One potential comorbidity after congenital diaphragmatic hernia (CDH) is gastroesophageal reflux (GER), which can have a substantial effect on patients’ quality of life, thriving, and complications later in life. Efforts have been made to reduce gastroesophageal reflux with a preventive anti-reflux procedure at the time of CDH repair. In this follow-up study of neonates participating in a primary RCT study on preventive anti-reflux surgery, symptoms of GER were assessed longitudinally. Long-term data with a median follow-up time of ten years was available in 66 patients. Thirty-one neonates received an initial fundoplication. Secondary anti-reflux surgery was necessary in 18% and only in patients with large defects. It was required significantly more often in patients with intrathoracic herniation of liver (p = 0.015) and stomach (p = 0.019) and patch repair (p = 0.03). Liver herniation was the only independent risk factor identified in multivariate regression analysis. Primary fundopexy and hemifundoplication did not reveal a protective effect regarding the occurrence of GER symptoms, the need for secondary antireflux surgery or the gain of body weight regardless of defect size neither in the short nor in the long term. Symptoms of GER must be assessed carefully especially in children with large defects, as these are prone to require secondary anti-reflux surgery in the long-term. Routine evaluation of GER including endoscopy and impedance measurement should be recommended especially for high-risk patients.

Background: Unstable diametaphyseal radius fractures (DMRFs) can be prone to complications, and treatment strategies are heterogeneous. Studies are difficult to interpret as definitions of the diametaphyseal junction zone (DMJZ) are impractical for clinical use, imprecise, or prone to error. Methods: We introduce the forearm fracture index (FFI) to define DMRFs in radiographs and ultrasound. The FFI is calculated by the ratio of the fracture’s distance to the distal radius growth plate over the width of the radius growth plate. The higher the FFI, the more proximal the fracture is. We define DMRFs to have an FFI between 1 and 2. All DMRFs treated at our institution between 2010 and 2020 were identified, and demographic data, fracture characteristics, and therapeutic strategies were assessed retrospectively. Comparative sub-analysis was performed between DMRFs(−) as defined in previous publications (Lieber in Unfallchirurg 114:292–299, 2011) and DMRFs( +) that were more proximal but still met our criteria. Results: 516 DMRFs were identified, representing 13.0% of all screened radius fractures. Excluding buckle fractures and patients lost to follow-up, 366 DMRFs were eligible for further analysis. Conservatively managed DMRFs were more distal than those managed operatively, represented by a lower FFI (1.28 vs. 1.34, p = 0.0051). 21 (5.7%) of all DMRFs were identified as DMRFs( +). These were significantly more dislocated and necessitated surgery more often than DMRFs(−) (52.4 vs. 24.6%, p = 0.009). Conclusions: The FFI may be a good tool to identify and describe DMRFs. It can help guiding treatment decisions and make future studies on this entity more comparable. Level of evidence: Study of Diagnostic Test, Level II.

Background: Diametaphyseal radius fractures (DMRF) in children pose a challenge to pediatric traumatologists. Numerous techniques to address the problems of conventional osteosynthesis have been published. Still, immobilization in a cast is the treatment of choice in most cases. The aim of this study was to assess risk factors for the failure of conservative treatment in DMRFs. Methods: This is a single-center, retrospective study of 270 patients with conservatively treated DMRFs. Demographic data and radiologic fracture characteristics were assessed. Univariate and multivariate regression analyses were performed to identify risk factors for secondary dislocation, refracture, or secondary osteosynthesis. Significant variables were included in a risk prediction model. Results: Secondary dislocation, refracture, and secondary osteosynthesis occurred in 10.0%, 5.6%, and 11.0%, respectively. Increasing angles of the fracture line, severe angulation, and greenstick fractures were identified to significantly predict either one of these complications. Surprisingly, proximal DMRFs with an increased forearm fracture index were less likely to dislocate secondarily. Conclusions: Conservatively treated DMRFs with severe angulation, tilted fracture lines, and greenstick fractures are more likely to suffer complications. Hence, these fractures should be stabilized with osteosynthesis primarily. The introduced risk prediction tools should be validated prospectively.

Background: Defining risk factors for long-term comorbidities in patients after neonatal repair of congenital diaphragmatic hernia (CDH) is an important cornerstone of the implementation of targeted longitudinal follow-up programs. Methods: This study systematically assessed serial chest radiographs of 89 patients with left-sided CDH throughout a mean follow-up of 8.2 years. These geometrical variables for the left and right side were recorded: diaphragmatic angle (LDA, RDA), diaphragmatic diameter (LDD, RDD), diaphragmatic height (LDH, RDH), diaphragmatic curvature index (LDCI, RDCI), lower lung diameter (LLLD, RLLD) and thoracic area (LTA, RTA). Results: It was demonstrated that the shape of the diaphragm in patients with large defects systematically differs from that of patients with small defects. Characteristically, patients with large defects present with a smaller LDCI (5.1 vs. 8.4, p < 0.001) at 6 months of age, which increases over time (11.4 vs. 7.0 at the age of 15.5 years, p = 0.727), representing a flattening of the patch and the attached rudimentary diaphragm as the child grows. Conclusions: Multiple variables during early follow-up were significantly associated with comorbidities such as recurrence, scoliotic curves of the spine and a reduced thoracic area. Some geometrical variables may serve as surrogate parameters for disease severity, which is associated with long-term comorbidities.

Introduction: Diametaphyseal radius fractures (DMRF) in children are characterized by special biomechanical behavior. They present with a stereotypical loss of reduction (radial translation and ulnar tilt) of the distal fragment when stabilized with elastic stable intramedullary nailing (ESIN), the standard osteosynthesis for pediatric diaphyseal forearm fractures. No consensus has been found on the definition of the diametaphyseal junction zone (DMJZ). Some authors claim that diaphyseal fractures immediately proximal to the metaphysis, as defined by the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO-PCCF), can safely be stabilized with ESIN. They confine the DMJZ to a small part within the metaphysis. Other definitions of the DMJZ extend slightly more proximally, including a small part of the distal diaphysis. The forearm fracture index (FFI) calculates the ratio of the fracture’s distance to the radius’ growth plate over its width and defines DMRF to have an FFI between 1 and 2. The aim of this case series was to demonstrate that these particular fractures, which can be considered diaphyseal according to the AO-PCCF, still exhibit biomechanical characteristics typical of DMRF. Materials and methods: Radiologic and clinical outcomes of 11 DMRF, that would be considered diaphyseal by the AO-PCCF classification but fall into the DMJZ when using the FFI, are being reported. Results: 7 fractures were treated with ESIN and 4 with transepiphyseal percutaneous intramedullary Kirschner-wire (TEPIK) fixation. ESIN osteosynthesis led to only a small reduction in angulation but a notable increase in translational dislocation in the a.p. radiograph, both typical dislocation patterns seen in DMRF. Fractures stabilized with TEPIK, an osteosynthesis technique obeying the biomechanical demands of DMRF, did not present with these stereotypical dislocation patterns. Conclusions: The biomechanical demands typical of DMRF also apply to very distal diaphyseal forearm fractures. Hence, a larger definition of the DMJZ might include all fractures with the characteristic biomechanical behavior.