Timing of osteosynthesis of fractures in children changes the outcome.

PURPOSE: The search for optimal treatment strategies for fractures in children that require osteosynthesis is controversial and is still being debated. A major factor that has been under discussion is the impact of the timing of surgery: the time delay between the trauma and the operation, as well as the duration of the surgical procedure, and the time of day that the operation is performed are potential factors that might influence the outcome. Therefore, the aim of our study was to investigate the influence of these factors on the outcome after osteosynthesis of diverse fractures of the extremities in children. METHODS: In a retrospective study, 387 patients aged 1-18 years who presented with fractures of the extremities that underwent surgery were included. Patient records including radiological studies were analyzed. The follow up period lasted at least 12 months or until recovery. Statistical significance was set at an alpha level of P ≤ 0.05. RESULTS: Delayed surgery, as well as a prolonged duration of surgery, and the mode of transportation of the patient significantly were related to a higher rate of complications. However, in this study, the complication rate was not found to be influenced by the mode of reduction of the fracture, or the time of day or the day of the week. A further parameter that significantly changed the outcome was the mechanism of injury. However, the rate of complications was unchanged if a resident or a consulting was the performing surgeon so that a resident can safely perform the procedure in the presence of a consultant. CONCLUSION: Timing of surgery for fractures of the extremities in children, including the time from trauma to surgery, the duration of the operation and the mode of transportation to the ER, were found to have a significant impact on the occurrence of complications in this study while the mode of reduction and the time of day did not change the outcome. Future studies with a focus on selected types of fractures are needed to further enlighten this topic. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Lateral Condyle Fracture of the Humerus in Children: Kirschner Wire or Screw Fixation?

INTRODUCTION: The treatment of the displaced fracture of the lateral condyle of the distal humerus in children aims not only to avoid nonunion, malalignment, and impairment of the range of motion of the elbow but also to prevent delayed healing and the development of any prearthrotic deformity. To date there is no agreement on what kind of osteosynthesis should be used. So far, the screw fixation and Kirschner wire fixation have both been applied. Therefore, the goal of this study was to compare the outcome of these two methods. MATERIALS AND METHODS: A retrospective cohort study was undertaken including 43 patients aged 2 to 13 years who underwent osteosynthesis for a condylar fracture of the humerus over a period of 10 years. The electronic archive, including the radiological diagnostics, was analyzed. Statistical analysis was performed using IBM SPSS Statistics 20.0. Statistical significance was set at an α level of p = 0.05. RESULTS: Kirschner wire fixation was performed in 48.9% of condylar fractures of the humerus while screw fixation (alone or in combination with a pin) was assessed with a percentage of 51.1% of the cases in this study. Screw fixation only was applied in 20.9% of fractures of the lateral condyle. The selection of the method was independent of the age of the patient (p = 0.2). The comparison of the rate of complications and an impaired range of motion after Kirschner wire osteosynthesis to the rate after screw osteosynthesis showed a significantly lower percentage for the Kirschner wire group (p = 0.046). No case of nonunion, nerve palsy, or pin migration was detected in any patient in this study. CONCLUSION: Kirschner wire fixation of condylar humeral fractures in children resulted in a lower rate of complications than screw fixation. No case of nonunion of the fracture was found in the patients that we investigated so that we conclude that Kirschner wires sufficiently adapt the fracture in these cases. LEVEL OF EVIDENCE: Level III.

Ambulatory or inpatient management of mild TBI in children: a post-concussion analysis.

BACKGROUND: Diagnosis and treatment of children with mild traumatic brain injury (mTBI) remain a challenge since initial signs and symptoms do not always indicate the severity of the trauma. Therefore, guidelines regarding the decision upon imaging methods and ambulatory or hospitalized treatment are needed. The goal of our study was to investigate if the standard that was allied from the PECARN rules and is applied in this study can ensure that patients with clinically important brain injury are recognized and leads to outcomes with a low complication rate, a high patient satisfaction and minimal post-concussion syndrome incidence. METHODS: We enrolled 478 children with mTBI and contacted their families with a questionnaire. Out of these, 267 valid questionnaires were received. Patient records and questionnaires were analyzed yielding a number of 140 ambulatory and 127 hospitalized patients. RESULTS: Patients with mild TBI were admitted according to the above-mentioned guidelines or sent home for observation through their parents after thorough patient examination and information. Among ambulatory patients only 13 children (9%) underwent any imaging procedure; however, none of those showed any pathological findings. Next, in 41 of 127 hospitalized patients (32.2%) an imaging study was performed and of these only 3 according to 2.4% of hospitalized patients showed pathological findings, namely a skull fracture, two of them in combination with an intracranial hemorrhage. The duration of inpatient observation was 48 h in most cases (55.3%). Moreover, a majority of all patients (72.4%) did not seek any follow-up visit and did not need any further treatment. Of all patients in the study, only 10 patients according to 3.7% developed a post-concussion syndrome. Patient satisfaction was very high in both, the ambulatory and hospitalized patient group. CONCLUSION: This study confirms that PECARN rules as administered in this study can ensure safe decision-making regarding ambulatory or inpatient treatment.

Platelet Derived Growth Factor Has a Role in Pressure Induced Bladder Smooth Muscle Cell Hyperplasia and Acts in a Paracrine Way.

PURPOSE: Bladder outlet obstruction is a finding in many urological disorders, leading to bladder wall hyperplasia. We investigated platelet derived growth factor and its receptor in human bladder smooth muscle cells and urothelial cells exposed to hydrostatic pressure or PDGF in vitro. MATERIALS AND METHODS: Bladder smooth muscle cells and urothelial cells were exposed to elevated hydrostatic pressure for 1 hour. The expression of PDGF and PDGFR was evaluated using reverse transcriptase-polymerase chain reaction and Western blot analysis. Pressure or PDGF induced proliferation of bladder smooth muscle cells with or without pretreatment with lovastatin or imatinib was measured by enzyme-linked immunosorbent assay. PDGFRα was knocked down with siRNA. RESULTS: After hydrostatic pressure bladder smooth muscle cells showed increased PDGFRα and ß expression. PDGF was not expressed in bladder smooth muscle cells. Urothelial cells showed no expression of PDGFR but PDGF expression was noted. Western blot analysis of bladder smooth muscle cells revealed a pressure induced increase in PDGFR in the membrane fraction. Phosphorylation of PDGFR occurred with pressure induction. Bladder smooth muscle cell proliferation was increased in pressure and PDGF mediated fashion. Pretreatment with lovastatin or imatinib prevented proliferation. There was no cell proliferation after PDGFRα knockdown. CONCLUSIONS: Increased expression and phosphorylation of PDGFR in bladder smooth muscle cells after hydrostatic pressure suggests a pivotal role of the PDGF pathway in pressure induced hyperplasia of bladder smooth muscle cells. PDGF expressed in urothelial cells may act in a paracrine way. Cholesterol depletion, inhibition of receptor tyrosine kinase activity and knockdown of PDGFRα in bladder smooth muscle cells prevent pressure and PDGF mediated cell proliferation. Targeting PDGFR seems a promising way to influence pressure induced bladder wall hyperplasia.

Multiply trauma in children: pulmonary contusion does not necessarily lead to a worsening of the treatment success.

AIM: The aim of the study is to evaluate the impact of pulmonary contusion on the overall outcome in children with multiply injury. PATIENTS AND METHODS: Retrospective review of 123 multiply injured children during a 10-year period (January 2000 to February 2010) who were admitted to the intensive care unit of a university affiliated, tertiary care pediatric trauma center. The diagnosis of pulmonary contusion (case group) was defined by the clinical context and the results of chest X-ray and blood gas analysis. Data were compared with a matched control group without the diagnosis of pulmonary contusion. Matching criteria were as follows: (1) age difference within 2 years; (2) sex; (3) similar injury pattern; (4) Pediatric Trauma Score (PTS) difference within 2 points; (5) Glasgow Coma Score (GCS) in two categories. RESULTS: The risk of pulmonary contusion must not be underestimated in multiply injured children. In our study, 49 of 123 patients (40%) showed signs of pulmonary contusion. A matched and pair analysis was performed in 46 patients (94%). Pulmonary contusion had an impact on the Pao2/ FIo2 ratio. It was significantly reduced in patients and caused insignificant extension of the ventilation time. Overall length of stay (LOS), LOS at pediatric intensive care unit, complication rate, mortality rate, and short-term outcome did not differ significantly between cases and controls. CONCLUSIONS: Pulmonary contusion alters gas exchange but does not appear to increase morbidity and mortality of pediatric patients with multiply injury. Interpretation may be limited by sample size.

Long-term results of endoscopic treatment of vesicoureteral reflux in children: comparison of different bulking agents.

OBJECTIVE: To determine the long-term effect in children of endoscopic treatment of vesicoureteral reflux (VUR) using different bulking agents. VUR status, recurrence of urinary tract infection (UTI), and recurrence of febrile UTI were evaluated as endpoints. METHODS: From 1993 to 2005, we injected 229 refluxive ureters (VUR grade II-IV) in 135 children. Mean age of the children was 55.7 months. We used collagen in 98 (years 1993-2000), polydimethylsiloxane in 32 (years 1999-2000), and dextranomer/hyaluronic acid copolymer (Dx/HA) in 99 ureters (years 2000-2005). Of the 135 children, 127 underwent a voiding cystourethrogram (VCUG) (radiologic or nuclid) 3 months after the first injection, and 88 children a second VCUG (nuclid) after 37 months (mean) postoperatively. Clinically, patients were monitored for non-febrile or febrile UTI. Data were collected and analyzed retrospectively by chart review. RESULTS: After first injection with collagen, polydimethysiloxane and Dx/HA, 52%, 55% and 81.5% of the children were without VUR, respectively. Repeated injections were successful in only 21% (collagen) to 42% (Dx/HA). Of the 88 with a second VCUG, 48.5% of the initially reflux-free children developed relapse VUR after collagen, 45.5% after polydimethylsiloxane and 21.5% after Dx/HA injection. Clinically, there was a significant difference in postoperative UTI occurrence in favor of the Dx/HA group. CONCLUSIONS: Clinically and radiologically, Dx/HA exhibited the best results, giving better protection against UTIs and a better VUR cure rate. There was still a risk of VUR recurrence in successfully treated children after 3 years of follow up.

The treatment of supracondylar humeral fractures with elastic stable intramedullary nailing (ESIN) in children.

BACKGROUND: Supracondylar humeral fractures are the most common elbow fractures in children. In case of displacement and instability, the standard procedure is closed reduction and percutaneous Kirschner wire fixation. As Kirschner wire fixation requires postoperative cast immobilization, does not allow early mobilization, and is associated with the risk of damage of the ulnar nerve, innovative techniques should be evaluated. Therefore, the aim of the study was to assess both radiologic and functional outcome of supracondylar humeral fractures treated by elastic stable intramedullary nailing (ESIN) in a large pediatric cohort. METHODS: Retrospective review of children who underwent closed reduction and ESIN of displaced supracondylar humeral fractures in our institution between 2001 and 2009. RESULTS: One hundred twenty-seven children (mean age 6.1 y) with types II (60.6%), III (23.6%), and IV (15.7%) fractures according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Pediatric Comprehensive Classification were included. One hundred and eighteen patients (92.9%) had healing of fracture without any limitation in range of motion and 9 patients (7.1%) had some minor degree of long-term functional deficit (7 children with flexion and 2 with extension deficit). Two children had clinical cubitus varus deformity. No iatrogenic damage to the ulnar nerve occurred and no secondary reduction or a change of surgical strategy was necessary. Postoperative radiologic evaluation showed antecurvation in 1 case, recurvation in 3 cases, as well as cubitus varus deformity and rotation deformity in 1 child each. CONCLUSIONS: Antegrade ESIN is a technique suitable for all types of supracondylar humeral fractures with good functional results. The advantages include the avoidance of iatrogenic ulnar nerve injury, low rates of cubitus varus, cast-free treatment, and the possibility to evaluate clinical motion at all times postoperatively. Although biased toward milder forms of supracondylar fractures, our data clearly suggest that if closed reduction is possible, intramedullary nailing in these children is more than an alternative to Kirschner wire fixation as the standard procedure. LEVEL OF EVIDENCE: IV.

[Screw osteosynthesis of proximal femur fractures in children]. / Schraubenosteosynthese proximaler Femurfrakturen im Kindesalter.

OBJECTIVE: Optimal reposition and stable fixation of M/1 and M/2 fractures are necessary. Careful operation and urgent surgery prevent complications. INDICATIONS: M/1 and M/2 fractures of the proximal femur in children > 4 years. CONTRAINDICATIONS: E/1 fractures are fixed with Kirschner wires. M/3 fractures are fixed with elastic stable intramedullary nailing. Fractures up to the age of 4 are fixed with Kirschner wires. SURGICAL TECHNIQUE: Surgical approach via a lateral incision. Anatomic fixation of the fracture with two to three cannulated screws. POSTOPERATIVE MANAGEMENT: No weight bearing during the first 4-6 weeks. Physiotherapy is optional. Magnetic resonance imaging at least 1 year after the fracture or immediately in case of problems to control the vascular situation of the femoral head. RESULTS: Due to the rarity of these fractures, only few results from large series have been published. M/1 fractures show a higher complication rate than M/2 fractures. The risk of avascular necrosis has to be estimated at up to 40%.

Acquired heart block: a possible complication of patent ductus arteriosus in a preterm infant.

A large patent ductus arteriosus (PDA) is a frequently encountered clinical problem in extremely low birth weight (ELBW) infants. It leads to an increased pulmonary blood flow and in a decreased or reversed diastolic flow in the systemic circulation, resulting in complications. Here we report a possible complication of PDA not previously published. On day 8 of life, a male ELBW infant (birth weight 650 g) born at a gestational age of 23 weeks and 3 days developed an atrioventricular block (AV block). The heart rate dropped from 168/min to 90/min, and the ECG showed a Wenckebach second-degree AV block and intraventricular conduction disturbances. Echocardiography demonstrated a PDA with a large left-to-right shunt and large left atrium and left ventricle with high contractility. Within several minutes after surgical closure of the PDA, the heart rate increased, and after 30 min the AV block had improved to a 1:1 conduction ratio. Echocardiography after 2 h revealed a significant decrease of the left ventricular and atrial dimensions. Within 12 h, the AV block completely reversed together with the intraventricular conduction disturbances. We suggest that PDA with a large left-to-right shunt and left ventricular volume overload may lead to an AV block in an ELBW infant. Surgical closure of the PDA may be indicated.

Cajal-like cells in the upper urinary tract: comparative study in various species.

The interstitial cells of Cajal (ICC) play an important role in the control of gut motility. The recognition that the ICC cell membrane harbors the c-kit receptor (CD117) sparked rapid advancement in ICC research on the gut and certain pathologies using immunochemical and molecular methods. The question arises whether ICC exist in the upper urinary tract (UUT) and trigger motility. The present study analyzed the distribution of the c-kit receptor in the normal human UUT compared with various species. Immunohistochemistry (alkaline-phosphatase-anti-alkaline-phosphatase technique, immunofluorescence) was applied on serial sections using monoclonal and polyclonal antibodies recognizing the c-kit receptor. C-kit staining was compared with standard endothelial, epithelial, neurogenic, histiocytic, mast cell, and smooth muscle markers, as well as a negative control. Normal proximal, middle, and distal ureter segments were analyzed in rodents, carnivores, porcines, cow, and humans. In all species the c-kit receptor was detected in either round or spindle-shaped cells. Because of their antigenic profile, the round cells were identified as mast cells occurring in all layers of the ureteral wall except the urothelium and were more frequent in humans. In contrast, the population of spindle-shaped cells was marked only by anti-c-kit receptor antibodies, thus resembling ICC. These ICC-like cells were found among the inner and outer smooth muscle layers and in the lamina propria of all species. In humans, spindle-shaped cells were also found vertically oriented within the urothelium. Our morphological data present for the first time the distribution of ICC in the UUT of various species. The ubiquitous distribution in the entire pyeloureteral complex provides strong evidence that ICC generate electrical pacemaker activity within the UUT as an intrinsic system. Animal studies may help to understand the physiological importance of these ICC-like cells. The significance of these findings needs to be evaluated by functional studies and investigations of certain congenital pathologies with disturbance of the urinary outflow.

Cajal-like cells in the human upper urinary tract.

PURPOSE: Interstitial cells of Cajal (ICCs) have an important role in the regulation of gut motility as they are responsible for the slow wave activity of smooth muscle. It is still unknown if ICCs also occur in the human upper urinary tract. Since these cells express and are marked by the c-kit receptor CD117, we investigated its occurrence and distribution along the human upper urinary tract. MATERIALS AND METHODS: Tissues from 56 human ureters, spanning proximal, middle and distal ureter segments, were analyzed by indirect immunohistochemistry using the alkaline phosphatase-anti-alkaline phosphatase method and double labeling immunofluorescence on consecutive tissue sections. Several monoclonal and polyclonal antibodies to c-kit receptor were used in combination with various cell markers for histiocytic, mast cell, endothelial, epithelial, neuronal, smooth muscle and stem cell differentiation. RESULTS: The c-kit receptor was found in 3 cell types of the ureter and in round or spindle-shaped cells. Due to their antigenic profile the first one was revealed as mast cells occurring in all layers of the ureteral wall except the urothelium. In contrast, the population of spindle-shaped cells was only marked by c-kit receptor, thus, resembling ICCs. These ICC-like cells were found among the inner and outer smooth muscle layers, and in the lamina propria. They showed a slight decrease from proximal to distal ureteral segments. However, unlike intestinal ICCs their cytomorphology differed and some cells, representing the third group of c-kit receptor positive cells, were found within the urothelium. CONCLUSIONS: Our data demonstrate the presence of ICC-like cells and their ubiquitous distribution in the human ureter. The physiological importance and pathological significance of these findings must be evaluated by functional studies and investigations of certain pathological with urinary outflow disturbance conditions.

[Minimally invasive funnel chest correction: initial experiences and critical evaluation of this fascinating technique]. / Die minimal invasive Trichterbrustkorrektur: Erste Erfahrungen und kritische Würdigung dieser faszinierenden Technik.

The discussion about the surgical correction of funnel chest deformities enjoys a great renaissance since D. Nuss presented a new, minimal invasive technique. Although his method has gained wide acceptance among patients and pediatric surgeon the question arises, whether it can be considered as the Golden Standard' already. In 2000-2001 a total of 14 patients were corrected by transthoracic implantation of the pectus bar and subsequent elevation of the deformity. Results (mean data): age 14.3 years body weight 54 kg, height 170 cm, operative time 57 min, minimal blood loss, no intraoperative complications. The cosmetic result was considered as very good by all patients on the day of dismission. As a late complication one bar dislocated and had to be repositioned surgically. The minimal invasive approach for funnel chest corrections is a fascinating technique, which demonstrates striking advantages for the children: reduced operative trauma (no rib resections), shorter recovery, small incisions. However only few studies validate the long-term benefit of this procedure. Consequently, the minimal invasive method should not be advocated as the new Golden Standard', until these results meet the high quality of the conventional technique.

Perforation of a central venous catheter into the pelvis of the kidney: a rare complication.

Most adverse events related to central venous catheter (CVC) use in severely ill neonates who require total parenteral nutrition (TPN) are caused by malposition of the tip of the catheter, followed by complications such as infection, sepsis, thrombosis or, rarely, perforation of the vessel. Malpositioned tip of a CVC into the renal vein followed by thrombosis is well known. We report two cases of perforation of a CVC into the renal pelvis. To prevent this complication, the value of intra- or postoperative use of fluoroscopy with injection of contrast medium through the catheter is discussed.