[Arthroscopically Assisted Minimally Invasive Fixation of a Type D2c Scapular Fracture]. / Arthroskopisch gestützte minimalinvasive Schraubenosteosynthese einer Skapulafraktur Typ D2c nach Euler/Rüdi.

Fractures of the scapula are rare and have an incidence of 1% of all fractures. Publications highlight glenoid rim fractures. Classification by Ideberg and Euler and Rüdi are accepted. Euler and Rüdi describe three extra-articular and two intra-articular fracture patterns. The indications for surgery are displaced glenoid fractures, scapula tilt of more than 40° and injuries to the superior shoulder suspensory complex. We describe a case of a 22 year old man, who while cycling collided with a moving car due to wet roads. After his admission to hospital as a polytraumatised patient, the trauma CT-Scan showed haemothorax with several associated rip fractures, displaced humeral shaft fracture and fractures of the acromion and glenoid, classified as type D2c according to Euler and Rüdi. Following damage control principles, drainage of the haemothorax was already performed in the ER and surgical treatment of the displaced humeral shaft fracture was performed on the day of admission. No peripheral neurological deficits were evident. After pulmonary stabilisation, surgery was performed 6 days later on the glenoid and acromion fracture, which in conjunction may be regarded as an injury to the superior shoulder suspensory complex. We performed an arthroscopically-assisted screw fixation of the glenoid fracture (type D2c according to Euler and Rüdi) and an ORIF procedure at the acromion. Postoperative rehabilitation was performed with passive abduction and elevation up to 90° for the first two weeks and active abduction an elevation up to 90° for weeks 3 to 6. Full ROM was allowed at week 7. CONCLUSION: Articular fractures of the glenoid are rare and mainly seen as rim fractures. The indications for surgery are displaced articular fractures and injury to the superior shoulder suspensory complex. As demonstrated by this article, type D2c fractures according to Euler and Rüdi can be treated effectively as an arthroscopically-assisted screw fixation procedure.

Treatment strategies for intramedullary nailing of femoral shaft fractures.

Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).

Possibilities and limits of Internet-based registers.

The Internet is an inexpensive platform for the investigation of medical questions in case of low prevalence. By accessing www.ao-nailregister.org, every interested participant may participate in the English-language survey of the complications specific to the femoral nail. The address data of the participant, the anonymised key data of the patients and the medical parameters are entered. In real time, these data are checked for plausibility, evaluated and published on the Internet where they are freely accessible immediately. Because of national differences, data acquisition caused considerable difficulties at the beginning. In addition, wrong data were entered because of linguistic or contextual misunderstandings. After having reworked the questionnaire completely, facilitating data input and implementing an automated plausibility check, these difficulties could be cleared. In a next step, the automatic evaluation of the data was implemented. Only very few data still have to be checked for plausibility manually to exclude wrong entries, which cannot be verified by the computer. The effort required for data acquisition and evaluation of the Internet-based femoral nail register was reduced distinctly. The possibility of free international participation as well as the freely accessible representation of the results offers transparency.

Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients.

INTRODUCTION: It is well known that during posterior stabilization of the spinal column conventionally open methods are predominantly used. However, in this study a minimally invasive method was chosen to decrease the morbidity of the operative access and to protect the paravertebral musculature, which serves as an important spine-stabilizing factor during posterior stabilization. The aims of this retrospective non-randomized case-control study were to compare the clinical and radiological results of minimally invasive on the one hand and conventionally open posterior surgery on the other with each other and to measure the loss of correction after purely posterior stabilization. METHODS: Twenty-one consecutive non-randomized patients with thoracolumbar vertebral body fractures, which had been stabilized posteriorly without any intervertebral body fusion between 1996 and 1997, and without any neurological symptoms, were examined retrospectively more than 5 years after trauma. Eleven patients had been treated conventionally open and 10 patients minimally invasive. As methods of evaluation, the intra- and postoperative amount of blood loss, the X-ray time, the Hannover-Spine-Score, the SF-36 Health Questionnaire and radiological assessment of the bisegmental wedge and vertebral body angle were made use of. RESULTS: The blood loss was significantly lower among those patients who had been operated in a minimally invasive way. The operating time, the time of X-ray exposure and the loss of correction were identical in both groups. The first year after implant removal, the loss of correction was the highest with 2.1 degrees for the body angle and 6.86 degrees for the bisegmental wedge angle. Neither in the Hannover-Spine-Score nor in the SF-36 Health Questionnaire did both groups show a difference. A correlation between the loss of correction and the clinical results could not be demonstrated. CONCLUSION: The minimally invasive posterior stabilization leads to lower blood loss in comparison to the conventionally open method and can be carried out without any special effort limited to A-fractures without any neurological symptoms.