Eur J Trauma Emerg Surg (2014) 40:405–417 DOI 10.1007/s00068-014-0410-y

ABSTRACTS

33rd Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

June 13–14, 2014 Lu¨beck, Germany

Scientific chair PD Dr. med. Martin M. Kaiser Stellvertretender Direktor Klinik fu¨r Kinderchirurgie Universita¨tsklinikum S–H Campus Lu¨beck

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ActifuseÒ as a treatment option in pediatric bone cysts: first experiences Dietzel M1, Lieber J1, Tru¨ck M1, Fuchs J1, Kirschner HJ1 1

Department of Pediatric Surgery and Pediatric Urology, University Children’s Hospital, Hoppe-Seyler-Str. 3, 72076 Tu¨bingen, Germany Introduction: Treatment options of bone cysts in children and adolescents are still a matter of debate. We report first experiences using the alloplastic bone replacement material ActifuseÒ, a substitute on the basis of calcium phosphate (SiCaP). Its silicate enhancement is meant to improve bone remodelling. Methods: Retrospective data analysis of patients with juvenile or aneurysmatic bone cysts in which ActifuseÒ (ApaTech Ltd./Baxter, Elstree, United Kingdom) was used as a treatment option. Results: From 2008 to 2014, 8 children (age 10.4 years; range 3–16) with unicameral (n = 3) and aneurysmatic bone cysts (n = 5) were treated with ActifuseÒ. Treatment was initiated due to static concerns (n = 3), pain (n = 2), cyst extension (n = 2), or cyst recurrence (n = 1). Bone cysts were located in the proximal/distal femur (n = 3), proximal humerus, (n = 2), proximal ulna (n = 2), and calcaneus (n = 1). All cysts were filled with 10.75 ml (range 3–20) of ActifuseÒ after curettage. Additional ESIN osteosynthesis was inserted in 4 children (3 femur, 1 humerus). No local/systemic reactions or migration of the bone substitute were observed. In 2 cases recurrence of the bone cyst occured, of which one was revised and again filled with ActifuseÒ after the diagnosis of a giant cell tumor had been established by the pathologist. During follow-up (25 months; range 1–63) none of the patients showed functional deficits or complained about persisting pain. Radiological signs of increasing bone remodelling of SiCaP were found consecutively. Conclusion: ActifuseÒ is easy to apply due its porous texture and does not show migration into surrounding soft tissues. Local or systemic reactions have not been documented so far. Thus, ActifuseÒ represents a good and safe alternative in the treatment of benign bone cysts in children and adolescents.

Complications after operative treated both bone forearm fractures with ESIN in childhood and adolescence. A two center study Dudda M.1, Bunge P.1, Jones C.B.2,3, Schildhauer T.A.1, Kruppa C. 1, 4 1 Department of Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany; 2Michigan State University/ CHM, Grand Rapids, MI, USA; 3Orthopaedic Associates of Michigan, Grand Rapids, MI, USA; 4Grand Rapids Medical Education Partners, Grand Rapids, MI, USA

Introduction: Both bone forearm fractures are frequent injuries in childhood and adolescence. Operative treatment is frequently performed using intramedullary stabilization such as elastic intramedullary nails (ESIN). Purpose of this study was to analyze complication rates after intramedullary stabilization of both bone forearm fractures in childhood and adolescence retrospectively at two Level One Teaching Trauma Centers. Methods: At both centers operative treated both bone forearm fractures with ESIN were retrospectively evaluated over 10–12 years, respectively. Patients included had a diaphyseal both bone forearm fracture until the age of 15 and 17 years, respectively. Complications and necessity of further treatment intervention were analyzed. Center 1: 59 Patients with an average age of 11.0 years (range 5–15) were included. The study population at Center 2 consisted of 180

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Abstract Patients with 181 fractures. Average age was 9.7 years (range 3-17). A total of 23 (9.6 %) fractures were open. 202 (84.2 %) fractures were treated with ESIN radial and ulnar. In 26 (10.8 %) both bone fractures the radius was stabilized isolated, in 8 (3.3) fractures the ulna. Three (1.3 %) fractures were stabilized with intramedullar k-wires. One (0.4 %) with ESIN ulnar and k-wire stabilization radial. Results: 204 both bone forearm fractures had a total of 15 complications. Four superficial wound infections, four refractures after early hardware removal, two malunions, two ruptures of the extendor pollicis longus tendon and one compartment syndrome. In two cases reoperation with extramedullary stabilization was performed without further intervention. Conclusion: Intramedullary nailing of instable both bone forearm fractures is the method of choice in case operative treatment is required. The complication rate in our study population of 240 included fractures is low, therefore ESIN can be considered as a save procedure. Some complications such as EPL-tendon rupture and refractures could be avoided by improvement of the operation technique and careful consideration of the time of hardware removal.

Trampoline-related injuries in childhood. An increasing problem Dudda M., Ko¨nigshausen M., Kruppa C., Schildhauer T.A., Seybold D Department of Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany Introduction: The sales of recreational trampolines are increasing during past years. Partially, severe injuries are associated with trampoline sport in the domestic setting. Therefore, this study was conducted to confirm the hypothesis of an increase of trampoline-related injuries in conjunction with the increasing sales of recreational trampolines and to find out what kind of injuries are most frequent in this context. Methods: Between 01/1999 and 09/2013 all trampolin-related injuries of children (0–16 years of age) were assessed retrospectively. Only these cases were evaluated, which described securely a trampoline-associated trauma. The fractures were considered separately and were localised and assigned to its localisation. Additionally, accidents at home were differentiated from institutional accidents. Results: Within the past 13 years and 9 month trampoline-related injuries were found in 195 infants. Fractures were present in 83 cases (42 %). The average age was 10 ± 3.4 years (range 2–16 years). Within first half of observed time period (7 ‘ years; 01/1999–06/ 2006) 73 cases were detected with a significant increasing number of injuries up to 122 cases between 07/2006 and 09/2013 (7 years, 3 months), which corresponds to an increase of 67 % (p = 0.028). The vast majority of injuries happened in the domestic setting (90 %, n = 175), whereas only 10 % (n = 20) of traumas occured in public institutions. In 102 children (52 %) the lower extremity was affected and in 51 patients (26 %) the upper extremity was involved (Head/ Spine/Pelvis: n = 42, 22 %). The upper extremity was primarly affected of fractures and dislocations (n = 38, 76 %). Particularly at the lower extremity (LE), sprains, contusions or cutting damages (n = 66) were found, whereas 32 fractures occured (patella dislocation: n = 1; anterior cruciate ligament rupture: n = 3). At the upper extremity there were more injuries requiring surgery in contrast to lower extremity (n = 11) or cervical spine (n = 1). Conclusion: The underlying data show a significant increase of trampolin-related injuries within past years. The upper extremity is second most affected after lower extremity, but is more associated with fractures in contrast to other localisations and had to be operated on the most.

Abstract Because of the increase of recreational trampolines within past years an increase of trampoline-associated injuries has to be expected in the future. The security guidelines should be followed exactly and the infants should be under supervision.

Just another limping child—exceptions prove the rule Kolja Eckert, Peter Liedgens Department of Pediatric Surgery, Elisabeth-Hospital Essen, Klara-Kopp-Weg 1, 45138 Essen, Germany Introduction: Limp is a common complaint in childhood showing a broad spectrum of underlying causes ranging mostly from benign or self-limiting (e.g. trauma, transient synovitis) to limb- (e.g. osteomyelitis, septic arthritis) or rarely to life-threatening (e.g. malignant tumors) conditions. Case report: A 5-year old boy was presented to his pediatrician with intermittent, partly painful limp since 4 weeks. An underlying trauma was negated. The clinical examination reveales a modest, right sided limp without pain by palpation or apparent alterations of the affected leg. Sonographic and radiographic evaluation of the right leg and laboratory tests gave no useful indications. Because of persisting limp for another 4 weeks the boy was presented to our department. Our clinical examination at most revealed a modest, non painful limp especially when running. By palpation we found a very modest, hardly painful swelling at the proximal tibia. New plain radiographs of the knee and the lower leg revealed a periosteal reaction to the metaphyseal region of the proximal tibia. A MRT was done, which proved the suspected malignancy. The patient was discharged for further oncological evaluation and biopsy results confirmed Ewing’s sarcoma of the proximal tibia. Conclusion: The cause of limp usually can be determined by obtaining a careful history and physical examination. If limp remains unclear, diagnostic imaging and laboratory tests are required. Primary malignant tumors in childhood are rare, but must be considered in the differential diagnosis of a limping child. Bone tumors can be difficult to diagnose because they often begin with vague symptoms, which may be attributed erroneously to a minor injury or ‘‘growing pains’’ thus causing a diagnostical delay with severe sequelae. Bone pain due to malignant tumors are not continuously, mostly occurring at night with wakening of the child. Limp in combination with a visible and/or palpable swelling are cardinal symptoms of malignant bone tumors. Radiographic signs characteristic of malignant tumors include ‘‘onion skinning’’ caused by repetitive periosteal reactions, which may be attributed erroneously to posttraumatic alterations. Ewing´s sarcoma are rare and life threatening. Thus, in persisting limp of unknown origin a rapid and efficient diagnostic evaluation is mandatory.

Case report of a Brodie’s abscess of the distal humerus 6 years after the osteosynthesis of a supracondylar humerus fracture of a 9-year-old girl Fink, Matthias; Nuber, Stefan; Mayr, Edgar Klinik fu¨r Unfall-, Hand- und Wiederherstellungschirurgie, Department for Trauma, Hand and Reconstructive Surgery, Klinikum Augsburg, Leiter: Prof. Dr. Dr. h. c. Edgar Mayr, Stenglinstr. 2, 86156 Augsburg, Germany Question: In this case report we describe the operative treatment for a Brodie’s abscess of the distal humerus, which occurred 6 years after the osteosynthesis of a supracondylar humerus fracture.

407 Methods: In 2007 a 9-year-old girl with no comorbidities was treated for a fully displaced supracondylar humerus fracture in our institution. The fracture was reduced with a radial K-wire and an additive external fixation. After 6 weeks the K-wire and the external fixation were removed. There was no sign of a pin infection during that time. In 2013 the now 15 year old girl presented again in our hospital with a swelling and loss of range of motion (ROM) of the left elbow persisting for a few weeks. The MRI showed a low-grade osteomyelitis of the distal humerus with a Brodie’s abscess. In the first operation we performed a complete curettage of the lesion and the insertion of an antibiotic-chain through a small bone window. The antibiotic therapy was, according to the Staphylococcus aureus we found intraoperatively, continued for 8 weeks. In the second operation we released the circumferential adhesions of the distal humerus and filled the defect with autologous cancellous bone from the iliac crest. Results: Over the next months the osteomyelitis healed up completely, both clinically and radiologically, which was confirmed by X-ray and MRI. Since then, the patient has had no more symptoms and after 3 months she showed a completely free ROM of her left elbow. Conclusions: Our case report describes the rare complication of a delayed osteomyelitis 6 years after the operative treatment of a supracondylar humerus fracture with K-wires and an external fixation. With the complete curettage of the lesion through a bone window, the subsequent filling of the defect with autologous cancellous bone and a release of the adhesions we achieved a very good clinical and functional result.

Case report: infant from Libya with amputation of the lower leg and pseudarthrose of the femoral bone after gunshot wound Frimberger V, Hauptmann M, Bernius P Centre of paediatric and neuroorthopedics, Scho¨n Klinik, Mu¨nchen Harlaching Introduction: Gunshot wounds in infants, particularly combined with an amputation, are rare in Germany. The difficulty in treating these kinds of injuries is due to the extensive damages of the soft tissue with consecutive dysfunction of perfusion and innervation, osteal defects and deep contamination with germ colonization. The interdisciplinary teamwork of all involved departments is essential to provide a sufficient rehabilitation. Case presentation: We report on a case involving a boy at the age of 2 years and 8 months who suffered from a full penetration gunshot of the left femoral bone in Libya in September 2011. The initial medical care was provided locally. After being transferred to Tunisia for further treatment, the lower leg had to be ablated 8 cm below the left knee as a result of circulatory disturbance. For stabilisation purposes, an external fixateur was installed. With the help of an aid organisation the boy was brought to Germany in October 2011. After examining the leg, the diagnostic findings showed a badly maintained fixateur that bridged the osteal gap of the distal femur. The skin of the stump was roughly fitted by a few stitches below the knee. The soft tissue was destroyed to such an extent that it was possible to look right through the thigh showing the osteal stumps. As a first step the treatment focused on the soft tissue damage, which is a necessary precondition before an osteal consolidation can take place. Consequently the external fixateur was removed, the bone stumps were shortened and a vacuum dressing was applied. Over a

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408 period of 4 weeks and after nine operations, which included a skin graft, wound and stump closure were achieved. The child was then transferred to a paediatric orthopaedic department, where the femoral fracture and a residual and discharging fistula were treated. For the osteosynthesis of the femoral fracture two elastic stable intramedullary nails (ESIN) were used. Despite initial radiological findings of a pseudarthrose, an osteal consolidation process emerged soon after, caused by the enormous stimulus of the healing soft tissue defect. Finally, we manufactured a transtibial prosthesis in our orthopaedic workshop. That way, the boy could be mobilised, verticalised and finally managed to walk. Conclusion: Devastating injuries of the limbs caused by gunshots in infants and children are rare. The treatment represents a major challenge for all involved therapists. From our medical point of view, it is indispensable to first reconstruct the soft tissue and to handle the osteal complex of problems only in a second step. This requires stateof-the art equipment and highly qualified personnel as well as a holistic approach from all involved, i.e. physicians, qualified nurses, physiotherapy and orthopaedic engineering.

Growth plate areas, forces and compressive stresses at the growth plates of the proximal femoral end Heimkes B1, Gu¨nther CMJ1, Eibl D1, Geith T2, Baur-Melnyk A2 1

Klinik und Poliklinik fu¨r Orthopa¨die, Physikalische Medizin und Rehabilitation, Klinikum der Universita¨t, Campus Grosshadern, 2 Klinik fu¨r Klinische Radiologie, Klinikum der Universita¨t, Campus Grosshadern, Marchioninistr. 15, 81377 Mu¨nchen, Germany The proximal femoral end is particularly suitable for recognizing principles concerning the enchondral ossification and the longitudinal growth of the skeleton as it holds two morphologic identically structured growth plates of different size and different load. Purpose of the study was to compare the forces, areas and stresses acting on the epiphyseal growth plate and the greater trochanter growth plate during growth. Methods: Pseudonymised MRI-data of 36 hip-healthy children of different age and gender were taken to specify the loads, areas and compressive stresses on the epiphyseal and apophyseal growth plates. The areas were surveyed by means of the software tool OsiriX, the forces were calculated by established numerical modelings. Results: 1. The areas of the two mentioned growth plates steadily increased from infancy until puberty. The epiphyseal growth plate increases 0.8 cm2/year (r = 0.068), the apophyseal growth plate 0.5 cm2/year (r = 0.048). 2. The epiphyseal growth plate area and the apophyseal growth plate area are at a ratio of 1:0.56. This ratio remains unchanged during the entire growth period (b = 0.012). 3. Both growth plates are loaded highly different during growth, but their computed compressive stresses are at a ratio of re:ra = 1:1.07 during the entire growth period (b = -0.022). Conclusion: At least concerning the proximal femoral end you will find the fundamental skeletal remodeling law that growth plates of different size and different load are stressed by identical compressive stresses during the entire growth period. Increasing forces during growth enlarge the growth plates in order to keep compressive stresses constant.

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Abstract

Interdisciplinary care of a child with cervical spine injury and paraplegia in regional trauma network Sebastian Hentsch1, Andreas Ro¨hrig2, Benjamin Wafzig1, Dan Bieler1, Axel Franke1, Erwin Kollig1 1 Bundeswehrzentralkrankenhaus Koblenz Klinik f. Orthopa¨die und Unfallchirurgie, 2Asklepios Klinik Sankt Augustin GmbH, Abteilung fu¨r Kinderneurochirurgie, Ze.K.O.N

Introduction: Within the scope of the initiative TraumaNetwork DGUÒ (TNW) of the German Society for Trauma Surgery a narrow dovetailing was implemented by the medical centres which are involved in the trauma care. In the TNW Mittelrhein specialised treatment of seriously injured pediatric patients from the region takes place in the emergency hospital for children and adolescents in Sankt Augustin. Cooperation was agreed and founded between German Armed Forces Central Hospital in Koblenz as a Level I trauma centre and the Children Hospital in Sankt Augustin by contract. The following case shows the potentiality of prompt treatment for seriously injured children by coordination in the TNW. Method: 12-year-old boy was injured in a BMX bike accident in rural region in the evening. He showed a tetraplegia and apnea when ambulance service arrived (alarm 20:17/arrival 20:48). After intubation and ground transportation (departure 21:06) to Level l trauma centre (arrival 21:45) following clinical findings were observed: both pupils reacted to light deviation; bilateral corneal reflexes, no heamato-/liquorrhoe, no reaction on pain, reflexes were defuncted, no sphincter tone; priapism. After primary survey according to ATLS principles an Angio-CT and MRI of the head and the cervical spine were conducted. Whole diagnostic imaging was coordinated with the department of pediatric neurotraumatology Sankt Augustin by telephone and transfer was agreed after diagnostics without any delay. An unstable cervical spine (C3/4) fracture was proved with myelon contusion, intramedullar bleeding as well as hematoma ranged from C1 to C5. Further injuries were not detected. The patient was transferred to Sankt Augustin children hospital by military SAR helicopter at 23:11 local time. Electrophysiological investigation was performed before surgery, in which the complete loss of the SSEP for medianus and tibialis nerves were detected. For stabilization of the cervical spine fixateur interne (C2–C5) by dorsal instrumentation was used and bilateral laminectomie C3 and C4 was performed. Intraoperatively no structural damage of the myelon was found. During the course a ventral fusion (fixed angle plate C2/C5 with iliac crest interponate) as well as implantation of PEG, tracheostoma and suprapubic catheter were done. After 4 weeks the patient was transferred to neurological rehabilitation. Result: 8 months after accident the patient is currently spontaneous breathing and moves his shoulders. He is mobilised in a wheel-chair. After an initial depression he appears now very well motivated and mood-solidly 9 months after the accident. Summary: Interdisciplinary emergency treatment and transfer in case of seriously injured children and adolescents can be improved and coordinated using structures in the regional trauma network. In the presented case after 90 min all radiological diagnostics and interdisciplinary clinical examination were finished and transfer by helicopter was carried out to the children hospital for the further therapy in the appropriate specialized clinical setting.

Abstract

Regenerate associated complications in staged lower limb lengthening in young children with disproportionate short stature with achondroplasia Melanie J Horter, Bjo¨rn Vogt, Britta Schuhknecht, Henning Tretow, Frank Schiedel, Robert Ro¨dl 1

Kinderorthopa¨die, Deformita¨tenrekonstruktion und Fußchirurgie des Universita¨tsklinikums in Mu¨nster, Albert-Schweitzer-Campus 1, 48149 Mu¨nster Question: Achondroplasia is due to a FGFR3-activating mutation which results in impaired endochondral ossification and creates an external appearance of disproportionate short stature. The disproportion involves extremities that are too short relative to the trunk. We present the complications of a surgical leg lengthening concept with the aim to achieve physiological proportions. Method: Between 2005 and 2013 we underwent in 43 children with achondroplasia/hypochondroplasia limb lengthenings with a prospective follow-up. Using Paley’s multiplier method, the expected standing height, sitting height, and leg length can be predicted and an individualized treatment approach can be planned. Starting in the third year of life we can achieve almost physiological proportions and adjustment of leg length by an average of 24 cm until skeletal maturation has been completed. Our method includes two treatments on both tibiae simultaneously by diaphyseal osteotomia and external fixation [Taylor-Spatial-Frame (TSFÒ)] and two treatments on both femora simultaneously by diaphyseal osteotomia and external fixation [Limb Reconstruction System (LRSÒ)]. Results: We underwent in 43 children (20 female, 23 male) 102 tibiae and 78 femura lengthenings. The age was between 1.89 and 15.12 years at the date of operation. The mean fixator wearing period was 175 days, with a healing index of 28.24 days/cm. There were 21 males and 19 females with an initial height at the first operation between 71 and 124 cm and a predicted height between 112.40 and 142.64 cm. Complications which need a surgical treatment we found tibial at 10 patients 17 times, that means a complication rate of 16.67 % per segment. Femoral we found at 7 patients 10 of these complications, that means a complication rate of 12.82 % per segment. For each patient this implies a risk rate of 39.53 % to suffer at least one complication in need of an operative solution. We found regenerate associated complication (fracture, weakness) 3 times femoral (3.85 %) in 2 patients and 11 times (10.78 %) in 6 patients. There is at least a risk rate of 18.6 % to imply a regenerate associated complication. Conclusions: The low complication rate and good general interim results for the healing index scores, in comparison with other studies with older patients, confirm the approach presented here. In patients with achondroplasia, surgical reproportioning should start in early childhood to have optimal biologically conditions with optimal healing.

Preliminery results after dynamic intraligamentary stabilization in anterior cruciate ligament rupture in children Dagmar Kolp Paediatric Trauma and Orthopaedics, University Children‘s Hospital, Dept. of Paediatric Surgery, 3010 Bern, Schweiz Purpose: Management of anterior cruciate ligament lesions in children still remains controversial. Different operation techniques

409 (transphyseal, intra-epiphyseal, extra-epiphyseal) are known. We present our first results of 22 children with acute traumatic anterior cruciate ligament rupture, introducing a new technique for arthroscopic reconstruction of the ACL. Materials and methods: This is a retrospective study of 22 patients (mean age 13 years) with acute anterior cruciate ligament lesion. The dynamic intraligamentary stabilization technique is based on the repair of the ruptured ligament without using a tendon graft. The DIS technique combines an internal dynamic screw-spring mechanism with a braided polyethylene anchoring wire to provide continuous stability of the ACL and knee during self-healing. Clinical evaluation of the patients was performed 3, 6 weeks, 3, 6 and 12 months after operation. Results: We observed no surgery-related complications. All patients seen at 6 and 12 months follow up showed stable knee joints and were able to return to their previous sporting activity. Conclusion: The dynamic intraligamentary stabilization technique in acute traumatic rupture of the anterior cruciate ligament shows excellent results at follow up. The ACL healed in all patients and clinical evaluation showed stable knees. Our so far promising results will have to be reevaluated at an ongoing follow up date.

Fractures of the Acetabulum in Pediatrics and Adolescents Kruppa C.1,2; Dudda M.1; Khoriaty J.3; Sietsema D.3,4; Schildhauer T.1; Jones C.3,4 1 Department of Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany; 2Grand Rapids Medical Education Partners, Grand Rapids, MI, USA; 3Michigan State University, Grand Rapids, MI, USA; 4Orthopaedic Associates of Michigan, Grand Rapids, MI, USA

Introduction: Acetabular fractures in pediatric patients are rare. Fractures at the physis of the acetabulum (triradiate cartilage) may result in growths disturbances. Purpose of this study was to analyze acetabular fractures in childhood and adolescence concerning mechanism of injury, fracture pattern, initial treatment, as well as the clinical and radiologic outcome. Methods: 32 children with 37 acetabular fractures between 2002 and 2011 were retrospectively analyzed. Fractures were classified according to AO-Classification System. 12 (32 %) fractures were isolated (Group 1), 25 (68 %) were combined with a fracture of the pelvis (Group 2). The triradiate cartilage was involved in 12 (32 %) fractures. Mechanism of injury, associated injuries, Injury Severity Score (ISS), length of hospital stay and initial treatment for fracture were evaluated. Differences between Group 1 and 2 were analyzed. 18 children with 22 acetabulum fractures were included for follow up [6 months evaluation. Leg length discrepancy (LLD), hip dysplasia, pain and hip range of motion (ROM) were evaluated. Results: Age averaged 12.8 years (range 4–16 years). The main fracture pattern 75 % (9) in Group 1 was a posterior wall fracture (A1). Six occurred in consequence of a hip dislocation. The majority 21 (84 %) in Group 2 had anterior wall/column fractures (A3). Fractures in group 1 were caused by falls and sport injuries in 50 %; fractures in group 2 in 88 % by traffic accidents. Group 2 had significantly more associated injuries (p = 0.001), a lower GCS (p = 0.031), a higher ISS (p = 0.001) and a longer average hospital stay (p = 0.041). In total 9 (24.3 %) fractures were treated operative, this was significantly higher in Group 1 (p = 0.000). 5 (56 %)

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410 operative treated fractures had a hip dislocation. Follow up averaged 33.3 months (range 6–84). 3 (14 %) children had complications such as LLD (2) or hip dysplasia (2). One child required surgery for dysplasia. 96 % children had a full hip ROM, none reported hip related pain on final follow up. Conclusion: Acetabular fractures combined with a pelvis fracture are caused by a high-energy trauma. They are different injuries than isolated fractures, which are usually caused by falls and sport accidents. Those are more often treated conservatively. Leg length discrepancies and hip dysplasia can occur after injury of the triradiate cartilage.

Sacral fractures in pediatrics and adolescents Kruppa C.1,2; Dudda M.1;Khoriaty J.3; Sietsema D.3,4; Jones C.3,4 1 Department of Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany; 2Grand Rapids Medical Education Partners, Grand Rapids, MI, USA; 3Michigan State University, Grand Rapids, MI, USA; 4Orthopaedic Associates of Michigan, Grand Rapids, MI, USA

Introduction: Sacral fractures in pediatric and adolescent patients are rare. Misdiagnosis and underestimation of sacral fractures are frequently seen in adults. We analyzed sacral fractures in childhood and adolescence concerning injury and fracture pattern, treatment and outcome. Methods: Between 2002 and 2011, 52 children, 51 with an additional pelvic fracture, one without, were retrospectively analyzed. Sacral fracture patterns were classified according to Denis, pelvic fracture patterns according to AO classification system. Mechanism of injury, associated injuries, ISS, GCS, intial treatment and neurologic symptoms were determined. Clinical and radiographic outcome was evaluated. Results: Age averaged 12.2 years (range 3.0–16.0). 20 (39 %) children were immature, 32 (61 %) mature. 39 (75 %) fractures involved zone 1 and were crush injuries to the anterior sacral ala, 11 (21 %) zone 2, and 2 (4 %) zone 3. Both zone 3 fractures were transverse sacral fractures. 13 (25 %) fractures could be directly identified on plain radiographs and 20 (39 %) fractures could only be identified with additional CT scans. GCS averaged 13.3 (range 3-15); ISS 23.6 (range 4–66). Main mechanism of injury in 42 (81 %) children was a traffic accident. Operative stabilization was performed in 9 (17 %) children with sacroiliac screw fixation. 4 (8 %) children had neurologic symptoms. All four children had a pelvic ring injury OTA B3 or B2. 24 children were available for follow up [6 months, mean 25.2 months (range 6–84). No nonunion was recorded. 11 (46 %) children had low back or SI joint pain on final follow up. 7 (29 %) had a superior sacral displacement of 5–10 mm in their final radiographic outlet view, 9 (38 %) had a posterior sacral displacement of 5–10 mm in their final inlet view. All children return regular activities. One child had persistent neurologic symptoms. Conclusion: Sacral fractures in children and adolescents are rare. Three of four fractures are crush injuries to the anterior sacral ala in combination with a pelvic fracture, but more complex sacral fractures with neurologic symptoms occur and need to be stabilized. As in adults direct fracture identification by plain radiographs is often difficult. Persistent pain and deformities even in the pediatric population are present.

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Abstract

Talar fractures in pediatrics and adolescents Kruppa C.1,2; Dudda M.1; Snoap T.3; Sietsema D.3,4; Schildhauer T.1; Jones C.3,4 1 Department of Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany; 2Grand Rapids Medical Education Partners, Grand Rapids, MI, USA; 3Michigan State University/CHM, Grand Rapids, MI, USA; 4Orthopaedic Associates of Michigan, Grand Rapids, MI, USA

Introduction: Talar fractures in adolescence and childhood are rare. Due to higher activity levels and high intensity sports, more complex fractures of the foot, including the talus, are seen. Avascular necrosis (AVN), as well as arthrosis of the surrounding joints can occur. The purpose of the study was to determine the clinical and radiographic outcomes following talar fractures in childhood and adolescence. Methods: Between 2002 and 2010, 52 children with 54 talar fractures were retrospectively evaluated. 26 children with 28 fractures were available for follow up [6 months. Patients who had follow up \12 months (6) had a no signs for avascular necrosis (Hawkins sign). Treatment and complications such as nonunion, infection and AVN, as well as final clinical and radiographic outcome concerning arthrosis signs, arthrodesis and range of motion (ROM), pain and pain medication were analysed. Results between children \13 years and [13 years were compared. Results: Age averaged 14.2 years (4–18). Mean follow up was 32.1 months (6–95). Two (7 %) fractures were open. Fractures were classified according to Marti-Weber. Neck fractures were classified according to Hawkins. Nonunion occurred in 3 (11 %) fractures (1 talar neck, 2 talar dome fractures). AVN occurred in 3 (11 %) fractures (1 Hawkins Type 1, 2 Hawkins Type 3). One AVN had no further treatment, one subtalar and ankle fusion, and one talar dome excision with allograft reconstruction were performed. 43 % (12) children showed arthrosis in at least one of the surrounding joints. One ankle fusion and one talar with ankle fusion were present. Ankle ROM averaged 20° (0–35) dorsiflexion and 37° (0–45) plantarflexion. 10 subtalar joints had \50 % ROM. The majority (67 %) of fractures in children \13 years were undisplaced (Marti-Weber 1 + 2). 83 % (10) arthrosis and 100 % (2) arthrodesis occurred in children [13 years. Conclusion: Talar fractures in pediatrics and adolescents are severe injuries of the foot, which can result in arthrosis and even arthrodesis. Adolescents ([13 years) sustain more complex talar fractures and have a higher risk of longtime complications. Anatomic reduction and fixation is necessary to reduce the rate of those longtime complications.

Hemiepiphysiodesis to correct lower limb deformities— effect on mechanical axis and frontal knee joint line Nils Kudernatsch, Barbara Behnke, Jan Schagemann, Hagen Mittelsta¨dt, Martin Russlies Sektion fu¨r Orthopa¨die, Klinik fu¨r Chirurgie des Stu¨tz- und Bewegungsapparates, Universita¨tsklinikum Schleswig-Holstein, Campus Lu¨beck, Ratzeburger Allee 160, 23538 Lu¨beck, Germany Rationale: Guided growth by hemiepiphysiodesis using eight-plates is an established procedure for the alignment of posttraumatic or

Abstract idiopathic lower limb angular deformities. Literature proofs this technique to be safe and effective in order to correct the mechanical leg axis and knee joint orientation angles (mLDFA/mMPTA). However, reliable data on the effect of singular hemiepiphysiodesis (distal femoral or proximal tibial) compared to combined femorotibial procedures on knee joint line orientation or joint parallelism to the floor is sparse. In case of valgus or varus deformities, mechanical knee joint angles are altered. However, this does not necessarily apply to the frontal joint line. According to Pailey et al., frontal joint line declines approximately 2° medially corresponding to mLDFA of 88° and mMPTA of 87°. This setup can be altered by means of hemiepiphysiodesis and should be undertaken at the site of highest angle deviation. Objective: The aim of the present study was to evaluate the outcome of this particular technique with respect to correction potential of both the mechanical axis and the frontal joint line of the knee. Methods: 42 patients were enrolled in the clinical trial (20 m/22 f, mean age at time of surgery: 12 years and 3 months, mean time until correction/implant removal: 9.7 months, range 3–29 months). Overall 80 primary or secondary angular deformities of lower extremities were treated using eight-plates (valgus n = 65, varus n = 15, unilateral valgus and contralateral varus deformity n = 4, single hemiepiphysiodesis (singleHEPD: distal femoral or proximal tibial) n = 57, combined hemiepiphysiodesis (combiHEPD: femoral and tibial) n = 23). Long led radiographs were used to measure mechanical axis, mLDFA and mMPTA prior to surgery and during follow-up. Regular clinical and radiological follow-up examination was documented until complete deformity correction in all cases. 38 patients had an additional follow-up beyond end of growth. Results: Compared to the pre-treatment angles, follow-up radiographs revealed an overall mean difference of the mechanical axis of 6.6° and 21.1 mm (MAD; 0.98° and 3.1 mm/month). The frontal joint line differed as follows: mLDFA 6.2° (0.84°/month), mMPTA 4.5° (0.55°/month). SingleHEPD led to a mean correction of the mechanical axis of 0.8°/month corresponding to mLDFA of 0.9°/ month and mMPTA of 0.44°/month. CombiHEPD led to a mean correction of the mechanical axis of 1.2°/month corresponding to mLDFA of 0.8°/month and mMPTA of 0.7°/month. mLDFA or mMPTA of the untreated corresponding part of the joint in the singleHEPD group changed 1.1° overall (0.1°/month). The latter observation corresponded to the extent of deformity correction. In cases of angular deformities [8°, the knee orientation angle of the untreated corresponding part of the joint changed 2.1° (overall mean), in cases of deformities B8° the knee orientation angle of the untreated corresponding part of the joint changed 0.7° (overall mean). Preoperative deviation of frontal joint line (CLF: angle between the frontal center line of knee joint and the floor = 0–2° corresponding to a physiological medial descent of 2°; lateral descending values are expressed as neg. values) was 3.6° (min. -4°/max. 10°, overall mean) in valgus, and 0.8° (min. -4°/max. 9°, overall mean) in varus deformities. At time of complete correction, mean CLF was 0.0° (min. -7°/max. 6°) in valgus, and 0.1° (min. -4°/max. 4°) in varus deformities. The mean change of CLF (deltaCLF) in valgus deformities was higher in singleHEPD (femoral EPD: 6.3°, range 1–15°; tibial EPD: 3.1°, range 1–10°) than in combiHEPD (2.8°, range 0–8°). Conclusion: Temporary hemiepiphysiodesis of the knee joint influences both the mechanical axis of the limb and the frontal knee joint line. However, the site of hemiepiphysiodesis is crucial. Compared to combiHEPD, singleHEPD seems to be associated with a higher risk of unphysiological change of the frontal joint. Therefore, a thorough examination both clinical and radiologically is indispensable. This allows for timely planning of hemiepiphysiodesis and implant removal, and avoids adverse effects on the untreated corresponding part of the joint.

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Less is more—reduction of intraoperative fluoroscopy time to minimize radiation exposure in children with forearm fractures Lindert, Judith; Duhnke, Jennifer; Wu¨nsch, Lutz Kinderchirurgie, Universita¨t Lu¨beck, Ratzeburger Alle 160, 23538 Lu¨beck, Germany Introduction: Orthopaedic surgery contributes significantly to the radiation exposure of children and staff. Forearm fractures are the most common fractures also in children. It is the responsibility of the operating surgeon to achieve the best possible surgical result with a minimum of radiation exposure. Our investigation aims to evaluate if a recommendation for intraoperative fluoroscopy could reduce radiation exposure in forearm fractures? Method: Literature review on the topic. Retrospective study of forearm fractures (distal and diaphyseal fractures) Group 1 operated in 2011,. Radiation exposure intervention and prospective analysis after 3 and 12 month (Group 2). The Radiation exposure intervention consisted: Information of the theater personnel and doctors, structured fluoroscopy protocol for K-wire fixation and intramedullary nailing, preoperative briefing, discussion of radiation data in a postoperative conference. Descriptive analysis with SPPS 11.5. Results: Out of the 159 fractures we have treated, 58 were distal forearm fractures with K-wire and 101 were diaphyseal fractures with intramedullary nailing. Median age for distal fractures was 11.2 years, 66.7 % were boys and 63.3 % of the time the left arm was affected. 80 % were operated by residents with a mean fluoroscopy time of 26.5 s before and 14.9 s after the intervention. Median age for diaphyseal forearm fractures was 9.3 years, 68.3 % were boys, 53.8 % of the time the left arm was affected. 63.5 % were operated by residents with a mean fluoroscopy time 55 s before and 40.5 s after the intervention. Logistic regression shows an independent correlation of the intervention and of the operation time on fluoroscopy time in diaphyseal fractures. Conclusion: Different fluoroscopy times reflect different complexity of the operation. Both, 3 and 12 month after the intervention we find a significant reduction in fluoroscopy time. Repeated radiation exposure interventions in all disciplines using intraoperative fluoroscopy will minimize radiation exposure for patients and staff.

Short and long term complications in non-operative treatment of femur fractures in the 2nd and 3rd year of life Judith Lindert1, Friederike Grauel2, Marion Rapp3, Christoph Gielok4, Martin Michael Kaiser5 1

Pediatric surgery, Universita¨tsklinikum Lu¨beck, Ratzeburger Alle 160, 23538 Lu¨beck, Germany, 2Pediatric surgery, Charite´ Berlin, Augustenburger Platz 1. 13353 Berlin, Germany, 3Pediatric surgery, Klinikum Kassel, Mo¨nchebergstraße 41-43, 34125 Kassel, Germany, 4 Pediatric surgery, Kinderchirurgie Dr. von Haunersches Kinderspital, Lindwurmstr. 4, 80337 Mu¨nchen, Germany, 5Pediatric surgery, Universita¨tsklinikum Lu¨beck, Ratzeburger Alle 160, 23538 Lu¨beck, Germany Background: Fractures of the femur contribute to 4 % of all long bone fractures in children. The guidelines of the German pediatric society recommend a non-operative treatment—with spica cast or

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412 skin traction—in the first 3 years of life. Despite this, in recent years more children have been treated operatively than before on. Reasons are a potential limb length difference as a complication in the nonoperative treatment and increasing use of ESIN-osteosynthesis. The aim of this study is to evaluate short and long term complications in the non-operative treatment of femur fractures in toddlers. Methods: Retrospective evaluation of the current treatment of femoral fractures in children in the 2nd and 3rd year of life. We analysed the children treated between 1/2004 and 12/2011 in four pediatric trauma clinics (Berlin Charite´, Hauner´sches Kinderkrankenhaus Mu¨nchen, Klinikum Kassel, University hospital Lu¨beck). Evaluation of the short and long term outcome according to non-operative treatment under consideration of patients and fractures characteristics. Results: 139 Patients with fractures of the femur were treated during the study period. 55 children had an initial operation (2nd year of life n = 11; 3rd year of life n = 44) and 84 were treated with a non-operative approach (2nd year of life n = 43; 3rd year of life n = 41). More than two third of the non-operatively treated fractures were spiral or oblique fractures. In more than half of the cases, the cause was a fall from\1 m. There were 5 pathologic fractures in the study group. 31 of the 84 children were treated with initial spica casting (2nd year of life n = 21; 3rd year of life n = 10), seven with a dorsal long leg cast (2nd year of life n = 2; 3rd year of life n = 5) and 46 were treated with initial skin traction. In the group with spica casting or long leg cast, there was an early treatment change in five of 31 cases. In the skin traction group occurred a treatment change in 23 of the 46 cases; in 17 cases a change to spica cast and in six cases to elastic stable intramedullary nailing was performed. In each of these groups treated with traction, three skin lesions were documented. In the first 6 months after fracture, three limb length differences (1–2 cm) and 13 axial deviations[10° were recorded. At follow-up more than 2 years after the fracture three limb length difference (1–1.5 cm) and two patients with axial deviation over 10° were documented. None of our patients had pain or a motion deficit in the follow up. Conclusion: In this study population, 60 % of the children were treated non-operatively in the 2nd and 3rd year of life. We found a low incidence of complications requiring treatment; however, there was a treatment change necessary in about one-fourth of the patients. We recorded more treatment changes in patients with initial skin traction. Initial axial deviations subsided with the physiologic remodeling. We found persistent leg length discrepancies in three cases in the follow up. Nevertheless, the primary treatment approach should be nonoperative and any operational procedure needs to be compared to the results of the non-operative treatment.

Femoral shaft fractures in young children Operative and non-operative treatment in clinical practise Marion Rapp1, Friederike Grauel2, Judith Lindert3, Christoph Gielok4, Martin M. Kaiser3, Peter Illing1 1

Klinik fu¨r Kinderchirurgie, Mo¨nchebergstr. 41-43, 34125 Kassel, Germany, 2Klinik fu¨r Kinderchirurgie, Augustenburger Platz 1, 13353 Berlin, Germany, 3Klinik fu¨r Kinderchirurgie, Ratzeburger Allee 160, 23538 Lu¨beck, Germany, 4Kinderchirurgische Klinik und Poliklinik, Lindwurmstrasse 4, 80337 Mu¨nchen, Germany Background: Femoral shaft fractures occur in around 4 % of all long-bone fractures in children, whereas several age-related treatment options exist. According to guidelines produced by the German Society of Paediatric Surgery, these fractures should be treated by

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Abstract elastic stable intramedullary nailing (ESIN) in children over 3 years of age because of earlier mobilisation, patients’ comfort and to avoid axial deviations or limb length differences. In contrast the American Academy of Orthopaedic Surgery recommends early spica casting or traction with delayed spica casting for children age 6 months–5 years. This study investigates operative and non operative treatment and there complications in femoral shaft fracture of young children. Methods: This study evaluates the day by day treatment of femoral shaft fractures in children aged 6–60 months in four major paediatric surgery trauma centres in Germany from 01/2004 to 12/2011 by chart review. We analyzed all patient related data, causes of fracture, fracture type, treatment method and post treatment complications. Results: We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from a fall of\1 or 3 m and most often ([40 %) a long spiral fracture occurred. Below the age of 1 year the children (n = 19) were treated by casting or traction. Between the age of 12–24 months (n = 56) different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months operative and non-operative treatment were equally distributed. In children older than 36 months (n = 64) nearly all fractures were treated by ESIN; six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or combination of methods. 42 changes of treatment were necessary: traction to spica casting or secondary operative treatment and 21 complications (nails left to long, skin defects or wound infections) occurred. Conclusions: Children younger than 3 years of age can still be treated non-operative, because there is no evidence that the complication rate of operative treatment is lower than for non-operative treatment. In children older than 3 years of age elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures. Very few of these older children profit by spica casting, traction or external fixation. Overall our results show the practicability of the guidelines of the German Society of Paediatric Surgery.

Pathologic fractures caused by juvenile or aneurysmal bone cysts—Comparison of different treatment concepts focused on humeral and femoral bone cysts Marion Rapp1, Friederike Grauel2, Tilmann Ru¨ckauer3, Lucas M. Wessel3, Martin M. Kaiser4 1 Klinik fu¨r Kinderchirurgie, Mo¨nchebergstr. 41-43, 34125 Kassel, Germany, 2Klinik fu¨r Kinderchirurgie, Augustenburger Platz 1, 13353 Berlin, Germany, 3Klinik fu¨r Kinderchirurgie, Theodor-Kutzer-Ufer 1, 68167 Mannheim, Germany, 4Klinik fu¨r Kinderchirurgie, Ratzeburger Allee 160, 23538 Lu¨beck, Germany

Introduction: A treatment concept for acute pathologic fractures caused by juvenile or aneurysmal bone cysts (JBC/ABC) should be a single approach with high success and low complication rate and fast recovery. This study evaluates how current treatment concepts fulfil these aims. Methods: Children below 15 years of age with an acute humeral and femoral pathologic fracture caused by a JBC or ABC were interrogated by chart review in four major paediatric trauma centres between 1.1.2001 and 31.12.2010. Next to age and gender fracture localisation, X-ray findings and treatment concept as well as treatment outcome— assessed by the classification of Capanna—were analysed. Results: 70 children [49 male, 21 female; mean age: 9 years (4–14 years)] were included. Bone cysts were juvenile in 48 and aneurysmal in 21 cases, ten cysts could not be classified definitively. More than half of all humeral bone cysts were treated non-operative, but only six of 34 reached nearly or complete resolution of the cyst

Abstract (Capanna I/II); 24 got further treatment. In 13 cases the first treatment consisted of elastic stable intramedullary nailing and included up to three nail exchanges, only six of these reached Capanna grade I or II. Also in 2nd or 3rd treatment cycle, nailing alone was not successful in humeral bone cysts (39 Capanna II, 19 III, 59 IV). This was consistent to the unsatisfying results in femoral fractures with K-wire-, plate osteosynthesis or nailing only if no curettage was done or if only cortisone was applied. Instillation of cortisone was also not successful in five out of five cases of humeral bone cysts. Combined treatment with curettage, elastic stable intramedullary nailing, (artificial) bone substitute and in some cases growth factors was performed in 1st line treatment in ten patients with humeral bone cysts and further in 2nd or 3rd line treatment in 13 humeral cysts (129 Capanna I, 69 II, 19 III, 49 IV). This combination therapy lead also to three complete resolutions and three nearly complete resolutions in femoral bone cysts. Complications occurred in humeral bone cysts with impossible implant removal in six patients and in femoral bone cysts with exchange of nails, redo-surgery because of nails left to long, refracture or limb length differences of more than 1.5 cm. Conclusion: Success in non-operative treatment, elastic stable intramedullary nailing alone or use of cortisone is very low in treating acute pathologic fractures caused by humeral and femoral bone cysts. The guideline of the German Society of Peadiatric Surgery recommends a combined mechanical and biological treatment with curettage, elastic stable intramedullary nailing, (artificial) bone substitute and suggested use of growth factors. Our results support a combined therapy with the importance of the cysts’ curettage; the best bone substitution and growth factors has to be evaluated in randomised controlled trials.

Treatment of femoral shaft fracture in older children with a body weight of more than 49 kg—Multicentre chart review of the scientific working group of the Sektion Kindertraumatologie der DGU Marion Rapp Klinik fu¨r Kinderchirurgie, Mo¨nchebergstr. 41-43, 34125 Kassel, Germany, on behalf of the scientific working group of the Sektion Kindertraumatologie der DGU in association with the German Society of Paediatric Surgery Background: The treatment of femoral shaft fractures in heavier children and adolescents is known to be associated with a high complication rate in most operative treatment concepts. This multicentre study investigates the day by day treatment and its complication in older children and adolescents with a body weight of more than 49 kg. Methods: 18 clinics took part in the interrogation. Included were all children between 10 and 17 years of age with a femoral fracture and a body weight of more than 49 kg [01/2008–12/2012]. Analysed were all short and long term complications in relation to age and body weight as well as to the treatment concept. Children with diseases of bone metabolism or pathological fractures were excluded. Results: 53 children with 54 femoral shaft fractures fulfilled the inclusion criteria [boy to girl = 2–1; mean age: 13 ‘ years; mean body weight: 60 kg (50–95 kg)]; 11 children suffered a polytrauma. In most cases the shaft fracture was located in the middle part of the diaphysis [AO-PCCF: 239 32-D/4.1, 79 32-D4.2, 89 32-D5.1, 169 32-D5.2; LiLa: 319 3.2.s.3.2., 239 3.2.s.4.2.]. 13 fractures were treated with elastic stable intramedullary nailing (ESIN) without any modifications, in these four times the treatment concept had to be changed and twice nails had to be shortened after ‘‘telescoping’’ of the fracture. In three children treated with additional end caps no

413 complications occurred; in only one of eleven children with a third nail ESIN-osteosynthesis a treatment change to an external fixation was necessary. Five children received combined therapies. Eleven times external fixation was used as primary treatment and treatment modality had to be changed in ten cases; those children suffered up to four redosurgeries. Plate osteosynthesis in five children lead to two refractures and one deep wound infection. No complications occurred as an expert adolescent lateral femur nail (ALFN) was used in primary care in two cases, but as a second line treatment (n = 3) one pseudarthrosis and one deep infection was documented. In seven patients with (nearly) closed physis an adult nail was used as primary or secondary treatment. Overall patients with short term complications and more than one redo-surgery suffered more limb length differences or limitations in range of movements. Conclusions: Until now no optimal treatment concept for femoral shaft fractures in older and heavier children exists. The implantation of a 3rd nail in elastic stable intramedullary nailing seems to reduce the high complication rate of in these heavier children. Even the ALFN can not afford a complication free therapy which might be partially a result of a ‘‘learning curve’’.

Retrograde percutaneous nailing of proximal tibia shaft fractures in adolescents Stephan Rohleder, Martin Schwind, Salmai Turial Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany Purpose: Treatment of proximal tibial fractures in children and adolescents presents a particular challenge. Common used osteosynthesis procedures for proximal tibia shaft fractures have great risk to provide insufficient rotational and torsion stiffness for older or heavier children. We investigated the use of a retrograde implanted Retron Nail (Tantum, Neumuenster, Germany) in a sawbone and cadaver model for proximal tibia shaft fractures. Methods: In an AO 41/42.A2 fracture model of 5 left small sawbones with proximal tibia fracture and in 2 cadaver tibia a Retron Nail was retrograde inserted. Dynamic and static locking of the nail was tested in relationship to the proximal tibia growth plate and tuberositas tibiae. Results: Using the aiming device the 8 mm Retron Nail and the locking screws could be placed in the proximal tibia metaphysis without interfering with the tibia growth plate or tuberositas tibiae. Tibial entry was in median 9.4 cm (min 8.9 cm, max 11.6 cm) distal of the proximal tibia growth plate. The fracture was located 8.8 cm (min 7.8 cm, max 10.5 cm) from the superior articular surface of the tibia. Conclusions: The Retron Nail was safely placed in proximal tibia fractures in the bone and cadaver model in regard of the proximal tibia growth plate and tuberositas tibiae. Therefore rotational and torsion stiffness of this osteosynthesis for the treatment of proximal tibia fractures and should be further investigated. Keywords: Adolescent, pediatric, proximal tibia fracture, intramedullary nailing, tibia nailing

Extra-articular transitional fractures of the distal tibia Thomas Ruffing, Markus Muhm, Hartmut Winkler Department of Trauma and Orthopaedic Surgery, Westpfalz-Klinikum Kaiserslautern, Germany Subject: The approximately 18-months lasting physiological closure of the distal tibia physis occurs in girls between the age of 12 and

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414 14 years, in boys 1 year later. During this time, transitional fractures like two or triplane fractures may occur. Reports about extra-articular transitional fractures are rare. Methods: Two cases of extra-articular transitional fractures of the distal tibia are reported. After computed tomography (CT) surgical treatment was performed. Results: In the follow-up, physiological range of motion was observed in both cases. Bone healing was anatomical according to axes and joint surface. Conclusion: Extra-articular transitional fractures of the distal tibia are rare. Considering the physiological closure of the distal tibia physis, these kind of fractures can be explained easily. In order to improve the planning of the therapy CT imaging should be performed.

Radiographs of the ankle joint in injured children and adolescents—analysis of the predominantly mandated radiograph in emergency department Thomas Ruffing, Markus Muhm, Hartmut Winkler Department of Trauma and Orthopaedic Surgery, Westpfalz-Klinikum Kaiserslautern, Germany Background: The key for appropriate treatment of injured children and adolescents in the emergency department (ED) is an adequate interpretation of radiographs. Radiographs of the ankle joint are predominantly mandated. For the purposes of structuring education and training, the frequency of conventional radiographs of the ankle joint obtained in the ED should be analyzed. Materials and Methods: Retrospectively, over a period of 18 months, 1,125 radiographs of the ankle joint of acutely injured underaged patients were analyzed according to their age and sex as well as according to their proportion of the entire X-ray images (10,232). Results: Both the number of the radiographs of the ankle joint as well as their proportion of the entire X-ray images of injured children and adolescents increased with age. Conclusion: Due to the permanent presence of traumatologic issues according to the ankle joint in children and adolescents in the ED, radiographs of these particular body region should be adequately taken into account in medical education and training. Based on different age-dependent radiographs, knowledge of the second decade of life should be imparted primarily.

Pathological fracture of the femoral neck after septic coxitis as complication of Lemierre’s syndrom—case report—issue, Lemierre’s syndrom, the ‘‘forgotten’’ disease—no problem in times of widespread use of antibiotics and university-level high performance medicine? Dominik Vogt1, Ludger Tu¨shaus2, Martin Russlies1, Martin Kaiser2 1 Universita¨tsklinikum Schleswig-Holstein, Klinik fu¨r Chirurgie des Stu¨tz- und Bewegungsapparates, Sektion fu¨r Orthopa¨die, Ratzeburger Allee 160, 23538 Lu¨beck, Deutschland, Germany, 2Universita¨tsklinikum Schleswig-Holstein, Klinik fu¨r Kinderchirurgie, Ratzeburger Allee 160, 23538 Lu¨beck, Deutschland, Germany

Method: Case report. Results: Lemierre’s syndrom is defined by a usually unilateral thrombophlebitis of the internal jugular vein following an acute

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Abstract oropharyngeal infection and often complicated by consecutive bacteraemia with septic metastasis in different organs, which is generally caused by Fusobacterium necrophorum. Most frequently lungs and joints are affected. We portray the case of a 16 years old girl who initially presented with characteristic symptoms of Lemierre’s syndrome with involvement of her right hip in a reduced but stable general condition. Despite a rapid diagnosis and an immediately initiated, interdisciplinary coordinated, conservative as well as surgical therapy a full-blown sepsis, which resulted in almost 2 months of intensive care, developed within a short time. While the primary focus and the coxitis could be successfully controlled, a progressive avascular necrosis of the right proximal femur developed subsequently which finally led over a course of several months to a pathological fracture of the femoral neck. After excluding the persistence of a bacterial coxitis the fracture was treated by a total hip replacement. Conclusion: Although Lemierre’s syndrome has become rare, the diagnosis must be confirmed rapidly and an adequate, preferably interdisciplinary coordinated therapy of the commonly young and previously healthy patient has to be initiated immediately because the course of disease is quite often fulminant. Considering these requirements a complete recovery can mostly be achieved. In this case, however, a progressive destruction of the hip followed by total hip replacement could not be avoided.

Factors influencing the outcome and survival in a polytraumatized pediatric patient population— experience at a Level 1 Trauma Center M. Winnisch, M. Michel, T. Tiefenbo¨ck, J. Jo¨stl, M. Hofbauer, T. Heinz, S. Hajdu Department of Trauma Surgery, Medical University of Vienna, Wa¨hringer Gu¨rtel 18-20, 1090 Wien, Austria Introduction: Pediatric polytrauma patients pose a major challenge to most orthopaedic trauma surgeons since multiple injured children constitute a non-routine, unique management situation. Pediatric polytrauma is very rare and physiological and anatomic differences distinguish the pediatric patient population from adults. The aim of this study was to evaluate potential risk factors influencing the mortality and outcome in a cohort of pediatric polytrauma patients. Methods: All pediatric polytrauma patients (age\16 years), admitted to the Department of Trauma Surgery at the Medical University of Vienna, an urban Level I trauma center, from January 1992 to December 2013 were included in this study. Polytrauma was defined as injuries of two or more body cavities (injury to the head, chest, abdomen, pelvic and spine with neurological symptoms) or one body cavity and fractures of at least two long bones with an accumulated Injury Severity Score (ISS) C16. We obtained information concerning demographic data (age and sex), mechanism of injury (MOI), injury severity scale (ISS), Glasgow Coma Scale (GCS), hemodynamic parameters and pupillary response on ED admission, location of major injury (LOMI), as well as outcome variables including mortality and cause of death. Results: A total of 100 patients met the inclusion criterias and were included in this study. There were 64 males and 36 females with a mean age of 9.5 years (range 6 months–16 years). The most common injury mechanism was a motor vehicle accident in 50 cases, followed by a fall from height (41 cases) and others (9 cases). The mean GCS score at admission was 7.2 ± 5.4, the mean ISS score was 32.7 ± 16.1. 73 patients sustained a traumatic brain injury (mean AIS 3.85), 78 patients a chest trauma (mean AIS 3.36), 43 patients an abdominal trauma (mean AIS 3.36), 70 patients injuries to the extremities (mean AIS 2.53). A total

Abstract of 28 patients died with an mean ISS of 41.5; 12 (43 %) patients died during treatment in the emergency room and 16 (67 %) patients died at the intensive care unit between two and 7 days. Conclusion: Although pediatric polytrauma is rare, the morbidity and mortality rate high. Careful attention to possible injuries, expeditious treatment of life threatening conditions and consideration of the anatomical and physiological differences of children are tremendous tools to achieve initial survival and the best clinical outcome.

Traffic accidents in children and adolescents Causes— Injuries—Outcome Saschah Zaheri Department for pediatric surgery, Klinikum Klagenfurt am Wo¨rthersee, Carinthia, Austria We conducted a retrospective study in our own patients (n = 259, age 0–18 years, relation male/female 142: 117, time: 2009 until may 2013). Inclusion criteria were participating in a traffic accident, treatment at a hospital ward, age under 18. We sorted the data in accident groups (pedestrians, bike accidents, small motorbikes accidents, car accidents, train accidents) and in the different kind of injuries (bruise/ distortion/ excoriation, wounds, fractures, brain concussion, traumatic brain injuries, bodily injuries, polytrauma). So it was found out that the most deaths and injuries were caused by falls with small motorbikes (28 %), car accidents (25 %), accidents with small motorbikes (19 %), pedestrians (14 %), bike accidents (13 %) and train accidents (1 %). Referring to our data, polytrauma was caused in almost the same relation by car accidents (n = 3), bike accidents (n = 3) , accidents with small motorbikes (n = 3), pedestrians (n = 1) and in train accidents (n = 1). Bodily injuries were mostly caused in accidents with small motorbikes (43 %), bike accidents (29 %), car accidents (21 %) and in train accidents (7 %). Traumatic brain injuries were mostly caused in pedestrians involved in an accident (34 %), accidents with small motorbikes (33 %), car accidents (22 %) and in bike accidents (11 %). Fractures were mostly caused in accidents with small motorbikes (55 %), car accidents (27 %), pedestrians involved in an accident (10 %), bike accidents (7 %) and in train accidents (1 %). The cause of death in those who died were subarachnoidal bleeding in a bike accident, massive atlanto- occipital dislocation in a small motorbike accident and in two times a burst fracture of the head with massive traumatic brain injuries in pedestrians. The conclusion: Due to the fast and high-quality pre-clinical emergency treatment, the interdisciplinary work in a right- equipped hospital, survival and outcome for the young patients are rather satisfying. But there are still almost no possibilities for those who suffer severe traumatic brain injury.

415 battered child syndrome as a possible cause. Further investigations are indicated if lesions occur in typical locations and if the caretaker’s explanations regarding the cause of the injury do not seem plausible. Case: A mother presented her 3-month-old son after noticing a swelling at the right anterior tibia which had been growing rapidly. The child was transferred to our pediatric surgical outpatient clinic. Ultrasound and X-ray of the right leg showed a pronounced callous formation throughout the whole tibial diaphysis. No history of trauma was reported. Results: The child was admitted to our pediatric surgery unit with suspected battered child syndrome. The patient history showed an uneventful pregnancy and a non-traumatic though prolonged spontaneous delivery at 38 week gestation. The infant’s further development had been normal. The child had received routine examinations and vaccinations according to schedule. On presentation, the child showed a good general and nutritional status and no apparent injuries. The parents were cooperative. Further investigations were performed according to our childwelfare-protocol. X-ray analyses showed multiple callous-like lesions at different locations in addition to the right tibia: at the femural and radial diaphysis bilaterally and at the mandible. These results supported our suspicion of battered child syndrome. A cerebral MRI-scan showed no evidence of recent or past bleeding. Fundoscopic examination as well as blood and urine tests were inconspicuous. The unusual mandibular findings were discussed among pediatric surgery, radiology and orthopedics. A specific mandibular X-ray examination was performed, which showed bilateral lamellated periosteal reactions with a 3 mm diameter. As these are typical findings in Caffey disease, the child was transferred to a specialized pediatric orthopedic hospital. Conclusion: Caffey disease (infantile cortical hyperostosis) is a disease entity which has first been described in 1945. Children typically present in early infancy, rarely after the 5th month of age, showing sudden painful soft tissue swelling, erythema and fever. On X-ray, specific periosteal reactions are seen, most commonly located at the mandible, clavicle, and ulna. In most of the cases the symptoms will regress within a few weeks to months, healing spontaneously. Due to the self-limited character of this disease the treatment is symptomatic (pain relief). In specific cases it is recommended to apply high-dose immunoglobulins or corticosteroids. In cases of pediatric fractures of unknown or implausible origin it is necessary to rule out the possibility of battered child syndrome. However, parents should not be prejudged and other, though rare, possible causes of bone injury should be considered.

FlexTackTM and LockTackTM – New implants for correction of angular deformities of the knee and leg length discrepancies by temporary epiphysiodesis B. Vogt1, H. Tretow1, B. Schuhknecht1, M. Horter1, F. Schiedel1, R. Roedl1

At what time should bone lesions be interpreted as a sign of battered child syndrome?

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Children’s Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Geba¨ude A1, 48149 Mu¨nster, Germany

K. Langanke1, W. Novak2, G. Pa¨rtan3, A. Rokitansky1 1

Department of Pediatric Surgery, Donauspital, Vienna, Austria, 2 Department of Pediatrics, Donauspital, Vienna, Austria, 3Department of Radiology, Donauspital, Vienna, Austria Introduction: In case of unclear fractures in children, especially during infancy, medical personnel is trained to always consider

Introduction: Epiphysiodesis (ED) is the first line treatment for coronal angular deformities of the knee (ADK) and moderate leg length discrepancies (LLD) in growing children. Modern implants like the eight-PlateTM solved many problems that were observed using staples for temporary ED. Rather than creating rigid compression forces on the growth plate (GP) like staples, the eight-PlateTM causes a flexible tension band effect for guided growth. The im- and

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explantation of the plate with its two non-locking cannulated screws is more simple and implant-associated complications are less frequent compared to staples. Aim of the study: However, there are still certain problems with the eight-PlateTM. Hardware failures are observed in excessive corrections like in cases with Blount disease or greater LLD. The rebound phenomenon remains unpredictable. The main issue, however, concerns the correction of LLD. The shift of the fulcrum for correction outside the GP (extraphyseal)—a decisive advantage when correcting ADK—can cause significant central deformation of the femoral and particularly tibial joint line when using medial and lateral plates in LLD. Development of iatrogenic ADK in the coronal and especially sagittal plane (recurvation) in correction of LLD is also a remarkable problem. Methods and Results: In consequence of these persistent problems concerning the eight-PlateTM our group developed new implants for temporary ED. The devices consist of anatomically preformed staples with cannulated branches ensuring the simple and precise implantation technique of the eight-PlateTM. The 13? trapezoid shaped design properly fits to the anatomic proportions of the medial and lateral part of each, the distal femur and the proximal tibia in different ages. However, two different constructions were engineered to meet the divergent requirements for correction of ADK and LLD. Staples with flexible ridge (FlexTackTM) are used for correction of ADK to constitute the tension band effect at the edge of the GP by analogy with the eight-PlateTM. To ensure a complete and evenly distributed arrest of the entire GP and therefore to prevent complications concerning iatrogenic ADK and joint line deformation, staples with rigid ridge are implanted (LockTackTM) (Fig. 1). Discussion and Conclusion: The preliminary results of our first 32 consecutive patients confirm these expectations (Fig. 2). This development is a reasonable synopsis of staples and simply handled canullated screw/plate devices that offers the appropriate biomechanical effect for both, correction of ADK and equation of LDD. Figures Please contact the author Keywords: Epiphysiodesis, guided growth, leg length discrepancy, angular deformity of the knee, FlexTack, LockTack, children

mean age 9.7 y) including mainly OI (25 rods in 13 pat.) and other conditions (3 rods in 2 pat.) with generally diminished bone quality and Gr. B (m = 2, f = 3; mean age 7.0 y) including mainly CTP in NF I (4 rods in 4 pat.) and tibial osteofibrous dysplasia Campanacci (OFD) (1 rod in 1 pat.) with locally affected bone quality. Indications for surgery in Gr. A were acute fracture stabilization (10/28) and deformity correction (18/28). In Group B FD-rodding was performed subsequent to segmental resection and TSF-controlled distraction osteogenesis. Intraoperative complications were recorded. At followup the healing progress of the fracture, osteotomy, or pseudarthrosis site and implant associated problems like rod migration, lack of telescoping and soft tissue irritation were assessed. Results: An uneventful postoperative course was observed in 18 / 28 rods in Gr. A and in 3 / 5 rods in Gr. B. Delayed or non-unions were detected in 4 / 28 rods in Gr. A and in 2 / 5 rods in Gr. B. Implant associated problems were found in 9 / 28 rods only in Gr. A and comprised of 7 rod migrations concerning the female component in 2 rods and the male component in 5 rods, and also of proximal soft tissue irritation in 2 humeral rods (Fig. 1). Revision surgery was required in 5 / 28 rods in Gr. A and in 1 / 5 rods in Gr. B. In all cases a stable consolidation of the CTP site was achieved (Fig. 2). No infections or neurovascular damages occurred in the entire series. Discussion: Our results and complication rates are in agreement with literature reports [1, 2]. The technique of using FD-rods is demanding and associated with some intra- and postoperative pitfalls. Ex situ cutting of the male component is advised particularly in humeral rods to avoid soft tissue irritation. To obtain longitudinal stability the (optional) interlocking of the male component is considered indispensable. However, the missing rotational stability of the FD-rod may lead to hypertrophic pseudarthrosis. Therefore, our group is working on a solution for a telescopic nail that provides antirotational stability. References 1 Birke et al., 2011 2 Ruck et al., 2011 Figures Please contact the author Keywords: Fassier Duval, rodding, telescopic nail, osteogenesis imperfecta, congential tibial pseudarthrosis

Outcomes using the Fassier-Duval Telescopic Rod in Osteogenesis Imperfecta (OI) and Congential Tibial Pseudarthrosis (CTP)

Dislocation of radial head: Etiology and possible therapeutic options on the basis of three cases J. Wirmer1, S. David1, K. Rothe1

B. Vogt1, H. Tretow1, N. Broeking1, M. Horter1, F. Schiedel1, R. Roedl1

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Charite´ Campus Virchow-Klinikum, Klinik und Poliklinik fu¨r Kinderchirurgie Augustenburger Platz 1, 13353 Berlin, Germany

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Children’s Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Geba¨ude A1, 48149 Mu¨nster, Germany Introduction: The benefits of intramedullary rodding for long-bone fractures, pseudarthroses or deformities in children with conditions of diminished bone quality, such as OI or CTP is well known. The Fassier-Duval telescopic nail (FD-rod) offers the advantage of a single entry point over the traditional telescopic rods. Only two groups (including the originators of the technique) published their early results in the literature as yet [1, 2]. Patients and Methods: A chart and x-ray review of 20 patients (pat.) (m = 10, f = 10; mean age 9.2 y) with 33 consecutive FD-rod insertions (femoral: 12 rods in 10 pat., tibial: 16 rods in 12 pat., humeral: 4 rods in 3 pat., radial: 1 rod in 1 pat.) with a minimum of 1-year follow up (1–3 y) was performed. Dependent on the underlying diagnoses the patients were divided into Group (Gr.) A (m = 8, f = 7;

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Introduction: Although referred to as one of the most frequent malformations of the elbow, the congenital dislocation of the radial head remains rare with an incidence of 0,06 to 0,16 %. Most cases are associated with congenital radiolunar synostosis, however, isolated forms do occur. Since, in most cases, symptoms occur in adolescence, the differentiation of the latter from missed Monteggia-fractures can be difficult. In the following, we demonstrate three cases of patients with radial head luxation and discuss therapeutic options. Results: Patient 1 fell on his right elbow at the age of ten. Until then, no limits of function had been noticed. Initially, the patient was pain free. In the following, a constraint in pronation was noticed. The x-ray showed a luxation of the radial head, in the mri a rupture of the ligamentum anulare radii was suspected. Even after numerous operations, the clinical situation had not improved. The family is intending to sue.

Abstract Patient 2 had a both sided, congenital dislocation of the radial head. An operative treatment of the right side was performed at the age of 11 years. In the following, he developed an ulnar impaction syndrome with need for reoperation. At last, the clinical result did not show an improvement compared to the other side. In Patient 3, a dislocation of the radial head was diagnosed after he had fallen on his elbow at the age of ten, which was judged as a coincidental finding. Under conservative treatment, the patient is currently completely pain free. Conclusion: The three cases demonstrate the pitfalls and problems of the dislocation of the radial head: As shown in case 1 and 3, the

417 diagnosis in chronological context with an injury can complicate the differentiation of traumatic from congenital dislocation, with consequences for the following therapeutic strategy. Even when there is clarity about the etiology, a surgical therapy is not necessarily efficient, as shown in case 2 and 3. So far, there is no predominant treatment concerning the functional outcome. Critical assessment and detailed information of patients and the parents about the limitations of the procedure is absolutely essential.

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