Immediate mobilization of distal radius fractures stabilized by volar locking plate results in a better short-term outcome than a five week immobilization: A prospective randomized trial.

OBJECTIVE: To evaluate the impact of immediate (first day after surgery) mobilization compared to standard five weeks cast immobilization on the functional outcome after volar locking plate fixation of distal radius fractures. DESIGN: Prospective randomized parallel group comparative trial. SETTING: Trauma Hospital, Austria. PARTICIPANTS: Patients with isolated unstable distal radius fractures, stabilized with volar angular stable locking plate. INTERVENTIONS: The immediate mobilization group received a removable forearm splint for one week and active supervised group physiotherapy and home exercises for the shoulder, elbow, wrist, and fingers from the first postoperative day. The cast immobilization group received a non-removable cast for five weeks. In the first five weeks supervised group physiotherapy and home exercises were performed for shoulder, elbow, and fingers. Thereafter additional supervised and home exercises for the wrist were started. MAIN MEASURES: At regular intervals of six and nine weeks, three and six months, and one year post surgery range of motion, grip strength, and x-rays were evaluated. Additionally, the shortened disabilities of the arm, shoulder and hand (QuickDASH) score, Patient-rated Wrist Evaluation, Mayo Wrist score, and pain according to the Visual Analog Scale score were analyzed. RESULTS: One hundred and sixteen patients were prospectively randomized into two study groups. At the one-year follow-up, patients in the immediate mobilization group showed a significantly higher range of motion in extension/flexion (mean difference 10.2°, 99% confidence interval 0.6-19.8), grip strength (mean difference 5.1 kg, 99% confidence interval -0.5 to 10.7), and Mayo Wrist score (mean difference 7.9 points, 99% confidence interval 2.3-13.5) than the cast immobilization group. Range of motion in supination/pronation (mean difference 13.4°, 99% confidence interval 1.5-25.3) and in radial/ulnar deviation (mean difference 6.3°, 99% confidence interval 0.9-11.7) differed significantly up to nine weeks favoring the immediate mobilization group. The Patient-rated Wrist Evaluation revealed significantly better scores after three months (mean difference 9.3 points, 99% confidence interval 0.5-18.1) and QuickDASH after six months (mean difference 7.3 points, 99% confidence interval 0.3-14.3) in the immediate mobilization group. All other subsequent follow-up examinations indicated no significant differences in respect of pain, range of motion, and patient-reported outcome measurements between the study groups. There were no significant differences in respect of radiological loss of reduction and complications between the groups. CONCLUSIONS: Immediate mobilization in combination with supervised physiotherapy of the wrist after volar locking plate fixation of unstable distal radius fractures results in a significantly improved range of motion and grip strength after one year compared to cast immobilization. No increased risk for loss of reduction and other complications was observed.

Open reduction and fixation with a locking plate without bone grafting is a reasonable and safe option for treating proximal humerus nonunion.

AIM OF THE STUDY: The aim of this study was to evaluate union rate and clinical outcome in patients with proximal humeral nonunions treated by open reduction and locking plate fixation without bone grafting. METHODS: From 2011 to 2016, nine patients were treated using open reduction and locking plate stabilization without bone grafting. They were examined both clinically and radiologically, with a mean follow-up period of 31 months. Outcome was evaluated using pain and range of motion (ROM) parameters. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Constant-Murley Score, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. A CT scan of the shoulder was performed to analyze union. RESULTS: At checkup, all patients showed union in the CT scans, where the mean ROM in abduction was 139° (SD 50°), in adduction 39° (SD 8°), in forward flexion 136° (SD 40°), in extension 44° (SD 11°), in internal rotation 62° (SD 15°), and external rotation 54° (SD 31°). ROM improved significantly in all planes of motion, except for adduction, post-surgery (p < 0.05). Plate removal was necessary in three patients. No complications were reported. CONCLUSION: Open reduction and locking plate fixation without bone grafting is a reasonable and safe option for treating proximal humerus nonunion. It leads to a high union rate, significant improvement in ROM, and in the majority of the cases to an "excellent" and "good" functional outcome without an increased risk of complications.

Volar Radioscapholunate Arthrodesis and Distal Scaphoidectomy After Malunited Distal Radius Fractures.

PURPOSE: The purpose of this study was to assess range of motion (ROM), pain, and incidence of radiographic degenerative joint disease (DJD) after volar radioscapholunate (RSL) arthrodesis and distal scaphoidectomy (DSE) following malunited distal radius fractures (DRF). METHODS: Fourteen patients with malunited DRF and DJD limited to the radiocarpal joint underwent RSL arthrodesis and DSE between 2006 and 2014. These were retrospectively analyzed both clinically and radiologically. Eleven patients with a mean follow-up of 63 months (range, 30-97 months) were included in the final analysis because 1 was unavailable and 2 had died. The outcome was evaluated using parameters of pain, ROM, grip strength, nonunion rate, and DJD of the adjacent joints. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Patient-Rated Wrist Evaluation score, and Michigan Hand Outcomes Questionnaire. To investigate DJD and union, a computed tomography (CT) scan at the final follow-up visit was performed. RESULTS: All patients showed union and no midcarpal DJD in the CT scans at final follow-up. The mean ROM in extension was 53°, flexion 42°, supination 81°, pronation 85°, radial deviation 10° and ulnar deviation 25°. The ROM in extension, extension/flexion arc, and supination improved significantly after surgery. Patients achieved a mean of 80% of grip strength compared with the other hand. CONCLUSIONS: Volar angular stable plate RSL arthrodesis with resection of the distal scaphoid pole is a safe and effective method for treating malunited DRF. This leads to an improved ROM and low pain level. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Results of dynamic treatment of fractures of the proximal phalanx of the hand.

BACKGROUND: The treatment of fractures of the proximal phalanx in three-phalanx fingers has for a long time been the domain of conservative static treatment in a plaster cast. After removal of the plaster, there was usually limitation of mobility of the interphalangeal joints. Fractures of the proximal phalanx are managed with conservative functional treatment in our clinic. The aim of this method is to achieve bony healing and free mobility at the same time and not in succession. We evaluated our treatment outcomes in a follow-up study. METHODS: The dressing consists of a dorsopalmar plaster splint and a so-called finger splint. The wrist and metacarpophalangeal joints are immobilized with the plaster cast. The wrist is dorsiflexed 30 degrees, and the metacarpophalangeal joints are flexed 70 degrees to 90 degrees. In this intrinsic plus position, the extensor aponeurosis is taut and covers two-thirds of the proximal phalanx, thus leading to firm splinting of the fracture. RESULTS: Sixty-five patients (46 men and 19 women) with 78 proximal phalanx fractures were followed up after an average of 23 months (12-69 months). The average age of the patients was 41 years (18-93 years). Among our patients, the ring finger was affected most often, with transverse fractures predominating. As regards the location, fractures in the proximal third were most frequent (51%). All fractures consolidated. Delayed fracture healing or pseudarthrosis was not observed. Sixty-seven fingers (86%) showed full range of motion at follow-up. In 11 cases (14%), there was limitation of finger joint movements, with inhibition of extension of the proximal interphalangeal joint in nine patients up to a maximum of 20 degrees. Two patients had limitation of flexion with a fingertip-palm distance of 1.1 cm. CONCLUSION: The aim of functional treatment of proximal phalanx fractures is to achieve bony healing and free mobility at the same time and not in succession. Active exercises in the proximal and distal interphalangeal joints prevent limitations of mobility and the subsequent occurrence of rotational and axial deformities.

First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions.

BACKGROUND: Plate osteosynthesis of the scaphoid, as reported earlier by Ender, has lost its importance in the past few years, after Herbert's introduction of the simple and successful technique of screw osteosynthesis. Only in rare cases does one encounter failed healing or instability of the fragments. Even with a vascularized bone chip, it is not always possible to achieve consolidation. Particularly in these situations, poor interfragmentary stability seems to be the reason for failed healing. METHODS: Between January 2007 and August 2009, we treated 7 men and 4 women of mean age 37 years (22-53 years) by scaphoid plate osteosynthesis. All the patients had fractures of the waist of the scaphoid with established nonunion persisting for at least 6 months after the causative injury, with wrist pain, weakness, or both. All 11 patients had clinical and radiologic follow-up for at least 6 months. RESULTS: All the fractures united at a median time from operation of ∼4 months. All patients reported an improvement in their symptoms and function. The mean DASH score was 28 points. CONCLUSIONS: Scaphoid plate osteosynthesis should be regarded as a salvage procedure, and the indication for the procedure should be established accordingly. It is a simple procedure in terms of technique. The plate can be adjusted very well to the anatomic shape of the scaphoid, and one can achieve a high degree of stability, particularly rotational stability.

Unstable distal radius fractures in the elderly patient--volar fixed-angle plate osteosynthesis prevents secondary loss of reduction.

BACKGROUND: Because of demographic changes in industrialized countries, signifying a growing population of the aged and a markedly increased life expectancy, the incidence of the distal radius fracture is expected to increase by a further 50% until the year 2030. Osteoporosis characterizes the radius fracture in elderly patients. Primarily weakening metaphyseal bone, osteoporosis renders simple fractures unstable and makes distal bone fixation a challenge. The introduction of fixed-angle plate systems for extension fractures of the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new plating system. The focus of our interest was whether a secondary loss of reduction can be prevented by this plating system in the elderly patient. METHODS: We reviewed 58 patients aged 75 years or older treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, wrist splint used for 4 weeks, and physiotherapy. At the time of follow-up, after a mean period of 13 months (range, 12-15 months), standard radiographic and clinical fracture parameters were measured and final functional results were assessed. RESULTS: Bone healing had occurred in all patients at the time of follow-up. On X-rays taken at the time of follow-up, 53 patients (91%) had no radial shortening, 5 patients (9%) had a mean radial shortening occurred during follow-up of only 1.3 mm (range, 1-2 mm) compared with the contralateral side. Comparing the first postoperative X-rays with those taken at final evaluation showed no measurable loss of reduction in the volar tilt or radial inclination. Castaing's score yielded a perfect outcome in 25 cases, a good outcome in 30 cases, and an adequate outcome in 3 cases. On an average, the range of motion was reduced by 19% during extension/flexion, by 13% during radial/ulnar deviation, and by 9% in pronation/supination compared with the contralateral side. Grip strength was 55% higher than that of the contralateral side. Eleven patients (19%) reported pain at rest with a mean Visual Analog Pain Scale score of 3.1 (range, 1-6), whereas 30 patients (52%) had pain on load-bearing with a mean Visual Analog Pain Scale score of 3.4 (range, 1-8). The mean disabilities of the arm, shoulder, and hand (DASH) score (Jester A, Harth A, Germann G. J Hand Surg Am. 2005;30:1074.e1-1074.e10) was 28 points. A carpal tunnel syndrome with abnormal nerve conduction velocity was diagnosed in three patients, a rupture of the flexor pollicis longus tendon was seen in one patient. CONCLUSION: Fixed-angle plate osteosynthesis at the distal radius in the elderly patient signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist associated with a low complication rate. This technique with its simple palmar access, allows exact anatomic reduction of the fracture, allows early return to function, and minimizes morbidity in the elderly patient. Secondary correction loss can be prevented by this procedure.

Volar fixed-angle plating of extra-articular distal radius fractures--a biomechanical analysis comparing threaded screws and smooth pegs.

BACKGROUND: Distal radius fractures represent the most common fractures in adult individuals. Volar fixed-angle plating has become a popular modality for treating unstable distal radius fractures. Most of the plates allow insertion of either threaded locking screws or smooth locking pegs. To date, no biomechanical studies compare locking screws and pegs under axial and torsional loading. METHODS: Ten Sawbones radii were used to simulate an AO/OTA A3 fracture. Volar fixed-angle plates (Aptus Radius 2.5, Medartis, Switzerland) with threaded locking screws (n = 5) or smooth locking pegs (n = 5) were used to fix the distal metaphyseal fragment. Each specimen was tested under axial compression and under torsional load with a servohydraulic testing machine. Qualitative parameters were recorded as well as axial and torsional stiffness, torsion strength, energy absorbed during monotonic loading and energy absorbed in one cycle. RESULTS: Axial stiffness was comparable between both groups (p = 0.818). If smooth pegs were used, a 17% reduction of torsional stiffness (p = 0.017) and a 12% reduction of minimum torque (p = 0.012) were recorded. A 12% reduction of energy absorbed (p = 0.013) during monotonic loading and unloading was recorded if smooth pegs were used. A 34% reduction of energy absorbed in one cycle (p < 0.007) was recorded if threaded screws were used. Sliding of the pegs out of the distal radius metaphyses of the synthetic bones was recorded at a mean torque of 3.80 Nm ± 0.19 Nm. No sliding was recorded if threaded screws were used. CONCLUSIONS: According to the results of this study using Sawbones, volar fixed-angle plates with threaded locking screws alone are mechanically superior to volar fixed-angle plates with smooth locking pegs alone under torsional loading.

[Palmar radioscapholunate arthrodesis with distal scaphoidectomy]. / Radioskapholunäre Arthrodese mit Entfernung des distalen Skaphoidpols von palmar.

OBJECTIVE: Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint. INDICATIONS: Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stage II. CONTRAINDICATIONS: Mediocarpal osteoarthritis, poor patient compliance, SLAC from stage III, osteitis. SURGICAL TECHNIQUE: The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, a longitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of a volar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using a K-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K­wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using a Codeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws. POSTOPERATIVE MANAGEMENT: Immobilization using a plaster cast or thermoplastic short-arm orthosis for 5 weeks. After 2 weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks. RESULTS: Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows a high union rate and pain relief while maintaining good residual mobility of the wrist.

Retrospective review of outcome after surgical treatment of enchondromas in the hand.

BACKGROUND: Tumours of the skeleton of the hand are rare. While the majority of bone tumours are benign (89.4%), a small number show signs of malignancy (4.4%). Among the benign bone tumours of the skeleton of the hand, enchondromas are the most common, at 35-65%. METHODS: In the period from 1998 to 2005, a total of 35 enchondromas on the hand were diagnosed at the Trauma Center Lorenz Boehler. These were 16 women and 19 men with an average age of 36 years (age range 16-66). The most common site of an enchondroma was the proximal phalanx in 17 cases, followed by the metacarpal bone in 8 cases and the middle phalanx in 5 cases. In five patients, an enchondroma was found in the carpal bones. Twenty-nine patients underwent surgery. RESULTS: The follow-up findings (average follow-up time, 47 months) were assessed in accordance with the formula outlined by Wilhelm and Feldmaier. Twenty-five of 27 patients who underwent follow-up examination showed an excellent result. In two patients, the result was assessed as good on account of restricted mobility caused by increased scar formation. No recurrence was detected in X-ray controls. CONCLUSION: Enchondromas of the hand are usually detected after a bagatelle trauma. For accurate diagnosis, conventional X-ray examination and if necessary, a contrast medium MRI should be performed. Histological investigation is compulsory due to the risk of malignancy. Depending on its spread, the defect in the extirpation cavity should be filled with autogenous spongy bone.

Volar fixed-angle plate osteosynthesis of unstable distal radius fractures: 12 months results.

BACKGROUND: With an incidence of about 2-4 per 1,000 residents per year, the distal radial fracture is the most common fracture in the human skeleton. The introduction of fixed-angle plate systems for extension fractures at the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new system. The focus of our interest was whether a secondary loss of reduction can be avoided by this plating system. METHODS: We reviewed 80 patients treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, a wrist splint used for 4 weeks and physiotherapy. Standard radiographic and clinical fracture parameters after 12 months (range 12-14 months) were measured and final functional results where assessed. RESULTS: Bone healing had occurred in all patients at the time of follow-up after 1 year. On X-rays taken at the time of follow-up 60 patients (75%) had no radial shortening, 20 patients (25%) had a mean radial shortening of only 1.8 mm (range 1-3 mm) compared to the contralateral side. The radial tilt was on average 22 degrees (range 14 degrees-36 degrees); the volar tilt was on average 6 degrees (range 0 degrees-18 degrees). Comparing the first postoperative X-rays with those taken at final evaluation showed no measureable loss of reduction in the volar or radial tilt. Castaing's score, which includes the radiographic results, yielded a perfect outcome in 30 cases, a good outcome in 49 cases and an adequate outcome in one case. The range of motion was on average reduced by 21% during extension/flexion, by 11% during radial/ulnar deviation and by 7% in pronation and supination compared to the contralateral side. Grip strength was 65% that of the contralateral side. The mean DASH score was 25 points. CONCLUSION: Fixed-angle plate osteosynthesis at the distal radius signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist. The technically simple palmar access, with a low rate of complications, allows exact anatomical reduction of the fracture. The multidirectional fixed-angle system we used provides solid support for the joint surface even in osteoporotic bone and allows simple subchondral placement of screws with sustained retention of the outcome of reduction. Secondary correction loss can be avoided by this procedure. Early mobilisation can be achieved and is recommended.

[Therapy of Dupuytren's contracture with collagenase - Evidence-based Consensus Statement of Austrian Surgical Societies]. / Therapie der Dupuytren'schen Kontraktur mit Kollagenase.

Dupuytren's contracture (DC) or Dupuytren's disease (DD) is a progressive fibro-proliferative disease of palmoplantar connective tissue, resulting in characteristic nodal and/or cord formation from collagen disposition. When the disease progresses, the thickening and shortening of the cords eventually leads the affected fingers to being pulled into flexion, which may be associated with marked disability, especially with bilateral disease. DD is relatively common in Europe, with the highest prevalence in Nordic countries. In Austria approx. 200 000 people are affected. The incidence increases with increasing age, with men being more often and earlier affected than women. The aetiology of DC is not completely clear, but it seems to be multifactorial; twin and familial studies confirm a genetic predisposition. The natural course of the disease can vary between relatively benign and massive progression and recurrence. In most cases, there is a fluctuating course. The DC is not curable; treatment methods range from minimally invasive to open surgical procedures. Collagenase Clostridium histolyticum (CCH) is a nonsurgical, enzymatic injection treatment for adult patients (≥ 18 years) with a palpable cord and has been approved in Europe since 2011. Clinical studies and practical experience of individual centres confirm the efficacy and safety of CCH treatment of DC. The present consensus statement was prepared under the auspices of the Austrian Society of Hand Surgery with the participation of the Austrian Society for Trauma Surgery, the Society of Orthopaedics and Orthopaedic Surgery as well as the Society for Plastic, Aesthetic and Reconstructive Surgery. On the basis of current literature and the experts' experience, it describes the various surgical procedures, with particular reference to collagenase treatment and provides guidance for their use. The statement is intended not only to illustrate the state of the art of current treatment, but also to support the achievement of uniform high quality standards in the treatment of DC in surgical centres and specialised medical practices throughout Austria.

Gelatin thrombin granules for hemostasis in a severe traumatic liver and spleen rupture model in swine.

BACKGROUND: Treatment of traumatic liver and spleen rupture is a major challenge for the surgeon. Because of their excellent blood supply and tissue structure, rupture of the liver and spleen is often associated with massive abdominal hemorrhage. Frequently the surgeon's only feasible option is partial or total resection of the organ. The purpose of this study was to test the hemostatic efficacy of gelatin thrombin granules (FloSeal) in a standardized severe traumatic liver and spleen rupture model in swine (representing a grade IV-V rupture) during severe hemorrhagic shock and coagulation disorder. METHODS: Standardized combined penetrating liver and spleen rupture was inflicted in 10 anesthetized swine. Hemorrhagic shock was induced after heparinization. Gelatin thrombin granules were used to treat both the ruptured liver and the ruptured spleen. Blood loss, hemostasis, and 48 hours survival rate were quantified. Cardiorespiratory parameters, activated clotting time, and plasma fibrinogen level were monitored. After 1 hour and 48 hours a second look evaluation was performed to detect any postoperative hemorrhage. Ruptures were then examined macroscopically and histologically. RESULTS: Hemostasis was achieved with FloSeal in all swine. The mean amount of FloSeal used was 14 mL +/- 2.5 mL. Macroscopic and histologic findings after 48 hours showed excellent clot integration into the surrounding tissue without any adverse effects. CONCLUSION: Gelatin thrombin granules (FloSeal) are effective in treating severe penetrating rupture of the liver and spleen even during hemorrhagic shock, retransfusion conditions, and coagulation disorder.

Early Rehabilitation of Distal Radius Fractures Stabilized by Volar Locking Plate: A Prospective Randomized Pilot Study.

Background Distal radius fractures are very common and an increased incidence of 50% is estimated by 2030. Therefore, both operative and postsurgical treatment remains pertinent. Main aim in treating intra-articular fractures is to restore the articular surface by internal fixation and early mobilization (EM). Questions/Purposes The purpose of this study was to compare functional results between EM immediately after surgery and 5 weeks of immobilization (IM). Patients and Methods In a randomized prospective study, 30 patients with an isolated distal radius fracture were treated by open reduction and internal fixation using a single volar locking plate excluding bone graft. Fifteen patients were randomized in the EM group and 15 in the IM group. At 6 weeks, 9 weeks, 3 months, 6 months, and 1 year postsurgery, range of motion, grip strength and X-rays were evaluated. Additionally, Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaire, Patient-Rated Wrist Evaluation (PRWE), modified Green O'Brien (Mayo) score, and pain according to the Visual Analog Scale score were analyzed. Results Patients in the EM group had a significantly better range of motion in the sagittal plane, in grip strength up to 6 months, in the frontal plane up to 9 weeks, and in forearm rotation up to 6 weeks. Also QuickDASH and PRWE scores were better up to 6 weeks postsurgery. The Green O'Brien score differed significantly up to 1 year. At 1 year, 93% "excellent" and "good" results in the Green O'Brien score with a mean QuickDASH of 5.98 ± 10.94 and PRWE score of 4.27 ± 9.23 were observed in the EM group. No differences regarding loss of reduction, pain, duration of physiotherapy, and sick leave were noted. Conclusion EM of surgically treated distal radius fractures (without bone graft) is a safe method for postoperative aftercare and leads to an improved range of motion and grip strength at 6 months postsurgery compared with an IM of 5 weeks. Level of Evidence This is a level Ib clinical study.

GFAP versus S100B in serum after traumatic brain injury: relationship to brain damage and outcome.

Research indicates that glial fibrillary acidic protein (GFAP), part of the astroglial skeleton, could be a marker of traumatic brain injury (TBI). S100B, an astroglial protein, is an acknowledged marker of TBI. Our goal was to analyze the relationship of GFAP/S100B to brain damage and outcome, and to compare the accuracy of GFAP/S100B for prediction of mortality after TBI. Our prospective study included 92 patients admitted <12 h after TBI (median injury severity score 25, median Glasgow Coma Scale 6). TBI was verfied by computerized tomography. GFAP/S100B were measured immunoluminometrically at admission and daily in the intensive care unit (average 10 days, range 1-21 days). We compared GFAP/S100B in non-survivors versus survivors, accuracy for mortality prediction according to receiver operated characteristic curve analysis, correlation between GFAP and S100B, relationship of GFAP/S100B to computerized tomography, cerebral perfusion pressure (CPP), mean arterial pressure (MAP) and 3-month Glasgow Outcome Score (GOS). GFAP (p < 0.005) and S100B (p < 0.0005) were higher in non-survivors than survivors. Both GFAP and S100B were accurate for mortality prediction (area under curve 0.84 versus 0.78 at <12 h after TBI). GFAP and S100B release correlated better later than 36 h after TBI (r = 0.75) than earlier (r = 0.58). GFAP was lower in focal lesions of <25 mL than in shifts of >0.5 cm (p < 0.0005) and non-evacuated mass lesions of >25 mL (p < 0.005). S100B was lower in focal lesions of <25 mL than in non-evacuated mass lesions (p < 0.0005) and lower in swelling than in shifts of >0.5 cm (p < 0.005). GFAP and S100B were lower in ICP < 25 than ICP > or = 25 (p < 0.0005), in CPP > or = 60 than CPP < 60 (p < 0.0005), in MAP > 70 than MAP < or = 70 mm Hg, and in GOS 4-5 than GOS 1 (p < 0.0005). Both measurement of GFAP and S100B is a useful non-invasive means of identifying brain damage with some differences based on the pattern of TBI and accompanying multiple trauma and/or shock.

Extensor pollicis longus rupture after distal radius fracture: results of reconstruction by transposition of the extensor indicis tendon and postoperative dynamic splinting.

Injury of the extensor pollicis longus tendon is one of the commonest extensor tendon injuries after distal radius fracture. In 2003-2005 we performed extensor indicis transfer in 31 patients with loss of function of the EPL tendon and postoperative dynamic splinting. In 25 patients, a distal radius fracture managed surgically led to the EPL rupture (wire internal fixation in 23 patients, plate internal fixation in 2 patients). In 6 patients, the cause was a distal radius fracture treated conservatively. Out of our 25 followed-up patients, 9 (36%) had a very good and 15 (60%) a good result in the Geldmacher score. We did not identify any re-rupture. In injuries of the extensor pollicis tendon, transposition of the extensor indicis tendon is a simple and uncomplicated procedure. Considerable improvement of thumb extension can be achieved through this substitution repair.

Intra-arterial tert-Butyl-hydroperoxide infusion induces an exacerbated sensory response in the rat hind limb and is associated with an impaired tissue oxygen uptake.

The objective of this study was to investigate oxidative stress and oxygen extraction mechanisms in an animal model of continuous intra-arterial infusion of a free radical donor and in an in vitro model using isolated mitochondria. tert-Butyl-hydroperoxide (tert-BuOOH, 25 mM) was infused for 24 h in the left hind limb of rats to induce soft tissue damage (n = 8). After 7 days, we assessed local sensory response, tissue oxygen consumption, oxygen radicals, and antioxidant levels. In vitro mitochondrial function was measured after stimulation of isolated mitochondria of skeletal muscle cells with increasing doses of tert-BuOOH. tert-BuOOH infusion resulted in an increased skin temperature (p = 0.04), impaired function, and a significantly increased pain sensation (p = 0.03). Venous oxygen saturation levels (p = 0.01) and the antioxidant ceruloplasmin (p = 0.04) were increased. tert-BuOOH inhibited mitochondrial function in vitro. Induction of free radical formation in the rat hind limb results in an exacerbated sensory response and is associated with impaired oxygen extraction, which likely results from mitochondrial dysfunction caused by free radicals.

Volar fixed-angle plating of distal radius extension fractures: influence of plate position on secondary loss of reduction--a biomechanic study in a cadaveric model.

PURPOSE: Treatment of extension fractures of the distal radius with volar fixed-angle plates has become increasingly popular in the past 2 years. It has been observed clinically that placement of the distal screws as close as possible to the subchondral zone is crucial to maintain radial length after surgery. The purposes of this study were (1) to evaluate radial shortening after plating with regard to plate position and (2) to evaluate whether plate position has an influence on the strength and rigidity of the plate-screw construct. METHODS: An extra-articular fracture (AO classification, A3) was created in 7 pairs of fresh-frozen human cadaver radiuses. The radiuses then were plated with a volar distal radius locking compression plate. Seven plates were applied subchondrally; 7 plates were applied 4.5 mm to 7.5 mm proximal to the subchondral zone. The specimens were loaded with 800-N loads for 2,000 cycles to evaluate radial shortening in the 2 groups. Each specimen then was loaded to failure. RESULTS: Radial shortening was significantly greater when the distal screws were placed proximal to the subchondral zone. The amount of shortening after cyclic loading correlated significantly with the distance the distal screws were placed from the subchondral zone. Rigidity of the plate systems was significantly higher in radiuses in which the distal screws were placed close to the subchondral zone. CONCLUSIONS: To maintain radial length after volar fixed-angle plating, placement of the distal screws as subchondral as possible is essential. The subchondral plate-screw-bone constructs showed significantly greater rigidity, indicating higher resistance to postoperative loads and displacement forces.

Assessment of bone union/nonunion in an experimental model using microcomputed technology.

BACKGROUND: High-resolution microcomputed tomography (microCT) is one of the most recent technical developments to visualize and quantify primarily cancellous bone. Regarding bone formation, microCT is becoming increasingly important, although its reliability has not yet been evaluated. Our study had two goals: to develop a reproducible nonunion model and to determine the efficacy of microCT for the assessment of bone healing in this model. METHODS: The designed fracture model in the rat simulates secondary fracture healing. After plate fixation to the femur, diaphysis transverse middiaphyseal osteotomy was performed with a reciprocating saw, resulting in a 0.38-mm gap with a defect of bone and periosteum corresponding to the thickness of the blade. Proximally and distally to this gap, the periosteum was preserved. Thus, three separate zones were defined: proximal femur diaphysis with periosteum, gap, and distal femur diaphysis with periosteum. In the nonunion group (NM group), a model of impaired bone healing (nonunion), silicone foil was wrapped around the femur diaphysis to block any influence from surrounding tissue. Coverage of the bone repair site by thigh muscles was designed for a model of bone union (M group). Four weeks postoperatively, callus formation was determined by conventional anterior-posterior and lateral plain radiographs. Ten weeks later, a second x-ray series was done as the clinical standard evaluation method. Afterward, specimens were harvested for microCT examination (two-dimensional and three-dimensional [3D]). Biomechanical testing was carried out to determine fracture healing. RESULTS: Our model is highly reproducible and results in bone nonunion in five out of six cases (83.3%). In determining fracture site, plain radiographs the least reliable method in comparison to the biomechanical testing which is the most accurate reference method. In contrast, microCT (the 3D reconstruction) showed significant correlation (r = 1) to the results assessed by biomechanical testing, whereas microCT was correct in 100%. We found bone healing in five out of six animals in the M group verified by microCT (in accordance to biomechanical data). In the M group, significantly enhanced bone formation (50%) (p = 0.008) was observed within the osteotomy site (i.e. within the gap), but there was no difference in periosteal bone formation between the groups proximally and distally to the gap. Interestingly, we did not find statistically significant differences in mineralization. CONCLUSION: We conclude that microCT with 3D reconstruction is the optimal method diagnostic tool in fracture healing, especially in nonunion. Furthermore, direct coverage of the fracture site by muscle flaps results in a mineralized enhanced bone formation within the osteotomy site (i.e. within the gap). Skeletal muscle coverage hypothetically might have osteogenic augmentation potential, thus being able to prevent pseudoarthrosis.

Why patients choose regional anesthesia for orthopedic and trauma surgery.

BACKGROUND: While both surgeons' and anesthesiologists' preference of regional over general anesthesia is increasing, the patients' preference remains limited. Little is known about why patients choose regional anesthesia. The aim of our study was to answer this question with regard to orthopedic and trauma surgery. METHODS: The study was carried out prospectively from 1999 to 2001 and included 238 patients scheduled for arthroscopy of the lower limb or other orthopedic or trauma surgery. All patients were informed about regional and general anesthesia in a pre-anesthesia interview and subsequently chose the method they preferred. RESULTS: Curiosity was the main reason why patients chose regional anesthesia for arthroscopy ( n=155, p<0.0001). For all other types of orthopedic or trauma surgery ( n=83), patients chose regional anesthesia to avoid postoperative pain ( p<0.01) and/or the side-effects of general anesthesia ( p<0.0001). Younger ( n=128) and low-risk ( n=184) patients chose regional anesthesia because they were curious ( p<0.01 and p<0.001, respectively), while older ( n=110) and unhealthier patients ( n=56) did so for safety ( p<0.01 and p<0.001, respectively). CONCLUSIONS: Patients choose different types of regional anesthesia for different reasons. While spinal anesthesia and femoral and sciatic block were chosen for curiosity reasons, brachial plexus block was chosen to avoid the side effects of general anesthesia. The patients' choice of regional anesthesia for orthopedic and trauma surgery is significantly influenced by the type of surgery, age, and health.