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Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures. Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children's fractures. The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent-and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend. It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children's fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children.

Background:No high level of scientific evidence exists about the use of asymmetry of skin creases (ASC) on the groin and thigh regions in diagnosing developmental dysplasia of the hip. The aim of this comparative study was to revisit whether or not ASC was a significant clinical finding in developmental dysplasia of the hip.Methods:This was retrospective analysis of a prospectively collected data. Control group was composed of 1000 consecutive healthy infants (mean age, 46.7 d) whose both hips were considered Graf type I (normal). Study group (SG) was composed of 246 consecutive patients (mean age, 96.5 d) whose treatments by abduction bracing were initiated due to unilateral or bilateral Graf type IIa(-) and worse hips.Results:SG included 178 patients with bilateral or unilateral dysplastic hips [Graf type IIa(-), IIb, IIc] and 68 patients with at least 1 decentered hip (Graf type D, III, IV). ASC was seen in 63 of 101 patients (63%) having positive clinical finding(s). The rates of both ASC alone (P0.001; odds ratio, 3.46) and ASC total (ASC with and without additional findings) (P0.0001; odds ratio, 7.48) were significantly higher in SG than in control group. ASC was the only clinical finding in 31 patients and 24 of these 31 patients (77%) had unilateral or bilateral dysplastic hips. Sensitivity and specificity of ASC alone were 12.60% and 96.00%, respectively. ASC was accompanied by other clinical findings (mostly Galeazzi sign and limitation of abduction) in 32 patients and 23 of these 32 patients (72%) had at least 1 decentered hip. Sensitivity and specificity of ASC total were 25.61% and 95.60%, respectively.Conclusions:ASC is a significant finding, as there is considerable increased risk of having dysplastic or decentered hips in infants having such a finding alone or associated with other findings. ASC alone is more commonly seen in patients with dysplastic hip(s) whereas ASC is mostly accompanied with other clinical finding(s) in patients with decentered

Günümüzde çocuk kırıklarının görülme sıklığında belirgin artış görülmektedir. Sosyoekonomik nedenler, yaşam tarzında değişiklikler, gelişen teknoloji, ileri görüntüleme yöntemleri, ortopedik cerrahların eğitimi, velilerin mükemmel sonuç beklentileri, bireysel ve takım sporlarına katılımın artması son yıllarda çocuk kırıklarında tedavi yöntemini cerrahi yönde artırmaktadır. Her ne kadar yukarıda sayılan faktörler tedavi seçimi ve sonuçları etkilese de, ortopedik cerrahların çocuk kırıklarının tedavisinde iyi fonksiyonel sonuç elde edebilmeleri için güncel bilgiler ışığında, çocuk kırıklarının özelliklerini, tedavi prensiplerini, kompleks yaralanmalarda dikkat edilmesi gereken husuları, sonuca etkileyebilecek bireysel faktörleri bilerek tedavi planlaması yapmaları gerekmektedir., There is a significant increase in children's fractures. Socio-economic reasons, change in life-style, advanced technology and imaging techniques, training of orthopedic surgeons, parents excellent result expectations and increased participation in individual and team sports has recently influenced the treatment of pediatric fractures towards surgical procedures. Although the above mentioned factors affect the type of treatment and its outcomes, in order to achieve good functional results, orthopedic surgeons should make their treatment plans in the light of recent knowledge, knowing the properties of pediatric fractures and related treatment principles, issues in complex injuries and individual factors that may affect the overall result.

Günümüzde çocuk kırıklarının görülme sıklığında belirgin artış görülmektedir. Sosyoekonomik nedenler, yaşam tarzında değişiklikler, gelişen teknoloji, ileri görüntüleme yöntemleri, ortopedik cerrahların eğitimi, velilerin mükemmel sonuç beklentileri, bireysel ve takım sporlarına katılımın artması son yıllarda çocuk kırıklarında tedavi yöntemini cerrahi yönde artırmaktadır. Her ne kadar yukarıda sayılan faktörler tedavi seçimi ve sonuçları etkilese de, ortopedik cerrahların çocuk kırıklarının tedavisinde iyi fonksiyonel sonuç elde edebilmeleri için güncel bilgiler ışığında, çocuk kırıklarının özelliklerini, tedavi prensiplerini, kompleks yaralanmalarda dikkat edilmesi gereken husuları, sonuca etkileyebilecek bireysel faktörleri bilerek tedavi planlaması yapmaları gerekmektedir., There is a significant increase in children's fractures. Socio-economic reasons, change in life-style, advanced technology and imaging techniques, training of orthopedic surgeons, parents excellent result expectations and increased participation in individual and team sports has recently influenced the treatment of pediatric fractures towards surgical procedures. Although the above mentioned factors affect the type of treatment and its outcomes, in order to achieve good functional results, orthopedic surgeons should make their treatment plans in the light of recent knowledge, knowing the properties of pediatric fractures and related treatment principles, issues in complex injuries and individual factors that may affect the overall result.

Background:No high level of scientific evidence exists about the use of asymmetry of skin creases (ASC) on the groin and thigh regions in diagnosing developmental dysplasia of the hip. The aim of this comparative study was to revisit whether or not ASC was a significant clinical finding in developmental dysplasia of the hip.Methods:This was retrospective analysis of a prospectively collected data. Control group was composed of 1000 consecutive healthy infants (mean age, 46.7 d) whose both hips were considered Graf type I (normal). Study group (SG) was composed of 246 consecutive patients (mean age, 96.5 d) whose treatments by abduction bracing were initiated due to unilateral or bilateral Graf type IIa(-) and worse hips.Results:SG included 178 patients with bilateral or unilateral dysplastic hips [Graf type IIa(-), IIb, IIc] and 68 patients with at least 1 decentered hip (Graf type D, III, IV). ASC was seen in 63 of 101 patients (63%) having positive clinical finding(s). The rates of both ASC alone (P0.001; odds ratio, 3.46) and ASC total (ASC with and without additional findings) (P0.0001; odds ratio, 7.48) were significantly higher in SG than in control group. ASC was the only clinical finding in 31 patients and 24 of these 31 patients (77%) had unilateral or bilateral dysplastic hips. Sensitivity and specificity of ASC alone were 12.60% and 96.00%, respectively. ASC was accompanied by other clinical findings (mostly Galeazzi sign and limitation of abduction) in 32 patients and 23 of these 32 patients (72%) had at least 1 decentered hip. Sensitivity and specificity of ASC total were 25.61% and 95.60%, respectively.Conclusions:ASC is a significant finding, as there is considerable increased risk of having dysplastic or decentered hips in infants having such a finding alone or associated with other findings. ASC alone is more commonly seen in patients with dysplastic hip(s) whereas ASC is mostly accompanied with other clinical finding(s) in patients with decentered

[No abstract available]

Legg-Calvé-Perthes hastalığı, femur başı epifizinin ar-teriyel kan akımının bozulması sonucu özgün klinik ve radyolojik bulguların görüldüğü bir çocukluk yaş grubu hastalığıdır. En sık 4–8 yaş arası çocuklarda görülür ve erkeklerde kızlara göre 4–5 misli daha fazladır. Kalıtsal nedenler, kemik gelişme gecikmesi, kanda pıhtılaşma bo-zuklukları, Tip II kollajen mutasyonu, hiperaktivite/dikkat eksikliği, travma, pasif sigara içiciliği, hastalığın ortaya çıkmasında rolü olduğuna inanılan başlıca etkenlerdir. Ancak, hastalığın günümüzde muhtemelen birden fazla etkenin varlığında ortaya çıktığına inanılmaktadır. Belli başlı histopatolojik bulgular; sinovit, eklem kıkırdağının derin tabakalarında nekroz, kemik epifizde nekroz, re-zorpsiyon ve yeni kemik oluşumu birlikteliği (rezorpsiyon daha baskın olmak üzere), büyüme plağında bozulma ve metafizyel değişikliklerdir., Legg-Calvé-Perthes disease is a childhood disorder in which specific clinical and radiological findings due to disruption in the arterial circulation of the capital femoral epiphysis are seen. It is most commonly seen in children between 4 and 8 years of age and is 4–5 times more common in boys than in girls. Hereditary influences, delay in bone matu-ration, blood coagulation abnormalities, type II collagen mutation, hyperactivity/attention deficit disorder, trauma, exposure to smoking are the main factors which are con-sidered to correlate with the origination of the disease. However, it is currently believed that the origin is probably multifactorial. Synovitis, necrosis in deep layers of the artic-ular cartilage, necrosis, resorption and new bone formation coupling (being the bone resorption more dominant) in the bone epiphysis, disruption in the physis and metaphyseal changes are the main histopathological findings.

Bu derlemede çocuklarda tiplerine göre kırıkların temel tedavi prensipleri ve fizis kırıkları, çoklu kırıklar, açık kırıklar ve patolojik kırıkları içeren özel durumların genel yönetim prensipleri özetlendi. Yaralanma mekanizmasını daha iyi anlamak, uygun bir tedavi stratejisi belirlemek ve prognozu tahmin etmek için kırığın tanımlanması gereklidir. İyileşme süreci daha az komplike, yeniden şekillenme kapasitesi daha yüksek ve kaynamama seyrek olduğu için çocuklarda kırıklar çoğunlukla cerrahi dışı yöntemlerle tedavi edilir. Çoklu yaralanması olan çocuklarda, açık kırıklarda, bazı patolojik kırıklarda, damar yaralanması eşlik eden kırıklarda, öncesinde başarısız konservatif tedavi öyküsü olan kırıklarda ve femur boyun kırıkları gibi konservatif tedavinin hiç yeri olmadığı/az yeri olduğu kırıklarda, bazı fizis kırıklarında, deplase ekstansiyon ve fleksiyon tipi humerus suprakondiler kırıklarında, deplase humerus lateral kondil kırıklarında, büyük çocuklar ve ergenlerdeki femur, tibia ve önkol cisim kırıklarında, instabil pelvis ve asetabulum kırıklarında cerrahi tedavi tercih edilir. Çocuklarda kırıkların çoğu cerrahi dışı yöntemlerle başarıyla tedavi edilebilir., This review aims to summarize the basic treatment principles of fractures according to their types and general management principles of special conditions including physeal fractures, multiple fractures, open fractures, and pathologic fractures in children. Definition of the fracture is needed for better understanding the injury mechanism, planning a proper treatment strategy, and estimating the prognosis. As the healing process is less complicated, remodeling capacity is higher and non-union is rare, the fractures in children are commonly treated by non-surgical methods. Surgical treatment is preferred in children with multiple injuries, in open fractures, in some pathologic fractures, in fractures with coexisting vascular injuries, in fractures which have a history of failed initial conservative treatment and in fractures in which the conservative treatment has no/little value such as femur neck fractures, some physeal fractures, displaced extension and flexion type humerus supracondylar fractures, displaced humerus lateral condyle fractures, femur, tibia and forearm shaft fractures in older children and adolescents and unstable pelvis and acetabulum fractures. Most of the fractures in children can successfully be treated by non-surgical methods.

Objectives: This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes. Patients and methods: Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9 +/- 2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20 degrees of hip flexion contracture, more than 30 degrees of hip abduction, a negative prone Ely test, less than 50 degrees of popliteal angle and at least 5 degrees of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement. Results: Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures. Conclusion: Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.

Paper submitted at the 37th EPOS Annual Meeting, Oslo, Norway, April 11-14, 2018 published in this Special Issue of J Child Orthop., Purpose The aim of this article is to review the current concepts in the indications, results and failure causes of the treatment of developmental dysplasia of the hip (DDH) with the Pavlik harness. Methods: The reported variables influencing the outcome in the Pavlik harness treatment were analyzed. Results Significant discrepancies about the clinical and radiological outcomes, the rates of failure and complications as well as the variables influencing the treatment outcome occur in the published studies due to the heterogeneity of the data and the differences in the methods used. The overall short-, mid- or long-term success rate of the treatment ranges from 45% to 100% and it is commonly over 75%. The rate of osteonecrosis of the femoral head ranges from 1% to 30%. Age, gender, laterality, radiological or clinical severity of the initial hip pathology and parents’ compliance are the commonly reported determinants of failure of the treatment. Conclusion The failure in treatment with the Pavlik harness is multifactorial, initial type of hip dysplasia being the most prominent followed by the treatment initiation age. This type of treatment cannot be considered as the best option in Graf IV hips (hip ultrasonography) or highly dislocated hips (plain radiography) and in infants older than three months of age, as the risk of failure and development of complications including osteonecrosis and femoral nerve palsy seem to increase in such circumstances. Large-scale, comparative studies including homogenous data are needed to answer the unsolved questions concerning indications., EPOS

AMAÇ: Çalışmada AO tip 13C humerus distal kırıklarında olekranon osteotomisi ile birlikte açık redüksiyon ve internal tespit yapılan hastaların fonksiyonel ve klinik sonuçlarını ortaya koymaktır. GEREÇ VE YÖNTEM: AO Tip 13C distal humerus kırığı tanısı mevcut olan ve cerrahisi yapılan 39 hasta (ortalama yaş, 44.7; Erkek, %56.4) geriye dönük olarak değerlendirildi. Hastaların demografik verileri, tıbbi öyküleri, radyolojik ve fonksiyonel sonuçları kayıt altına alındı. Hastaların fonksiyonel sonuçları Mayo Dirsek Performans Puanlama Sistemi’ne (MEPI) göre değerlendirildi. BULGULAR: Ortalama dirsek fleksiyon derecesi 102.2 (60–120 derece) ve ortalama ekstansiyon kaybı derecesi 11.4 (0–25 derece) olarak hesaplandı. Mayo Dirsek Performans Puanlama skorlama sistemine göre yedi hastada mükemmel, 12 hastada iyi, 13 hastada orta ve 7 hastada kötü sonuç elde edildi. Tüm hastalarda ameliyat sonrası altıncı ayda radyolojik olarak kaynama görüldü. Tip 13C3 kırıklarda tip 13C1 ve 13C2’ye göre daha fazla ekstansiyon kaybı, daha düşük fleksiyon derecesi ve daha düşük ortalama MEPI skoru tespit edildi. Fonksiyonel sonuçlara bakıldığında olekranon fiksasyon yönteminin (tansiyon bant ve kanüle vida) anlamlı farklılık yaratmadığı tespit edildi. TARTIŞMA: AO tip 13C1 ve tip 13C2 kırıkların klinik ve fonksiyonel sonuçlarının AO tip 13C3 kırıklara göre daha iyi olduğu ve iki farklı olekranon fiksasyon yönteminde fonksiyonel sonuçların değişmediği görüldü., BACKGROUND: To investigate the outcomes of patients undergoing open reduction and internal fixation with olecranon osteotomy due to AO type13C fractures of the distal humerus. METHODS: Data of 39 patients (mean age, 44.7 years; males, 56.4%) undergoing surgery with the diagnosis of AO type 13C distal humeral fractures were retrospectively evaluated. Patients’ demographic characteristics, medical history, and radiological and functional outcomes were recorded. The patients were evaluated at the final follow-up according to the Mayo Elbow Performance Index (MEPI). RESULTS: The mean degrees of flexion and extension loss were 102.2 degrees (range, 60–120 degrees) and 11.4 degrees (range, 0–25 degrees), respectively, at the final follow-up. According to the MEPI score, outcomes were excellent in seven, good in 12, fair in 13, and poor in seven patients. All patients achieved a radiological union of the fracture site within the first postoperative six months. It was found that the loss of extension was more severe, the range of flexion was decreased, and the mean MEPI score was lower in the patients with type C3 fractures than in those with type C1 and type C2 fractures. No significant difference was determined between fixation techniques (tension band vs. cannulated screw) regarding the functional outcomes. CONCLUSION: Our results revealed better prognosis in AO type C1 and type C2 fractures than in AO type C3 fractures and no different effects of two fixation techniques in olecranon osteotomy on the outcomes.

[No abstract available]

Objectives: This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes. Patients and methods: Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9 +/- 2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20 degrees of hip flexion contracture, more than 30 degrees of hip abduction, a negative prone Ely test, less than 50 degrees of popliteal angle and at least 5 degrees of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement. Results: Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures. Conclusion: Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.