[Surgical Treatment of Clavicle Midshaft Fractures - Prospective Randomized Trial]. / Operacní lécba zlomeniny diafýzy klícní kosti ­ prospektivní randomizovaná studie.

PURPOSE OF THE STUDY Comparison of the outcomes of clavicle midshaft fractures using two different surgical techniques, namely intramedullar osteosynthesis using elastic stable intramedullary nailing (ESIN) with medial cap and extramedullar plate osteosynthesis. MATERIAL AND METHODS The prospective randomized trial was conducted at the Department of Trauma Surgery of the Department of Surgery of the University Hospital Hradec Králové in the Czech Republic at the Level I Trauma Center between 2014 and 2018 and compared two types of osteosynthesis of clavicle midshaft fractures. 60 patients were enrolled in the study and were randomly assigned to one of the two groups. In Group 1, the participants were treated by ESIN and in Group 2 by plate osteosynthesis. The operative technique was chosen by the sealed envelope method. According to the randomization list created by a specialised statistical company, every envelope was marked with a unique number and contained the intramedullar "IM", or the extramedullar "EM" sign. RESULTS The observation of statistical parameters by unpaired t test detected significantly different results: a shorter incision using ESIN osteosynthesis (median = 2.9 cm) compared with plate osteosynthesis (median 14 cm, p < 0.001), longer X-ray exposure using ESIN (median = 325 s) compared with plate osteosynthesis (median = 16.5 s, p < 0.001) and radiation dose using ESIN (median = 996 cGy/cm2) compared with plate osteosynthesis (median = 4 cGy/cm2, p < 0.001). The difference in other parameters such as operative time, in-patient length of stay and duration of rehabilitation was not statistically significant. The time to clavicle fracture repair was comparable in both the surgical arms, i.e. approximately 3 months. Also, the duration of incapacity for work was not statistically different. Functional Constant Shoulder Score at a one-year followup is comparable in both the two arms (p = 0.268). The Dunn s method necessitated a longer operative time when treating multifragmental midshaft clavicle fracture by the ESIN compared to simple fractures. No statistically significant difference was detected in the operative time of different procedures and in the number of bone fragments. The functional outcome was excellent in 25 patients (83%) in each method. DISCUSSION Most midshaft clavicle fractures are still treated non-operatively with good outcomes. The indication for surgical treatment is the dislocation of fragments greater than the width of the clavicle bone, the shortening of fragments greater than 2 cm and the angulation of more than 30°. Patient after operative treatment profits from bone healing by absolute or relative stability. In recent years, new intramedullar techniques other than open plate reduction and fixation have emerged. For example, elastic stable intramedullary titan nailing. Both the methods are full-fledged without functional differences in longterm follow-up. CONCLUSIONS We consider the intramedullar osteosynthesis to be the most appropriate surgical approach for simple midshaft spiral, oblique and transverse clavicle fractures and also wedge oblique fractures. Plate osteosynthesis is useful for all types of fractures. No statistically significant difference in the rate of bone healing was observed after intramedullar or extramedullar ostesynthesis, but multifragmentary fractures healed faster when plate osteosynthesis was used. The determining factor for the received radiation dose is solely the surgical method, not the type of fracture. There is a statistically significant difference in shorter X-ray exposure and lower received radiation dose in plate fixation and reduction. The complication rate is comparable in both the methods. Key words: elastic stable intramedullary nailing, midshaft clavicle fracture, ESIN, TEN, titan elastic nail, clavicle plate osteosynthesis, 3.5 LCP clavicular plate, indication for midshaft fracture treatment.

[Descending Thoracic Aortic Injury in Flail Chest]. / Poranení sestupné hrudní aorty pri blokové zlomenine zeber.

The authors present a case of 74-year-old female patient who suffered a flail chest in motor vehicle accident. First day after injury a descending thoracic aorta was injured, most likely during manipulation with the patient. This injury was verified by operation, which was indicated 26 hours after the hospital admission, because of a sudden decrease of blood pressure with blood loss over 600 ml through the chest tube. The female patient died during surgery despite all efforts. Due to our experience with this rare case and after literature studying, we would recommend to consider early surgical revision. Based on the close contact of severely displaced sharp edges of ribs to the descending aorta, which was visible on the CT scan. Even through the absence of clear leak of contrast in the CT examination. We could resect these parts of ribs. Key words: flail chest, descending thoracic aortic injury.

[Role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Save Life in Bleeding in a Patient with a Pelvic Ring Injury]. / Role balonové endovaskulární okluze aorty (REBOA) pri záchrane zivota u pacientu s krvácením z pánve.

The author presents a case study of the use of resuscitative endovascular balloon occlusion (REBOA) as a suitable alternative to thoracotomy and clamping of the descending aorta to control retroperitoneal bleeding in a patient with a pelvic injury. The patient who suffered multiple trauma after car accident, type C pelvic injury and retroperitoneal bleeding among other things, was following the pre-hospital ambulance care transported to the department of emergency medicine, with catecholamine infusion to support the blood flow. After the primary survey following the ATLS principles, the patient was taken for a CT scan. The CT examination revealed also multiple sources of retroperitoneal bleeding. Subsequently, the patient was brought to the operating room, where endovascular balloon occlusion of the descending aorta was performed to temporarily control retroperitoneal bleeding, which provided more time to treat the patient in line with the damage control surgery principles. In bleeding patients who suffered blunt torso traumas and serious haemorrhagic shock, or patients "in extremis", the survival after emergency thoracotomy ranges only around 1%. The to date results of REBOA technique applied in same indications are very promising globally. The survival rate increases multiple times especially in hypotensive patients, without the necessity of their immediate cardiopulmonary resuscitation. Key words:resuscitative balloon occlusion of the aorta, REBOA, haemorrhagic shock, retroperitoneal bleeding.

[Extracapsular Proximal Femoral Fractures - Retrospective Evaluation of a Group of Patients with a Focus on Complications of Treatment]. / Extrakapsulární zlomeniny proximálního femuru ­ retrospektivní vyhodnocení souboru pacientu se zamerením na komplikace lécby.

PURPOSE OF THE STUDY The purpose of this study is to retrospectively evaluate the treatment and the complications in patients with extracapsular proximal femoral fractures. MATERIAL AND METHODS The evaluation focused on a group of patients who underwent a surgery at the authors department in the period from 1 January 2011 to 31 December 2013. The inclusion criteria were a simple fall and a monotrauma. The injury-to-surgery interval, course of the surgery and hospital stay, occurrence of early and late complications were assessed. RESULTS In the respective period 286 patients underwent surgery, with the mean age of 79 years (36-101). A basicervical fracture was suffered by 20 patients, a pertrochanteric fracture by 228 patients and 38 patients sustained a subtrochanteric fracture. Osteosynthesis using the DHS was applied in 113 patients, in 110 patients PFNA osteosynthesis was performed and in 51 patients osteosynthesis using an Ender nail was conducted. Yet another type of plate osteosynthesis was opted for in 12 patients. The most frequent postoperative complication was delirium, which was reported in a total of 38 patients. Non-infectious early seroma and hematoma type collection was observed in 6 patients. An infection occurred in one patient. Apart from 8 patients who died during the primary hospital stay, the fracture healing was followed up in 252 patients (91% of 278). The length of healing was 15 weeks on average, delayed healing was reported in five patients. Primary malposition was seen in 9 patients (3%) and secondary malposition occurred in five patients (2%). There were five cases of non-union (2% of 278) in our group of patients. In the followed-up period, a total of 86 patients (30 % of 286) died within one year after the injury. In cases of death, the follow-up was 100% thanks to the data obtained from the Institute of Health Information and Statistics of the Czech Republic (UZIS). Death as a direct consequence of proximal femur fracture occurred in 66 patients (23% of 286). DISCUSSION The results of complications in our group (infection, delayed healing, malposition and non-union) are comparable to those identified by other authors, with the exception of one-year lethality, which is lower in the presented group. CONCLUSIONS The occurrence of complications after proximal femur surgeries is affected by multiple factors. The most important are the choice of a suitable implant, technically correct execution of osteosynthesis and intensive postoperative treatment, including the continuity of care after hospital discharge. Key words:extracapsular proximal femoral fractures, complications.

Fibular Strut Graft for Posterior Pelvic Ring Nonunion - a Case Report.

Posttraumatic pelvic nonunions in combination with malposition are uncommon in the present-day era of modern pelvic surgery. The case describes a new surgical technique for treatment of the nonunion localized to iliosacral joint. A 42-year-old polytraumatized male presented with a pelvic fracture (type 61-C2.3) associated with a complex acetabular fracture. The patient was treated and the pelvis stabilized according to damage control principles (external fixation and pelvic C-clamp) and subsequently definitively treated according to principles of current pelvic surgery. The posterior pelvis was stabilized by bilateral S1 iliosacral screws, however the posterior pelvic ring injury on the left side was not well reduced. The result was a nonunion formation in the left sacroiliacal joit with screw loosening. Two attemps at bone grafting and repeat stabilization were done, but the nonunion did not heal. The end result was a nonunion through left sacroiliacal joint with destruction of the lateral part of sacral bone. The nonunion was treated with nonvascularised autologous fibular strut graft in combination with allogenic corticocancellous grafting. The fibular graft was placed into the bone void after the removal of the iliosacral screw. Radiographically the nonunion healed completely six months after the fibular grafting and the patient had improved clinical outcome. The described technique solves both instability and bone defect in posterior pelvic ring even in the case with low contact areas. The nonvascularised autologous fibular grafting is an effective technique for sacroiliac joint nonunion treatment even in case with large bone defect. Key words: pelvis; nonunion; fibular graft.

[Impaired Healing after Surgery for Femoral Fractures]. / Poruchy hojení po operacní lécbe zlomenin stehenní kosti.

PURPOSE OF THE STUDY: The aim of the study was to analyse causes of impaired bone healing in femoral fractures and to present options of their management. MATERIAL AND METHODS: This is a retrospective study of the data on complications prospectively collected between 2008 and 2013. The patients admitted for primary treatment at the Trauma Centre of the Faculty of Medicine in Hradec Kralove from January 2008 to December 2013 included 1186 patients with injury severity scores (ISS) > 15 and 1340 patients with new injury severity scores (NISS) >15, all older than 16 years. With the exception of two patients, the primary treatment involved the application of an external fixator as part of damage control surgery. Definitive surgery, regardless of the site of fracture, was performed using unreamed femoral nails (UFN) in 51, distal femoral nails (DFN) in 33, plates in 26, long proximal femoral nail antirotation (PFNA-long) in 14 and nails combined with dynamic hip screw (DHS) plates in five fractures. The analysis revealed both mechanical and biological causes of poor bone healing. RESULTS: Of the 124 patients whose multiple injuries included a fracture of the femur, 11 died within 24 hours in spite of intensive resuscitation. In the remaining 113 patients there were 16 bilateral fractures, 20 fractures of the proximal femur (extraarticular), 72 diaphyseal femur fractures and 26 distal femur fractures. Nine patients sustained segmental femoral shaft fractures. Ten diaphyseal and 14 distal femur injuries were open fractures (13.5% and 54%, respectively). Pseudarthrosis developed in a total of 12 fractures (9.3%); six (7.2%) were diaphyseal fractures, of which three were initially open fractures, and six (21.4%) were distal femur fractures with two initially open injuries. All proximal femur fractures healed completely. DISCUSSION: The frequency of non-union femoral diaphyseal fractures in our patients treated by unreamed intra-medullary nailing is in agreement with the literature data. The frequency of non-union distal femur fractures in our group was slightly higher than is published in the literature. This can be accounted for by the characteristics of our group consisting of patients with multiple severe injuries in whom fractures are due to high-energy trauma; the overall severity of injuries negatively affects the biological potential of a human organism for bone healing. CONCLUSIONS: A successful outcome of femoral fracture repair is based on an understanding of the biomechanical principle, i.e., correct fracture reduction and stable osteosynthesis fitting the morphology of the fracture. Comminuted femoral fractures heal well with the use of a narrow long nail whose working length allows for even distribution of movement at a fracture line amongst the fragments and thus fracture motion load does not exceed 20%. On the other hand, short oblique and transverse fractures are examples of problematic fractures which require maximum possible stability provided by a thick nail with a short working length; this is achieved by reaming the medullary cavity or adding lag screws. In our group of patients these fractures were also the most problematic ones. Generally, nailing remains the golden standard in the management of femoral fractures.

[Surgical treatment of ischial apophysis avulsion. Case report]. / Operacní lécba avulze apofýzy sedacího hrbolu - kazuistika.

The optimal management of ischial apophysis avulsion, especially indications for surgery, is not well defined. The authors present the case of a 16-year-old man who sustained an avulsion fracture of the ischial apophysis during his athlete training programme. The avulsion was diagnosed by X-ray. Because of displacement, surgery was indicated and open reduction with osteosynthesis was performed using a subgluteal approach on the eighth day after injury. Full weight bearing was allowed at nine weeks after injury, after the post-operative rehabilitation programme had been completed. Return to his sports activity was allowed at four months after injury. At one post-operative year the patient was free of any symptoms. The proper surgical treatment of a displaced ischial apophysis avulsion and subsequent rehabilitation allow for early full weight bearing, including sports activities. The subgluteal approach provides good access to the ischial tuberosity with a minimal risk of complications and a good cosmetic outcome. Key words:apophysis, ischial tuberosity, avulsion.

[Surgical treatment of humeral diaphyseal fractures]. / Operacní lécba zlomenin diafýzy humeru.

PURPOSE OF THE STUDY: The aim of the study was to compare two surgical methods of treating diaphyseal fractures of the humerus. MATERIAL AND METHODS: A prospective randomised study on the surgical treatment of humeral diaphyseal fractures was carried out between September 2009 and January 2013. The patients indicated for surgical treatment fell into two groups according to the technique used as follows: minimally invasive plate osteosynthesis (MIPO) with a locking compression plate (LCP; Synthes, Switzerland); depending on the fracture type and course of fracture line, either a straight narrow or a Philos or a metaphyseal LCP was used (group 1); and intramedullary nailing (EHN, Synthes, Switzerland) (group 2). A total of 49 patients were entered into the study. The men-to-women ratio was about 1:1 and the average age was 52 years (18 to 83). Of them, 45 patients with 46 humeral fractures were followed up and evaluated. The injury was caused by a fall from standing or while walking (n=21), traffic accident (n=16), sports activity (n=3) or work-related activity (n=5). A single injury was treated in 72% and multiple trauma in 28% of the patients. Using the AO classification, fractures were diagnosed as types A, B and C in 25, 10 and 11 patients, respectively. The patients were randomised into the groups using a computer programme allowing for the maintenance of group homogeneity. Each patient received information on the method to be used in a sealed envelope. RESULTS: The average injury-surgery interval was 6 days (range, 0 to 26). The average operative time was 128 minutes (80 to 200). The average intra-operative exposure to X-ray was 8 minutes (3 to 20). The average hospital stay was 20 days (4 to 100) The average rehabilitation time till functional recovery was 17 weeks (3 to 37), the time of bone union by radiographic assessment was 20 weeks (12 to 40). The functional outcome was assessed using the Constant-Murley (CM) and Liverpool Elbow Score (LES) systems. The relative CM/LES score, as compared with the healthy extremity, was 95/100. Excellent and good results were achieved in 89% and complications were recorded in 26% of the patients. The most frequent complication was impingement syndrome or prolonged rehabilitation both in the patients with proximal humerus fractures managed with the Philos locking plate and in those treated by intramedullary nailing, although this was not necessarily due to a technical error, i.e., osteosynthetic material protrusion. Iatrogenic radial nerve injury was found only in one patient treated by intramedullary nailing and was associated with traction during reduction and nail insertion. Pseudoarthrosis was recorded in one patient of each group and there were no infectious complications. DISCUSSION: Intramedullary nailing has not yet shown such good outcomes in humeral as in tibial fractures. The results of metaanalysis have indicated that humeral fractures treated by plate osteosynthesis have fewer complications and require repeat surgery less frequently. However, as shown by most recent studies, this difference is getting smaller. The MIPO technique was adopted at our department several years ago and the aim was to compare our results with those of other centres. The studies so far published have show that MIPO and conventional open plate osteosynthesis give comparable outcomes. CONCLUSIONS The statistical evaluation using the unpaired t-test did not show any significant differences in either the functional results or the number of complications between the two methods. Both achieved about 90% of excellent and good results and had 26% of complications. The only significant difference was found in the length of operative time (136 min in MIPO versus 117 min in EHN). With use of the Chi-Square test, a significant correlation between AO fracture type and treatment outcome in the MIPO group was found, i.e., no poor result was recorded for type A fractures, as assessed by the CM/LES score. No such correlation between the fracture type and the functional outcome was seen in the EHN group.

[True/Flex intramedullary nailing for forearm shaft fractures. Long-term results]. / Nitrodrenová osteosyntéza diafyzárních zlomenin predloktí hrebem TrueFlex - dlouhodobé výsledky.

PURPOSE OF THE STUDY: Presentation of technical experience and the clinical and functional results of intramedullary fixation of forearm shaft fractures. MATERIAL AND METHODS: Between January 1994 and December 2009, a total of 96 patients with 144 radial and/or ulnar fractures (ulna, 33; radius,15; both, 48) were treated by nailing (True/Flex®). According to the AO classification there were 22-A, 22-B and 22-C type fractures in 39 (41%), 44 (46%) and 13 (13%).cases, respectively. Of these, 82 (85%) were closed (types: 0, 48; I, 33; II, 1) and 14 (15%) were open (types: I, 13; II, 1; III, 0) fractures. Seventy-eight patients (81%) were followed up and their functional outcomes were evaluated according to the criteria of Anderson et al. The average interval between the operation and final follow-up was 28 months (15 to 96 months) RESULTS: The average time to surgery was 2.2 days (0 to 25 days). Early complications were recorded in 4% of the patients (1x bursitis olecrani; 1x end cup replacement; 1x bending of nails) and late complications in 15% (5x non-union; 2x delay union; 4x bursitis olecrani; 1x ruptured tendon). Bone healing was achieved in 95% of the cases and took on average 16 weeks (7 to 34 weeks). No infection, refracture or synostosis occurred. Primary loss of reduction was recorded in four cases due to distraction in one, bent nails in two and a wrong size of the implant in one; secondary loss of reduction was found in three cases, with two cases of radius shortening and one 10°malrotation. No primary malrotation was recorded, but secondary loss of alignment was seen in the distal part of the radius and the proximal part of the ulna. Functional results according to the Anderson criteria were excellent and good in 87% of the cases. DISCUSSION: Intramedullary mailing provides good stability to mid- and distal-third shaft fractures of the ulna and mid- and proximalthird shaft fractures of the radius, particularly in AO type A and type B fractures. The technical aspects of the method are analysed in detail in this paper. CONCLUSIONS: True/Flex® intramedullary nailing, because of its minimally invasive approach and close reduction, allows us to minimise the risk of wound and neurovascular complications, especially in proximal shaft fractures of the radius.

[Surgical treatment for proximal humerus fracture]. / Operacní lécba zlomenin proximálního humeru.

PURPOSE OF THE STUDY: The aim of the study was to compare the medical aspects of alternative surgical methods for treatment of proximal humerus fractures in specific indications (two- and three- fragment fractures). MATERIAL AND METHODS: A prospective randomised study on surgical treatment of two- and three-fragment fractures of the proximal humerus was carried out at the Department of Surgery, University Hospital in Hradec Králové, from January 2006 till January 2010. The study comprised patients with proximal humerus fractures indicated for surgical treatment. Study inclusion criteria were as follows: informed consent, AO fracture types A2, A3, B1 or C1, age between 18 and 80 years, and patient compliance. Exclusion criteria included open fracture, associated injury (AIS . 2), open growth plates, or such state of the patient's health that would limit the extent of surgery. Two groups were compared. One included patients treated by the Zifko method of minimally invasive osteosynthesis with intramedullary K-wire insertion (MIO group) and the other (ORIF group) consisted of patients undergoing open reduction with angle-stable osteosynthesis using a Philos plate (Synthes, Switzerland). The patients were randomised to the groups by a computer programme which facilitates the maintenance of homogeneity of the groups compared. The procedure in each patient was based on the sealed-envelope method. RESULTS: The ORIF group comprised 28 patients. It took them an average of 27.2 weeks (9-72) to regain normal upper limb function. The final CM score was 86.6% (64-100%) as compared with the healthy limb. Excellent and good results were achieved in 89% of the patients; complications were recorded in 39% of them. The MIO group included 27 patients. The fractures healed in all of them. Normal upper limb function was regained at an average of 21.4 weeks (13-36). The final CM score was 87.5% (52-100%) in comparison with the healthy limb. Excellent and good results were achieved in 89% and complications developed in 33% of the patients. CONCLUSIONS: The statistical evaluation of the results, using the unpaired t-test, did not show any significant differences either in functional outcomes or the number of complications between the two groups. The only significant difference was found in operative times (117 min and 72 min in ORIF and MIO groups, respectively). The difference in time needed to regain limb function (27 and 21 weeks) was at a marginal level of statistical significance. With both methods 89% of excellent and good results were achieved, and a similar number of patients had complications (11 and 9).

[Surgical repair of bladder rupture associated with the pelvic fracture without suprapubic tube--a case report]. / Osetrení ruptury mocového mechýre pri zlomenine pánve bez epicystostomie--kazuistika.

The authors are presenting a case of 42-year-old polytraumatized man with pelvic fracture associated with extraperitoneal urinary bladder rupture. This was verified by intraoperative retrograde cystography and treated with suture without making suprapubic tube drainage. Urinary draining was assured with a transurethral permanent urinary catheter. Conversion from external fixation to internal osteosynthesis of pelvic fracture was performed as far as 26 days after admission for significantly poor overall condition of the patient. Injury of the bladder and pelvic fracture healed without any complications. This case review points to the possibility of surgical repair of bladder rupture without epicystostomy, which is an obstacle or an increased risk of infection for internal fixation of anterior part of the pelvic ring. Suprapubic tube is not beneficial in surgical repair of urinary bladder rupture. However, it is normal practice that the suprapubic tube associated with bladder suture is indicated according to urology department tradition or by an individual physician - urologist himself. In the choice of surgical treatment tactics in these types of injuries proper communication between the urologist and the surgeon dealing with complex pelvic trauma is important.

[Percutaneous fixation of anterior column acetabular fractures--first experience]. / Perkutánní osteosyntéza predního pilíre acetabula: první zkusenosti.

PURPOSE OF THE STUDY: Percutaneous fluoroscopy-assisted fixation of acetabular fractures is not a widely used technique. Its advantage lies particularly in percutaneous placement of screws in the anterior column of the acetabulum. The operative procedure is described and the first experience of the authors with this minimally invasive technique at their department is reported. MATERIAL: Between December 2007 and April 2009, 10 fractures of the anterior column of the acetabulum were treated by percutaneous stabilisation in 10 patients. There were six men and four women aged 25 to 76 (average, 46) years. Retrograde screw fixation was used in three, anterograde screw fixation in two and anterograde screw placement following retrograde guide wire insertion in five patients. METHODS: The minimally invasive method of acetabular stabilization using 6.5-mm or 7.3-mm cannulated screws was facilitated by the use of intra-operative fluoroscopic imaging. Following fracture reduction, a percutaneous guide wire, aided by a C-arm, was placed in the upper pubic ramus and the anterior column of the acetabulum in either an anterograde or a retrograde mode. Subsequently, a traction cannulated screw was inserted. When anterograde guide wire placement was difficult to do, the retrograde guide wire placement was used for anterograde screw insertion. The quality of fracture reduction and the placement of screw were evaluated by a post-operative CT examination. RESULTS: The average follow-up was 11 (range, 2-19) months. The average operative time necessary for percutaneous screw insertion in the anterior column of the acetabulum was 26.4 (range, 15-45) min, and the average X-ray exposure time for the screw placement was 3 min and 13 sec (range, 40-448 sec). The average time needed for screw insertion following the retrograde guide wire was 2 min and 30 sec (range, 40-242 sec). The average post-operative fragment dislocation leading to incongruency was 1.3 mm (range, 0-4 mm). The results of reduction assessed as excellent (<2 mm) and poor (>or=2 mm) were achieved in six and four patients, respectively. No screw malplacement was recorded. Post-operative infectious complications occurred in one (10 %) patient. DISCUSSION: Important factors for avoidance of intra-operative complications included a thorough pre-operative planning on the basis of CT diagnostic examination, meeting the indication criteria and using a safe stabilisation technique. However, the percu- taneous fluoroscopy-assisted method requires a longer exposure to X-ray than do the techniques utilising computerised navigation. The occurrence of infectious complications was not lower than with the use of open reduction and internal fixation methods. CONCLUSIONS: After the operative technique has been mastered, the minimally invasive method of osteosynthesis is likely to become a method of choice for certain kinds of acetabular fractures. The current, most frequent indications are minimally displaced transverse fractures, T-shaped fractures and anterior column acetabular fractures. A limiting factor of this technique is reduction. It is certain that further evolution of this technique and its more frequent use will be associated with computerised navigation.

[Expert Tibial Nail (ETN) for treatment of diaphyseal tibial fractures in current and extended indications: technique and clinical results]. / Diafyzární zlomeniny bérce--technika a klinické výsledky s pouzitím Expert Tibial Nail (ETN) v klasických a rozsírených indikacích.

PURPOSE OF THE STUDY: To present the authors' technical experience with the use of the Expert Tibial Nail (ETN) technique and its clinical results. MATERIAL AND METHODS: Between December 2005 and the end of 2007, the ETN technique was used in 41 patients to treat 41 diaphyseal tibial fractures. All patients were followed-up prospectively. RESULTS: The injury Severity Score (ISS) was in the range of 4 to 25 (average, 5.9). Eight patients suffered multiple trauma, 33 had isolated injuries. Of the 41 fractures, 31 were closed and 10 were open injuries. The fracture types according to the Tscherne classification were as follows: closed 0 type (n=10); closed type I (n=18); closed type II (n=3); open type I (n=3); open type II (n=5); open type III (n=2). The injury-to-surgery interval ranged from 1h and 50 min to 25 h and 12 min (median, 8 h and 52 min).The operative time ranged from 50 to 170 min (average, 87 min). Infectious complications or a secondary loss of reduction were not recorded. Three cases of insufficient primary reduction underwent repeat surgery during the first stay in hospital. Full weight-bearing with no pain was reported in the range of 10 to 24 weeks (average, 18 weeks) after surgery. DISCUSSION: A choice of the nail diameter in relation to the marrow cavity width can be made during surgery with no loss of reduction (guidewire; undreamed/reamed nail). Because of a shorter straight lower part of the nail (compared to a UTN), a very steep position of the nail is necessary at its insertion in a short proximal metaphyseal fragment. The blunt lower ETN end can produce fracture line distraction when an effort is made to drive the nail as deep as possible into the short distal meta- physeal block, if this has not been reamed. CONCLUSIONS: The ETN provides sufficient stability of diaphyseal tibial fractures including those involving the metaphysis. However, in some instances, poler screws are still indispensable. Sufficient reduction is necessary before nail insertion.

[Radial nerve palsy caused by a nonunion of the humeral shaft--a case report]. / Paréza radiálního nervu zpusobená pakloubem diafýzy humeru--kazuistika.

This is a case of late-onset radial nerve palsy associated with the nonunion of the humeral shaft. Nonunion formation was caused by insufficient osteosynthesis and lack of proper biomechanical conditions for fracture healing. A good final outcome was achieved by simultaneous surgical treatment both nonunion of the humerus and radial nerve palsy. Radial nerve palsy presenting without delay after trauma or after reduction is well known complication of the humeral fracture. Case of late-onset palsy is very rare.

[Minimally invasive plate osteosynthesis (MIPO) in the humeral diaphysis fractures]. / Minimálne invazivní dlahová osteosyntéza (MIPO) zlomenin diafýzy humeru.

INTRODUCTION: Most of the humeral shaft fractures can be successfully treated conservatively. Due to increasing number of multiple and high-energy injuries, necessity of patient's compliance and restriction of his selfcare is conservative treatment in background. Humeral shaft fractures indicated to operation treatment are mostly solved by closed reposition and internal fixation with intramedullar nail (CRIF) or open reposition and internal fixation (ORIF). AIM: The aim is to prove that miniinvasive plate osteosynthesis (MIPO) of the humeral shaft fractures combines advantages of the both currently used methods. In other words, to use a plate osteosynthesis with minimal invasiveness and to exclude unexpected complications of radical operation approach by open reposition and problems related to nailing. MATERIAL AND METHOD: From March 2007 to August 2008 we operated on 20 patients with humeral shaft fractures using MIPO technique. Fractures were classified according to AO-classification: A - 9x, B - 5x, C - 6x. There were monotraumas and multiple injuries, as well. RESULTS: The results were evaluated by Constant-Murley test and Liverpool elbow scoring system. The mean value was 92/9.1 points. In 75% of patients we have reached good and excellent results. Complications were observed in 5 patients (20%). All patients have been healed. CONCLUSION: In spite of the limited number of patients in case serie our results are in accordance with current published data. Minimally invasive plate osteosynthesis is in our opinion safe and effective operation method for humeral shaft fractures treatment.

[Case report: fat embolism syndrome--grave handicap after traumatic long-bones fractures]. / Syndrom tukové embolie--prehled problematiky a kazuistika: závazný prubeh po traumatu dlouhých kostí.

Embolism of fat and bone marrow tissue is quite often due to bone fractures but it is seldom with signs of systemic involvement as a fat embolism syndrome. The main forming factor is late stabilization of fractures and hypovolemia too. Clinical image of fat embolism syndrome results from lung and systemic microembolism which leads to activation of inflammatory and thrombogenic cascades. We present a case report of a 24-year-old male after bike accident in low speed suffering from isolated thighbone fracture--osteosynthesis was applied in 6 hours after injury. The very first day the organ failure and coma with negative CT occurred, then ARDS, petechiae into the skin of chest and conjunctiva, also embolic closure of a. centralis retinae. Treatment interventions included anticoagulation, steroids, artificial ventilation for 17 days. After 3 weeks from injury he was still unconscious (with GCS 10) so that we tried a hyperbaric oxygen therapy. The patient regained consciousness after 3 months after injury. One year later he is able to walk alone, he has no visual failure, but he is still quadruspastic although able to manipulate with a mobile phone. We discuss diagnostic criteria and treatment. We also point out need of volumetherapy in prevention of fat embolism syndrome--this was underrated here because of primary missed out diagnose of co-existing tibia fracture at the same time (this was stabilised 18 hours after injury).

[Operation treatment of the humeral shaft fractures]. / Operacní lécba zlomenin diafýzy humeru.

INTRODUCTION: Nowadays the humeral shaft fractures represent about 4% of all fractures. Most of them can be treated conservatively. In this type of treatment the cooperation of the patient is necessary, treatment is long lasting and needs the extremity to be immobilized. That's why still more fractures are indicated for the operation treatment, which enables an early rehabilitation and selfcare of the patient. AIM: The aim of our work was to assess the functional and clinical results in patients after the operation of the humeral shaft fractures treated by closed reposition and intramedullary fixation or by open reposition and plate osteosynthesis (ORIF). DESIGN: Retrospective descriptive study--case serie MATERIAL AND METHODS: In our department within the years 2001-2006 we operated on 101 patients with humeral shaft fractures. 65 patients came to be checked, the follow up rate--65%. Fractures were classified according AO: A--50%, B--29%, C--21%. The ORIF was used in 18 patients, closed reduction and locked intramedullary nail in 21 patients, and closed reduction and K-wires bundle (Hackethal) in 26 patients. RESULTS: The resulting conditions we evaluated by Constant-Murley and Liverpool elbow scoring system. The mean value reached 86/8.9. In 82% of patients we have reached good to excellent results. Complications were noted in 34 CONCLUSION: In spite of limited number of patients in our study the results of ours generally are not in contradiction to the current literature data. The best results were achieved by ORIF. On the contrary, the worst outcomes with greatest number of complications were in Hackethal group.

[Surgical management of proximal humeral fractures using the Hackethal (Zifko) method--a case review]. / Operacní lécba zlomenin proximálního humeru metodou podle Hackethala (Zifka)--case serie.

BACKGROUND: Fractures of the proximal humerus actually represent 5% of all fractures and 45% of all humeral fractures with the highest incidence in women over 60 years of age. The outcomes of the greatest concern at these patients (pain, function of the shoulder and activities of daily living) get worse with age, osteoporosis, grading of fracture type and of initial fracture displacement. According to the literature (Evidence Based Medicine--EBM level II-III) operative treatment of displaced fractures reduces pain and need for assistance in activities of daily living, but open reduction with internal fixation by conventional screws and plates was connected with implant loosening, infection and avascular necrosis, whereas closed reduction with different methods of miniinvasive percutaneous stabilisation is threatened by primary malreduction. AIM: Evaluation of clinical and functional outcomes and analysis of results of proximal humerus fractures treated by closed or percutaneous reduction and intramedullary fixation by means of bundle of Kirschner wires after Zifko. DESIGN: Retrospective descriptive study--case serie. MATERIAL AND METHODS: Within January 1, 2005 - December 31, 2005 there were 87 patients with 87 two- and three-fragments fractures of proximal humerus (according to Neers classification) operated at our institution, from which 76 by the method after ZiFko. 36 patients from these 76 came to final evaluation (follow-up rate 47%). AO fracture types were: A2-36%, A3-33%, B1-19%, C1-12%. RESULTS: The resulting Constant-Murley (CM) score reached in mean 89 points with 89% of excellent--good functional results. Complications were recorded in 30% of cases and were represented mainly by proximal migration of K-wires. Avascular necrosis of humeral head occured in two cases (5.5%). CONCLUSION: In spite of low follow-up rate we conclude, that the method of closed reduction and intramedullary fixation of two- and three-part fractures of proximal humerus after Zifko offers above-average final results with acceptable rate of complications, mostly not severe ones. The essential pre-condition of good result is proper reduction--closed of percutaneous one. On the contrary, suboptimal results correlate with primary and secondary malreductions. The incidence of latter increases in intraarticular fracture types with small fragment of head and thus with insuficient implant retention. To evaluate the merit of the method in relation to angle-stable extra-/or intramedullary implants, the prospective trials are needed.

[Data collection and the Czech Republic Trauma Registry]. / Sber dat a Urazový registr Ceské republiky.

INTRODUCTION: A trauma registry is an integral part of any thorough traumatological care conception. The essential task of such a data collection is to provide complex information on conditions, treatment, outcomes and trauma treatment costs, considering a region or other registered part of, usually, a state entity. MATERIAL, METHODOLOGY: Registration of individual trauma characteristics throughout the state territory is a prerequisite for creating a data set, providing information for making valid conclusions applicable for all ranges of human activity. The trauma registry outputs are essential for traffic institutions, police, commercial inspection, commercial and health insurance companies, hospitals, etc. With respect to traffic problematics, the trauma registry plays a significant role in pointing out the most risk places in the region, in assessing the traffic type and use of protective tools. Furthermore, it facilitates exact aiming of preventive and corrective measures. CURRENT CONDITION: Current legislation does not require reporting data to the trauma database, insufficient data are provided by UZIS only. Our Clinic of Paediatric Surgery, Orthopaedics and Traumatology iniciated a model version of the Czech Republic National Trauma Registry. Our activities were approved by and supported by the Society of Traumatologic Surgery. It is a question of time, when sufficient pressure is exerted and the trauma registry becomes an integral part of the traumatological care in the Czech Republic.

[Personal experience with the treatment of fractures of the distal end of the radius using an external fixation method]. / Nase zkusenosti s lécením zlomenin distálního konce rádia metodou zevní fixace.

The authors discuss possibilities as regards therapy, of unstable and comminutive intraarticular fractures of the distal end of the radius. They mention external fixation as one of the therapeutic methods in these fractures and describe their own experience and results with the original Ilizarov external fixation device in a group of 14 patients.