Unfallchirurgie (Heidelberg, Germany)最新文献

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.

There is an increasing focus on preparation for disasters, crises and wars. The ability to react to such exceptional situations affects many pillars of a society. A key component of crisis response is the maintenance of medical care. This, in turn, has a significant impact on care in the outpatient and inpatient settings. Accordingly, hospitals must be prepared for such situations. An important element of such preparation is the hospital emergency and contingency planning (HECP). This requires detailed organization, structuring, planning, training and practice. Important elements of HECP are leadership, communication, zoning and the management of personnel, space and resources. The establishment of a leader of the HECP who coordinates and implements the planning is important and must be accompanied by an appropriate indemnification. Funding must be considered but cannot be an argument for failing to make serious and effective planning. Disasters that hit us unprepared will seriously jeopardize the healthcare system and thus the health of the population. Robust healthcare systems and robust hospitals can play their part in reducing the medical and social impact of disasters.

In order to prepare hospitals better for the necessary crisis care in a shortage situation, the Clinical Disaster Medicine Germany (LeiKliKatMeD) guidelines are currently being developed. They are funded by a research and development project of the Federal Office of Civil Protection and Disaster Assistance (BBK) and are being developed by the section assignment, disaster and tactical surgery (EKTC) of the German Society for Trauma Surgery (DGU) in collaboration with 38 specialist societies. This article describes the framework conditions and basic assumptions that were taken into account. In addition to recommendations for the treatment of typical injury and illness patterns in disasters, crises and war, the guidelines describe, for example, the requirements of hospital alert and operational planning as well as general points. After successful preparation and implementation these can lead to a reduction in the workload of medical treatment facilities in a crisis, so that the stage of compensated crisis care can be maintained for as long as possible in the exceptional situation of an extensive or prolonged damage position. For the prioritization and disposition of medical treatment measures in this situation, the categorization according to the urgency of treatment as part of the initial triage is an important point for the successful management of a damage situation. As a preview of the content of the guidelines, which are expected to be completed by the end of this year, these points are summarized and explained in order to facilitate the successful consideration and implementation of the expected recommendations even now.

Background: In the authors' opinion the prevalence of equinus foot deformities is an underestimated medical and socioeconomic problem that has not yet been adequately investigated. A  dorsiflexion in the ankle joint of < 10° can lead to limitations in gait.

Objective: The aim of the present study was to determine the prevalence of equinus foot deformities based on the degree of restriction of dorsiflexion in the ankle joint in hospitalized patients.

Material and methods: In this cross-sectional study the active range of motion of the ankle joint in 205 patients at Münster University Hospital was prospectively examined with a goniometer. Included in the study were 136 trauma surgery and 69 neurology patients. The association of restricted dorsiflexion with other clinical parameters was investigated using the χ²-test or Fischer's exact test. The significance level was set at p < 0.05.

Results: In total, 205 patients with mean age of 59 years were included. There was a slight predominance of males (55.1%) in the gender distribution. The average dorsal extension of the ankle joint was 7.03°on the right side and 8.92° on the left side. Of the patients 72.2% had a dorsiflexion in the ankle joint of < 10°, 38.1% a dorsiflexion < 5° and 16.1% a dorsiflexion < 0° on at least one side. A relevant association between age, gender, duration of hospitalization and the reason for treatment with a restriction of dorsiflexion could not be observed.

Conclusion: The results suggest that restriction of dorsiflexion is a frequent problem in our group of trauma surgery and neurology patients. In particular, the presence of a manifest equinus deformity of the foot of > 10% that could not achieve the neutral position is a relevant finding.