Operative Orthopadie Und Traumatologie最新文献

Objective: Conservative treatment for femur shaft fractures in small infants and for distal femur and lower leg fractures with sufficient stability in every age, if axial deformities, including rotational failures, are reliably avoided and normal limb function without pain is ensured.

Indications: Femur shaft fractures in infants up to 3 years of age. Undisplaced, stable fractures and/or fractures within the range of age-dependent spontaneous correction as well as stable reducible fractures of distal femur and of the whole lower leg, especially buckle, greenstick and isolated tibia fractures, mainly in children less than 10 years of age.

Contraindications: Femur shaft fractures in children > 3 years of age or > 15 kg body weight. Instable and displaced fractures at distal femur and whole lower leg beyond the range of age-dependent spontaneous correction, especially if the fibula is involved.

Surgical technique: 1. Spica cast in children in the first and second year of life for femur shaft fractures. 2. Closed split long leg cast for distal femur fractures and for fractures of the proximal tibia and lower leg shaft fractures as well as in all small infants who easily slip out of shorter casts. 3. Closed split lower leg cast or wide lower leg splint for distal lower leg fractures including ankle fractures and distorsions as well as fractures of the foot, except for small infants who easily lose lower leg casts and need long leg casts even in distal lower leg fractures. 4. Sarmiento cast for special situations or for functional treatment.

Postoperative management: Stable fractures: Cast removal after 3-4 weeks, clinical control of consolidation and start of mobilization. Fractures displaced or reduced within the range of spontaneous correction: x‑ray control of alignment after 1 week to exclude secondary displacement, closing the cast if necessary, x‑ray control of consolidation without cast 4 weeks later, further immobilization if necessary depending on age and extent of callus formation.

Results: With consequent and professional postoperative management, results of conservative treatment for femur shaft fractures in small children, in distal femur and lower leg fractures are good. Skin complications especially at the heel occur in about 2% of cases and these must be prevented with adequate padding.

Objective: The fasciocutaneous flap according to Becker and Gilbert is used to cover soft tissue defects of the hand and wrist.

Indications: Soft tissue reconstruction of palmar and dorsal defects of the hand and wrist. Coverage of the median nerve after neurolysis.

Contraindications: Stenosis of the ulnar artery, scars at the ulnar distal forearm.

Surgical technique: Drawing the flap design with the pivot point 2-4 cm proximal to the pisiform. Maximal length: 20 cm, maximal width: between palmaris longus muscle and finger extensor tendons. The flap is cut from radial palmar to ulnar dorsal and from proximal to distal together with the underlying fascia. The ulnar artery, the ulnar nerve and the dorsal branch of the ulnar artery are prepared distally. After cutting the distal skin bridge the flap is transposed to the defect. The donor side is closed directly or by a skin graft. As a modification, the flap is prepared as a fascious flap with overlying fat to cover the median nerve after neurolysis.

Postoperative management: Immobilization of the wrist , in a soft palmar cast for 10 days; regular examination of the circulation of a fasciocutaneous flap.

Results: The Becker flap was used in 10 persons: 4 times as fasciocutaneous flap, 6 times as fascious flap. For closing the donor side, a skin graft was necessary in 2 cases; no flap was lost.

Objective: Stable reduction of pediatric fractures to the accepted position. Prevention of recurrent dislocation or loss of reduction to avoid invasive surgery.

Indications: Pediatric fractures of the upper and lower extremities.

Contraindications: Joint fractures, comminuted fractures, open fractures.

Technique: A comfortable environment for the child as well as sufficient pain management is of highest importance for successful treatment. Depending on the location of fracture or fracture pattern, indirect reduction (e.g. by cuff and collar), or direct manual reduction is applied with or without fixation of the fragments (screws, Kirschner wire, external fixator).

Postoperative management: Follow-up radiograph 5-7 days after closed reduction. In case of retention with hardware, a consolidation control with radiograph 3-6 weeks postintervention (depending on the age of the patient) is appropriate.

Results: Introduction of closed reduction techniques makes pediatric fracture treatment feasible without open interventions or need of osteosynthesis.

Objective: Correction of pediatric fractures by cast wedging to achieve acceptable positioning for conservative fracture management. Efficient and convenient treatment to avoid invasive manipulation or hospitalization.

Indications: Fractures of distal forearm shaft or distal metaphyseal forearm. Tibial shaft fractures from midshaft to distal metaphyseal region.

Contraindications: Proximal and middle forearm fractures. Complete dislocation. Articular fractures. Very young children (compliance problems). Open fractures.

Surgical technique: Immediate cast application for fracture treatment as usual. After 8-10 days wedging of the cast at concavity of fracture site leads to gentle fracture reduction within a few days.

Postoperative management: Depending on the age of the patient and location of the fracture, weekly visits to look for any discomfort or pain while cast treatment after wedging. Depending on the age of patient, duration of the cast is 4-6 weeks.

Results: A recent analysis of 199 fractures in Sankt Pölten (average age 8.9 years) showed low refracture rates. In only 2 cases did unsuccessful wedging lead to surgical treatment (proximal radius-elastic stable intramedullary nailing [ESIN], distal tibial metaphysis-K-wires). Furthermore, refracture after cast removal occurred in 4 out of a total of 78 greenstick fractures of the radius (refracture rate 5%, well below the usual figures reported in the literature). The treatment goal was achieved with cast wedging in 96% of the patient population.

Objective: Conservative treatment of stable fractures of the upper extremity in children.

Indications: Undisplaced and age-tolerable displaced fractures of the hand, forearm, and elbow.

Contraindications: Open fractures.

Treatment options: Forearm splint/forearm cast for stable injuries to the radius or ulna. Long arm splint/long arm cast for injuries to the radius and ulna and after reduction of the forearm, as well as for stable, undisplaced injuries to the elbow. Intrinsic plus splint for injuries to the four fingers (excluding the thumb) and metacarpus.

Further treatment: For stable injuries, immobilization for analgesia for 3-4 weeks. Clinical check after treatment. In the case of repositioned fractures or fractures displaced within the spontaneous correction limits, clinical-radiological control (if necessary, with cast wedging) after 1 week. Immobilization for 4 weeks (prepubertal children) or 5 weeks (pubertal children).

Results: Conservative treatment of fractures of the upper extremity is still the gold standard today. In pediatric patients in particular, but also in adult patients, correct healing of the fracture with good analgesia can be achieved with manageable effort and a good cost-benefit ratio through correct cast immobilization. A measurable parameter for monitoring a good cast is the cast index.

Objective: Conservative treatment using a backpack bandage (RSV) for clavicle fractures in children and adolescents serves to restore anatomy and function. The technique used in adult patients with elastic stable intramedullary nailing (ESIN) from the medial end of the clavicle involves the risk of growth disturbance of the growth plate, which has been open for a very long time; in addition, a cosmetically disturbing scar usually forms there. Treatment with an intrafocal intramedullary nailless osteosynthesis allows length and axis to be restored within the age-specific correction limits using a soft tissue-sparing surgical method in adolescents with, among other things, severe shortening of the fracture. Sufficient stability ensures early functional follow-up treatment without weight-bearing.

Indications: Conservative therapy using a figure-of-eight style brace or an arm sling can be applied to nearly all clavicle fractures in children and adolescents. Displaced and significantly shortened fractures can be addressed with intramedullary nail osteosynthesis.

Contraindications: Open injuries at the site of the figure-of-eight style brace application should be immobilized with the Gilchrist bandage. Multifragmentary or open fractures are not suitable for intramedullary nail osteosynthesis.

Surgical technique: The figure-of-eight style brace is applied in a figure-eight fashion around both shoulders or clavicles. A loop or knot is tied between the shoulder blades. For intrafocal intramedullary nailless osteosynthesis, an incision is made approximately 3-4 cm along the course of the clavicle directly above the fracture. After blunt dissection, the nail is first extracted laterally through the clavicle dorsally through the cortical bone. Here, the lateral clavicle may need to be reamed intramedullary and dorsolaterally through the opposite cortex using a 2.5-3.2 mm drill bit to facilitate insertion of the ESIN. A stab incision is made over the palpable end of the nail and the nail is removed. The ESIN is then grasped with the Jacob's reamer and advanced medially after reduction of the fracture. It may be useful to reduce the curvature at the tip of the ESIN. This is done as long as simple advancement is possible and until the clavicle stabilizes. The lateral end of the nail is pinched off subcutaneously and the wound is closed in several layers on all sides.

Postoperative management: Conservative treatment involves immobilization for 2-3 weeks, depending on age, until the patient is free of symptoms. Depending on age, the patient should refrain from sport for 4-8 weeks. The aim of osteosynthesis is early functional follow-up treatment without weight bearing. Rest is recommended for 8 weeks, which only applies to adolescents. Metal should be removed early after consolidation around the 8th-12th week.

Results: Our own pat

Support bandages and casts are used to immobilize and stabilize limbs after various types of injuries that require appropriate immobilization. Depending on the type of injury, different types of support bandages/casts and different materials are used. Due to the increasing surgical treatment of fractures in children, we are observing a decline in the practical skills needed to properly apply supportive bandages, particularly plaster casts. In the following, the different materials of support bandages and their properties are presented as well as their corresponding indications.

Objective: Refixation of a posterior root lesion of the medial meniscus via a tibial drill tunnel and prevention of extrusion using a meniscotibial suture (centralization).

Indications: Posterior root lesion of the medial meniscus.

Contraindications: Grade 4 cartilage damage in the corresponding compartment, uncorrected varus or valgus deformities, symptomatic instabilities, extensive degenerative tears apart from the root region.

Surgical technique: Knee arthroscopy via the high anterolateral standard portal. Diagnostic arthroscopy to check indication. Locate the insertion zone on the tibial plateau and local debridement until the bone of the tibial plateau is visible. Insertion of a targeting device and drilling of a targeting wire into the center of the insertion zone in the area of the intercondylar eminence. Overdrill the target wire with a 4.5 mm drill. Reinforcement of the medial meniscus posterior horn with braided suture material. The reinforcing thread is inserted into the bone tunnel via an eyelet wire with a thread loop. Optional additional centralization with incision in the middle part of the meniscus. Reinforcement of the meniscus base with braided suture material using the "outside in" technique and fixation of the inner meniscus base at the edge of the tibial plateau using a transosseous extraction suture or a suture anchor.

Postoperative management: Six weeks nonweight-bearing (0 kg), then gradually increased load. Range of motion: 4 weeks E/F 0-0-60°, 2 weeks 0-0-90°, optionally use of a valgus brace (varus of < 5°).

Results: In root lesions of the medial meniscus, transosseous refixation significantly improves knee function (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee Injury and Osteoarthritis Outcome scores) and reduces osteoarthritis progression. However, a transosseous suture alone could not significantly reduce postoperative extrusion. However, previous studies have shown that additional centralization can significantly reduce extrusion.

Objective: To achieve stable fixation to allow early mobilization by using a low profile contoured biplanar implant to avoid soft tissue problems and to minimize need for implant removal.

Indications: Unstable and displaced medial clavicle fractures in young patients with high functional demands.

Contraindications: Open/contaminated fractures. Fractures in geriatric patients with low functional demands.

Surgical technique: Saber cut incision over the medial clavicle. Perpendicular incision to open the calvipectoral fascia. Fracture reduction and temporary retention. Contouring and attachment of the plate. Definitive plate fixation. Radiological documentation.

Postoperative management: Cryotherapy, anti-inflammatory medication on demand. Shoulder sling for comfort for 1-2 weeks. Physical therapy with active flexion and abduction limited to 90° for 6 weeks. Clinical and radiological follow up for 6-12 months.

Results: In total, 5 patients were treated with the described technique. All patients were very satisfied with the result. The mean Constant-Murley score was 91 points and the mean Quick DASH (disabilities of shoulder and hand) was 3% after an average follow-up of 74 months. In none of the cases implant removal was necessary.