal diagnosis of congenital uropathies provides early treatment burdened with less risk.

[Consequences from prenatal sonography of urinary tract abnormalities]. / Konsequenzen aus der pränatalen Sonographie von Harnwegsfehlbildungen.

At the Gynaecologic Clinic of the University of Milan/Italy from 1979-1983, pathological changes of the urinary tract were diagnosed in 55 foeti on the occasion of routine sonography of pregnants. In 23 children prenatal diagnosis was confirmed. 5 neonates had another disease than the disease of the urinary tract assumed during the prenatal period. In 19 neonates the first diagnosis had to be rescinded because of a second examination showing normal findings. 8 neonates could not be examined a second time. Advantages of an intrauterine diversion of urine could not be verified. Therefore, the following diagnostic and therapeutic consequences from the prenatal examination by sonography are recommended: Immediate check and analysis of prenatal findings in the neonatal period by further examinations. Short-term checks to clarify indication for operation. Avoidance of early complications and other kidney changes by early therapy.

[Mesenteric cysts in childhood]. / Mesenterialzysten im Kindesalter.

5 children with mesenteric cysts, 3 boys and 2 girls, aged 2 to 10 years, were admitted with acute abdominal pain. In adults the most common symptom is chronic abdominal pain whereas in children the onset of symptoms is acute due to intestinal obstruction. Sonography, performed in two patients, is the diagnostic method of choice. Excision of the cyst required resection of the small intestine in 2 patients, while simple enucleation was possible in 3. All 5 patients survived, and there have been neither complications nor recurrences. Early recognition and appropriate resection of these occasionally life-threatening malformations are associated with a good prognosis.

[Appendicitis in childhood]. / Appendizitis im Kindesalter.

Appendectomy was performed on 1,059 children at the University Clinic of Paediatric Surgery in Mainz from 1. 1. 1975 to 31. 6. 1983. For the retrospective examination of the indication for appendectomy histopathological and intraoperative findings were analysed and evaluated. Histologically five types of appendicitis were differentiated: 1. acute appendicitis (two forms: acute ulcero-phlegmonous appendicitis with or without perforation and acute superficial appendicitis), 2. chronic appendicitis, 3. lymphatic hyperplasia, 4. submucosal fibrosis, 5. rare diseases. In 618 cases (= 58.3%) acute appendicitis was diagnosed histologically. In another 203 cases (= 19.2%) intraoperative findings (e.g. Lymphadenitis mesenterialis, Meckel's diverticulum) were retrospectively collected; they caused symptoms similar to those of appendicitis. However, there remain retrospectively 22% of all appendectomised children with no indication for laparotomy. The statistical analysis of postoperative complications showed a significant dependance from the histopathological findings. The highest rate of complications was seen in cases with perforated (34%) or non-perforated (10%) ulcero-phlegmonous appendicitis. Children with acute superficial appendicitis had a complication-rate of 5%; those with lymphatic hyperplasia and submucosal fibrosis of 6% each. Relaparotomies were almost exclusively necessary in cases with acute appendicitis; septic and pulmonary complications were mostly seen either in infants with malformations or other perinatal risks, or in children with additional severe diseases. Therefore non-acute appendicitis justifies a wide indication for appendectomy because of a low complication-rate; this, however, is not valid for high-risk children (e.g. malformations). In these cases sonography might be useful for preoperative diagnosis.

[Methodologic studies of manometry of the rectum]. / Methodische Untersuchungen zur Manometrie des Enddarmes.

For the purpose of an experimental study in which the three different types of pressure catheters most commonly used in anorectal manometry were compared, a Starling-resistance could be established. Under equal conditions the pressures could be changed in this resistance and the data obtained by using a membrane-catheter, an open-tip and an open-side-catheter were compared among one another and to the known ideal straight line. The open tip catheter measures the opening pressure and the recorded pressure does not necessarily reflect the pressure at the site of the tip hole. Because of its elastic and plastic characteristics, the membrane-catheter yielded the best results with prestretch of the membrane and with calibration before and after each study.

[Femoral neck fractures in childhood]. / Die Schenkelhalsfraktur im Kindesalter.

Twenty-eight fractures of the neck of the femur occurred in children between 1963 and 1982 were treated and followed up at the Pediatric Surgical Hospital of the University of Mainz. Three children had transepiphyseal fractures (type I), eight children transcervical fractures (typ II), six children cervicobasal fractures (typ III), and eleven children pertrochanteric fractures (typ IV). Surgical intervention was performed in fifteen children, and thirteen children were submitted to conservative treatment. The results were evaluated according to a new system considering troubles, mobility, and X-ray findings. The evaluation showed good results in twenty children, bad results in two children, and satisfactory results in one child. Five children could not be evaluated. Complications necessitating an osteotomy with change of the bone position were only seen after conservative treatment. The therapeutic procedure applied in order to prevent the most severe complication, i.e. the aseptic necrosis of the femoral head, is pointed out.

[Optical-acoustical analogous biofeedback conditioning in the treatment of fecal incontinence in childhood]. / Optisch-akustisch analoges Biofeedback-Conditioning zur Behandlung der Stuhlinkontinenz im Kindesalter.

This is a report on the treatment of anal incontinence by biofeedback conditioning. Since August 1982 9 children with incontinence (8 rectoanal agenesia, one Morbus Hirschsprung) were treated by simultaneous optical and acoustical analogous biofeedback conditioning. Training of sensitivity and voluntary contractions were performed and controlled electromanometrically. According to the pressure waves electrical alterations were transformed and feedback visually and acoustically. Results of the training of the maximal voluntary contraction are presented and the superiority of this method for the coordination of the anorectal sphincter function is stressed.