European Journal of Trauma and Emergency Surgery

Eur J Trauma Emerg Surg 2009 DOI 10.1007/s00068-009-2001-x Published Online: June 1, 2009xxxx, 2009

Abstracts 28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU) June 19–20, 2009 Mannheim, Germany

Scientific Chair Prof. Dr. med. Lucas Wessel Department of Pediatric Surgery Prof. Dr. med. Hans-Peter Scharf Center of Orthopedic and Trauma Surgery Mannheim Prof. Dr. med. Udo Obertacke Center of Orthopedic and Trauma Surgery University Medical Center Mannheim Medical Faculty Mannheim Heidelberg University Theodor-Kutzer-Ufer 1–3 68167 Mannheim Germany

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

Abstracts

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

Abstracts

Content No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

25.

Chance Fracture – A Rare Injury in Pediatric Patients? U. Subotic, S. Holland-Cunz, M. Bardenheuer, L. Wessel Fractures of Thoracic and Lumbar Spine in Children and Adolescents – Experiences in 86 Cases. R. Kraus, J.-P. Stahl, R. Schnettler Instrumentation versus Conservative Treatment of Craniocervical Region and Upper Cervical Spine Injuries in Pediatric Patients. A. Ro¨hrig Injuries in the Region of the Occipito-cervical Junction in Children. J. Harms Case Report of a Combined Injury of Spine and Abdomen: A Child in a Interdisciplinary Conflict? T. Meyer, E. Schroepfer, B. Ho¨cht Thoracic SCIWORA after Sport Injury with Complete Recovery. I. Rohard, P. Kunkel, D.W. Sommerfeldt Treatment of Atlanto-axial Rotatory Subluxation in a Three-year-old Boy. S.C. Kunze, C. Thome´, K. Schmieder The Treatment of Pediatric Spine Deformities with the VEPTR (Vertical Expandable Prosthetic Titanium Rib) Method. A.K. Hell, J.J. Grannemann DET – Telescope Screw Ostheosynthesis in Cause Fibrous Dysplasia Proximal Femur, Prohylactic Concept in Pathologic Fracture Risk. U. Bu¨hligen The Nutcracker Fracture in Children – Indication for Fixed-angle Platting? T. Ruffing, M. Muhm, H. Winkler Elastic Stable Intramedullary Nailing (ESIN) for Forearm Fractures in Children. M. Glass, P. Philippe, J. Kieffer Fracture Treatment in Children and Adolescents – Are Locked Implants Worthwhile? B. Bohn, R. Werbeck, A. Schulz, C. Ju¨rgens Diagnosis and Development of Posttraumatic Rotational Deformity after Supracondylar Fractures in Children. A.K. Hell, C. Rudolph, J.J. Grannemann Elastic Stable Intramedullary Nailing of Spiral Fractures of the Femoral Diaphysis Synthetical Bones: Biomechanical Measurements of Different Fixation Techniques. M. Kaiser, G. Zachert, A. Zens, L.M. Wessel Crush Injuries of the Pelvis in Children – Management and Outcome. A. Ga¨nsslen, T. Hu¨fnerr, C. Krettek Fractures of the Acetabulum in Childhood. H. Schmal, P. Strohm, O. Hauschild, J. von Heyden, N. Su¨dkamp Complex Pelvic Fracture in Association with a Severe Degloving Injury in a Polytrauma of an 11-year-old Girl – A Case Report. W. Korsch, S. Krischak, O. Segitz, R. Holz, E. Mayr Case Reports of Severe Pelvic Injuries in Children. B. Bohn, U. Hu¨bner, A. Schulz, S. Fuchs, C. Ju¨rgens Common MRI Findings after Acute Inversion Ankle Injury in Children. D. Endele, F. Mauch, G. Bauer Triplane Fracture of the Distal Fibula. T. Ruffing, M. Muhm, H. Winkler High-tech or Minimal Work – Which Diagnostic Work Does the Sprain Trauma of the Upper Ankle Need? T. Scheltz, W. Barthlen Different Therapeutical Approaches in Physeal Injuries to the Lower Extremity. R. Kraus, C. Ro¨der, G. Perner, M. Kaiser, D. Schneidmu¨ller, W. Linhart Deformation of Radius after Metaphysial Fracture of the Left Forearm after/because of Change of Treatment. T. Bielefeld Posttraumatic Torticollis in an Elementary-school-age Children: Fracture, Congenital Anomaly or Ageappropriate Radiological Findings of the Atlas. M. Burkhardt, P. Fries, P. Garcia, J. Heinzmann, T. Pohlemann, A. Pizanis Hypertrophic Pseudoarthrosis in a Pediatric Patient Associated with Metallosis after Multiple Failed Osteosyntheses. I. Beshir

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

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No. 26. 27. 28. 29. 30. 31. 32. 33. 34.

Late Diagnosis of a Chance Fracture Caused by a Typical Mechanism of Accident. S. Zoller, S. Altermatt, S. Dierauer, U. Subotic Fractures of the Proximal Tibia in Children – A Retrospective Study. C. Illian, B. Veigel, A. Scholz, H.-R. Kortmann Preserved Extremity in a Case of Long-distance Tibia Necrosis and Major Loss of Soft-tissue During a Mission in Afghanistan. S. Hentsch, E. Kollig, M. Johann, A. Franke Complicated Course after Complex Distal Lower Leg Fracture in Adolescence Evaluation and Follow-up. T. Vogel, M. Baumann, K. Weise, J. Rether, F. Stuby ESIN Failure after Treatment of Forearm Fractures in Children – Failure Evaluation and Treatment Options. T. Vogel, M. Baumann, K. Weise, J. Rether, F. Stuby Treatment of a Septic Pseudarthrosis of a Fractured Congenital Tibia Vara and Fibula Aplasia Using a Taylor Spatial Frame. M. Tinelli Dislocation of the Elbow in Children. G. Frongia, P. Gu¨nther, M. Keßler, S. Holland-Cunz A Superficial Bite with Consequence. J. Do¨rges, A. Schultens Degenerative Disc Disease in Adolescents from the Neurosurgical Perpesctive. K. Schmieder

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

1 Chance Fracture – A Rare Injury in Pediatric Patients? U. Subotic1, S. Holland-Cunz2, M. Bardenheuer3, L. Wessel4 1 Inselspital, Kinderchirurgie, Bern, Switzerland 2 Universita¨t, Kinderchirurgie, Heidelberg, Germany 3 Klinikum, Unfallchirurgie und Orthopa¨die, Landshut, Germany 4 Universita¨t, Kinderchirurgie, Lu¨beck, Germany We report on a 9-year-old girl who was involved in a car accident. She suffered severe polytrauma with torn abdominal muscles, rupture of the mesenteric arteries, bowel and bladder, hematoma at the right colonic flexure and disruption of the intervertebral ligaments L2/L3, including the intervertebral disc, typical of Chance fracture. The abdominal bleeding was stopped, the bowel resected and the fracture fixed with an internal fixation. The patient developed a postoperative enterocutaneous fistula in the right flank and paraplegia. She underwent three laparotomies with ileostomy and closure of the fistula. Two years later, she has normal bowel movement, the wounds are closed, the internal fixation has been removed, she is able to walk with crutches and suffers from a mild bladder dysfunction. Chance fracture is a typical fracture in adults involved in motor vehicle accidents. In the last 10 years, there have only been four case reports describing this fracture in children under the age of 10. All of these individuals were involved in a car accident and fixed with a lap belt. With the increasing use of lap belts, this fracture has to be considered even in young children. Mild clinical symptoms can be associated with severe intra-abdominal injuries.

2 Fractures of Thoracic and Lumbar Spine in Children and Adolescents – Experiences in 86 Cases R. Kraus1, J.-P. Stahl2, R. Schnettler1 1 Universita¨tsklinikum Gießen, Unfallchirurgie, Gießen, Germany 2 Klinikum Dortmund, Unfallchirurgie, Dortmund, Germany Introduction: In literature fractures of the thoracic and lumbar spine make 0.1–1.8% of all fractures in childhood and adolescence. Whereas injuries of the cervical spine are typical for newborn and infants, the number of thoraco-lumbar fractures increases with age. Material and Methods: From 2005 to 2008 data from all patients younger than 16 years with fractures of the thoracic and lumbar spine where collected and worked out prospectively. All of the patients could be followed up for at least 3 months, maximum 32 months. Results: 86 patients where treated, thereof 61.5% female and 38.5% male aged 2–15 years (average: 11.9 years). Only 21.2% where younger than 10 years. Focusses of injuries where found in the middle thoracic spine (Th 5–8, 47.1%) und in the thoraco-lumbar region (Th 11-L1, 41.2%). In 1/3 of the patients there was more than a single vertebral fracture. The number of fractures per patient increased with the number of diagnostic tools (MRI). Sports injuries where responsible fort he vertebral injuries in 53.8% (horse riding, trampoline, apparatus gymnastics), traffic accidents in 28.2%, but the last led to more than 77% of indications for surgical treatment. 89% of the operated patients were older than 10 years (average 14.4 years). The indication for surgical treatment was made in 22% for neurological deficits (all thoracic) and in 78% for vertebral instability (more than 90% thoraco-lumbar). All cases treated conservatively reached their former level of daily activity and sports within 3 months. In 2 patients with primary

Abstracts

paraplegia, neurological deficits recovered uncompletely, despite emergency stabilization and decompression. Discussion: Sportive activities are the main reason for vertebral fractures, as for extremity fractures, too, in children and adolescents. The increasing involvement in traffic, matched with the increasing risk willingness in adolescence leads to most of the unstable fractures of the thoraco-lumbar spine region, which need operative stabilization. Multi-vertebral fractures of often detected, when MRI scans are used, but almost never lead to a change of therapeutic regime.

3 Instrumentation versus Conservative Treatment of Craniocervical Region and Upper Cervical Spine Injuries in Pediatric Patients A. Ro¨hrig1 Asklepios Kinderklinik, Neurochirurgie, Sankt Augustin, Germany

1

Patients who survived the lesion need early neurologic rehabilitation to reach a good restitution. The most important precondition for transfer to a rehabilitation unit is the possibility to fully mobilize the child. It is doubtful whether immobilization with halo jacket alone will lead to sufficient long term stability. Therefore early occipital cervical fusion is recommended if neurological outcome is expected to be fair at least. Probably it is not necessary to remove the instrumentation. There are no data showing a benefit of removing of the implants. The spinal canal is wide in age of four years and will not be narrowed by pedicle screws. Some Patients may be managed successfully with orthotic immobilization alone. Long term X-ray follow up is indicated, particulary in cases with conservative treatment. Secondary instability must be detected early in adjacent segments following instrumentation.

4 Injuries in the Region of the Occipito-cervical Junction in Children J. Harms1 SRH Klinikum Karlsbad-Langensteinbach, Wirbelsa¨ulenchirurgie, Karlsbad, Germany 1

Injuries of the cervical spine in children are infrequent, even more infrequently found are injuries in the occipito-cervical junction. When these injuries occur in small children, diagnostics is difficult due to the fact that ossification is not yet been completed. Also, it is difficult is to define the ligamentary injuries. In addition to the bone and soft tissue diagnostics, thorough diagnostics of the vertebral artery is required as it is frequently affected as well in such injuries. The diagnostics and therapy of such injuries in the region of the upper cervical spine in children and infants is demonstrated.

5 Case Report of a Combined Injury of Spine and Abdomen: A Child in a Interdisciplinary Conflict? T. Meyer, E. Schroepfer, B. Ho¨cht1 1 Chirurgische Universita¨tsklinik, Abt. fu¨r Kinderchirurgie, Wu¨rzburg, Germany Traumatic injuries of the lumbar spine are very rare in childhood and differ in pathomorphology, healing process and prognosis from those

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

of adults. We report on an eight year old boy, who had a traffic accident and suffered from a flexion-distraction-injury of the lumbar L2/3 segment. After initial stabilisation, a monosegmental fixateur interne was positioned. The initial diagnosis showed 80 ml free abdominal fluid (FAF) without any signs of injury of the parenchyma of liver, spleen or mesenterium. Fortunately, there was no increase of FAF visible in further sonographies. Therefore the abdomen was treated conservative. Six days after trauma, the boy developed symptoms of an ileus. MRI showed a mesenteric trauma with dilatation of the proximal loops of the small bowel. Intraoperatively two defects of the mesenterium were found, which lead to a segmental injury of the upper jejunum. A partial resection of the small bowel with following jejuno-jejunostomy was performed. Further progress of the spine and the abdomen was free of complications. This case showed that injuries of the spine are a result of strong force and are often associated with serve thoracic and abdominal injuries. This kind of injuries must be treated together by trauma - and pediatric surgeons.

6 Thoracic SCIWORA after Sport Injury with Complete Recovery I. Rohard1, P. Kunkel2, D.W. Sommerfeldt3 1 Altonaer Kinderkrankenhaus/UKE, Kinderchirurgie, Hamburg, Germany 2 Altonaer Kinderkrankenhaus/UKE, Kinderneurochirurgie, Hamburg, Germany 3 Altonaer Kinderkrankenhaus/UKE, Kindertraumatologie, Hamburg, Germany Background: SCIWORA is an acronym for ‘‘Spinal Cord Injury Without Radiographic Abnormality’’ firstly defined by Pang and Wilberger in 1982. This pathology is based on traumatic myelopathy without overt vertebral column disruption as displayed by spine x-rays or computer tomographic scans (CT). It mainly affects infants and children during accidental trauma or after sport injury with a predisposition of the cervical spine. In few cases where SCIWORA was found in the thoracic spine, the underlying mechanism was severe trauma as it might occur during motor vehicle accidents. We present a very rare case of a boy with presentation of SCIWORA of the thoracic vertebra after being kicked in the back. Case report: A soccer colleague had kicked a 13-year-old boy in the right lower thoracic back. Initially the boy suffered from pain of the lower thoracic spine and developed dyspnoea. One day later he was admitted to our emergency room with symptoms of incomplete paraplegia like paraparesis and hypaesthesia of the lower extremities as well as retention of urine. Physical examination revealed hypalgesia from dermatomes nine to ten downwards as well as absent knee jerk and triceps surae tendon reflexes. Pyramidal signs were not detectable. Spine radiographs were without pathologic findings. The following spine MRI revealed neither fractures nor myelon compression or oedema in sagittal, T1and T2-sequences. However, a reduction of somatosensory evoked potentials (SSEP) of N. tibitalis reflected an irritation of the funiculus dorsalis, thus leading to the diagnosis SCIWORA. During a 2-week stay on the peripheral ward persistent neurogenic bladder dysfunction required application of a suprapubic catheter. Apart from this, the boy’s overall condition improved steadily: Loss of sensibility and muscular power declined and he could be transferred to rehabilitation for physiotherapy. Another 2 weeks later, bladder function was restored making urine catheter needless and the

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

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boy regained his ability to walk on his own again. He could be discharged in good clinical condition with only a mild residual coordination deficit after major physical exertion. Discussion: SCIWORA, representing a spinal cord injury in the absence of bony radiographic abnormalities, is a pathology typically seen in paediatric populations. Its incidence varies from 19% to 34% of paediatric spinal cord injuries and is mostly found in the cervical vertebra. The high prevalence is likely attributable to the fact, that the inherent elastic spine, especially in the upper region, can compensate and accommodate to intersegment displacement without fracture or ligamentous rupture, whereas the underlying spinal cord is not able to withstand significant stretch without injury. However, the final pathophysiologic mechanism has not yet been elucidated completely. The number of thoracic lesions is much smaller than the one of cervical lesions, but often they are much more severe. This vulnerability may be related to the distribution of exiting nerve roots and dentate ligaments. High-energy trauma, like motor vehicle accidents, is the typical cause, often accompanied by extra neural injuries such as visceral rupture, cerebral contusion and limb fractures. In our case, a blunt thoracic trauma leads to a spinal contusion with incomplete, sensomotoric paraplegia for four weeks. Diagnostic tools like x-ray and MRI were inconclusive, except SSEP. In cervical SCIWORA a 3-month immobilization and activity restriction is proposed. We, in contrasted performed an early physiotherapeutic training to remobilise the boy, resulting in a quick and good convalescence without major residues.

7 Treatment of Atlanto-axial Rotatory Subluxation in a Three-year-old Boy S.C. Kunze, C. Thome´, K. Schmieder1 1 Universita¨tsklinikum Mannheim, Klinik fu¨r Neurochirurgie, Mannheim, Germany Introduction: Atlanto-axial rotatory subluxation in infants is a rare condition. Possible strategies of treatment range from strictly conservative approaches to surgical posterior fusion depending on the age of the affected child. Case report: A 3-year-old boy had fallen out of a bed. He was taken to the emergency room with his neck in fixed 90-rotation to the left. The boy showed no neurologic deficits, but was unable to turn back his neck into a neutral position. Cervical spine radiography was suspicious for atlanto-axial rotatory subluxation. A computed tomography (CT) scan confirmed a rotatory subluxation of C1 on C2 to the right. No fracture was identified. Immediately following the CT scan, skull traction was applied, which allowed clinical reduction of the subluxation. Magnetic resonance tomography (MRT) performed after clinical reduction showed no residual subluxation, but injury to the atlanto-axial joint capsule. The alar and transverse ligaments appeared intact, however, as did the vertebral arteries. Due to the injury to the capsule, the atlanto-axial rotatory subluxation was classified unstable and the neck was immobilized in a rigid collar for four weeks. Discussion: Treatment options for atlanto-axial rotatory subluxation comprise rigid neck collar, halo skull traction and posterior fusion. Especially in infants posterior fusion should be avoided. Up to seventy percent of all complications of treatment are caused by halo scull traction. Pang and coworkers prospectively studied the different types of rotatory subluxation, available treatment options and their respective outcomes. Main causes of atlanto-axial rotatory sublux-

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

ations were trauma, nasopharygeal infections or antecedent head and neck surgery. The C1 to C2 angle was measured by CT and a threegrade classification was made. Following successful reduction all patients were treated with a rigid neck collar for 3 months. The first recurrences were treated with repeat traction and a rigid neck collar. Second recurrences were treated with the halo device for 3 months. Third recurrences, and recurrence while in halo or after completion of halo immobilization, were treated with posterior C1/C2 fusion. Immediate treatment of acute cases showed that almost none of these patients required halo immobilization or posterior fusion during their course. Our case showed a correct atlanto-axial position following reduction and was treated with a rigid neck collar according to the recommendations of Pang et al. Follow-up examinations will reveal whether repeat reduction or halo immobilization will be required. Summary: Treatment of atlanto-axial rotatory subluxations in infants should be individually tailored depending on clinical and radiological findings. Early immobilization using a rigid neck collar is the treatment of choice, while halo immobilization or posterior fusion should be avoided.

8 The Treatment of Pediatric Spine Deformities with the VEPTR (Vertical Expandable Prosthetic Titanium Rib) Method A.K. Hell, J.J. Grannemann1 1 Universita¨t Go¨ttingen, Kinderorthopa¨die, Go¨ttingen, Germany The vertical expandable prosthetic titanium rib (VEPTR) implantation is primarily used for young children with congenital scoliosis. The longitudinal rib implant enlarges the thorax and straightens the spine thus restoring thoracic volume, symmetry and stability. Despite these classical indications an increasing number of patients with other spinal deformities (neuromuscular or traumatic) are treated with this method. 53 children and adolescents with various diagnosis (congenital scoliosis, cerebral palsy, spinal muscular atrophy, trisomie 18, posttraumatic, myelomeningocele etc.) were treated with expansion thoracoplasty and VEPTR implantation. Expansions were carried out every six months. Advantages and disadvantations as well as complications of these method are discussed. Lung-, thorax- and spinal growth as well as a comparatively low number of complications are be big advantages of this new method.

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Specific sites such as a fibrous dysplasia neck of the leg make useful prophylactic implants. To use a telescope screw (DET) to the bone the necessary stability and development of the epiphysis of the head of femur not disrupted. Appropriate case report describe the therapeutic approach.

10 The Nutcracker Fracture in Children – Indication for Fixed-angle Platting? T. Ruffing, M. Muhm, H. Winkler1 1 Westpfalz-Klinikum, Klinik fu¨r Unfall- und Wiederherstellungschirurgie, Kaiserslautern, Germany This is a report of a 9-year-old girl, who suffered an impression fracture of the cuboid falling off a tree. The CT-scan revealed an impaction of the calcaneus-sided articular surface of the cuboid, which was the indication for operative treatment. Considering operative treatment in adults, we used a fixed-angle plate for internal fixation after open reduction. In literature there is little reporting of cuboid fractures in children so far. This kind of fracture can be considered as a preliminary stage of a luxation in the mid tarsal (chopart’s) joint. The incidence of the injury of the chopart’s joint is 0.02–0.9%. Forced abduction of the mid- or forefoot causes compression of the cuboid. Due to the rigid ligamentary fixation the cuboid is cracked like a nut in a nutcracker. This mechanism led to the term nutcracker fracture. Considering the 2-column model of the foot, impaction of the cuboid results in a contraction of the lateral column. Untreated cuboid fractures lead to severe foot deformity with a pes plano-valgus. Therefore surgical treatment with anatomical reduction is necessary. The rarity of this injury in children results in a lack of standardized procedures. If severe impaction is present, bone grafting is recommended. Usually transarticular K-wires are used for reduction and transfixation of the calcaneocuboid joint or the two lateral metatarsal bones. Disadvantages are the affection of the cartilage and possible loss of the anatomical reduction of the cuboid. Using fixed-angle plates these risk are negligible and bone grafting is not obligatory necessary. Due to the ongoing growth in children the plate has to be removed.

11 Elastic Stable Intramedullary Nailing (ESIN) for Forearm Fractures in Children

9 DET- Telescope Screw Ostheosynthesis in Cause Fibrous Dysplasia Proximal Femur, Prohylactic Concept in Pathologic Fracture Risk

M. Glass, P. Philippe, J. Kieffer1 1 Centre Hospitalier de Luxembourg, Kannerklinik Kinderchirurgie, Luxembourg, Luxembourg

U. Bu¨hligen1 1 Klinik und PK fu¨r Kinderchirurgie, Kinderchirurgie, Leipzig, Germany

Introduction: Diaphyseal forearm fractures, radial neck fractures and Monteggia lesions were usually treated by closed reduction and an above elbow cast. Due to fracture instability and unacceptable angular deformity many of them require osteosynthesis. ESIN with steel or titanium nails represents an option for these cases. Material and Methods: The data of a consecutive series of 124 children treated for diaphyseal forearm fractures, radial neck fractures or Monteggia lesions with ESIN between January 1998 and December 2008 have been reviewed retrospectively. Initially we used titanium nails, switched later to stainless steel nails because of their higher stability. Results: There were 68 boys and 56 girls with a mean age 9.6 (3.3– 14.7) respectively 8.8 (1.3–14.5) years. Average duration of surgery

Pathological fractures are differentiated problems for patients and doctors. For one requires the localization of structural changes in the bone costly procedures, on the other hand, recurrent fractures significant burden for the patient. So there are many different causes, so different are the therapeutic possibilities. The most common pathologic fractures found in connection with juvenile bone cysts. Differential diagnosis of osteogenesis imperfecta, fibrous dysplasia, osteoporosis, metabolic disorders of calcium/phosphorus system with osteomalacia, and tumor metastases, immobilisation be considered.

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

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was 42 (15–140) minutes and mean postoperative hospital stay was 1.2 (1–7) days. An open reduction before osteosynthesis was necessary in 8 children. In the 14 children with a grade I and 1 with a grade II open fracture (Gustillo) no osteomyelitis occurred. The mean time until radiological union was 7 (4–21) weeks. The nails were removed after an average of 5 (1–24) months. At the time of nail extraction the range of motion was normal in all cases. The complication rate was 11% (14 cases). Five children had pin perforation with 3 of them having concomitant local pin site infection, 2 had a lesion of the superficial sensitive branch of the radial nerve (all resolved secondary to nerve repair), 1 had a lesion of the median nerve being trapped at the radial fracture site (nerve repair resulting in motor recovery), 2 had a luxation of the distal ulna respectively proximal radius requiring a second procedure, 1 had a delayed union and 1 an ulnar non-union after 7 months, 1 fell again on his arm four weeks after the surgery with a 90 angulation of the fracture site and the hardware and in one case the extraction of the radial nail was impossible. Conclusion: This results show that the intramedullary fixation of displaced diaphyseal forearm fractures, radial neck fractures and Monteggia lesions in children is a safe, minimally invasive surgical technique with an acceptable complication rate and excellent functional results.

humerus were followed clinically and sonographically. At the first follow-up (average 1.43 years after the accident) all children presented with rotational deformity (average 15). One year later half of these children showed some correction which was more pronounced if the accident had happened lately and if rotational deformity was significant. Internal rotational deformity greater than 20 and external deformity showed an average of 6 correction whereas internal rotation below 20 only showed 3 of derotation. We were able to show, for the first time to our knowledge, that derotation of the humerus takes place after posttraumatic rotational deformity.

12 Fracture Treatment in Children and Adolescents – Are Locked Implants Worthwhile?

Introduction: Intramedullary stabilization of femoral fractures in children has a lower risk of refracture compared to external fixation, allows access through smaller incisions and the risk of femoral head necrosis can be avoided. Therefore increasingly more diaphyseal femoral fractures have been treated with ESIN within the last 10 years, first in Europe, afterwards also in North America. Nowadays ESIN fixation is used for older, as well as an increasing number of younger children (Huber et al. 1996; Flynn et al. 2001; Naranayan et al. 2004). Indications for this good-natured (Slongo 2005) excellent, reliable and ,,elegant method (Ligier et al. 1985) are both, proximal and distal diaphyseal fractures, for the central area transverse fractures as well as diagonal or spiral fractures (Ligier et al. 1985; Slongo 2005). Furthermore surgical manuals (Metaizeau 1988; Dietz et al. 1997) account fractures with a bend wedge or rotatory wedge suitable, if setting and anchorage are good. In contrast to these findings are worse results in specific error analyses, with up to 50% complications (Flynn et al. 2001; Luhmann et al. 2003; Flynn & Schwend 2004; Narayanan et al. 2004; Sink et al. 2005; Lascombes et al. 2006). In children with a weight > 49 kg the chance for complications was 5 times bigger than in children with a lower weight (Moroz et al. 2006), HO et al. (2006) found significantly higher complication rates in children older than 10 years. Biomechanical investigations on this subject were published only seldom and deal with transverse fractures mostly (Gwyn et al. 2004; Mahar et al. 2004; Green et al. 2005; Mani et al. 2006). Objectives of Research/Question: Hence, with this study the following questions should be cleared: a) is it possible to develop a standardized biomechanical model to assess the technically complex care supply of long spiral fractures qualitatively? and b) produces the use of end caps or the implantation of an additional intramedullary nail better results? Material and Methods: We used Composit-synthetical bones (Sawbones, Sweden) because these are nearly identically to the human bone and were therefore already used in different investigations. The length of the bones amounted to 455 mm with a diameter of the marrow cavity of 10 mm (smaller models were not available). A series of long spiral fractures was sawed in the central area of the

B. Bohn1, R. Werbeck2, A. Schulz3, C. Ju¨rgens1 1 BG-Unfallkrankenhaus Hamburg, Unfall- und Wiederherstellungschirurgie, Hamburg, Germany 2 Katholisches Kinderkrankenhaus Wilhelmstift, Kinderchirurgie, Hamburg, Germany 3 Universita¨tsklinikum Schleswig-Holstein Campus Lu¨beck, Klinik fu¨r Chirurgie des Bewegungsapparates, Lu¨beck, Germany For highly unstable and comminuted fractures of the lower extremity in older children and adolescents, K-wire and ESIN osteosynthesis often are of limited value. Bridging the gap of stability, external fixation is sometimes of value in these cases. In other instances, the use of locked implants can be an alternative. We report the clinical use, the postoperative treatment and the results of locked implants in selected cases. In these patients, an early weight bearing, a secure bone healing and a free range of motion could be achieved.

13 Diagnosis and Development of Posttraumatic Rotational Deformity after Supracondylar Fractures in Children A.K. Hell, C. Rudolph, J.J. Grannemann1 1 Universita¨t Go¨ttingen, Kinderorthopa¨die, Go¨ttingen, Germany After supracondylar fractures of the humerus in children the role of rotational deformity remains controversial. Some authors see it as a cause of the cosmetically disturbing cubitus varus whereas others think that fracture instability and consecutively medial tilting results in a varus deformity. We present a simple sonographic method for measurement of humeral torsion. In a longitudinal prospective study 22 children with surgically treated supracondylar fractures of the

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

14 Elastic Stable Intramedullary Nailing of Spiral Fractures of the Femoral Diaphysis Synthetical Bones: Biomechanical Measurements of Different Fixation Techniques M. Kaiser1, G. Zachert2, A. Zens1, L.M. Wessel3 1 Universita¨tsklinikum, Klinik fu¨r Kinderchirurgie, Lu¨beck, Germany 2 Universita¨tsklinikum, Labor fu¨r Biomechanik der Klinik fu¨r Chirurgie des Stu¨tz- und Bewegungsapparates, Lu¨beck, Germany 3 Universita¨tsmedizin, Kinderchirurgische Klinik, Mannheim, Germany

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

diaphysis. The length of the spiral was 90 mm and therefore 3.3 times longer than the diameter in this area. 2 ESIN (company Santech, titanium) with a size of 3.5 mm, analogue to 70% of the marrow cavity, were used in all experiments. Every ESIN was prebent with a stencil in an identical pattern: a convexity of 40 was manufactured, the ends of the nails were prebent at an angle of 30. Variation 1: Both ESIN were introduced in 2-C configuration from the distal end of the synthetical bone, in a manner that one crossing of the ESIN is located distal and the other one is located proximal of the spiral fracture. The peaks of both ESIN ended on the same level in the area of the greater trochanter. Variation 2: In addition to the technique mentioned above, End Caps (Synthes company) were attached to the distal ends of the ESIN. Variation 3: In addition to the technique of Variation 1, a third 2.5 mm ESIN was inserted anterolateral and pushed forward into the greater trochanter up to the level of the first two ESIN. The 8 bones of each variation were measured standardized afterwards: First with the axial compression the alignment in 0 was measured, then a) varus stress b) valgus stress c) recurvation stress and d) antecurvation stress, furthermore rotational bending stress in internal and lateral rotation was measured, finally compression in 9 position. Results: With the experimental setup all aimed measurements could be carried out easily. Three nails showed some effect to be more stable, no benefit could be shown with the combination of 2 ESIN with end caps. Summary and Prospect: In comparison to the 2-C configurations the results for the 3 ESIN showed some effect to be more stable. Using end caps did not enhance the measured stability. The model offers the opportunity to investigate osteosynthetical variations as well as new osteosynthetical techniques in this complex fracture type, before they are used in the infantile fractured femur.

15 Crush Injuries of the Pelvis in Children – Management and Outcome A. Ga¨nsslen, T. Hu¨fnerr, C. Krettek1 1 Medizinische Hochschule Hannover, Unfallchirurgische Klinik, Hannover, Germany Introduction: Unstable pelvic injuries in children are rare injuries with the presence of complex pelvic trauma with severe soft-tissue injuries in polytrauma situations in the majority of cases. The management of these injuries makes highest demands for the interdisciplinary primary and secondary management. Our experience on the basis of five patients who were treated during the last 10 years is reported. Material and Methods: Between 1997 and 2008 a total of 1078 patients with pelvic ring injuries were treated. 43 patients were children £ 14 years. From these 5 (11.6%) showed an unstable crush injury of the pelvis. These are analysed. Demographic data, accident data, concomitant injuries, radiological data, surgical data, type of primary management, secondary procedures and long-term consequences wee analysed. Results: Gender relation m:w was 2:3. The average age was 6.9 years (2–10 years). Accident cause was a crush injury as a pedestrian by car, truck or bus. Four children were transferred secondarily. The injury severity (ISS) was 22.2 points on average. Concomitant injuries were seen in four patients. Three patients showed a Morel Levalle´ injury of the pelvis-hip region, two patients had a rectum injury and two an urethral disruption, one patient suffered on bilateral femur fractures. Body trunk injuries were not observed. All patients showed

Abstracts

a type C injury of the pelvis, in three cases with accompanying injury of an acetabulum. The pelvic ring stabilisation was performed dorsoventral in three patients, two patients had stabilisation by external fixator. In addition, multiple extensive debridements were necessary in patients with Morel Levalle´ lesions. The pelvic ring fractures healed anatomically in four cases. A patient had been fixed primarily in false position dorsally. ICU treatment was necessary on average for 16 days (1–30 days). Mobilisation could be performed after 6 weeks on average. Acute complications appeared only in terms of superficial infections or wound healing problems. Long term problems were problems in the area of the hip joints in three patients. One patient developed a posttraumatic dysplasia with subluxation of the hip joint with still good mobility. One patient presented with an ankylotic hip joint hip dislocation and Pipkin fracture and one patient showed an epiphysiodesis after overlooked injury of the acetabulum. The clinical-functional results are shown. Conclusion: Crush injuries of the pelvis in children show a high challenge in management and therapy. Long term problems are functional restrictions due to extensive scar formation and soft-tissue problems, especially if injury to a hip joint was present.

16 Fractures of the Acetabulum in Childhood H. Schmal, P. Strohm, O. Hauschild, J. von Heyden, N. Su¨dkamp1 1 Universita¨tsklinik Freiburg, Orthopa¨die und Traumatologie, Freiburg, Germany Fractures of the acetabulum in childhood are rare injuries; therefore, experiences with treatment are limited. Aim of this study was a survey about epidemiology and treatment strategy of this injury including a comparison to adults. In a multicenter register study (AG Becken DGU), data of all patients who have been treated over different time periods since 1991 were included. Data of 3 periods (1991–93, 1998–00, 2004–08) were pooled and analyzed for incidence, epidemiology, injury severity, therapy and outcome of acetabulum fractures in infants. Out of 8437 patients 151 children with an age under 15 years (1.8%) were included in the study. In only 13 of these little patients a fracture of the acetabulum was diagnosed what correlates with a portion of 8.6% of all pelvic fractures in infants or 0.15% of all registered pelvic fractures. The average age of all children with fractures of the acetabulum reached 9.8 ± 2.9 years, the gender distribution showed a slight overbalance of boys with a portion of 55%. There were no significant differences in Tile’s classification in terms of A, B, or C type fractures between children and adults (p = 0.36). However, the subgroup distribution of children was significantly different from the adults. This was namely because of the lower portion of acetabular fractures (p < 0.0001). 11 of the 13 cases with fractures of the acetabulum were isolated; 2 times the fracture with accompanied by B-type pelvic fractures. The portion of multiple injured children was 36%; one child died because of a severe traumatic head injury in the emergency room, all other patients survived the injury. The average ISS reached 14.4, the average PTS 13.8 points. According to the classification of Judet and Letournel fractures of the dorsal column (4) and the dorsal wall (4) preponderated, composed fractures were not found. As generally seen in pelvic fractures, treatment strategy has been changed with a tendency towards more frequent operative care. During the time period between 1991 and 1993 no child received operative treatment, between 2004 and 2008 the portion of operated children reached 2/3, operations were indicated following an average dislocation of 5 mm. Correlating with fracture localiza-

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28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

tion and classification either a Kocher-Langenbeck approach or a percutaneous osteosynthesis were applied. Complications were not observed except a peroneal palsy in a conservatively treated child with femoral shaft fracture and hip dislocation. The long term prognosis is supposably determined by affection of the acetabular triradiate physeal cartilage, because premature closure of the epiphysis may lead to growth disturbances. Unfortunately, only case reports exist for judgment how specific acetabular fractures affect pelvic static. Fractures of acetabulum in childhood remain a rare injury with specific characteristics according to frequency and classification when compared to adults. Considering the treatment strategy a growing incidence of operations was observed, indications are based on experiences made in treatment of adults.

17 Complex Pelvic Fracture in Association with a Severe Degloving Injury in a Polytrauma of an 11-year-old Girl – A Case Report W. Korsch, S. Krischak, O. Segitz, R. Holz, E. Mayr1 1 Klinikum Augsburg, Klinik fu¨r Unfall-, Hand- und Wiederherstellungschirurgie, Augsburg, Germany Introduction: Due to the high elasticity of the pelvis in children, additional injuries have to be ruled out actively. In the acute situation degloving injuries are often underestimated or even missed and so severe complications can occur. Case Report: An 11-year-old girl on a bike was hit by a truck. The most impressive diagnostic findings in the emergency room were a complex pelvic fracture with retroperitoneal bleeding, a sub-trochanteric femoral fracture with a small skin contusion and a superficial vaginoperineal laceration. During the acute operative procedure with external fixation of the fractures and coiling of the bleeding the skin contusion turned out, as expected, to be a large subcutaneous degloving injury reaching from the ventro-lateral femur to the gluteal region (Morell-Lavalle´e-Lesion). This injury was mainly responsible for the following course of the therapy. In addition to the internal osteosynthesis, several operations were necessary to clear up all necrotic soft tissue. Thanks to strict vacuum therapy wound infection was avoided and the initial subcutaneous caverns were diminished. Ultimately, the remaining skin defects were covered by mesh graft. Discussion: On the basis of the present case, apart from the possible ostheosynthesis of a pelvic fracture in a child, a frequently missed or underestimated injury, the Morel-Lavalle´e-Lesion, is shown. Pathophysiologies as well as possible complications are demonstrated on the basis of the current literature. Conclusion: Degloving lesions represent an injury requiring a strictly therapeutic concept to avoid far- reaching complications.

18 Case Reports of Severe Pelvic Injuries in Children B. Bohn1, U. Hu¨bner2, A. Schulz3, S. Fuchs1, C. Ju¨rgens1 1 BG-Unfallkrankenhaus Hamburg, Unfall- und Wiederherstellungschirurgie, Hamburg, Germany 2 Katholisches Kinderkrankenhaus Wilhelmstift, Kinderchirurgie, Hamburg, Germany 3 Universita¨tsklinikum Schleswig-Holstein Campus Lu¨beck, Klinik fu¨r Chirurgie des Bewegungsapparates, Lu¨beck, Germany

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Abstracts

Pelvic injuries in children are rare and often heal without further disabilities. In complex cases, acute intraabdominal injuries with further complications or fatal bleeding are possible. Soft tissue trauma can sometimes be difficult to treat. Long term outcome of complex fracture patterns sometimes includes deformity of the pelvis and functional disability of the hip. Diagnostics and treatment algorithm of these injuries deem a multidisciplinary team approach necessary and should be included in the multiply-injured treatment plan. We report on the surgical treatment of such injuries in selected cases in children and adolescents and would like to see a multi-disciplinary discussion about the topic.

19 Common MRI Findings after Acute Inversion Ankle Injury in Children D. Endele, F. Mauch, G. Bauer1 1 Sportklinik Stuttgart, Stuttgart, Germany Purpose: Little is known about injury patterns of acute ankle sprains in children. This study was done to find out whether magnetic resonance imaging can reveal relevant patterns of injuries in acute ankle distorsions in children that are not detected by clinical, radiological and sonographical examination. Methods: In a prospective study we investigated 30 children with an acute inversion injury of the ankle. In addition to the conventional two plane radiologic examination a MRI of the ankle was done. Depending on the severity of clinical symptoms the children were divided into three groups. Children of Group I could walk, had only little soft tissue edema and no clinical instability. Children of Group II were not able to walk without pain, had moderate soft tissue edema and a discreet instability. Group III combined children who could not walk, had extensive soft tissue edema and considerable ankle instability. All children were treated conservative functional with the use of an ankle brace. Children of Group I had the brace for 6 weeks, Children of Group II for 8 weeks and children of Group III for 12 weeks. 12 weeks post trauma all children could be examined in a follow-up. Approximately 18 months post trauma all children of Group III were examined in a clinical and MRI follow-up. Results: Ligament lesions could be seen in 15/30 cases. Avulsion fractures were found in 10%. The avulsion fractures were not diagnosed in the radiologic examination. 4/30 patients showed a Salter I lesion. A bone marrow edema was found in 18/30 cases. Changes in bone marrow signal were most frequently located at the medial part of the talus. Children assigned to Group I didn’t show major lesions in the MRI. 50% of the children of Group II sustained a ligament lesion. In 3/12 cases a Salter I lesion could be seen. Patients of Group III showed in the MRI the most serious injuries. A talar bone marrow edema was seen in 8/8 (100%) cases, ligament lesions or avulsion fractures occurred in 8/8 (100%) cases. MRI diagnosis led in no case to a change of therapy. In the follow-up examination 12 weeks after the accident no differences in terms of pain, instability and movement restrictions were found in the different groups. At the time of abstract submission the control MRI of the 8 children of Group III has not been completed yet. Conclusion: Relevant patterns of injuries could be seen in the MRI. In particular patients of Group II showed despite mild clinical symptoms severe injuries. Although MRI did not lead to changes in therapy, in 3 cases an avulsion fracture was diagnosed in the MRI that was not seen in the radiologic examination. All patients of

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

Group III had considerable talar bone marrow edema. Whether the existence of bone marrow edema should lead to a modification of treatment regime the clinical and MRI control 18 months post trauma will show.

20 Triplane Fracture of the Distal Fibula T. Ruffing, M. Muhm, H. Winkler1 1 Westpfalz-Klinikum, Klinik fu¨r Unfall- und Wiederherstellungschirurgie, Kaiserslautern, Germany This is a case report of a 14-year-old girl with a triplane fracture of the distal fibula. The radiological examination after injury of the distal right lower leg revealed no fracture. Magnifying the anteroposterior X-ray of the right ankle a small flake was seen in the position of the joint space between the lateral wall of the talus and the distal fibula. The CT-scan revealed a transitional fracture of the distal fibula. The fracture showed displacement and was treated by open reduction and internal fixation. Intra-operatively the flake was part of the medial metaphysis and epiphysis of the distal fibula. Due to the closed growth plate of the medial distal fibula, the flake was not divided in an epiphyseal and metaphyseal part. In addition lateral of the fracture zone an epiphyseolysis was found. A 5 weeks period of external immobilization followed surgery. The follow-up 5 months after injury yielded an excellent clinical result. Triplane fractures are also seen in other locations than the growth plate of the distal tibia. Physiologic closure of the growth plate of the distal tibia occurs between the age of 12 and 14 years in girls and between the age of 15 and 18 years in boys. During this time a fracture may occur through the unfused portion of the physis, causing either a twoplane or a triplane fracture. Where as the twoplane fracture crosses only the articular surface, epiphysis and physis, the triplane fracture affects the metaphysis. Due to the occurrence close to the end of the growth period, the potential for growth deformity is negligible. During growth the undulated and extensive peripheral lapped formation of the distal fibula physis is the reason for the minimal incidence of physeal injury as well as the absence of displacement in this location. There has been no previous report of a transitional fracture of the distal fibula in literature so far.

21 High-tech or Minimal Work – Which Diagnostic Work Does the Sprain Trauma of the Upper Ankle Need? T. Scheltz, W. Barthlen1 1 Ernst-Moritz-Arndt Universita¨t, Klinik und Poliklinik fu¨r Kinderchirurgie, Greifswald, Germany Question: Has the primary abdication of image-guided therapies on a sprain trauma of the upper ankle a negative influence on the result of the therapy? Methods: Every year the hospital and polyclinic for paediatric surgery of the Ernst-Moritz-Arndt University in Greifswald looks after 2500 traumatized children from newborn up to 16 years. In the previous years an average of 13 children per month having a sprain trauma were applied to our paediatric surgery. The district covers about 100.000 inhabitants. Since the beginning of 2009 all children having had an distorsion accident of their ankle joint have been registered and treated by following a standard procedure. This procedure includes an accurate anamnesis, an initial, economical and

Abstracts

clinical examination as well as the consequent abdication of imageguided methods. Within our medical therapy we take care of the patients until the complete convalescence – including sport – only in our department of physiotherapy. The aim of our procedure is to reduce the unnecessary image-guided methods because of the negative influence of X-rays. In addition we don’t tolerate the loss of quality because of overlooked fractures. Results: After 6 weeks of testing there are no applicable experiences about a permanent success of our conception. Conclusions: The good results so far and the acceptance of our conception by children and parents legitimate our conception. After finishing the results will be provided other medical departments.

22 Different Therapeutical Approaches in Physeal Injuries to the Lower Extremity R. Kraus1, C. Ro¨der2, G. Perner2, M. Kaiser3, D. Schneidmu¨ller4, W. Linhart5 1 Universita¨tsklinikum Gießen, Unfallchirurgie, Gießen, Germany 2 Universita¨t, Institut fu¨r evaluative Forschung, Bern, Switzerland 3 Universita¨tsklinikum Lu¨beck, Kinderchirurgie, Lu¨beck, Germany 4 Universita¨tsklinikum Frankfurt, Unfallchirurgie, Frankfurt am Main, Germany 5 Universita¨tsklinikum Graz, Kinderorthopa¨die, Graz, Austria Introduction: Medical treatment of children and adolescents in german speaking countries traditionally is carried out by physicians of different origin. This also is fact in pediatric traumatology. Leading faculties on this field are pediatric and orthopedic and trauma surgery. Aim and content of this study, initiated by ‘‘Li-La-Licht und Lachen fu¨r kranke Kinder e.V.’’, was to proof differences in understanding and therapeutical concepts between different traumatological professions, using the example of physeal injuries (Salter I/II) to the lower extremity. Material and Methods: Overall 82 general, trauma, orthopedic and pediatric surgeons, working on the field of pediatric trauma in Germany, Austria and Switzerland where asked to fill up a eleven page questionnaire. In its general part, professional field, environment (hospital, ordination) and experience were evaluated. Furthermore frequency of physeal injuries of the lower extremity and their main complication of growth disorders in the own daily work was asked for. Finally the overall frequency of growth disturbances and their causes were to be estimated. Beneath that, 10 cases of physeal injuries to the lower extremities were presented to the participants. For every case degree of displacement, concept of treatment and individual risk for the development of a growth disturbance was asked for. The selection of fractures was made in correspondence with averaged epidemiologic data concerning age, localization and fracture morphology from current literature. Results: 46 questionnaires (rate of responders 56.1%) could be included (28· general/trauma surgery, 21· pediatric surgery, 8· orthopedic surgery (multiple answer possible)). Amongst non-pediatric surgeons the average amount of children and adolescents as a part of the total number of patients was about 16% (5–50%). Pediatric surgeons expected the risk of growth disturbances to be lower than the others did. Pediatric and Trauma surgeons as well named repeated reduction maneuvers to bet he most frequent cause for growth disorders. As further reasons the age of the patient (pediatric surgeons) and the mechanism of the accident (trauma surgeons) were mentioned. Trauma surgeons do not see open reduction maneuvers as a risk factor.

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28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

The analysis of the 10 case reports was done especially concerning different concepts of treatment performed by pediatric and trauma surgeons. Pediatric surgeons mentioned closed reduction with consecutive immobilization 2.2-fold more frequent than trauma surgeons, who 1.6 fold indicated reduction and osteosynthesis. In two cases osteosynthesis was indicated by trauma surgeons alone. Open reduction was mentioned by trauma surgeons 5-fold compared with pediatric surgeons. The risk to develop a growth disturbance was estimated higher by trauma surgeons in 7 of 10 cases. Both groups did not make a difference in patient age and primary degree of displacement as indicators for growth disturbances. Physeal injuries of the distal femur were addressed to be 1.4-fold more in danger than distal tibial injuries not depending on pediatric or trauma surgeons. Discussion: The results of the questionnaire allow the conclusion, that knowledge, education and experiences are similar in pediatric, trauma and orthopedic surgeons concerning physeal injuries of the lower extremities in children and adolescents. However the therapeutical concepts of trauma surgeons are more aggressive on average with more frequent indications for open reduction and osteosynthesis. They estimate the risk to develop growth disturbances higher than pediatric surgeons at the same time. At this time an extensive prospective multicenter study, including 300 physeal fractures Salter I/II of the lower extremities, investigates, weather these different approaches may lead to different results and different rates of posttraumatic growth disturbances.

23 Deformation of Radius after Metaphysial Fracture of the Left Forearm after/because of Change of Treatment T. Bielefeld1 St. Marienhospital, Kinderchirurgie, Bonn, Germany

1

Case Report: 8-year-old boy with dislocated metaphysial fracture of the left forearm. Open reduction und fixation with wire in the radius. Dorsal radial redislocation after remobilisation without cast and wire. Refracture in the radial diaphysis after six months. Closed reduction and descending nailing with ESIN. Removing of the nail after six months. Refracture radial diaphyseal after one month. Cast for the whole arm; ossification of the distal radial epipysis and of the medullary bone with development of a deviation in the diaphysis. Resection of the callus over the distal radial epiphysis. Open reduction diaphysis radius and fixation with a fixateur externe. After removing the fixateur the epiphysis stays open, but the diaphysis remains in a deviation volar. What can we do now?

24 Posttraumatic Torticollis in an Elementaryschool-age Children: Fracture, Congenital Anomaly or Age-appropriate Radiological Findings of the Atlas M. Burkhardt1, P. Fries2, P. Garcia1, J. Heinzmann1, T. Pohlemann1, A. Pizanis1 1 Universita¨tsklinikum des Saarlandes, Klinik fu¨r Unfall-, Hand- und Wiederherstellungschirurgie, Homburg/Saar, Germany 2 Universita¨tsklinikum des Saarlandes, Klinik fu¨r Diagnostische und Interventionelle Radiologie, Homburg/Saar, Germany

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Abstracts

Fortunately, cervical spine (c-spine) injuries are extremely rare in the paediatric population. At the same site, in children under 10 years with spine injuries, the c-spine is the most common site of injury. Here, especially injuries of the atlas and axis can be life-threatening. We describe a case of a 6-year-old schoolgirl with neck pain after falling onto her head at ground level. The girl first was admitted to a subregional hospital with a painful posttraumatic torticollis. After x-ray imaging of the c-spine under clinically difficult circumstances because of the rigid c-spine, a fracture of the dens axis was suspected. Therefore, the c-spine was immobilized in a rigid cervical collar and the girl was transferred to our Level I Trauma Center. After admission in our clinic, computed tomography (CT), magnetic resonance imaging (MRI) as well as a dynamic fluoroscopy of the c-spine were performed. CT of the c-spine showed no fracture of the dens axis but a disruption in the anterior and posterior arch of the atlas. The subsequently performed MRI then ruled out a fracture of the atlas without any signs of a bone edema or pathologies of the surrounding soft tissue. Additional, dynamic fluoroscopy did not reveal any instability of the upper c-spine. Therefore, the reason for the posttraumatic torticollis was prompted out to be a benign whiplash injury to the neck that was treated conservatively without immobilization of the c-spine. Normally, the two centers for the lateral masses of the atlas unite posteriorly by perichondral growth, giving rise to the posterior arch at 3–4 years of age. The anterior center for the anterior tubercle and anterior arch usually unite with the two lateral centers at 7–9 years of age. Accordingly, we assume a congenital non-union of the posterior arch on the one hand. On the other hand, the anterior arch either reflects a non-union too, or depicts an age-appropriate radiological finding in the growing child at 6 years of age. During the hospital stay, the torticollis disappeared under analgetic therapy and local thermal application. The girl was discharged on day two with complete recovery of the symptoms. In conclusion our findings underline the difficulties but also importance of careful evaluation of children with c-spine injuries. Besides discoligamental injuries and fractures of the paediatric c-spine one has to consider congenital anomalies and the immature anatomy of the cspine in children. Therefore, evaluation and therapy of potential spinal injuries in children should be performed in Trauma Centers with expertise and familiarity.

25 Hypertrophic Pseudoarthrosis in a Pediatric Patient Associated with Metallosis after Multiple Failed Osteosyntheses I. Beshir1 Altonaer Kinderkrankenhaus, Hamburg, Germany

1

Case Report: We describe a case of a boy with a tibial fracture and multiple failed osteosyntheses, finally resulting in a pseudoarthrosis. After several operations, including multiple plating efforts as well as intramedullary nailing, a pseudoarthrosis developed. The patient was presented with pains and swelling of the left tibia and inability to weight bear on this leg. The pseudoarthrosis was operatively removed in our institution followed by primary shortening and compression nailing in conjunction with application of Bone Morphogeneic Protein 7 (BMP-7, OP-1). The patient has now successfully undergone secondary lengthening by callus distraction using an ILIZAROV frame. Histopathological analysis of removed bone segment with pseudoarthrosis revealed severe intraosseous metallosis and periprosthetictype tissue reactions with no sign of infection. The possibility of

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

intraosseous metallosis should be considered in cases with multiple revisions and non-healing fractures. Conclusion: Correct indications for surgery are especially necessary in young patients as conservative treatment of the tibial fracture would most likely have resulted in uneventful healing.

26 Late Diagnosis of a Chance Fracture Caused by a Typical Mechanism of Accident S. Zoller, S. Altermatt, S. Dierauer, U. Subotic1 1 Universita¨tskinderspital Zu¨rich, Chirurgische Klinik, Zu¨rich, Switzerland Introduction: In 1948, G.Q. Chance was the first to describe a spine injury as a ,,horizontal splitting of the spine’’ with a fracture through the posterior spinous process, the pedicles and the anterior part of the vertebral body consecutive to a flexion trauma. These so called Chance factures occur in children in particular due to car accidents with fastened lap belts. Searching the literature we find within the last 10 years nine published case reports of children aged 4–15 years. In the University Children’s Hospital of Zurich there was one case of a Chance fracture within the last 10 years. Case Report: 11 2/12-aged boy who sustained a flexion trauma by a head-on collision with another car while sitting behind the driver and using a lap belt restraint. After the accident the boy complained about abdominal pain and backache. A tender abdomen and diffuse guarding were noted. Radiographic findings (X-ray of thoracic spine and CT- scan of the abdomen) showed a retroperitoneal haematoma and an injury of the pancreas without other noticeable problems. Initially the posttraumatic course proceeded uneventfully under conservative therapy. During mobilisation 4 weeks after the trauma an increasing pain in the area of the lumbar spine was noticed. Plain radiographic examination of the lumbar spine showed a Chance fracture of L1. In retrospect the fracture was already seen in the initial radiographic diagnostic. The fracture was treated over 6 weeks with a 3-point-brace. The result was a thoraco-lumbar kyphosis caused by a consecutive wedge-shape of the vertebra. So far the boy is free of complaints (follow-up of 3 years). Summary: This case report of a child using a lap belt restraint presents a typical mechanism of accident leading to a Chance fracture. Frequently they come along with intraabdominal injuries. Due to their severity often those abdominal lesions are ostensible und lead to a delay in diagnosis of the Chance fracture. In case of a characteristic mechanism of accident one must systematically search for a Chance fracture in order to minimize the risk of neurological and functional restraints by missed diagnosis.

27 Fractures of the Proximal Tibia in Children – A Retrospective Study C. Illian, B. Veigel, A. Scholz, H.-R. Kortmann1 1 BG Unfallklinik Duisburg, Unfallchirurgie, Duisburg, Germany Introduction: Although fractures of the lower leg are very common in children, proximal fractures are rare. They are most often caused by direct trauma. The international literature distinguishes three types of proximal tibia fractures, apophyseal, epiphyseal and metaphyseal fractures. Patients and Methods: We performed a retrospective study on 33 patients, 24 boys and 9 girls (average age of 12.7 years, range 4–16)

Abstracts

who suffered from a proximal tibia fracture and were treated in our hospital between January 2002 and June 2008. We operated on 26 patients, 7 were treated without surgery. The follow up period lasted between 6 and 72 months. We investigate the complication rate as well as the outcome of treatment. Results: Most patients suffered from an epiphyseal (n = 15) or an apophyseal fracture (n = 14). A few (n = 4) had a metaphyseal fracture. The following complications were found: Two operated epiphyseal fractures dislocated secondarily. One of them showed an arthrofibrosis postoperatively. 4 patients showed early closure of the epiphysis combined with minimal growth disturbance with a shortness of the leg. Posttraumatic varus- or valgus-deformities were not be found in our patients. Conclusion: In general proximal tibia fractures are usually treated operatively. The most common complications described in international literature could not be found in our patients. This may be due to the fact that anatomical reduction is necessary. Despite the good outcome in our patients the indication for treatment should be chosen critically to minimize iatrogenic failures.

28 Preserved Extremity in a Case of Long-distance Tibia Necrosis and Major Loss of Soft-tissue During a Mission in Afghanistan S. Hentsch, E. Kollig, M. Johann, A. Franke1 1 BWZK, Unfallchirurgie und Orthopa¨die, Koblenz, Germany Introduction: During foreign missions of the medical service of the German armed forces, humanitarian tasks are not directly envisaged. However, where capacity is available, this service is able to treat Afghan patients in co-operation with local medical facilities. The main focus is upon the traumatological-orthopaedic field, and approximately 30% of the patients are children. Case Description: A 9-year-old boy was suffering from hematogenic osteomyelitis of the tibia after trauma and several operations in local Afghan hospitals. He was sent to the Bundeswehr trauma centre (Kunduz, Afghanistan) for amputation. Hospital and Procedure: Initial clinical examination revealed a longdistance circular necrosis of the tibia diaphysis and a complete absence of ventral soft tissue. The case was discussed with the surgical experts in Germany by telemedicine, and it was decided that an attempt to protect the extremity be made. First, the complete debridement of bone and soft tissue and the resection of 12 cm tibia diaphysis were performed. After this only 5 cm of proximal and 7 cm of distal tibia meta- and epiphysis remained. A simplified vacuum-assisted closure was performed to achieve softtissue conditioning of the affected region. As the transfer of a free flap was not possible under these temporary conditions, and further treatment in Germany was not available, a mesh graft was subsequently used to cover the affected area. Stabilisation of the calf was achieved by using a frame installation combined with the external fixator usually used in field missions. After complete healing of the soft tissue, a distal transportation corticectomy was performed. Afterwards the frame external fixator was reconstructed with sterile screw thread rod of the repair unit into an extemporised transport external fixator. After completion of segment transport, proximal docking surgery with osteosynthesis was performed with attachment of autologous spongiosa and soft-tissue cover by a regional gastrocnemius flap.

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28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

Results: After 15 months the treatment was ended, following the completion of the healing process that resulted in a completely resilient extremity without loss of length. Conclusion: This case report gives an example that under the temporary and difficult conditions of field missions the protection of an extremity in a child can be achieved by an improvised procedure applying traumatological and plastic-surgical expertise and telemedicine.

29 Complicated Course after Complex Distal Lower Leg Fracture in Adolescence Evaluation and Follow-up T. Vogel, M. Baumann, K. Weise, J. Rether, F. Stuby1 1 Berufsgenossenschaftliche Unfallklinik Tu¨bingen, Klinik fu¨r Unfallund Wiederherstellungschirurgie der Eberhardt-Karls-Universita¨t, Tu¨bingen, Germany Two-plane and triplane fractures of the distal tibia are not very common. Missed diagnosis or wrong interpretations are often seen. Demonstrating the case of a 16-year-old boy we want to show that the triplane fracture of the distal tibia especially because of a metaphyseal spiral fracture with accompanying distal fibula fracture was missed although a epiphyseal involvement of the tibia was identified during surgery and a traction screw was implanted. After revision and correct osteosynthesis of the fracture the course was furthermore complicated. The presentation of this case and the discussion of its course should clarify whether by correct classification of the fracture the course would have been positively influenced. Whether or not the initial radiologic diagnostics were sufficient will also be discussed and it has to be clarified whether a CT-scan should be requested in cases with uncertain fracture morphology.

30 ESIN Failure after Treatment of Forearm Fractures in Children – Failure Evaluation and Treatment Options T. Vogel, M. Baumann, K. Weise, J. Rether, F. Stuby1 1 Berufsgenossenschaftliche Unfallklinik Tu¨bingen, Klinik fu¨r Unfall- und Wiederherstellungschirurgie der Eberhardt-KarlsUniversita¨t, Tu¨bingen, Germany ESIN treatment of forearm fractures in children is a generally accepted and widely spread osteosynthetic treatment with only little complication. Demonstrating an ESIN treated distal forearm fracture and a ESIN treated forearm shaft fracture we want to show that using a wrong indication or technique may lead to problems that require revision surgery. Especially the case with the secondary displaced forearm shaft fracture was unusual because of an irritation of the medianus nerve. We do demonstrate the possibilities of revision surgery and osteosynthesis using a k-wire in the first case and a plate osteosynthesis in the second case and present the radiological and clinical outcome.

31 Treatment of a Septic Pseudarthrosis of a Fractured Congenital Tibia Vara and Fibula Aplasia Using a Taylor Spatial Frame 1

M. Tinelli 1 BG-Unfallklinik Ludwigshafen, Unfallchirurgie und Orthopa¨die, Ludwigshafen, Germany

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL

Abstracts

We describe the case of a 1996 born girl with a fracture of a congenital tibia vara and aplasia of the fibula that developed a septic pseudarthrosis. After almost 5 years treatment, multiple operations in several hospitals and months of hospitalisation we finally reached the consolidation of the fracture using a Taylor Spatial Frame. Despite several osteosynthesis she developed a pseudarthrosis. After resection of the pseudarthrosis an callus distraction we reached a consolidation of the bone in varus malposition that we excepted cause of the duration and problems of the treatment. Unfortunately in an outwarts hospitals followed the correction osteotomy in the former pseudarthrosis and plate osteosynthesis and so she developed a septic pseudarthrosis with a fistula. After resection of the fistula and the pseudarthrosis we chose the Taylor Spatial Frame for stabilisation and compression of the fracture and simultaneously a cutanouscortikoperiostal flap for soft tissue coverage. After almost 5 months without weight bearing a consolidation of the tibia and a healing of the soft tissue has developed.

32 Dislocation of the Elbow in Children G. Frongia, P. Gu¨nther, M. Keßler, S. Holland-Cunz1 1 Chirurgische Universita¨tsklinik, Sektion Kinderchirurgie, Heidelberg, Germany Traumatic dislocation of the elbow is rare in children with an incidence of only 3–6% of all elbow injuries. The most recent publications are case reports of rare forms of dislocation and associated complications. The aim of this evaluation was to analyze the outcome after a dislocation of the elbow in our own patient collective. In the present study all children treated in our clinic with an acute traumatic dislocation of the elbow in the years 2001 to 2008 were retrospectively included. Based on patient records and radiographs the injury patterns, therapy and further treatments were outlined. Furthermore current clinical examinations of the range of movement were performed. Overall 33 children were included. All events were unilateral, one child (3%) showed a recurrence of elbow dislocation after 9 weeks. Ten children (30%) had a pure dislocation, 23 children (70%) had a concomitant fracture. 18 children (55%) had a fracture of the epicondylus ulnaris, two children (6%) a fracture of the epicondylus radialis and three children (9%) a further fracture. 82% of fractures (19 children) required an open repositioning with osteosynthesis. After an average of 54 months a total of 22 children (66%) were clinically examined. The results of the follow-up showed no limitations of the overall quality of life. In individual cases there were minor functional deficits of elbow mobility without instability. Mostly they consisted in deficits of flection up to a maximum of 10, without any subjective limitation. The dislocation of the elbow in childhood differs in the patterns of injuries from one in adults. Initial radiograph must be carefully evaluated for children-specific associated avulsions and fractures around the elbow. Despite severe joint trauma with frequently accompanying injuries, post-traumatic functional deficits are seldomly limiting. The frequency of recurrence is low and instabilities are rare.

33 A Superficial Bite with Consequence J. Do¨rges1, A. Schultens2 1 Evangelisches Krankenhaus Go¨ttingen-Weende, Unfallchirurgie, Go¨ttingen, Germany 2 Universita¨tsmedizin Go¨ttingen, Ana¨sthesie, Go¨ttingen, Germany

28th Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU)

The case of an 11-year-old boy is presented. The boys brother had struck his right thigh above the knee with his open mouth. This resulted in a small abrasion a few millimeters in size, cephalad to the patella. To the parents the bite wound was not obvious. Four days following the accident the boy was brought to our hospital with an empyema of the knee. Obviously all layers of the extremely slim boy ‘s skin had been perforated by his brother’s teeth, including the joint’s synovia. A complete surgical sanitization proved arduous. Despite a consistent surgical therapy it did not succeed at first to calm the infection down and to receive an adequate mobility. Following the initial surgical therapy arthofibrosis developed within 14 days. A radical dorsal synovectomy as well as an open arthrolysis were necessary and brought the turn. Follow up until a satisfying range of motion was achieved required a year. For the patient injury and recovery were a trial of faith. During the initial 4 week hospitalization period parents and health care providers needed to establish a trustworthy and reliable relationship to guarantee consistent adherence to therapy.

34 Degenerative Disc Disease in Adolescents from the Neurosurgical Perspective

Abstracts

In a large study for juvenile degenerative disc disease no sex related differences could be detected. Furthermore, neurological deficits were rare. MRI revealed in more than 90% of the cases a monolevel disease. In the majority of cases L4/5 was mainly affected (Swischuk 1998). Degenerative changes in the involved levels are less severe compared to older people. However, accompanying anomalies of the lumbar spine are common such as spondylolisthesis, hyperlordosis, sacralisation or lumbalisation (Erkintalo 1995). In patients suffering from chronic lumbago Schmorl’s disease or Scheuermann’s disease was present more frequently than in controls (Salminen 1999). In addition a subgroup with genetic spinal stenosis and multilevel degeneration was found in one study (Dimar 2007). In the majority of cases conservative treatment was successful. Patients younger than 20 years account for 1–3% of all patients having lumbar disc surgery per year (Kumar 2007). Surgery itself is similar to that in older patients, however removal of disc material is harder since the disc material is still more attached to the adjacent endplates. Therefore, removal of the herniated part of the disc is the primary goal of surgery leaving the disc space unopened. Since the majority of disc herniations is lateralised this is possible. Postoperative results in long term evaluations are good in 78% of the patients (Ebersold 1987).

K. Schmieder1 1 Medical faculty Mannheim, University Heidelberg, Department of Neurosurgery In this age group ongoing back pain is mainly suspected to be caused by serious general diseases or psychological problems. Juvenile degenerative disc disease is not considered in the first place (Dimar 2007).

Eur J Trauma Emerg Surg 2009  URBAN & VOGEL