[Neuromuscular complications of fractures of the extremities, part 2 : Nerve injuries and iatrogenic damage]. / Neurovaskuläre Komplikationen bei Frakturen der Extremitäten, Teil 2 : Nervenverletzungen und iatrogene Schäden.

Lesions of peripheral nerves substantially influence the long-term prognosis and functional outcome. Approximately 70% of peripheral nerval lesions are associated with vascular injuries and occur more frequently with certain fractures and osteosynthesis types. The prognosis and treatment depend on the severity of the injury and the presence of axonal lesions, in particular, determines the further procedure. Treatment as early as possible is associated with a clear improvement in the prognosis. Defects longer than 8 mm in size necessitate a nerve transplantation. Iatrogenic vascular lesions occur particularly in percutaneous interventions and are reported in up to 8% of cases after operations involving the musculoskeletal system. Iatrogenic nerve lesions are almost exclusively the result of surgical procedures and represent up to 17.5% of traumatic nerve injuries. For all lesions the general principles of surgical treatment are valid and the rapid involvement of professional expertise is decisive.

[Multihospital use of imaging techniques in decentralized trauma care]. / Multihospitale Nutzung bildgebender Verfahren in der dezentralen Traumaversorgung.

BACKGROUND: Decentralized trauma care in the Wald and Weinviertel region in the north of lower Austria comprises five hospitals for primary care including one regional trauma center. Due to the geographical position and adverse weather conditions a web-based teleradiology system was established to ensure the best possible treatment and joint access to the results of radiological investigations. OBJECTIVE: The article describes a new picture archiving and communication system (PACS), which provides an online teleradiological workflow between the central trauma care unit and peripheral departments in a local trauma network as well as the advantages and disadvantages. MATERIAL AND METHODS: A corporately used PACS enables streaming-based full access to studies which are created within the system. Radiological studies can be obtained on request from all subscribers within the network. RESULTS: Teleradiological networks can essentially contribute to a suitable treatment pathway in an association of hospitals and therefore lead to a rapid initiation of treatment. CONCLUSION: Especially in rural areas with decentralized trauma care, the joint use of teleradiological resources can lead to a better treatment quality.

[Bony knee injuries in childhood and adolescence]. / Knöcherne Knieverletzungen im Kindes- und Jugendalter.

While fractures around the knee are known to be rare, physicians have encountered a rise in the frequency due to the increased participation of children and adolescents in high-impact sports at a younger age. Even if the treatment of fractures in some cases resembles that in adults, the diagnostics and treatment in childhood and adolescence require a hígh level of experience in order avoid possible sequelae and to enable early recognition. Thorough diagnostics using clinical and imaging investigations as well as a precise weighing up of the treatment are essential to minimize differences in leg length and axial malpositioning of the leg. A decision between conservative and operative treatment is made for both the femur and tibia depending on the type of fracture. Decisive is the degree of dislocation of the fracture. In operative treatment, the axis conform reduction and subsequent stress stable treatment are particularly decisive. Avulsion trauma, bony avulsions of the intercondylar eminence and patellar injuries are also treated conservatively with immobilization or surgically with the aid of various fixation techniques, depending on the degree of dislocation.

[Neurovascular complications in fractures of the extremities, part 1 : Vascular lesions]. / Neurovaskuläre Komplikationen bei Frakturen der Extremitäten, Teil 1 : Gefäßläsionen.

Neurovascular injuries in fractures threaten at least the function of extremities. The timely interaction between diagnosis and treatment of vascular injuries helps to avoid a poor outcome or even fatal complications. An important parameter is to "think about it" for injuries under strain. An ankle-brachial index (ABI) of <0.9 is an indicator. Massive bleeding, manifest and long-lasting peripheral ischemia and a rapidly expanding hematoma necessitate an immediate surgical intervention. Endovascular techniques are recommended on the extremities of stable patients with circumscribed vascular lesions. The debate about the sequence of repair (vascular vs. osseous) has to be decided on an individual basis; however, when in doubt vascular repair should be given priority. Vessel reconstructions should be performed without tension and must be covered by vital soft tissues, the indications for fasciotomy should be liberally interpreted. The prognosis with respect to preservation of the extremity and long-term functional outcome substantially depends on the quality of treatment of accompanying injuries.

[Intracranial pressure monitoring in polytrauma patients with traumatic brain injury]. / Hirndruckmonitoring beim Polytraumatisierten mit Schädel-Hirn-Trauma.

BACKGROUND: The monitoring of intracranial pressure (ICP) represents a cornerstone in the intensive care of patients with traumatic brain injury (TBI) and the industry provides various technical solutions to this end. Decompressive craniectomy can be an option if conservative measures fail to reduce excessive ICP. OBJECTIVE: To examine the pathophysiology of ICP in trauma, the management of polytrauma involving TBI, and the indications for decompressive craniectomy; and to compare the different monitoring systems and their complications. MATERIAL AND METHODS: A retrospective analysis of TBI patients between 2010 and 2016 was performed. Relevant publications are discussed, particularly those relating to the indications for monitoring and its influence on polytrauma management. RESULTS: Between 2010 and 2016, 106 patients with closed TBI and a mean age of 65.9 years received a total of 120 ICP monitors, most of which were parenchyma devices (111/120), followed by intraventricular catheters (8/120), and one combined system (1/120). Of these patients, 27.4% had sustained polytrauma, whilst 33% regularly used anticoagulants. ICP monitors were removed after 8.5 days on an average and the mean ICU stay was 20 days. Probe insertion was combined with craniectomy in 69.8% patients. Probe-related complications, most commonly involving malfunction, were seen in 6.6%. The duration of monitoring was significantly related to polytrauma (p ≤ 0.001) and age <60 (p = 0.03). ICU stay was also significantly related to polytrauma (p = 0.02) and monitoring complications (p ≤ 0.001). Mortality was related to anticoagulant medication (p = 0.01) and age <60 (p = 0.03). CONCLUSIONS: ICP monitoring is one of the most important tools in TBI treatment. The course and outcome of these severe injuries is affected by polytrauma, age, and the use of anticoagulants.

[School re-integration after child brain dislocation : The trauma surgeon's role]. / Schulische Reintegration nach kindlicher Gehirnerschütterung : Die Rolle des Unfallchirurgen.

Concussion injury of the brain is still a frequently underestimated injury, which can be associated with long-lasting consequences. Compared to adults, the recovery phase is often prolonged in childhood. Primary treatment consists of symptom-dependent physical and mental activities. Re-integration into daily life is crucial. In childhood, the primary focus is therefore on returning to school. New symptoms, or an increased presence of symptoms must be detected, to avoid prolonged recovery courses. School restrictions have to be minimized. Corresponding concepts are already implemented in North America. Comparable concepts are not established in Germany. In addition to well-known standard return-to-play protocols for sport re-integration, it is urgently recommended to integrate gradual return-to-learn protocols.Thus, academic adaptations and support must be established as well as symptom-oriented organizational and teaching modules.

Concussion in Sports - What Trauma/Orthopedic Surgeons Need to Know!

Concussion in sport is often underdiagnosed with the potential risk of long-term sequelae. This article presents the mechanisms, the underlying pathophysiology and typical primary signs and symptoms. The recognition and resulting medical measures including the present recommendations and decisions on return to play are described. The majority of patients with concussion present with clinical and cognitive symptoms only for short time intervals. As a rule a complete subjective recovery is observed within a few hours or days. Although neurocognitive impairments can persist in individual cases, they also show a good tendency to heal. Thus, after 1 year nearly all patients no longer have any relevant disorders. In a few cases long-term disturbances can occur in the presence of certain risk factors and/or after repetitive concussion. Unspecific symptoms and some cognitive impairments are the main reported problems; however, there is also a potential but individually unpredictable risk of developing neurodegenerative alterations and diseases.

[Distal femoral fractures]. / Distale Femurfrakturen.

Fractures of the distal femur still represent injuries that are difficult to treat as they either affect younger patients after a high-energy trauma with soft tissue damage and osseous comminution or elderly people with impaired local vascularity and a poor bone stock. However, exactly these fractures profit from new, biological principles of treatment, which help to diminish additional surgical trauma by indirect fracture reduction and insertion of stabilizing implants via mini-incisions. Basically, these techniques are represented by retrograde intramedullary nails and submuscularilly inserted plates/internal fixateurs. While intramedullary nails are well suited to fix extramedullary and simple articular fractures (C1), plates can also be used to treat complex articular fractures. Nevertheless, any displaced articular fracture component must still be anatomically reduced by an open approach and fixed with absolute stability. Technical advances as well as demographic changes will continue to represent challenges in the treatment of these fractures.

Comment on "An early Miocene extinction in pelagic sharks".

Sibert and Rubin (Reports, 4 June 2021, p. 1105) claim to have identified a previously unidentified, major extinction event of open-ocean sharks in the early Miocene. We argue that their interpretations are based on an experimental design that does not account for a considerable rise in the sedimentation rate coinciding with the proposed event, nor for intraspecific variation in denticle morphology.

[Minimally invasive plate osteosynthesis: current state. Part 1: General information]. / Aktueller Stand der minimal-invasiven Plattenosteosynthese. Teil 1: Allgemeines.

Minimally invasive techniques and developments of implants with angular stability have led to a renaissance of plate osteosynthesis for fracture stabilization in recent years. They represent a major source of success which has facilitated minimally invasive plate osteosynthesis (MIPO) or even made it feasible. For implants with LCP technology all current types of screws can be used and/or combined. However, the treating surgeon is still confronted with the decision which fixation mode, absolute or relative stability, is required for each individual fracture. Moreover, reduction techniques, intra-operative imaging and the biomechanical features of the selected implant require a more meticulous preoperative planning. Minimizing the surgical trauma has resulted in decreased complication rates of problematic fractures. However, the particular inherent risks of a closed procedure have to be evaluated for each body region to avoid severe complications.

[Current status of minimally invasive plate osteosynthesis: specific part II]. / Aktueller Stand der minimal-invasiven Plattenosteosynthese. Teil 2: Spezielles.

With the increasing use of minimally invasive plate osteosynthesis in the last years almost every anatomical region was included in this new technique. Thus, it is not used any more for certain fractures and problematic areas, but also in fractures where it represents a challenge to established osteosynthesis techniques like intramedullary nailing or conventional plating. Therefore the challenge for the treating surgeon increased to find the right answer for the particularities of an individual fracture by choosing the optimal method. The most popular indications for the use of minimally invasive plate osteosynthesis are presented and the technical details are discussed. The possibilities for complications--in a common way and for specific fractures--are presented and discussed.

Minimal invasive plating of distal radius fractures. A safe procedure?

BACKGROUND: Minimal invasive plate osteosynthesis (MIPO) with preservation of the pronator quadratus (PQ) muscle represents a new technique for stabilization of distal radius fractures. However, the complex anatomy of the distal radius metaphysis requires implants with features that address all morphologic specifics of this area to avoid complications, which are still reported with this technique. It was the aim of our anatomic investigation to evaluate the feasibility of plate insertion via a minimal transverse approach as well as the risk of soft- tissues compromise with the use of an implant, which is only partially adapted to the characteristics of distal radius metaphysis. METHODS: Twenty forearm specimens, conservated with Thiels method, have been used for this study. The majority (n = 19/20) of implants (2.4 mm small fragment juxta-articular locking compression/ LCP T-plate -5-hole; Depuy - Synthes®, Solothurn, Switzerland) could be inserted easily and all were seated proximal to the so called "watershed line" (n = 20/20). RESULTS: In a total of 8/20 specimens close contacts or potential compromise to neighboring soft- tissues was seen: perforation of the PQ muscle by the plate occurred in 2/20 specimens and was related to an extreme muscle morphology. In 7/20 specimens close contacts between the T-plate and other soft tissues were observed, which were exclusively located at the radial edge of the distal transverse bar. They affected the brachio-radialis tendon (elevation: 2/20, side-to-side contact: 3/20, overriding: 1/20) and the radial artery (elevation: 4/20, side-to-side contact: 2/20, overriding: 1/20). No significant differences of morphologic types of PQ muscle and the difficulty of plate insertion, adjustment on the bone, PQ muscle damage and contact to neighboring soft-tissues could be evaluated. CONCLUSIONS: Insertion of volar radius plates through a MIPO approach can be easily accomplished without detachment and damage to the PQ muscle even with grossly adapted implants. However, perfectly pre-shaped plates which are adapted to all anatomic aspects of the distal radius metaphysis are required to achieve optimal contact with the metaphyseal bone and to avoid potential complications.

Report of the equine herpesvirus-1 Havermeyer Workshop, San Gimignano, Tuscany, June 2004.

Amongst the infectious diseases that threaten equine health, herpesviral infections remain a world wide cause of serious morbidity and mortality. Equine herpesvirus-1 infection is the most important pathogen, causing an array of disorders including epidemic respiratory disease abortion, neonatal foal death, myeloencephalopathy and chorioretinopathy. Despite intense scientific investigation, extensive use of vaccination, and established codes of practice for control of disease outbreaks, infection and disease remain common. While equine herpesvirus-1 infection remains a daunting challenge for immunoprophylaxis, many critical advances in equine immunology have resulted in studies of this virus, particularly related to MHC-restricted cytotoxicity in the horse. A workshop was convened in San Gimignano, Tuscany, Italy in June 2004, to bring together clinical and basic researchers in the field of equine herpesvirus-1 study to discuss the latest advances and future prospects for improving our understanding of these diseases, and equine immunity to herpesviral infection. This report highlights the new information that was the focus of this workshop, and is intended to summarize this material and identify the critical questions in the field.

Direct and sex-specific enhancement of bone formation and calcification by sex steroids in fetal mice long bone in vitro (biochemical and morphometric study.

The study was carried out to examine the direct effect of the sex hormones 17 beta-estradiol (E2) and testosterone on the modeling of cultured fetal mouse long bones separated according to their sex. The culture system used allowed for the simultaneous assessment of bone growth, mineralization, and resorption on each bone. Bones from 16-day-old male and female mouse fetuses were cultured in BGJ medium, supplemented with either 10% fetal calf serum or 4 mg/ml BSA (serum-free medium) for 48 h. The bones were harvested, and their length; the length of their diaphyses; their hydroxyproline, calcium, and phosphorus contents; and their 45Ca release were measured. Histomorphometric analyses on midlongitudinal sections of bones from parallel experiments were also performed. The results indicate that in medium supplemented with 10% fetal calf serum, E2 had a dose-dependent stimulatory effect on bone formation and mineralization at 10(-7) and 10(-9) M, with no effect on bone resorption. This effect was specific to bones from female mice and to E2, since 17-alpha-estradiol had no effect. Testosterone had similar effects specific to bones from male mice, resulting in the stimulation of bone formation and mineralization at 10(-7)- and 10(-9)-M concentrations. These effects were absent when serum-free medium was used. E2 and testosterone had an anabolic effect on endochondral and periosteal bone formation and mineralization, but no effect on bone resorption. This effect is dependent on the presence of a serum factor(s).

An experimental evaluation of a prototype public access nutrition information system for supermarkets.

Located the Nutrition for a Lifetime System (NLS-1), a prototype interactive information system, in a large supermarket to help users decrease high-fat food purchases and increase high-fiber food purchases. Study participants were randomly assigned to control (n = 23; used the NLS-1 to enter food purchases only) or experimental (n = 26; viewed videodisc instructional programs, received prompts, made commitments, received feedback from the NLS-1) conditions. According to data entered in the NLS-1 and actual food shopping receipts, experimental participants significantly reduced higher fat purchases. Increases in higher fiber purchases favored the experimental group but were not significant.

Diagnostic and therapeutic management of esophageal and gastric caustic burns in childhood.

Early esophago-gastroscopy is the most effective investigation for the classification of caustic burns. Evaluation includes graduation of the pathological lesion. Assessment of extension of spread and of control of motility of esophagus and stomach. The aim of all therapeutic procedures is to preserve the patients' own esophagus. All endoscopies were done under general anesthesia. From September 1988 to April 1992, 102 endoscopies were carried out on 39 patients. Gastric lesions with clinical relevance were found in 10 patients (26%). First degree of corrosion was found in 21 patients (54%): they were discharged without any therapy within 48 hours. Maximal second degree was seen in 14 patients (36%), who were successfully treated with diet, antacids and H2-blockers: they were discharged after control-endoscopy after one week. Four patients (10%) suffered from third-grade lesions: a gastrostomy was performed as well as treatment with cortisone, antibiotics and H2-blockers. Bouginage was started between the 5th and 7th day after ingestion and was necessary for 8, 11 and 16 weeks in three patients and more than 2 years in one patient. Even in this last case we could preserve the esophagus, although a gastric or colon interposition was discussed.

Interphalangeal dislocation of the fourth toe with avulsion-fracture in a child: report of a case.

Phalangeal dislocations of toes are extremely rare in childhood and usually can be treated by closed reduction. We present a proximal interphalangeal dislocation of the fourth toe with an irreducible avulsion fracture of the middle phalanx requiring open reduction. To our knowledge concomitant avulsion fractures in this condition have not been reported thus far in pediatric patients. The pathological mechanism of this injury is discussed, and the significance of the plantar plate for joint stability is emphasized.

[Treatment of fingertip defect injuries with a semi-occlusive dressing]. / Die Behandlung von Fingerkuppendefektverletzungen mit einem semiokklusiven Verband.

In the treatment of substance loss of fingertips it is crucial to maintain functional length and to restore adequate sensibility. By treating those injuries with a semiocclusive dressing according to Mennen and Wiese (1993), we were able to achieve both goals with excellent results, avoiding the necessity of local or regional flaps as well as shortening of bone to achieve primary closure. 82 patients with 85 injured digits were treated either conventionally (primary closure with or without shortening of bone, vaseline gauze dressings: 31 digits) or with semiocclusive dressings (54 digits). 42 digits of the latter group with complete protocols were evaluated at the end of treatment. 26 digits with defects of skin and subcutaneous tissue of less than 1 cm2 to more than 2 cm2 necessitated an average of 18 days until complete healing (minimum 6, maximum 46 days). Eight digits with loss of skin, subcutaneous tissues and nailbed healed within 10 to 32 days (average 22 days) and eight digits in which defects included bone loss averaged 49 days for complete healing (37 to 64 days). No complications, especially no infections have been observed. All healed finger-tips were well padded, painless, many without visible scar and with static two-point discrimination between 2 and 8 mm.