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The treatment of pediatric patients in trauma surgery is a special situation in every aspect. For deciding on the correct treatment of fractures of the lower leg and ankle joint, various parameters, such as residual growth rate, skeletal age and height of the patient are decisive. The differences between fractures in children and adolescents are the open epiphyseal plate and the resulting residual growth. The bones of young children have a higher healing tendency and a greater potential for correction than in adolescents. Especially in the lower leg and the ankle joint, the potential for correction is decisive for the healing of fractures and for possible development of growth disorders. The limits of tolerance concerning axial malalignments and the expected spontaneous potential for correction must play an essential role for further treatment with conservative or operative therapy. This article deals with the special features of pediatric fractures of the lower leg and ankle joint.

To address recurrent patellar instability in children and young adolescents a variety of therapeutic options exist either as non-operative or operative treatment. Recent options, such as reconstruction of the medial patellofemoral ligament have evoked a new focus of attention on this topic. The intention of this article is to present diverse therapeutic options and to evaluate them by reference to the current literature.

Bone fractures in childhood are a common occurrence. A differentiated assessment of fractures is of great importance for the diagnostics, therapy planning and estimation of the prognosis. This review article explains the most important characteristics of skeletal trauma in childhood. Skeletal development, the mechanisms of fracture healing and growth disorders after injury to the epiphyseal plates and classification of fractures will be discussed and typical bone fractures in children and the pitfalls in X-ray diagnostics are demonstrated.

Aim: Angular deformities of the lower extremity are considered as prearthrotic factors. Osteotomy is regarded as a way of corrective treatment. But this intervention is considered as complex and requires a special after-treatment. During childhood and with remaining growth, guided growth offers an elegant solution for this problem. Resulting in a temporary hemiepiphyseodesis, the eight-Plate offers an alternative technique besides the Blount staples and the definitive epiphyseodesis. We evaluated the effect of this device on the correction of angular deformities in children with different diagnoses and at different ages., Method: Since 04/2006 22 patients with angular deformities of the lower extremities due to different diagnoses were treated at our department with the eight-Plate (42 eight-Plates). In this study we evaluated the outcome of 13 patients (26 eight-Plates) until the completed angular correction and removal of the eight-Plate. A special treatment after plate removal was not applied., Results: All patients improved their mechanical leg axis. The average age at implantation was 9.4 years (2.3-13.7 years). The average time until plate removal was 10.7 months (6-34 months). No hardware failures, extrusions, growth arrests, wound infections or other complications were observed. Two patients did not achieve the desired axis correction because of insufficient remaining growth potential. An additional surgical intervention was realised. The average correction of the study group regarding the mechanical axis deviation (MAD) was 22 mm (6-43 mm) and 10.6 degrees (5-27 degrees) regarding the angular correction of the mechanical lateral distal femoral angle (mLDFW). The mechanical medial proximal tibial angle (mMPTW) changed by 8.0 degrees (3-15 degrees)., Conclusion: In our opinion the eight-Plate seems to be a safe and reliable device for guided growth of angular deformities around the knee. The technique is easy to learn and the complication rate low compared to the staple technique. A special after-treatment is not needed and there is only minor operative trauma. At present there are only few data on long-term follow-up after plate removal until skeletal maturity. The definition of the ideal point in time for plate removal is still open.

Aim: The treatment of choice for skeletally immature patients with anterior cruciate ligament (ACL) deficiency is an ACL reconstruction. In a retrospective study we analysed the clinical results after ACL reconstruction in skeletally immature patients., Material and Method: In 55 immature patients the ACL was replaced with a four strand-hamstring graft in an anatomic transepiphyseal origin. The fixation was by means of an extracortical button femoral and a suture washer or staple tibial. Patient mean age at operation was 13 years (8 to 16 years)., Results: The mean follow-up was at 3.2 years (1 to 7.5 years) postoperatively. The objective IKDC 2000 score was 90.7 % normal or almost normal values. The mean Lysholm score was 94.1 points (70 - 100), the mean Cincinnati knee score was 93.9 points (76 - 100) and 88 % of the patients went back to normal or almost normal sports according to the Tegner score. Stability testing performed with the KT-1000 arthrometer was 1.0 mm (0 - 4 mm) (preoperative average 5.8 mm). The traumatic re-rupture rate was 5.5 %. In two additional cases a partial rupture of the graft was analysed by arthroscopy. Growth deformities or leg length differences were not seen in any case., Conclusion: ACL reconstruction with hamstrings and extracortical fixation showed good results and might be the treatment of choice in immature patients. The complication rate was low and there were no postoperative growth deformities.

Fractures in children require special knowledge and skills due to the differences in biological and biomechanical properties of growing skeletons. Children suffer from fractures of the upper extremities much more than fractures of the lower extremities. While fractures of the diaphysis have a high regenerative and proliferation potential, impairment of the growth plate with consecutive disturbance of growth can be found more often in fractures close to the epiphysis. Most epiphysis fractures in children can be identified by a set of 2-plane X-ray images but precise knowledge about the skeletal maturation is required. In order to correctly decide about treatment regimes (conservative versus operative treatment) the limitations and limits of the ability of bone to correct misalignment must be anticipated. Clinical examination following fracture healing is mandatory to recognize differences in length, misalignment and deficits in function, which should receive further treatment.

The longitudinal growth of long bones occurs in the epiphyseal plates at their ends. After a center of ossification has developed in the epiphysis, a cartilaginous plate, characterized by a typical zonal arrangement is formed. The cartilaginous plate proliferates using cells from a reservoir at the epiphyseal (i.e. articular) side of the plate. The cells are orientated to longitudinal rows and become thickened towards the metaphysis. The extracellular matrix between the hypertrophic chondrocytes becomes calcified and is subsequently replaced in an ossification process by lamellar bone. Cell proliferation in the epiphyseal plate is regulated by a number of different factors (e.g. IGF-I and BMP-7). The extracellular matrix is rich in glycosaminoglycans, proteoglycans and type II collagen, whereas especially at the edges type I and type VI collagen can be observed, too. The three dimensional orientation of the epiphyseal plate is determined by local mechanical influences. The adjacent bony endplates exhibit a higher central mineralization pattern with lower density values at their edges. The region of failure predominantly concerns the proximal zone of the longitudinal rows. The mechanical properties of the epiphyseal plate are influenced by endocrine as well as by metabolic factors. Any case of an epiphysiolysis is caused by a misproportion between acting shear forces and cartilaginous strength.

Fibrous metaphyseal defects (FMD) are tumor-like bone lesions according to the WHO classification of 1994. They are found in children and adolescents. FMD occur at characteristic points in the circumference of long bones. Depending on age, the distance to the epiphyseal line varies. The longitudinal axis of FMDs in the direction of the epiphysis meets a tendon or ligamentous structure inserting at the growth plate line. This tendon, which inserts at the perichondrium of the epiphyseal cartilage and the surrounding periosteum, seems to have a causal relationship in the pathogenesis of FMDs. In 152 specimens obtained from the autopsy of long tubular bones with open epiphyseal growth plates, the tendons and ligamentous structures inserting into the perichondrium of the epiphyseal plate cartilage were examined. Within the site of two tendon-inserting areas (Ranvier's node), the pathomorphological picture revealed that the normal medullary tissue is displaced by fibroblastic tissue. In addition to the etiopathogenesis of FMD's the radiological, clinical and histological features and the prognosis are discussed.

Deviations of the axis or leg-length discrepancies after fractures in children and adolescents can be due to growth disturbances or can be the result of incomplete reduction of the fracture. We distinguish between four types of growth disturbances. In type I, the overall growth activity of the cartilage is increased; growth is then enhanced, which results in the affected bone being too long without deviation; this usually occurs after fractures of the metaphysis or diaphysis. In type II, activity, the epiphyseal cartilage is severely impaired or completely arrested. The direction of growth is unchanged. This results in shortening of the bone, usually due to severe damage to the germination zone of the growth cartilage after destruction of the vessels or infection. In type III, growth of the epiphyseal plate is partially stimulated. The consequence of this disturbance is deviation of the axis with overgrowth (this is in fractures of the proximal tibia). Type IV is characterized by an asymmetric arrest of growth. This results in deviation of the axis and shortening. The cause of such growth arrest can be epiphyseolysis or epiphyseal fracture. The defect in growth cartilage heals with a bone bridge. This is a very serious kind of growth disturbance, and it occurs in only 1% of all fractures before skeletal maturity. Correction after incomplete reduction of fractures during growth can be direct or indirect and specific or nonspecific. Direct corrections occur in combination with fracture healing; indirect corrections occur with physiological changes of the growing skeleton without association with the healing process.(ABSTRACT TRUNCATED AT 250 WORDS)

In general, prophylactic treatment of the contralateral hip in manifest unilateral EFH is a well-proven and efficacious preventive measure. Shortly before the end of growth, however, due to asynchronous closure of the growth plate, the contralateral side may already be fused, so that there is no longer any danger of the hip slipping. Diagnostic difficulties in radiologic assessment of growth plate structure can be resolved with CT. In a two-year period, CT confirmation of closure of the growth plate enabled surgery on the contralateral side to be dispensed with in 3 cases (out of a total of 9).

In a study of 72 rabbits, four, eight, twelve and 16 weeks old, the mechanical resistance of the distal radius and ulna epiphyseal plate against shear strength has been examined. On one side the extremity has been freed of all soft-tissue attachments except the periosteum, on the other side the periosteum of the epiphyseal plate additional has been removed. The mechanical strength of the epiphyseal cartilage increases with age. A decrease of the resistance during sexual maturation has not been observed. In all age groups the stability of the epi-metaphyseal junction is significantly higher with the periosteum. In younger animals it is more marked than in older ones. The biomechanical behaviour of the periosteum can be explained with the principle of a "traction strap": the fibrous periosteum, firmly attached at the perichondrial ring, is stretched from epiphysis to epiphysis and fixes the epiphysis to the metaphysis. The periosteum and its continous tension takes not only part in regulating the longitudinal growth but also increases the resistance of the growth cartilage against shear strength. The dominated influence of the periosteum on the integrity of the epiphyseal cartilage is also supported by corresponding results dealing with the occurrence of Salter and Harris-type I or II fractures in absence or presence of the periosteum.