The concept of "sense of coherence" and the development of posttraumatic stress disorder in traffic accident victims.

According to the "sense of coherence" concept, those subjects who can give meaning to a traumatic event can comprehend what has happened and have a sense of manageability of the sequelae, are able to cope better with the traumatic event itself. In the present study, this concept was applied to traffic accident victims. Severely injured traffic accident victims were assessed a few days after the accident and at 6-month follow-up. At follow-up, patients filled in the 29-item version of the Sense of Coherence (SOC) self-rating scale. The results show that the SOC total score correlated negatively with the development of: (i) posttraumatic psychopathology; (ii) psychological disorders (i.e., posttraumatic stress disorder after the accident); and (iii) anxious cognitions. The personality trait of neuroticism correlated negatively and extraversion and frustration tolerance correlated positively with SOC total score. Previous hypotheses are supported by our findings.

[Quantitative CT assessment of the proximal femur. Experimental studies on its correlation with breaking load in femoral neck fractures]. / Quantitative CT des proximalen Femurs. Experimentelle Untersuchungen zur Korrelation mit der Bruchlast bei Schenkelhalsfrakturen.

PURPOSE: In an experimental study, the correlation between the trabecular bone density of the different regions of the proximal femur and the fracture load in the setting of femoral neck fractures was examined. METHODS: The bone mineral density of 41 random proximal human femora was estimated by single-energy quantitative CT (SE-QCT). The trabecular bone density was measured at the greatest possible extracortical volume at midcapital, midneck and intertrochanteric level and in the 1 cm3 volumes of the centres of these regions in a standardised 10 mm thick slice in the middle of the femoral neck axis (in mg/ml Ca-hydroxyl apatite). The proximal femora were then isolated and mounted on a compression/bending device under two-legged stand conditions and loaded up to the point when a femoral neck fracture occurred. RESULTS: Statistical analysis revealed a linear correlation between the trabecular bone density and the fracture load for the greater regions, with the highest value in the maximal area of the head (coefficient factor r = 0.76). CONCLUSION: According to our data, the measurement of the trabecular bone by SE-QCT at the femoral head is a more confident adjunct than the neck or trochanteric area to predict a femoral neck fracture.

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

Ligamentotaxis with an internal spinal fixator for thoracolumbar fractures.

We assessed narrowing of the spinal canal in 39 burst fractures and fracture-dislocations of thoracolumbar vertebrae treated by the AO Internal Spinal Fixator, using CT preoperatively and at various stages postoperatively. Computer-aided planimetry was used to measure the narrowing, and its restoration shortly after instrumentation, or at 15 months. The mean initial reduction of canal area was to 63.7% +/- 18.8% of normal; this was restored to a mean of 95.4% +/- 21.2% of normal when measured either soon after surgery or at 15 months (p < 0.001 for both groups). There was more improvement in cases assessed later. For fractures from D12 to L3, the mean canal area was restored to 99.4% of normal; but at L4 or L5 the mean restitution was to only 60.9% (p < 0.05). We found no correlation between preoperative loss of area and amount of restoration, or severity of neurological deficit. Nor was there any correlation between the delay before surgery and the improvement achieved. The mechanism of fracture reduction appears to be a combination of distraction ligamentotaxis and forced hyperextension.

[Allogeneic bone transplantation. Indications--preservation--results]. / Die allogene Knochentransplantation. Indikation--Konservierung--Ergebnisse.

For 15 years the University Department of Traumatology Freiburg i.Br. is using deep frozen preserved allogenous bone grafts. Organization and service of the "bone bank" are standardized and simple. Basing on long experience the following indications for this technique have been developed: fresh fractures à deux étages, comminuted and compression fractures of long tubular bones that were stabilized operatively by plate-osteosynthesis showing smaller or bigger osseous defects, furthermore basic defects of the acetabulum with total hip replacement. Suppositions for the transplantation of allogenous cancellous bone are: well vascularized bed without infect, sufficient amount of cancellous bone and no disturbing movement of the bone at the place of transplantation. The results are excellent if one pays attention to these suppositions. Open fractures and local infections are absolute contraindications. As deep frozen preserved cancellous bone is always and sufficient available it is a precious help especially in polytraumatized patients. So the deposits of autogenous cancellous bone can be reserved for special problems. The little prolonged time of consolidation is only observed in the first phase until about the 20th week, after that time there are no significant differences to autogenous cancellous bone.

[Results of osteosynthesis of medial femoral neck fractures with the angled plate]. / Ergebnisse nach Osteosynthese medialer Schenkelhalsfrakturen mit der Winkelplatte.

Among 82 patients still alive after osteosynthesis of femoral neck fractures between 1974 and 1983, 67 (i.e. 81.7%) were controlled clinically and radiologically. The average follow-up period was 57.0 months. The average age of 36 men was 45.3 years, the average age of 31 women was 56.1 years. Fractures were divided in lateral and medial femoral neck fractures, the medial fractures were classified according to Pauwels and Garden. The rate of avascular head necrosis mounted 20.7%, the rate of non union 13.8%. Both complications were dependent on the type of fracture. Besides reduction and impaction of fragments time of operation proved to be important: In 37 fractures type Garden III and IV the rate of avascular head necrosis was 3-fold higher after secondary osteosynthesis than after emergency operation at the day of accident. Our concept in treatment of femoral neck fractures is based on these factors: Emergency operation, decompressive capsulotomy, valgus reduction, impaction of the fragments and internal fixation to allow movement.

[Does covered tibial intramedullary nailing promote formation of a compartment syndrome? Perioperative and intraoperative continuous monitoring of compartmental pressure in covered tibial intramedullary nailing]. / Begünstigt die gedeckte Tibiamarknagelung die Ausbildung eines Compartmentsyndroms? Perioperative und intraoperative kontinuierliche Gewebedruckmessung bei der gedeckten Tibiamarknagelung.

Between October 1988 and October 1989 we performed a continuously pressure monitoring with the infusion technique in the tibialis anterior and deep posterior compartment of the lower leg during the nailing of the tibia in complete fractures of the lower leg in 16 patients. We set up 2 groups of patients because of different pathophysiological conditions: patients, who were operated on a few days after trauma (Group A) and patients operated on months after the trauma (Group B) because of non-union of the tibia. The effects of the preoperative, intraoperative, and postoperative manipulations were recorded. In no case we saw a beginning compartmental syndrome, although very high pressures of 100 mmHg in Group A and 55 mmHg in Group B in the deep posterior compartment during reduction of the fracture were registrated. The registrated pressures correlated very well with the manipulations during the operation and were absolutely reversible after the ending of these manipulations. In our observation the closed tibia nailing does not favorize the development of a compartmental syndrome, if not done during the vulnerable phase after the first days after trauma, in blunt multiple trauma patients and during bleeding complications.

[Osteosynthesis of the clavicle. Indications, surgical technique, results]. / Die Osteosynthese der Clavicula. Indikation, Operationstechnik, Ergebnisse.

The osteosynthesis of the clavicle should be the exception and should only be indicated in the case of complicated fractures. The high rate of pseudoarthrosis given in medical literature, is due to errors in indication, selection of implants and in surgical techniques. Procedures like intramedullar wiring, axial screwing and single cerclage-wire suture are unsuited for osteosynthesis of the clavicle. After osteosynthesis of the clavicle we have found exceptional positive results, with respect to functional, radiological and after subjective evaluation, at a low rate of complication without any consequences occurring in the years to come. These results show, that mainly good or even excellent success can be achieved, at a limited indication, combined with careful surgery and a standardized surgery procedure of osteosynthesis of the clavicle.

[Selection of procedure in the management of recurrent juvenile and aneurismatic bone cysts]. / Verfahrenswahl bei der Behandlung des Rezidivs von juvenilen und aneurysmatischen Knochencysten.

Aneurysmal and juvenile bone cysts are characterized by frequent recurrence and pathological fractures caused by such bone cysts also recur frequently. Curettage of the cyst and spongiosaplasty is often unsuccessful. According to our experience, excochleation must be followed by drilling the cyst wall and fraising off the compact substance. Densely packed homologous spongiosa must then be implanted. In case of recurrence or if the cyst increases in size, radical en-bloc resection is indicated and the defect must be bridged by osteoplastic and osteosynthetic methods. We have treated four difficult cases successfully with this procedure. In one case, resection with limb shortening lead to full recovery.

[Successful therapy of a severe dextran incident using histamin H1- and H2-receptor blockaders]. / Erfolgreiche Therapie eines schweren Dextran-Zwischenfalles mit Histamin H1- und H2-Receptorenblockern. Ein fallbericht.

A case of a severe systemic anaphylactoid reaction is reported in a patient treated with dextran 60 to prevent venous thrombosis. Significant improvement of clinical symptoms occurred after the usual treatment of such incidents with corticosteroids, histamine H1 receptor antagonists, and plasma substitutes was supplemented with a histamine H2 receptor antagonist. We would therefore like to recommend that for such cases a histamine H2 receptor antagonist should be given in addition to the usual medication with corticosteroids and histamine H1 receptor antagonists. However, the value of complete histamine antagonism in these rather rare occurrences, can only be determined after furtherexperience has been gained.

[Causes of vascular injuries in alloplastic hip replacement]. / Ursache von Gefässverletzungen beim alloplastischen Hüftgelenksersatz.

Vascular injuries were treated in 8 cases of total hip replacement. Acute and subacute arterial thrombosis, an AV fistula, and local thrombosis of pelvic veins were observed. These vascular complications of total hip replacement must be avoided by an effective local operative technique. Contact of bone cement with the vascular loge must also be avoided in order to prevent toxic or thermic irritation of arteries or veins.

[Significance of ligamentotaxis for internal fixator osteosynthesis in fractures of thoracic and lumbar vertebrae]. / Die Bedeutung der Ligamentotaxis für die Fixateur-interne-Osteosynthese bei Frakturen der Brust- und Lendenwirbelsäule.

Between 1985 and 1990 104 operations on the lower thoracic and lumbar spine using the AO-internal spinal fixation system were performed. The preoperative computed tomography (CT) scans as well as either the postoperative CT scans or the CT scans taken after implant removal of 41 cases were available for evaluation of the narrowing of the spinal canal and the subsequent fracture reduction by means of computer-aided planimetry. It is shown that a near normal reduction of the spinal canal through ligamentotaxis is achieved for a fracture between T 12 and L 2, whereas for fractures between L 3 and L 5 an incomplete reduction is observed. A correlation between the neurologic deficit and the degree of narrowing of the spinal canal could not be established. Obviously, the damage to the spinal cord is determined primarily through the dynamic forces of the impact. Also no statistical correlation could be demonstrated in our cases of the time interval between accident and operation to the degree of reduction of the fracture achieved.

[Reconstruction of open width of the spinal canal by internal fixator instrumentation and remodeling]. / Zur Wiederherstellung der lichten Weite des Spinalkanals durch Fixateur-interne-Instrumentation und Remodeling.

In 106 cases of unstable vertebral fractures treated with the ASIF internal fixator, the degree of restoration of the spinal canal could be studied in detail. Computer-aided planimetry was used to measure the area of the spinal canal. Three series could be studied, where the postoperative CT scans had been performed at different times. The first series of 58 cases had the CT scans taken immediately after surgery; the initial mean traumatic narrowing of the spinal canal had been 42.8%, but after surgery it was only 25.2%. The second series consisted of 74 CT scans performed after implant removal. At this time, a residual defect of only 3.7% was observed. In a third series 31 cases could be analysed where CT scans obtained both directly after surgery and after implant removal were available. This confirmed the first two series insofar as it demonstrated the existence of a further mechanism, i.e. remodeling, that served to increase the degree of restoration of the spinal canal. This biological-functional process operates to approximately the same degree at each fracture level, demonstrated by the almost parallel course of the graph showing reduction plus internal fixation and remodeling. In summary, the remaining deficit of 25% after surgery is restored almost to normal through remodeling and can be neglected, provided there is no neurologic damage.

Indications, techniques and complications in surgical treatment of the acetabulum.

Almost 50 % of acetabular fractures occur in polytraumatized patients; in over 80 % additional injuries are found. The surgical goal is anatomical restoration of the acetabulum and stable fixation, in order to avoid postoperative external fixation.Careful clinical and radiological evaluation is essential to successful surgery. Standard radiological investigations include an anteroposterior view of the pelvis, a "spot" radiograph of the affected hip as well as obturator and iliac oblique views. The latter arc is especially helpful in assessing the central segment of the acetabulum ("dome fragment"). The documentation of any primarily traumatic sciatic nerve lesion is very important, and the quality of reduction depends greatly on the timing of surgery. The operation should be performed as early as possible after the surgical procedure has been carefully planned. A 3-D CT scan provides good information in choosing the surgical approach for complex fractures. In most cases, adequate reduction cannot be accomplished without appropriate aids. For internal fixation, both curved ASIF plates and straight plates are used. The operation demands a high degree of experience.Postoperative complications include iatrogenic nerve palsy, insufficient reduction, incorrectly placed implants, unstable fixation, redislocation, etc. With scrupulous aseptic conditions, the postoperative wound infection rate is low. Ectopic bone formation can occur after extensive surgical approaches and may, depending on size (Brooker III and IV), impair the range of motion of the hip. Indometacin given perioperatively is always indicated. Postoperative radiation treatment should as a rule be viewed critically.

Long-term outcome and late complications of acetabular fracture.

The long-term functional results of acetabular fractures are assessed in terms of the corresponding criteria of Merle-D'Aubigné and Postel (pain, mobility, walking). Other essential criteria include the quality of reduction and the radiological appearance.The age of the patient, the type of fracture and, above all, the interval between the accident and the surgical treatment or reduction of the fracture must be counted among the decisive factors which influence the late effects of this injury. Whether or not reduction can correctly center the femoral head in the socket is of paramount importance, but postoperative infection or the development of a hematoma may also critically affect outcome. In addition to a report on the long-term results achieved at the Trauma Department of the University Hospital of Freiburg, Germany, the literature on the late complications of acetabular fracture is also reviewed.

[The value of homologous spongiosa in en-bloc resection of juvenile bone cysts of the upper arm]. / Was leistet die homologe Spongiosa bei der en-bloc-Resektion juveniler Knochenzysten am Oberarm?

The recurrence rate after excochleation and homogeneous bone grafting of juvenile and aneurysmal bone cysts is high. One of the reasons is the poor vascularisation of the wall of the cyst. En-bloc resection is recommended in cases of recurrence after curettage and bone grafting and in cases of prior conservative treatment after pathological fracture followed by a rapid growth of the cyst. Excellent results of en-bloc resection in 8 cases of humerus bone cyst are reported. Good vascularisation of the juvenile periosteum and the surrounding soft tissue is most important for new bone formation after homogeneous bone grafting.

[Delayed osteosynthesis of forearm fractures after primary conservative treatment (author's transl)]. / zur sekundären Osteosynthese nach primär konservativer Vorderarmschaftfrakturbehandlung.

From 1970 to 1978 61 patients with forearm fractures were treated by delayed osteosynthesis after primary conservative therapy. The reasons for this procedure are given. Therapy results of 96 adults with forearm fractures and primary osteosynthesis are better than those with a delayed operation, i.e. after four weeks or even longer.

[Lower leg fracture--still the most frequent fracture during skiing? (author's transl)]. / Der Unterschenkelbruch--immer noch die häufigste Skifraktur?

Evaluation of more than 17,300 injuries caused by skiing in the Black Forest region between 1936 and 1980, shows that there has been a change in the pattern of injuries. However, the most frequent fracture occurring during skiing is, as it has always been, the fracture of the lower leg. Whereas ankle-joint fractures have receded, knee injuries have been increasing. This shows that the type of injuries to the leg have been undergoing a change as a result of modern skiing technique.

[Traumatology in the elderly. Treatment concept in per- and subtrochanteric fractures in the elderly]. / Traumatologie beim alten Menschen. Behandlungskonzept bei per- und subtrochanteren Frakturen alter Menschen.

The aim of treatment of trochanteric fractures in the elderly patient is a prompt procedure, which allows early load bearing. Between 1986 and 1988 272 patients were treated with per- and subtrochanteric fractures: pertrochanteric fractures were stabilised by means of the dynamic hip screw (DHS), subtrochanteric fractures via the 95 degree condylar plate. With both methods an early mobilisation of the patients is possible. In 70 per cent of cases treated with DHS, early load bearing could be achieved within one week. 80 per cent of the patients were operated on within the first 24 hours after trauma. Complications of the methods (incorrect position of the lag screw, plate protrusion) were seen in one case in each group. The overall infection rate was 2.2 per cent. Hospital mortality was 10 per cent. On reviewing the results obtained, we approved of the concept of treatment.