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ZusammenfassungDer Klumpfuß gehört zu den häufigsten angeborenen Fehlbildungen. Buben sind häufiger betroffen als Mädchen – in etwa 40% tritt ein Klumpfuß bilateral auf. Mit der Ponseti-Therapie können über 90% der Klumpfüße erfolgreich und überwiegend konservativ korrigiert werden. Die Ponseti-Therapie gilt heute als weltweiter Goldstandard. Ziel ist ein plantigrader, schmerzfreier, gut beweglicher Fuß. Im Folgenden wird über eine Patientin mit congenitalem Klumpfuß im Langzeitverlauf berichtet.

Background Only few reports have described the outcome of pediatric patients following radial head resection. Therefore, the aim of the present study was to assess clinical and radiologic outcome of patients with open physes following resection of the radial head. Materials and methods Skeletally immature patients treated with resection of the radial head were included. Range of motion (ROM) of the elbow joint was compared with preoperative values. Grip strength, pronation and supination strength, and carrier angle were compared with the unaffected side. Radiographs were assessed for signs of arthrosis, radial migration, and perifocal ossification. Disabilities of the Arm, Shoulder and Hand and Mayo Elbow Performance scores were obtained. Results The study included 7 patients (mean age, 11 years), 5 with post-traumatic and 2 with congenitally impaired elbow joint motion. Mean follow-up was 47 months. Pronation/supination ROM improved significantly (P = .018). Extension/flexion ROM did not improve significantly (P = .122). Although grip strength (P = .027) and pronation strength (P = .028) of the affected side were significantly lower compared with the contralateral side, supination strength did not differ significantly (P = .176). The carrying angle was increased in 3 patients. Significant radial migration occurred (mean, 3 mm; standard deviation [SD], 3 mm; P = .018). Arthrosis was found in 3 patients. The mean Disabilities of the Arm, Shoulder and Hand score was 16.1 (range 8.8-30.8; SD, 10.1) and mean Mayo Elbow Performance Score was 88 (range, 70-100; SD, 12). Conclusions Radial head excision may be considered for selected patients with open physes in cases of severe impairment of pronation/supination. However, sequelae such as radial migration, arthrosis, and elevation of the carrying angle should be expected.

Background Extracellular vesicles are small vesicles that are released from many cells, including neurons. α-Synuclein has recently been described in extracellular vesicles derived from the central nervous system and may contribute to the spreading of disease pathology in α-synuclein-related neurodegeneration. Objectives We aimed to examine the potential diagnostic value of α-synuclein in plasma extracellular vesicles from patients with Parkinson's disease (PD). Methods Preanalytical variables were studied to establish an optimized assay for preparation of plasma extracellular vesicles and detection of extracellular vesicle-derived α-synuclein. Plasma samples were obtained from 2 independent cohorts. The Tubingen cohort contained 96 patients with PD, 50 patients with dementia with Lewy bodies, 50 patients with progressive supranuclear palsy (PSP), and 42 healthy controls; the Kassel cohort included 47 patients with PD, 43 patients with dementia with Lewy bodies, and 36 controls with secondary parkinsonian syndromes. Extracellular vesicles were prepared from total plasma by size exclusion chromatography and quantified by nanoparticle tracking analysis, α-synuclein content was measured by an electrochemiluminescence assay. Results α-Synuclein concentration in plasma extracellular vesicles provided the best discrimination between PD, dementia with Lewy bodies, PSP, and healthy controls, with an area under the curve of 0.804 (PD vs dementia with Lewy bodies), 0.815 (PD vs. PSP), and 0.769 (PD vs healthy controls) in the Tubingen cohort. Results were validated in the Kassel cohort. Conclusions The concentration of α-synuclein in plasma extracellular vesicles may serve as a potential diagnostic biomarker for PD. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Background Patellar instability is a considerable problem that leads to pain and anxiety during simple functional tasks. Femoral derotational osteotomy has become a common surgical procedure to improve patella mechanics, stability and loading. However, it remains unclear if static (MRI measured) femoral anteversion is sufficient to capture the dynamic femoral rotation during walking and represents a good indication for the surgical procedure. This research investigates the relationship between static femoral anteversion and internally rotated gait in adolescents with patellofemoral instability. Methods This retrospective study included 30 adolescents with recurrent patella instability (minimum three patella dislocations) aged 12 to 18 years (28 female/2 male; 22 unilateral/8 bilateral). All participants were assessed with 3D gait analysis and the femoral anteversion was examined using a rotational MRI. Multiple kinematic parameter were correlated with the ipsilateral femoral anteversion and tibia torsion using the Pearson coefficient. Findings The correlation between parameters of dynamic hip rotation (e.g. maximum and mean internal hip rotation in stance and swing) and MRI measured femoral anteversion (mean 26.5° ± 9°) was weak and did not reach statistical significance. We found 47% (14 out of 30) subjects with increased femoral anteversion but normal hip rotation in stance. Interpretation There was no relationship between increased femoral anteversion and dynamic hip rotation. Consequently, femoral anteversion should not be used as the only indication for femoral derotational osteotomy. Three-dimensional gait analysis might be necessary to assess the appropriate surgical intervention in adolescents with patello femoral instability.

Treatment of idiopathic clubfoot has shifted from extensive surgical release to conservative Ponseti method; however, randomized prospective trials to compare both methods are lacking. The goal of this study was to compare the long-term results of Ponseti method with those of surgery in terms of morphology, function, X-rays, overall health and gait. In 2001, a single center, prospective, randomized, and controlled trial with a parallel design was started. Twenty-four feet of 15 patients were randomly assigned to two groups: 12 feet each to a Ponseti and surgical group. Mean follow-up was 10 years. International Clubfoot Study Group score (ICFSG), the Pediatric Outcomes Data Collection Instrument (PODCI) and the Functional Rating System (FRS) were used to compare morphology, functional, radiological and subjective outcomes, and the Oxford Foot Model (OFM) was used to evaluate foot kinematics. No significant difference was seen between groups in the initial Pirani scores (p=0.618). Ponseti group had more favorable long-term outcomes according to the FRS (p=0.005), higher ICFSG, scores for morphology (p=0.021), function (p=0.005) and X-rays (p=0.02), and better parent reported functional status according to the PODCI (p=0.018). Surgically treated clubfeet were stiffer - ankle dynamic range of motion (p=0.015) and the maximal hindfoot dorsiflexion during gait were limited as measured by OFM (p=0.039). This was compensated by an increase in motion between the hindfoot and forefoot. Furthermore, these children had more difficulty playing sports and experienced more pain, which might have led to inferior results in the happiness domain of the PODCI. These results suggest that the Ponseti method provides superior long-term outcomes for idiopathic clubfoot deformity.

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management.Im September 2018 fand in Csolyospalos, Ungarn, ein internationales Treffen von Fachärzten unterschiedlicher Disziplinen mit Expertise in der Diagnostik und Behandlung von DDH statt. Ziel war das Erreichen eines Konsenses zu den einzelnen Aspekten der DDH, die Entwicklung eines standardisierten Lehr- und Trainingssystems für die Anwendung von Hüftultraschall (US) sowie die Sicherung der Anwendungsqualität. Ein starker Konsens bestand darin, dass die klinische Untersuchung alleine unzureichend und eine Ultraschalluntersuchung unerlässlich ist. Die Methodik nach Graf wurde dabei als erste Wahl konsentiert. Ein möglichst vor der sechsten Lebenswoche durchgeführtes generelles US-Screening wurde stark favorisiert. Wesentliches Prinzip der US-gesteuerten Therapie ist dabei der möglichst frühe Behandlungsbeginn zur Reposition bzw. Retention und Nachreifung. Konsens bestand darin, dass die Effektivität eines Screenings stark von der korrekten Anwendung der Scan-Technik abhängt, weswegen eine standardisierte Ausbildung in der Methode nach Graf unerlässlich ist. Korrekt angewendet ist US kosteneffektiv, führt nicht zu Übertherapie und hilft, langfristige Folgen der DDH erheblich zu reduzieren. Daher sollen ein einheitlicher Lehrkatalog und Ausbildungsmaterialien entwickelt werden. Auch eine Zertifizierung, Re-Zertifizierung und mögliche Audits wurden eingehend diskutiert. Die Aufgabe des internationalen, interdisziplinaren Konsensuskomitees fur DDH Evaluation (ICODE) ist es, einen internationalen Konsens über Diagnostik- und Behandlungsstandards der DDH herzustellen sowie einen internationalen, standardisierten Lehr- und Ausbildungsplan in der Methodik nach Graf zu entwickeln und zu etablieren.

The incidence of osteomyelitis constantly declines. While the disease most commonly affects the long bones, involvement of the patella is rarely seen. Due to this rarity and the variable clinical presentation, diagnosis is often delayed. The present case report describes a 10-year-old female patient with a delayed diagnosis of patella osteomyelitis. The diagnostic procedures and the treatment regimen are described. Additionally, a detailed literature review of the available publications reporting osteomyelitis of the patella in children is presented.

Background and purpose - Heavily displaced radial neck fractures in children are sometimes associated with poor outcome. A substantial number of these fractures require open reduction. We hypothesized that Judet type-IV fractures with a completely displaced radial head would result in a worse outcome than radial neck fractures with remaining bony contact. Patients and methods - We analyzed 19 children (median age 9.7 (4-13) years) who were treated for Judet type-IV radial neck fractures between 2001 and 2014. The outcome was assessed at the latest outpatient visit using the Linscheid-Wheeler score at a median time of 3.5 (1-8) years after injury. The patients were assigned either to group A (9 fractures with remaining bony contact between the radial head and the radial neck) or to group B (10 fractures without any bony contact). Results - The 2 groups were similar concerning age and sex. The rate of additional injuries was higher in group B (7/10 vs. 1/9 in group A; p = 0.009). The rate of open reduction was higher in group B (5/10 vs. 0/9 in group A; p = 0.01). Poor outcome was more common in group B (4/10 vs. 0/9 in group A; p = 0.03). In group B, the proportion of children with poor outcome (almost half) was the same irrespective of whether open or closed reduction had been done. Interpretation - The main causes of unfavorable results of radial neck fracture in children appear to be related to the energy of the injury and the amount of displacement-and not to whether open reduction was used.

Purpose: Presently, there is no publication combining clinical follow-up with magnetic resonance imaging (MRI) to determine possible post-traumatic alterations following paediatric intra-articular fractures of the medial malleolus. Therefore, the aims of this study were to retrospectively analyze a cohort of patients with Salter–Harris (SH) III and IV fractures of the medial malleolus and to evaluate their long-term outcome. MRI was used to assess possible changes of the articular surface that cannot be diagnosed on native radiographs. Patients and Methods: Fifty-four patients with SH III ( n = 38) or IV fractures ( n = 17) of the medial malleolus treated between 2001 and 2011 were invited for a follow-up examination. Clinical outcome was assessed with the Weber score and osteoarthritis with the Kellgren and Lawrence classification. MRI was rated by the Outerbridge classification. Correlations between the clinical and radiological outcomes were calculated. Results: Seventeen patients were recruited for long-term follow-up at a mean of 112 (range, 65–184) months. The Weber score was very good for 5 patients, good for 10 patients and poor for 2 patients; the Kellgren and Lawrence score revealed a favourable grade 0 in 15 patients and grade 1 in 2 patients. The MRI-based Outerbridge classification yielded grade 0 for 12 patients, grade 1 for 1 patient, grade 2 for 2 patients and grade 3 for 1 patient. The Outerbridge score significantly ( p < 0.05) correlated with the Weber score. Conclusion: This study shows excellent and good outcome of SH III and IV fractures of the medial malleolus. Worse clinical outcome correlated with post-traumatic changes of the articular cartilage seen on MRI.

Purpose The aim of the present study was to describe epidemiology, management and outcome of pediatric and adolescent patients with posterior cruciate ligament (PCL) injuries. Methods Sixteen patients of less than 18 years of age with 7 PCL avulsion fractures and 9 PCL tears were included over a 10-year period. Trauma mechanism, additional injuries and treatment methods were analyzed. Follow-up examination included range of motion and ability to perform squats. Pedi-IKDC and Lysholm score were obtained and posterior shift was measured in kneeling view radiographs and compared to the contralateral side. Patients were grouped into pediatric patients with open physes at the time surgery and adolescent patients with closing or closed physes. In case of open physes, growth disturbances were assessed. Results Six of the treated patients (median age 12.5 years, range 10–13) had open physes at time of surgery. Five of those sustained avulsion fractures and treatment consisted of open reduction and screw fixation in four cases and graft reconstruction in one case. One patient sustained a PCL tear and underwent graft reconstruction. Follow-up at a median of 71.5 months (range 62–100) did not reveal any growth disturbances. Median Pedi-IKDC was 71.9 (range 51.7–92.1), median Lysholm score was 81.5 (range 66–88) and median posterior shift difference was 2.5 mm (range 0–11). The remaining 10 patients (median age 16 years, range 14–17) had closing/closed physis at the time of operation. Two patients presented with avulsion fractures treated with open reduction and screw fixation and 8 patients sustained PCL tears treated with graft reconstruction. At a median follow-up of 69.5 months (range 11–112), median Pedi-IKDC was 86.8 (range 36.8–97.7), median Lysholm score was 84.0 (range 45–95) and median posterior shift difference was 4 mm (range 0–15). Conclusions In our small number of pediatric patients with PCL injuries, open reduction and epiphyseal screw fixation of displaced avulsed fractures and steep tunnel drilling in case of PCL reconstruction did not cause growth disturbances. Nevertheless, long-term functional impairment should be expected and close follow-up has to be recommended. Level of evidence Therapeutic, Level IV.

Type A fractures of the spine requiring operative stabilization are rare injuries in the pediatric population. Current reports have demonstrated the safety of the combination of balloon kyphoplasty and minimal invasive management of thoraco-lumbar fractures in adults. There is no information about the efficacy of this approach in managing pediatric vertebral fractures. The aim of the present study was to report the outcome of a small series of children with A fractures of the lumbar spine treated with the combination of the abovementioned techniques. Three male patients without neurological deficits aged 11, 12 and 14 years were treated with fractures located at L1, L1/L2 and L2/L3, respectively. In total, six kyphoplasties were performed (monolateral in 4 vertebrae, bilateral in one vertebra). Neither cases of cement leakage nor intra- or postoperative complications were noted. Minimally invasive kyphoplasty and stabilization led to a significant improvement of the sagittal index of all five treated vertebrae which could be maintained at follow-up (14, 19 and 20 months postoperatively). This study is the first one to present an excellent outcome of children with type A fractures treated with a combination of balloon kyphoplasty and percutaneous stabilization.

An avulsion fracture occurs when the growth plate of an apophysis is injured due to a sudden and forceful contraction of the attaching musculotendinous unit. Usually it is adolescents who sustain these injuries, and a significant male preponderance has been found. Even though apophyseal fractures have been described in a variety of locations, the apophyses of the pelvis and hip are more prone to these injuries. Due to their rarity, avulsion fractures of the pelvis are often misdiagnosed. Additionally, patients can present late, and other pathologies are suspected initially. In most acute cases conservative treatment is successful. However, some cases require operative intervention. To plan an optimal treatment regimen, it is important to be familiar with the typical pathomechanism, the typical clinical findings, and the most commonly applied imaging modalities of these injures. The present review analyzes the currently available literature on the most frequently encountered apophyseal injuries of the pelvis in adolescent patients. Some case examples are also presented.

Background: Foot fractures account for 5% to 13% of pediatric fractures. Fractures of the hallux require special attention due to its role in weight bearing, balance, and pedal motion. In this study, a large series of children with hallux fractures is presented. Methods: All children treated with fractures of the hallux between June 2004 and December 2011 were included. The medical records were analyzed and X-rays were reviewed. The fractures were classified according to their anatomic location and the type of fracture. Three hundred seventeen patients (mean age = 11.7 years; range, 1-18 years; 65% male) sustained a fracture of the hallux. Results: Most accidents (28%) occurred at sports facilities, and soccer was the most common cause of a fracture of the hallux (28%). Closed injuries were diagnosed in 92% of the patients; 8% of the children presented with open fractures. In 144 children, the growth plate was affected. Fifty-nine patients presented with diaphyseal fractures, 42 patients with osseous avulsions, and 40 patients with fractures of the distal part of the phalanx. Nineteen children had incomplete and 13 patients comminuted fractures. The vast majority of the children (86%) were treated conservatively. Operative interventions were required in 14% of the patients. Good outcome was achieved in both conservatively and operatively treated patients. Conclusion: In children, fractures of the hallux were most often caused by ball sports and had a good prognosis. The vast majority of these fractures could be treated conservatively yielding good outcome. Level of Evidence: Level IV, case series.

Pediatric supracondylar humeral fractures are regularly complicated by vascular compromise. However, the treatment regimen for pulseless hands with good capillary refill time is discussed controversially. The aim of the present study was to present our treatment strategy in a series of children sustaining supracondylar humeral fractures associated with impaired peripheral blood flow.Medical charts of all children sustaining supracondylar humeral fractures treated between 1995 and 2009 were reviewed. Treatment and the course of patients with impaired peripheral blood flow were evaluated. Patients were invited for a follow-up examination.Forty of 499 patients sustaining a supracondylar humeral fracture presented with peripheral pulselessness. Two children underwent immediate vascular surgery. In the remaining 38 patients, the fracture was reduced, followed by a re-evaluation of the peripheral circulation. Twenty-four of those patients had normal peripheral pulse and capillary refill time, and no further therapy was necessary. Fourteen patients had a persisting absent peripheral pulse after fracture reduction. While in 4 of those patients-including 3 patients with prolonged peripheral capillary refill time-vascular surgery was performed, 10 patients were successfully treated with "watchful waiting." At follow-up of 3.5 years (range, 2-6 years), the performed diagnostic workup including capillary refill time and blood pressure was without pathologic findings in all patients.Our data suggest that blood flow often recovers following reduction of supracondylar fractures with impaired peripheral vascularization. In cases of a "pink pulseless hand" (absent peripheral pulse and good peripheral capillary refill time), "watchful waiting" instead of immediate surgical exploration might be a treatment option. However, further studies with more patients have to be conducted to formulate a recommendation for the treatment of these severe injuries.Therapeutic study, level V.

Die Patellaluxation ist die haufigste Kniegelenkverletzung mit Hamarthros bei Kindern. Sie muss immer auf Begleitverletzungen, die primar einer operativen Sanierung bedurfen, untersucht werden. Die unkomplizierte Erstluxation wird konservativ im Gips behandelt. Rezidivierende Luxationen werden operativ versorgt. Zur Schonung der Wachstumsfugen sind besondere Techniken erforderlich. Die Eminentiafraktur der proximalen Tibia entspricht einer knochernen Ausrissverletzung des vorderen Kreuzbands (VKB). Lasst sie sich in Uberstreckung reponieren, wird sie im Gips konservativ behandelt, ansonsten wird sie operativ unter Schonung der Wachstumsfuge stabilisiert. Intraligamentare VKB-Verletzungen werden bei Kindern und vor allem bei Jugendlichen zunehmend haufiger gesehen. Das Risiko instabilitatsbedingter sekundarer Gelenkschaden ist hoch. Bei bleibender Instabilitat nach Rehabilitation ist die Rekonstruktion auch bei offenen Wachstumsfugen zu empfehlen. Hierfur wurden verschiedene Techniken beschrieben, bisher zeigte sich keine als uberlegen. Die Kreuzbandchirurgie bei offenen Wachstumsfugen sollte erfahrenen, mit den Besonderheiten des wachsenden Skeletts vertrauten Operateuren vorbehalten bleiben. Meniskusverletzungen sollten fruh operativ stabilisiert werden. Die Heilungschancen sind bei Kindern gut.

Supracondylar fractures are commonly encountered in the pediatric population. An impacted radial or ulnar column may result in the deviation of the elbow axis in the frontal plane clinically seen as cubitus varus or valgus. Antegrade nailing has become a feasible alternative to treat supracondylar fractures. It is not known whether it can prevent the development of cubitus varus or valgus in the cases of fractures with impacted columns. Between 1994 and 2009, 264 supracondylar humeral fractures were treated. Nineteen patients presented with either an impacted ulnar (n = 12) or radial (n = 7) column and were included in the study. The average elbow angle in fractures with impacted radial column was 159° mean (range 153-167°) compared with 179° (range 173-184°) in fractures with an impacted ulnar column. After closed reduction and antegrade nailing, the elbow angle was restored to normal values. At follow-up examination after a mean of 3.8 years (range 2.4-7.6 years), no further changes of the humeral-ulnar angle were seen. We are able to show that antegrade nailing is a safe method to treat supracondylar humeral fractures with impacted columns.

Avulsion fractures of the ischial tuberosity are rare sports injuries typically occurring in young athletes. Their misdiagnosis may lead to chronic pain or disability. The aim of this study is to report a retrospective series of patients sustaining a fracture of the ischial tuberosity and to propose decision guidelines.The mechanism of accident, the diagnostic management, the mode of treatment and outcome after avulsion fractures of the ischial tuberosity in adolescents were analysed.Thirteen patients (1 female and 12 males) with a median age of 15 years (range 13-16 years) with an avulsion fracture of the ischial tuberosity were included. Twelve of these patients suffered from sports injuries leading to the avulsion fracture. Five of our patients with a displacement of15 mm were treated operatively. The outcome was excellent in cases of acute presentation and osteosynthesis. Eight patients were treated conservatively: four of them showed a displacement of15 mm and had an excellent outcome; and the other four patients had a displacement of15 mm. Two of those patients had excellent outcome with regular bone healing, the remaining two patients developed pseudarthrosis associated with a good outcome.The present paper shows that in patients with displacement of15 mm, conservative treatment yields excellent results and early operative intervention should be considered in physically active patients with displacement of15 mm.

Die haufigsten Frakturen im Wachstumsalter betreffen die obere Extremitat. Vor allem nach ellenbogengelenknahen Frakturen kommt es oft zu Komplikationen. Die Fugen um das Ellenbogengelenk sind am Langenwachstum nur mit 20% beteiligt und besitzen daher nur ein geringes Korrekturpotenzial. Auch die Moglichkeit der Spontankorrektur ist bereits mit dem 7. Lebensjahr ausgeschopft. Die Konsequenzen einer unzureichend versorgten, ellenbogennahen Fraktur konnen den Patienten somit ein Leben lang begleiten. Fur den behandelnden Chirurgen sind posttraumatische Fehlstellungen am kindlichen Ellenbogen eine Herausforderung. Haufig sind sie die Folge einer unzureichenden Primartherapie und selten auf Wachstumsstorungen zuruckzufuhren. Die haufigste posttraumatische Fehlstellung ist der Cubitus varus, gefolgt vom Cubitus valgus. Beide Deformitaten konnen aus einer ungenugend behandelten suprakondylaren Humerusfraktur, einer Condylus-radialis-Fraktur oder einer ubersehenen Luxation des Radiuskopfchens resultieren.

Objective: Dislocations of the sternoclavicular joint are rare injuries mainly caused by massive forces applied directly or indirectly to the joint. A high rate of complications has been reported following this injury emphasizing the importance of an accurate diagnosis and therapy. Material/Methods:[for full text, please go to the a.m. URL], 7th EFSMA – European Congress of Sports Medicine, 3rd Central European Congress of Physical Medicine and Rehabilitation

Introduction Children with severe spastic cerebral palsy (CP) are highly limited in daily life activities causing a reduced quality of life (QoL). This is partly due to an increased muscle tone causing pain and contractures. Continuous intrathecal infusion of baclofen (ITB) reduces the spasticity of affected patients. The hypothesis of the present study was that ITB leads to a significant improvement of QoL in non-ambulant children with CP. Patients and Methods 13 patients (10 male, 3 female, mean age 14 years) were included. Mean time between pump implantation and follow-up was 60 months (range, 12–100). QoL was assessed before and after baclofen pump implantation using standardized questionnaires (CP CHILD, KINDL). Spasticity was evaluated using the modified Ashworth Scale (MAS) at the two time points. Results QoL evaluated with the CPCHILD questionnaire and the KINDL improved from pre - implantation to follow-up. MAS markedly decreased from 3.8 to 1.7. All interviewed participants indicated that their expectations had been met and that they would choose ITB treatment again. Conclusion Intrathecal treatment of baclofen is an excellent method for spasticity management in children with severe cerebral palsy. Quality of life sustainably improves, parents' satisfaction is high and the level of spasticity decreases. Therefore, baclofen treatment can be highly recommended in non-ambulant children with CP suffering from spasticity.

Single event multilevel surgery (SEMLS) has become a standard intervention for children with cerebral palsy (CP). SEMLS proved to improve the gait in bilateral spastic cerebral palsy and those improvements can be maintained in the long term. However there is no evidence on the long-term outcome of unilateral SEMLS in children with unilateral spastic cerebral palsy. The gait analyses and clinical data of 14 children (9 male/5 female, mean age 12.1) with unilateral CP (6 children Gross Motor Function Classification System Scale level I and 8 children level II) were retrospectively reviewed at four time-points: preoperatively, 1year, 3-5 years and approximately 10 years after unilateral SEMLS. The Gait Profile Score (GPS) of the affected leg was used as a main and the number of fine tuning procedures as well as complications rate (Clavien-Dindo classification) as secondary outcome measures. The gait improved postoperatively and the GPS of the affected leg significantly declined by 3.73° which is well above the minimal clinical important difference of 1.6°. No deterioration of GPS occurred throughout the follow-up period. Therefore the postoperative improvement was maintained long-term. However, additional fine-tuning procedures had to be performed during the follow-up in 5 children and three complications occurred (one level II and two level III). The results indicate that children with unilateral cerebral palsy benefit from unilateral SEMLS and maintain gait improvements long-term.

Background Injections of the acromioclavicular joint (ACJ) are performed routinely in patients with ACJ arthritis, both diagnostically and therapeutically. The aim of this prospective controlled study was to estimate the frequency of successful intra-articular ACJ injections with the aid of sonographic guidance versus non-guided ACJ injections. Materials and methods A total of 80 cadaveric ACJs were injected with a solution containing methylene blue and subsequently dissected to distinguish intra- from peri-articular injections. In 40 cases the joint was punctured with sonographic guidance, whereas 40 joints were injected in the control group without the aid of ultrasound. Results The rate of successful intra-articular ACJ injection was 90% (36 of 40) in the guided group and 70% (28 of 40) in the non-guided group. Ultrasound was significantly more accurate for correct intra-articular needle placement ( P = .025). Discussion The use of ultrasound significantly improves the accuracy of ACJ injection.

Background and purpose In skeletally immature patients, surgical options due to recurrent patella dislocation are limited, because bony procedures bear the risk of growth disturbances. In this retrospective study, we report the long-term functional and radiographic outcome in skeletally immature patients using the modified Grammont surgical technique. Patients Between 1999 and 2004, 65 skeletally immature knees (49 children) were treated with a modified Grammont procedure: an open lateral release and a shift of the patella tendon insertion below the growth plate on the tuberositas tibia, allowing the tendon to medialize. At mean 8 (5.6–11) years after surgery, 58 knees in 43 patients were evaluated by clinical examination, from functional scores (Lysholm, Tegner), and from radiographs of the knees. Results Mean Lysholm score was 82 postoperatively. Tegner score decreased from 6.2 to 5. Eight knees had a single dislocation within 3 months of surgery. 3 knees had repeated late dislocations, all with a high ...

Introduction The acute compartment syndrome (ACS) of the lower leg is a rare but serious complication following either fractures or soft tissue injuries. An acute intervention consisting of fasciotomy is indicated as ACS may cause muscle and nerve damage. The aim of the present study was to evaluate the cause, the incidence, the time to fasciotomy and the outcome of ACS of the lower leg following fractures in a paediatric population. Patients and methods A retrospective analysis of all patients with ACS following a fracture of the lower leg treated from 1998 to 2010 was performed. The time from admission to occurrence of the ACS, the kind of fracture and surgical treatment was evaluated. Accident mechanisms were recorded. Results A total of 1028 fractures of the lower leg were treated. 31 patients (3%) with a median age of 14.6 years (range 7.3–17.1 years) developed an ACS. In the group of patients younger than 12 years the incidence was even lower (1.3%). 81% of injuries leading to ACS were caused by high-energy trauma, with motorcycle accidents being the most common (45%). External fixation was used in 45%, including all open fractures. The diagnosis of an ACS was primarily based on clinical symptoms. In 23 cases an intracompartmental pressure of median 55 mmHg (range 40–100 mmHg) were measured. ACS was diagnosed after 19 h mean (range: 1.5–65 h). There was a tendency that the ACS occurred earlier after high-energy trauma than after low energy trauma (mean 16.9 vs. mean 28 h). No complications linked to the compartment syndrome were observed. Discussion ACS can occur up to 65 h after an accident and therefore clinical monitoring is fundamental in order to be able to surgically intervene as soon as possible when needed. With early decompression complications can be prevented.

This study compared the long-term outcome of single-event multilevel surgery in spastic diplegic cerebral palsy (CP) on the basis of sex. We hypothesized that boys would have a worse outcome than girls. Thirty-four children (19 boys and 15 girls) with diplegic spastic CP and a minimal follow-up of 10 years were included. The Gillette Gait Index was the main outcome measure. We found no differences in surgical treatment, and both groups initially benefited from the surgery. However, although girls maintained the enhanced level of walking, walking ability in boys deteriorated constantly. Such a finding suggests that sex might have an important influence on treatment outcomes in children with CP.

Although equinus gait is the most common abnormality in children with spastic cerebral palsy (CP) there is no consistency in recommendations for treatment, and evidence for best practice is lacking. The Baumann procedure allows selective fractional lengthening of the gastrocnemii and soleus muscles but the long-term outcome is not known. We followed a group of 18 children (21 limbs) with diplegic CP for ten years using three-dimensional instrumented gait analysis. The kinematic parameters of the ankle joint improved significantly following this procedure and were maintained until the end of follow-up. We observed a normalisation of the timing of the key kinematic and kinetic parameters, and an increase in the maximum generation of power of the ankle. There was a low rate of overcorrection (9.5%, n = 2), and a rate of recurrent equinus similar to that found with other techniques (23.8%, n = 5).As the procedure does not impair the muscle architecture, and allows for selective correction of the contracted gastrocnemii and soleus, it may be recommended as the preferred method for correction of a mild fixed equinus deformity.

Background Unstable meniscal tears are rare injuries in skeletally immature patients. Loss of a meniscus increases the risk of subsequent development of degenerative changes in the knee. This study deals with the outcome of intraarticular meniscal repair and factors that affect healing. Parameters of interest were type and location of the tear and also the influence of simultaneous reconstruction of a ruptured ACL. Methods We investigated the outcome of 25 patients (29 menisci) aged 15 (4–17) years who underwent surgery for full thickness meniscal tears, either as isolated lesions or in combination with ACL ruptures. Intraoperative documentation followed the IKDC 2000 standard. Outcome measurements were the Tegner score (pre- and postoperatively) and the Lysholm score (postoperatively) after an average follow-up period of 2.3 years, with postoperative arthroscopy and MRT in some cases. Results 24 of the 29 meniscal lesions healed (defined as giving an asymptomatic patient) regardless of location or type. 4 patients re-ruptured their menisci (all in the pars intermedia) at an average of 15 months after surgery following a new injury. Mean Lysholm score at follow-up was 95, the Tegner score deteriorated, mean preoperative score: 7.8 (4–10); mean postoperative score: 7.2 (4–10). Patients with simultaneous ACL reconstruction had a better outcome. Interpretation All meniscal tears in the skeletally immature patient are amenable to repair. All recurrent meniscal tears in our patients were located in the pars intermedia; the poorer blood supply in this region may give a higher risk of re-rupture. Simultaneous ACL reconstruction appears to benefit the results of meniscal repair.

Injuries in childhood and adolescence are frequent and the knee is one of the most common sites of injuries. This study aimed to analyze the epidemiology, gender distribution, age, and circumstances of knee injuries in childhood at a Level I Trauma Center in Austria. All pediatric and adolescent trauma patients who presented in a 2-year period were recorded. Children managed with knee injuries were selected prospectively. Patients were divided into five age groups: infants (younger than 1 year); pre-school aged children (1–6 years); pre-pubertal school-aged children (7–10 years); early adolescent patients (11–14 years); and late adolescent patients (15–18 years). Five diagnosis-related groups were formed: extraarticular soft tissue injuries, intraarticular soft tissue injuries, patella disorders, fractures, and overload injuries. The study included 23,832 patients up to the age of 18 years, who presented with 1,199 knee injuries. There was a male predominance (m:f = 58,6%:41.4%). Boys had a lower mean age at presentation (11.9 years) as girls (12.3 years). The most common accident sites were outdoors (34.8%) and sports facilities (32.8%). Leading injury mechanisms were falls on level surfaces (58.1%) and traffic accidents (13.4%). The number of knee injuries and its severity increased with age. Knee injuries did not occur in infants. In general, extraarticular soft-tissue injuries were most common and fractures were rare. Knee injuries in children and adolescents are rare and extraarticular soft-tissue injury is the most frequent type of knee trauma. The number of knee injuries and its severity increases with age with a male predominance. Sports facilities and traffic injuries are important scenes of knee trauma. Mechanisms and patterns evaluated in this study can serve as the basis for knee-injury prevention efforts in children and adolescents and may be used for necessary precautions. Level of evidence: IV

Legg-Calvé-Perthes disease (LCP) severely limits the range of hip motion and hinders a normal gait. Loading of the hip joint is a major consideration in LCP treatment. The aim of this study was to evaluate gait patterns in LCP and identify gait modifications to decrease the load on the affected hip.Forty children with unilateral LCP were divided into three groups based on the time base integral of the hip abductor moments during single stance on the affected side acquired during instrumented 3D gait analysis. X-rays of the affected hip were classified according to Herring and Catterall.Children in the "unloading" group spontaneously adopted a Duchenne-like gait with pelvis elevation, hip abduction and external rotation during single support phase. The "normal-loading" group showed pelvis elevation with a neutral hip position in the frontal plane. In the "overloading" group the pelvis dropped to the swinging limb at the beginning of stance accompanied by prolonged hip adduction. The time base integral of the hip abductor moments during single stance correlated positively with the X-ray classifications of Herring and Catterall, hip abduction angle and age. Older children preferred to walk in hip adduction during single stance, had more impaired hips and tended to overload them.The hip overloading pattern should be avoided in children with LCP. Gait training to unload the hip might become an integral component of conservative treatment in children with LCP.

Aim Information on the timing and long-term outcome of single-event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single-event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events. Method We performed a retrospective analysis of the long-term outcomes of single-event multilevel surgery. Thirty-two children (17 males, 15 females) who had received single-event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo–15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single-event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow-up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow-up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman’s rank correlation coefficient were used to prove the hypothesis. Results The older the child was at the time of the surgery, the better the long-term result (Age,Time=0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft-tissue procedures performed initially as well as during the 10 years of follow-up. Interpretation Children with CP who require single-event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.

Injections into the subtalar joint may be performed for diagnostic or therapeutic reasons. The anterolateral approach is most commonly utilised for this purpose. We evaluated the success of an intra-articular puncture by using the anterolateral in comparison to the posterolateral approach.Sixty-eight cadaver adult feet were used for performing injections into the subtalar joint without fluoroscopic or ultrasound guidance. Methylene blue dye was infiltrated into 34 of the 68 subtalar joints through an anterolateral approach and into 34 through an posterolateral approach. An arthrotomy was then performed to confirm the placement of the dye within the joint.Twenty-three of the anterolateral injections (67.6%) were successful as were 31 of 34 (91.2%) of the posterolateral. The posterolateral approach showed a greater accuracy with a statistically significance (p = 0.016).Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Comparing the anterolateral to the posterolateral approach with regards to the rate of successful intra-articular puncture of the subtalar joint without the use of imaging there is a greater accuracy with the PL with statistically significance.

Svehlik M, Zwick EB, Steinwender G, Kraus T, Linhart WE. Dynamic versus fixed equinus deformity in children with cerebral palsy: how does the triceps surae muscle work? Objectives: To detect outcome measures that could help differentiate between dynamic and fixed equinus (FEQ) deformities in children with cerebral palsy, and secondary, to describe the function of the gastrocnemius and soleus (SOL) muscles when either dynamic triceps surae tightness or FEQ contracture is present. Design: A group-comparison study. Setting: Gait analysis laboratory. Participants: Children (N=23; 31 limbs) with cerebral palsy; 12 limbs showed a fixed contracture (FEQ group) and 19 limbs showed dynamic tightness of the triceps muscle (dynamic equinus group). Healthy children (N=12) without a neurologic or orthopedic disorder served as the control group. Interventions: Not applicable. Main Outcome Measures: Time-distance, kinematic and kinetic gait variables, muscle-tendon length, and velocity parameters. Results: Maximal ankle dorsiflexion angles were decreased in both equinus groups compared with the control group. Ankle range of motion, maximal power generation of the plantar flexors, and its timing during the gait cycle were different among groups. The ankle slope parameter showed substantial differences among groups. Muscle-tendon length parameters for the SOL and the medial (MGAC) and lateral gastrocnemius muscles were abnormal in both equinus groups compared with the control group. Maximal muscle lengths of the MGAC and SOL were longer in the dynamic equinus than FEQ group. Peak lengthening velocity of the triceps surae muscle was significantly slower for all triceps surae muscles in the FEQ group than in the dynamic equinus group and occurred in the early swing phase. Conclusions: The presented results indicate that peak lengthening velocity of the triceps surae muscle might be one of the discriminating factors between FEQ and dynamic equinus deformity in children with cerebral palsy. This could help clinical decision making for treatment of an equinus gait pattern.

Object-based semi-automated segmentation and classification approaches have gained importance in the analysis of remote sensing data over the last few years. Particularly when it comes to operational processing of multi-seasonal input data, independent and robust algorithms are needed. At the German Aerospace Center (DLR) a new method for forest type classification has been developed, covering all processing steps for object-based classification. An automatic adaptation of scene-specific feature values for the classification is implemented, based on automated extraction of feasible ground data. Therefore, no manual sampling of training data is necessary. For classification of mixed forests on the basis of IKONOS data, a special algorithm was developed that can be adapted to any kind of mixed forest definition. Forest age classes are derived based on a digital surface model. The developed method can be used for area-wide forest-type classification on the basis of high and very high-resolution satellite data.

Arthroskopisch assistierter Ersatz des vorderen Kreuzbands (VKB) bei Kindern mit kompletter VKB-Ruptur und klinischen Zeichen einer Instabilitat. Moglichst anatomiegerechte Rekonstruktion unter Risikominimierung einer Wachstumsstorung. Je junger das Kind, desto strenger ist die Indikation zu stellen. Durch Trainingstherapie und Sportreduktion uber mindestens 6 Monate nicht kompensierbarer Verlust der Funktion des VKB nach ligamentarer Ruptur. Sekundar instabilitatsbedingte Verletzungen der Menisken. Zu erwartende mangelnde Mitarbeit bei der postoperativen Behandlung (instabile Familie). Falsche Erwartungshaltung wie postoperativ uneingeschrankter fruher Einsatz im Leistungssport. Tanner-Stadium 2 oder junger ohne vorherigen konservativen Behandlungsversuch. Knocherne Ausrisse, Teilruptur oder Elongation bei erhaltener Kontinuitat der ligamentaren Fasern, da sich bei diesen Verletzungsformen die Instabilitat im Laufe des Wachstums bessern kann. Diagnostische Arthroskopie zur Erfassung begleitender Meniskusschaden und Knorpeldefekte und nach Moglichkeit Behandlung der Begleitverletzungen in gleicher Sitzung. Gewinnung der Semitendinosussehne mit dem offenen Sehnenstripper. Transepiphysare Technik mit extraossarer Fixation. Je nach Sehnendicke dreifach oder vierfach gelegte Semitendinosussehne, Ein-Kanal-Technik. Anpassung der Bohrkanalgrose an die Grose des Kinderknies (zwischen 6 und 8 mm), sehnige Fullung der Bohrkanale in Hohe der Fuge. Tibiale Bohrkanalanlage medial der Tuberositas tibiae mit Zentrum auf Hohe des Ausenmeniskusvorderhorns. Negativer Impingementtest des Fuhrungsdrahts in Streckung. Femorale Bohrkanallage 10:00–10:30 Uhr rechts und 01:30–02:00 Uhr links, Offset 4–6 mm. Bei Tanner-Stadium 3 oder junger keine fugenkreuzenden Fixationsmaterialien, sondern extraossare kortikale Fixation femoral durch Endobutton und tibial durch Suture-disc. Fixation in 30° Beugung unter geringer Spannung. Ohne Begleitverletzung nach 1 Woche Ubergang von Teilauf Vollbelastung. Bei zusatzlicher Meniskusnaht 4-wochige Entlastung und Begrenzung der Beugung auf 60°, in Wochen 4–6 Teilbelastung und Beugung bis auf 90°. Belastungsfreigabe ab der 6. Woche und Beginn mit Krafttraining in geschlossener Kette. Keine Beuge-Dreh-Belastung bis zum Ende der 12. Woche. Beginn mit Alltagssport nach 6 Monaten, mit Leistungssport in kniebelastenden Sportarten erst nach 9 Monaten. VKB-Ersatz mit Kniesehnentransplantaten bei 57 Patienten mit einem Durchschnittsalter von 14,7 Jahren und offenen Wachstumsfugen zwischen 2002 und 2007. 45 Patienten wiesen zusatzliche Meniskusverletzungen auf. Seit 2006 wird die Endobuttontechnik in der beschriebenen Weise verwendet. Ergebnisse mit dieser Technik liegen noch nicht vor, da sich die Patienten noch im Wachstum befinden. Bis 2006 wurden bei 30 Patienten in den Tanner-Stadien 4–5 die transepiphysaren Kniesehnentransplantate mit bioresorbierbaren Schrauben fixiert. 15 Patienten wurden nach Wachstumsabschluss nachuntersucht. Es fanden sich ausnahmslos gute bis sehr gute Ergebnisse in den Tegner-, Lysholm- und IKDC-Scores (International Knee Documentation Committee) ohne klinischen oder radiologischen Hinweis auf eine Wachstumsstorung.

Wiederherstellung der physiologischen Achsenverhaltnisse der oberen Extremitat sowie der Funktion des Ellbogengelenks. Cubitus varus/valgus. Bewegungsdefizit des Ellbogengelenks. Gestorte Kosmetik des Arms. Leidensdruck der Patienten und Eltern. Degenerative Veranderungen des Ellbogengelenks mit entsprechender Bewegungseinschrankung bei Jugendlichen oder Erwachsenen. Entzundlich-rheumatische Veranderungen. Dreidimensionale Korrektur der Fehlstellung ohne Keilentnahme und Stabilisierung mit auserem Spanner. Bewegungsfreigabe des Ellbogengelenks unmittelbar postoperativ. Durchschnittliche Tragedauer des Fixateurs 10–12 Wochen. Zwischen 1998 bis 2006 wurden zehn Kinder wegen einer suprakondylaren Fehlstellung einer Korrektur mit dreidimensionaler Umstellung des distalen Humerus ohne Keilentnahme und mit Stabilisierung durch externe Fixation unterzogen. Alle Patienten zeigten praoperativ kosmetisch oder funktionell beeintrachtigende Fehlstellungen. Die Patienten wurden zwischen 1 und 9 Jahre (7,4 Jahre) nach der Korrektur nach subjektiven, klinischen und radiologischen Kriterien nachuntersucht. Es fanden sich drei sehr gute, sechs gute und ein schlechtes Ergebnis. Auf das schlechte Ergebnis wird im ausfuhrlichen Ergebnisteil naher eingegangen wird. Zwei oberflachliche Infektionen der Pineintrittsstellen und eine passagere Ulnarisirritation waren als Komplikationen zu verzeichnen.

Aims Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them. Methods In total 39 children (17 females and 22 males; mean age at SEMLS ten years four months, standard deviation 37 months) with bilateral CP (20 Gross Motor Function Classification System (GMFCS) level II and 19 GMFCS level III) treated with SEMLS were included. Children were evaluated using gait analysis and the Gait Deviation Index (GDI) before SEMLS and one, two to three, five and at least ten years after SEMLS. A linear mixed model was used to estimate the effect of age at the surgery, GMFCS and follow-up period on GDI. Results There was a mean improvement of 12.1 (-15.3 to 45.1) GDI points one year after SEMLS (p < 0.001) and 10.3 (-23.1 to 44.2) GDI points ten years after SEMLS compared with before SEMLS (p < 0.001). GMFCS level III children aged ten to 12 years had the most improvement. The GMFCS III group had more surgical procedures at the index SEMLS (p < 0.001) and during the follow-up period (p = 0.039). After correcting for other factors, age at surgery was the only factor predictive of long-term results. Our model was able to explain 45% of the variance of the change in GDI at the different time points. Take home message: Children with GMFCS III level aged ten to 12 are the benchmark responders to SEMLS in the long-term. Cite this article: Bone Joint J 2016;98-B:278–81.

Purpose The aim of the present study is to present the outcome of a cohort of adolescent patients with trochlear dysplasia and elevated tibial tuberosity trochlear groove (TTTG) distance suffering from recurrent patellar dislocation. Treatment consisted of medial patellofemoral ligament (MPFL) reconstruction and a modified Grammont procedure. Methods MRI examinations were obtained pre- and postoperatively. Trochlear dysplasia was classified according to Déjour, and TTTG was measured on MRI. The Tegner Activity Scale and the Kujala Knee Score were assessed preoperatively and at follow-up. The Kujala Knee score and the IKDC 2000 knee score were documented at follow-up (median 50, range 20–61 months; SD 16.6). Results Seven knees of six patients (median age 16.5 years, range 14–17 years) with trochlear dysplasia and elevated TTTG distance (median 17 mm, range 16.1–21.9 mm; SD 2.8) were treated. Trochlear dysplasia was classified as Déjour type A in 1, type B in 5, and type C in 1 knee. The Kujala Knee Score significantly increased from values of 55 (range 17–88; SD 25.9) to 94 (range 73–100; SD 9.1) at follow-up (p = 0.028). TAS improved from preoperative 2 (range 0–7; SD 2.5) to 5 (range 4–9; SD 1.8) at follow-up (p = 0.034). Median IKDC 2000 Knee Score at follow-up was 89 (range 61–100, SD 13.4). No re-dislocations were encountered. Conclusion In selected adolescents with recurrent patellofemoral instability, MPFL reconstruction in combination with a modified Grammont technique yields excellent functional outcome and could, therefore, help to avoid major procedures, such as osteotomies. Level of evidence Therapeutic, Level IV.

Disability is a condition or function that is judged to be significantly impairing relative to the usual standard of an individual or group. The spectrum of musculoskeletal disabilities in children is immense and varied. Musculoskeletal disabilities are congenital or acquired; they affect a child partially or generally and can occur as a permanent or transient disability. Although injuries still represent a major concern for children and adolescents worldwide, studies focusing on injuries in physically disabled children are lacking. To detect musculoskeletal injuries, radiographs are frequently required. In disabled children the radiographic findings can detect the skeletal injury but also can present special radiographic findings of the underlying disease. This review offers an overview of different musculoskeletal disabilities and their related injuries as well as characteristic findings on radiographs.

In recent decades operative fracture treatment using elastic stable intramedullary nails (ESINs) has mainly taken precedence over conservative alternatives in children. The development of biodegradable materials that could be used for ESINs would be a further step towards treatment improvement. Due to its mechanical and elastic properties, magnesium seems to be an ideal material for biodegradable implant application. The aim of this study was therefore to investigate the cellular reaction to biodegradable magnesium implants in vitro.Primary human growth plate chondrocytes and MG63 osteoblasts were used for this study. Viability and metabolic activity in response to the eluate of a rapidly and a slower degrading magnesium alloy were investigated. Furthermore, changes in gene expression were assessed and live cell imaging was performed.A superior performance of the slower degrading WZ21 alloy's eluate was detected regarding cell viability and metabolic activity, cell proliferation and morphology. However, the ZX50 alloy's eluate induced a favourable up-regulation of osteogenic markers in MG63 osteoblasts.This study showed that magnesium alloys for use in biodegradable implant application are well tolerated in both osteoblasts and growth plate chondrocytes respectively.

Different femoral origins for both the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) have been reported in the growing skeleton (epiphyseal and metaphyseal). Knowledge about the exact attachment sites is mandatory for anatomically correct reconstruction. This study assesses the femoral origins of the knee collateral ligaments in skeletally immature individuals using magnetic resonance imaging (MRI).MRIs of 336 knee joints (median age 15 years (range 2-18 years), m = 209 and f = 127) were retrospectively analysed to assess the distances between the femoral origins of the MCL and LCL to the distal femoral growth plate. In 175 patients, the body sizes were additionally retrieved from medical records.Both MCL and LCL ligament origins were invariably located on the epiphysis. Mean MCL origin-growth plate distance was 9.6 mm (SD 2.1 mm; range 2.2-13.6 mm) in boys and 8.6 mm (SD 1.5 mm; range 3.4-12.0 mm) in girls. Mean LCL origin-growth plate distance was 9.3 mm (SD 1.8 mm; range 4.3-13.0 mm) in boys and 8.2 mm (SD 1.5 mm; range 3.4-11.8 mm) in girls. The distance between the growth plate and both collateral ligaments as well as the length of the LCL correlated positively with patients' age and body size (MCL R(2) = 0.673 and 0.556, LCL R (2) = 0.734 and 0.645, LCL length R(2) = 0.589 and 0.741; all p0.001).During growth, the femoral origins of the MCL and the LCL are constantly located on the distal femoral epiphysis. There is a linear increase in the distances from the ligaments' origins to the growth plate according to age and body size. This new information may be of clinical importance for reconstructive surgery of the knee's collateral ligaments.

Significantly displaced juvenile proximal humeral fractures (Neer-Horowitz type 3 and 4) usually require reduction and fixation. The most commonly used fixation methods are Kirschner wire (K-wire) pinning or retrograde elastic stable intramedullary nailing (ESIN). However, results comparing the long-term outcome of both methods are absent in the literature. The aim of this study was to provide an outcome comparison of both techniques.Included were 40 patients treated between 1998 and 2008 and who had complete records concerning operation time, duration of hospital stay, and time until implant removal. The assessment of clinical (Disabilities of Arm, Shoulder and Hand [DASH] and Constant-Murley scores) and radiologic long-term outcome was possible in 31 patients (78%). Preoperative, postoperative and follow-up radiographs of these patients were evaluated for angular deformity, reduction, and remodeling.The mean follow-up of the 31 patients (16 ESIN; 15 K-wire) was 5.8 ± 3.6 (standard deviation) years. The operative time of the primary fixation procedure was shorter in the ESIN group (P.001), but the hospital stay and the time until implant removal were significantly longer. No significant difference was seen between the groups at follow-up for the mean DASH (ESIN, 1.44; K-wire, 1.66) or Constant-Murley (ESIN, 89.5; K-wire, 92) scores. The neck-shaft angle was significantly improved by reduction in both groups (P.001) and remained unchanged at follow-up.ESIN and K-wire pinning have a favorable and comparable functional outcome and therefore seem to be adequate methods for treating Neer-Horowitz type 3 and 4 proximal humeral fractures in juvenile patients. The initially achieved improvement of the neck-shaft angle can be maintained at long-term follow-up.

Background/Purpose Ulnar polydactylies present with a wide variation in the size and appearance of the affected finger, ranging from small cutaneous appendages to fully formed additional fingers. Since ulnar polydactyly is rarely associated with functional disabilities, psychological and cosmetic reasons are the main rationale for surgical treatment. The aim of this study was to present the appearance, treatment regimen, and outcome of a series of children treated with ulnar polydactylies. Methods Data of all pediatric patients treated between 2000 and 2010 were included. For assessing long-term outcome, patients were contacted via mail and asked to complete a questionnaire concerning location and appearance of the scar as well as functional and cosmetic satisfaction (VAS 0–100). Results In that period, 32 patients (20 male, 12 female) with 53 ulnar polydactylies were treated. In 20 patients the polydactyly occurred bilaterally (63%), in 10 patients on the left side (31%), and 2 patients presented with right-sided ulnar polydactyly (6%). The vast majority of ulnar polydactylies were floating cutaneous appendages. The mean age of the patients at operation was 8.6months (range 0 to 10years). 20 patients (63%) responded to the postal questionnaire. Follow-up time was 4.9years (range 2.1 to 10years). The majority of patients reported a flat scar (n=18, 90%). Mean overall satisfaction with the postoperative result using a VAS 0–100 score was 89. Conclusion We were able to report a good postoperative outcome of a series of patients suffering from ulnar polydactylies.

The aim of this study was to provide guidance on the safe zones for the exposure of the proximal radius by measuring the distance from the PIN to various anatomical landmarks in the proximal forearm in pronation and supination.Twenty cadaveric arms were used for this study. On the anterior aspect of the forearm, the distance between insertion of the biceps tendon and the arcade of Frohse as well as the shortest distance between the PIN and the ulnar aspect of the radial neck were measured. On the posterior aspect of the forearm, the shortest distance between the PIN and the ulnar border of the interosseous membrane was measured at 30 and 50 mm distal to the articular surface of the radial head.The distance between the PIN and ulnar aspect of the radial neck had a mean of 21.6 mm in supination and 13.3 mm in pronation. The distance between the radial tuberosity and the arcade of Frohse was 18.6 mm. The mean distance between the PIN and the radial border of ulna at 30 mm distal to the articular surface of the proximal radius was 12.3 mm in supination and 22.3 mm in pronation. At 50 mm distal to the articular surface of the proximal radius the mean distance was 8 mm in supination and 16.2 mm in pronation.The course of this nerve is variable as it winds around the radial neck within the belly of the supinator muscle. Safe distances for dissection have been presented in our study.

Six tarsal coalitions in children were managed surgically using a deepithelialized skin flap for interposition after resection of the bony, fibrous or cartilaginous coalition. The advantage of this technique is that due to positioning the skin flap, joint motion can be preserved. The clinical results using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society were excellent in two and good in four cases. The radiographs at follow-up showed no recurrences of the resected coalitions. This study shows that the use of deepithelialized skin flap interposition is effective in providing pain relief for the patients in symptomatic coalitions.

The Ponseti method of treatment for congenital clubfeet has gained widespread clinical acceptance. We have used manipulation, serial casting, and surgery to treat congenital clubfeet for almost 3 decades. Considering the Ponseti method of treatment to replace our traditional treatment method, we conducted a randomized, controlled trial evaluating the short-term outcome of the two treatment protocols. We evaluated foot function and applied a standardized measure of health status for children with orthopaedic problems. Nineteen patients (28 feet) were included in the trial. Nine infants (12 feet) were assigned to the Ponseti treatment group, and 10 (16 feet) were assigned to a group with initial casting and posteromedial release at the age of 6 to 8 months. The minimum followup was 3.3 years (mean, 3.5 years; range 3.3–3.8 years). Outcome measures included the Functional Rating System of Laaveg and Ponseti, the Pediatric Outcomes Data Collection Instrument (PODCI), and standardized radiographic measurements. At last followup the mean Functional Rating score was higher in the Ponseti group. Passive dorsiflexion and passive inversion-eversion were better in the Ponseti group. PODCI scales were comparable and radiographic outcome measures were similar in both groups. This trial has documented a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Introduction: The development of contractures in children with spastic cerebral palsy is an important clinical as well as scientific issue. A common model for the development of contractures suggests that increased muscle tone shortens muscles, which leads to reduced growth of sarcomeres and tighter noncontractile muscle and tendon tissue. However, the spasticity is not the only factor influencing the contracture development. Based on our clinical observation we hypothesize that the body growth might play a key role in development of gastrocnemius contracture. Patients/materials and methods: We performed a retrospective cross-sectional analysis of 3D gait data of 244 children (385 legs) with spastic diplegic CP and equinus gait. Children were subdivided according to age into 6 subgroups (5–6, 7–8, 9–10, 11–12, 13–14 and 15–18 years) to show the changes during the whole period of growth. The height of all the participants at each visit was recorded. A formerly trained Generalized Dynamic Neuronal Network (GDNN) [1], a reliable method of automatic gait pattern recognition and classification, was used to discriminate between dynamic and fixed contracture of gastro-soleus muscle based on the ankle and knee kinematics and moments. The Spearman correlation coefficient was used to show the relationship between the growth and gastro-soleus contracture development. Results: The relative increase of fixed contracture of the gastrosoleus muscle between the age groups correlates positively with the relative increase in height (r=0.9; p