Unfallchirurgie (Heidelberg, Germany)最新文献

Ankylosing spinal diseases, such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), are highly important in spinal traumatology and are therefore specifically considered in the AO Spine Classification of spinal injuries. These diseases make the spine extremely susceptible to injury and also complicate the diagnosis and treatment, leading to an increased mortality. Concomitant neurological injuries are frequent. The treatment of such injuries requires great attention and careful preparation. Early and precise diagnostics using computed tomography (CT) and magnetic resonance imaging (MRI) as well as a surgical intervention are crucial for the survival and the quality of life of patients. The treatment is carried out surgically as conservative treatment often leads to high complication rates. In postoperative care special attention must be paid to cardiopulmonary complications.

This article reports on a complicated case of a soft tissue defect with challenging soft tissue coverage on the lower leg. After a lower leg fracture and treatment with a tibial nail, a 29-year-old man developed compartment syndrome due to massive secondary bleeding with a lesion of the common peroneal nerve and muscle necrosis around the fibular muscles. The initial coverage with split skin showed no tendency to heal, so the patient was admitted to this hospital with a soft tissue defect of approximately 25 cm × 10 cm on the lateral lower leg with an exposed tibia over a length of 15 cm. The primary attempt was coverage with a split-thickness skin graft after secondary granulation; however, due to the previously damaged vascular supply, the wound demonstrated a delayed incomplete healing over 8 months. In addition, X‑ray imaging revealed a nonunion and a resulting screw fracture of the two distal locking screws. The indications for revision surgery to treat the fracture and change the implant were fulfilled. In the same procedure, the residual cutaneous defects were closed. Given the previously complication-prone course and a difficult local blood flow situation, the choice of reconstruction procedures was limited. A bridge flap of the medial lower leg was performed in an interdisciplinary approach. The lifting defect was covered with split-thickness skin. In this way, the wound was finally adequately covered after 1 year.

Background: In surgery for sepsis it is a well-established principle that no internal osteosynthetic material should be implanted in cases of chronic osteomyelitis. Therefore, the surgical treatment with intramedullary nails is so far used only rarely in cases of chronic osteomyelitis.

Objective: This study analyzed whether the implantation of tibial intramedullary nails is an effective treatment for chronic osteomyelitis and how high is the rate of reinfection.

Material and methods: A retrospective analysis of patients with an infected pseudarthrosis of the tibia in whom a gentamycin-coated nail (ETN) or an uncoated tibial intramedullary nail (UCN) was implanted between December 2011 and December 2019 was carried out. The preoperative, perioperative and postoperative results were evaluated.

Results: During the study period 29 patients received a UCN and 27 patients received an ETN. Of the patients 95% (n = 53) had been previously unsuccessfully treated with external fixation. Postoperative complications occurred in 45% of the patients and more often in the ETN group (48% vs. 41%). Reexacerbation of the infection occurred in 20 patients and more frequently in the UCN group (38% vs. 33%). The nonunion already showed a bony consolidation at the time of the exacerbation in 10 patients (50%). At the end of the follow-up a consolidation was present in 48 patients (86%), more frequently in the UCN group (90% vs. 78%). Of the patients 50 (89%) reached full weight bearing without any differences between the groups.

Conclusion: Despite a relatively high a rate of postoperative complications the risk of reinfection was acceptable with good functional and radiological results. The main general advantages of nailing are without doubt the high primary stability, the implantation with preservation of the soft tissue and the improved wearing comfort for patients.

After conservative treatment nonunion (pseudarthrosis) of the clavicle can be observed approximately 10 times more frequently (15-24%) than after surgical treatment (1.4%). Risk factors include the fracture location, displacement, fracture type, sex, the severity of the accident and refractures. The diagnosis of pseudarthrosis of the clavicle can be made by a thorough medical history, clinical examination and imaging procedures. The main symptom is pain, often accompanied by malalignment, instability, neurological symptoms and restricted mobility of the affected shoulder. The diagnosis is confirmed by X‑ray images and, if necessary, a computed tomography (CT) scan. Pseudoarthrosis is classified according to the morphological appearance in X‑ray images and the cause. A differentiation is made between vital and nonvital pseudarthroses. Only symptomatic pseudarthrosis requires treatment. Nonoperative methods, such as magnetic field therapy or ultrasound are minimally effective. Surgical interventions are indicated for pain, movement restrictions or neurovascular problems. The goals of surgical treatment are to restore the vitality, bone length and stability through angular stable osteosynthesis. In cases of surgical pretreatment the anteroinferior plate position offers a good alternative to the superior plate position. In some cases double plating osteosynthesis can be indicated. Autogenous bone material, allogeneic substitute material and vascularized grafts are used for bony defects. Surgical treatment shows high rates of healing but also carries an increased risk of infection.

Background: Primary periphyseal stress injuries (PPSI) of the hand and fingers are a rare condition overall but are most commonly seen in adolescent rock climbers and is the most common sport-specific injury in young climbers. Early diagnosis and treatment are crucial for a good treatment outcome and to avoid chronic sport-related injury.

Objective: The aim of the study is to introduce the injury to a wider audience. Based on an analysis of the current literature, the pathophysiology is demonstrated and the diagnostic and treatment standards are analyzed. Prophylactic measures are also reported.

Material and methods: Based on a systematic multiple database analysis, the current literature on PPSI of the hand and fingers in climbers were collected and further analyzed in a narrative review. The pathophysiology, diagnostic and treatment concepts are presented.

Results: Most cases of PPSI to the hand and fingers are in young rock climbers; however, a few cases have been reported in gymnasts, baseball players and piano players. Overall, there are over 200 documented cases in the literature. Most are Salter-Harris III/Aitken II fractures but grade I, II and IV fractures have also been reported. Patients are mostly 13-15 years of age and within the main pubertal growth spurt. After diagnosis, usually by magnetic resonance imaging (MRI), treatment is often conservative, with an increasing number of cases requiring surgical revision. Surgery usually involves spot drilling of the growth plate to induce fusion.

Discussion: Early diagnosis and treatment are critical for a good outcome. This includes specific education and information for athletes, coaches, parents and treating physicians. Also, the frequent use of the crimp position has also been shown to increase the risk of PPSI. Preventive aspects should target this as well as overall load management.

Medial clavicle fractures and injuries to the sternoclavicular joint are rare injuries but can have life-threatening consequences. There are no standardized treatment algorithms or guidelines for the diagnostics and treatment. This article provides an overview of the individual topographies as well as the conservative and surgical treatment strategies.Conservative treatment is preferred for medial clavicle fractures. The indications for surgical treatment are variable but this is frequently carried out if there is a fracture displacement > 1 cm or 1 shaft width and high functional demands. In the case of accompanying injuries to neurovascular structures, an open fracture or the threat of perforation of the skin, surgical treatment is mandatory. Open reduction and internal fixation using (locking) plates is currently the preferred form of treatment.In the case of posterior dislocation of the sternoclavicular joint, an immediate closed reduction must be attempted with the patient under analgosedation and with emergency treatment on standby. This temporal urgency does not exist for anterior and superior dislocations. Surgical treatment is indicated in cases of unsuccessful reduction, persistent symptomatic instability or injuries of the neurovascular bundle. From a multitude of treatment options, arthrodesis with suture cerclage has shown good results. Tendon grafts as well as special hook plates are increasingly being used due to better biomechanical qualities. The surgical treatment of combined injuries is determined by the individual injury pattern.Despite the variety of treatment strategies, the long-term outcome has consistently been positively described.

Background: Clavicle fractures are among the most frequent injuries of the shoulder girdle. Nondisplaced fractures are generally treated conservatively, whereas dislocated fractures require surgical reduction and stabilization. A variety of implants and surgical techniques with reliable results are available. While all techniques provide similar healing rates, they share a common disadvantage with the high incidence of implant irritation and correspondingly high rates of second interventions for material removal.

Objective: The various surgical techniques for clavicle shaft fractures with their specific areas of application as well as advantages and disadvantages are presented. This review also provides an aid for deciding which surgical technique is most appropriate based on the fracture morphology. Furthermore, an overview of current research activities is presented, with a specific focus on new implants which could help to reduce implant irritation.

Results and conclusion: Open superior and anteroinferior plate osteosyntheses each show similar reliable results. The minimally invasive plate osteosynthesis (MIPO) technique offers an alternative for multifragmented fractures as it has a lower complication rate compared to the open procedure. Double plate osteosynthesis using minifragment plates shows promising results with respect to the incidence of implant-related irritation. Larger prospective studies are still pending. Intramedullary nailing offers a good alternative, especially if material removal is planned anyway, e.g., in the pediatric setting.