Risk of extrapelvine vascular injuries in osteosynthesis with gliding hip screws.

BACKGROUND: Dynamic hip screw (DHS) osteosynthesis represents one of the most frequently performed fixation methods in orthopedic practice. The purpose of this study was to determine the potential risk of vascular damage by DHS side-plate screws (PS) and plunging instruments for individual femoral vessels and screw positions. METHODS: In ten hemipelvic/leg specimens mounted with a large femur distractor, a DHS system with a four-hole side-plate was inserted. PS were inserted in 3 consecutive courses with different inclinations in the frontal plane of 0° (group 1), - 30° posterior (group 2) and + 30° anterior (group 3) in relation to the side-plate's surface, resulting in 120 PS positions. After screw tightening, the soft tissues on the medial side of the femur were dissected and investigated for vascular compromise; in each course, the effect of overshot instruments within a range of 50 mm beyond the side-plate's surface was also tested. RESULTS: Totally, 37/120 screw positions (31%) revealed potential vascular compromise which comprised of 15/120 (13%) direct hits by screw tips and 22/120 (18%) potential impacts by plunging instruments. The deep femoral artery system (DFA) was significantly (p = 0.007) most often affected but no significant differences for individual vascular structures were seen. Direct vascular impacts occurred significantly more often (p = 0.0047) in screws with 0° inclination compared to + 30° inclination (p = 0.017). Significant differences among individual screw positions were only found in group - 30° with direct vessel contacts (p = 0.038). CONCLUSIONS: The DFA system is significantly more at risk while significant preference of a certain vessel is missing. Our data indicate that more than 30% of 120 screw positions in DHS osteosynthesis revealed a potential danger of vascular compromise, when surgical principles are denied in hip fracture fixation. CLINICAL RELEVANCE: Though vascular complications are infrequently encountered in DHS osteosynthesis they have to be considered as a potential complication when surgical principles are not followed in this anatomic area.

Vascular complications in plating of the proximal femur: review.

INTRODUCTION: Plating of the proximal femur represents a standard fixation method in orthopedic and trauma surgery. Vascular lesions are uncommon but potentially life-threatening. With the increasing number of hip surgery also more of these complications have to be anticipated. The purpose of this study was to evaluate the most common types and locations of vascular lesions after plating of the proximal femur as well as the most important causes. MATERIALS AND METHODS: A literature research was undertaken of the English and german literature on vascular complications after plating of the proximal femur following a structured search protocol. RESULTS: 62 cases with vascular compromise after plating of the proximal femur revealed significantly more iatrogenic origin (n = 41/62) was observed than lesions caused by fracture fragments (n = 11/62) (p = 0.0001); most iatrogenic reasons (n = 28/62) were related to the insertion of plate screws (PS). Lesions were significantly more often located (57/62) in the deep femoral artery (DFA) system than in other vascular systems (n = 5/62) (p = 0.0001). Vascular damages represented significantly more often pseudoaneurysms (PA) (42/62) than major lesions in the vessel wall with acute bleeding (17/62) or vascular occlusions (3/62); (p = 0.0001). PA cases also revealed a significantly longer diagnostic delay than other lesions (36 days vs. 2 days, p = 0.0064). Among clinical symptoms swelling of the thigh (57/62), local pains (42/62) and anemia (26/62) were most often observed. Swelling and pains were significantly more often reported in PAs (p = 0.0338; p = 0.0003). Most patients achieved full functional recovery (n = 41/62), but over-all complication rate was quite high (n = 18/62). CONCLUSIONS: Vascular compromise in plate osteosynthesis of the proximal femur affects significantly more often the DFA system and represents most often PA. As the majority of cases revealed iatrogenic origin, a thorough surgical technique and awareness can help to avoid these complications.

Minimally invasive approach to the radial nerve--A new technique.

PURPOSE: To describe a minimally invasive approach to find the radial nerve (RN) simply and safely by tracing the posterior antebrachial cutaneous nerve (PACN) without damaging muscles, using only the surgeon's hand to define a window for the skin incision. BACKGROUND: Although it is absolutely necessary to locate the radial nerve during osteosynthesis of the humerus, the literature lacks guidelines on how to do so. METHODS: We have dissected the upper extremities of 54 adult human cadavers, embalmed using Thiel's method. After the PACN was identified in a defined space, its course was traced proximally by incising the lateral intermuscular septum (LIS) of the upper arm and thereby reaching the radial nerve (RN). Subsequently, using the lateral epicondyle (LE) of the humerus as a reference point, the distances to the points where the PACN perforated the LIS, and where the RN was identified, were measured. These individual data were related to the total length of the humerus. RESULTS: The results indicate that with this approach and without harming musculature, the RN can be reached by tracing the PACN at a height of 11.1-13.0 cm (females) and 11.9-14.0 cm (males) starting from the LE. CONCLUSION: Our examination shows the PACN to be a convenient guide to the RN.

[Ultrasound diagnosis in knee and foot trauma]. / Die Sonographie beim Knie- und Fusstrauma.

Subsequent to clinical and radiologic examination, ultrasonography is an important diagnostic method in knee and foot trauma, especially to assess pathologic conditions of the periarticular soft tissue. The main indications for ultrasonographic assessment of the knee region are fluid conglomerations, injuries of tendons, ligaments, and muscles, and vascular diagnosis. The indications for ultrasonography in the foot region are diagnosis of foreign bodies, dislocation of the peroneal tendons, lesions to the flexor and extensor tendons, and osseous capsular and ligamentous avulsions. Changes of the soft tissues include articular effusion, fluid conglomeration, ossification, and vascular lesions. Fractures involve the base of the fifth metatarsal, navicular and sesamoid bones, and epiphysiolysis. Rare indications are the search for free articular bodies and free air and the depiction of cartilaginous lesions and fractures of the knee region.