[Distal fracture of the radius]. / Distale Radiusfraktur. Konservativ oder operativ versorgen?

The distal radius is the most common site of a fracture. The type of fracture presenting, stability/instability and concomitant injuries are the factors that determine whether the fracture should be treated conservatively or surgically. Possible sequelae include a dystrophy syndrome.

Assessment of peripheral sympathetic nervous function for diagnosing early post-traumatic complex regional pain syndrome type I.

Clinical diagnosis of complex regional pain syndrome type I (CRPS I) in post-traumatic patients is often delayed since the clinical appearance of this disease resembles normal post-traumatic states to a certain extent (pain, edema, loss of function). The purpose of this study was to assess the incidence of specific clinical features in CRPS I patients and normal post-traumatic patients and to evaluate the diagnostic value of a bedside test that measures the sympathetic nervous function. Fifty patients with post-traumatic CRPS I of the upper limb and 50 patients 8 weeks after distal radius fracture with an undisturbed course of disease were subjected to a detailed clinical examination. Pain was assessed using the VAS (visual analog scale), skin temperature measured with an infrared camera and grip-strength with a pneumatic manometer. In CRPS I patients, motor disturbances defined as an impaired active range of motion of the hand, were most frequent (96%, fracture patients: 40%), followed by edema (88%, fracture patients: 80%) and spontaneous pain (VAS 4.0 +/- 2.3, fracture patients: VAS 1.3 +/- 0.6). Systematic temperature differences (>1 degree C) between the affected and unaffected limbs were seen in only 42% of CRPS I patients and in 34% of the fracture patients. Further sensory, sudomotor or trophic changes of the hands were rare. As expected, there were significant differences in the quantity of edema, motor disturbances and sensory disturbances between CRPS I patients and normal fracture patients. However, normal fracture patients still suffered from several of the evaluated symptoms 8 weeks after trauma, which makes an early clinical diagnosis of the complication more difficult. Using a newly developed bedside test, the peripheral sympathetic nervous function was assessed in both groups of patients and in 50 age-matched healthy controls. The decrease in skin blood flow following sympathetic provocation maneuvers, detected by laser Doppler flowmetry, was quantified as sympathetic reactivity. In the affected hands of CRPS I patients, as well as in the contralateral hands, the sympathetic reactivity was obliterated or diminished in contrast to the age-matched controls and normal fracture patients. A multivariate analysis did not reveal any correlation between sympathetic function and the severity of any clinical symptom. Sympathetic reactivity seems to be an independent variable in CRPS I and the test presented may facilitate the difficult clinical diagnosis of this disease.

Incidence and mortality of severe sepsis in surgical intensive care patients: the influence of patient gender on disease process and outcome.

OBJECTIVE: Laboratory studies demonstrated significant detrimental effects of male sex-steroids (testosterone) on immune functions following hemorrhagic shock and soft-tissue trauma. Moreover, better survival of female mice subjected to severe sepsis was observed when compared to male animals. The aims of the present study were to evaluate whether or not gender differences regarding incidence and mortality of severe sepsis do exist in surgical intensive care patients and to elucidate the influence of patient age on incidence and mortality of severe sepsis/septic shock. DESIGN: Data base review of prospectively collected data from surgical intensive care patients. SETTING: Surgical intensive care unit of the department of surgery of a university hospital. PATIENTS: Prospectively collected data of 4,218 intensive care patients (2,709 male, 1,509 female). RESULTS: Significantly fewer female patients were referred to the intensive care unit (6.6 % vs 10.8 % of all patients; P < 0.05) leading to a significantly smaller proportion of female intensive care patients (35.8% vs 64.2%). No gender differences regarding number of failing organs or surgical procedure (exception vascular surgery) were observed in patients with and without severe sepsis/septic shock, indicating that the patients studied are comparable regarding general health prior to admission to SICU. Among all female patients referred to SICU only 7.6 % developed severe sepsis/septic shock, while 10.4% of all male patients suffered from severe sepsis or septic shock (P < 0.05). This gender difference results from a significantly lower incidence of severe sepsis/ septic shock in female patients between 60 and 79 years. No gender difference regarding mortality rates of severe sepsis/septic shock was observed (men 64.9 %, women 65.5%). CONCLUSIONS: Our results indicate a significantly smaller number of female patients requiring intensive care as well as a significantly lower incidence of severe sepsis/septic shock in female intensive care patients. Mortality from severe sepsis/ septic shock, however, is not affected by gender.

Peripheral sympathetic function as a predictor of complex regional pain syndrome type I (CRPS I) in patients with radial fracture.

Complex regional pain syndrome type I (CRPS I) is a frequent complication after injuries of the upper limbs. The pathophysiology of this disease remains unclear, although disturbances of the sympathetic nervous system have been detected in several clinical studies, and sympathetic blocks resolve the symptoms in many of the cases. To investigate the meaning of sympathetic dysfunction at the beginning of the disease, 27 patients with distal radial fracture were examined prospectively during the course of the disease with regard to their clinical symptoms and their peripheral sympathetic nervous function. Sympathetic nervous function was examined by testing the vasoconstrictor response to sympathetic stimuli--recorded with laser Doppler fluxmetry--of the fingertips of both hands. Four patients developed CRPS I during the 12-week observation time and two patients presented an incomplete clinical CRPS I picture ('borderline patients'). The complaints of all patients (normal fracture patients, CRPS I patients, borderline patients) were similar during the first week after trauma with focus on pain, motoric disturbances and autonomic symptoms. After 1 or 2 weeks, a larger clinical difference developed between normal fracture patients and CRPS I or 'borderline patients'. In CRPS I patients and 'borderline patients', the sympathetic vasoconstrictor response was diminished or absent from the first posttraumatic day throughout the observation time, whereas the normal fracture patients revealed slightly impaired sympathetic nervous function on the first posttraumatic day and normal results during the rest of the observation time. With regard to the unaffected contralateral hand, CRPS I patients also showed impaired sympathetic nervous function. The results of the present study suggest that the disturbances in the sympathetic nervous system in CRPS I patients are systemic and not limited to the affected limb. Their occurrence before the clinical breakout of the disease may serve as a marker that might be useful for early therapy and lead to further understanding of the pathophysiology of CRPS I.

Effect of immunization on gastrin release in rat antrum mucosa.

Helicobacter pylori (H.P.) infection is the main cause of chronic active gastritis and is closely associated with peptic ulcer disease. Chronic hypergastrinaemia is known to be induced in patients infected with this pathogen. Gastrin is the most potent stimulator of gastric acid secretion. In animals infected with H.P. or H. felis vaccination against H.P.can eliminate the bacterium and alleviate associated gastritis. However little is known on the influence of immunization regimes on gastrin release. The aim of this study was to evaluate the effect of systemic immunization on gastrin release in a rat model, using a well defined but for the rat unknown protein. OVA-immunized and non immunized animals received OVA intragastrically in vivo, and serum gastrin was measured. Stimulation with bovine serum albumin (BSA) served as control. In vitro single cell suspensions of the antrum mucosa and mucosal fragments of immunized and non immunized animals were also incubated with OVA and BSA. The results show specific significant gastrin suppression after immunization and antigen feeding. The same results were obtained in the model of mucosa fragments but not in single cell suspensions. This hypothesized that gastric suppression could be mediated by mast cells or T-helper two cells (TH2) in the mucosal layer of the stomach. A single cell suspension is not suitable for studying immunologically mediated gastrin release because direct cell contact is necessary. Further studies with these animal models have to show whether effects seen by vaccination could be mediated by induction of gastrin suppression and studies on human tissues are necessary to show possible similar effects with H.P.

Clinical and finite element analysis of a modular femoral prosthesis consisting of a head and stem component in the treatment of pertrochanteric fractures.

OBJECTIVE: To determine the biomechanical characteristics and potential clinical efficacy of a cementless modular femoral prosthesis consisting of a variable head (50 to 80 millimeters) and stem (length 120 to 280 millimeters, diameter 10 to 20 millimeters) component in patients with pertrochanteric femoral fracture. DESIGN: Finite element analysis (FEA) of different lengths and diameters of prosthesis components and first clinical prospective study in pertrochanteric femoral fracture. METHOD: Using a 3D-CAD program, a model of femoral cortical bone with a pertrochanteric fracture was created and combined with a model of the prosthesis. This model was transferred into an FEA program. After applying a torsion-bending load of 2,000 N (25 degrees, 45 degrees) on the prosthesis, stress distribution in the cortical bone was determined for different lengths (160 to 240 millimeters) and diameters (10 and 12 millimeters) of stem. PATIENTS: Twenty-eight patients with pertrochanteric fractures (very unstable or osteoarthritis) were treated with a modular hip arthroplasty. Complications, fracture healing, and results at first follow-up (average 13 months) were determined. RESULTS: FEA analysis indicated that reduction in stress was less when a prosthesis with a short stem was used. Shear stress in the interface bone/prosthesis was not affected by stem length. Prostheses with thin stems produced higher sheer stresses than those with thick stems. Results of FEA were used as the basis for clinical application of the device. None of the patients died, and all patients were able to walk, although some needed a cane or walker after surgery. There was no increase in thigh pain compared with reported pretrauma levels. Radiographs showed subsidence of up to 5 millimeters in 20 percent of patients. However, all but one prosthesis was stable at follow-up. Fracture healing was achieved in all patients. CONCLUSIONS: If proximal fixation of a femoral uncemented stem cannot be achieved, stem diameter should provide maximum cortical contact to reduce sheer stress. Longer stems do not necessarily provide additional stability. By using this prosthesis and selection method, a good outcome at first follow-up was observed.

[Treatment of femoral bony defects with a modular hip prosthesis and distal interlocking]. / Der Einsatz einer modularen Hüftprothese (MHP) mit distaler Verriegelungsmöglichkeit bei Knochendefektsituationen des Femurs.

Patients with bony defects of the proximal femur after trochanteric fracture, implant failure (cut-out), periprosthetic fracture or aseptic loosening of prosthesis are difficult to treat with primary or revision endoprosthesis. Modular femoral hip prosthesis (MHP) with stems of different length and the possibility of distal interlocking screws are an operative solution for those patients. In a prospective study from January 1996 to January 2002 all patients treated with a MHP because of proximal and / or distal femoral bony defect or fracture were included. Follow-up after 6 to 30 months was evaluated clinically and radiologically in hospital. Change of modified Harris Hip Score and radiological signs of loosening (radiolucent line, migration of MHP, breaking interlocking screw) were documented. 106 patients with a follow-up of 58.5 % were included in the study. At time of follow-up clinical and radiological outcome after trochanteric fracture was good. Harris Hip Score was comparable to the situation of patients before fracture, only one MHP was loose. However in patients after revision arthroplasty 25 % of MHP were loose and in many patients the interlocking screw was broken. Distal interlocking screw in MHP prevents stability after trochanteric fracture to achieve osseointegration. However in case of periprosthetic fracture or revision arthroplasty MHP shows insufficient stability in many cases.

[Spinal fractures in multiply injured patients: an analysis of the German Trauma Society's Trauma Register]. / Wirbelsäulenfrakturen bei Mehrfachverletzten : Eine Analyse des DGU-Traumaregisters.

OBJECTIVE: Spinal trauma is frequently found in multiply injured patients. To gain more insight into the epidemiology and the clinical course of this entity, we analyzed the relevant data held in the German Trauma Registry (German Trauma Society, DGU). The Registry provides prospective, standardized and anonymous documentation on severely injured patients at different predetermined time points from the site of the accident until they are discharged from hospital. METHODS: Out of 8,057 patients whose details are recorded in the German Trauma Registry, 772 (approximately 10%) with severe spine trauma (AIS>/=3) patients were identified. Far more men (72%) than women (28%) had such spinal injuries. The mean age of the patients with severe spine injury was 37+/-17 years; their mean Injury Severity Score (ISS) was 29+/-15 (range 9-75) points. RESULTS: The age group 15-54 years was the largest (80%). Motor vehicle accidents (MVA) were the most frequent cause of severe spine trauma (49%), followed by falls from a great height (20%). About half of all severe spine injuries were not suspected in the prehospital setting. Symptoms of incomplete paraplegia were found in 20% of the patients and symptoms of complete paraplegia, in 27%. Patients with injuries to the thoracic spine more often had a lengthy average stay in the intensive care unit, because they were accompanied by thoracic trauma significantly more often than were injuries to the other spinal segments (96% vs 37%). Patients who underwent spinal surgery at an early stage (70% operated on <72 h after their injuries were sustained) showed a tendency to shorter periods ventilatory support and did not remain in the intensive care unit or indeed in the hospital as long as the other patients. Seventy-eight percent of the patients had survived for 90 days after sustaining their injuries. CONCLUSION: Almost 10% of all documented cases of patients with severe injuries in the German Trauma Registry had severe spinal injuries. These injuries were frequently not recognized or their extent underestimated in the preclinical setting. About 70% underwent spine stabilization within 72 h after being injured. These results support previous findings suggesting that early stabilization of vertebral fractures might be beneficial in multiply injured patients.

[Surgical management of spondylodiscitis. An analysis of 78 cases]. / Die operative Therapie der Spondylodiszitis. Eine Analyse von 78 Patienten.

Spondylodiscitis is a rare bacterial infection of the spine with an inflammatory, destructive course. To obtain further information on the therapeutic management and clinical course of spondylodiscitis, we retrospectively investigated 78 patients after surgical intervention. Mean age was 64 years (+/-4.6 years; range 21-80 years), the mean length of stay 49 days (+/-8.2 days; 3-121 days) including 24 days (+/-4.7 days; 0-112 days) in ICU. In hospital mortality was 9%. The cervical spine was affected in 10%, the thoracic spine in 35% and the lumbar/sacral spine in 55% of patients. Abscess formation occurred in 65% and destruction of the vertebral body in 74%. A total of 75% of patients presented with neurological deficits which could be improved by surgical intervention in 82% of cases. 24 patients were treated by ventral debridement and stabilization alone, 20 patients with a combined dorsoventral method. Most patients (n=34) were stabilized via dorsal bridging instrumentation without ventral debridement of the focus. Of this group, 23 patients were initially scheduled for secondary ventral debridement but complete healing was achieved prior to this, so further surgical therapy was unnecessary. Successful cure was obtained in 92% of cases. Based on our findings, we favor a split surgical approach: initially with dorsal internal fixation only. Abscesses can be drained percutaneously. Ventral debridement and stabilization is only recommended if insufficient stability can be obtained by dorsal fixation alone, as shown by the persistence of infection or pain.

[Change of daily life activity after femoral hip fracture in elderly patients]. / Veränderung der Lebenssituation des alten Patienten nach koxaler Femurfraktur.

Hospital mortality after hip fracture in elderly patients has decreased significantly in previous years. However, patients often show reduction of daily life activity. The aim of the following study was to assess clinical and radiological results nine months after operation of hip fracture. A total of 127 patients (mean age 77.2 years) were stabilized by arthroplasty because of femoral neck fractures or by gamma locking nail because of trochanteric fractures. Modified Harris-Hip-Score as well as social situation at time of follow-up compared to pretrauma situation were evaluated. Hospital mortality was 3.2 percent. Follow-up could be performed in 78 patients clinically and radiologically by examination in the hospital. At time of follow-up 19.7 percent of patients had already died independent of the operative procedure. Only 65 percent of patients were able to live at home. Modified Harris-Hip-Score at follow-up was decreased significantly by 16 points compared to the situation before the trauma. The reduction of the score was caused mainly by deterioration of hip function and less by femoral or hip pain. In future the main scope after hip fracture must be an improvement of rehabilitation of elderly patients.

Activation of lymphocytes isolated from the gastric mucosa of the mouse.

A method for the isolation of lymphocytes and epithelial cells from the murine gastric mucosa has been developed. Gastric lymphocytes were stimulated by T-cell mitogens in vitro. When mice were sensitized systemically with human gammaglobulin (HGG) and given the antigen orally 4 days before cell isolation, both the number of mucosal lymphocytes and their capacity to incorporate [3H]thymidine ([3H]TdR) was enhanced. Gastric epithelial cells added to cultures of syngeneic spleen cells enhanced both phytohaemagglutinin (PHA) responsiveness and mixed lymphocyte reactions (MLR) in low numbers, but significantly suppressed these responses at high concentrations. These findings suggest that gastric lymphocytes, like those of the gut, are involved in the immune response against antigens taken in by mouth, and that there may be in vivo interactions between gastric mucosa lymphocytes and epithelial cells.

[Unspecific spondylodiscitis following anastomotic leakage after rectal resection]. / Die unspezifische Spondylodiszitis als Folge einer Anastomoseninsuffizienz nach Rektumresektion.

Anastomotic leakage is a serious complication in abdominal surgery. We report on two cases of spondylodiscitis L5/S1 following anastomotic leakage with fistula after low anterior rectal resection. Within five months after rectal resection two patients with massive back pain were admitted to our department. MRI established the diagnosis of spondylodiscitis. Ventral debridement, spondylodesis and protective stoma were performed. With this procedure we were able to achieve control of infection. There were no further complications in the follow-up. Stability of the spinal column was restored and massive back pain was entirely relieved. No signs of rectal cancer recurrence were seen in both cases during the observation period.

Bioabsorbable expansion bolt fixation in anterior cruciate ligament reconstruction.

The current study evaluated initial fixation strength of a bioabsorbable expansion bolt compared with interference screw fixation in anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft. Thirty calf tibial plateaus with adjacent patella and extensor ligaments were used. Bioabsorbable poly-L-lactide interference screws were used for graft fixation in Group I, titanium screws in Group II, and bioabsorbable poly-DL-lactide expansion bolts were used in Group III. The mean force-to-failure (+/- standard deviation) in the three groups was 487 +/- 205 N, 713 +/- 218 N, and 594 +/- 224 N, respectively. The differences between Groups I and II were significant. No statistical differences were found regarding stiffness. Graft damage was significantly less in Group III compared with screw fixation. The fixation concept of an expansion bolt shows similar fixation strength and less graft damage compared with the established interference screw fixation. Because of the total absence of torque forces in contrast to bioabsorbable screws, the risk of implant breakage is minimized.

Endoscopic osteosynthesis after thoracic spine trauma: a report of two cases.

Modern concepts of treating thoracic diseases suggest more and more the use of minimally invasive thoracoscopic techniques to reduce morbidity and save costs. For treatment of specific lesions at the thoracic spine, several thoracoscopic procedures have been performed successfully. The present report examines the feasibility of thoracoscopic osteosynthesis in two patients with ventral hyperextension injuries and anterior instability of the thoracic spine. After initial correction of the anatomical deformity, autologous bone was harvested from the anterior iliac crest. Using a ventral, thoracoscopic approach, the main location of the ventral, damaged spinal segment was identified by the covering pleural haematoma. After endoscopic ventral bone grafting, osteosynthesis was performed, using dynamic compression plates, cardan drills and screw drivers. The perioperative course was uneventful, and follow up examinations after 3 years and 9 months, respectively, revealed an unchanged stable spinal segment. Our results show thoracoscopic osteosynthesis to be technically possible, with a potential for yielding satisfying long-term results.

[Experiences with calcitonin treatment of patients with type I complex regional pain syndrome (CRPS I--Sudeck disease)]. / Erfahrungen mit der Kalzitonin-Behandlung bei Patienten mit Complex Regional Pain Syndrome Type I (CRPS I--M. Sudeck).

UNLABELLED: PURPOSE/METHODS/PATIENTS: Calcitonin is a common treatment in patients suffering from Complex Regional Pain Syndrome Type 1 (CRPS I), although its effects are being controversially discussed. In a prospective study of 24 patients with CRPS I of the upper limb, we examined the tolerance of daily doses of 0.5 mg human calcitonin administered subcutaneously over 8 weeks. To assess the benefit of this therapy, the patients were clinically examined every second week. The results were compared to a consecutive group of 25 CRPS 1 patients who received only analgetics and physiotherapy. RESULTS: With regard to all examined parameters (spontaneous pain, grip strength, edema, hand function, systematic temperature difference), the patients treated with calcitonin showed an improvement during the observation time. However, a statistically significant difference to the control group was calculated only for the reduction of the edema (P < 0.01). 83% (20/24 patients) of the calcitonin-treated patients suffered from severe, mostly gastroenterological side-effects. Hence therapy had to be discontinued in 3 cases (13%). CONCLUSION: The therapy with calcitonin has the burden of numerous unpleasant side-effects and causes only a slight therapeutic improvement. Thus, calcitonin must only be prescribed with reservations for patients suffering from CRPS I.

[Unstable pediatric femoral and forearm shaft fractures. Comparison between conservative treatment and stable intramedullary nailing]. / Instabile kindliche Femur- und Unterarmschaftfrakturen. Vergleich zwischen konservativer Behandlung und stabiler intramedullärer Schienung.

Elastic intramedullary nailing represents a new surgical concept in the treatment of unstable shaft fractures in children. The present case control study wanted to examine the superiority of intramedullary nailing in comparison to conservative therapeutic concepts which had been applied so far. 13 children with forearm fractures who were treated initially by conservative measures were compared to 13 other children who received a primary intramedullary nailing. With femoral fractures, 12 children were included in each group. In each patient pair age, type and localisation of the fracture were comparable. During the observation period (until the termination of final therapeutic measures or until the third year after injury) we examined clinical variables and subjective findings. Both therapeutic concepts led to comparably good functional results. Also subjective judgement of the therapeutic success did not differ between groups. However, with intramedullary nailing of shaft fractures of the femur the mean hospital length of stay (7.0 +/- 3.5 days) was significantly shorter than with initial conservative treatment (36.5 +/- 2.2 days, P < 0.05). Irrespective of the localisation of the fracture intramedullary nailing required significantly less x-ray examinations during the observation period. These results suggest intramedullary nailing to be the procedure of choice to treat unstable forearm and femoral fractures in children.

Metastatic lesions of the humerus treated with the isoelastic diaphysis prosthesis.

Between January 1, 1987, and December 31, 1997, an isoelastic polyacetal resin prosthesis was used in 50 patients with metastatic bone disease to reconstruct pathologic or impending fractures of the humeral diaphysis. Fifty-seven operations were performed, including seven revision surgeries. The patients were assessed before and after surgery for limb function and quality of life using a modified Karnofsky scale. The mean survival time was 440 days. Ninety-one percent of the operations resulted in restoration or improvement of quality of life. Limb function was good or excellent in more than 80% of the patients after surgery. Breaking of the implant (n = 3), loosening of the implant (n = 2), periprosthetic fracture (n = 1), hematoma (n = 2), infection (n = 1), and one radial nerve paralysis were the main complications. In the cases of implant failure, the prosthesis broke at the site of a locking screw that was inserted across the prosthetic shaft in the cementless implantation technique. This kind of complication could be avoided by using bone cement for implantation or additional plate osteosynthesis between the prosthesis and humeral shaft. The isoelastic diaphyseal prosthesis offers a promising method of treating patients with metastatic lesions of the humeral shaft.

A rare case of osteoporotic spine fracture associated with epidural lipomatosis causing paraplegia following long-term cortisone therapy.

Cushing's syndrome is frequently associated with osteoporosis. Therefore, the incidence of osteoporotic spine fractures is significant. They are a rare cause of paraplegic syndromes. Additionally, epidural lipomatosis may occur in those patients. The combination of both fracture and lipomatosis may cause neurological deficit. A case of a young patient suffering from drug-induced Cushing's syndrome is reported. She developed progressive paraplegia. Radiographs demonstrated kyphosis of the thoracic spine from T7 to T9 and pathologic fractures. Urgent operation was planned to stabilize and decompress the spinal cord in the area of the kyphosis. Fortunately, magnetic resonance imaging (MRI) was conducted first. It confirmed pathologic fractures of T7-9 but also showed massive epidural fat extending from the level of T1 to T9. As suspected, laminectomy alone in the area of the fracture proved to be insufficient, as shown by myelography during operation. For treatment of paraplegia in this case of symptomatic epidural lipomatosis, an expanded laminectomy was necessary to remove all the epidural fat. Having undergone this procedure, the patient is now recovering from paraplegia. Our experience suggests that care should be taken before operative treatment of patients with pathological fractures in combination with Cushing's syndrome. In addition to vertebral fractures, epidural lipomatosis has to be taken into consideration. Those patients with neurological deficits have to be treated by an extensive laminectomy.