MORFOMETRIJSKA ANALIZA VASKULARNIH KLEFTOVA U DJECE SA SIMPTOMIMA AKUTNOG APENDICITISA I NEGATIVNOM APENDEKTOMIJOM

Objective: Many cases of clinically suspected acute appendicitis show no microscopic signs of acute inflammation. Negative appendectomy rates differ greatly, partly due to various criteria used by different institutions to define acute appendicitis. In our practice, we have noticed that many of the negative appendectomy specimens contain prominent vascular clefts. The objective of this study was to determine the possible signifi cance of vascular clefts, which has not been investigated yet. Our hypothesis was that vascular clefts are early, as yet unrecognized signs of acute appendicitis. Methods: We conducted a retrospective study by searching for patients who had negative appendectomy at the Zagreb Children’s Hospital (2014-2019). There were 151 patients aged 1-18 years, 124 of which were included in the study group and 27 in the control group. Vascular clefts, if present, were measured microscopically. Statistical analysis was performed using Kolmogorov-Smirnov, Kruskal-Wallis, Mann Whitney, χ2 and Spearman’s rank correlation tests. The level of statistical signifi cance was set at p<0.05. Results: Out of the 124 patients included in the study group, 50.8% were female (n=63) and 49.2% were male (n=61). Mean age of the patients was 11.5 years and median 12 years. Negative appendectomy specimens showed prominent vascular clefts in 94 of 124 (75.8%) study group patients. Vascular cleft width varied between 140 and 1751 μm. Twelve (9.7%) specimens showed no signs of vascular clefts, and 18 specimens had partial vascular clefts that did not penetrate muscular wall of the appendix and consequently could not be measured. We also showed that there was a statistically signifi cant difference between the number of appendices that contained fecaliths in their lumina in the study group as compared to the control group (p<0.01). Discussion: Negative appendectomies are still a problem in the 21st century medical practice. Although many cases of clinically suspected acute appendicitis microscopically show no signs of inflammation, in some cases symptoms may regress after appendectomy has been performed, even if there are no histopathologic signs of inflammation. In everyday practice, we noticed that in cases of acute suppurative or phlegmonous appendicitis, a dense infl ammatory infi ltrate is often seen passing through prominent vascular clefts, which we defi ne as fi ssures of the muscular layer of the bowel (or in this case appendiceal) wall through which blood vessels and peripheral nerve branches pass on their way to and from the bowel. We tried to determine the possible signifi cance of these vascular clefts. We collected 124 negative appendectomy specimens from the archives of our Department of Pathology and Cytology, all of which were removed from pediatric patients at the Zagreb Children’s Hospital due to clinically suspected acute appendicitis. None of the 124 appendices met our criteria for acute appendicitis. We found that 94 of 124 (75.8%) negative appendectomy specimens showed vascular clefts. We also calculated the Zagreb Children’s Hospital negative appendectomy rate during the 5-year period, which was 9%. Conclusion: Our results show that prominent vascular clefts in the muscular layer of the appendiceal wall are frequently found in negative appendectomy specimens. These clefts could be implicated in the pathophysiology of acute appendicitis and might be one of the fi rst signs of acute appendicitis.Cilj: Mnogi slučajevi klinički dijagnosticiranih akutnih apendicitisa ne pokazuju znakove akutne upale. Stopa negativnih apendektomija znatno varira, dijelom i zbog različitih kriterija koje razne institucije primjenjuju u defi niciji akutnog apendicitisa. U našoj svakodnevnoj praksi primijetili smo da mnogi od uzoraka negativnih apendektomija sadrže izražene vaskularne kleftove. Cilj ove studije bio je odrediti moguće značenje vaskularnih kleftova koje nitko dosad nije istražio. Naša hipoteza je bila da su vaskularni kleftovi rani, dosad neprepoznati znakovi akutnog apendicitisa. Metode: Proveli smo retrospektivnu studiju tražeći bolesnike s negativnom apendektomijom u Klinici za dječje bolesti Zagreb (2014.-2019.). Pronašli smo 151 bolesnika u dobi 1-18 godina, od kojih smo 124 uključili u istraživanu, a 27 u kontrolnu skupinu. Vaskularne kleftove smo mjerili mikroskopski. Učinjena je statistička analiza pomoću Kolmogorov-Smirnovljeva, Kruskal-Wallisova, Mann Whitneyeva, χ2 i Spearmanova rank korelacijskog testa. Razina statističke značajnosti utvrđena je na p<0,05. Rezultati: Od 124 bolesnika u istraživanoj skupini 50,8 % je bilo ženskih (n=63) i 49,2 % muških (n=61). Srednja dob bolesnika bila je 11,5 godina, a medijan 12 godina. Devedeset i četiri od 124 (75,8 %) uzorka negativnih apendektomija pokazivalo je izražene vaskularne kleftove. Širina vaskularnih kleftova je varirala između 140 i 1751 μm. Dvanaest uzoraka (9,7 %) nije pokazivalo znakove vaskularnih kleftova, a 18 uzoraka je imalo djelomične vaskularne kleftove koji nisu penetrirali kroz čitavu debljinu stijenke apendiksa i stoga se nisu mogli izmjeriti. Također smo pokazali statistički značajnu razliku u broju apendiksa koji su sadržavali fekolite u lumenu između istraživane skupine i kontrolne skupine (p<0,01). Rasprava: Negativne apendektomije su i dalje problem u medicinskoj praksi 21. stoljeća. Iako mnogi slučajevi kliničke sumnje na akutni appendicitis mikroskopski ne pokazuju znakove upale, u nekim slučajevima simptomi se mogu povući nakon provedene apendektomije, iako nema patohistoloških znakova upale. U svakodnevnoj praksi primijetili smo da u slučajevima akutnog supurativnog i fl egmonoznog apendicitisa gusti upalni infi ltrat često prolazi kroz izražene vaskularne kleftove, koje defi niramo kao procjepe mišićnog sloja stijenke crijeva (u ovom slučaju apendiksa) kroz koji krvne žile i periferni ogranci živaca prolaze u crijevo. Pokušali smo odrediti značenje ovih vaskularnih kleftova. Sakupili smo 124 uzorka iz arhive našeg Zavoda za patologiju i citologiju, od kojih su svi odstranjeni iz pedijatrijskih bolesnika zbog kliničke sumnje na akutni apendicitis. Nijedan od 124 apendiksa nije ispunjavao naše kriterije za akutni apendicitis. Utvrdili smo da su vaskularni kleftovi bili prisutni u 94 od 124 (75,8 %) uzorka negativnih apendektomija. Također smo izračunali stopu negativne apendektomije za Kliniku za dječje bolesti Zagreb u petogodišnjem razdoblju koja iznosi 9 %. Zaključak: Naši rezultati pokazuju da su izraženi vaskularni kleftovi u mišićnom sloju stijenke apendiksa često prisutni u uzorcima negativnih apendektomija. Ti kleftovi bi mogli biti uključeni u patofi ziologiju akutnog apendicitisa i mogli bi biti među prvim znakovima akutnog apendicitisa

MORFOMETRIJSKA ANALIZA VASKULARNIH KLEFTOVA U DJECE SA SIMPTOMIMA AKUTNOG APENDICITISA I NEGATIVNOM APENDEKTOMIJOM

Objective: Many cases of clinically suspected acute appendicitis show no microscopic signs of acute inflammation. Negative appendectomy rates differ greatly, partly due to various criteria used by different institutions to define acute appendicitis. In our practice, we have noticed that many of the negative appendectomy specimens contain prominent vascular clefts. The objective of this study was to determine the possible signifi cance of vascular clefts, which has not been investigated yet. Our hypothesis was that vascular clefts are early, as yet unrecognized signs of acute appendicitis. Methods: We conducted a retrospective study by searching for patients who had negative appendectomy at the Zagreb Children’s Hospital (2014-2019). There were 151 patients aged 1-18 years, 124 of which were included in the study group and 27 in the control group. Vascular clefts, if present, were measured microscopically. Statistical analysis was performed using Kolmogorov-Smirnov, Kruskal-Wallis, Mann Whitney, χ2 and Spearman’s rank correlation tests. The level of statistical signifi cance was set at p<0.05. Results: Out of the 124 patients included in the study group, 50.8% were female (n=63) and 49.2% were male (n=61). Mean age of the patients was 11.5 years and median 12 years. Negative appendectomy specimens showed prominent vascular clefts in 94 of 124 (75.8%) study group patients. Vascular cleft width varied between 140 and 1751 μm. Twelve (9.7%) specimens showed no signs of vascular clefts, and 18 specimens had partial vascular clefts that did not penetrate muscular wall of the appendix and consequently could not be measured. We also showed that there was a statistically signifi cant difference between the number of appendices that contained fecaliths in their lumina in the study group as compared to the control group (p<0.01). Discussion: Negative appendectomies are still a problem in the 21st century medical practice. Although many cases of clinically suspected acute appendicitis microscopically show no signs of inflammation, in some cases symptoms may regress after appendectomy has been performed, even if there are no histopathologic signs of inflammation. In everyday practice, we noticed that in cases of acute suppurative or phlegmonous appendicitis, a dense infl ammatory infi ltrate is often seen passing through prominent vascular clefts, which we defi ne as fi ssures of the muscular layer of the bowel (or in this case appendiceal) wall through which blood vessels and peripheral nerve branches pass on their way to and from the bowel. We tried to determine the possible signifi cance of these vascular clefts. We collected 124 negative appendectomy specimens from the archives of our Department of Pathology and Cytology, all of which were removed from pediatric patients at the Zagreb Children’s Hospital due to clinically suspected acute appendicitis. None of the 124 appendices met our criteria for acute appendicitis. We found that 94 of 124 (75.8%) negative appendectomy specimens showed vascular clefts. We also calculated the Zagreb Children’s Hospital negative appendectomy rate during the 5-year period, which was 9%. Conclusion: Our results show that prominent vascular clefts in the muscular layer of the appendiceal wall are frequently found in negative appendectomy specimens. These clefts could be implicated in the pathophysiology of acute appendicitis and might be one of the fi rst signs of acute appendicitis.Cilj: Mnogi slučajevi klinički dijagnosticiranih akutnih apendicitisa ne pokazuju znakove akutne upale. Stopa negativnih apendektomija znatno varira, dijelom i zbog različitih kriterija koje razne institucije primjenjuju u defi niciji akutnog apendicitisa. U našoj svakodnevnoj praksi primijetili smo da mnogi od uzoraka negativnih apendektomija sadrže izražene vaskularne kleftove. Cilj ove studije bio je odrediti moguće značenje vaskularnih kleftova koje nitko dosad nije istražio. Naša hipoteza je bila da su vaskularni kleftovi rani, dosad neprepoznati znakovi akutnog apendicitisa. Metode: Proveli smo retrospektivnu studiju tražeći bolesnike s negativnom apendektomijom u Klinici za dječje bolesti Zagreb (2014.-2019.). Pronašli smo 151 bolesnika u dobi 1-18 godina, od kojih smo 124 uključili u istraživanu, a 27 u kontrolnu skupinu. Vaskularne kleftove smo mjerili mikroskopski. Učinjena je statistička analiza pomoću Kolmogorov-Smirnovljeva, Kruskal-Wallisova, Mann Whitneyeva, χ2 i Spearmanova rank korelacijskog testa. Razina statističke značajnosti utvrđena je na p<0,05. Rezultati: Od 124 bolesnika u istraživanoj skupini 50,8 % je bilo ženskih (n=63) i 49,2 % muških (n=61). Srednja dob bolesnika bila je 11,5 godina, a medijan 12 godina. Devedeset i četiri od 124 (75,8 %) uzorka negativnih apendektomija pokazivalo je izražene vaskularne kleftove. Širina vaskularnih kleftova je varirala između 140 i 1751 μm. Dvanaest uzoraka (9,7 %) nije pokazivalo znakove vaskularnih kleftova, a 18 uzoraka je imalo djelomične vaskularne kleftove koji nisu penetrirali kroz čitavu debljinu stijenke apendiksa i stoga se nisu mogli izmjeriti. Također smo pokazali statistički značajnu razliku u broju apendiksa koji su sadržavali fekolite u lumenu između istraživane skupine i kontrolne skupine (p<0,01). Rasprava: Negativne apendektomije su i dalje problem u medicinskoj praksi 21. stoljeća. Iako mnogi slučajevi kliničke sumnje na akutni appendicitis mikroskopski ne pokazuju znakove upale, u nekim slučajevima simptomi se mogu povući nakon provedene apendektomije, iako nema patohistoloških znakova upale. U svakodnevnoj praksi primijetili smo da u slučajevima akutnog supurativnog i fl egmonoznog apendicitisa gusti upalni infi ltrat često prolazi kroz izražene vaskularne kleftove, koje defi niramo kao procjepe mišićnog sloja stijenke crijeva (u ovom slučaju apendiksa) kroz koji krvne žile i periferni ogranci živaca prolaze u crijevo. Pokušali smo odrediti značenje ovih vaskularnih kleftova. Sakupili smo 124 uzorka iz arhive našeg Zavoda za patologiju i citologiju, od kojih su svi odstranjeni iz pedijatrijskih bolesnika zbog kliničke sumnje na akutni apendicitis. Nijedan od 124 apendiksa nije ispunjavao naše kriterije za akutni apendicitis. Utvrdili smo da su vaskularni kleftovi bili prisutni u 94 od 124 (75,8 %) uzorka negativnih apendektomija. Također smo izračunali stopu negativne apendektomije za Kliniku za dječje bolesti Zagreb u petogodišnjem razdoblju koja iznosi 9 %. Zaključak: Naši rezultati pokazuju da su izraženi vaskularni kleftovi u mišićnom sloju stijenke apendiksa često prisutni u uzorcima negativnih apendektomija. Ti kleftovi bi mogli biti uključeni u patofi ziologiju akutnog apendicitisa i mogli bi biti među prvim znakovima akutnog apendicitisa

The limping child

Šepanje kod djece uvijek je patološki nalaz koji zahtijeva detaljnu evaluaciju. Razmatrajući diferencijalnu dijagnozu šepanja, kliničar se susreće sa širokom paletom mogućih uzroka kao što su trauma, infekcija, novotvorina te inflamatorne, kongenitalne, neuromuskularne i razvojne bolesti. U većini slučajeva detaljna anamneza i klinički pregled uputit će nas na ispravnu dijagnozu. Potreba za dodatnom obradom mora se temeljiti na kliničkom nalazu i izraženoj sumnji da je riječ o potencijalno ozbiljnoj patologiji. Nužno je razumijevanje normalnog hoda, kako bismo prepoznali i ispravno interpretirali onaj poremećeni. Postoji više dijagnostičkih modaliteta koji se primjenjuju pri evaluaciji šepanja kod djece. Primjereno znanje o prednostima i nedostatcima dostupnih dijagnostičkih modaliteta te njihovim ograničenjima, pomaže nam u postavljanju brze i točne dijagnoze.Limping in children is never normal and it deserves a full evaluation. The causes of limping are extensive and very often age-specific. In considering the differential diagnosis the clinician faces a rather broad category of possible etiologies and concomitant diseases, such as traumatic, infectious, neoplastic, inflammatory, congenital, neuromuscular or developmental. It is necessary to understand the normal gait cycle in order to recognize and correctly interpret the pathological one. A systematic approach should include a thorough history and physical examination combined with appropriate imaging studies and laboratory testing. There are several diagnostic modalities that are available in the evaluation of a child with a limp. A thorough understanding of the advantages, disadvantages and limitations of these modalities will help in identifying those children who require urgent diagnostic and therapeutic interventions in the emergency department

Liječenje prijeloma bedrene kosti kod djece u Gradu Zagrebu

Femur fractures in children can be treated with a number of operative and conservative methods. Numerous factors determine which method is optimal for a specific fracture. The aim of this research was to analyze distribution of femur fractures in children living in the urban communities of Zagreb and Zagreb County by localization, type and frequency of treatment methods used according to age and fracture mechanism. The research included 103 children aged up to 18 years, treated for femur fractures at the Zagreb University Hospital Centre and Zagreb Children’s Hospital. Data were collected from these institutions and a retrospective study covered the 2010-2015 period. The cause of fracture and diagnosis were coded with the help of the International Statistical Classification of Diseases and Related Health Problems. Operative treatment was applied in 55% of cases, which is contrary to previous researches. The highest incidence of femur fractures was recorded in the 0- to 4-year age groups, accounting for 49.1% of all fractures. These fractures mostly occurred due to falls and were more often treated with non-operative methods. All other age groups were mostly treated with operative methods. Coxofemoral immobilization and traction were used as non-operative methods, whereas flexible intramedullary nailing was the most frequently used operative method. The treatment depended on age, complexity of the fracture, fracture type, fragment displacement, and associated injuries. The cause was also an important factor on choosing the treatment method. Nonoperative treatment was mostly used for fractures caused by falls (64.71% of cases due to falls) and operative treatment was mostly used for fractures caused by traffic accidents (79.4% of cases due to traffic accidents). It is a wide-known opinion that the best treatment for femur fractures in children is non-operative treatment. However, recent studies have shown that the use of operative methods in femur fracture treatment is growing. Our cohort of children treated during a five-year period (2010- 2015) also underwent operative treatment more often than non-operative one. Two non-operative and eight operative methods were used. With such a large number of methods, it is clear that there is no unique method for all fractures. However, it is clear that the trend of using operative treatment is connected to the perennial trend of considerable sociodemographic and socioeconomic changes in urban settings such as Zagreb. Lifestyle changes directly affect the prevalence of femur fractures among children, as well as approach to treatment choice. General opinion is that most of fractures that occur at an early age can be treated with non-operative methods. Our research on femur fractures in children confirmed this rule. The youngest age group that had the highest incidence of fractures (49.1% of all fractures) was treated with non-operative methods in 75% of cases. Operative methods prevailed in other age groups. Similar results have been published by other authors. In conclusion, nearly half of all femur fractures (49.1%) occurred at a young age (0-4 years). Diaphysis fractures were most common. Most of the fractures that occurred during the 2010-2015 period were treated with operative methods, mostly in children aged 5-9 years. Out of eight different operative methods, elastic stable intramedullary osteosynthesis was most frequently used (60%). Coxofemoral immobilization and traction were used as non-operative methods.Prijelomi bedrene kosti u djece mogu se liječiti operativno ili konzervativno. Više čimbenika utječe na izbor najbolje metode liječenja ovisno o vrsti prijeloma. Cilj ovoga istraživanja bio je utvrditi učestalost prijeloma bedrene kosti u djece na području Grada Zagreba i Zagrebačke županije i raspodjelu učestalosti prema mjestu nastanka, dobi djeteta te vrsti, načinu nastanka i načinu liječenja prijeloma. Istraživanje je uključilo 103 djece u dobi do 18 godina liječene zbog prijeloma bedrene kosti u Kliničkom bolničkom centru Zagreb i Klinici za dječje bolesti Zagreb. Podaci za ovu retrospektivnu analizu su prikupljeni iz navedenih ustanova za razdoblje od 2010. do 2015. godine. Uzroci nastanka prijeloma su šifrirani prema Međunarodnoj klasifikaciji bolesti. Kirurško liječenje je bilo potrebno u 55% bolesnika, što nije u skladu s podacima iz prethodnih analiza. Najveća učestalost prijeloma bedrene kosti bila je u dobnoj skupini od 0 do 4 godine, koja čini 49,1% svih bolesnika. U toj skupini su prijelomi najčešće nastali prilikom pada i većinom su liječeni konzervativno. U svim ostalim dobnim skupinama prevladavalo je operativno liječenje. Najčešće primijenjeni konzervativni način liječenja je bila kokso-femoralna imobilizacija, a najčešći operativni način stabilna elastična osteosinteza titanskim čavlima. Način liječenja je ovisio o dobi, vrsti i složenosti prijeloma, pomaku ulomaka i udruženim ozljedama. Uzrok nastanka prijeloma je također bio važan čimbenik u odabiru načina liječenja. Konzervativno liječenje je većinom primijenjeno kod prijeloma koji su nastali padom (u 64,7% prijeloma nastalih padom), a operativno liječenje većinom kod prijeloma nastalih u prometnim nezgodama (79,4% tako nastalih prijeloma je liječeno operativno). Opće prihvaćeno je stajalište da je konzervativno liječenje najbolje za dijete. Ipak, u novijim radovima je povećana učestalost operativnog liječenja prijeloma bedrene kosti u djece. U našoj skupini bolesnika liječenih u razdoblju od 2010. do 2015. godine operativno liječenje također je bilo češće nego konzervativno. Primijenjena su dva načina konzervativnog liječenja i osam načina operativnog liječenja. Tako velik broj različitih načina liječenja pokazuje da ne postoji jedinstvena metoda za liječenje svih prijeloma. S druge strane, porast učestalosti operativnog liječenja je očito posljedica trajnih socio-demografskih i socio-ekonomkih promjena u urbanim područjima poput Zagreba. Promjena načina života izravno utječe na učestalost prijeloma bedrene kosti, kao i na način njihovog liječenja. Mišljenje većine je da se prijelomi nastali u ranoj dobi uglavnom mogu liječiti konzervativno. Naše istraživanje to potvrđuje: 75% bolesnika u najmlađoj dobnoj skupini, koji su činili većinu ozljeđenika (49,1%), liječeni su konzervativno. Operativno liječenje je prevladavalo u drugim dobnim skupinama, a drugi autori su objavili slične rezultate. Zaključno, najmlađi bolesnici (u dobi od 0 do 4 godine) čine gotovo polovicu (49,1%) svih bolesnika s prijelomom bedrene kosti. Najčešće mjesto prijeloma je bila dijafiza. Većina prijeloma u razdoblju od 2010. do 2015. godine liječena je operativno, većinom u djece u dobi od 5 do 9 godina. Od osam različitih operativnih načina liječenja, stabilna elastična osteosinteza bila je najčešća (60%). Kokso-femoralna imobilizacija ili trakcija bile su najčešći konzervativni načini liječenja

FEMUR FRACTURES IN CHILDREN – CAUSES AND MECHANISMS OF INJURY

Djeca su zbog hiperaktivnosti često izložena ozljedama. Visoka pojavnost prijeloma i moguća invalidnost unatoč primjerenom liječenju opravdavaju istraživanja u području prevencije nastanka prijeloma. Preventivni postupci mogući su jedino uz poznavanje uzroka i okolnosti nastanka prijeloma. Cilj je ovog rada analizirati okolnosti i mjesta nastanka prijeloma bedrene kosti po dobnim skupinama djece. U ovu retrospektivnu studiju uključeno je 103-je djece u dobi do 18 godina, liječene u Kliničkome bolničkom centru Zagreb ili Klinici za dječje bolesti Zagreb u razdoblju 2012. – 2016. Analizirano je 35 djevojčica (33%) i 71 dječak (67%) s prijelomom femura. Prosječna dob djece iznosila je pet godina. Najveći broj ozlijeđene djece, 52 (55,2%) bio je u najmlađoj dobnoj skupini, od 0 do 4 godine života. Najčešći su bili prijelomi dijafi ze – 66 (62%), a najrjeđi distalne metafi ze – 14 (13%). Kod kuće je nastao 41 (38%), na ulici ili cesti 38 (36%), na rekreacijskome mjestu 22 (21%), a 3 (3%) prijeloma nastala su u školi ili vrtiću. Najčešći uzroci nastanka prijeloma bili su padovi – 38 (57,5%), nezgode s motornim vozilima – 35 (33,0%) te sudaranja ili izravni udarci – 10 (9,5%). Oko trećine djece s prijelomom femura imalo je pridružene ozljede, a četiri petine uzrokovane su nezgodama s motornim vozilima. Rezultati ovog istraživanja pokazuju da su prijelomi bedrene kosti najučestaliji u najmlađim dobnim skupinama, a najčešće nastaju kao posljedica nezgoda kod kuće, i to padovima, rjeđe na ulici i rekreacijskim mjestima. Roditelje predškolske djece treba poučiti o prevenciji padova kod kuće, a djecu školske dobi o opasnostima od prijeloma na rekreacijskim mjestima i u cestovnom prometu.Children are often exposed to injuries due to their hyperactivity. Femur fractures can however leave permanent consequences despite adequate treatment. The high prevalence and possible invalidity justify research in the fi eld of prevention of this injury. But prevention is possible only by knowing the causes and circumstances of the fractures. The aim of this research is to analyze the circumstances and places of occurrence in femur fractures according to children age groups. This retrospective study includes 103 children up to the age of 18 years treated at the University Hospital Center of Medicine Zagreb, or at the Clinic for children diseases Zagreb in the period from 2012 to 2016. The study includes 35 (33 %) girls and 71 (67 %) boys, a total of 106 children with femur fractures. The average age was fi ve years. The majority of the injured children, 52 children (55,2 %), belonged to the youngest age group from 0 to 4 years of age. Diaphysis fractures were the most common with 66 fractures (62 %), and the rarest were fractures of the distal metaphysis with 15 fractures (13 %). The fractures occurred at home in 41 cases (38 %), in the street in 38 cases (36 %), at recreation in 22 cases (21 5), and at school or kindergarten in 3 cases (3 %). The most common causes of femur fractures were falls in 38 cases (57,5 %), motor vehicle accidents in 35 cases (33 %), and crashes and blows in 10 cases (9,5 %). One third of the children with femur fractures had associated injuries, and four fi fths of them were caused by motor vehicle accidents. The results of this study show that femur fractures are most frequent in the youngest age groups, and are generally a consequence of accidents at home (mostly falls), seldom in the streets or recreational places. Parents of preschool children should be educated about prevention of falling at their homes, and parents of school children should be educated about the dangers of fractures at recreational places and traffi

Prijelomi bedrene kosti u djece – okolnosti i uzroci nastanka [Femur fractures in children – causes and mechanisms of injury]

Children are often exposed to injuries due to their hyperactivity. Femur fractures can however leave permanent consequences despite adequate treatment. The high prevalence and possible invalidity justify research in the field of prevention of this injury. But prevention is possible only by knowing the causes and circumstances of the fractures. The aim of this research is to analyze the circumstances and places of occurrence in femur fractures according to children age groups. This retrospective study includes 103 children up to the age of 18 years treated at the University Hospital Center of Medicine Zagreb, or at the Clinic for children diseases Zagreb in the period from 2012 to 2016. The study includes 35 (33 %) girls and 71 (67 %) boys, a total of 106 children with femur fractures. The average age was five years. The majority of the injured children, 52 children (55,2 %), belonged to the youngest age group from 0 to 4 years of age. Diaphysis fractures were the most common with 66 fractures (62 %), and the rarest were fractures of the distal metaphysis with 15 fractures (13 %). The fractures occurred at home in 41 cases (38 %), in the street in 38 cases (36 %), at recreation in 22 cases (21 5), and at school or kindergarten in 3 cases (3 %). The most common causes of femur fractures were falls in 38 cases (57,5 %), motor vehicle accidents in 35 cases (33 %), and crashes and blows in 10 cases (9,5 %). One third of the children with femur fractures had associated injuries, and four fifths of them were caused by motor vehicle accidents. The results of this study show that femur fractures are most frequent in the youngest age groups, and are generally a consequence of accidents at home (mostly falls), seldom in the streets or recreational places. Parents of preschool children should be educated about prevention of falling at their homes, and parents of school children should be educated about the dangers of fractures at recreational places and traffic

The limping child

Šepanje kod djece uvijek je patološki nalaz koji zahtijeva detaljnu evaluaciju. Razmatrajući diferencijalnu dijagnozu šepanja, kliničar se susreće sa širokom paletom mogućih uzroka kao što su trauma, infekcija, novotvorina te inflamatorne, kongenitalne, neuromuskularne i razvojne bolesti. U većini slučajeva detaljna anamneza i klinički pregled uputit će nas na ispravnu dijagnozu. Potreba za dodatnom obradom mora se temeljiti na kliničkom nalazu i izraženoj sumnji da je riječ o potencijalno ozbiljnoj patologiji. Nužno je razumijevanje normalnog hoda, kako bismo prepoznali i ispravno interpretirali onaj poremećeni. Postoji više dijagnostičkih modaliteta koji se primjenjuju pri evaluaciji šepanja kod djece. Primjereno znanje o prednostima i nedostatcima dostupnih dijagnostičkih modaliteta te njihovim ograničenjima, pomaže nam u postavljanju brze i točne dijagnoze.Limping in children is never normal and it deserves a full evaluation. The causes of limping are extensive and very often age-specific. In considering the differential diagnosis the clinician faces a rather broad category of possible etiologies and concomitant diseases, such as traumatic, infectious, neoplastic, inflammatory, congenital, neuromuscular or developmental. It is necessary to understand the normal gait cycle in order to recognize and correctly interpret the pathological one. A systematic approach should include a thorough history and physical examination combined with appropriate imaging studies and laboratory testing. There are several diagnostic modalities that are available in the evaluation of a child with a limp. A thorough understanding of the advantages, disadvantages and limitations of these modalities will help in identifying those children who require urgent diagnostic and therapeutic interventions in the emergency department

POSSIBILITIES OF DIAGNOSTIC IMAGING IN ASSESSMENT OF SPORTS INJURIES IN YOUNG ATHLETES

U posljednje vrijeme svjedoci smo sve većeg uključivanja djece u organizirane športske aktivnosti i natjecateljski šport. To znatno pridonosi kvalitetnijem tjelesnom a isto tako i psihičkom razvoju djeteta. Osim pozitivnih učinaka bavljenja natjecateljskim športom, masovnije sudjelovanje djece u takvoj organizaciji športske aktivnosti neminovno dovodi i do porasta učestalosti akutnih športskih ozljeda kao i onih koje svrstavamo u sindrome prenaprezanja. Brojni dodatni čimbenici koji potpomažu nastanku ozljede isti su kod djece i adolescenata kao i kod odraslih. Međutim, neki su od uzroka ozljeđivanja u djece specifični, a to su prvenstveno čimbenici vezani za trenutni tjelesni rast. Ti čimbenici utječu na osjetljivost tih struktura za vrijeme brzog rasta. Radiološko oslikavanje ima važnu ulogu u dijagnozi i zbrinjavanju športskih ozljeda u djetinjstvu i adolescenciji. Široki raspon radioloških dijagnostičkih metoda danas je dostupan: konvencionalna radiografija, ultrazvuk, računalna tomografija i magnetska rezonancija. Svaka od tih metoda ima svoje točno određeno mjesto u algoritmu dijagnostičkih pretraga, a neke od njih se i nadopunjuju. Radiolog treba biti sastavni dio medicinskog tima što brine o ozlijeđenom mladom športašu, a koji čine specijalisti s potrebnim znanjem i koji su senzibilizirani za probleme djece športaša. Radiolog mora biti sposoban primijeniti sve potrebno od dijagnostike, ali u uskoj suradnji s kliničarom.The number of children and adolescents involved in organized sports has increased dramatically over recent decades. The benefits to health and social development of youth participation in sports are generally accepted. However, more participation has led to more sports-related injuries. The increase has been in both acute injuries and, even more, in overuse injuries. Many contributory factors (training errors, anatomic variants and abnormalities, environmental factors) are the same in children and adolescents as in adults. Certain causative factors are unique to young athletes: bone often grows faster then the surrounding muscle-tendon unit, relative weakness of cartilage at physes, apophyses and over epiphyseal surfaces. These factors render immature structures vulnerabile, especially during the period of rapid gorwth. Imaging plays an important role in the diagnosis and menagement of sports injuries of childhood and adolescence. Wideband of radiological diagnostic modalities are available now: conventional radiography, ultrasound, computet tomography and magnetic resonance. Each modality has its owen place in diagnostic algorithm, some of them are compatibile. Radiologist have to be part of medical team of specialists who has appropriate knowledge and appreciation for young athletes. Radiologist must be able to applay the full range of imaging modalities when evaluating the injured young athlete, but in close cooperation with clinitian

Epifizeoliza distalne tibije u zagrebačke djece [Distal tibial epiphyseal fractures]

Distal tibial epiphyseal fractures are significant because they often cause tibial growth disturbance. Distal tibial epiphyseal fractures are the second most common epiphyseal fractures, after distal radial epiphysis. Despite prompt diagnosis and correct treatment, serious complications, such as progressive deformation and permanent disability, are possible. Therefore, it is necessary to prevent these injuries. Prevention is possible only by studying injury pattern, mechanism and locations where fractures occur. In total, medical records of 197 children treated for distal tibia epiphyseal fracture in the period from January 1st , 2010 to January 1st , 2017 were analyzed. Due to insufficient data, 80 of them were excluded from the study. Thirty-seven children were treated in Clinical Hospital Center Zagreb and eighty in the Children’s Hospital Zagreb. In the studied group of children, there were 81 (69.2%) boys and 36 (30.8%) girls. The average age at the time of injury was 12.3 years, with boys being on average 17 months older than girls. ICD 10 classification was used. The most common mechanism of injury was falling, in 90 cases (76.9%). Sport grounds were the most common location where injuries occurred, in 36 cases (30.8%), while the household was the second most common, 27 (23.1%) cases. The most common activities during which injuries occurred were leisure activities, in 52 (44.4%) patients, and sports in 47 (40.2%) patients. The most common activity during which distal tibial epiphyseal fractures occurred was football and leisure activities on inadequate sport grounds. Prevention measures should mainly focus on the sports activities in children aged between 10 and 16 years