Unfallchirurgie (Heidelberg, Germany)最新文献

The reconstruction of long bone defects as a result of primary traumatic, secondary infection or tumor-related loss of substance continues to represent a surgical challenge. Callus distraction via segment transport, vascularized bone transfer and the induced membrane technique (IMT) are established methods of reconstruction. In recent decades IMT has experienced increasing popularity due to its practicability, reproducibility and reliability. At the same time, the original technique has undergone numerous modifications. The results are correspondingly heterogeneous. This overview is intended to explain the basic principles of IMT and to provide an overview of the various modifications and their complications.

The supracondylar humerus fracture is the most frequent fracture of the elbow region during the growth period. The peak age is around 5 years. Extension fractures predominate. The clinical diagnostics are supplemented by X‑ray images in two projections. Growth-associated spontaneous corrections of posttraumatic deformities rarely occur. The goal of treatment is therefore the active transformation of every displaced fracture into a nondisplaced stably fixed fracture.If this is not successful, the consequences of healing in a malalignment can be, e.g., restriction of elbow flexion due to remaining antecurvation or cubitus varus. Combinations are often present. The causes include technical problems with reduction and retention but also misjudgement of the X‑ray findings, ignorance of the growth prognosis or inadequate verification of whether the treatment goal has been achieved.Unsatisfactory treatment results should be corrected as early as possible. This can be done primarily before bony healing is completed or secondarily as a corrective osteotomy at any later point in time. The earlier the correction of the malalignment is performed, the greater the chances of a complete restoration to the original condition. Depending on the type and extent of the deformity various techniques for corrective osteotomy are suggested in the literature.

Background: Fractures of the distal radius in childhood are frequent but rarely lead to relevant growth disturbances.

Objective: The experiences of a pediatric trauma center over 15 years are exemplarily presented and discussed.

Material and methods: Osteotomies of the distal radius were selected and the clinical and radiological findings were recorded and analyzed.

Results: Posttraumatic growth disturbances were corrected in 10 cases with a median age of 13 ½ years. In six cases an iatrogenic cause was also possible. In two cases callus distraction with secondary palmar plate osteosynthesis was used for consolidation. In eight cases primary ad hoc corrections were carried out using palmar plate osteosynthesis (six with iliac crest and two with allogeneic grafts). In five cases the distal ulnar growth plate was also addressed. During follow-up breakage of one plate was registered. After an average of 31 months postoperatively, 9 children had full range of motion (ROM) and in 1 case there was an extension deficit of 10^o.

Conclusion: It is important to evaluate the cause of the mostly partially inhibiting growth disturbances to draw preventive conclusions. From a clinical perspective the visible deformity is given priority and the pain and functional limitations are less relevant. The indications for corrective surgery must include the age of the patient, remaining growth potential, size and localization of the growth plate bridge, the deformity and the individual wishes of patients and parents. In most cases a full correction is possible with palmar plate osteosynthesis and an iliac crest graft. External fixation and callus distraction is an alternative in cases where the correction is more extensive. The distal ulnar growth plate should be controlled concerning further growth potential before hardware removal.

Background: To break or not to break-That is the question that has been asked in pediatric traumatology for many years regarding the treatment of greenstick fractures of the diaphyseal forearm shaft.

Objective: The frequency of greenstick fractures of the forearm shaft in children and adolescents; the influence of breaking the fracture on the refracture rate.

Methods: Analysis and discussion of relevant articles, analysis of the refracture rate of pediatric greenstick fractures of the forearm shaft in our own patient population.

Results: Greenstick fractures frequently occur in the area of the forearm shaft and incomplete consolidation leads to an increased refracture rate. In the patient collective of the authors of 420 children with greenstick fractures of the diaphyseal forearm, there was a refracture rate of 9.5%; however, the rate for non-completed fractures was significantly higher compared to the group with completed fractures (15.2% vs. 3%). While in the subgroup of conservatively treated fractures (n = 234), breaking the intact cortex significantly reduced the refracture rate, breaking the intact cortical bone during surgical treatment with elastic stable intramedullary nailing (ESIN) did not change the refracture rate.

Conclusion: As part of the conservative treatment of greenstick fractures of the diaphyseal forearm, completing the fracture can be recommended in order to lower the refracture rate. Completing the fracture does not appear to be necessary during surgical treatment using ESIN.

Background: Due to continuous improvements in treatment, more and more severely and seriously injured patients are surviving. The complexity of the injury patterns of these patients means that they are difficult to map in routine data.

Aim of the work: The aim of the data exploration was to identify ICD 10 diagnoses that show an association with an injury severity score (ISS) ≥ 16 and could therefore be used to operationalize severely injured patients in routine data.

Material and methods: The coded four-digit ICD 10 S diagnoses and the calculated ISS of trauma patients from the Armed Forces Central Hospital Koblenz (BwZKrhs) and the University Hospital Düsseldorf (UKD) were analyzed using statistical association measures (phi and Cramer's V), linear regressions and machine learning methods (e.g., random forest).

Results: The S diagnoses of facial, head, thoracic and pelvic injuries, associated with an ISS ≥ 16 were identified. Some S diagnoses showed an association with an ISS ≥ 16 in only 1 of the 2 datasets. Likewise, facial, head, thoracic and pelvic injuries were found in the subgroup of 18-55-year-old patients.

Discussion: The current evaluations show that it is possible to identify ICD 10 S diagnoses that have a significant association with an ISS ≥ 16. According to the annual report of the trauma register of the German Society for Trauma Surgery (TR-DGU®), injuries with an abbreviated injury scale (AIS) ≥ 3 are particularly common in the head and thoracic regions.

Lisfranc injuries are rare but severe injuries of the foot. They range from ligament sprain to complex fracture dislocations. Etiologically, a distinction is made between indirect and direct force and between high-energy and low-energy trauma. Inadequate diagnostics (injuries overlooked or misinterpreted) can lead to painful posttraumatic osteoarthritis, chronic instability and deformity of the foot. A fracture, malalignment and unclear findings in conventional radiological diagnostics necessitate computed tomography imaging including 3D reconstruction. Lisfranc injuries are often associated with accompanying pathologies of the foot that also need to be addressed. Only stable non-displaced fractures can be treated conservatively. Depending on the injury pattern, surgical treatment is performed percutaneously, minimally invasive or open. The prognosis following Lisfranc injury is determined by the severity of damage and the quality of reconstruction.

Surgical techniques in amputation medicine did not change for a long time, while prosthesis technology underwent rapid development. The focus shifted to optimising the residual limb for prostheses use. At the same time, digital technologies such as gamification, virtual and mixed reality revolutionised rehabilitation. The use of gamification elements increases motivation and adherence to therapy, while immersive technologies enable realistic and interactive therapy experiences. This is particularly useful in the context of controlling modern prostheses and treating phantom pain. In addition, digital applications contribute to optimised documentation of symptoms and therapy successes. Overall, these technologies open up new, effective and personalised therapeutic approaches that can significantly improve the quality of life of amputation patients.

Background: Calcanectomy and Achilles tendon resection are very hard to repair.

Objective: Ilizarov's "calcaneogenesis" is possible with ankle joint preservation. Even after 3.5 years of functio laesa of the triceps surae muscle it can be rebuilt.

Material and methods: A 25-year-old motorcyclist suffered a 3rd degree open calcaneal dislocation fracture (type 5). Osteitis and necrosis required calcanectomy, resection of the Achilles tendon and a latissimus dorsi muscle transfer. A talus corpus osteotomy with Ilizarov distraction created in the 1st step a "neo-calcaneus". In a delayed 2nd step a fresh-frozen Achilles tendon-bone block allograft was transplanted to regain active plantar flexion.

Results: The initial AOFAS score of 35 points was significantly improved to 70 points 12 years after step 1. After both operations the patient could walk without an orthosis and regained 88% of normal plantar flexion strength. Quantitative measure of health outcome according to EQ-5D-5L was marked by the patient with 80 out of 100 points.

Discussion: "Calcaneogenesis" with preservation of the ankle joint is possible and innovative. Despite 3.5 years of disconnection of the triceps surae muscle, an Achilles tendon-bone block allograft could restore 88% of the push-off force even attached to a neo-calcaneus that is 1/3 smaller than normal, which is also new.

The abrupt onset of the situation after a traumatic amputation and the preparatory discussions following unsuccessful attempts to preserve limbs with necessary amputation require a high level of empathy, attention and well-founded information individually tailored to the affected individuals. Optimization of the treatment process can only be achieved by considering these aspects.The self-motivation and cooperation of the patient should be encouraged. To achieve this goal, the professions involved are less suitable for counseling due to a lack of personal experience, whereas so-called peers, as knowledgeable and experienced advisors, are more appropriate. This insight can be derived from existing studies. Peer counseling has increasingly been integrated into routine treatment following amputations in trauma surgery, with positive effects. It is considered guideline-compliant therapy not only in rehabilitation. Against the background of long-standing legislation, especially the UN Convention on the Rights of Persons with Disabilities and the demands of those affected by amputation, the following presentation focuses on the instrumentalization and benefits of counseling. The structures of this particular counseling option, including regular training of counselors and established implementation, are currently not necessarily given but are continuously expanding and being adapted to needs. Concrete scientific evidence regarding measurable effects and positive impacts on outcomes is pending and are presented in a current research project.