Dorien Schneidmüller

Delayed healing of forearm shaft fractures in children after intramedullary nailing.

Background: In displaced and unstable forearm shaft fractures, elastic stable intramedullary nailing represents the current treatment of choice. Delayed healing has been observed in single cases, but the incidence of healing disturbances remains unclear. Methods: Retrospective analysis of all patients with forearm shaft fractures and open epiphyseal plates, treated with elastic stable intramedullary nailing between 2000 and 2004 in 5 pediatric trauma units, was conducted. Evaluation of cases with insufficient consolidation 90 days after osteosynthesis was performed. Results: Ten (1.9%) of 532 cases showed delayed healing. Mean age (12.3 years), part of open fractures (30%), and part of open reductions (60%) were clearly higher than in a nonselected collective; the ulna was concerned in 70%. One refracture, 1 local soft tissue infection, and 1 small sequestration were found. In 5 children, nails were extracted with (2×) or without (3×) local surgical intervention. In the other 5 children, the nails were left in place. All fractures healed within 13 months posttrauma without relevant functional restrictions. Conclusions: Delayed healing is possible especially in open fractures or open reduced fractures of the ulna in older children, but healing takes place up to 13 months. Therefore, no change of treatment principles is necessary. Protection of ulna periost has to remain in the center of surgical focus. Level of Evidence: Retrospective comparative study, Level III.

Pediatric Polytrauma Management

Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

Development and validation of a paediatric long-bone fracture classification. A prospective multicentre study in 13 European paediatric trauma centres

BackgroundThe aim of this study was to develop a child-specific classification system for long bone fractures and to examine its reliability and validity on the basis of a prospective multicentre study.MethodsUsing the sequentially developed classification system, three samples of between 30 and 185 paediatric limb fractures from a pool of 2308 fractures documented in two multicenter studies were analysed in a blinded fashion by eight orthopaedic surgeons, on a total of 5 occasions. Intra- and interobserver reliability and accuracy were calculated.ResultsThe reliability improved with successive simplification of the classification. The final version resulted in an overall interobserver agreement of κ = 0.71 with no significant difference between experienced and less experienced raters.ConclusionsIn conclusion, the evaluation of the newly proposed classification system resulted in a reliable and routinely applicable system, for which training in its proper use may further improve the reliability. It can be recommended as a useful tool for clinical practice and offers the option for developing treatment recommendations and outcome predictions in the future.

Epidemiology and Management of Injuries to the Spinal Cord and Column in Pediatric Multiple-Trauma Patients

Injuries to the spinal column and cord in children are a rare condition. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of children with spinal injuries who were admitted to the emergency room. The patients were analyzed regarding age, mechanism, and distribution of their injuries to all spinal regions and treatment strategies. Thirty-five children met the inclusion criteria with severe spinal injuries (Abbreviated Injury Scale [AIS] for Region 6 [spine]; AIS region 6) in a period from January 2003 to December 2009. The incidence was extremely low in younger children, with increasing numbers during adolescence. Neurological deficit without fracture accounted for almost 25% of all patients. The majority of patients were treated conservatively; operative treatment was performed in 25% of patients with unstable fractures, particularly in adolescents. Treatment strategies differ according to the type and degree of injury, age, and level of spine maturation.

LiLa classification for paediatric long bone fractures. Intraobserver and interobserver reliability

BACKGROUND There are two child-specific fracture classification systems for long bone fractures: the AO classification of pediatric long-bone fractures (PCCF) and the LiLa classification of pediatric fractures of long bones (LiLa classification). Both are still not widely established in comparison to the adult AO classification for long bone fractures. METHODS During a period of 12 months all long bone fractures in children were documented and classified according to the LiLa classification by experts and non-experts. Intraobserver and interobserver reliability were calculated according to Cohen (kappa). RESULTS A total of 408 fractures were classified. The intraobserver reliability for location in the skeletal and bone segment showed an almost perfect agreement (K = 0.91-0.95) and also the morphology (joint/shaft fracture) (K = 0.87-0.93). Due to different judgment of the fracture displacement in the second classification round, the intraobserver reliability of the whole classification revealed moderate agreement (K = 0.53-0.58). Interobserver reliability showed moderate agreement (K = 0.55) often due to the low quality of the X-rays. Further differences occurred due to difficulties in assigning the precise transition from metaphysis to diaphysis. CONCLUSIONS The LiLa classification is suitable and in most cases user-friendly for classifying long bone fractures in children. Reliability is higher than in established fracture specific classifications and comparable to the AO classification of pediatric long bone fractures. Some mistakes were due to a low quality of the X-rays and some due to difficulties to classify the fractures themselves. Improvements include a more precise definition of the metaphysis and the kind of displacement. Overall the LiLa classification should still be considered as an alternative for classifying pediatric long bone fractures.

Frakturklassifikationen im Kindesalter

Die Einteilung von Verletzungen nach verschiedenen Klassifikationen ist eine notwendige Voraussetzung, um in multizentrischen Studien anhand einer grosen Anzahl von Kranken eine Aussage z.B. uber Aufwand und Ergebnisse unterschiedlicher Therapiemethoden oder die Prognose von bestimmten Verletzungen treffen zu konnen. Eine umfassende, spezifische Klassifikation fur Frakturen der langen Rohrenknochen im Kindesalter wurde bisher noch nicht entwickelt, sodass meist die fur Erwachsene gultige AO-Klassifikation auf das kindliche Skelett ubertragen wurde. Aufgrund der Besonderheiten des kindlichen Skeletts ist dies jedoch nicht sinnvoll. Im Gegensatz zum Erwachsenen lasst sich aufgrund der Verletzung keine Hierarchie bezuglich des Schweregrads sowie kein therapeutischer Hinweis ableiten. Art und Ausmas der Therapie sind nicht standardisiert und viel mehr abhangig vom Alter des Kindes sowie der Frakturlokalisation und — dislokation. Klassifikationen machen nur Sinn, wenn sie sich nach morphologischen Gesichtspunkten richten und in ein vernunftiges Dokumentationssystem eingebettet sind. Solche Dokumentationen sind auch fur die Kindertraumatologie unerlasslich und stellen gleichzeitig die Grundlage fur eine adaquate Qualitatssicherung dar.

LiLa-Klassifikation für Frakturen der langen Röhrenknochen im Wachstumsalter

BACKGROUND There are two child-specific fracture classification systems for long bone fractures: the AO classification of pediatric long-bone fractures (PCCF) and the LiLa classification of pediatric fractures of long bones (LiLa classification). Both are still not widely established in comparison to the adult AO classification for long bone fractures. METHODS During a period of 12 months all long bone fractures in children were documented and classified according to the LiLa classification by experts and non-experts. Intraobserver and interobserver reliability were calculated according to Cohen (kappa). RESULTS A total of 408 fractures were classified. The intraobserver reliability for location in the skeletal and bone segment showed an almost perfect agreement (K = 0.91-0.95) and also the morphology (joint/shaft fracture) (K = 0.87-0.93). Due to different judgment of the fracture displacement in the second classification round, the intraobserver reliability of the whole classification revealed moderate agreement (K = 0.53-0.58). Interobserver reliability showed moderate agreement (K = 0.55) often due to the low quality of the X-rays. Further differences occurred due to difficulties in assigning the precise transition from metaphysis to diaphysis. CONCLUSIONS The LiLa classification is suitable and in most cases user-friendly for classifying long bone fractures in children. Reliability is higher than in established fracture specific classifications and comparable to the AO classification of pediatric long bone fractures. Some mistakes were due to a low quality of the X-rays and some due to difficulties to classify the fractures themselves. Improvements include a more precise definition of the metaphysis and the kind of displacement. Overall the LiLa classification should still be considered as an alternative for classifying pediatric long bone fractures.

The role of TNXB single-nucleotide polymorphisms in recurrent shoulder dislocation

Tenascin‐X (TNX) is an extra‐cellular matrix glycoprotein associated with collagen fibril deposition. Recent reports have linked truncated TNX mutations (TNXB) to generalized joint hypermobility and most importantly recurrent joint dislocation. In the present study, we investigated whether there is an association between joint dislocation recurrence rate and the frequency of TNXB single‐nucleotide polymorphisms (SNPs). Seventy‐eight patients treated for post‐traumatic shoulder instability and 82 healthy controls were genotyped for selected TNXB SNP using TaqMan® Genotyping Assays. At a mean follow‐up of 24 months recurrence rate and clinical outcomes were evaluated using the Constant and Murley, Rowe, and DASH scores. The association between genotypes and joint dislocation was tested using the dominant, recessive and additive models, and the model‐free approach. Genotype distribution of the examined SNPs did not significantly deviate from the Hardy–Weinberg equilibrium (HWE) neither in patients nor in the controls. Moreover, there was no significant difference in genotype and allele distribution between patients and controls. Finally, no difference in genotype frequency was detected between patients who experienced a re‐dislocation after the initial surgery and patients who did not sustain a re‐dislocation. The SNPs investigated in this study have no clinically relevant influence on TNXB gene expression and/or TNX function. Therefore, these SNPs could not be used for predicting individual risk of recurrent shoulder dislocation.

Do paediatric and adult surgeons follow different approaches to physeal fractures

INTRODUCTION The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS). METHODS 62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases. RESULTS Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis. DISCUSSION There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

LiLa-Klassifikation für Frakturen der langen Röhrenknochen im Wachstumsalter@@@LiLa classification for paediatric long bone fractures: Intra- und Interobserverreliabilität@@@Intraobserver and interobserver reliability

BACKGROUND There are two child-specific fracture classification systems for long bone fractures: the AO classification of pediatric long-bone fractures (PCCF) and the LiLa classification of pediatric fractures of long bones (LiLa classification). Both are still not widely established in comparison to the adult AO classification for long bone fractures. METHODS During a period of 12 months all long bone fractures in children were documented and classified according to the LiLa classification by experts and non-experts. Intraobserver and interobserver reliability were calculated according to Cohen (kappa). RESULTS A total of 408 fractures were classified. The intraobserver reliability for location in the skeletal and bone segment showed an almost perfect agreement (K = 0.91-0.95) and also the morphology (joint/shaft fracture) (K = 0.87-0.93). Due to different judgment of the fracture displacement in the second classification round, the intraobserver reliability of the whole classification revealed moderate agreement (K = 0.53-0.58). Interobserver reliability showed moderate agreement (K = 0.55) often due to the low quality of the X-rays. Further differences occurred due to difficulties in assigning the precise transition from metaphysis to diaphysis. CONCLUSIONS The LiLa classification is suitable and in most cases user-friendly for classifying long bone fractures in children. Reliability is higher than in established fracture specific classifications and comparable to the AO classification of pediatric long bone fractures. Some mistakes were due to a low quality of the X-rays and some due to difficulties to classify the fractures themselves. Improvements include a more precise definition of the metaphysis and the kind of displacement. Overall the LiLa classification should still be considered as an alternative for classifying pediatric long bone fractures.