[Nonsurgical and surgical management of osteoporotic vertebral body fractures : Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)]. / Nichtoperative und operative Behandlung der osteoporotischen Wirbelkörperfraktur : Empfehlungen der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU).

STUDY DESIGN: Prospective clinical cohort study (data collection); expert opinion (recommendation development). OBJECTIVES: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures differ widely. Based on the current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification), the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. METHODS: A total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed for guidance in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X­rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scans. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. RESULTS: A score of less than 6 points advocates nonsurgical management; in cases with more than 6 points, surgical management is recommended. The primary goal of treatment is fast and painless mobilization. Because of the expected comorbidities in this age group, minimally invasive procedures are preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. The instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment, the necessity to fuse, multiple level fractures, consecutive and adjacent fractures and fractures in ankylosing spondylitis are addressed separately. CONCLUSIONS: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for the treatment choices available. However, intermediate clinical situations with a score of 6 points remain, allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the subsequent step, the recommendations presented will be further evaluated in a multicentre controlled clinical trial.

Sensitivity and specificity of ultrasound in spinal trauma in 29 consecutive patients.

PURPOSE: Indication for surgery in spine trauma patients depends on the extent of destruction of the spine. Computer-assisted tomography scan (CAT scan) is not suitable to diagnose type B-injuries. Aim of the study was to investigate whether ultrasound is able to detect destruction of the posterior ligament complex (PLC). METHODS: Twenty-nine patients were included. The results of ultrasound were compared with magnetic resonance imaging (MRI), CAT scan, X-ray, intraoperative findings. Statistical analysis was carried out by an independent observer. RESULTS: In 27 cases both ultrasound and MRI had the same result. In two cases, ultrasound failed to detect ligamentous injury. The sensitivity of ultrasound was 0.82 (CI 0.48-0.98), its specificity: 1. MRI and Ultrasound findings had a strong positive correlation (phi = 0.85, Cohen's kappa: 0.85, with 95 % confidence interval 0.65-1) and a high significance (Fischer's exact test: p < 0.0001). CONCLUSION: Ultrasound may indicate rupture or integrity of PLC in cases where MRI is missing.

[Structured rehabilitation after lumbar spine surgery : subacute treatment phase]. / Strukturierte Rehabilitation nach lumbaler Wirbelsäulenoperation : Subakute Behandlungsphase.

BACKGROUND: There are currently no uniform standards regarding rehabilitation of patients after lumbar spine surgery. Due to significant improvements in surgical methods in recent years, an increase in postoperative training intensity is now possible. Conservative rehabilitation has yet to adapt to this reality. Earlier initiation of structured rehabilitation after the acute phase is often regarded with skepticism. OBJECTIVE: To evaluate the effect of structured rehabilitation after lumbar spine surgery in the early phase of treatment (2 weeks after surgery), a group of seven spinal surgery clinics, two inpatient and three outpatient rehabilitation centers in the Rhine-Main area in Germany was formed. MATERIALS AND METHODS: In this prospective study, 124 patients were divided into groups (A/B/C) by their surgeon, regardless of diagnosis and surgical procedure. For each group of participants, the content of therapy was preplanned. RESULTS: The statistical analysis using the visual analog scale (VAS), Oswestry Disability Index (ODI), and short form-12 health survey (SF-12) to evaluate changes in impairment caused by back pain and in health-related quality of life was evaluated. In all three groups, significant improvements in VAS, ODI, and SF-12 were shown. Re-operation was unnecessary due to the absence of postoperative complications. CONCLUSION: A structured postoperative rehabilitation program results in significant improvements in the parameters of pain and quality of life, and does not increase the risk of postoperative complications.

[Proximal tibial fractures]. / Frakturen der proximalen Tibia.

Only 1-4% of all long bone fractures in children involve the proximal tibia. To evaluate these fractures appropriately, it is mandatory to differentiate between articular fractures and metaphyseal fractures. Articular fractures of the proximal physis are rare and include Salter Harris type III and IV injuries. The reconstruction of the articular surface is the fundamental goal of therapy. Injuries of the anterior crucial ligament which typically appear as an avulsion of the tibial spine and the avulsion fracture of the tibial tubercle apophysis can involve the articular surface. Dislocated fractures should be reduced and stabilized. Extraarticular fractures include Salter Harris type I and II fractures. Other types of metaphyseal fractures are the complete fracture, the compression fracture and the bending fracture of the proximal tibia. Care should be taken while treating bending fractures, especially a valgus deformity must be excluded. Due to unequal growth stimulation during remodelling, a progressive valgus deformity frequently develops. Small deformities in the sagittal plane can be compensated by spontaneous remodelling during further growth. Dislocated fractures should be reduced and stabilized by K-wires. The retention of bending fractures by a compression plate or external fixator for medial compression might be more beneficial.

[Recommendations for the treatment of thoracolumbar and lumbar spine injuries]. / Therapieempfehlungen zur Versorgung von Verletzungen der Brust- und Lendenwirbelsäule.

This paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the "Deutsche Gesellschaft für Unfallchirurgie" and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

Biomechanical comparison of an interspinous device and a rigid stabilization on lumbar adjacent segment range of motion.

PURPOSE OF THE STUDY: Decompression surgery with or without fusion is the gold standard treatment of lumbar spinal stenosis, but adjacent segment degeneration has been reported as a long-term complication after fusion. This led to the development of dynamic implants like the interspinous devices. They are supposed to limit extension and expand the spinal canal at the symptomatic level, but with reduced effect on the range of motion of the adjacent segments. The aim of the present study is the evaluation of the biomechanical effects on the range of motion (ROM) of adjacent lumbar segments after decompression and instrumentation with an interspinous device compared to a rigid posterior stabilization device. MATERIALS AND METHODS: Eight fresh frozen human cadaver lumbar spines (L2-L5) were tested in a spinal testing device with a moment of 7.5 Nm in flexion/extension, lateral bending and rotation with and without a preload. The preload was applied as a follower load of 400N along the curvature of the spine. The range of motion (ROM) of the adjacent segments L2/L3 and L4/L5 was measured with the intact segment L3/L4, after decompression, consisting of resection of the interspinous ligament, flavectomy and bilateral medial facetecomy, and insertion of the Coflex® (Paradigm Spine, Wurmlingen) and after instrumentation with Click X® (Synthes, Umkirch) as well. RESULTS: The interspinous and the rigid device caused a significant increase of ROM at both adjacent segments during all directions of motion and under follower load, without significant difference between these devices. The ROM of L2/L3 tends to increase more than the ROM of L4/L5 after instrumentation without statistical significance. DISCUSSION: The "dynamic" Coflex device caused a significant increase of ROM at both adjacent lumbar segments comparable to the increase of ROM after instrumentation with the rigid Click X device. Other in vitro studies observed comparable biomechanical effects on the adjacent segments after fusion, but biomechanical spacer studies concentrated on the "noncompressible" X-Stop® and could not demonstrate a significant adjacent segment effect of this device. CONCLUSIONS: The hypothesis, that an interspinous device would reduce the stress on adjacent segments compared to a rigid posterior stabilization device, could not be demonstrated with this biomechanical in vitro study. Therefore, the protection of adjacent segments after instrumentation with dynamic devices is still not completely achieved.

Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery.

The second, internet-based multicenter study (MCSII) of the Spine Study Group of the German Association of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie) is a representative patient collection of acute traumatic thoracolumbar (T1-L5) injuries. The MCSII results are an update of those obtained with the first multicenter study (MCSI) more than a decade ago. The aim of the study was to assess and bring into focus: the (1) epidemiologic data, (2) surgical and radiological outcome, and (3) 2-year follow-up (FU) results of these injuries. According to the Magerl/AO classification, there were 424 (57.8%) compression fractures (A type), 178 (24.3%) distractions injuries (B type), and 131 (17.9%) rotational injuries (C type). B and C type injuries carried a higher risk for neurological deficits, concomitant injuries, and multiple vertebral fractures. The level of injury was located at the thoracolumbar junction (T11-L2) in 67.0% of the case. 380 (51.8%) patients were operated on by posterior stabilization and instrumentation alone (POSTERIOR), 34 (4.6%) had an anterior procedure (ANTERIOR), and 319 (43.5%) patients were treated with combined posteroanterior surgery (COMBINED). 65% of patients with thoracic (T1-T10) and 57% with lumbar spinal (L3-L5) injuries were treated with a single posterior approach (POSTERIOR). 47% of the patients with thoracolumbar junction (T11-L2) injuries were either operated from posterior or with a combined posterior-anterior surgery (COMBINED) each. Short angular stable implant systems have replaced conventional non-angular stable instrumentation systems to a large extent. The posttraumatic deformity was restored best with COMBINED surgery. T-spine injuries were accompanied by a higher number and more severe neurologic deficits than TL junction or L-spine injuries. At the same time T-spine injuries showed less potential for neurologic recovery especially in paraplegic (Frankel/AISA A) patients. 5% of all patients required revision surgery for perioperative complications. Follow-up data of 558 (76.1%) patients were available and collected during a 30-month period from 1 January 2004 until 31 May 2006. On average, a posterior implant removal was carried out in a total of 382 COMBINED and POSTERIOR patients 12 months after the initial surgery. On average, the rehabilitation process required 3-4 weeks of inpatient treatment, followed by another 4 months of outpatient therapy and was significantly shorter when compared with MCSI in the mid-1990s. From the time of injury until FU, 80 (60.6%) of 132 patients with initial neurological deficits improved at least one grade on the Frankel/ASIA Scale; 8 (1.3%) patients deteriorated. A higher recovery rate was observed for incomplete neurological injuries (73%) than complete neurological injuries (44%). Different surgical approaches did not have a significant influence on the neurologic recovery until FU. Nevertheless, neurological deficits are the most important factors for the functional outcome and prognosis of TL spinal injuries. POSTERIOR patients had a better functional and subjective outcome at FU than COMBINED patients. However, the posttraumatic radiological deformity was best corrected in COMBINED patients and showed significantly less residual kyphotic deformity (biseg GDW -3.8° COMBINED vs. -6.1° POSTERIOR) at FU (p = 0.005). The sagittal spinal alignment was better maintained when using vertebral body replacement implants (cages) in comparison to iliac strut grafts. Additional anterior plate systems did not have a significant influence on the radiological FU results. In conclusion, comprehensive data of a large patient population with acute thoracolumbar spinal injuries has been obtained and analyzed with this prospective internet-based multicenter study. Thus, updated results and the clinical outcome of the current operative treatment strategies in participating German and Austrian trauma centers have been presented. Nevertheless, it was not possible to answer all remaining questions to contradictory findings of the subjective, clinical outcome and corresponding radiological findings between different surgical subgroups. Randomized-controlled long-term investigations seem mandatory and the next step in future clinical research of Spine Study Group of the German Trauma Society.

Volar and dorsal mid-shaft forearm plating using DCP and LC-DCP: interference with the interosseous membrane and forearm-kinematics.

PURPOSE: To clarify if dorsal plate osteosynthesis of the forearm shaft is associated with impingement of the interosseous membrane (IOM) and if rotational kinematics of the forearm are influenced. BACKGROUND: Forearm fractures are treated by separate incisions. Osteosynthesis via one approach in proximal forearm fractures was associated with higher rates of synostosis. It has been claimed that this is due to IOM impingement. MATERIALS AND METHODS: 16 forearms of fresh frozen cadavers were dissected until only radius, ulna and the IOM remained. To preserve physiological forearm rotation, the elbow joint, the distal radio-ulnar joint and the carpus remained intact. In group 1, LC-DC and DC plates were placed on the flexor aspect of the respective bone. In group 2, the plates were placed ulnodorsal and radiodorsal. The distance between the plates and their effect on the IOM were investigated in a newly designed forearm simulator and measured in 30 degrees, 60 degrees and 90 degrees of pronation and supination respectively. RESULTS: The IOM was affected in neither group. There was no interference of the kinematics in group 1. In group 2, plate contact appeared in one pair in both types of plate. The plates were significantly closer in all positions in group 2. There was no difference between the various plates in the two groups. CONCLUSION: Dorsal plate osteosynthesis of the forearm shaft is not associated with an impingement of the IOM. Malpositioning of the plates is more likely to be of more effect in dorsal plate positioning and leads to interference with the kinematics.

[Operative treatment of traumatic fractures of the thorax and lumbar spine. Part II: surgical treatment and radiological findings]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule. Teil II: Operation und röntgenologische Befunde.

The Spine Study Group (AG WS) of the German Trauma Association (DGU) presents its second prospective Internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries. This second part of the study report focuses on the surgical treatment, course of treatment, and radiological findings in a study population of 865 patients. A total of 158 (18,3%) thoracic, 595 (68,8%) thoracolumbar, and 112 (12,9%) lumbar spine injuries were treated. Of these, 733 patients received operative treatment (OP group). Fifty-two patients were treated non-operatively and 69 patients were treated with kyphoplasty/vertebroplasty without additional instrumentation (Plasty group). In the OP group, 380 (51.8%) patients were instrumented from a posterior (dorsal) position, 34 (4.6%) from an anterior (ventral) position, and 319 (43.5%) cases with a combined posteroanterior procedure. Angular stable internal spine fixator systems were used in 86-97% of the cases for posterior and/or combined posteroanterior procedures. For anterior procedures, angular stable plate systems were used in a majority of cases (51.1%) for the instrumentation of mainly one or two segment lesions (72.7%). In 188 cases (53,3%), vertebral body replacement implants (cages) were used and were mainly implanted via endoscopic approaches (67,4%) to the thoracic spine and/or the thoracolumbar junction. The average operating time was 152 min in posterior-, 208 min in anterior-, and 298 min in combined postero-anterior procedures (p<0,001). The average blood loss was highest in combined operations, measuring 959 ml vs. 650 ml in posterior vs. 534 ml in anterior operations (p<0,001).Computer-assisted intraoperative navigation systems were used in 95 cases. At the time of hospital admission, 58,7% of the patients had spinal canal narrowing of an average of 36% (5-95%) at the level of their injury. The average spinal canal narrowing in patients with a complete spinal cord injury (Frankel/ASIA A) was calculated to be 70%, vs. 50% in patients with incomplete neurologic deficits (Frankel/ASIA B-D), and 20% in patients without neurologic deficits (Frankel/ASIS E; p<0,001). The average procedure in the plasty treatment subgroup was 50 min (18-145 min) to address one (n=59) or two (n=10) injured vertebral bodies. In patients with nonoperative treatment mainly three-point-corsets (n=36) were administered for a duration of 6-12 weeks. During their hospital stay 93 of 195 (44,7%) patients with initial neurologic deficits improved at least one Frankel/ASIA grade until the day of discharge. Two patients (0,2%) showed a neurologic deterioration. The highest rate of complete spinal cord injury (n=36, 23%) was associated with thoracic spine injuries. Nine (1%) patients died during the initial course of treatment. A total of 105 (14,3%) cases with intraoperative (n=56) and/or postoperative complications (n=69) were registered. The most common intraoperative complication was bleeding (n=35, 4,8%). A higher relative frequency of intraoperative complications was noticed in combined (n=34, 10,7%) vs. isolated posterior (n=22, 5,9%; p=0,021) procedures. The most common postoperative complication was associated with wound healing problems in 14 (1,9%) patients. Except in the non-operative treatment subgroup, a correction of the posttraumatic measured radiological deformity was achieved to a different extent within every treatment subgroup. There were no statistically significant differences between the postoperative radiological results of the treatment subgroups (dorsal vs. combination), taking into consideration the influence of relevant parameters such as different fracture types, patient age, and the amount of posttraumatic deformity (p=0,34, ANOVA).

[Operative treatment of traumatic fractures of the thoracic and lumbar spinal column. Part I: epidemiology]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule: Teil I: Epidemiologie.

The Spine Study Group (AG WS) of the German Trauma Association (DGU) has now been in existence for more than a decade. Its main objective is the evaluation and optimization of the operative treatment for traumatic spinal injuries. The authors present the results of the second prospective internet-based multicenter study (MCS II) of the AG WS in three consecutive parts: epidemiology, surgical treatment and radiologic findings and follow-up results. The aim of the study was to update and review the state-of-the art for treatment of spinal fractures for thoracic and lumbar spine (T1-L5) injuries in German-speaking countries: which lesions will be treated with which procedure and what differences can be found in the course of treatment and the clinical and radiological outcome? This present first part of the study outlines the new study design and concept of an internet-based data collection system. The epidemiologic findings and characteristics of the three major treatment subgroups of the study collective will be presented: operative treatment (OP), non-operative treatment (KONS), and patients receiving a kyphoplasty and/or vertebroplasty without additional instrumentation (PLASTIE). A total of 865 patients (OP n=733, KONS n=52, PLASTIE n=69, other n=7) from 8 German and Austrian trauma centers were included. The main causes of accidents in the OP subgroup were motor vehicle accidents 27.1% and trivial falls 15.8% (KONS 55.8%, PLASTIE 66.7%). The Magerl/AO classification scheme was used and 548 (63.3%) compression fractures (type A), 181 (20.9%) distraction injuries (type B), and 136 (15.7%) rotational injuries (type C) were diagnosed. Of the fractures 68.8% were located at the thoracolumbar junction (T11-L2). Type B and type C injuries carried a higher risk for concomitant injuries, neurological deficits and additional vertebral fractures. The average initial VAS spine score, representing the status before the trauma, varied between treatment subgroups (OP 80, KONS 75, PLASTIE 72) and declined with increasing patient age (p<0.01).

[Operative treatment of traumatic fractures of the thoracic and lumbar spinal column: Part III: Follow up data]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule: Teil III: Nachuntersuchung.

In this third and final part, the Spine Study Group (AG WS) of the German Trauma Association (DGU) presents the follow-up (NU) data of its second, prospective, internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries including 865 patients from 8 trauma centers. Part I described in detail the epidemiologic data of the patient collective and the subgroups, whereas part II analyzed the different methods of treatment and radiologic findings. The study period covered the years 2002 to 2006 including a 30-month follow-up period from 01.01.2004 until 31.05.2006. Follow-up data of 638 (74%) patients were collected with a new internet-based database system and analyzed. Results in part III will be presented on the basis of the same characteristic treatment subgroups (OP, KONS, PLASTIE) and surgical treatment subgroups (Dorsal, Ventral, Kombi) in consideration of the level of injury (thoracic spine, thoracolumbar junction, lumbar spine). After the initial treatment and discharge from hospital, the average duration of subsequent inpatient rehabilitation was 4 weeks, which lasted significantly longer in patients with persistent neurologic deficits (mean 10.9 weeks) or polytraumatized patients (mean 8.6 weeks). Following rehabilitation on an inpatient basis, subsequent outpatient rehabilitation lasted on average 4 months. Physical therapy was administered significantly longer to patients with neurologic deficits (mean 8.7 months) or type C injuries (mean 8.6 months). The level of injury had no influence of the duration of the inpatient or outpatient rehabilitation. A total of 382 (72.2%) patients who were either operated from posterior approach only or in a combined postero-anterior approach had an implant removal after an average 12 months. During the follow-up period 56 (8.8%) patients with complications were registered and of these 18 (2.8%) had to have surgical revision. The most common complications reported were infection, loss of correction, or implant-associated complications. Clinical data showed a 2.9 higher relative risk for smokers compared to non-smokers to suffer from wound healing problems. The neurologic status of 81 (60.4%) out of 134 patients with neurologic deficits at the time of injury improved until follow-up. Neurologic deterioration was documented in 8 (1.3%) cases. Complete neurologic deficits after injury to the thoracic spine improved in 9% of the cases, whereas 59% of the cases with complete neurologic deficit improved after injury to the thoracolumbar junction. The surgical approach (posterior or combined postero-anterior) had no significant influence on neurological results at follow-up. Patient age, sex and neurologic deficits showed a statistically significant influence (p<0.05) on the fingertip-floor distance (FBA) at follow-up. Patient back function improved during the follow-up period. More than 2 years after the time of injury 32.2% of the patients had no complaints with respect to back function. The relative frequency of patients with unrestrained back function was greater after posterior surgery (24.2%), than anterior surgery (13.8%), or combined surgery (17.3%) (p=0.005; chi(2)-test). At follow-up there were no statistically significant differences of unrestrained back function between different levels of injury (thoracic spine 17.4%, TL junction 22.5% and lumbar spine 13.6%). The relative frequency of patients with injury to the thoracolumbar junction who reported "no complaints from the anterior approach" at follow-up, was calculated to be 55.6% after open versus 63.8% after endoscopic approaches with no significant differences. Of the patients 56.3% reported no donor site morbidity following iliac crest bone harvesting. The VAS spine score at follow-up was calculated within different treatment subgroups: OP 58.4 points, KONS 59.8 points, and PLASTIE 59.7 points. Statistically significant differences of the VAS spine score between posterior (64.9 points) versus combined surgery (47.8 points) were only verified at the level of injury of the thoracic spine (p=0.004). The relative frequency of patients regaining at least 80% of the initial score level was OP (posterior 60.4%, anterior 61.1%, combined 51.4%), 52.9% KONS and 67.6% PLASTIE. After surgery the mean period of incapacity from work was 4 months. Patients with a sedentary occupation before the time of injury were fully reintegrated into work in 71.1% of the cases. Patients with a physical occupation were fully reintegrated in 38.9% of the cases at follow-up. At follow-up 87 (31.2%) patients after posterior and 50 (20.1%) after combined surgery had no restrictions to their recreational activities (p=0.001). Treatment subgroups PLASTIE and KONS show a similar radiological result at follow-up with a bisegmental kyphotic deformity (GDW) of -9 degrees and -8.5 degrees, respectively. With all operative methods it was possible to correct or partly correct the posttraumatic kyphotic deformity. Until follow-up there was a loss of correction depending on the surgical approach and level of injury. Combined postero-anterior stabilization gave statistically significant better radiological results with less kyphotic deformity (-3.8 degrees) than posterior stabilization alone (-6.1 degrees) (p=0.005; ANOVA). Thus combined surgery was superior in its capability to restore spinal alignment within the observational period. At follow-up the use of titanium vertebral body replacement implants (cages) to reconstruct and support the anterior column showed significantly better radiological results with less kyphotic deformity and loss of correction (GDW 0.3 degrees) than the use of iliac bone strut grafts (-3.7 degrees ) (p<0.001). Neither additional anterior plates nor the combination of anterior plates with a cage or bone graft had a statistically significant influence on the kyphotic deformity measured at follow-up. A matched-pair analysis of anterior surgery alone versus combined surgery for the treatment of compression fractures (type A) at the thoracolumbar junction showed a significantly greater intraoperative blood loss but better radiological results in terms of monosegmental and bisegmental kyphotic deformity after combined surgery (p<0.05). A matched-pair analysis of treatment results between non-operative and operative treatment for burst fractures (type A3.1-2) showed a period of inability to work (6 months) which was twice as long for the non-operative treatment group. At the same time significantly better radiological results at follow-up were achieved after operative treatment of these fractures (p<0.05).

In vivo ultrasound real-time motion of the cervical spine during intubation under manual in-line stabilization: a comparison of intubation methods.

BACKGROUND AND OBJECTIVE: In emergency trauma situations, manual in-line stabilization of the cervical spine is recommended to reduce cervical spine movement during intubation. The aim of this study was to compare the effect of manual in-line stabilization during different intubation techniques on three-dimensional cervical spine movements and times to intubation. METHODS: Forty-eight subjects without any history of trauma, inflammatory or degenerative disorder of the cervical spine were randomly grouped, regardless of gender or age. All underwent elective surgery under general anaesthesia. Under manual in-line stabilization, laryngeal intubation with Macintosh laryngoscope, intubating laryngeal mask airway, fibre-endoscopic oral intubation and fibre-endoscopic nasal intubation was performed. During the intubation process, cervical three-dimensional motion was detected by an ultrasound real-time motion analysis system and intubation times were measured. RESULTS: Cervical spine range in the extension/flexion direction of orolaryngeal intubation with Macintosh (17.57 +/- 8.23 degrees ) showed significantly more movement than using the intubating laryngeal mask airway (4.60 +/- 1.51 degrees ) and fibreoptic procedures. Intubating laryngeal mask airway was significantly different than the fibreoptic intubation techniques. There was also a significant difference between oral (3.61 +/- 2.25 degrees ) nasal and (5.88 +/- 3.11 degrees ) fibreoptic intubation. Times to intubation all differed significantly (P < 0.05) for the Macintosh laryngoscope (27.25 +/- 8.56 s) and for the intubating laryngeal mask airway (16.5 +/- 9.76 s). Fibreendoscopic laryngoscopic oral (52.91 +/- 56.27 s) and nasal (82.32 +/- 54.06 s) intubation resulted in further prolongation of the times to intubation. CONCLUSIONS: The intubating laryngeal mask airway with manual in-line stabilization is a potentially useful adjunct to intubation of patients with potential cervical spine injury, if there are no contraindications to these methods. These results predict that fibreoptic procedures may be a safe instrument for airway management in patients with potential cervical spine injuries; however, the main disadvantages are the longer intubation times.

Elastic intramedullary nailing of midclavicular fractures.

The majority of midclavicular fractures are treated conservatively. Fractures that require internal fixation are treated by plate osteosynthesis as the standard procedure. Elastic stable intramedullary nailing is an increasingly popular alternative for the internal fixation of displaced midclavicular fractures. In a three-year period, 15 fractures of the clavicle were treated by elastic intramedullary nailing. Fracture healing, clinical outcome and complications were assessed. Mean follow-up time was one year All fractures healed clinically and radiologically. Non-union or infections were not observed. Functional results according to the Constant score were excellent. Complications consisted of skin irritation in four cases. One acromioclavicular joint separation was observed postoperatively. Elastic stable intramedullary nailing of displaced midclavicular fractures is a minimally invasive technique with excellent functional results and early pain relief.

[Operative strategies in the treatment of upper limb fractures in polytraumatized patients]. / Operative Versorgungsstrategien von Frakturen an der oberen Extremität beim Polytrauma.

BACKGROUND: Optimal timing of operative treatment of upper extremity long bone fractures in polytraumatized patients depends on the type and location of the fractures, as well as on the cardiorespiratory stability of the patient, and should be early in diaphyseal fractures in order to optimize intensive care treatment. The timing of surgery in cases of upper limb fractures is secondary to life-saving therapies. The same applies to stabilization of fractures of the lower limbs, including fractures of the femur and tibial shaft. METHODS: The recommended operative procedure for adult polytraumatized patients with closed or open humeral shaft fractures of grade I or II is intramedullary nailing or plating. For closed or open lower arm fractures of grade I or II, plating is the best procedure, or alternatively nailing. For upper extremity epi- or metaphyseal fractures plating is preferred. Specific fracture situations require specific operative treatments, for example traction band for olecranon fractures, external fixation for distal radial multi-fragmentary fractures. The external fixator may be the optimal approach in grade III open fractures of the upper extremity long bones. The main difference in paediatric fractures is not the timing of the procedure, but the selection of the technique, which has to respect the epiphyseal growth plates. RESULTS: Additional vessel injuries require quick diagnosis and early vessel reconstruction in the presence of cardiopulmonary stability. Open fractures should have a higher therapeutic priority if they are associated with vessel/nerve lesions. The strategy in additional nerve injuries depends on the type of lesion. Nerve decompression should take place together with fracture stabilization; necessary nerve reconstruction should be performed secondarily. The primary phase should be limited to fracture fixation. If the fracture is combined with a compartment syndrome, decompression by fasciotomy together with fracture fixation ensuring cardiopulmonary stability has be performed. CONCLUSION: Amputations at the upper extremity in polytraumatized patients are only occasionally indicated in very severe injuries. In injuries involving total amputation, depending on the condition of the limb, immediate reattachment should be attempted if the cardiorespiratory situation of the patient is stable.

Three-dimensional cervical spine movement during intubation using the Macintosh and Bullard laryngoscopes, the bonfils fibrescope and the intubating laryngeal mask airway.

BACKGROUND AND OBJECTIVE: Cervical spine movement may be limited for morphological reasons or through injury. The major goal of the present study was to evaluate the three-dimensional cervical spine movement during intubation with a Macintosh or Bullard laryngoscope, a Bonfils fibrescope or an intubating laryngeal mask using an ultrasound-based motion system. METHODS: Forty-eight patients without any history of cervical spine problems who had to undergo elective surgery in general anaesthesia were intubated using a Macintosh or Bullard laryngoscope, a Bonfils fibrescope or an intubating laryngeal mask airway. During intubation, cervical motion as well as overall time to intubation, number of attempts, and postoperative complaints were noted. RESULTS: The range of cervical spine motion during intubation, especially concerning extension, using the Macintosh laryngoscope was much greater (22.5 degrees +/- 9.9 degrees) than using Bullard (3.4 degrees +/- 1.4 degrees), Bonfils (5.5 degrees +/- 5.0 degrees) or intubating laryngeal mask (4.9 degrees +/- 2.1 degrees). Time to intubate the trachea using Bonfils (52.1 +/- 22.0 s) and intubating laryngeal mask (49.8 +/- 18.7 s) were much longer than with Macintosh (18.9 + 7.1s) and Bullard laryngoscope (16.1 + 6.2 s) (significance level: 0.05). CONCLUSIONS: Our findings suggest that the Bullard laryngoscope may be a useful adjunct to intubate patients with cervical spine injuries. In elective situations when time to intubation is not critical Bonfils as well as intubating laryngeal mask airway should also be considered as serious alternatives to direct laryngoscopy.

[Traumatological reflection on the narrow spinal canal. Review and our own concept]. / Der enge Spinalkanal aus traumatologischer Sicht. Ubersicht und eigenes Konzept.

Even today, injuries of the spinal column still pose a large challenge for the treating trauma surgeons. In the last century due to more differentiated diagnostics, the concept of predominantly conservative treatment changed to interventional procedures especially in the so-called unstable injuries. Discrepancies still exist in the evaluation of stability. In the last few years, dorsal, ventral, or combined interventional procedures have become established. The narrow spinal canal and neurological deficits represent important factors. Based on the literature, the different procedures and evaluations are discussed and finally we introduce our own concept.

[Mortality, morbidity and functional outcome after open book and lateral compression lesions of the pelvic ring. A retrospective analysis of 100 type B pelvic ring lesions according to Tile's classification]. / Mortalität, Morbidität und funktionelles Endergebnis nach "Open-book-Verletzungen" und lateralen Kompressionsverletzungen des Beckenringes. Eine retrospektive Analyse von 100 Beckenringverletzungen des Typ B nach Tile.

A retrospective study was made of 100 Tile type B and 122 type C pelvic ring lesions. Type B1-open book lesions occurred in 52 patients while 48 had lateral compression lesions of type B2 or B3. Only 13.1% of the patients showed no associated lesions. The frequency of associated neurological lesions in the B1 group with 21% was higher than in the B2/B3 group with 12%. The frequency of urologic lesions in group B1 was 9.6% but in B2/B3 patients it was only 2.1%. A total of 66% of B-lesion patients were stabilized with an external fixator. The frequency of secondary operative procedures was 23% in B1-patients and 6.25% in the B2/B3 group. Overall mortality was 10.4%: 5% in the B-group and 14.8% in the C-group. Outcome for patients with B2/B3 lesions was, with 92% excellent and good end results,much better than in patients with B1 lesions (74%). The inverse was true for radiologic results: 93% of the B1- but only 75% of the B2/B3-patients had an anatomical reduction. Open book lesions, lateral compression lesions and combined vertical stable lesions should be differentiated. We suggest that lateral compression lesions be characterized as B1 and open book lesions as B2 type injuries in the classification system of AO.