[Thoracolumbar Compression Fractures in Children]. / Kompresivní zlomeniny thorakolumbální pátere u detí.

PURPOSE OF THE STUDY The study aimed to draw up a diagnosis and treatment guidelines for the management of the most common compression fractures of the thoracolumbar spine in children. MATERIAL AND METHODS Between 2015 and 2017, pediatric patients with a thoracolumbar injury aged 0-12 years were followed up in the University Hospital in Motol and the Thomayer University Hospital. The age and gender of the patient, injury etiology, fracture morphology, number of injured vertebrae, functional outcome (VAS and ODI modified for children), and complications were assessed. An X-ray was performed in all patients, in indicated cases also an MRI scan was done, and in more severe cases a CT scan was obtained as well. RESULTS The average vertebral body kyphosis in patients with one injured vertebra was 7.3° (range 1.1°-12.5°). The average vertebral body kyphosis in patients with two injured vertebrae was 5.5° (range 2.1°-12.2°). The average vertebral body kyphosis in patients with more than two injured vertebrae was 3.8° (range 0.2°-11.5°). All patients were treated conservatively in line with the proposed protocol. No complications were observed, no deterioration of the kyphotic shape of the vertebral body was reported, no instability occurred, and no surgical intervention had to be considered. DISCUSSION Pediatric spine injuries are in most cases treated conservatively. Surgical treatment is opted for in 7.5-18% of cases, in dependence on the evaluated group of patients, age of the patients and philosophy of the department concerned. In our group, all patients were treated conservatively. CONCLUSIONS 1. To diagnose F0 fractures, two unenhanced orthogonal view X-rays are indicated, whereas MRI examination is not routinely performed. In F1 fractures, an X-ray is indicated, and an MRI scan is considered based on the age and extent of injury. In F2 and F3 fractures, an X-ray is indicated and subsequently the diagnosis is confirmed by MRI, in F3 fractures also a CT scan is performed. 2. In young children (under 6 years of age), in whom an MRI procedure would require general anaesthesia, MRI is not routinely performed. 3. In F0 fractures, crutches or a brace are not indicated. In F1 fractures, verticalization using crutches or a brace is considered in dependence on the patient's age and extent of injury. In F2 fractures, verticalization using crutches or a brace is indicated. 4. In F3 fractures, surgical treatment is considered, followed by verticalization using crutches or a brace. In case of conservative treatment, the same procedures as in F2 fractures are applied. 5. Long-term bed rest is contraindicated. 6. Duration of spinal load reduction (restriction of sports activities, or verticalization using crutches or a brace) in F1 injuries is 3-6 weeks based on the age of the patient, it increases with the age, with the minimum being 3 weeks. 7. Duration of spinal load reduction (verticalization using crutches or a brace) in F2 and F3 injuries is 6-12 weeks based on the age of the patient, it increases with the age, with the minimum being 6 weeks. Key words: pediatric spine injury, thoracolumbar compression fractures, children trauma treatment.

[Migration of the Tips of Metal Implants during Treatment of Coxa Vara Adolescentium (Slipped Capital Femoral Epiphysis)]. / Migrace spicek kovových implantátu v prubehu lécby u coxa vara adolescentium.

PURPOSE OF THE STUDY This paper aims to detect, through a retrospective study, the migration of the tips of used metal implants (K-wires or a screw) in the direction out from the proximal femoral epiphysis as a part of studied basic radiometric characteristics of the cohort, with no intention of the authors to evaluate the therapy outcomes. MATERIAL AND METHODS It was a retrospective multicentre study including patients of two orthopaedic clinics and one department of orthopaedics treated in the period 2005-2018. The same treatment procedure was used in all three centres. The "in situ" fixation was indicated in patients, in whom the Southwick angle in anteroposterior and Lauenstein views was not much greater than 30°, whether primarily due to a mild slip or thanks to careful reduction either in acute or acute-on-chronic forms. All X-rays were measured by a single author (M.S.). In AP and Lauenstein view, overlap of the implant tip (K-wire or a screw) above the subcapital growth plate, the height of epiphysis and Southwick angle are measured at the beginning and at the end of treatment. In a smaller group of patients, also the inter-observer error (M.S. and J.P.) was identified. RESULTS K-wire transfixation was used in 43 patients (50 joints), with the mean age of 11.7 years and the mean duration of transfixation of 18.2 months. The slip of the implant tip out of the head, assessed separately for each introduced K-wire and then averaged, was in both views considered statistically significant (in AP view the level of significance was 5% (p-value = 1.393 x 10^(-6) < 0.05) , in Lauenstein view the level of significance was also 5% (p-value = 0.0001652 < 0.05)). The Wilcoxon signed rank test with continuity correction was used. Transfixation by screw alternatively with one K-wire was used in 23 patients (28 joints), with the mean age of 12.4 years and the mean duration of transfixation of 14.4 months. The slip of the screw tip outside the head was assessed as significant (in AP view at the level of significance of 5% (p-value = 9.41 x 10^(-5) < 0.05), in Lauenstein view at the level of significance of 5% (p-value = 0.003557 < 0.05)). The Wilcoxon signed rank test with continuity correction was used. DISCUSSION This paper aims to detect, through a retrospective study, the so-called migration of the tips of used metal implants (K-wires or a screw) outside the femoral head. Smooth and thin implants such as Kirschner wires should not compromise the continuing growth from subcapital growth plate contrary to the AO screw with threads in the femoral head, the screw head rested against the lateral cortical bone and the screw inserted as a compression one. Nonetheless, with some exceptions, the literature confirms the continued growth of the femoral neck even in the case of screws. In general, implants that do not compromise femoral neck growth provide an opportunity to remodel the anterolateral prominence of the femoral metaphysis, especially in younger patients. In agreement with other authors, the data from our study confirmed, even after a short period of time, a certain degree of proximal femoral remodelling expressed by changes in the Southwick angle. CONCLUSIONS Our study confirmed that in the case of "smooth" K-wires as well as cannulated screws the tips of both implants migrate outside the head. The differences were statistically significant. Therefore, the introduction of a conventional cannulated screw cannot be claimed to immediately produce the effect of epiphyseodesis. Yet, smooth implants less compromise the growth of the femoral neck, which is why they have recently been preferred. Key words: coxa vara adolescentium, metal implants, migration.

Ultrasound diagnostics of a rare injury of the unossified pediatric skeleton - case report.

Plain X-ray remains a standard diagnostic tool for evaluation of skeletal injuries in children. However, it provides inadequate imaging of unossified, cartilaginous parts of pediatric bones. Our article presents the possibilities of ultrasound imaging based on the case report of a seven years old patient with a rare injury of the unossified medial epicondyle of the humerus where the diagnosis and indication for osteosynthesis has been made based on ultrasound examination of the injured elbow. Ultrasound imaging is an ideal, accessible and affordable examination not stressful for the patient; this technique can be used to verify of skeletal injuries that cannot be diagnosed by plain X-ray. Ultrasound imaging should be a standard part of the diagnostic algorithm of skeletal injuries in the pediatric population where a discrepancy is present between distinctive symptoms and negative radiographs.

Management of ileocolic intussusception in the Czech Republic.

INTRODUCTION: Ileocolic intussusception is one of the most frequent causes of acute abdomen in infants and toddlers. The purpose of this study was to evaluate the treatment of ileocolic intussusception in the Czech Republic in 2019. METHODS: Fourteen departments of paediatric surgery participated in this multicentre retrospective study. A SurveyMonkey Inc. questionnaire was used for anonymous data collection of patients with ileocolic intussusception. RESULTS: In 2019, ileocolic intussusception was diagnosed in 162 patients; median age was 30 months (3 months to 9.5 years). Contrast enema was indicated in 133 patients, primary surgery in 14 patients and spontaneous reduction was found in 15 patients. All departments using contrast enema had a success rate of 89.5%; 12 departments approached the contrast enema procedure under general anaesthesia (including myorelaxation at 7 departments) and 2 departments under sedation. Contrast enema under general anaesthesia with/without myorelaxation was significantly more successful than contrast enema under sedation (108/113, 95.6% vs 11/20, 55%; p.

[Toddler's Fractures: Definition, Differences between the Diagnostic and Therapeutic Approach]. / Batolecí zlomeniny ­ Toddler's Fractures: vymezení pojmu, rozdíly v diagnostickém a terapeutickém prístupu.

PURPOSE OF THE STUDY The term toddler's fracture was first coined by J. S. Dunbar in 1964 as a nondisplaced fracture of the distal tibia in children aged 9 months to 3 years. Over time, many other authors extended this definition as to the location as well as age range. The purpose of this paper is to provide a comprehensive overview of the existing studies focusing on the topic of toddler's fractures, to compare individual diagnostic and therapeutic approaches, and to specify the term toddler's fracture. Also, a group of patients with this diagnosis is presented, treated at our department. MATERIAL AND METHODS A retrospective study of a group of patients treated at the Department of Paediatric and Trauma Surgery, 3rd Faculty of Medicine, Charles University in the period from 1. 1. 2012 to 2. 8. 2017. The defined age range of patients was 9 months up to 3 years. The most frequent type of skeletal injury at this age was identified. Also, the etiology of injuries, the method and duration of fixation were examined. Moreover, an overview of foreign articles, with a focus on diagnosis and therapeutic approach is presented. RESULTS In the respective five-year period, a total of 15,679 children with a skeletal injury were treated at the Department of Paediatric and Trauma Surgery, of whom 57 patients at the age of a toddler (9 months to 3 years of age) sustained a nondisplaced distal tibial metaphyseal fracture (0.4%). In addition, 147 patients were treated for nondisplaced fracture of the first metatarsal base (0.9%) - in 98 of whom it was a torus fracture, in 49 patients the fracture line extended into the physis; therefore, it concerned the Salter-Harris type II separation of epiphysis. The group included only one patient with a nondisplaced calcaneal fracture. DISCUSSION Despite differences in the definition as to the location and age of patients, the toddler's fractures can always be defined as nondisplaced, and in many cases, they are difficult to diagnose based on the initial X-rays. Crucial for a differential diagnosis is to distinguish them from osteomyelitis, synovitis of the hip joint, or a tumour. In case of unclear history, also the Child Abuse and Neglect syndrome shall be considered. When any of the aforementioned diagnoses is suspected, methods with a higher diagnostic yield (but in case of computed tomography and scintigraphy also with a higher burden) - ultrasound, CT or scintigraphy - can be used. CONCLUSIONS We recommend that the term "toddler's fracture" is used for nondisplaced fractures of the distal third of the tibia with respect to the original criteria proposed by Dunbar. We consider as an option to include in this group also the first metatarsal fractures due to their frequency in this age group, provided that the stated conditions are met. Key words: toddler's fracture, tibial fractures, toddlerhood, diagnosis, treatment.

[Advantages and Pitfalls of Stabilisation of Supracondylar Humerus Fractures in Children by Lateral Approach Only]. / Výhody a úskalí stabilizace suprakondylických zlomenin humeru u detí pouze z laterálního prístupu.

PURPOSE OF THE STUDY Supracondylar humerus fracture (SCF) with dislocation is indicated for closed reduction and osteosynthesis. The method achieving the best stability is CRCPP (closed reduction and crossed percutaneous pinning), even though there is a risk of iatrogenic ulnar nerve injury. The CRLPP (closed reduction and lateral percutaneous pinning) method eliminates this risk at the cost of less stable osteosynthesis. The purpose of this study is to compare the SCF stabilisation by CRLPP with the stabilisation by CRCPP in rotationally stable fractures and to identify the risk of iatrogenic ulnar nerve injury, or the failure of osteosynthesis with recurrent dislocation of fragments. MATERIAL AND METHODS The prospective group of the patients with SCF type 1/2 (classification according to Havránek) treated in the period 2016-2018, in whom the method of osteosynthesis (number of implants, method of their insertion), resulting condition and complications (nerve injury, failure of osteosynthesis) were evaluated. In the second half of the study, in CRLPP one of the implants was inserted "quadricortically", i.e. through the olecranon fossa of the humerus (hereinafter referred to as fossa), while until then both the implants had been inserted through the radial column outside fossa. RESULTS In the period 2016-2018, 791 patients with SCF were treated at our department. In 225 cases (28.5%) the patients sustained the type 1/2 fracture and in all the cases closed reduction and percutaneous osteosynthesis were performed, namely CRCPP in 185 cases (82.2%) and CRLPP in the remaining 40 cases (17.8%). Signs of ulnar nerve injury after osteosynthesis were observed in 35 patients (15.6% of SCF 1/2), always after the use of at least one ulnar implant (18.9% of CRCPP). A failure of osteosynthesis occurred in 2 cases (0.9% of SCF 1/2), always when only lateral implants were used (5% of CRLPP). DISCUSSION In both the patients in our study in whom after CRLPP a failure of osteosynthesis with rotational dislocation occurred, the original CRLPP was performed by inserting both the implants through a single column outside fossa. Both the patients were indicated for revision reduction and osteosynthesis was subsequently performed through CRCPP. The patients healed with no further complications. In the group of patients with an ulnar nerve injury, the original condition was fully restored, after 3.6 months (range of 1-10, median 3) on average. The results of our study show the need to guide the implants inserted through the radial column divergently so that they are at the fracture line level as far apart as possible (with adequate fixation of fragments). One of the implants is inserted through fossa, i.e. quadricortically. Based on our experience, the compliance with these principles alone shall ensure adequate rotational stability of SCF of type 1/2. In CRLPP, after the insertion of implants the stability is tested under the Xray image intensifier intraoperatively so that a medial implant can be added in case of unstable osteosynthesis. CONCLUSIONS Based on the results of our study we recommend to stabilise the rotationally stable SCF (type 1/2 according to Havránek) only from the radial column (and thus eliminate the risk of iatrogenic ulnar nerve injury), provided the fracture characteristics allows so. Nonetheless, the CRLPP has its own specific rules for implant entry which have to be adhered to. Key words: supracondylar fracture of the humerus, paediatric fractures, closed reduction, percutaneous pinning, lateral percutaneous pinning, iatrogenic ulnar nerve injury, osteosynthesis failure.

Monteggia lesion and its equivalents in children.

PURPOSE: The aim of the study is to evaluate our group of paediatric patients with Monteggia lesion and its equivalents and to compare the characteristics of basic types of these lesions concerning therapeutic approach and results of the treatment. METHODS: Retrospective study of 111 children treated in the Department of Pediatric and Trauma Surgery of the Thomayer Hospital in Prague between 2001 and 2013 (13 years). When evaluating the outcome of the therapy, Bruce's criteria modified by Letts that assesses range of movement, pain and deformity of the elbow joint were applied. Regarding the therapeutic approach, four groups were compared: nonoperative treatment, reduction and casting, closed reduction and internal fixation (CRIF) and opened reduction and internal fixation (ORIF). Results were compared between three groups of patients (Monteggia lesions, displaced equivalents and non-displaced equivalents) using Fisher´s exact test with α set to 0.05. RESULTS: In all, 46 patients were treated for (true) Monteggia lesion, 27 for non-displaced Monteggia equivalent and 38 for displaced equivalent. There is a statistically significant difference in therapeutic approach between all three groups of patients. There is no significant difference in outcome between Monteggia lesions and both types of Monteggia equivalents, but there is a statistically significant difference between displaced and non-displaced equivalents. CONCLUSION: There are only two lesions that meet the criteria of Monteggia - (true) Monteggia lesion and displaced Monteggia equivalent. The non-displaced equivalent does not meet the criteria of Monteggia and, therefore, should not be termed a Monteggia equivalent. LEVEL OF EVIDENCE: Level III - Retrospective comparative study.

[Triplane Fractures of the Distal Tibial Epiphysis - Contributions of CT Scans to Indication and Planning of Osteosynthesis]. / Trírovinná zlomenina distální epifýzy tibie ­ prínos CT k indikaci a plánování osteosyntézy.

PURPOSE OF THE STUDY The triplane fracture of the distal tibial epiphysis is characterised by the fracture line in typical three planes which can, however, differ case by case. The authors use the CT imaging as the perfect examination method to determine the nature of the fracture to plan the osteosynthesis. MATERIAL AND METHODS In the five-year retrospective study of a group of patients treated at their own department in the period 2011-2015 the authors assess a total of 55 patients with a triplane fracture. The radiograph, the CT scan and the specific therapeutic process are evaluated. Regarding the imaging methods, they focus on the fracture line, the number of fragments and the size of the dorsal metaphyseal fragment. As concerns the method of treatment, they zero in on the indication for osteosynthesis and the number and location of used implants. RESULTS The authors present a total of nine different treatment options of the triplane fracture of distal tibial epiphysis. Of 55 followedup patients, in seventeen cases (30.9%) conservative treatment was opted for, in seven cases (12.7%) a reduction under general anaesthesia was an adequate option, whereas in the remaining thirty-one cases (56.4%) an osteosynthesis had to be performed. In the group with osteosynthesis, in altogether twenty cases (64.5%) only a single implant was used: of which in twelve cases it was transepiphyseal, in eight cases transmetaphyseal. In the other eight cases (25.8%) two implants were used, one metaphyseal and one epiphyseal. In three remaining patients (9.7%) two implants were introduced, both into the metaphysis. DISCUSSION The world literature has been referring to the importance of CT scan in relation to the triplane fracture of the distal tibial epiphysis since 1980s. Some papers have only highlighted the necessity of the CT scan for the examination of a complex ankle injury, covering also the triplane fracture, while in majority of injuries involving the distal tibia region a common X-ray examination suffices;also mentioned has been its importance for determining the number of fragments, or in some papers also for preoperative planning. At our department, in correlation with the majority of authors, we routinely use two basic projections (AP view and lateral view) to examine the ankle. In the case of suspected intraarticular fracture, both the mortise views (internal and external) are added. The CT scan is a standard procedure used at our department for confirmed triplane fractures. In severely displaced fractures we recommend to perform a CT scan only after the closed reduction of fragments under general anaesthesia. CONCLUSIONS An X-ray obtained from 4 views is a standard examination in diagnosing a triplane fracture. A CT scan than makes it possible to precisely locate the fracture line, to determine the size of fragments and to plan the optimal placement of osteosynthetic material. Key words: tibial fractures, distal tibia fractures, paediatric fractures, triplane fracture, physeal fracture, CT imaging, minimally invasive osteosynthesis, treatment of distal tibia, osteosynthesis planning.

[Supracondylar fracture of the humerus in childhood]. / Suprakondylická zlomenina humeru u detí.

INTRODUCTION: Supracondylar fracture of the humerus can be considered the most serious fracture in childhood. Problems with its diagnostics and treatment as well as its complications and sequels have not been fully solved yet. That is evidenced by a large amount of articles with frequently inconsistent conclusions. The aim is to evaluate contemporary diagnostic and therapeutic approach based on our own clinical experience. METHODS: A total of 2847 children with skeletal injury were treated by the authors during the year 2016. Two hundred and seventy-five of them suffered from supracondylar fracture of the humerus (9.66%). All the fractures were classified using the authors own scheme. Fragment displacement was evaluated according to a three-degree scale. RESULTS: Ninety-three of 275 supracondylar fractures were treated non-operatively (33.8%) and 182 by surgery (66.2%). Closed reduction and percutaneous pinning by K-wires under X-ray (C-arm) control was the method of choice. Crossed K-wires were used in 90% and in 9.9% two K-wires were inserted laterally only. In 70.9%, pins were buried and in 29.1 % unburied pins were used. Neurological lesions were noted in 13.5%. A total of 82.9% of children were healed without any sequels. CONCLUSION: Supracondylar fracture of the humerus in children should be managed in pediatric trauma centers, especially in more complicated cases. Fracture classification needs to be more detailed than those commonly used so far. Closed reduction and percutaneous pinning is the method of choice. Acute neurological and/or vascular complications can be managed in an overwhelming majority of cases, after fragment fixation, non-surgically.Key words: supracondylar fracture humerus, miniinvasive osteosynthesis neural lesion compartment syndrome.

CURRENT CONCEPTS IN PERIPHERAL NERVE INJURY REPAIR.

Even though reconstructive surgery of the nerves underwent significant progress due to experimental and clinical research over the past 40 years, injuries to the peripheral nerves still remain a great challenge for microsurgery. Literature results of these procedures are often evaluated as very good but the final result is often characterized by an achievement of only a useful and not full function, which is rather rare. It is not only a simple suture; the success is also based on functional regeneration and interconnection of the nerve fibres. This is limited by correct surgical technique, the age of the patient, delay from the time of injury and the mechanism or localization of the injury. Some injuries even now remain untreatable (such as the most severe brachial plexus injuries or long traction injuries of the peroneal nerve). Apart from standard neurolysis and epi- or perineural suture with or without nerve grafts, distal nerve transfers (in case of proximal injuries) and end-to-side neurorrhaphy (mainly in trauma of sensitive nerves) have recently been frequently used. The future is however based on influence of nerve regeneration at the cellular level using substances with growth potential. The main prerequisite of successful surgery is however early indication of surgical revision in a specialized centre.

[Effects of infrainguinal bypasses on long-term patency in pelvic procedures--the significance of hybrid procedures]. / Vliv infrainguinálních bypassu na dlouhodobou pruchodnost pánevních intervencí--význam hybridních výkonu.

OBJECTIVE: The hitherto published data did not provide clear answer to whether the adjustment of poor runoff through infrainguinal by-pass can improve long-term patency of iliac interventions in patients with multiple-stage arterial lesion. Our intent was to respond to this question. MATERIAL AND METHODS: In the period since 1st January 2003 until 31st May 2005 we evaluated two groups of revascularized patients with similar angiographic affection of the iliac and femoropopliteal arteries and statistically comparable input parameters. In the first group incorporating 38 procedures the vascular surgeon performed hybrid intervention (group 1)--one-step iliac intervention with infrainguinal ipsilateral bypass, in the second group incorporating 43 patients angioradiologist performed single percutaneous iliac intervention in catheterization laboratory (group 2). RESULTS: Observation median was 71 months (60-86). Three-year primary patency of iliac interventions was 83% in the hybrid group (group 1) and 72% in single angioplasty group (group 2). Five-year patency was 77% in group 1 and 69% in group 2. In secondary patency the three-year and five-year patency was 94% in group 1 and 83% in group 2. Statistically we did not prove that poor infrainguinal runoff is negative factor of primary patency of iliac intervention (K-M, log rank test, p = 0.58628), as well as secondary patency (p = 0.11474). CONCLUSION: From the long-term perspective it is not possible to consider poor runoff to be independent risk factor of patency of iliac intervention. Infrainguinal bypass within the hybrid procedures shall not improve the results of iliac intervention.

[Monteggia lesions in the growing skeleton: principles of therapy]. / Monteggiova léze rostoucího skeletu: principy lécby.

PURPOSE OF THE STUDY: In this retrospective study we analyse the methods of Monteggia lesion (ML) treatment in children used in our department. Based on the results we propose several general principals for the therapy of this complex injury to the forearm in agrowing skeleton. MATERIAL: The group included patients with the diagnosis of acute ML treated at our department in the 2003-2007 period. No patients in whom therapy was started later than two weeks after injury were included. METHODS: We assessed injuries according to the Bado classification system modified by Olney for young age, and also by the system based on ML stability assessment previously published by us.We evaluated the type of ulnar fracture and lesions affecting the radio-humero-ulnar joint, and the therapeutic method used. The treatment outcome was evaluated by the criteria proposed by Letts et al. for the elbow joint in children (minimal follow-up of one year). RESULTS In the five-year period, we treated 36 children with acute ML. The most frequent were patients with Bado type I equivalent lesion (61 %) and those with unstable ML (53 %).We treated 39 % of the patients conservatively and 61% by osteo-synthesis. The ;osteosynthesis of one bone was performed in 30 % (radius, 11 % ulna, 19 %) and of both bones in 31 % of the cases. The outcome assessed by the Letts score was excellent in 80 %, good in 17 % of the patients and poor in only one patient (3 %). DISCUSSION: There is general consensus in the literature that childhood ML, if early and correctly diagnosed and correctly treated, has a good prognosis in most of the cases, in contrast to adult ML. However, the views on therapy vary from closed reduction under general anaesthesia to routine surgical exploration of the radio-humero-ulnar joint with open reduction of dislocation of the radial head and temporary radio-humeral arthrodesis. However, a unified therapeutic approach to an immature skeleton has not been proposed yet. CONCLUSIONS: In the treatment of a growing skeleton, the reduction and stabilisation of an ulnar fracture is of primary concern. Only then is the management of injury to the radio-humero-ulnar joint reasonable. Any ML should always be considered on the whole. In most cases, a stable lesion is indicated for conservative treatment and an unstable one for surgical stabilisation. Apotentially unstable lesion should first be managed conservatively and, if this fails, by surgical stabilisation.

Salter (Rang) type 6 physeal injury.

INTRODUCTION: Type 6 physeal injuries, described by Rang as a displacement of the perichondrial ring usually caused by a lawn-mower scalping mechanism or a closed trauma to the distal femoral physis avulsed by the lateral collateral ligament, are extremely rare. This type of injury was later included in Salter and Harris' classification of physeal injuries as type 6. No large series of type 6 physeal injuries has been described in the literature. The aim of the study is to present a relatively large series of patients with this trauma and offer some new observations. MATERIAL AND METHODS: Over a 20-year period, 36 children with a type 6 physeal injury were treated in the authors' institution. The affected bone and physis, mechanism of injury, age, gender, method of treatment and sequelae are reported. RESULTS: Out of 36 patients with type 6 physeal injuries 21 were boys and 15 girls (mean age 11.6 years). The distal fibular physis was most commonly affected, followed by the distal femoral and distal tibial physis. In 29 cases the fracture was undisplaced, while 3 children suffered an open injury with a loss of soft tissue. No injuries were due to lawn-mowers. Two cases were due to gunshot wounds. DISCUSSION: Although no larger series of type 6 physeal injuries has been described to date, it is clear that the mechanism of trauma has changed from earlier reports of open lawn-mower injuries to closed soccer and athletic sports fractures. Closed type 6 injuries are usually not or only minimally displaced and do not require surgery. Open fractures were associated with soft tissue loss; they were caused by scraping of the ankle (knee, elbow) by a car or bicycle wheel on a road surface or the result of a gunshot injury with the projectile destroying the peripheral portion of the physis.

Mutual position of the distal fibular physis and the tibiotalar joint space - radiological typology and clinical significance.

AIM: The mutual position of the distal fibular physis compared to the tibiotalar joint space in the immature skeleton was investigated in X-ray studies. The clinical relevance of the recorded mutual position was evaluated for paediatric skeletal traumatology. MATERIALS AND METHODS: 140 radiographs of immature ankle joints without skeletal injury were reviewed and the mutual position of the distal fibular physis and tibiotalar joint space was tested. We then reviewed a cohort of 30 children with skeletal injuries of both the distal tibial epiphysis and the distal fibula. The type of distal fibular injury was evaluated according to the mutual position of the distal fibular physis and the tibiotalar joint space. RESULTS: We found that in about one-half of cases the distal fibular physis is located distally to the plane of the tibiotalar joint, which has not been considered in the literature. Thus, we defined three radiological types of immature ankle joint according to the vertical position of the distal fibular physis in relation to the tibiotalar joint space: type 1 - distal fibular physis is above the joint space; type 2 - distal fibular physis is on the same level as the joint space; type 3 - distal fibular physis is below the joint space. In the second cohort, we found that type 2 predisposes to physeal fibular injury and type 3 predisposes to metaphyseal fibular injury. All data obtained were statistically evaluated. CONCLUSIONS: There are three radiological types of immature ankle joint. Type 1 is only an evolutionary type without clinical significance, type 2 predisposes to physeal and type 3 to metaphyseal fibular injury in combination with distal tibial physeal injury.

[Spinal injuries in children and adolescents]. / Poranení pátere u detí a adolescentu

PURPOSE OF THE STUDY: Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Due to anatomical and biomechanical properties of the growing spine, there are great differences between spinal injury in childhood and adulthood. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. In this retrospective study, the effectiveness of conservative and surgical treatment of injured spines in children is evaluated in a 10-year period. MATERIAL: All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0-9, 10-14, 15-18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up. METHODS: We used conservative treatment in patients with stable spinal injury who had no neurological deficit and in patients with neurological deficit but without apparent injury to the skeleton. Surgery was indicated in patients with unstable spinal injury and in those with neurological deficit and apparent injury to the skeletal structures. Injuries to the cervical spine were treated conservatively using a Philadelphia collar or a halo-vest in more serious cases. For treatment of injury to the thoracolumbar spine, the Magnuson method was preferred, together with rest in bed until subsidence of acute pain, followed by application of a vest and active rehabilitation to strengthen postural muscles. When surgery was used, the procedure was selected on a strictly individual basis in patients under 12; in older patients it was carried out according to the adult treatment protocol. RESULTS: During 1996 through 2005, we treated a total of 15 646 patients with injury to the skeleton, aged 0 to 18 years. The spine was affected in 571 cases, which is 3.6 %. We used conservative treatment in 528 (92.5 %) and surgery in 43 (7.5 %) children. The period between surgery and evaluation ranged from 6 to 120 months (average, 46.3 months) in the patients treated conservatively, and from 6 to 66 months (average, 27 months) in the surgically treated patients. The group of patients treated conservatively consisted of 292 boys (55. 3 %) and 236 girls (44.7 %); of these 219 (41.5 %) were in the 0-9 year category, 251 (47.5 %) were between 10 and 14 years and 58 (11 %) were 15 to 18 years old. The average age in this group was 10.2 years. The most frequent cause of injury was a fall (277; 52.2 %), then sports activity or games (86; 16.3 %), car accidents (34; 6.4 %) and diving accidents (30; 5.7 %). Pedestrians were injured on 25 occasions (4.7 %) and other causes of injury were recorded in 76 patients (14.4 %). In all age categories, injury to the thoracic spine was most frequent (340; 64.4 %). Three and more vertebrae were injured (multi-segment injury) in 124 patients (23.5 %). The thoracolumbar spine was affected in 22 patients (4.2 %), and lumbar vertebrae were injured in 28 patients (5.3 %). Injury to the cervical spine, both upper and lower, was least frequent, including four (0.8 %) and 10 (1.9 %) patients, respectively. None of the patients in this group showed neurological deficit. The surgically treated group included 29 (67.4 %) boys and 14 (32.6 %) girls; two (4.7 %) children were between 0 and 9 years, nine (20.9 %) between 10 and 14 years, and 32 (74.7 %) between 15 and 18 years, with an average of 15.1 years for the whole group. The frequent causes of injury were car accidents and falls in 21 (48.8 %) and 14 (32.6 %) children, respectively. Other causes were infrequent. The upper cervical spine was operated on in five (11.6 %), lower cervical spine in eight (18.6 %), thoracic spine in 13 (30.2 %), thoracolumbar spine in five (11.6 %) and lumbar vertebrae in 12 (27.9 %) patients. Thirty-six (83.7 %) patients had fractures, five had dislocated fractures (11.6 %) and two (4.7 %) had a dislocation. Of the 43 children in this group, neurological deficit was recorded in nine (20.9 %); this included a complete spinal cord lesion, an incomplete spinal cord lesion and a nerve root lesion in three, five and one patient, respectively. DISCUSSION: The results of this study confirm, in the majority of aspects, the conclusions of previously published papers. In some of the characteristics described above, however, our results are different, which can be explained by some specific features of care for injured children in the Czech Republic. CONCLUSIONS: Childhood spinal injuries account for only 2 to 5 % of all spinal injuries and for 3.6 % of all skeletal injuries in children. Particularly at the age of 11 to 12 years, they differ significantly from spinal injuries in adults and therefore require different therapeutic approaches. The cervical spine is affected most often in younger children, while the thoracolumbar spine in older children. Multi-segment injuries are typical in the childhood spine, particularly in smaller children. Typically, children show SCIWORA and a more rapid improvement of neurological deficit than adults. Conservative treatment is preferred; surgery before 12 years of age is strictly individual, while after 12 years therapy is similar to that used in adults.

Rare injuries to the distal tibiofibular joint in children.

Injuries to the distal tibiofibular junction have been very precisely described in adults including diagnosis and treatment. By comparison, only two types of epiphyseal fracture were described as the equivalent of such an injury in the growing skeleton until now: the juvenile Tillaux fracture and the lateral triplane fracture. During a five-year period (1997 - 2001) twenty children with distal tibiofibular joint injury were treated in our department. Three previously unpublished types of epiphyseal injury to the distal tibial mortise are presented: intraepiphyseal fractures of Chaput's tubercle type 7A and 7B according to Ogden's classification (in two and one cases, respectively) and an intraepiphyseal subcortical tibial mortise disruption (one case). The authors suggest that these three types are transitive types between juvenile Tillaux fracture in children and disruption of the distal tibiofibular syndesmosis in adults. All three types were without significant displacement and were stable in stress positions of the ankle joint. Thus, the treatment was nonoperative with excellent results and without sequelae.

[Pathologic proximal femoral fractures in children in an unicameral bone cyst]. / Patologické zlomeniny proximálního femuru u detí v juvenilní kostní cyste.

PURPOSE OF THE STUDY: Proximal femoral fractures in children are rare, pathologic fractures being extremely rare. Despite many meanings these fractures are still "unsolved" there are some definite rules for treatment of true accidental injuries. Pathologic fractures are outstanding with their extremely rare incidence. The aim of the study is to overview a large clinical material, find out the incidence of this pathologic fracture, the extent and shape of the unicameral bone cyst (UBC), specific therapeutic approach, technical problems of eventual osteosynthesis, number of reoperations and sequels. MATERIAL: Altogether 49 children with 50 accidental and pathologic fractures of proximal part of the femur treated in the Regional Pediatric Trauma Centre of the Department of Pediatric and Trauma Surgery, 3rd Faculty of Medicine, Charles University, Prague. METHODS: Retrospective and prospective study of children (0 to 15 years of age) treated with proximal femoral accidental and pathologic fractures during the 20 year period (from August 1984 to November 2004). Classification of fractures according to Delbet and Colonna. Diagnosis of bone cyst with plain X-rays, eventually CT scans. RESULTS: During the 20 years period (August 1984 to November 2004) 49 children with 50 proximal femoral fractures were treated in the Department. Four patients sustained a pathologic fracture through an unicameral bone cyst. Two of these latter children were treated by an open reduction and osteosynthesis with the use of the proximal femoral AO-ASIF angled-plate and two children nonoperatively using skeletal traction because of impossibility of insertion of the osteosynthetic material without a damage of the growth plate. Subsequent operations of the UBC were necessary in these two children. All four patients recovered well without sequels. DISCUSSION: Pathologic fractures in UBC are usually treated nonoperatively and the cyst itself is treated after fracture healing. Proximal femoral impairment is the exception from this rule because of weigh bearing necessity. However, there may be problems with insertion of the implant when the cyst is very near to capital physis and traction treatment is then the method of choice with a delay of operative treatment of the cyst. CONCLUSIONS: Pathologic proximal femoral fractures in UBC are extremely rare and need individual approach. Some of them should be operated on the others primarily treated by traction with secondary operation of the cyst. Complications can be frequent.

[Monteggia's lesion in childhood--proposal for a new classification system]. / Monteggiova léze v detském veku--návrh nové klasifikace.

PURPOSE OF THE STUDY: The former classification systems have failed to provide an exact characterization of Monteggia's lesions (ML) in a growing skeleton. We studied the stability of both ulnar fracture and injury to the radio-humero-ulnar joint and our clinical findings fully warrant the proposal of a new classification system. MATERIAL: We carried out a retrospective study of 76 children, aged 2 to 15 years, treated for Monteggia's lesion in our department during 12 years, from 1990 till 2001. METHODS: X-ray images of all injured limbs were evaluated and each injury was categorized as stable, potentially unstable or unstable. This concerned both ulnar fractures and lesions affecting the radio-humero-ulnar joint. An assessment of the therapeutic method used was also included. RESULTS: The final assessment of each injury involved the category of ulnar fracture and the category of radio-humero-ulnar joint lesion and produced three ML types, namely, stable, potentially unstable and unstable types. A stable ML type was found in 30 (39.5 %) patients and, in most of them, conservative treatment was sufficient. Osteosynthesis was required in only 6.7 % of the cases. A potentially unstable ML type was recorded in 27 (35.3 %) patients. Fifteen of these (55.6 %) underwent osteosynthesis because conservative treatment had failed. An unstable ML type was diagnosed in 19 (25 %) children and nearly all of them (89.5 %) had to undergo osteosynthesis. DISCUSSION: The previous classification systems have been based on either anatomical aspects (direction of ulnar fragment displacement and proximal radius dislocation) or the type of ulnar fracture. In our view the characterization of each ML type in children involves the stability of ulnar fraction as well as the stability of injury to the radio-humero-ulnar joint. CONCLUSIONS: Our classification allows us to predict the stability of each Monteggia's lesion and to choose an appropriate approach to its treatment.

Avulsion fracture of the pelvis: separation of the secondary ossification center in the superior margin of the acetabulum.

A 13-year-old female sustained a rare avulsion fracture of the secondary ossification center in the superior margin of the acetabulum as the result of contraction of the reflected head of the rectus femoris muscle. Diagnosis was made from plain films and CT scans with 3D image reconstruction. The patient was treated non-operatively by bed rest with semiflexion of the hip and knee, and appropriate analgesia.