A series of four agreement studies (classification sessions) were conducted to support the development and validation of a comprehensive pediatric long bone fracture classification system. This system follows the principle of the Müller-AO classification for long bones in adults and integrates most relevant existing pediatric classification systems. The diagnosis includes the distinction between epiphyseal (E), metaphyseal (M), or diaphyseal (D) fractures, as well as identification of child-specific features. This article describes the proposed system in some detail. Digital standard preoperative anteroposterior and lateral radiographs from 267 consecutive pediatric patients (<16 years old and open physis) with single fractures of the distal humerus, radius, or tibia were collected at a single university children's hospital. Fractures were classified independently by five experienced pediatric surgeons. The classification process was assessed for reliability using the kappa coefficient and accuracy using latent class modeling separately for each bone for bone type, and separately for each bone type for child codes. At the last classification session, kappa values for E-M-D and child code classifications were mostly above 0.90, and accuracy estimates were between 75% and 100% for different surgeons, types, and bones. Disagreement and misclassification of fractures were overall very low; hence, experienced and trained surgeons can classify pediatric long bone fractures using the proposed system with high accuracy based on standard radiographic views. The authors encourage wide consultation and further evaluation of this proposed pediatric long bone classification system with a larger number of future users with different training before being used for documentation and clinical studies.
Road traffic accidents often cause serious physical and psychological sequelae. Specialists of various medical faculties are involved in the treatment of accident victims. Little is known about the factors which might predict psychiatric disorders, e.g. Posttraumatic Stress Disorder (PTSD) after accidents and how psychological problems influence physical treatment. In a prospective study 179 unselected, consecutively admitted road traffic accident victims were assessed a few days after the accident for psychiatric diagnoses, severity of injury and psychopathology. All were inpatients and had to be treated for bone fractures. At 6-months follow-up assessment 152 (85%) of the patients were interviewed again. Of the patients, 18.4% fulfilled the criteria for Posttraumatic Stress Disorder (DSM-III-R) within 6 months after the accident. Patients who developed PTSD were injured more severely and showed more symptoms of anxiety, depression and PTSD a few days after the accident than patients with no psychiatric diagnosis. Patients with PTSD stayed significantly longer in the hospital than the other patients. Multiple regression analysis revealed that the length of hospitalization was due mainly to a diversity of factors such as severity of injury, severity of accident, premorbid personality and psychopathology. Posttraumatic stress disorder is common after road traffic accidents. Patients with PTSD at follow-up can be identified by findings from early assessment. Untreated psychological sequelae such as PTSD cause longer hospitalization and therefore more costs than in non-PTSD patients.
Summary: Bone has the ability to regenerate and remodel itself. In the clinic circumstances appear when bone defects do not heal spontaneously. These situations frequently result from trauma, congenital abnormities, infection or tumor resection. Hence, filling of the resulting defect by bone transplantation is a common practise with an increasing value in the re‐establishment of the musculoskeletal system to promote bone healing. Since decades, efforts have been put to improve the effectiveness of bone substitutes. Conventional approaches with the use of ivory, animal and also human bone were not satisfactory. Negative effects like allergic reactions, rejection reactions, inflammations and other problems occurred. These led to implant failure, non union and amputation, to only mention a few. The introduction of bone banks and the development of standards in bone transplantation brought up the false hope to find a final solution for the treatment of bone loss. Disease transmissions (HIV) by allografts caused critical discussions. Despite all efforts, transplantation of autogenous cancellous bone is still the “gold standard” to induce bone healing. However, autografts are only limited available and are accompanied with high morbidity and mortality during the harvest. The problems associated with autologous and allogenous bone grafts promoted the development of multiple organic and inorganic bone substitutes. Well established substitutes at the present are demineralised bone matrix (DBM), composites and calcium phosphates (hydroxyl apatite and tri‐calcium phosphate). These osteoconductive substances have shown to improve new bone formation. Nevertheless, clinical application of these materials is merely successful in a good bony environment but does not induce large progress in critical bone defects.
We assessed narrowing of the spinal canal in 39 burst fractures and fracture-dislocations of thoracolumbar vertebrae treated by the AO Internal Spinal Fixator, using CT preoperatively and at various stages postoperatively. Computer-aided planimetry was used to measure the narrowing, and its restoration shortly after instrumentation, or at 15 months. The mean initial reduction of canal area was to 63.7% +/- 18.8% of normal; this was restored to a mean of 95.4% +/- 21.2% of normal when measured either soon after surgery or at 15 months (p < 0.001 for both groups). There was more improvement in cases assessed later. For fractures from D12 to L3, the mean canal area was restored to 99.4% of normal; but at L4 or L5 the mean restitution was to only 60.9% (p < 0.05). We found no correlation between preoperative loss of area and amount of restoration, or severity of neurological deficit. Nor was there any correlation between the delay before surgery and the improvement achieved. The mechanism of fracture reduction appears to be a combination of distraction ligamentotaxis and forced hyperextension.
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