Search

Introduction: Clavicle shaft fractures are among the most common fractures in childhood and adolescence. In the past they were almost exclusively treated conservatively but in recent years there has been an increase in surgical treatment. Nevertheless, exact recommendations for the choice of diagnostics and for the treatment regimen do not yet exist., Material and Methods: Therefore, our aim was to develop a consensus within the 7th scientific working meeting of the section for pediatric traumatology in the German Society for Trauma Surgery based on expert opinion., Results: Single-plane radiographic imaging is considered the gold standard diagnostic tool. Children younger than 10 years are primarily treated conservatively, and the type of immobilization is secondary. In girls older than 12 years and boys older than 14 years, fractures dislocated by more than the shaft width and shortened by > 2 cm should be treated by open reduction and stabilized by osteosynthesis, followed by free-functional follow-up treatment., Conclusion: In addition to X‑rays, diagnostics using ultrasound must be further established. Treatment continues to be primarily conservative, but surgical treatment is also important, especially in adolescents. If the indications are correct, a good outcome can be expected regardless of the choice of treatment., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The integrity of the talus is crucial for the physiologic function of the feet. The present study sought to summarize the available evidence on clinical outcomes and complications following conservative and surgical treatment of talar fractures. We systematically searched Medline via OVID to find relevant studies with a follow-up of at least six months. Hereafter, the success and complication rates were extracted and analyzed in a random effects proportion meta-analysis. Complications were defined as avascular bone necrosis (AVN) and posttraumatic osteoarthritis (OA). Additionally, a subgroup analysis was performed for fracture localization (talar neck fractures (TN) and combined talar body/neck fractures (TN/TB)) and severity of the fracture. The quality of the included studies was assessed utilizing the Coleman Methodology Score (CMS). A total of 29 retrospective studies, including 987 fractures with a mean follow-up of 49.9 months, were examined. Success rates were 62%, 60%, and 50% for pooled fractures, TN, and TN/TB, respectively. The overall complication rate for AVN was 25%. The rate was higher for TN (43%) than TN/TB (25%). Talar fractures revealed a 43% posttraumatic osteoarthritis (OA) rate in our meta-analysis. Success rates showed an association with fracture severity, and were generally low in complex multi-fragmentary fractures. The mean CMS was 34.3 (range: 19-47), indicating a moderate methodological quality of the studies. The present systematic review on clinical outcomes of patients undergoing conservative or surgical treatment for talar fractures reveals a lack of reliable prospective evidence. Talar fractures are associated with relatively poor postoperative outcomes, high rates of AVN, and posttraumatic osteoarthritis. Poor outcomes revealed a positive association with fracture severity. Prospective studies investigating predictors for treatment success and/or failure are urgently needed to improve the overall quality of life and function of patients undergoing surgical treatment due to talar fractures.

Injuries in the pelvic region in children and adolescents are very rare and often associated with a high energy trauma. Aim of this prospective multicenter study was, by analyzing the data from the TraumaRegister Deutsche Gesellschaft für Unfallchirurgie (TR-DGU), to evaluate any correlation between the severity of pelvic fractures and resulting mortality in different age groups.These study findings are based on a large pool of data retrieved from the prospectively-setup pelvic trauma registry established by the German Trauma Society (DGU) and the German Section of the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) International in 1991. The registry provides data on all patients suffering pelvic fractures within a 14-year time frame at any 1 of the 23 level 1 trauma centers contributing to the registry. The analysis covers 4 age groups ranging from 0 to 17 years, covering different factors regarding pelvic fractures and their treatment.We identified a total of 9684 patients including 1433 pelvic fractures in children aged ≤17 years. Those patients were divided into 4 subgroups according to the patients' age (groups A-D) and according to the fracture severity (group 1 =  Abbreviated Injury Scale (AIS) score pelvis ≤2, and group 2 = AIS pelvis ≥3). The mortality in group 1 was 8.8% with a RISC (Revised Injury Severity Score) II of 8.6%, standard mortality rate (SMR) of 1.02 and 7.2% in group 2 with an RISC II of 9.9% (SMR 0.73). In pelvic factures of Type A (Tile classification of pelvic fractures), an SMR of 0.76 was recorded, in Type B fractures the SMR was 0.65, and in Type C fractures 0.79. Severe pelvic injuries (AIS pelvis ≥2) were associated with a higher rate of whole body computer tomograph (CT) scans (1-5 years: 80%, 6-10 years 81.8%, 11-14 years 84.7%, and 15-17 years 85.6%). The rate of pelvic surgery rose with the pelvic injury's severity (AIS 2: 7.6%, AIS 3: 35%, AIS 4: 65.6%, AIS 5 61.5%). We observed higher rates of preclinical and initial clinical hypotension defined as Riva-Rocci (RR) <90 mmHG) as well as of preclinical fluid application in all age groups. The presence of a pelvic injury was associated with a higher rate of severe abdominal injuries with an AIS of ≥3 (25.1% vs. 14.6%) and of severe thorax injuries with an AIS≥3 (43.6% vs. 28.6%).We have been able to analyze an enormous number of pelvic fractures in children and adolescents including different age groups by relying on data from the TR-DGU. Mortality seems to be associated with the severity of the pelvic injury, but is lower than the RISC II score's prognosis.

Introduction: Controversy exists on optimal operative treatment of vertically unstable Neer IIB lateral clavicle fractures. Aim of this study was to analyse and compare clinical and radiological results and complications of locking plate osteosynthesis (LPO) versus hook plate osteosynthesis (HPO) with acromioclavicular joint (ACJ) stabilization. The hypothesis was, that HPO would recreate coracoclavicular stability more effectively and potentially lead to a superior outcome., Methods: This retrospective, observational cohort study included 32 patients (19 HPO, 13 LPO) with a mean age of 44.1 ± 14.2 years at surgery. The mean follow-up period was 54.2 months (range 25.2-111.4 months). Besides standard radiography, bilateral coracoclavicular distances were assessed by means of preoperative and follow-up stress radiographs after implant removal. Clinical outcome measures included the Constant score (CS), the Oxford shoulder score (OSS), the subjective shoulder value (SSV) and the Taft score (TS)., Results: Bone union occurred in all but one patient and proved to occur delayed in five patients (15.6%). Radiographical healing required a mean of 4.2 ± 4.0 months irrespective of the type of osteosynthesis. At follow-up, mean coracoclavicular distance was increased by 34% (±36) without significant differences between both groups. HPO patients obtained a significantly lower TS (HPO: 9.5 ± 1.5 points, LPO: 11.1 ± 1.3 points; p = 0.005). Other mean score values did not differ (CS: 90.1 ± 7.4 points, OSS: 43.2 ± 9.2 points, SSV: 91.1 ± 14.7%). Sixteen patients (50.0%) experienced complications. Overall prevalence of complications was significantly higher in the HPO group (p = 0.014)., Conclusions: Both HPO and LPO were equally effective in relation to restoration of vertical stability, overall functional outcome and fracture consolidation in treatment of Neer IIB fractures. Contrary to our hypothesis, HPO was not associated with superior recreation of the coracoclavicular distance. Considerable drawbacks of HPO were an inferior ACJ-specific outcome (Taft-Score) and a higher overall complication rate. Level of evidence IV.

Although non-unions in the upper limb are rare different treatment options of this challenging situation are still affected with up to 20% of failure rate due to current literature. Risk factors for delayed and non-union of fractures are mainly the size of the fracture gap and bone loss of open fractures or in primary surgery followed by other relevant internal and external factors. In the upper limb non-unions of long bones are described with up to 30% after operative intervention. Especially in the upper limb range of motion is limited in non-union cases and disables adjacent joints like the shoulder, elbow and wrist hence reducing the total activity level of affected patients. Beside careful investigation of the causes leading to the non-union a comprehensive treatment plan should be defined to achieve successful results. Treatment can be non-operative in several, selected cases, but in the majority of cases revision surgery is necessary to achieve osseous healing. Our own experience showed that non-union in the upper limb are rare and account for only 1.7% of all surgical managed upper limb fractures. Non-union of upper limb fractures occur most frequently in clavicle fractures followed by humeral fractures. Atrophic non-union is the most frequent reason for osseous non-union (57%) and osseous healing after revision surgery in non-unions is completed after a mean of 6.45 months. This article will give a brief overview of the genesis, clinical evaluation, treatment options and recommendations in upper limb non-unions according to the current literature. Key words: fracture, upper-limb, non-union, osteosynthesis, cancellous bone-graft.

As pelvic fractures in children and adolescents are very rare, the surgical management is not well delineated nor are the postoperative complications. The aim of this study using the prospective data from German Pelvic Trauma Registry study was to evaluate the various treatment approaches compared to adults and delineated the differences in postoperative complications after pelvic injuries.Using the prospective pelvic trauma registry established by the German Society of Traumatology and the German Section of the Arbeitsgemeinschaft für Osteosynthesefragen (AO), International in 1991, patients with pelvic fractures over a 12-year time frame submitted by any 1 of the 23 member level I trauma centers were reviewed.We identified a total of 13,525 patients including pelvic fractures in 13,317 adults and 208 children aged ≤14 years and compared these 2 groups. The 2 groups' Injury Severitiy Score (ISS) did not differ statistically. Lethality in the pediatric group was 6.3%, not statistically different from the adults' 4.6%. In all, 18.3% of the pediatric pelvic fractures were treated surgically as compared to 22.7% in the adult group. No child suffered any thrombosis/embolism, acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), or neurologic deficit, nor was any septic MOF detected. The differences between adults and children were statistically significant in that the children suffered less frequently from thrombosis/embolism (P = 0.041) and ARDS and MOF (P = 0.006).This prospective multicenter study addressing patients with pelvic fractures reveals that the risk for a thrombosis/embolism, ARDS, and MOF is significant lower in pediatric patients than in adults. No statistical differences could be found in the ratios of operative therapy of the pelvic fractures in children compared to adults.

Objective: Avulsion fractures of the fifth metatarsal base (MTB5) are common fore foot injuries. Based on a radiomorphometric analysis reflecting the risk for a secondary displacement, a new classification was developed., Materials and Methods: A cohort of 95 healthy, sportive, and young patients (age ≤ 50 years) with avulsion fractures of the MTB5 was included in the study and divided into groups with non-displaced, primary-displaced, and secondary-displaced fractures. Radiomorphometric data obtained using standard oblique and dorso-plantar views were analyzed in association with secondary displacement. Based on this, a classification was developed and checked for reproducibility., Results: Fractures with a longer distance between the lateral edge of the styloid process and the lateral fracture step-off and fractures with a more medial joint entry of the fracture line at the MTB5 are at higher risk to displace secondarily. Based on these findings, all fractures were divided into three types: type I with a fracture entry in the lateral third; type II in the middle third; and type III in the medial third of the MTB5. Additionally, the three types were subdivided into an A-type with a fracture displacement <2 mm and a B-type with a fracture displacement ≥ 2 mm. A substantial level of interobserver agreement was found in the assignment of all 95 fractures to the six fracture types (κ = 0.72). The secondary displacement of fractures was confirmed by all examiners in 100%., Conclusions: Radiomorphometric data may identify fractures at risk for secondary displacement of the MTB5. Based on this, a reliable classification was developed.

Background: Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw's correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools. The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications., Methods: This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry., Results: A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187×with surgical interventions) and 597 patients with sacral fractures (334×with surgical interventions). The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p=0.4242). Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p=0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications., Discussion: In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: Percutaneous iliosacral screw placement following pelvic trauma is associated with high rates of revisions, screw malpositioning, the risk of neurological damage and inefficient stability. The correct entry point and the small target corridor may be difficult to visualize using only an image intensifier. Therefore, 2D and 3D image-based navigation and reconstruction techniques could be helpful tools. The aim of this systematic review and meta-analysis was to evaluate the best available evidence regarding the rate of malpositioning and revisions using different techniques for screw implantation, i.e., conventional, 2D and 3D image-based navigation and reconstruction techniques, CT navigation., Methods: A systematic review and meta-analysis were performed using the data available on Ovid Medline. 430 studies published between 1/1948 and 2/2011 were identified by two independent investigators. Inclusion criteria were percutaneous iliosacral screw fixation after traumatic pelvic fractures with included revision rate or positioning of the screw, language of the article English or German. Exclusion criteria were osteoporotic fracture, tumor, reviews, epidemiological studies, biomechanical/cadaveric studies, studies about operative technique. For statistical analysis the random effect model was used., Results: A total of 51 studies fulfilled the inclusion requirements describing 2,353 percutaneous screw implantations following pelvic trauma in 1,731 patients. The estimated rate of malposition was 0.1 % for 262 screws using CT navigation. This rate was significantly lower (p < 0.0001) than for the conventional technique with malposition rate of 2.6 % (total 1,832 screws). Using 2D and 3D image-based navigation and reconstruction techniques, the malposition rate was 1.3 % (total 445 screws). No significance was observed between the conventional and the 2D and 3D image-based navigation and reconstruction techniques. The rates of revision were not statistically significant with 2.7 % (1,832 implantations) in the conventional group, 1.3 % (445 implantations) in the group of 2D and 3D image-based navigation and reconstruction techniques and 0.8 % (262 implantations) using the CT navigation., Conclusions: CT navigation has the lowest rate of screw malposition, but on the other hand it could not be used for all type of fractures where surgical procedures (reduction maneuvers, additional osteosynthetic procedures) are necessary. The 2D and 3D image-based navigation and reconstruction techniques provide encouraging results with slightly lower rate of complications compared to the conventional technique and are additional tools to enhance the precision and decrease the rate of revision.

Background: The precision of sacroiliac screw placement can be improved with the use of navigation techniques. The purpose of this study was to evaluate the accuracy of 3D-navigated sacroiliac screw positioning in relation to the surgeon's experience with the navigation technique., Patients and Methods: A consecutive series of 3D-navigated sacroiliac screw placements were prospectively evaluated between December 2005 and February 2008. Postoperatively the precision of screw placement was analyzed in relation to the surgeon's navigation experience with a CT-scan using the criteria of Smith., Results: A total of 37 screws were implanted by 7 surgeons in 33 patients. In the group of surgeons with less experience in navigation techniques two cases of malpositioning led to revision of the screws. No screws which were implanted or assisted by surgeons experienced in navigation needed to be revised. There was no significant difference in the malposition rate., Conclusion: In the clinical setup a malpositioning of sacroiliac screws is possible even with the use of 3D navigation. One reason may be a low level of navigation experience of the surgeon in combination with low experience in the conventional technique. Therefore even in navigation-based placement of sacroiliac screws the malpositioning rate is dependent on the surgeon's experience with the navigation technique. The correct placement of the screws should be controlled intraoperatively using the 3D image intensifier.

Unlabelled: Insertion of percutaneous iliosacral screws with fluoroscopic guidance is associated with a relatively high screw malposition rate and long radiation exposure. We asked whether radiation exposure was reduced and screw position improved in patients having percutaneous iliosacral screw insertion using computer-assisted navigation compared with patients having conventional fluoroscopic screw placement. We inserted 26 screws in 24 patients using the navigation system and 35 screws in 32 patients using the conventional fluoroscopic technique. Two subgroups were analyzed, one in which only one iliosacral screw was placed and another with additional use of an external fixator. We determined screw positions by computed tomography and compared operation time, radiation exposure, and screw position. We observed no difference in operative times. Radiation exposure was reduced for the patients and operating room personnel with computer assistance. The postoperative computed tomography scan showed better screw position and fewer malpositioned screws in the three-dimensional navigated groups. Computer navigation reduced malposition rate and radiation exposure., Level of Evidence: Level II, therapeutic study.