[Growth behavior after epiphyseal plate injury: importance of "watertight" osteosynthesis]

BACKGROUND

The frequency figures for epiphyseal plate injuries of long bones given in the literature are inexact and they probably occur with a frequency of 15% of all fractures of the growing skeleton. In order to be able to give correct figures in the future a classification system, such as the LiLa classification should be used, which does not attempt to be oriented to an assumed growth prognosis but is oriented to therapy and makes a strict differentiation between shaft and joint fractures. For epiphyseal joint fractures a differentiation must be made between those where the epiphysis is still open and those where the epiphysis has begun to close, in order to be able to incorporate all epiphyseal joint fractures and differentiate them from epiphyseal shaft fractures (epiphysiolysis).

CLINICAL ASPECTS

The growth prognosis encompasses stimulatory and inhibitory growth disorders as well as spontaneous correction of residual axial deviations. The prognosis is fundamentally dependent on the biological age of the patient by fracture, on the localization in the skeleton and the localization in the segment because the growth components of epiphyses are asymmetrically distributed in the segment. Stimulatory growth disorders in the actual growth phase < 10 years of age are the obligatory growth disorders which lead to overgrowth of the section of the skeleton affected. In an age over 10 years they lead to an also obligatory premature closure of adjacent or affected epiphyses which is expressed as a slight shortening. Asymmetrical stimulations are most common in the upper extremities following intra-articular fractures of the radial condyle as the obligatory growth disorder at this site. Asymmetrical stimulation is rare in the lower extremities after extra-articular metaphyseal valgus fractures of the proximal and distal tibia. Asymmetrical premature closure of the epiphysis in the upper extremities is rare in contrast to partial stimulation with less than 5% after extra-articular fractures of the distal radius and proximal humerus. Conversely, asymmetrical inhibitory growth disorders are found significantly more often in the lower extremities after extra-articular and intra-articular fractures of the distal femur, proximal tibia and distal tibia between 50% and 20%. "Spontaneous corrections" of residual axial deviations and side to side shifts after epiphyseal shaft fractures occur reliably without resulting in growth disorders, provided the patient is young enough.

THERAPEUTIC TARGETS

In cases of displacement the aim of therapy in epiphyseal shaft fractures is to reconstitute age-related and tolerable axes. For displaced epiphyseal joint fractures the aim is to reconstruct the joint surfaces. The basic principles of an efficient and targeted diagnostics and the therapeutic options for diminishing the clinical sequelae of growth disorders are discussed.

CONCLUSION

No growth disorders, which are to be expected as a result of every epiphyseal injury, can primarily be therapeutically avoided; however, better foundations can be achieved to reduce the clinical sequelae of growth disorders. Therapy can only follow the differentiation into shaft and joint (and not an assumed growth prognosis) and should integrate a scientifically proven and reasonable spontaneous correction for the patient. A classification must achieve a therapy-related uncoupling of the epiphyseal injuries into shaft and joint fractures.

[Conservative treatment of fractures of the long bones during the growth phase]

In the treatment of fractures of the long bones in children and adolescents, surgical and conservative methods are not mutually exclusive alternatives; rather, each can complement the other in the overall treatment strategy. Many operative procedures, such as fixation of juxtaarticular, metaphyseal fractures, need to be supplemented by conservative procedures, such as immobilization by means of casts. We refer to methods that are performed without anaesthesia and do not involve the implantation of osteosynthetic foreign material as conservative. These are: immobilization with no further treatment, plaster wedging, and functional treatment options. The indications for purely conservative treatment strategies are basically different for articular and nonarticular fractures. Whereas in the case of articular fractures only the nondisplaced fractures are treated by conservative methods, in the case of nonarticular (shaft) fractures those involving a degree of displacement, as long as it is not too pronounced to allow the integration of spontaneous corrections, can also be treated conservatively.

Effiziente Bildgebung von Ellenbogenverletzungen bei Kindern und Jugendlichen

The purpose of imaging of the elbow region in children after acute trauma is the diagnosis of injuries that require further treatment. Basic diagnostic consists of standard X-rays of the elbow in two planes. Exceptions can be made in the case of nursemaid's elbow lesion (subluxation of the radial head; pronation douloureuse; Chassaignac lesion) with unambiguous mechanism of the trauma where no X-ray imaging is needed and in heavily dislocated fractures for which one plane can be sufficient. X-ray imaging of the uninjured side is obsolete. Follow-up X-ray imaging is only allowed if consequences for the further treatment are expected. Ultrasound may partially replace X-rays in the future if further standardization of this technique can be achieved. MRI provides additional information in acute trauma which, however, remains currently without consequences for the further treatment strategy.

Allgemeine Gesichtspunkte zur kindorientierten Behandlung von Verletzungen

This report discusses the differences between the paediatric and adult musculoskeletal system. Consideration is given to preventive measures and the epidemiology and aetiology of fractures in relation to the developmental milestones in children. The principles of growth disturbances (overgrowth or growth arrest) and their management are presented. Pitfalls in diagnosis and different treatment options for paediatric fractures are discussed. Doctor-patient communication at different stages of growth and the importance of respecting the opinion of the child in management planning is emphasised.

[Supracondylar humerus fracture in childhood--an efficacy study. Results of a multicenter study by the Pediatric Traumatology Section of the German Society of Trauma Surgery--I: Epidemiology, effectiveness evaluation and classification]

In this retrospective study of the pediatric trauma group of German trauma society, issued to investigate the state of the art treatment of the supracondylar fracture of the humerus, 13 clinics took part. In this first part of our study we tested the epidemiology and effectivity of therapeutic interventions based on the classification of v. Laer. 886 fractures were included with an average patients age of 5.8 years (+/- 2.9). Causes of trauma was in 45% playing, followed by school/kindergarden and sports injuries. Fractures were initially classified according to v. Laer and showed following displacement: 35.4% Type I, 21.9% Type II, 18.1% Type III and 24.6% Type IV. 10 of the 886 cases (1.1%) were open fractures. Damages to nerves were described in 45 patients (5.1%) and only 7 (0.7%) had primary vessel lesions. 476 patients were treated by reduction of fragments, 72% using a closed technical approach and 28% using an open approach. 6% underwent a second resposition-maneuver, which was mainly observed after crossed Kirschner-wire in type-III-and-IV-fractures. Therapy was changed in 5.1% mostly of the cases were initially closed reduced and then fixed with a collar and cuff sling. 540 patients were seen at follow-up (61%). 81.1% of these patients showed symmetrical axis compared to the uninjured arm. A varus-deformity was noted in 11.7%, a valgus-deformity in 7.2%. Analysis of effectivity showed that the primarily used classification was not sufficient for prediction of the outcome after reposition and retention. Therefore the classification was modified based on 4 groups: Type I undisplaced, Type II displacement in one plane, Type III displacement in two planes and Type IV displacement in three spatial planes. Using this classification we could found that in group II 25% of reduction an 7% of retentions were ineffective. For group III and IV we found that > 20% of the retention proofed to be ineffective.

[Supracondylar humerus fracture in childhood--an efficacy study. Results of a multicenter study by the Pediatric Traumatology Section of the German Society of Trauma Surgery--II: Costs and effectiveness of the treatment]

The following are the results and conclusions of a retrospective research study done on 886 patients with supracondylar fractures of the humerus. The study evaluates how effective the treatment procedures of the fractures are. The patients' fractures were categorized into four groups. It made it easier to differentiate between dislocated and undislocated fractures (see part I Weinberg A et al.). The following parameters were established to evaluate the treatment procedures and to create relevancy to the final outcome depending on the degree of difficulty of the fractures: Length of hospitalization, amount of repositioning procedures (including if an open or closed procedure was needed), amount of post repositioning procedures and the recommended change of therapy, method of retention and fixation, necessary metal removal, amount of check ups needed. The amount of x-ray exams could not be established due to insufficient documentation. The study showed a rather random pattern regarding length of hospitalization and the amount of check ups especially among type I and II patients. Open versus closed repositioning procedures did not seem to be advantageous. The implanted wires did not prevent infections. It just increased the treatment procedure by another hospitalization and anesthesia to remove the implanted wires. Physical therapy was not necessary and was only prescribed in cases of prolonged immobilization. The results of this study generated consequences regarding treatment procedures and developed a more efficient treatment protocol: Type I and II (dislocated and undislocated fractures in one plane) will be treated conservatively on an out-patient basis. Type I in a cast. Type II in a blount or plaster cast with flexed angle between 100 degrees and 130 degrees. Type III an IV (dislocated and undislocated fractures in two or three planes) will be treated if possible with a closed repositioning procedure. Otherwise a close repositioning procedure will be necessary and followed with some kind of KD-osteosynthese to capture the fracture. The patient will be hospitalized for a short period. The blount procedure will not be sufficient for this type of fracture. Therapy and procedure will be translated put in a perspective research study.

Secondary radial head dislocation and dysplasia of the lateral condyle after elbow trauma in children

We report five cases of a rare complication of childhood fractures of the elbow region. The complication consists of posttraumatic dissolution of the lateral humeral condyle followed by secondary radial head overgrowth and dislocation. The initial injuries ranged from displaced lateral condyle fractures (three patients) to a supracondylar fracture and an open elbow dislocation. Dysplasia of the lateral humeral condyle was first noted 1 to 4 years after the trauma (mean, 2.5 years) and seemed to be caused by removal of the displaced fracture fragment in one patient, and possibly by malfixation and repeated surgical procedures in the others. Because of loss of motion, ulnar nerve irritation, and cosmetic deformities, corrective osteotomies had to be performed in four patients and additional radial head removal in two patients.

Prevention of growth disturbances after fractures of the lateral humeral condyle in children

Growth disturbances after fractures of the lateral condyle of the distal humerus in children present mostly as transient stimulation of the lateral physis. Clinically lateral condylar overgrowth leads to a radial bony prominence and varisation of the elbow. From 1974 to 1994, 66 fractures were prospectively diagnosed with standard roentgenograms and treated by open reduction and internal fixation with a metaphyseal lag screw in case of displacement. Fifty-four patients (82%) were reviewed with an average length of follow-up of 10 years (range, 2-22 years) to assess all sequelae of growth disturbances. Screw osteoynthesis led to anatomical union, symmetric carrying angles and full range of motion in all 27 operated cases, and proved to prevent stimulating growth disturbances contrary to the common but relatively unstable fixation with Kirschner wires.

[Pathophysiology of posttraumatic deformities of the lower limbs during growth]

Posttraumatic deformities after pediatric fractures are either the result of incomplete or failed remodeling, complete or partial stimulation of the growth plates, or complete or partial closure of a growth plate. In contrast to fractures of the upper extremities, spontaneous remodeling should not be intentionally integrated in the treatment algorithm. Thus, stimulative growth disturbances with subsequent changes of the leg length can be prevented. Therefore, one should strive for anatomical alignment and rotation without shortening. The latter provokes remodeling, with activation of the adjacent physis. Growth disturbances with partial stimulation typically occur after metaphyseal bending fractures of the proximal tibia. If minimal valgization is overlooked, growth disturbances will lead to a progressive valgus deformity. Partial closure of a growth plate is still inevitable after epiphyseal fractures (Salter-Harris type III and IV) as well as after simple epiphysiolysis (Salter-Harris-type I, II). The resulting deformity depends on the size of the physeal closure, its localization, and on the remaining growth. A "waterproof" reduction and osteosynthesis of type III and IV fractures may well diminish the risk of a partial physeal closure but will not reliably prevent it. It will occur in about 35% after physeal fractures at the distal femur, in 30% at the proximal and 20% at the distal tibia. Based on this knowledge patients and parents should be informed correspondingly and follow-up should be continued until skeletal maturity.

[Spontaneous corrections, growth disorders and post-traumatic deformities after fractures in the area of the forearm of the growing skeleton]

Growth phenomena after paediatric forearm fractures are described. The capacity for spontaneous remodelling of malunions should be primarily considered in the treatment of fractures of the growing skeleton. Thus, unnecessary reductions, anaesthesia and posttraumatic deformities can be prevented. Generally speaking, a high remodelling capacity can be expected in cases of enough remaining growth, proximity to a physis with high activity, and if the main deformity lies in the plane of motion of the nearest joint. It is widely accepted that distal radius and/or ulna fractures are fully remodelled up to the age of 11 to 12 years. However, the remodelling capacity of fractures of the proximal and middle third of the shaft is smaller and less well known. Stimulating growth disturbances at the upper extremities are clinically of minor importance. Growth arrests are rare. Their fateful occurrence is not predictable and not closely related to fracture pattern or amount of dislocation.

[Screw osteosynthesis in dislocated fractures of the radial condyle of the humerus in the growth period. A prospective long-term study]

Pseudoarthrosis and cubitus valgus as main complications following displaced fractures of the radial condyle in children can be prevented by open reduction and fixation by K wires. However, delayed union and stimulation of the radial physis with condylar overgrowth and varisation of the elbow as well as fishtail deformities of the distal end of the humerus are reported nevertheless. To prevent those growth disturbances all primary and secondary (4-day X-ray control) displaced fractures of the radial condyle, i.e. those with a central gap of more than 2 mm, were prospectively treated by open reduction and osteosynthesis with a metaphyseal lag screw beginning 1974. Sixty-six patients (41 boys, 25 girls) with an average follow-up of 10 years (2-22 years) sustained 28 primary and 6 secondary displaced fractures. In 5 cases a K wire fixation was performed in view of the smallness of the fragment. Two children with conservative treatment following overlooked displaced fractures showed condylar overgrowth and varisation of the elbow. Screw osteosynthesis led to symmetric elbow angles and function in all cases, whereas fishtail deformities could be observed in 8 of 27 children, probably as a consequence of the remaining central fracture instability.

CONCLUSION

Open reduction and osteosynthesis with a metaphyseal lag screw prevents condylar overgrowth in displaced fractures of the radial condyle by guaranteeing fracture healing in anatomic position within 3-4 weeks. However, fishtail deformity can not be prevented by metaphyseal compression only.

[Post-traumatic problem cases involving the elbow in children]

In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity.

SECONDARY TREATMENT

In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory.

INITIAL TREATMENT AND CAUSES

Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy.

CONCLUSION

In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90% of severe posttraumatic elbow deformities in children.

Posttraumatic elbow deformities in children

In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity. Secondary treatment: In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory. Initial treatment and causes: Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy.

CONCLUSION

In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90 % of severe posttraumatic elbow deformities in children.

[Traumatic loosening of apophyses in the pelvic area and the proximal femur]

Avulsion fractures of the pelvis and the proximal femur are relatively rare injuries in the adolescent age group of 11 to 17 years. The overall prognosis for spontaneous healing is good. The injury most frequently involves the apophysis of the anterior inferior iliac spine and of the lesser trochanter, followed by anterior superior iliac spine. In our experience the avulsion fractures involving the ischial tuberosity and the greater trochanter are extremely rare. The latter can have dire consequences.

[Natural course following fractures during the growth years]

"Spontaneous" correction of axial deformities after trauma is shown, as well as the limiting factors of such remodelling by growth. The prognosis of all sorts of post-traumatic growth disturbances is discussed. After any fracture during growth, stimulation of the function of one or more growth plates can be anticipated. The outcome is dependent on the age of the patient at the time of the accident: an overgrowth with lengthening will take place in the patient under 10 years of age; early closure of the plate with shortening will occur in patients more than 10 years. Post-traumatic leg length discrepancies do not show remodelling during further growth. Partial stimulation has clinical importance in the proximal tibia where it leads to a unilateral genu valgum. If the patient is young enough, the joint will grow away from this deformity, whereas the proximal and distal epiphysis of the tibia will grow again into the correct position for the weight-bearing forces. The most important growth disturbance is premature partial closure of a growth plate, which leads to increasing axial deformity and shortening. If there is a small osseous bridge between the metaphysis and epiphysis, "spontaneous" bursting of this bridge is possible. If there is a large bridge resection, osteotomy may also be necessary. In both cases--"spontaneous bursting" and resection--a late recurrence of such a bridge during puberty--years after the accident--is possible. It is described as late weakening of the growth forces in the former traumatized area of the growth plate.

[Experience with external fixation in treatment of shaft fractures in childhood]

In a retrospective study 89 shaft fractures sustained during childhood and treated by external fixation were analysed [80 fractures of the lower extremity (59 of the femur) and 9 of the upper extremity]. The operative investment (operating time, period of hospitalization, time for fluoroscopy, general anaesthesia, start of mobilization, number of X-rays) correlated with the success of the treatment. The overall complication rate was 19.1%. Technical errors occurred in 5.6% of all cases; the infection rate was 4.5%; refractures were seen in 4.5% of all patients and reinfarction also in 4.5%. The last 10 femur fractures were analysed separately and the overall complication rate was demonstrably reduced to 3.2%. All technical errors are avoidable and the infection rate could be minimized by better care of the pin, exit points, and by ensuring more stable anchorage of the screws. The consolidation time is longer than with plate osteosynthesis and medullary nailing. But in contrast to adults, in children the treatment was completed with external fixation, and no pseudarthrosis was seen. The consolidation time was shorter with dynamic external fixation. With dynamic systems healing took an average of 7 weeks, while rigid systems needed an average of 9 weeks. Refractures and reinfarction were caused by the rigidity of the external fixation system. In isolated dislocated shaft fractures in childhood the advantages of the fixateur externe are its easy application, low level of invasiveness and early mobilization. It was used in all kinds of fractures in children aged 4-13 years.

[Malunited supracondylar and condylar humeral fractures]

We present three important types of posttraumatic deformity of the distal humerus: varus deformity, valgus deformity and complex deformity. Their primary causes are discussed. Slight varus deformities are the result of purely lateral slip of supracondylar fractures or radial overgrowth after a lateral condylar fracture. Severe varus deformities occur after ulnar slip of the distal fragment following supracondylar fracture caused by a rotational deformity. The results after correlation of varus deformities with a rotational deformity are poor. The only way of obviating this problem is to recognize a rotational deformity as soon as possible before adaptation of the elbow occurs, and also to correct it early, if necessary. Valgus deformities occur mostly after radial malunion. Depending on the size of the fragment and the disability of the patient, the fragment should be stabilized-but the potential involvement of the malunion in the elbow function must be borne in mind. Complex deformities and their unknown origins are also discussed. The correction of such deformities depends exclusively on the elbow function. More aggressive primary regimens are urgently needed to prevent the necessity for such secondary corrections, which are very demanding and, depending on the type, have a high failure rate.

[Principles and pathogenesis of post-traumatic axial malalignment in the growth years]

Deviations of the axis or leg-length discrepancies after fractures in children and adolescents can be due to growth disturbances or can be the result of incomplete reduction of the fracture. We distinguish between four types of growth disturbances. In type I, the overall growth activity of the cartilage is increased; growth is then enhanced, which results in the affected bone being too long without deviation; this usually occurs after fractures of the metaphysis or diaphysis. In type II, activity, the epiphyseal cartilage is severely impaired or completely arrested. The direction of growth is unchanged. This results in shortening of the bone, usually due to severe damage to the germination zone of the growth cartilage after destruction of the vessels or infection. In type III, growth of the epiphyseal plate is partially stimulated. The consequence of this disturbance is deviation of the axis with overgrowth (this is in fractures of the proximal tibia). Type IV is characterized by an asymmetric arrest of growth. This results in deviation of the axis and shortening. The cause of such growth arrest can be epiphyseolysis or epiphyseal fracture. The defect in growth cartilage heals with a bone bridge. This is a very serious kind of growth disturbance, and it occurs in only 1% of all fractures before skeletal maturity. Correction after incomplete reduction of fractures during growth can be direct or indirect and specific or nonspecific. Direct corrections occur in combination with fracture healing; indirect corrections occur with physiological changes of the growing skeleton without association with the healing process.(ABSTRACT TRUNCATED AT 250 WORDS)

Indication and procedure of the operative treatment of benign bone cysts in children and adolescents

In 2-3 reviews 30 patients with non ossifying fibroma and 31 patients with a solitary bone cyst were examined to evaluate the prognosis of these diseases. It has been shown that the cure rate of non ossifying fibromas of 95% and solitary bone cysts of 70% is extraordinarily good and does not depend on the treatment that has been realized. For that reason, the indication for operative treatment must be differentiated: Non ossifying fibromas should be left to spontaneous healing. Solitary bone cysts in the upper limb should be treated by puncture only when they show great activity, otherwise they can be left to spontaneous healing, too. In the lower limb active cysts with or without fracture should be operated, while inactive cysts should to be cured by puncture only.

[Traumatic hip injuries in the growth stage]

Injuries to the hip joint during growth are rare, but can nevertheless be problematic. Many of the complications described in the literature can be avoided by immediate, low-stress, but adequate therapy. With such an approach, however, fateful complications such as head necrosis cannot be avoided with absolute certainty. Therefore, management of such injuries must include correct enlightenment of the patient's parents and systematic follow-up of the patient, in order to identify complications which might have a negative influence on the prognosis and to treat them at an early stage.

Nonosseous lesions of the anterior cruciate ligaments in childhood and adolescence

Damage of the knee joint has increased during the last few years owing to overindulgence in sports. The anterior cruciate ligaments play a major role in knee joint stability. Treatment of injured knee joint structures in childhood and adolescence is more complicated than in adults. From 1972 to 1987 we have seen 330 patients with knee injuries, 28 of whom had nonosseous lesions of the anterior curciate ligaments. Of these, 20 were followed-up; 17 children were operated on primarily, 3 were conservatively immobilized. On follow-up, 15 patients showed signs of residual instability. Primary treatment depends on the presence and the extent of associated injuries of the knee joint.

[Foot dislocation in the child]

Fibulotalar distortions of the ankle are differentiated from distortions with and without instability, as well as instabilities with and without decompensation. Physiological lateral tilting of the talus is shown to be dependent on age and sex as well as on the kind of ligament lesion--avulsion or rupture--likewise dependent on age. The factors involved in the early or late prognosis are discussed. A prospective study is introduced, which differentiated is between primary and secondary distortions or more. Primary distortions (without an osseal lesion) are treated conservatively. Secondary additional distortions with no case history of compensation for the instability are treated operatively, as are avulsions with displaced osseal fragments.

Classification, diagnosis, and treatment of transitional fractures of the distal part of the tibia

I studied the anatomical relationships in thirty-two transitional fractures of the distal part of the tibia by standard radiography and in thirteen of these patients by computerized axial tomography. Three different configurations of fractures could be identified: biplane fractures and two different types of triplane fractures (Type I and Type II). In the biplane lesion the fracture is restricted to the epiphysis, while the triplane fractures are characterized by a wedge of metaphyseal bone. In the Type-I triplane lesion the metaphyseal portion of the fracture ends in the physis, while in the Type-II triplane lesion the metaphyseal portion of the fracture line extends through the physis into the epiphysis and the joint. On the anteroposterior radiograph, the epiphyseal fracture line in both the biplane and the two types of triplane fractures may be found anywhere from the extreme medial to the extreme lateral position. Its location, however, is exclusively dependent on the maturity of the distal tibial physis and is not influenced by the mechanism of injury. The use of computerized axial tomography has revealed the true dimensions of these fractures, and the diagnosis of biplane and triplane fractures can now be made by standard radiography alone. However, the evaluation of undisplaced or only slightly displaced Type-II triplane fractures will still occasionally require the use of computerized axial tomography. Displaced transitional fractures with a fracture gap of more than two millimeters in the weight-bearing portion of the epiphysis require open reduction. If the gap is less than two millimeters, non-operative treatment with a plaster cast is sufficient.

[Epiphyseal fractures and epiphysiolyses of the distal tibia]

In the years 1979, 1980 and 1981 a follow-up of 72 epiphyseal of the distal tibia was made. Half of the cases of epiphyseal fractures were treated conservatively, the other half operatively. Epiphysiolyses were treated conservatively without exception. In both groups disturbances of growth with partial closure of the growth plate and following malgrowth were found. The statistic evaluation of the case histories showed neither a sign of the cause nor a definite primary therapeutic influence on the disturbance of growth. On the basis of these results the classification effected to date of the epiphyseal traumas as well as their prognosis will be critically examined. From the clinicotherapeutic point of view epiphyseal fractures must be classified as joint lesions and epiphysiolyses as shaft fractures, even if the later are still lesions of the growth plate if considered from an anatomical point of view. On the basis of a clinically-orientated new classification of growth plate lesions, therapeutic principles are discussed.

The fracture of the proximal end of the radius in adolescence

According to a follow-up of 50 fractures of the proximal end of the radius in adolescence the cause and prevention of later persisting functional disturbances, posttraumatic valgisation of the elbow axis and posttraumatic growth disturbances are investigated. Furthermore, the limitations of spontaneous correction of malposition in this area during further growth should be defined. Contrary to current opinion prevailing till now in the literature, not the primary tilt, but the performed therapy turned out to be the cause for later functional disturbance: we found significantly more frequently functional restriction of pro-supination after closed or open repositions than after primary casts without any reposition. The primary malposition of the fracture has no influence on this result just as little as the remaining malposition at consolidation. Furthermore, we noted that the spontaneous correction of malposition in further growth is far more than assumed up to now: all still noticeable malpositions at consolidation up to maximum 65 degrees were corrected again spontaneously in further growth. The posttraumatic valgisation of the elbow axis showed no dependence most of all upon therapy or malposition. According to the results we recommend the following therapeutical procedure for this fracture, using to the full the correcting forces of the growing skeleton, noe performing any reposition, neither closed nor open. With that, the posttraumatic disturbance of nutrition of the proximal end of the radius should be kept to a minimum, furthermore the frequency and extent of the restriction of prosupination diminished resp. avoided. For tilts over 60 degrees as well as displacements and latus over half the width of the shaft we recommend open reposition, if possible without any fixation.

[Fracture of condylus radialis humeri during skeletal growth (author's transl)]

A long term follow-up study of 54 fractures of the lateral condyle of the humerus was done to assess their special problems during the period of skeletal growth. It was demonstrated, that valgisation of the carrying angle will always be a result of an increasing displacement of the peripheral fragment. Furthermore it was shown that the most significant growth disturbance following this fracture is a partial stimulation of the radial part of the growth plate. This leads to radial overgrowth and thereby to varus deformity of the axis of the elbow joint. The extent of this varus deformity is significantly dependent on the time interval between fracture and consolidation. The premature partial closure of the radial side of the growth plate is of no importance clinically. The causes for general growth disturbance as well as fishtail deformities are shown. To eliminate instability of the fracture and to reduce the duration of the consolidation period a metaphyseal AO-screw for compression osteosynthesis is recommended.

[Conservative treatment of finger fractures during growth period (author's transl)]

The subject dealt with is the prognosis of residual axis deviations following finger fractures in the growing phase. By means of individual examples it is shown that the axis deviation in the frontal plane does not undergo any correction during further growth, whereas the axis deviation in the movement plane - the sagittal plane - can still be completely corrected even in cases of premature joins. Thus the limits of conservative treatment are shown: fractures with axis derivation in the sagittal pland can in most instances be treated conservatively. Fractures with axis deviation in the frontal plane, on the other hand, are better treated operatively, if up to consolidation there is no certainty of stabilizing the correction of this fault by the conservative method.

[The supracondylar fracture of the humerus in children (author's transl)]

To find out the cause of posttraumatic varus and valgus deformity of the elbow a long-term follow-up examination of 183 dislocated and 20 undislocated supracondylar extension-fractures of the humerus was done. There were different methods of treatment: In most of the cases closed reduction was performed and fixation in acute angle-plaster or by percutaneous radial or radial and ulnar wires. 75% showed radiologically and 55% clinically an alteration of the carrying angle. The clear reason for this deformity was a rotation displacement, which leads in oblique fractures directly, in transverse fractures--caused by an instability--indirectly seldom to a valgus, in most of the cases to a varus deformity of the elbow. A special quotient to judge the rotation displacement is presented: the rotation failure quotient (rfq). There is no influence of lateral compression to the carrying angle. Lateral tilting is in any case a result of rotation displacement. Growth disturbance after supracondylar fractures is possible without lesion of the epiphysial plate: but as growth disturbances are seldom and their extent small, they are of no significant clinical importance. Extension displacement of the distal fragment will be spontaneously corrected in ca. 80% of all cases during the further growth. The clinical importance of posttraumatic deformities and the primary management to avoid them is discussed. The crossed percutaneous rotation-stable wire osteosynthesis is recommended as the best way of treatment. For all kinds of treatment the challenge is asked to avoid the ventral spur as a sign of rotation till consolidation of the fracture. By correct reposition in all other planes complicated measurements and reflections, as for instance the alpha-angle by Baumann, oblique or transverse fracture, pro- or supination of the forearm during fixation a.o. are unnecessary.

[Overgrowth (of the femoral shaft) and rotational deformities following femoral shaft fractures in childhood (author's transl)]

A follow-up study of 149 pediatric fractures of the femoral shaft (146 patients had a radiographic control) demonstrated a significant influence of multiple reductions and residual axial deviations on the incidence and extent of post-traumatic overgrowth. The presented group of patients did not show a positive correlation between therapeutic shortening at the time of the initial reduction and reduced incidence of long term overgrowth. Neither extent nor incidence of overgrowth could be prevented by this method. We therefore recommend to reduce fractures of the femoral shaft without forshortening, because it stimulates repair mechanisms at the growth plate and enhances overgrowth. In contradiction to the current concept of therapeutic recommendations it could be shown that post-traumatic rotational deformities will correct themselves in the course of physiologic detorsion of the femoral neck. In 67% of the studied group of patients initial errors of rotation corrected themselves by this mechanism. According to our results the therapeutic concept of pediatric femoral shaft fractures is revised and a new concept of initial and long term treatment is proposed.