Neurological examination in children presenting with upper limb fractures is often poorly performed. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our own hospital and performed a further 3 month clinical review to detect any resulting change in practice. In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination. Following introduction of the guideline, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. Introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown. This study wants to identify the factors determining a patient's recovery after surgical treatment of compression fractures of the thoracolumbar spine. Therefore, in 31 surgically treated patients the pre-injury versus the 12-month follow-up differences in back pain, in global outcome and in participation were prospectively recorded. For this, the visual analogue scale for pain (VAS scale) and the Greenough and Fraser low back outcome scale were used. Of the latter scale, the 3 questions pertaining to participation were combined to create a participation subscale. For these differences and for time lost from work multiple linear regressions with combinations of 16 possible predictors were performed.

At one year patients who smoke report a 25% less favorable global outcome and return 2.8 points (out of 10) less closely to their pre-injury pain level than patients who do not smoke. Patients with a fracture at the thoraco-lumbar junction return 3.3 points less closely to their pre-injury level on the VAS scale than those with a lumbar fracture. For each decrease in 1 of the 3 education levels, the patients stay away from work 15 weeks longer. Per degree of sagittal index at follow-up, patients stay 9 days longer at home. For each increase in level of occupation the return to the pre-injury participation level is 10% less favorable. The variability of time lost from work and of recovery of global outcome, pain and participation level explained by our models is 73%, 37%, 25% and 13% respectively.

Smoking, localization of the fracture at the thoraco-lumbar junction and a high pre-existent level of occupation are strong negative predictors for recovery. A lower education level and sagittal fracture deformity at follow-up are negative predictors for sick leave but might also reflect the concerns of the physician when deciding about return to work.

Objectives

To determine the limits of spinal displacement before the onset of neurophysiological changes during spinal surgery. Assessing if the type of force applied or the section of the adjacent nerve roots increases the tolerance to displacement.

Aims

The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated.

INTRODUCTION. Surgical correction of spinal deformities in the growing child can be applied with or without fusion. Sublaminar wiring, first described by Luque, allows continuation of growth of the non-fused spine after correction of the deformity. Neurological complications and wire breakage are the main clinical problems during the introduction and removal of currently used sublaminar wires. In this pilot study a posterior hybrid construction with the use of a medical-grade UHMWPE (Dyneema Purity®) sublaminar wire was assessed in an ovine model. We hypothesized that such a hybrid construction can safely replace current titanium laminar wires, while providing sufficient stability of the non-fused spinal column with preservation of growth. MATERIALS AND METHODS. This study included 6 Tesselaar sheep, age 7±2months. Two pedicle screws (Legacy system, Medtronic) were placed at lumbar level. Four consecutive laminae were attached to two titanium bars (4.5 mm) using 3 mm diameter UHMWPE (Dyneema Purity®) on the left side and 5 mm diameter on the right side. The sublaminar wires were fixed with a double loop sliding knot and tightened with a tensioning device. As a control, in one animal titanium sublaminar wires (Atlas cable, Medtronic) were applied. After sacrifice the spine of the animals was harvested. Radiographs were taken and CT scans were performed. The vertebrae were dissected and placed in formaldehyde for macroscopic and histological evaluation. RESULTS. The animals were sacrificed after a (minimal) postoperative period of 15 weeks. One animal developed a wire fistula and one animal died the first postoperative day due to complications of the anesthesia. None of the 3 or 5 mm knots loosened and no neurological complications occurred. An average of 8.7 mm growth was seen over the segment operated on. Computed tomography confirmed the preserved stability. Even though no decortication was performed, variable bone bridges with fused levels were seen on CT. Macroscopic and histological analysis showed no inflammation at lamina and dura levels containing Dyneema Purity®, with the exception of the case with the fistula where it was observed locally. DISCUSSION. This pilot animal model study shows that the UHMWPE laminar wire made by Dyneema Purity® has good handling and tensioning properties and can provide sufficient stability in fusionless spinal instrumentation while allowing substantial growth. The examined model showed to be a feasible spinal study model, without occurrence of neurological problems. Reactive periostal bone formation with fusion levels led to some restrictions in this model. In the future it will be necessary to test the described construction in a large animal scoliosis model

Purpose of the Study. At our Department, we prefer surgical treatment of all patients with Type II and III fractures of the dens, regardless of the age, with the exception of non-displaced fractures or perfectly reduced fractures in young patients. Material and Methods. We treated surgically 28 patients 65 years old and older with dens fractures. The group consisted of 13 men and 15 women with a mean age of 77.4 years (range, 65–90 years). According to the type of treatment, anterior srew fixation or posterior C1–C2 fixation, the whole cohort was divided into 2 groups that were subdivided into two age groups of patients 65–74 years old and 75 years old and older. The age group of patients 65–74 years old included 8 patients with a mean age of 68.5 years and the mean age of the age group of patients 75 and more years old was 81 years. The injury was caused in 22 cases by a fall, in 5 by a car accident. Only in 1 case the injury was caused differently. Neurological deficits were found in three patients, all of them Frankel D type. All patients with injury to the dens underwent radiograph examination in the lateral and transoral projections and CT scan including the sagittal and frontal reconstructions of the atlantoaxial complex and in most cases also MRI examination to eliminate injury to the transverse ligament of the atlas. Based on these examinations, the type of injury was determined and method of treatment indicated. Final retrospective evaluation of the patients was carried out at the interval of 12 to 78 months after the primary surgery (mean 31.3 months) taking into account aetiology of the injury, type of injury, neurological finding, method of treatment, union of the dens fracture line or, where appropriate, C1–C2 fusion, stability of the spine and the final outcome. Statistical analysis was based on X2-test. Results. Comparison of the two age groups showed a statistically significant difference in the mortality (p<0.05), with 0% in the younger group and 40% in the older group. In total, mortality within 6 weeks after the injury accounted for 28.6%. Comparison of surgical techniques revealed 21.4% mortality after anterior screw fixation of the dens and 35.7% mortality after posterior instrumented fusion. The difference was statistically insignificant (p>0.05). Of the 20 surviving patients, 11 were treated with anterior screw fixation and 9 with posterior instrumented fusion. In the two groups there was only one case of nonunion of the dens (9.1%) and one fibrous callus in the region of C1–C2 fusion and the fracture line in the dens (11.1%). The difference was again insignificant (p>0.05). Conclusions. Active surgical treatment conduces considerably to the improvement of the quality of life of elderly patients after dens fractures. Surgical technique should be tailored to the patient's general condition, and osteoporosis and degenerative changes of the spine in particular. Mortality is influenced by the patient's age rather than by the surgical technique used. Elderly patients with a neurological deficit mostly die of associated diseases regardless of the method of treatment

INTRODUCTION. Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. MATERIAL. All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0–9, 10–14, 15–18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up. RESULTS. During 1996 through 2005, we treated a total of 15 646 patients with injury to the skeleton, aged 0 to 18 years. The spine was affected in 571 cases, which is 3.6 %. We used conservative treatment in 528 (92.5 %) and surgery in 43 (7.5 %) children. The group of patients treated conservatively consisted of 292 boys (55. 3 %) and 236 girls (44.7 %); of these 219 (41.5 %) were in the 0–9 year category, 251 (47.5 %) were between 10 and 14 years and 58 (11 %) were 15 to 18 years old (mean age 10.2 years). The most frequent cause of injury was a fall (277; 52.2 %), then sports activity or games (86; 16.3 %), car accidents (34; 6.4 %) and diving accidents (30; 5.7 %). Pedestrians were injured on 25 occasions (4.7 %) and other causes in 76 patients (14.4 %). Thoracic spine was most frequent (340; 64.4 %), multi-segment injury in 124 patients (23.5 %). The TL spine was affected in 22 patients (4.2 %), and lumbar vertebrae were injured in 28 patients (5.3 %). Injury to the cervical spine, both upper and lower, was least frequent, including 4 (0.8 %) and 10 (1.9 %) patients, respectively. None showed neurological deficit. The surgically treated group included 29 (67.4 %) boys and 14 (32.6 %) girls; two (4.7 %) children were between 0 and 9 years, nine (20.9 %) between 10 and 14 years, and 32 (74.7 %) between 15 and 18 years (mean age 15.1 years). The frequent causes of injury were car accidents and falls in 21 (48.8 %) and 14 (32.6 %) children, respectively. Other causes were infrequent. The upper cervical spine was operated on in five (11.6 %), lower cervical spine in eight (18.6 %), thoracic spine in 13 (30.2 %), TL spine in five (11.6 %) and lumbar vertebrae in 12 (27.9 %) patients. Thirty-six (83.7 %) patients had fractures, five had dislocated fractures (11.6 %) and two (4.7 %) had a dislocation. Neurological deficit was recorded in nine (20.9 %). CONCLUSIONS. Childhood spinal injuries account for only 2 to 5 % of all spinal injuries and for 3.6 % of all skeletal injuries in children. The cervical spine is affected most often in younger children, while the thoracolumbar spine in older children. Multi-segment injuries are typical in the childhood spine, particularly in smaller children. Typically, children show SCIWORA and a more rapid improvement of neurological deficit than adults. Conservative treatment is preferred; surgery before 12 years of age is strictly individual, while after 12 years therapy is similar to that used in adults

Aims

Our aim was to analyse the long-term functional outcome of two forms of surgical treatment for active patients aged > 70 years with a displaced intracapsular fracture of the femoral neck. Patients were randomised to be treated with either a hemiarthroplasty or a total hip arthroplasty (THA). The outcome five years post-operatively for this cohort has previously been reported. We present the outcome at 12 years post-operatively.

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children.

Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%).

A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients.

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.