Purpose: X-Rays are presented on CD’s in a digital format with increasing frequency. The impression is that this technique requires more time to present a given x-ray compared to conventional pictures.

Methods: Time was measured for 6 orthopaedic residents presenting the most recent ap-view out of a given set. Ten sets of 6 x-rays for each case were saved in the conventional and digital format each. The order was randomised. As a precondition the computer was on and the same viewer software was used for all digital sets. The results were compared using a non linked student’s t-test (significance level p=0,05).

Results: Presentation of conventional x-rays required 21 sec (+− 7,46), of digital x-rays 90 sec (+− 27,56) respectively (p< 0,001).

Conclusions: In spite of ideal conditions digital x-rays on CD need significant more time in the orthopaedic clinic. In major centres patients present with different software and software in other languages which increase the required time even furhter. This latter problem will be assessed in another study.

Significance: This increase of preparation time used by a highly qualified staff member has implications on economics and logistics.

Introduction: The variety of operative procedures for neglected Monteggia lesions reflect the difficulty to securely keep the radial head relocated. The amount and direction of angulation in case of an ulnar oste-otomy can only be defined intraoperatively by empirically searching for the appropriate position since the primary ulnar deformity has already partially or completely remodelled with growth in most cases.

Material and Methods: Retrospective study. From Janu-ary 1998 to May 2001 14 patients with late missed Mon-teggia lesions (Bado type I) underwent an osteotomy and external fixation (Hoffmann II compact, Howmed-ica) of the ulna combined with an open reduction of the radial head but without reconstruction of the anular ligament. The average age of 7 girls and 7 boys at the time of reconstruction was 9 years (5 to 15 years), the mean interval between the primary trauma and the reconstructive procedure 21 months (2 weeks to 7 years). Removal of the external fixator:12 weeks (7 – 16 weeks).

Results: In 12 patients the radial head remained located, in 2 patients it re-dislocated postoperatively. After early postoperative closed reduction in one patient and open relocation of the radial head in the other patient with modification of the external fixation, the radial head remained located. Preoperatively 7 of the 14 patients showed a decreased range of motion which improved postoperatively in most cases. Thirteen of the 14 patients had a clinical and radiological follow-up 14 months (3 – 44 months) after the reconstructive procedure. There were no complications.

Conclusions: Ulnar osteotomy, external fixation and open reduction of the radial head without ligament reconstruction or transarticular wire fixation proved to be a technically simple and safe procedure. It allows early functional after treatment without plaster. In case of posttraumatic overlength of the radius, it can be combined with acute or gradual lengthening of the ulna. Radio-humeral joint reconstruction in case of incongruency of the radial head and the capitullum, as well as reconstruction in adults with longstanding dislocation of the radial head are prone to failure.

Introduction: Closed reduction and percutaneous pinning techniques for displaced supracondylar fractures of the humerus in children have overcome disastrous ischemic complications and long inpatient treatment. Closed reduction of those highly unstable fractures and the demanding pin placement itself are potential sources of failure for the inexperienced reflected by the rate of cubitus varus which is still about 5 to 15% in recent series. Rotational primary and residual displacement has to be appreciated to prevent permanent cosmetic deformity. Malrotation is the major source of instability since bicolumnar support is lost which allows the distal fragment to tilt.

Anatomy: The transverse section of the distal humerus is the key to all stability related problems faced in supra-condylar fractures of the humerus in children. In the supracondylar region the radial and ulnar column are only connected by a thin bony wafer which results from the presence of the cubital and olecranon fossa. In case of a fracture. In case of a fracture rotation leads to decrease of bony contact and hence to instability.

Epidemiology: Elbow fractures account for 7–10% of all pediatric fractures whereof 80–90% are located at the distal humerus with 80% involvement of the supracondylar region. Most of the supracondylar fractures occur between ages 5 and 10 years.

Mechanism of injury: Fall from a height, usually from a household object in the age group < 3 years or from a playground equipment in children > 4 years on the outstretched nondominant arm (indirect elbow trauma). 96% of all supracondylar fractures are extension type injuries. Open fractures, mostly grade 1, occur when the anterior spike of the proximal fragment pierces through the brachialis muscle and the skin of the cubital fossa. Their incidence is about 1–3% in major referral centers.

Differential diagnosis: Supracondylar fractures have to be differentiated from transcondylar fractures and dislocations of the elbow. In a supracondylar fracture the fracture line stays proximal to the distal humerus physis. If it runs across it, it is most likely a supracondylar fracture. Dislocations of the elbow typically after the age of 10 years.

Neurologic compromise: Fracture related peripheral neuropathies have an incidence of 10 to 17%. With rare exceptions concomitant nerve lesion recover spontaneously within a time range of 1 to 4 months. The rate of iatrogenic nerve injuries is 3%–16% with the ulnar nerve being the most susceptible due to inadvertent pinning. Despite a high recovery rate, they are a nuisance for the patients.

Vascular compromise: Early recognition of vascular compromise with subsequent reduction and fixation of the fracture and avoidance of extreme flexion at the elbow have decreased the incidence of ischemic complications. An initially absent radial pulse is found in up to 19% in displaced fractures. Closed reduction restores pulsation in about 80%. Patients with postreduction lack of pulse or poor capillary refill should undergo vascular revision. There is still controversy regarding the management of a post reduction pink, warm but pulse less hand with adequate capillary refill. Simple observation and conservative management leads to a favourable clinical outcome in most cases but cold intolerance or exercise induced ischemic symptoms is a potential sequel.

Treatment:

Undisplaced fractures: simple immobilisation e.g. collar and cuff

Incomplete displacement: in case of malrotation and/or age-related unacceptable extension (> 20° in patients older than 6 years) closed reduction and pinning otherwise conservative management

Complete displacement: Attempt for closed reduction and percutaneous pinning. Irreducibility is found in up to 22%. Open reduction is most widely as a last resort.

Complications:

Infection

Occasionally, superficial infection after pinning occurs despite all preventive measure (wires left protruding through the skin should not be covered by plaster to prevent rubbing; pin care instruction for the parents; regular follow-up for pin site inspection)

Cubitus varus

Most common complication with an overall incidence of about 20%. As a malunion in the coronal plane it has no capacity for remodelling. Although this deformity is mainly a cosmetic problem and does not interfere with the range of motion, it may be a functional problem in some activities e.g. in apparatus gymnastics.

Malunion/Stiffness

Even after perfect reduction, lack of full extension is common and usually takes over 6 months to improve. Impaired range of motion may be prolonged or even persistent due to an underlying pathology. Malunion is the most common one. In the sagittal plane, antecurvation leads to hyperextension and reduced flexion of the elbow. Significant remodelling with growth can only be expected below the age of 6 and in antecurvations of less than 20°. Rotatory malunion with an anterior spur restrains flexion. Complete remodelling of the spur usually takes place even in older children. Volkmann’s contracture represents the most severe complication after supracondylar fractures. Fortunately, it has become a rarity.

Conclusion:

The human factor, in view of the particular anatomy of the supracondylar region and the extreme fracture instability seems to be more decisive for the end result than any biomechanical differences of various pin configurations. Repeat instruction by an experienced surgeon for proper reduction technique, assessment of achieved reduction and technically correct pin placement is crucial to further improve the outcome of this challenging fracture.

Modern concepts in paediatric fracture respect individual, social and economic needs:

the patient’s demand for early mobility and capability to play

The decision between conservative and operative treatment is based on the radiological assessment of fracture stability. Fractures with fragments in contact and at most with some angulation but no shortening may be termed stable. Conservative treatment on an outpatient basis is adequate: plaster immobilization and wedging of the plaster in case of a primary or secondary angulation. Fully displaced fractures or long oblique fractures with a strong tendency for shortening as well as comminuted fractures are unstable. Stable fixation with a child-adapted implant is required: closed reduction, minimal approach, satisfying scars, early full weight bearing, short hospital stay, and a minimal procedure for metal removal are achieved either by external fixation or elastic intramedullary nailing dependent on the fracture pattern and the surgeon’s preferences.

Humeral shaft fractures are the domain of non-operative treatment: immobilization e.g., with a U-plaster followed by functional bracing (Sarmiento) is efficient and more comfortable than a heavy hanging cast. Retrograde intramedullary nailing is indicated in open fractures, multiple injury patients, arterial injuries and compartment syndromes, or if conservative treatment does not lead to a satisfactory alignment. Concomittant radial nerve palsies: since natural history is excellent, observation instead of primary exploration is recommendable. Forearm: in case of complete fractures, closed reduction and plaster immobilisation is only justified if one of both bones is stable. If not, primary elastic intramedullary nailing prevents posttraumatic deformities and loss of function. Femur: Non-displaced fractures (less than 10° angulation in the sagital plane, no varus or valgus deformity, no malrotation) as well as displaced fractures in children younger than four years can be treated with a hip spica. In older children closed reduction followed by external fixation or elastic intramedullary nailing provides early stability and a quick return to play and school. Shortening and angulations with a subsequent high remodelling activity should be avoided in order to prevent femoral overgrowth. Lower leg: Most isolated tibial fractures (intact fibula) are managed conservatively in a long leg plaster. Radiological monitoring is recommended to detect secondary varus deformites which can be easily reduced by wedging of the plaster after 8 to 10 days. Fully displaced transverse tibia fractures and unstable fractures of the tibia and fibula – oblique fractures with shortening or fully displaced fractures – are either stabilised by external fixation or elastic intramedullary nailing.