Unfallchirurgie (Heidelberg, Germany)最新文献

Background: Femoral intramedullary nailing is the gold standard in the surgical treatment of femoral shaft fractures and can generally be performed using an antegrade or retrograde technique. As an intramedullary load-sharing device this type of osteosynthesis has biomechanical advantages. Retrograde intramedullary nailing is becoming increasingly more important in the treatment of periprosthetic, metaphyseal and intra-articular distal femoral fractures.

Objective: This article aims to demonstrate the value of retrograde femoral nailing and to discuss the clinically relevant advantages and disadvantages that need to be considered.

Material and methods: Systematic literature search using PubMed, Google Scholar and Cochrane Library using the keywords "femoral fracture, retrograde nailing, periprosthetic fracture, intramedullary nailing and locking plate osteosynthesis".

Results: In distal femur fractures retrograde nailing shows significantly less nonunions and infections than lateral locking plate osteosynthesis. In the treatment of intra-articular comminuted distal femur fractures, the rates of complications and revisions were lower with retrograde nailing than with plate osteosynthesis. Counterintuitively, there was no increased risk of septic arthritis of the knee joint after primary treatment of open fractures with a retrograde femoral nail. There is an increased risk of postoperative knee complaints.

Discussion/conclusion: Retrograde intramedullary femoral nailing provides many advantages with a comparatively low risk profile and can be used in a variety of forms for femoral fractures. The risk of postoperative knee complaints should be considered when determining the indications.

The wrist extends anatomically and functionally from the distal forearm to the metacarpal bones and encompasses the entire carpal region. The large number of bones and joints involved are stabilized in a highly complex system of extrinsic and intrinsic ligaments, which enables a variety of different movements and stability in all positions for the best possible use of the hands. While injuries to individual ligaments or joints, most commonly the scapholunate (SL) ligament, can cause major problems the injuries associated with perilunate dislocations and dislocated fractures represent one of the greatest challenges in hand surgery.

The indications for tibial nailing are increasingly extending into periarticular regions, often under critical and challenging soft tissue conditions. Furthermore, due to the demographic development fractures of compromised osteoporotic bone must increasingly be surgically treated.Suprapatellar and parapatellar approaches have emerged as effective alternatives to the traditional infrapatellar approach, which simplify the operative technique of reduction and nail insertion, reduce the duration of intraoperative fluoroscopy time and yield improved reduction outcomes particularly in complex periarticular fractures.The insertion of the intramedullary locking nail into the medullary canal does not automatically guarantee an adequate reduction outcome. This article outlines key operative tips and tricks aimed at supporting the orthopedic surgeon in obtaining reproducible optimal surgical outcomes especially in borderline indications.Technological advancements in nail design and fixation methods enable more reliable and precise reduction even in complex cases, especially with fractures involving short metaphyseal fracture fragments. This article also addresses the specific requirements for achieving stable intramedullary fixation.

An overseas assignment in a rural hospital in Tanzania provides surgeons with extraordinary insights into clinical practice under completely different conditions. The injury patterns are largely determined by motorcycle accidents: open fractures, traumatic brain injuries and polytrauma dominate the spectrum. Limited resources make simple and robust techniques, such as external fixation, lag screw osteosynthesis and plaster cast treatment central to patient care. Diagnostic options and intensive care are restricted, requiring a renewed focus on clinical examination, prioritization and pragmatic solutions. In addition to clinical work, the training of young colleagues plays a key role in sustainably strengthening local structures. Such an assignment broadens professional horizons, sharpens clinical judgment and fosters a deep appreciation of the possibilities offered by modern surgery in Europe.

Periprosthetic distal femoral fractures (PPDFF) following knee arthroplasty represent an increasing challenge for trauma surgery and orthopedics, particularly for older multimorbid patients. Treatment concepts vary depending on the fracture type, prosthesis stability, bone quality and patient factors [1, 6-10, 13]. Depending on the fracture type and bone quality, modern locking angle plates, retrograde intramedullary nails with angulated stems, double plate and nail-plate constructs provide a high primary stability and usually enable early functional mobilization [5, 6, 11, 13, 30-33]. In very distal, osteoporotic or complex fractures, double plating is often biomechanically superior and reduce complications such as nonunion and implant failure [2, 10, 11, 13, 14, 22, 29], although there is also a risk that the bone behind the femoral shield will not properly consolidate. Distal femoral replacement is indicated in cases of extensive bone loss or primary loosening of the prosthesis [8]. Early mobilization, especially in the mostly older patient population, improves the functional outcome and reduces mortality [1, 5, 11, 13, 16, 27, 30-33]. The aim of this review article is to systematically present and evaluate current treatment options, their evidence, specific complications and functional outcomes.

Extra-articular fractures of the distal femur are gaining relevance as a typical injury in geriatric traumatology. While conservative treatment is reserved for exceptional cases, minimally invasive angular stable plate osteosynthesis and retrograde intramedullary nailing are established options for surgical treatment. Depending on the type of fracture and patient-specific factors double plate osteosynthesis using additional medial helical plates or combinations of different types of osteosynthesis are used.

Shaft fractures of the upper extremities represent a significant challenge in trauma surgery due to their functional importance. The epidemiological analysis reveals characteristic distribution patterns: humeral shaft fractures (1.2-5% of all fractures) show a bimodal age distribution, with peaks at 20-30 years and above 60 years. Forearm shaft fractures (13.8/100,000 inhabitants [1]) occur particularly frequently in children and decrease with advancing age. The classification primarily follows the AO/OTA system, which was comprehensively revised in 2018, supplemented by specific classifications for special types, such as Monteggia and Galeazzi fractures. In the diagnostics, conventional radiography remains the initial standard, while computed tomography (CT), magnetic resonance imaging (MRI) and increasingly high-resolution sonography serve as complementary methods for assessing complex fracture morphologies and associated soft tissue injuries. Concomitant neurological injuries, especially radial nerve palsy in humeral shaft fractures (2-17%), which otherwise occur less frequently in routine trauma surgery, require differential diagnostics and individualized treatment concepts. While the majority of nerve lesions show spontaneous remission, microsurgical reconstruction techniques exist for persistent cases. Innovative approaches such as biological augmentation, virtual reality (VR)-based neurorehabilitation or functional electrical nerve stimulation could improve outcomes in the future. Interdisciplinary collaboration between orthopedic surgery, neurology and rehabilitation medicine is essential for optimal treatment results.

The tertiary survey serves to identify injuries and their consequences in the hours and days following polytrauma. A structured process has been proven to result in a high rate of previously missed additional diagnoses, leading to subsequent changes in patient management; however, to date there are no concrete practical recommendations or widespread implementation of the tertiary survey in German trauma centers. We recommend performing the tertiary survey for the first time as early as possible in the intensive care unit, followed by repeated assessments as needed when the patient´s clinical condition changes. Furthermore, we recommend utilizing the tertiary survey as a structured re-evaluation of the patient beyond physical examination. This should include the assessment of psychological stress, a thorough review of imaging and consultative findings and the collection of additional information regarding the accident and the patient´s medical history. After compiling all information further treatment plans should be evaluated and defined. The Trauma Section of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) is developing a freely available tertiary survey form, which will undergo continuous optimization supported by scientific evaluation. In the long term, the goal is to provide a standardized tool for integration into local standard operating procedures of trauma centers, quality management systems and digital emergency care pathways.