The treatment of fractures in children and adolescents must be based on an adequate knowledge of the physiology of the growing skeleton. Treatment failures usually do not result from technical deficiencies, but rather from a misunderstanding of the special considerations applying to the treatment of fractures in this age group. We selectively reviewed recent publications on the main types of long bone fracture occurring in the period of skeletal development. Alleviating pain is the first step in fracture management, and due attention must be paid to any evidence of child abuse. The goals of treatment are to bring about healing of the fracture and to preserve the function of the wounded limb. The growth that has yet to take place over the remaining period of skeletal development also has to be considered. Predicting the growth pattern of fractured bones is a basic task of the pediatric traumatologist. During the period of skeletal development, conservative and surgical treatments are used in complementary fashion. Particular expertise is needed to deal with fractures around the elbow, especially supracondylar humeral fractures, displaced fractures of the radial condyle of the humerus, radial neck fractures, and radial head dislocations (Monteggia lesions). These problems account for a large fraction of the avoidable cases of faulty fracture healing leading to functional impairment in children and adolescents. The main requirements for the proper treatment of fractures in children and adolescents are the immediate alleviation of pain and the provision of effective treatment (either in the hospital or on an outpatient basis) to ensure the best possible outcome, while the associated costs and effort is kept to a minimum. Further important goals are a rapid recovery of mobility and the avoidance of late complications, such as restriction of the range of motion or growth disorders of the fractured bone. To achieve these goals, the treating physician should have the necessary expertise in all of the applicable conservative and surgical treatment methods and should be able to apply them for the proper indications.

Background: The 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.Methods: Using 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.Results: The 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.Conclusions: In 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.

Elastic stable intramedullary nailing (ESIN) is currently the therapy of choice in unstable, transverse and short oblique femoral and tibial-fibular shaft fractures in childhood and adolescence. As with every intramedullary technique, it requires a greater intraoperative reliance on radiological imaging. Literature concerning intraoperative radiation load in ESIN is rare, results having a wide range from less than 1 minute to more than 15 minutes. We performed a retrospective analysis of 53 femoral and 24 tibial shaft fractures. In addition, image intensifier times of several steps of the operative procedure in 10 femoral shaft fractures were evaluated prospectively. The average radiation time in femoral fractures was 70.3 (range, 12-193) seconds, in tibial shaft fractures, 42.4 (range, 16-108) seconds. The prospective analysis of femur shaft fractures was able to show the most intense use of imaging during fracture passage (43.2%) and placement of the nail tips (26.6%). Image intensifier times in educational operations were not significantly higher than in operations performed by experienced surgeons. The actual intraoperative radiation load is influenced by bone mass and soft tissue coverage. Surgeons are able to reduce it only by decreasing the fluoroscopy time. According to our results, image intensifier time should not exceed 3 minutes in ESIN of femoral shaft fractures and 2 minutes in ESIN of lower-leg fractures. Low intraoperative radiation times are a mark of quality with respect to the interests of patients, surgeons, and operation theater staff.

Background: Although calcification of the Achilles tendon has been described by several authors, a detailed evaluation of its frequency and effects on clinical outcome has not been reported. The purposes of this work were to determine the frequency of calcifications in the Achilles tendon after open repair and their effects on clinical outcomes and to identify possible risk factors for postoperative calcification. Methods: Thirty-six patients with open Achilles tendon repair were evaluated at an average followup of 19 months. Evaluation included a self-assessment questionnaire concerning treatment outcomes, clinical examination, and radiographic and ultrasonographic examinations. Results: No patient had calcifications in the Achilles tendon area before surgery. Postoperatively, intratendinous or peritendinous calcifications, ranging in size from 3 mm to 37 mm, were found in 10 (28%) of the 36 patients. The development of calcifications was associated with chronic swelling, decreased range of motion of the ankle joint, and increase pain, especially with calcifications larger than 10 mm. No association was found between the development of calcifications and the surgical technique, suture materials, time from injury to surgery, or postoperative management, and no risk factors could be identified. Conclusions: Calcifications of the Achilles tendon appear to be frequent after open tendon repair and to have a negative effect on clinical outcome.

Background: Dislocations of the sternoclavicular joint (anterior/posterior) and acromioclavicular joint (SCJ and ACJ, respectively) are rare injuries in childhood/adolescence, each having its own special characteristics. In posterior SCJ dislocation, the concomitant injuries in the upper mediastinum are most important complication, while in anterior SCJ dislocation there is a risk of permanent or recurrent instability. Methods: In a retrospective analysis from seven pediatric trauma centers under the leadership of the Section of Pediatric Traumatology of the German Trauma Society, children (<18 years) were analyzed with focus on age, gender, trauma mechanism, diagnostics, treatment strategy and follow-up results. Additional epidemiological big data analysis from routine data was done. Results: In total 24 cases with an average age of 14.4 years (23 boys, 1 girl) could be evaluated (7x ACJ dislocation type ≥ Rockwood III; 17x SCJ dislocation type Allman III, including 12 posterior). All ACJ dislocations were treated surgically. Postoperative immobilization lasted 3–6 weeks, after which a movement limit of 90 degrees was recommended until implant removal. Patients with SCJ dislocation were posterior dislocations in 75%, and 15 of 17 were treated surgically. One patient had a tendency toward sub-dislocation and another had a relapse. Conservatively treated injuries healed without complications. Compared to adults, SCJ injuries were equally rarely found in children (< 1% of clavicle-associated injuries), while pediatric ACJ dislocations were significantly less frequent (p<0.001). Conclusions: In cases of SCJ dislocations, our cohort analysis confirmed both the heterogeneous spectrum of the treatment strategies in addition to the problems/complications based on previous literature. The indication for the operative or conservative approach and for the specific method is not standardized. In order to be able to create evidence-based standards, a prospective, multicenter-study with a sufficiently long follow-up time would be necessary due to the rarity of these injuries in children. The rarity was emphasized by our routine data analysis.