Unfallchirurgie (Heidelberg, Germany)最新文献

Background: Humeral shaft fractures occur with an incidence of approximately 12-25 per 100,000 per year and exhibit two age peaks, young patients following high-energy trauma and older patients with low-energy trauma.

Treatment: Principally, conservative treatment is a viable option, which requires high patient compliance but shows good healing rates in appropriate cases, particularly for fractures of the middle third of the shaft. Compared to surgical treatment there is a slightly increased rate of pseudarthrosis. In the case of surgical treatment, both plate osteosynthesis and intramedullary nailing show good results.

Radial nerve injury: A distinction must be made between primary radial nerve injury, which occurs immediately after trauma and generally has good spontaneous recovery rates, and secondary radial nerve injury, which is a consequence of the initiated treatment. In this case, careful consideration should be given to the potential need for a surgical intervention.

Conclusion: Overall, both conservative and surgical treatment approaches lead to good functional outcomes in appropriately selected patients. The choice of treatment should be made individually, considering the patient's age, fracture complexity, comorbidities and expected patient compliance.

The treatment of polytraumatized patients is challenging. Intensive efforts and interdisciplinary teamwork have improved survival rates of severely injured patients over the last decades. High quality guideline recommendations focusing on the prehospital setting, emergency room management and also the initial surgical phase have been published and are frequently updated. The current manuscript is part of new guidelines on an S3 level that focuses on treatment of polytraumatized patients who were transferred to the intensive care unit after initial emergency treatment. These patients have special needs, especially with respect to monitoring, pain management, ventilation strategy, nutrition etc. and most often require definitive surgical stabilization of injuries to the thorax, abdomen, pelvis and extremities. This article summarizes the current literature and gives recommendations with respect to early definitive treatment of patients with multiple trauma and particularly with a view to the best possible timing of the definitive treatment.

Background: With the 2023 revision of the German S3 guideline "Polytrauma/severely injured patient care" the criteria for trauma team activation (TTA) were revised. Accident mechanism-based criteria were largely eliminated. The impact of these changes on emergency department (ED) management, over- and undertriage following traffic accidents, and hospital length of stay has not yet been systematically evaluated.

Objective: The aim of this study was to assess the effects of the guideline update on patient treatment in the emergency department of a level I trauma center.

Methods: In a prospective, single-center observational study, all patients presenting after motor vehicle accidents were recorded over a 2-year period (pre- vs. postguideline update). Primary endpoints were the frequency and appropriateness of TTA as well as the distribution of treatment locations. Secondary endpoint was hospital length of stay.

Results: A total of 1438 cases were analyzed. The number of red-triaged patients decreased significantly (257 vs. 157; p < 0.001). The overtriage rate among TTA patients declined (27.6% vs. 21%, p < 0.01) without a significant increase in undertriage. Mortality and hospital length of stay did not differ significantly between groups.

Conclusion: The revision of TTA criteria led to a marked reduction in trauma team activations while maintaining quality of care. No significant increase in undertriage was observed. The updated TTA criteria may support resource-efficient patient care without compromising safety.

Background: Embolization via interventional radiology (IR) plays a critical role in the management of trauma patients and is effective in controlling arterial hemorrhaging in the pelvis, retroperitoneum, and gastrointestinal tract.

Objective: To evaluate the role of IR in the management of traumatic arterial bleeding in the pelvic, retroperitoneal and gastrointestinal regions.

Material and methods: A comprehensive literature review was conducted to assess the current evidence regarding the indications, procedural techniques and results of embolization following trauma in the named regions.

Results: The decision to perform embolization is determined individually and interdisciplinary based on contrast-enhanced computed tomography (CT). In cases of arterial bleeding, embolization following pelvic trauma is a key pillar of treatment. Posttraumatic retroperitoneal renal embolization is indicated as the method of choice in cases of traumatic arterial bleeding without devascularization or fragmentation of the kidney. Although there is a lack of robust data and clear guidelines for embolization in traumatic gastrointestinal and other retroperitoneal hemorrhages, evidence from nontraumatic cases suggests a high therapeutic potential. The endovascular techniques used in trauma closely mirror those employed in nontraumatic vascular occlusion interventions in these regions.

Discussion: Targeted embolization effectively controls traumatic bleeding.

Distal fractures of the femur are becoming increasingly more important due to demographic changes and the increasing use of endoprosthetic treatment. The updated S2 guidelines on distal femoral fractures were developed by an interdisciplinary consensus and combine current evidence and clinically proven procedures for the treatment of these diverse fracture types. The main focus is on a differentiated fracture classification, patient-specific risk factors and the precise assessment of fracture morphology, soft tissue damage and general condition. Compared to conservative measures, surgical treatment has become established as the standard, with various osteosynthesis techniques being used, from plate and screw osteosynthesis to intramedullary nailing and distal femur replacement. The guidelines also consider perioperative measures, imaging techniques and rehabilitative strategies to prevent long-term complications. The following article illustrates the practical implementation of the guidelines based on clinical case studies and offers practical guidance.

Objective of surgery: The aim of this surgery is to stabilize an unstable cervical spine injury.

Indications: Type B2 injury according to the AOSpine classification for injuries of the subaxial cervical spine and the associated instability. Guidelines and treatment recommendations for this injury.

Contraindications: Robotically assisted and navigated techniques have no special contraindications.

Surgical technique: Performed in the 3D navigation hybrid operating theatre "Robotic Suite" consisting of navigation unit "Curve Navigation System", robotic 3D cone beam computed tomography (CBCT) "Loop-X", robotic arm "Cirq Arm System" and wall monitor "BUZZ" (Brainlab, Munich, Germany). The individual surgical steps are explained in the video (English), available on the website under "Supplementary Information" or via the QR code.

Surgical steps: Preoperative: planning CT and screw planning.

Intraoperative: Carbon table, prone position and Mayfield clamp. Dorsal approach. Attachment of the reference array. 1) CBCT scan. Image fusion. Control of fusion result. Robot arm approach to the drilling trajectory, robotically assisted drilling. Insertion of the K‑wire. Navigated threading and navigated screw placement. 2) CBCT scan, control of the screw positions. Satisfactory screw position, insertion of connecting rods and bone substitute material, sterile wound closure.

Follow-up: No cervical orthosis necessary. Isometric physiotherapy. Adapted pain therapy as needed and according to WHO scheme. X‑ray control after 6 and 12 weeks. No metal removal.

Evidence: The video material shown is from a routine clinical operation. Robotically assisted and navigated operations at the subaxial cervical spine are performed with good surgical results and a high accuracy.

In the event of a disaster, compliance with basic hygiene measures is crucial. These measures are carried out regardless of the colonization or infection status of the patient in order to prevent the transmission of pathogens to other patients and personnel and to minimize the risk of a nosocomial distribution of (potential) infectious pathogens. This primarily includes hygienic hand disinfection and the use of special barrier precautions and personal protective equipement depending on the situation as well as safe injection and infusion techniques, proper processing of medical products and full vaccination protection of the personnel. When consistently applied basic hygiene measures also protect against the transmission of multidrug-resistant pathogens in undetected colonized patients and many viral infections. Due to a massive increase in demand (e.g., during the pandemic), disruptions in supply chains or breakdowns in facility-specific structures, prolonged shortages of materials that are important for implementing basic hygiene can occur. In these situations, substitution strategies are required, e.g., for the in-house production of hand and surface disinfectants, the handling of drinking water, alternative ways of processing medical products, wound care and the use of antibiotics.

The function of the hand can be substantially impaired by fractures of the finger and metacarpal bones. Metacarpal fractures account for up to 50% of hand fractures, followed by finger fractures (25%), with the fifth metacarpal most commonly affected. The diagnostics include the clinical examination, X‑ray and often computed tomography (CT) imaging. The treatment depends on the type of fracture and clinical function as well as the patient's needs. In many cases conservative treatment is possible. Surgically, K‑wires, plate or screw osteosyntheses and rarely external fixators are used. Postoperatively, the focus is on maintaining function and avoiding complications through specialized hand therapy. The aim is to restore pain-free and unrestricted hand function. This overview does not include the diagnostics and treatment of fractures of the thumb, only finger and metacarpal fractures.

In health crises marked by severe resource scarcity, such as during the COVID-19 pandemic and in anticipated scenarios of national or state defence, hospitals face the challenge of maintaining the best possible medical care under ethically and legally responsible conditions. This article analyzes the ethical, legal and operational foundations of resource allocation in clinical disaster medicine. Central to this are the principles of utility maximization, fairness and transparency, which necessitate a shift from standard individual-centered care to a population-oriented crisis response. Medical indication forms the cornerstone of any treatment and must be evidence-based and patient-centered, even under crisis conditions. Therapeutic goals and prognostic assessment within the given resource constraints serve as key criteria for prioritization and allocation decisions. The use of triage category IV (blue) and the implementation of tertiary (ex-post) triage within hospitals are only conceivable under conditions of existential scarcity and require clear legal and ethical justification. Clinical ethics committees and independent triage teams play a pivotal role in decision-making and communication. The legal interpretation, particularly in the context of § 5c of the German Infection Protection Act, remains controversial and demands nuanced evaluation. The article underlines the necessity of consistent decision-making processes, structured documentation and the inclusion of vulnerable populations in crisis planning. Finally, operational strategies, such as tactical abbreviated surgical care (TASC), are presented as resource-efficient approaches to care. The overarching goal is to enable as many patients as possible to access the best achievable medical care, even under extreme conditions, while upholding ethical standards.

Background: The most frequent side effect of local corticosteroid injections in athletes is the rupture of collagenic tissues, such as fascia and tendons.

Objective: 1. Warning against cortisone injections in the vicinity of tendons, fascia and retinacula. 2. Presentation of the anatomical restoration of the osteofibrous quiver of the tibialis posterior tendon. 3. Introduction of a pathogenetic classification of tibialis posterior tendon dislocation.

Material and method: A 23-year-old female ballet dancer suffered from pain and significant loss of strength despite stiff taping while dancing en pointe 8 months after radical debridement for a putrid infection with Klebsiella pneumoniae of the left tibialis posterior tendon with a sonographically detectable dislocation. After debridement and reduction of the partially ruptured, scarred and split tendon, an anatomical restoration of the osteofibrous tendon quiver was performed with local tissue and transosseous sutures. The targeted perioperative administration of antibiotics, a postoperative lower leg cast for 6 weeks with thrombosis prophylaxis and subsequent intensive rehabilitation measures resulted in the complete ability to work after 8 weeks.

Result: There were no recurrences over the 13-year period. With pain-free dancing en pointe without taping, the now 36-year-old soloist is still the lead female dancer at a renowned German opera house, is the mother of two children and believes that she dances better today than before.

Discussion: Whether the initial local corticosteroid injection caused a pathological retinaculum rupture with dislocation of the tibialis posterior tendon or whether it was originally caused by the putrid infection after tendon revision surgery or whether a necrotic retinaculum was ultimately subjected to radical debridement, must remain an open question.