[Imaging in pediatric traumatology and orthopedics]. / Bildgebung in der Kindertraumatologie/Kinderorthopädie.

Conventional or digital radiography is still the basis of imaging diagnostics of the skeletal system in pediatric patients. It is considered the gold standard for diagnosis, treatment selection, and follow-up. In addition, procedures such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and also nuclear medicine techniques can and should be used. It is advantageous to use trained radiology technicians who are familiar with the handling of children in X­ray diagnostics. If there is no dedicated pediatric radiology department, it is recommended to follow the guidelines from radiology societies (as low as reasonably achievable [ALARA]) and radiation protection commissions. The present article describes how state-of-the-art tools such as dose monitoring systems and software-controlled image processing and also postprocessing can be used. The article provides information on how the various modalities can be optimally used in order to achieve the best result, i.e., diagnosis, with the least possible effort and burden for the child.

A novel pre-bending tool for elastic stable intramedullary nailing: An efficient and accurate study.

Purpose: The elastic stable intramedullary nail has been recognized as an accepted technique for treating pediatric long bone fractures. The principle of the technique is "3-point support and fixation," and it should be followed to achieve the optimum outcome without implant failure and complications. However, tools have yet to be reported for pre-bending of the elastic stable intramedullary nail. This study aims to present a novel tool for pre-bending the elastic stable intramedullary nails and the results of using this tool by surgeons. Methods: A designed case of femoral shaft fracture was provided to the participants. All participants were divided into three groups according to their experience with the elastic stable intramedullary nail technique: resident, fellow, and attending groups. The time of completing the pre-bending and coronal plane deviation of the nails after pre-bending was recorded. Statistical analysis compared the data in a conventional way and with the new tools in each group. Results: A total of 30 physicians were recruited in this study. The pre-bending duration with the new tool was significantly shorter than that of the conventional method for all physicians (p < 0.001). The coronal plane deviation of nails after pre-bending by the new tool was significantly smaller than that of the conventional method for all physicians (p < 0.001). Conclusion: This novel tool for elastic stable intramedullary nail pre-bending was convenient and easy to use in achieving the principal role of the elastic stable intramedullary nail technique. Physicians could reduce the coronal plane deviation when pre-bending elastic stable intramedullary nails, especially for physicians with less experience with the elastic stable intramedullary nail technique. Level of evidence: IV.

[Surgical suture material-fundamentals]. / Chirurgisches Nahtmaterial ­ Grundlagen.

At the end of surgical therapy, the access is closed with sutures. Surgical sutures are thus used to adapt wound edges and tissues. The task of the suture material is to hold the tissues together until healing. For patients, a cosmetically good suture is often the sign of good surgery. Different tissues and layers have different requirements regarding the suture material. The different types from monofil to polyfil, braided, from absorbable to nonabsorbable are presented. The classification of suture strengths is compared. The areas of application of different strengths and the duration until removal of the sutures for the different body regions are presented. The one-hand and two-hand techniques of surgical knots are explained in detail. The technique of suture removal is presented. In the online material, the suture materials of different composition and manufacturers can be compared.

[Triple osteotomy for patients with Legg-Calve-Perthes disease]. / Tripleosteotomie bei Morbus Perthes.

OBJECTIVE: Osteotomy of iliac-pubic and ischial bone in order to cover the lateralized femoral head with the acetabulum. With the restoration of the containment of the hip joint, the acetabulum functions as a template for the femoral head, thus, allowing it to keep its sphericity during the vulnerable stages of Legg-Calve-Perthes disease. INDICATIONS: Lateralized femoral head in severe Legg-Calve-Perthes disease and visible head at risk signs on the radiographs. Prerequisite is possible concentric reduction of the femoral head (confirmed by preoperative abduction radiograph or arthrography). CONTRAINDICATIONS: Hinged abduction. Impossible concentric reduction of the femoral head. SURGICAL TECHNIQUE: Hip arthrography to confirm the indication of the triple pelvic osteotomy is recommended. Osteotomy of the ischial bone by a modified Ludloff approach. Osteotomy of pubic and iliac bone by anterior approach (Smith Peterson/bikini incision). Turning the acetabulum over the femoral head allows improvement of the containment of the hip. Fixation of the acetabulum with fully threaded Kirschner wires or 3.5 mm cortical screws. POSTOPERATIVE MANAGEMENT: Touch-down weight bearing with crutches (wheelchair in younger children) for 4-6 weeks depending on the age of the child. After radiologic evidence of consolidation, transition to full-weight bearing within 1-2 weeks. RESULTS: Promising results in our own practice. Good functional and radiological results in a to-date unpublished study of 30 patients with Legg-Calve-Perthes disease after an average 5­year follow-up.

[Femoral head reduction osteotomy to improve femoroacetabular containment in Legg-Calve-Perthes disease]. / Femurkopfreduktionsosteotomie zur Verbesserung des femoroazetabulären Containments bei Morbus Perthes.

OBJECTIVE: Restoration of hip congruence and containment through central femoral head resection/reduction via an extended surgical hip dislocation, while maintaining/respecting the femoral head blood flow. Simultaneous or subsequent reorientation of the acetabulum by triple TPO (Pediatric Triple Osteotomy) or PAO (Peri-Acetabular Osteotomy) may be necessary. INDICATIONS: Surgical hip dislocation with femoral head reduction can be performed at any age in cases with hinge abduction and Stulberg class IV and V deformity. Procedure indicated for patients with active or healed disease. After the resection, a viable residual femoral head must remain, i.e. at least 50% of the expanded femoral head, which is best planned using "comparative" 3D reconstruction. CONTRAINDICATIONS: Completely destroyed cartilage or femoral head. SURGICAL TECHNIQUE: The same surgical procedure as described for classic surgical hip dislocation is followed. Preparation of retinacular flaps. With detailed knowledge of the vascular supply and precise execution of this technique, blood supply to the femoral head will be preserved; once safely surgically dislocated, the femoral head and neck can be split and the necrotic part of the femoral head removed. Reformation of the femoral head as spherical as possible is achieved by screw fixation of the femoral neck to align the two articular parts of the femoral head. Distalization and fixation of the great trochanter helps to restore offset (functional femoral neck length). Depending on the congruence and stability of the femoral head in the acetabulum, a primary TPO or PAO may also be necessary. POSTOPERATIVE MANAGEMENT: Intraoperative stability must be achieved to ensure functional posttreatment without a hip spica cast. Walking with crutches with toe contact only is advised. Active rotation is not allowed. Active and passive flexion up to 90° allowed. These measures have to be observed for 8-10 weeks. Then, active physiotherapy rehabilitation may commence, depending on healing, as assessed clinically and radiologically. RESULTS: Our published follow-up examinations (currently 21 years) show consistently good results with a technically correct operation and correct indication as well as adequate follow-up treatment. No necrosis of the reduced femoral head has been observed. All split femoral heads and femoral necks are primarily healed.

[Surgical needles in orthopedics and trauma surgery]. / Chirurgische Nadeln in Orthopädie und Unfallchirurgie.

For surgeons in the clinic and practice, the handling of suture material is the "daily bread". Therefore, one might assume that knowledge of this material is competent and comprehensive. However, daily experience shows a different picture. Often, the knowledge regarding needle shape, needle composition as well as needle size is only marginal and the surgeon has to rely on the knowledge of his OR nurse.The choice of needle is critical for each surgical step and each tissue; however, the use of the correct suture material in relation to the tissue to be sutured is essential, not only with respect to the quality of the suture but also with respect to the traumatization of the tissue. Depending on the tissue, different requirements must be placed on or taken into account for both the needle and the sutures. The purpose of this article is to provide the most essential and basic knowledge, such as the influence of needle shape and dimensions, effect of atraumatic or traumatic (so called sharp) needles on the tissue and shape of the needle tip. The interaction between the needle holder and the needle and the surgeon's hand in different applications is presented. In this present article, the main focus is on the needle and needle holder. A follow-up article specifically dedicated to sutures is being planned. The article does not claim to be 100% complete but the most essential, everyday questions should be clarified.

[Approaches and fixation of femoral neck fractures in children-transgluteal approach]. / Zugangswege und Fixation kindlicher Schenkelhalsfrakturen ­ transglutealer Zugang.

OBJECTIVE: Transgluteal approach for anatomical reduction of femoral neck fractures (extra-intraarticular) in children under preservation of the blood supply of the femoral head. INDICATIONS: Femoral neck fractures AO 31-M/2.1 I­III; 31-M/3.1 I­III; 31-M/3.2 I­III. CONTRAINDICATIONS: None. SURGICAL TECHNIQUE: Preparation of a muscular flap including the proximal insertion of the vastus lateralis muscle and approximately one third of the gluteus medius muscle. Elevation of the gluteus minimus muscle from the hip capsule without completely detaching it from its insertion. Exposure of the anterolateral hip capsule and capsulotomy followed by controlled reduction of the fracture fragments without compromising the retinacular vessels. POSTOPERATIVE MANAGEMENT: Touch-down weightbearing for 4-6 weeks (age dependent). To protect the healing of the abductors, active abduction or passive adduction prohibited for 4-6 weeks. Consolidation radiographs 4-6 weeks postoperatively. RESULTS: Excellent results in 29 patients subsequently treated in the last 10 years by the transgluteal approach. No cases of avascular necrosis of the femoral head by this procedure.

[Technique and biomechanics of Kirschner wire osteosynthesis in children]. / Technik und Biomechanik der Bohr-Draht(Kirschner-Draht)-Osteosynthese bei Kindern.

OBJECTIVE: Safe and stable fixation of metaphyseal and epiphyseal fractures by Kirschner (K-)wire osteosynthesis. Use of various K­wire configurations depending on the fracture morphology. INDICATIONS: In accordance with the AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF), all Salter-Harris (SH) and metaphyseal fractures as well as fractures of the foot and hand independent of the reduction technique, closed or open, provided that adaptation osteosynthesis allows sufficient stability. Fixation/immobilization in a plaster cast is mandatory after K­wire osteosynthesis. CONTRAINDICATIONS: All diaphyseal fractures, if a K-wire is not used as an intramedullary nail. Fractures that can not be correctly reduced or are nonreducible fractures. SURGICAL TECHNIQUE: After closed or open, as anatomical reduction as possible, one, two, occasionally three K­wires per fragment are inserted under fluoroscopic control. Care must be taken that the K­wires optimally capture the fragment to be fixed as well as the main fragment (metaphysis). It must therefore be possible to make a strictly lateral and correct anteroposterior x­ray by image intensifier. It is important that the C­arm can be positioned at the appropriate level. Rotating the limb should be minimized, as prior to fixation the previously reduced fragments may shift again, resulting in poor K­wire fixation. Depending on the morphology of the fracture, size of the fragments and location of the fracture (humerus, forearm, femur or tibia, hand or foot), the K­wiring technique must be adapted, e.g., mono-laterally crossed, mono-laterally divergent, in an ascending or descending direction, or the most commonly used ascending crossed technique. In most cases, the K­wires protrude through the sin and the exposed ends are bent. This allows removal without renewed anesthesia in the outpatient setting. K­wire osteosynthesis is neither a compression osteosynthesis (OS) nor a neutralization OS, but is always an adaptation and fixation of the fragments. Therefore, K­wire OS always needs additional immobilization using a plaster or prefabricated splint. POSTOPERATIVE MANAGEMENT: Immobilization in plaster cast for 4-5 weeks, depending on the age; care must be taken to avoid interference between the cast and the skin/K-wires. RESULTS: With technically and optimally performed fixation and correct indication for K­wire OS, as well as adequate posttreatment, very good to good results are achieved.

Comparison of internal fixation vs. external fixation after corrective osteotomy in children with cubitus varus.

BACKGROUND: Cubitus varus deformity is a well-known late complication of supracondylar fractures in children. In this retrospective study, the primary objective was to compare clinical and radiologic outcomes of lateral closing-wedge osteotomy with either internal fixation or external fixation in pediatric patients with cubitus varus deformities. MATERIALS AND METHODS: From 2010 to 2017, 35 consecutive patients with cubitus varus deformities secondary to supracondylar fractures were included in this study. After corrective osteotomy was performed via a limited lateral approach, the method of definitive fixation was chosen between internal and external. Retrospectively, patients who underwent external fixation on the lateral aspect of the elbow were defined as group I (n = 16) whereas patients with unilateral single-plate fixation were defined as group II (n = 19). The functional outcome was evaluated using the Mayo Elbow Performance Score and Flynn criteria. RESULTS: No significant difference in age was found between the 2 groups (P = .15). Significantly lower costs, a shorter operation duration, smaller scars, and a shorter time for plaster cast use postoperatively were found in group I (P < .001). No nonunion or failure of fixation was found. No significant difference was noted in postoperative elbow range of motion or Mayo Elbow Performance Score (P = .64). Both groups achieved satisfactory functional and cosmetic results. CONCLUSIONS: In pediatric patients with cubitus varus, both methods of fixation after lateral closing-wedge corrective osteotomy are reliable, with a low rate of complications and satisfactory functional results. External fixation is more advantageous in terms of easier preoperative planning, shorter operative times, lower costs, and easier postoperative fixation removal.

Health-related Quality of Life After Fractures of the Lateral Third of the Clavicle in Children and Adolescents.

INTRODUCTION: The health-related quality of life after pediatric fractures of the lateral third of the clavicle is unknown. Given the trend in the literature toward surgical management of clavicular fractures in adults, we frequently receive referrals for surgical management of lateral clavicular fractures in children.Therefore, we examined (1) the health-related quality of life of patients who sustained a fracture of the lateral third of the clavicle in childhood and who were treated at a large regional pediatric trauma center, (2) if the health-related quality of life was associated with the age at the time of the injury, and (3) whether fracture and displacement patterns were associated with health-related qualify of life. METHODS: This is a retrospective case series. We were able to identify 69 patients (21 girls and 48 boys) who sustained a fracture of the lateral third of the clavicle between the period spanning from January 2004 to June 2015. These patients were asked to fill in a questionnaire that included the Quick version of the Disability of Arm, Shoulder, and Hand (DASH) (primary outcome) and the Pediatric Quality of Life Inventory (Peds-QL). Until July 2017, we were able to get a response from 56 of these patients, resulting in a follow-up of 81%. RESULTS: Treatment was conservative in all cases but one. In these cases, after a mean follow-up of 6.5 years (range, 1 to 13.2 y), the mean Quick-DASH was 1.2 (SD, 4.4) at a scale of 0 to 100, with lower values representing better quality of life. The mean physical function score of the Peds-QL was 97.8 (SD, 4.4), and the mean psychosocial function score was 91.8 (SD, 10.8), both at a scale of 0 to 100, with higher values representing better quality of life.There was no statistically significant association of age at the time of injury on the primary outcome Quick-DASH.There were no statistically significant associations between fracture or displacement patterns with regard to health-related quality of life. CONCLUSIONS: Conservative treatment of lateral clavicular fractures in children and adolescents is associated with excellent health-related quality of life, as measured with the disease-specific Quick-DASH and the non-disease-specific Peds-QL at a mean follow-up of 6.5 years (range, 1 to 13.2 y). There was no effect of age at the time of injury, and we were unable to identify associations to commonly analyzed risk factors, such as displacement patterns.As the conservative treatment of this type of fracture in children and adolescents is associated with such a good health-related quality of life, it is unlikely that these results could be further improved by surgical interventions. LEVEL OF EVIDENCE: Level IV-case series.

Bernese-type triple pelvic osteotomy through a single incision in children over five years: a retrospective study of twenty eight cases.

INTRODUCTION: Bernese-type triple pelvic osteotomy (BTPO) combines periacetabular and triple innominate osteotomy techniques. However, studies that evaluate the clinical and radiographic outcomes of BTPO are scarce. The aim of this study is to report on the clinical and radiographic outcomes of ambulatory children with developmental dysplasia of the hip (DDH) or Legg-Calvé-Perthes disease (LCPD) managed with BTPO that were older than five years of age at the time of surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of 27 consecutive patients with DDH or LCPD (mean age 7.6 ± 1.8; 28 hips) who were treated with the reported technique. All patients had regular clinical and radiographic follow-up. Post-operatively, changes in the acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured in all patients. The presence/absence of avascular necrosis of the femoral epiphysis was also noted in patients with DDH. Final radiographic results were evaluated with the Severin and Stulberg classifications. The Harris hip score was used in the functional evaluation of all patients. RESULTS: In patients with DDH, the mean age at the time of surgery was 7.5 ± 1.8 years and the mean follow-up time was 22.2 ± 10.7 months. Prior to surgery, the mean AI was 37.9° ± 7.6°. At their final follow-up visit, the mean AI and CEA were 10.8° ± 5.4° and 40.9° ± 8.6°, respectively. Moreover, 66.7% of hips (14/21) were graded as Severin type I, and 33.3% (7/21) were graded as type II. The overall AVN rate was 14.3% (3/21). The mean Harris score was 92.1 ± 7.7. In patients with LCPD, the mean age at the time of surgery was 7.9 ± 1.8 years, and the mean follow-up time was 18.4 ± 6.1 months. Prior to surgery, 85.7% of hips were graded as Herring C, and 14.3% were graded as grade B. Prior to surgery, the mean AI and CEA were 19.4° ± 5.3° and 19.1° ± 12.6°, respectively. At the final follow-up visit, the mean AI and CEA were 5.8° ± 3.4° and 50.3° ± 12.0°, respectively, and 57.1% of hips were graded as Stulberg II. The mean Harris score was 94 ± 5.4. Ischial osteotomy non-unions were recorded in three patients (10.7%). CONCLUSIONS: BTPO through a modified anterior Smith-Peterson approach is an alternative treatment for DDH and LCPD in older children who are skeletally immature. It not only provides for a large acetabular correction but also achieves good biomechanical stability.

[Thumb Lengthening Following Amputation at the Proximal Phalanx using a Semicircular Distraction Ring Fixator: Results of 5 Cases]. / Daumenverlängerung nach traumatischer Amputation auf Grundphalanxhöhe mit semizirkulärem Distraktions-Fixateur: Ergebnisse von 5 Fällen.

Traumatic amputation of the thumb at the proximal phalanx or the metacarpophalangeal joint can be treated by distraction lengthening depending on the location of the amputation, the patient's age, occupation and functional demands. We report the results of proximal phalanx lengthening in 5 patients using a semicircular ring-type external fixator device. This prototype was developed at our clinic in collaboration with a specialised small company (Rotomed AG, Allmenstrasse 4, CH-4512 Bellach, www.rotomed.ch) based on the principles of Ilizarov's external fixator. In all patients, subjective and objective results were satisfactory (26.2 mm distraction length and an average Michigan Hand Outcome Score of 82.2%) without any rotational/axial deformities or complications requiring revision surgery.

High Survivorship and Little Osteoarthritis at 10-year Followup in SCFE Patients Treated With a Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure has the potential to restore the anatomy in hips with slipped capital femoral epiphyses (SCFE) while protecting the blood supply to the femoral head and minimizing secondary impingement deformities. However, there is controversy about the risks associated with the procedure and mid- to long-term data on clinical outcomes, reoperations, and complications are sparse. QUESTIONS/PURPOSES: Among patients treated with a modified Dunn procedure for SCFE, we report on (1) hip pain and function as measured by the Merle d'Aubigné and Postel score, Drehmann sign, anterior impingement test, limp, and ROM; (2) the cumulative survivorship at minimum 10-year followup with endpoints of osteoarthritis (OA) progression (at least one Tönnis grade), subsequent THA, or a Merle d'Aubigné and Postel score < 15; (3) radiographic anatomy of the proximal femur measured by slip angle, α angle, Klein line, and sphericity index; and (4) the risk of subsequent surgery and complications. METHODS: Between 1998 and 2005, all patients who presented to our institution with SCFE were treated with a modified Dunn procedure; this approach was applied regardless of whether the slips were mild or severe, acute or chronic, and all were considered potentially eligible here. Of the 43 patients (43 hips) thus treated during that time, 42 (98%) were available for a minimum 10-year followup (mean, 12 years; range, 10-17 years) and complete radiographic and clinical followup was available on 38 hips (88%). The mean age of the patients was 13 years (range, 9-18 years). Ten hips (23%) presented with a mild, 27 hips (63%) with a moderate, and six hips (14%) with a severe slip angle. Pain and function were measured using the Merle d'Aubigné and Postel score, limp, ROM, and the presence of a positive anterior impingement test or Drehmann sign. Cumulative survivorship was calculated according to the method of Kaplan-Meier with three defined endpoints: (1) progression by at least one grade of OA according to Tönnis; (2) subsequent THA; or (3) a Merle d'Aubigné and Postel score < 15. Radiographic anatomy was assessed with the slip angle, Klein line, α angle, and sphericity index. RESULTS: The Merle d'Aubigné and Postel score improved at the latest followup from 13 ± 2 (7-14) to 17 ± 1 (14-18; p < 0.001), the prevalence of limp decreased from 47% (18 of 38 hips) to 0% (none in 38 hips; p < 0.001), the prevalence of a positive Drehmann sign decreased from 50% (nine of 18 hips) to 0% (none in 38 hips; p < 0.001), and both flexion and internal rotation improved meaningfully. Cumulative survivorship was 93% at 10 years (95% confidence interval, 85%-100%). Radiographic anatomy improved, but secondary impingement deformities remained in some patients, and secondary surgical procedures included nine hips (21%) with screw removal and six hips (14%) undergoing open procedures for impingement deformities. Complications occurred in four hips (9%) and no hips demonstrated avascular necrosis on plain radiographs. CONCLUSIONS: In this series, the modified Dunn procedure largely corrected slip deformities with little apparent risk of progression to avascular necrosis or THA and high hip scores at 10 years. However, secondary impingement deformities persisted in some hips and of those some underwent further surgical corrections. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Paediatric lower limb deformity correction with the Eight Plate: adverse events and correction outcomes of 126 patients from an international multicentre study.

No large multicentre studies have yet been published on tension-band-like implants such as the Eight Plate to treat limb-length discrepancies and varus valgus deformities in children. Therefore, we carried out a retrospective international multicentre study including 126 patients to assess outcomes and to reliably quantify the incidence of implant-related and growth-plate related adverse events (AEs). Correction was achieved in 66% of varus valgus deformities and in 59% of limb-length discrepancies and maintained in 85%. Twenty (18%) patients experienced 43 AEs, which were primarily screw-related. The AE rate of the Eight Plate is low; however, many of them could be avoided through tighter monitoring.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF. Patients and methods - We included children and adolescents (0-17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs. Results - Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures. Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents. Interpretation - The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the lower extremities of a representative population of children classified according to the PCCF. Patients and methods - We included patients up to the age of 17 who were diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at either of 2 tertiary care university hospitals in Switzerland. Patient charts were retrospectively reviewed. Results - More lower extremity fractures occurred in boys (62%, n = 341). Of 548 fractured long bones in the lower extremity, 25% involved the femur and 75% the lower leg. The older the patients, the more combined fractures of the tibia and fibula were sustained (adolescents: 50%, 61 of 123). Salter-Harris (SH) fracture patterns represented 66% of single epiphyseal fractures (83 of 126). Overall, 74 of the 83 SH patterns occurred in the distal epiphysis. Of all the metaphyseal fractures, 74 of 79 were classified as incomplete or complete. Complete oblique spiral fractures accounted for 57% of diaphyseal fractures (120 of 211). Of all fractures, 7% (40 of 548) were classified in the category "other", including 29 fractures that were identified as toddler's fractures. 5 combined lower leg fractures were reported in the proximal metaphysis, 40 in the diaphysis, 26 in the distal metaphysis, and 8 in the distal epiphysis. Interpretation - The PCCF allows classification of lower extremity fracture patterns in the clinical setting. Re-introduction of a specific code for toddler's fractures in the PCCF should be considered.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods - Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results - Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school-children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation - Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

Callus massage after distraction osteogenesis using the concept of lengthening then dynamic plating.

Correction of complex deformities is a challenging procedure. Long-term wearing of a fixator after correction and lengthening are inconvenient and has a high rate of complication. The goals of the surgical treatment in the presented case were: (1) correction of the deformity and lengthening of the left leg by the Taylor spatial frame (TSF, Smith and Nephew, Marl, Germany); (2) reduction in the time the patient wears the TSF by changing the fixation system to a plate (lengthening then plating-LTP) and using a locking compression plate in conjunction with the 5.0 dynamic locking screws in order to accelerate bone healing.