Zeitschrift fur Unfallchirurgie und Versicherungsmedizin : offizielles Organ der Schweizerischen Gesellschaft fur Unfallmedizin und Berufskrankheiten = Revue de traumatologie et d'assicurologie : organe officiel de la Societe suisse de ...最新文献

The correct therapy of osteochondritis dissecans in patients under 16 years is very important to prevent the knee joint from secondary arthritis. We analysed clinical, radiological and with MRI the long term (10 years) results of a follow-up study on 36 patients under 16 years with 42 operatively treated osteochondritis dissecans of the knee joint. There were excellent and good results in 81% of the patients. After an average of 10 years there were no signs of arthritis which would necessitate any treatment.

Although well accepted in pediatric patients, the nonoperative management of severe blunt hepatic trauma in adults remains controversial. On the basis of 3 cases with major liver injury, the rationale and prerequisites for a successful nonoperative treatment are discussed.

This presentation summarises the opinions concerning chronic pain after mild cervical trauma without neurological and radiological findings. Clinicians are often surprised by the disabling character of the pain, despite the lack of severe lesions. The initial lesions lead in some cases to chronic headache having different features associated with cervical pain, but in our opinion this pain does not have a disabling nature. When the disabling character is present, we postulated that it is associated with other psychological, social and professional factors. In fact, the pathogenesis of this chronic disorder is multifactorial. Its treatment doesn't lead to healing but to better management of patient life with chronic pain.

We know different surgical techniques for the treatment of lateral clavicle fractures (type 2 of the Neer-classification). Often an exercise stable osteosynthesis and early functional aftercare can be realized only with a jointconnecting transfixation (acromioclavicular joint). With a new osteosynthesis implant it is possible to solve the problems of this fracture with a save and relatively simple operation. The suggested implant guarantees an exercise-stable osteosynthesis that allows immediate functional aftercare. With this technique we can reduce the complication rate and reach full working capacity earlier. Within an observation period of about five years we used this implant on 21 patients and the clinical and radiological follow-up shows good to very good results in the medium and long-terms.

Only 17 cases of isolated avulsion fracture of the lesser tuberosity have been reported in the literature since Hartigan's report in 1895. Whereas in children, conservative treatment is almost successful, in adults operative restoration is the method of choice in order to obtain full painless range of motion with normal strength of muscle control. Surgical excision of the fragment of lesser tuberosity after failed conservative treatment may relieve the patient's symptoms. Three own cases and a review of the literature are discussed.

The pathogenesis of insertion tendinosis of the elbow,--lateral as well as medial epicondylitis--is difficult to define precisely. Different hypotheses have been postulated with a correspondingly large number of alternative therapeutic proposals. At first view, the prime factor may be a repetitive stress of the groups of muscles involved, respectively of the extensors of the hand and the wrist. In fact, the etiology is multifactorial and includes a cluster of causes. A series of 661 cases of insertion tendinosis of the elbow--lateral and medial epicondylitis--seen over 16 years in a private outpatients-practice for either conservative or operative treatment has been analysed in groups sorted by age, profession, and association with other inflammatory or degenerative changes in the superior limbs. The accumulation of cases in the preclimacteric age (4th decade)--in male as well as in female patients--, and the increased frequency of association with other inflammatory or degenerative changes of the superior limbs (34%), shows the important role of age and constitution. In a smaller series of 289 cases, the subjective causes mentioned by the patients for being the source of their troubles were recorded. These dealt with different areas, such as various professional activities (whether manual labor or not), household work, practising certain sports, leisure time activities (e.g., handicrafts, gardening, needle work), and sometimes as a consequence of trauma. From the medical insurance point of view it results from these observations that the occupational factor alone practically never reaches the 75% causal level required by law in Switzerland for considering lateral or medial epicondylitis as an occupational disease. Likewise, an acceptance as a sequel of an accident is only exceptionally possible, as far as major tissue damages have been proved.

The posterior shoulder dislocation is often misdiagnosed. The overall cost in medical care is about six times higher than an anterior dislocation. For the precise diagnosis, correct x-rays in exact ap- and Y-view of the shoulder are essential. The ultimate analysis can be made by a CT-scan. An alternative method is presented to reconstruct the defects (reversed Hill-Sachs) by particular placing of anchors (Mitek). One to two years after, no recurrence of dislocations could be observed (9 cases). In two cases an arthroscopic mobilisation of the shoulder had to be done to regain full range of motion after 4 months.

The biomechanical expert opinion on the injury mechanism is necessary in few cases only. However, the judgement of these cases is extremely compromised if mechanically wrong terms are introduced in the clinical report. Since the injury mechanism in the neck is very complex the clinical physician should concentrate on the clinical findings familiar to him; usually the clinician lacks technical case documentation and specific training in injury biomechanics. The relevant mechanisms of neck injuries are an indirect trauma induced by a) a head contact leading to compression, hyperflexion, hyperextension and/or hypertranslation and b) a non-head-contact mechanism (hyperflexion or hyperextension, hypertranslation, acceleration). A non-contact mechanism occurs e.g. during a rear end impact without head restraint (hyperextension) or a frontal collision of a belted occupant (hyperflexion) without head impact. The term "whiplash" is misleading and incorrect: It presumes a virtually non existing two phase movement back and forth (or vice versa) like during the development of the crack of the whip. Secondly, it mixes the physical criterion mechanism with the anatomical or morphological criterion injury e.g. distortion, sprain etc. A (head)-contact mechanism is due to a corresponding momentum exerted from the head on the neck. Again, the anatomical or morphological terms are equal, but the mechanism is different. During a contact mechanism as well as during a non-contact mechanism not only a hyperflexion or a hyperextension can occur; in the first phase of the impact also a shearing force between the upper vertebral bodies (CO-C2) may load the intervertebral structures by hypertranslation.

In an own prospective series with 18 endoscopic decompressed carpal tunnel syndrome patients the problems with this new release technique are described. Although most of the patients did clinically well, four major complications, all with revision operations, were observed. Two cases still suffer residual problems. Due to these complications we stopped the endoscopic technique and returned to the traditional surgical treatment of open carpal tunnel decompression.