[Fracture classification-part 1 : Modern low-dose radiation imaging in pediatric traumatology]. / Frakturklassifikation ­ Teil 1 : Moderne strahlensparende Diagnostik in der Kindertraumatologie.

BACKGROUND: Fractures in children are significantly more common than bone fractures in adults. Overall, they have a good prognosis regarding spontaneous correction and a restitutio ad integrum. The aim of this study is to provide an overview of established modern (low-dose radiation) imaging techniques in pediatric fractures. MATERIALS AND METHODS: Knowledge of typical fractures for different ages, of the individual bone nuclei of the growth plate, and epiphyseal injuries are important for the correct radiological diagnosis. This review also focuses on fractures of the elbow because misinterpretation may result in delays of consolidation with subsequent growth disturbances, joint dysfunctions, and malpositions. RESULTS AND CONCLUSIONS: In addition to conventional x­rays, fracture sonography is becoming increasingly important for the detection of fractures in children. In the upper extremity, a sensitivity of 96% and specificity of 97% can be achieved for some fracture entities, e.g., at the distal forearm. Computed tomography is used restrictively but plays an important role in a few special indications for polytraumatized children and preoperative assessment, e.g., in the case of transitional fractures.

[Inguinal hernia, and hydrocele--special features in infants and children]. / Leistenhernie, Maldescensus testis und Hydrocele testis--Besonderheiten beim Säugling und Kind.

Inguinal hernia, undescended testicle and hydrocele are typical and frequent diseases in infants and children. The paediatric inguinal hernia is a congenital defect and the hernial sac usually passes the inguinal canal. In order to diagnose the inguinal hernia in infants the physician is frequently dependent on the accurate observation of the parents. Although laparoscopic herniotomia is increasingly being discussed, it cannot be recommended yet as a standard operation because of a recurrence rate of 4%. Undescended testicle is classified into several subtypes with specific diagnostics and therapies. The role of hormonal therapy is currently controversial again, but the literature seems to point to a positive role for fertility in adulthood. The appropriate therapy should be performed by the end of the first year of life. A hydrocele is no acute reason for operative therapy; normally one can wait until the 2nd-4th year of life for spontaneous regression except for very large forms.

Transient renal insufficiency by bilateral renal cysts and posterior urethral valves.

Renal insufficiency developed in a newborn with huge bilateral renal cysts and posterior urethral valves. Definitive therapy consisted of laser coagulation of the valves and transient percutaneous drainage of the cysts.

Laser resection of posterior urethral valves.

Laser resection (LR) of posterior urethral valves during infancy as early as possible after diagnosis appears to represent a safe and reliable method. In contrast to other procedures, LR allows valve ablation with thin cystoscopes and carries little risk, even in premature and newborn infants. Its application in seven children in the course of 2 years principally confirmed its suitability for use: it could be applied in all cases without any problems and led to extensive resection of the valve tissue and removal of the obstruction in all patients. The encouraging clinical findings were confirmed by control cystoscopies and micturating cystourethrograms. Complications arising from the method were not observed.

Three-dimensional endosonography of the pelvic floor: an additional diagnostic tool in surgery for continence problems in children.

Three-dimensional endorectal sonography with a specially developed system is able to produce an image of the entire pelvic floor including the sphincter muscles and the rectal wall even in small children. This special system is based on conventional endorectal ultrasound and allows recording of a controlled withdrawal of the axially rotating transducer, creating an image sequence resembling that of a spiral CT-scan; this sequence is digitized off-line and evaluated in a three-dimensional form by a workstation computer. This evaluation has several advantages compared with conventional examination, for example, the complete recording of organs with the possibility of volumetry, construction of arbitrary sections, volume-rendering procedures and the interactive segmentation of organ borders and their three-dimensional visualization. Based on images from this 3D endorectal sonography, the normal anatomy of the pelvic floor that is visible using ultrasound is described, followed by some pathological findings concerning continence surgery. Finally we discuss the advantages and restrictions compared to other examination procedures and the possibilities of technical development.

[Endosonographic determination of the volume of anal sphincter muscles as a parameter for continence outcome in childhood]. / Endosonographisch bestimmtes Volumen der analen Kontinenzmuskulatur als Parameter für die Kontinenzleistung im Kindesalter.

The volumes of the external and internal anal-sphincter muscles, determined by three-dimensional (3d) endosonography, are linear to each other and to the body-height and body-surface ratios in normal children. In patients with an operation of the sphincter muscles, the reduced volume of the external sphincter system permits a differentiation of incontinent children; the volume of the internal sphincter muscles, however, doesn't give a significant difference nor does the muscle-thickness. An acceptable estimation of the sphincter muscles volume can be made with conventional endosonography by planimetry of the muscle tissue in four representative axial cut-planes and by measuring of the sphincter-length.

[Hospital ambulatory pediatric surgery]. / Krankenhausambulante Kinderchirurgie.

Since 1990, we have been conducting ambulatory pediatric surgery in an unit established solely for this purpose, supported by a team of kindergarten teachers, pediatric nurses, anesthesiologists and pediatric surgeons. This prospective investigation includes all ambulatory pediatric operations performed in our department from 1990 to 1995. In this time 3665 infants and children between the ages of 6 weeks and 18 years underwent an ambulatory operation. The ratio male to female was 4.1 to 1. The series consists of 1400 inguinal hernias, 722 inguinal testes, 191 hydroceles/funiculoceles, 75 umbilical hernias, 667 phimoses, 70 meatotomies, 59 hemangiomas, 217 endoscopies and 264 other surgical procedures. Postoperative complications defined as secondary hemorrhage, fever, obvious vomiting, urine retention and laryngospasm upon terminating anesthesia accompanied by subsequent vomiting occurred in 59 (1.6%) of all infants and children. Wound infections were seen in 0.48% (17/3517) of all patients. The recurrence rate for inguinal hernias were 0.79% and 1.12% for inguinal testes. Our experience enables us to summarize that a variety of pediatric operations can be performed today as ambulatory procedures. Nevertheless one must be prepared for the occurrence of complications and always have capacities free for inpatient care where adequate observation and treatment are available. Further improvement is necessary in quality management. In the last 20 years only a few data have been published about recurrence rates after pediatric ambulatory operations for inguinal hernias and inguinal testes. Therefore we started a prospective long- term study.

[Results of organ saving splenic surgery]. / Ergebnisse organerhaltender Milzchirurgie.

The charts of the 24 patients we treated in the past 7 years with spleen conserving methods after trauma and of the 13 patients we treated with splenic autotransplants were reviewed for this study. The results demonstrate, that the conservation of an injured spleen, desirable in adults too, is possible in appropriate cases without greater risk. Infrared coagulation and fibrin sealing proved as safe techniques, that can be augmented by others. Patients with subcapsular hematomas of the spleen can be left normally without operation in absence of other intraabdominal injuries; in these cases meticulous surveillance with the possibility of operations and ultrasound examinations at any time is necessary because of the risk of delayed bleeding. In the meantime we gave up the autotransplantation of splenic tissue after splenectomy for complications and doubts in the efficiency.

[Observations on post-traumatic osteitis]. / Beobachtungen zur posttraumatischen Osteitis.

The following study reports the frequency, the promoting factors, the therapy and her results of the 32 patients with posttraumatic osteitis we treated between 1984 and 1986 in the Surgical University Clinic Tübingen. Most of the primary injuries were caused by traffic-accidents; especially dangerous were those with motor-bikes, which led frequently via open fractures of the shank to osteitis. We saw the highest infection-rates after plate-osteosyntheses. The infects became obvious in most cases either about one month after the accident or a year later coinciding with the increased use of the limb. The most frequent bacterium was Staph. aureus both in the mono-infections and in the mixed-infections forming a third of the group. We always performed an operative therapy with the intention to stabilize the bone and to clean the infection-site. The strict performance of this management led to infect-suppression in all cases with the need of only one amputation.

Continuous or bolus chemotherapy with 5-fluoro-2'-deoxyuridine in transplanted experimental liver tumors?

The effect of continuous and discontinuous locoregional chemotherapy with Floxuridine (FUdR) was studied in a standardized and controlled animal model, using the transplantable Novikoff hepatoma in Sprague-Dawley rats. The liver was perfused after transplantation with a total of 420 mg/kg FUdR, via a fully implanted osmotic minipump or miniport and catheter in the hepatic artery, either continuously (n = 22) from day 5 to day 12, or discontinuously (n = 28) on days 5 and 8. Viable tumor volume and peritumorous cell infiltration were measured. No reduction in tumor volume was attained using discontinuous therapy, in contrast to a highly significant reduction using continuous therapy (P less than 0.001). Significantly less cell infiltration was found after discontinuous than after continuous therapy. In conclusion, continuous locoregional chemotherapy with FUdR was the superior administration method on measurable tumor effect, when compared to discontinuous infusion.