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ZusammenfassungKongenitale Deformitäten der Extremitäten treten mit einer Inzidenz von etwa 1,5 bis 3 Fällen pro 1000 Geburten auf. Einfache Deformitäten wie Syn- oder Polydaktylien sind um ein Vielfaches häufiger als komplexe Deformitäten, wie Radius- oder Ulnahypoplasien oder Peromelien, wobei dazu in Österreich (wie in den meisten Ländern der westlichen Welt) dokumentationsbedingt keine verlässlichen Daten existieren. Dank moderner diagnostischer Verfahren, insbesondere der immer besseren pränatalen Bildgebung, werden Deformitäten der Extremitäten zunehmend früher erkannt. Die Diagnose löst bei den Eltern stets große Verunsicherung aus, weswegen hier von Anfang an eine umfassende Beratung und empathische Begleitung notwendig ist. Kleinkinder mit Deformitäten der oberen Extremität empfinden subjektiv meist überhaupt keine Einschränkung und verwenden die Extremität auf die Art und Weise, die die Malformation erlaubt. Dazu sei erwähnt, dass in den allermeisten Fällen keine kognitiven Beeinträchtigungen bestehen und mit einer normalen geistigen Entwicklung gerechnet werden kann. Die Korrektur der Deformität hat zum Ziel, dem Kind eine sensible Extremität mit einer im Alltag verwendbaren Greiffunktion zu Verfügung zu stellen. Der ideale Operationszeitpunkt liegt zwischen dem 6. Lebensmonat und 2. Lebensjahr, um eine vollständige funktionelle Integration der rekonstruierten Hand ins Körperschema zu gewährleisten. Psychologische Betreuung der Eltern und Kinder bis zum Erreichen des Erwachsenenalters stärkt das Selbstbewusstsein der Betroffenen; dabei wird bewusst großer Wert auf die richtige Diktion gelegt und die Deformität von Anfang an positiv als Besonderheit und nicht als Fehlbildung bezeichnet.

In the last decade, new tumor entities have been described, including

Identifying potential gait deviations in patellofemoral instability (PI) can help with the development of effective rehabilitation strategies. The purpose of this systematic review was to examine whether there are specific gait alterations in subjects with PI. The present review followed the PRISMA guidelines and was initially registered at PROSPERO (CRD42021236765). The literature search was carried out in the databases of PubMed, the Cochrane library, Web of Science, ClinicalTrials.gov, and Medline. The search strategy resulted in the identification of seven relevant publications. Subjects with PI show decreased walking speed, stride length, and cadence. Some studies reported changes not only in knee kinematics and kinetics but also in hip and ankle kinematics and kinetics. There is evidence that most subjects with PI walk with a quadriceps avoidance gait and show increased genu valgum posture, but there is still great variability in the coping responses within individuals with PI. The discrepancy among the study results might underpin the fact that PI is a multifactorial problem, and subjects cope with the different underlying morphological as well as functional deficits using a variety of gait strategies, which makes the interpretation and understanding of the gait of subjects with PI a clinically challenging task.

The differentiation between mild forms of toe-walking (equinus) in cerebral palsy (CP) and idiopathic toe-walking (ITW) is often clinically challenging. This study aims to define kinematic and kinetic parameters using 3D gait analysis to facilitate and secure the diagnosis of “idiopathic toe-walking”. We conducted a retrospective controlled stratified cohort study. 12 toe-walking subjects per group diagnosed as ITW or CP were included and stratified according to age, gender and maximal dorsiflexion in stance. We collected kinematic and kinetic data using a three-dimensional optical motion analysis system with integrated floor force plates. Pairwise comparison between ITW and CP gait data was performed, and discriminant factor analysis was conducted. Both groups were compared with typically developing peers (TD). We found kinematic and kinetic parameters having a high discriminatory power and sensitivity to distinguish between ITW and CP groups (e.g., knee angle at initial contact (91% sensitivity, 73% specificity) and foot progression angle at midstance (82% sensitivity, 73% specificity)). The strength of this study is a high discriminatory power between ITW and CP toe-walking groups. Described kinematic parameters are easy to examine even without high-tech equipment; therefore, it is directly transferable to everyday praxis.

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.

Mg-based biodegradable materials are considered promising candidates in the paediatric field due to their favourable mechanical and biological properties and their biodegrading potential that makes a second surgery for implant removal unnecessary. In many cases the surgical fixation technique requires a crossing of the growth plate by the implant in order to achieve an adequate fragment replacement or fracture stabilisation. This study investigates the kinetics of slowly and rapidly degrading Mg alloys in a transphyseal rat model, and also reports on their dynamics in the context of the physis and consecutive bone growth. Twenty-six male Sprague–Dawley rats received either a rapidly degrading (ZX50; n = 13) or a slowly degrading (WZ21; n = 13) Mg alloy, implanted transphyseal into the distal femur. The contralateral leg was drilled in the same manner and served as a direct sham specimen. Degradation behaviour, gas formation, and leg length were measured by continuous in vivo micro CT for up to 52 weeks, and additional high-resolution µCT (HRS) scans and histomorphological analyses of the growth plate were performed. The growth plate was locally destroyed and bone growth was significantly diminished by the fast degradation of ZX50 implants and the accompanying release of large amounts of hydrogen gas. In contrast, WZ21 implants showed homogenous and moderate degradation performance, and the effect on bone growth did not differ significantly from a single drill-hole defect. Statement of Significance This study is the first that reports on the effects of degrading magnesium implants on the growth plate in a living animal model. The results show that high evolution of hydrogen gas due to rapid Mg degradation can damage the growth plate substantially. Slow degradation, however, such as seen for WZ21 alloys, does not affect the growth plate more than drilling alone, thus meeting one important prerequisite for deployment in paediatric osteosynthesis.

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 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.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).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.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.Therapeutic, Level IV.

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.

We report on the long-term effects of degrading magnesium implants on bone tissue in a growing rat skeleton using continuous in vivo micro-Computed Tomography, histological staining and Laser Ablation Inductively Coupled Plasma Mass Spectrometry (LA-ICP-MS). Two different magnesium alloys—one rapidly degrading (ZX50) and one slowly degrading (WZ21)—were used to evaluate the bone response and distribution of released Mg and Y ions in the femur of male Sprague-Dawley rats. Regardless of whether the alloy degrades rapidly or slowly, we found that bone recovers restitutio ad integrum after complete degradation of the magnesium implant. The degradation of the Mg alloys generates a significant increase in Mg concentration in the cortical bone near the remaining implant parts, but the Mg accumulation disappears after the implant degrades completely. The degradation of the Y-containing alloy WZ21 leads to Y enrichment in adjacent bone tissues and in newly formed bone inside the medullary space. Locally high Y concentrations suggest migration not only of Y ions but also of Y-containing intermetallic particles. However, after the full degradation of the implant the Y-enrichment disappears almost completely. Hydrogen gas formation and ion release during implant degradation did not harm bone regeneration in our samples., Acta Biomaterialia, 42, ISSN:1742-7061, ISSN:1878-7568

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.

This study investigates the degradation performance of three Fe-based materials in a growing rat skeleton over a period of 1 year. Pins of pure Fe and two Fe-based alloys (Fe-10 Mn-1Pd and Fe-21 Mn-0.7C-1Pd, in wt.%) were implanted transcortically into the femur of 38 Sprague-Dawley rats and inspected after 4, 12, 24 and 52 weeks. The assessment was performed by ex vivo microfocus computed tomography, weight-loss determination, surface analysis of the explanted pins and histological examination. The materials investigated showed signs of degradation; however, the degradation proceeded rather slowly and no significant differences between the materials were detected. We discuss these unexpected findings on the basis of fundamental considerations regarding iron corrosion. Dense layers of degradation products were formed on the implants' surfaces, and act as barriers against oxygen transport. For the degradation of iron, however, the presence of oxygen is an indispensable prerequisite. Its availability is generally a critical factor in bony tissue and rather limited there, i.e. in the vicinity of our implants. Because of the relatively slow degradation of both pure Fe and the Fe-based alloys, their suitability for bulk temporary implants such as those in osteosynthesis applications appears questionable.

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.