[A woman with a wound on her hand]. / Een vrouw met een wond op haar hand.

A 37-year-old woman came to the Emergency Room. Since 7 days she had a growing wound of the left hand with a necrotic centre. She had increasing erythema and edema of the left arm, and a fever. PCR-investigation revealed the cow pox virus. Cow pox are rare but self-limiting.

[Age-specific treatment of femoral shaft fractures in children]. / Leeftijdspecifieke behandeling van femurschachtfracturen bij kinderen.

In the treatment of femoral shaft fractures in children, the age, the anatomy of the epiphyseal plates, the vascularisation of the femoral head and the length of hospital stay play an important role. The degree in which a malposition after a femoral shaft fracture is corrected by growth depends on the size, the location and the type of dislocation, and on the residual growth potential of the child. In children up to the age of 4, treatment with traction followed by spica casting almost always gives good results. Children up to age 12 are preferably treated with elastic intramedullary nails, if necessary in combination with a spica cast. In special cases, plate osteosynthesis or external fixation can be used. Children older than 12 years are often too heavy for treatment using elastic nails. Because of the still open growth plate of the greater trochanter, the vascularisation of the femoral head and the diameter of the femur, a standard adult intramedullary nail is not always suitable. Recently, a smaller nail for adolescents was developed, which is currently being tested.

Displaced midshaft fractures of the clavicle: non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial.

BACKGROUND: The traditional view that the vast majority of midshaft clavicular fractures heal with good functional outcomes following non-operative treatment may be no longer valid for all midshaft clavicular fractures. Recent studies have presented a relatively high incidence of non-union and identified speciic limitations of the shoulder function in subgroups of patients with these injuries. AIM: A prospective, multicentre randomised controlled trial (RCT) will be conducted in 21 hospitals in the Netherlands, comparing fracture consolidation and shoulder function after either non-operative treatment with a sling or a plate fixation. METHODS/DESIGN: A total of 350 patients will be included, between 18 and 60 years of age, with a dislocated midshaft clavicular fracture. The primary outcome is the incidence of non-union, which will be determined with standardised X-rays (Antero-Posterior and 30 degrees caudocephalad view). Secondary outcome will be the functional outcome, measured using the Constant Score. Strength of the shoulder muscles will be measured with a handheld dynamometer (MicroFET2). Furthermore, the health-related Quality of Life score (ShortForm-36) and the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure will be monitored as subjective parameters. Data on complications, bone union, cosmetic aspects and use of painkillers will be collected with follow-up questionnaires. The follow-up time will be two years. All patients will be monitored at regular intervals over the subsequent twelve months (two and six weeks, three months and one year). After two years an interview by telephone and a written survey will be performed to evaluate the two-year functional and mechanical outcomes. All data will be analysed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION: This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. The gathered data may support the development of a clinical guideline for treatment of clavicular fractures. TRIAL REGISTRATION: Netherlands National Trial Register NTR2399.

[The midshaft clavicular fracture]. / De midclaviculaire fractuur.

Traditionally, midshaft clavicular fractures have been treated conservatively. However a review of the literature reveals that certain fractures can benefit from operative repair. Conservative treatment, preferably in the form of a sling, of an undisplaced midshaft clavicular fracture leads to excellent results . Dislocated fractures have an increased risk of non-union or malunion. Intramedullary fixation can give good results in simple dislocated fractures, but does not provide optimal preservation of length and rotation in comminuted fractures. Plate osteosynthesis can be used for all clavicular fractures and causes a reduction of the relative risk of non-union of 86%. Due to the increased risk of non-union or malunion and of a worse functional result, osteosynthesis should be considered for patients with dislocated or comminuted midshaft clavicular fractures, with due consideration for the patient's expectations and lifestyle.

Intussusception in adults: report of four cases and review of the literature.

Intussusception in adults is a rare clinical entity. The individual surgeon will not often encounter this condition. A lead-point for adult intussusception exists in 90% of cases and is frequently malignant. We present four cases and discuss treatment and diagnostic modalities. A comprehensive review of the literature is given. All cases were treated by resection according to oncologic principles without previous reduction. Histological examination showed non-Hodgkin lymphoma, lipoma, clear cell sarcoma and adenocarcinoma as the lead-points.