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1.  Childhood femoral fracture can lead to premature knee-joint arthritis 
Acta Orthopaedica  2013;84(1):71-75.
Background and purpose
During the past decades, treatment of pediatric femoral fractures in Finland has changed from mostly non-operative to more operative. In this retrospective study, we analyzed the long-term results of treatment.
Patients and methods
74 patients (mean age 7 (0–14) years) with a femoral fracture were treated in Aurora City Hospital in Helsinki during the period 1980–89. 52 of 74 patients participated in this clinical study with a mean follow-up of 21 (16–28) years. Fracture location, treatment mode, time of hospitalization, and fracture alignment at union were assessed. Subjective assessment and range of motion of the hip and knee were evaluated. Leg-length discrepancy and alignment of the lower extremities were measured both clinically and radiographically.
Results
Of the 52 children, 28 had sustained a shaft fracture, 13 a proximal fracture, and 11 a distal fracture. 44 children were treated with traction, 5 by internal fixation, and 3 with cast-immobilization. Length of the hospital treatment averaged 58 (3–156) days and the median traction time was 39 (3–77) days. 21 of the 52 patients had angular malalignment of more than 10 degrees at union. 20 patients experienced back pain. Limping was seen in 10 patients and leg-length discrepancy of more than 15 mm was in 8 of the 52 patients. There was a positive correlation between angular deformity and knee-joint arthritis in radiographs at follow-up in 6 of 15 patients who were over 10 years of age at the time of injury.
Interpretation
Angular malalignment after treatment of femoral fracture may lead to premature knee-joint arthritis. Tibial traction is not an acceptable treatment method for femoral fractures in children over 10 years of age.
doi:10.3109/17453674.2013.765621
PMCID: PMC3584607  PMID: 23343379
2.  Treatment of shoulder sequelae in brachial plexus birth injury 
Acta Orthopaedica  2011;82(4):482-488.
Background
Many children with permanent brachial plexus birth injury (BPBI) develop shoulder problems, with subsequent joint deformity without treatment. We assessed the indications and outcome of shoulder operations for BPBI.
Patients and methods
31 BPBI patients who had undergone a shoulder operation in our hospital between March 2002 and December 2005 were included in the study. Relocation of the humeral head had been performed in 13 patients, external rotation osteotomy of the humerus in 5 patients, subscapular tendon lengthening in 5 patients, and teres major transposition in 8 patients. Subjective results were registered. Shoulder range of motion was measured, and function assessed according to the Mallet scale. Magnetic resonance imaging (MRI) was performed pre- and postoperatively. Glenoscapular angle (GSA) and percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) were measured. Congruency of the glenohumeral joint (GHJ) was estimated. The mean follow-up time was 3.8 (1.7–6.8) years.
Results
At follow-up, the subjective result was satisfactory in 30 of the 31 patients. There were 4 failures, which in retrospect were due to wrong choice of surgical method in 3 of these 4 patients. Mean increase in Mallet score was 5.5 after successful relocation, 1.4 after rotation osteotomy, 2.2 after subscapular tendon lengthening, and 3.1 after teres major transposition. Congruency of the shoulder joint improved in 10 of 13 patients who had undergone a relocation operation, with mean improvement in GSA of 33º and mean increase in PHHA of 25%. There were no substantial changes in congruency of the glenohumeral joint in patients treated with other operation types.
Interpretation
Restriction of the range of motion and malposition of the glenohumeral joint can be improved surgically in brachial plexus birth injury. Remodeling of the joint takes place after successful relocation of the humeral head in young patients.
doi:10.3109/17453674.2011.588855
PMCID: PMC3237041  PMID: 21657969
3.  Range of motion and strength after surgery for brachial plexus birth palsy 
Acta Orthopaedica  2011;82(1):69-75.
Background
There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy.
Patients and methods
107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated.
Results
61 patients (57%) had no active shoulder external rotation (median 0° (-75–90)). Median active abduction was 90° (1–170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0–83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5–80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0–79)). Median active extension of the wrist was 55° (-70–90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0–121). Patients with total injury had poorer ROM and strength than those with C5–6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values.
Interpretation
ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.
doi:10.3109/17453674.2010.539499
PMCID: PMC3230000  PMID: 21142823
4.  Treatment injuries are rare in children's femoral fractures 
Acta Orthopaedica  2010;81(6):715-718.
Background and purpose
The current treatment for femoral fractures in children is mostly operative, which contrasts with treatment of other long bone fractures in children. We analyzed treatment injuries in such patients in Finland in order to identify avoidable injuries. Our other aims were to calculate the incidence of these fractures and to describe the treatment method used.
Methods
The Patient Insurance Centre (PIC) provides financial compensation of patients who have sustained an injury in connection with medical care. We retrospectively analyzed incidence, treatment methods, and all compensation claims concerning treatment of femoral fractures in children who were 0–16 years of age during the 8-year period 1997–2004.
Results
The incidence of childhood femoral fractures in Finland was 0.27 per 1,000 children aged < 17 years, and two-thirds of the patients were treated operatively during the study period. 30 compensation claims were submitted to PIC during the 8-year study period. The compensation claims mainly concerned pain, insufficient diagnosis or treatment, extra expenses, permanent disability, or inappropriate behavior of medical personnel. Of the claims, 16 of 30 were granted compensation. Compensation was granted for delay in treatment, unnecessary surgery, and for inappropriate surgical technique. The mean amount of compensation was 2,300 euros. Of the injuries that led to compensation, 11 of 16 were regarded as being avoidable in retrospect.
Interpretation
The calculated risk of a treatment injury in childhood femoral fracture treatment in Finland is approximately 2%, and most of these injuries can be avoided with proper treatment.
doi:10.3109/17453674.2010.533927
PMCID: PMC3216082  PMID: 21067428
5.  The mechanism of primary patellar dislocation 
Acta Orthopaedica  2009;80(4):432-434.
Background and purpose Several mechanisms are responsible for patellar dislocation. We investigated how the primary pathomechanism relates to patient characteristics and the outcome.
Methods 126 patients (81 females) with primary patellar dislocation reported the knee position before the episode, the movement during it, and whether the patella was locked in dislocation. The median age was 20 (9–47) years. The subjective outcome and Kujala, Hughston VAS, and Tegner scores were evaluated after an average of 7 years.
Results 102 patients moved to flexion during the dislocation, 98 from a straight start and 4 from a well-bent start. 10 extended the knee from a well-bent start; they were older (mean 25 vs. 19 years) and more often had low trauma energy (5/10 vs. 15/102) and a locked dislocation (10/10 vs. 50/102). 4 had a direct hit to the knee and 1 only rotated it while stretching. 24 of 60 patients with open growth line of the tibial tubercle and 43 of 66 with closed tubercle had locked primary dislocation (p = 0.005). 33% of girls, 52% of boys, 57% of women, and 71% of men had locked primary dislocation. There was no correlation between trauma mechanism and outcome.
Interpretation Movement to flexion occurred in 84% of primary patellar dislocations and movement to extension in 8%. Spontaneous patellar relocation is common in skeletally immature girls and locked dislocation is common in skeletally mature men.
doi:10.3109/17453670903110634
PMCID: PMC2823187  PMID: 19593720
6.  Injuries as a result of treatment of tibial fractures in children 
Acta Orthopaedica  2009;80(1):78-82.
Background and purpose Tibial fractures comprise 10% of all fractures in children. To our knowledge there have been no previous reports of treatment injuries in these fractures. We analyzed compensation claims concerning treatment of these fractures in Finland. We used this information to determine preventable causes of treatment injuries.
Material and methods In Finland, the Patient Insurance Center (PIC) provides financial compensation for patients who have sustained an injury in connection with medical treatment or operation. We retrospectively analyzed all claims for compensation arising from treatment of tibial fractures in children that had been received by the PIC between 1997 and 2004. The mode of treatment, complications, and permanent sequelae were assessed. We also estimated the number of avoidable treatment injuries.
Results and interpretation The PIC received 50 claims for compensation during the 8-year study period. The claims were based on the following issues: pain, incorrect diagnosis and treatment, permanent disability, extra treatment expenses, inappropriate behavior of the medical personnel, and loss of income of the parents. 35/50 claims had received compensation, of which 32 were related to the treatment and 3 to infections. The treatment injuries that had led to compensation comprised a delay in diagnosis and treatment in 15 patients, inappropriate casting in 9, inappropriate operative treatment in 5, and other causes in 3 patients. An unsatisfactory standard of treatment and missed diagnosis were the most common reasons for compensation. In restrospect, all but 1 of the 35 injuries that had led to compensation were considered to be avoidable.
doi:10.1080/17453670902805080
PMCID: PMC2823237  PMID: 19297789

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