Pelvic fractures in children and adolescents in polytrauma and high-energy injuries

BACKGROUND

This paper is a retrospective analysis of the treatment of pelvic fractures in children and adolescents who sustained polytrauma and high-energy injuries. Incidence varies from 0.2% to 7.5% of all pediatric injuries. Most often, these are isolated stable fractures that do not require hospitalization. However, a group of unstable fractures requiring surgical intervention remains.

MATERIAL AND METHODS

37 patients aged 5 to 17 years (mean: 13.6), were hospitalized between 2002 and 2010. This group comprised 21 boys and 16 girls who were followed up for 1 to 8 years (mean: 3.2). In this cohort, only cases of pelvic fractures that required hospitalization for other reasons were taken into account. The causes of injuries were car accidents, falls from bicycles and sports injuries. The Torode and Zieg classification was used for assessment, including surgical guidance by Mears/Gordon.

RESULTS

There were 11 cases of type I, 7 cases of type II and III and 9 cases of type IV fractures. Moreover, 3 cases of S-H II acetabular fractures were identified. The surgical treatment made use of external pelvic fixators, combined internal coaptation with cannulated screws or K-wires, and LCP plates or combined techniques.

CONCLUSIONS

1. Torode and Zieg type I to III pelvic fractures in children do not usually require surgical treatment. 2. To rode and Zieg type IV unstable fractures require operative treatment in order to avoid complications and aid faster recovery.

Analysis of the influence of Ascaris, Borrelia, Toxocara, Toxoplasma and Mycoplasma infections on the incidence and course of Perthes disease - pilot study

BACKGROUND

It is known from medical literature that such organisms as Ascaris, Borrelia, Mycoplasma, Toxocara and Toxoplasma can cause arthritis or cause vascular changes. We studied their influence on the incidence, course and outcome of Perthes disease.

MATERIALS AND METHODS

Sixty-one patients treated for Perthes disease were analysed. Thirty-seven of them took part in a follow-up examination after a mean of 2.8 years post first admission. A control group consisted of 22 patients treated operatively for other reasons. Blood tests, radiographic studies and a physical examination were carried out during the first admission and the follow-up visit.

RESULTS

Serologic tests were positive for at least one pathogen in 67.2% of the patients with Perthes disease. In the control group, the tests were positive for Borrelia in 52.2% of the patients and for Mycoplasma in 40.9%, compared to antibody rates of 17.1% and 29.3%, respectively, in the group with Perthes disease. The lack of statistically significant differences in the distribution of infected vs. not-infected children according to the Herring classification suggests the absence of influence of the pathogens on the radiographic severity of Perthes disease. There were no statistically significant differences in the range of internal rotation and abduction of the affected limb between patients with negative and positive blood tests. The radiographs failed to show statistically significant differences in the structure of proximal femur between infected and non-infected children.

CONCLUSIONS

Patients with a diagnosis of Perthes disease did not demonstrate more frequent infection with the organisms investigated than the control group. No link was found between those infestations and the course and prognosis of Perthes disease.

The analysis of self-esteem based on patients` self-perception after Ilizarov limb lengthening treatment

In the article there is shown the analysis of patients self-perception after the Ilizarov limb lenghening treatment due to inequality. 150 patients both sexes (78 girls and 72 boys) were tested between 1992 and 2003 in our center. The average age for girls at the time of follow-up was 19.5 years and 18.5 years for boys. In the survey there was used four point-scale SES by Irena Dzwokowska, Kinga Lachowicz-Tabaczek and Mariola Łagun which was based on Rosenberg work. The results were divided into two groups: low or high score. It was evaluated according to the table of standards which included people age and sex. Then the score was transformed into standard ten. For statistical calculations was used MicroSoft Excel spreadsheet. In the case of statistical studies was used Spss v.17.0. It was found that among survey respondents regardless of gender and age after the satisfactory completion of Ilizarov treatment patients gain a high level of self-assessment at 7 standard ten. The high self-esteem can predict the level of patients` comfort in many aspects of their lives. People with such a hight self-perception will experience more positive emotions and will be healthier and more active.

[Analysis of treatment results of humeral lateral condyle fractures in children]

On the basis of 60 cases authors analyze treatment results of the humeral lateral condyle fractures in children. This type of fracture is a second most common elbow fracture in children after supracondylar fracture of the humerus. Authors consider this fracture to be the most difficult to diagnose among all elbow injuries. Analyzed cohort of patients consists of 54 at age between 1.5 to 10 years and 6 patients between 12 to 17 years of age. In 75% of cases operative treatment was delayed due to late referral from other hospitals. According to appearance of the fracture line on X-rays there were 53 cases of type II and 7 cases of type 1 according to Milch classification system. The amount of displacement was evaluated according to Jakob scale and there were 35 cases of III degree, 17 cases of II degree and 8 cases of I degree of displacement. All patients were evaluated with antero-posterior and lateral distal humerus x-rays. In some cases other diagnostic techniques were used. In older children computerized tomography and in younger children ultrasound examination was performed. The treatment results were evaluated according to Hardacre scale. Follow-up time was 1 to 13 years. There were 27 very good and 27 good results in a 54 cases group of patients who underwent surgery within 15 days since injury. In other group which consists of 6 patients who underwent surgery more than 5 weeks after injury there were 2 cases of very good, 2 cases of good; and 2 cases of bad results. Authors believe that putting a proper diagnosis of humeral lateral condyle fracture in children and performing an operative treatment results in a good and a very good outcomes. Basing on the analysis of treatment results of authors cohort of patients, they claim that precise diagnosis and proper determining of degree of displacement increases the number of patients qualified to operative treatment.

[Early results of congenital clubfoot using Ponseti method]

Congenital clubfoot is one of the most common congenital skeletal defects. Its aetiology remains unclear. Due to its high incidence and social consequences, the therapy of congenital clubfoot presents an important medical issue. Non-surgical treatment methods are preferred. Many publications confirmed the efficacy of the Ponseti method. The aim of this study was to present early results of congenital clubfoot treatment using the Ponseti method in a one-year follow-up. The therapy protocol was in accordance with guidelines presented by the inventor. The necessity of surgical treatment was a criterion for negative treatment outcome. One hundred and sixteen feet of 92 children were analysed. A Dimeglio-Bensahel classification was used for the evaluation of the defect advance. Seventy-one feet (61.2%) were assessed as grade II, 43 feet as grade III (37.1%) and 2 feet as grade IV deformation. No patients with grade I deformation were included into the study. A positive treatment outcome was observed for 96 feet (82.7%), whereas a negative result for the remaining 20 feet (17.3%). Our results are therefore not consistent with the literature data. It could have resulted from the too precipitate qualification for surgery by the physician and problems with compliance. The Ponseti method is an effective and less straining treatment modality of the congenital clubfoot. In most cases it allows for avoiding extensive surgery and associated complications. A necessity of wearing an orthosis and a risk treatment failure, if not worn systematically, should be emphasised. A longer follow-up period is required for complete result analysis.

[Congenital talipes equinovarus--family occurrence]

Although congenital talipes equinovarus (CTEV) is one of the most frequently occurring congenital defects of locomotor organs, its ethiopathogenesis is still not fully known. Amongst the others, the inheritance patterns of that defect are not fully known, and that restricts genetic therapeutics and development of new treatment technologies. The aim of this study was analysis of family lineages of 205 children with CTEV (298 feet) treated at our centre in the years 1998-2008. The family occurrence of CTEV was found in 16 cases (8% of analysed group). 6 lineages, in which CTEV occurred in successive generations, were analysed in detail. Particularly interesting is the lineage of the family 1, in which the defect occurred in three successive generations. In case of that family, an autosomal dominant inheritance pattern is possible. Previously that pattern of CTEV inheritance was described only for isolated populations of Polynesians. In own material the family occurrence of CTEV was found to be less frequent than in bibliographic references. The defect occurred twice as often in boys, while the severe form was more frequently observed in girls, and that is consisted with data in the available bibliography. The analysis of presented lineages of families with CTEV did not allow unambiguous defining of the inheritance pattern for that defect. To confirm the autosomal dominant pattern of CTEV inheritance in the family in which the defect occurred in three successive generations, genetic tests would be necessary.

[Application of Ponseti method in case of neglected talipes equinovarus in 4 years and 9 months old boy with DiGeorge syndrome--case report]

Case report of application of Ponseti method in treatment of neglected congenital talipes equinovarus in boy with DiGeorge syndrome who was 4 years and 9 months of age at the beginning of the treatment. Foot was classified as very severe, scored 4.5 points according to Pirani and 15 points according to DiMeglio classification. After 9 casts set according to Ponseti protocol good correction of all components was achieved accept for the equinus deformity. Achilles lengthening procedure was done, but there was necessity to perform posterior release to achieve good dorsiflexion. Finally, goals of treatment were achieved: the foot is flexible, well shaped, pain free, ready for weight-bearing and use of commercial shoes. At current stage of treatment the foot scores 0.5 points according Pirani and 4 points according to DiMeglio classifications.

[Results of treatment of the intercondylar eminence of tibia in children]

Fracture of the tibial eminence in children is a condition in which there is no widely accepted and approved therapeutic scheme. The greatest divergence of treatment options concerns type II according to Mayers and McKeever classification. Described therapeutic options range from cast immobilisation of the lower extremity without attempt of closed reduction to open reduction with internal fixation. Paper shows the results of treatment of tibial emienence fractures in children treated at our institution. Cohort of patients consists of 21 children at age 7 to 16 years of age (mean 12.2 years). There were three cases of type I, five cases of type II and thirteen cases of type III fracture according to Mayers and McKeever classification. Operatively 16 patients were treated with type II and III fracture, and the rest of them were treated nonoperatively. Open reduction and internal fixation was performed according to modified technique described in 1937 by H. Lee. The results were evaluated by X-ray, clinical examination of stability and range of motion of the affected knee and by subjective clinical outcome with use of modified Lysholm knee scale. All patients treated operatively presented very good and good clinical outcome. Nonoperatively treated patients was a small and no homogenous group. Results of treatment ranged from very good to poor. Worse outcomes were associated with additional injuries to the affected knee (poor result in patient with type II fracture) and qualification for the conservative treatment in patient with type III fracture.

[Split posterior tibial tendon transfer as a selected technique of treatment of spastic equino-varus deformity in children]

Equinovarus deformity is one of the most common deformities seen in patients with cerebral palsy. During years between 1993 and 2004 in 36 patients with cerebral palsy 46 operative procedures of split posterior tibial tendon transfer to peroneus brevis muscle were performed to correct varus deformity of the foot. Additionally equinus was corrected by lengthening lengtheninglengthening of the calcaneal tendon in 42 cases and in 4 cases by gastrocnemius recession according to Baker modification of Vulpius procedure. Children's age at the time of operation was between 3.5 and 16 years of age (average 7.5). In our cohort of 36 patients there were 10 cases of quadriplegia (28%), 12 cases of hemiplegia (33%), 12 cases of paraparesis inferior (33%) and 2 cases of monoplegia (6%). 25 patients with 34 operated feet (73.9%) reported for final examination. Follow-up period was from 18 months to 11 years (average 5.5 years). At final examination we evaluated clinical effectiveness of gait, passive and active range of movement, plantograms, and subjective evaluation of patient and patients' parents. Wearing of orthoses and orthopaedic footwear was noted. The results were divided into groups according to Green's classification. There were 67.6% of very good results, 23.6% of good results and 8.8% of poor results. Basing on our experience in treatment of spastic equinovarus deformity of the foot in children with cerebral palsy we stand, that split posterior tibial tendon transfer can bring good results and is a valuable surgical technique in treatment of equinovarus deformity.

[Treatment of the femoral, tibia and humeral shaft fractures in children with the use of intramedullary nailing or external fixation, a long term study]

The treatment of long bones shaft fractures with intramedullary nailing and external fixation is gaining popularity nowadays. The aim of this study was to analyze operative methods of treatment of the long bones shafts fractures in children. We compared outcomes of surgical treatment with the use of external fixation and flexible nails. The study group consisted of 127 patients (4 to 18 years old) who were operated on in our hospital during the period 1990-2005: 90 patients with femoral shaft fractures, 31 with tibia fractures and 6 with humeral fractures. In 81 children we performed fixation with Wagner's tool and in 46 cases we used Prevot or Ender nails. The follow up (performed at least one year after treatment cessation) included clinical examination and X-ray imaging. Union in an almost anatomical position was obtained in 126 patients. There was one fracture-healing complication ( nonunion- due to to early hardware removal). The study showed many advantages of the surgical treatment: minimal invasiveness, short hospitalization period, early rehabilitation. In our group both methods of management were comparable. We recommend intramedullary nailing in closed, transverse fractures and external fixator in open, multifragmentary and possibly unstable fractures.

Professional shopping of physician services: an extension of the simulated patient technique

Health care researchers have recently begun to use professional shopping to evaluate physician services. The results of two studies conducted by The Cleveland Clinic Foundation indicate that: (1) such studies are easily conducted; (2) physicians are comfortable with the use of professional shopping to obtain patient feedback; (3) the technique is a valuable research tool for improving medical services from a patient's perspective; and (4) there is potential value in using professional shopping as a quality assurance technique.