[Fracture of the distal ulna accompanying fracture of the distal radius. Minimally invasive treatment with elastic stable intramedullary nailing (ESIN)]. / Distale Ulnafraktur als Begleitverletzung des körperfernen Speichenbruchs. Minimal-invasive Versorgung mittels elastisch-stabiler intramedullärer Nagelung (ESIN).

The distal radius is one of the commonest sites of fracture, and this injury is sometimes associated with fracture of the distal ulna. In recent years, surgical treatment of distal radius fractures has consisted increasingly in internal fixation with locking plates followed by early functional postoperative treatment. The associated injury to the distal ulna has so far not received much attention in the literature. Various techniques have veen described for its treatment: Kirscher wire fixation, tension band wiring, and internal fixation with screws and plates. Following positive results with elastic stable intramedullary nailing (ESIN) in the treatment of shaft fractures in children this technique was also applied in in fractures in adults (forearm, clavicle). Use of this technique for stabilisation of distal ulnar fractures has not previously been reported. In the course of a prospective longitudinal study (EBM level II), in 26 patients with an average age of 73.6 (42-88 years), bone healing in anatomical position was achieved in all cases within 6-12 weeks after closed reduction and anterograde ESIN with subsequent treatment that did not involve immobilization. No length differences of more than 2 mm and no functionally relevant deviations of the ulnar axis were observed. Apart from 3 cases of nail perforation at the distal end of the ulna, which had no clinical manifestations, there were no complications. ESIN offers a minimally invasive option for the treatment of unstable fractures of the distal ulna associated with distal radius fractures; it allows functional aftertreatment and can be regarded at least as an alternative to open reduction with internal fixation.

[CT-based analysis of cement distribution in unipedicular vertebroplasty]. / CT-gestützte Analyse der Zementdistribution bei monopedikulärer Vertebroplastie.

BACKGROUND: Vertebroplasty and kyphoplasty are being increasingly used in the treatment of osteoporotic vertebral body fractures. Shortening the duration of operative time and radiation exposure as well as reduction of cannulation-related risks and costs are advantages of the unipedicular technique in contrast to less homogeneous cement distribution as a possible disadvantage. Biomechanical investigations have shown similar results with respect to strength and stiffness both for uni- and bipedicular vertebroplasty. Studies evaluating cement distribution with CT scans using a unipedicular approach have not been published yet. MATERIAL AND METHODS: We present a prospective study on 92 vertebral body fractures (Th8-L5) in 60 patients, aged 76.8 (60-95) years, which were treated by unipedicular vertebroplasty using a para-/transpedicular approach. We evaluated needle position, injected cement volume, and cement deposition based on CT scans. The vertebral body was divided into nine segments in a frontal plane view. The needle was placed in the middle third in 85.9% (79/92), in the right in 11.9% (11/92), and in the left third in 2.2% (2/92). Complications associated with cannulation were not observed. The injectable cement volume was 4.5 (1.5-9.0) ml. RESULTS: With respect to superior, middle, and inferior parts, filling of the middle third was achieved in 94.9%, of the right third in 76.1%, and of the left third in 80.4%. Only the right- and left-sided inferior segments showed a filling rate below 75%. Positioning the needle into the right or left third resulted in comparably high filling rates of the middle third (100/83.3%) but only 50.0/54.5% of the contralateral third of the vertebral body. CONCLUSION: Unipedicular vertebroplasty using a modified approach permits a reliable placement of the needle into the middle third of the vertebral body, which is the optimal position regarding cement distribution. Unipedicular vertebroplasty allows homogeneous filling and augmentation of vertebral bodies without need for a second cannulation.

[Spondylosis hyperostotica--a rare cause of dysphagia, dyspnea, and neck-shoulder pain]. / Spondylosis hyperostotica--eine seltene Ursache von Dysphagie, Dyspnoe und Hals-Schulter-Schmerz.

Anterior or seldom posterior hyperostosis of the spine (Forestier disease, "diffuse idiopathic skeletal hyperostosis") is a common finding in elderly patients but is rarely associated with clinical symptoms. In some cases there is a wide range of symptoms which may not lead primarily to the correct diagnosis. We report a case in which the diagnosis was first made based on an unusual combination of symptoms after ENT and neurological examinations revealed no evidence for the underlying cause.

[A painless technique for reposition of anterior shoulder dislocation]. / Eine schonende Methode zur Reposition der vorderen Schulterluxation.

Acute shoulder dislocation is a common injury and characterized by an extremely painful lack of motion. The treatment objective after diagnosis is immediate reduction avoiding additional pain and complications. Various techniques have been described for more than 2000 years mostly using traction-countertraction, particularly combined with special positioning and leverage maneuvers. We report a reduction technique which is performed by a single person with the patient sitting on a chair and the physician standing behind him at the affected side. Positioning one fist in the anterior part of the axillary fossa for countertraction but avoiding direct pressure into the axillary fossa, the other hand uses traction grasping the patient's forearm. Only gentle traction is maintained until muscle relaxation is achieved and reduction mostly happens in this moment. Otherwise slow external rotation of the fist placed in the axilla can relieve reduction pushing the humeral head laterally. Additional leverage maneuvers are not necessary. This technique was successful in 98 of 108 (90.7%) patients. Only in 16.3% was premedication (intravenous analgesics) used. In ten patients general anesthesia was required to achieve reduction. No complications occurred in any of the patients. The reported technique allows a gentle and painless reduction of acute anterior shoulder dislocation with a high success rate mostly avoiding premedication.

[Minimally invasive treatment of monocondylar tibial plateau fractures. Percutaneous reduction and small fragment osteosynthesis]. / Minimal-invasive Versorgung monokondylärer Tibiakopffrakturen. Perkutane Reposition und Kleinfragmentosteosynthese.

BACKGROUND: Treatment of displaced tibial plateau fractures is often complicated by high-energy trauma and soft tissue damage. Therefore, numerous techniques such as indirect or arthroscopically controlled reduction and percutaneous osteosynthesis have been described to reduce the additional surgical trauma. MATERIAL AND METHODS: Twenty-three fractures (AO type 41-B2/3, Schatzker type II-IV) were treated with percutaneous, fluoroscopically guided reduction combined with small fragment osteosynthesis using a radius T-plate. In none of the patient was cancellous bone graft performed. Only in one case was arthrotomy necessary because of uncertain image intensification findings in an obese patient. One revision was done for a 4-mm step caused by an over reduced rim fragment. Fracture healing and full weight bearing were achieved after 8-12 weeks. Neither secondary displacement nor implant loosening was seen under primary functional treatment without immobilization. RESULTS: Functional recovery showed a mean ROM of 114 degrees after 6 weeks and 121 degrees after 3 months. The radius T-plate offers enough stability to allow primary functional treatment due to early recovery of joint motion. Percutaneous reduction and small fragment osteosynthesis is a less invasive approach in the treatment of displaced monocondylar tibial plateau fractures.

[Elastic, stable intramedullary nailing in midclavicular fractures--a change in treatment strategies?]. / Elastisch stabile intramedulläre Nagelung (ESIN) von Klavikulaschaftfrakturen -- Wandel eines Therapiekonzeptes?

Midshaft fractures of the clavicle are mostly treated conservatively. For the few cases in which stabilisation is needed, open reduction and plate fixation is the standard procedure. We report a minimally invasive technique of intramedullary stabilisation using a titanium nail carried out in 35 markedly displaced midclavicular fractures. Twelve fractures were simple and 23 consisted of more than two fragments. A total of 62.9% (22/35) of the patients presented additional injuries; 37.1% (13/35) with additional fractures. There were four ipsilateral scapular neck fractures. In 74.3% (26/35) of patients closed reduction was possible, whereas nine fractures required open reduction before the nail inserted from the sternal end of the clavicle could be introduced into the peripheral fragment. All fractures healed clinically and radiologically within 6 weeks. In contrast to conservatively treated fractures, length discrepancies of 1 cm or more, mainly shortening, could be avoided. Using a visual analog scale, significant pain relief (8.4-2.4 points) was already recorded on the first day after surgery. Patients with an isolated fracture of the clavicle showed a nearly normal range of motion only 1 week after surgery, whereas patients with associated scapular or rib fractures needed up to 3 weeks to reach normal shoulder function. No patient complications requiring interventional procedures occurred. Minimally invasive, elastic, stable intramedullary nailing of midshaft fractures of the clavicle should be recommended as an alternative to conservative treatment because of early pain relief, associated rapid functional recovery and anatomical restoration of the clavicle.

[Infection of the hip joint following psoas abscess. Case report and literature review]. / Die Infektion des Hüftgelenks als Komplikation eines Psoasabszesses. Kasuistik und Literaturübersicht.

Infection of the hip joint following psoas abscess is uncommon. In fact, only two cases have been reported in the literature. The clinical aspect of psoas abscess is characterised only by unspecific back pain and hip pain, which are responsible for delayed diagnosis. MRT and culture of joint aspirate can permit early diagnosis. The preferred treatment is immediate surgical intervention with debridement, drainage and antibiotic therapy. Percutaneous drainage of psoas abscess alone only rarely is sufficient. In cases of infected hip joint, resection arthroplasty often cannot be avoided. Following complete decline of inflammatory parameters and certain absence of bacteria confirmed by repeated joint aspiration, prosthetic joint replacement is possible. This decision should be made on an individual basis, because Girdlestone hip also can lead to a satisfactory result concerning pain relief and functional outcome.

[Do fixed-angle T-plates offer advantages for distal radius fractures in elderly patients?]. / Was leistet die winkelstabile Plattenosteosynthese bei der distalen Radiusfraktur des alten Menschen?

In the treatment of distal radius fractures, plate osteosynthesis using fixed-angle T-plates has become more common. Higher stability often allows functional aftertreatment in metaphyseal and articular fractures. So far it remains unclear whether these advantages also apply to elderly patients who commonly suffer from osteoporosis and reduced cooperativeness. Therefore, we evaluated the radiological loss of correction during fracture consolidation in patients aged more than 70 years. Fixed-angle plates were used in 44 patients (mean age: 79.4 years) while conventional T-plates were used in 30 patients (mean age: 78.2 years). Postoperative immobilization for 6 weeks by plaster or external fixator was performed in all patients. The loss of correction was significantly lower for fixed-angle plates (4.6% vs 40.0%). As a result of this study, we have gradually reduced immobilization in favor of early functional treatment. In a recent study fixed-angle plates so far seemed to permit stable fracture fixation. Our results underline the advantage of stable fixation in displaced fractures of the distal radius even in osteoporotic bone of elderly patients.

[Rupture of the azygos vein by blunt thoracic trauma. A case report and literature review]. / Ruptur der V. azygos beim stumpfen Thoraxtrauma. Fallbericht und Literaturübersicht.

Blunt chest trauma is a common injury in traffic accidents. Thoracic vessel trauma frequently affects intercostal arteries, the aorta and less often the subclavian artery. Azygos vein injury is uncommon and has previously been described in only 19 cases. The 20th case of blunt azygos vein injury due to high energy trauma as a consequence of a traffic accident is reported with a review of the literature. Preoperative diagnosis was performed by computed tomography. Azygos vein injury is rare but potentially lethal (8/20, 40.0%). Chest radiograph with right hemothorax is reported consistently except for two cases. Fractures of ribs and/or thoracic spine (T3-5) were found in nine patients, while neither were found in 11/20 cases. Pathognomonic signs have not been described in the literature. Early resuscitation and immediate thoracotomy with recognition and treatment of azygos vein rupture is necessary to avoid a fatal outcome.