[Proximal humerus fractures. Decisive factors for therapy choice, treatment and complications]. / Proximale Humerusfrakturen. Entscheidende Faktoren zur Therapiefindung, Behandlung und Komplikationen.

The majority of proximal humerus fractures are treated conservatively resulting in satisfying results. Fractures which need to be treated operatively are challenging for the therapist, postoperative treatment and the patient. It is inadequate to establish a therapy concept only by using radiological images and the resulting classification. Factors which take the patient, the injury and the surgeon into consideration have to be included in the decision-making process. Operative reconstruction results in a high rate of complications. This could be the reason why even complex fractures are treated conservatively by some therapists, especially in older patients. Locking plates are used increasingly. Specific complications, such as primary or secondary screw perforation result in a high rate of revision surgery.

[Reverse shoulder arthroplasty for primary fracture treatment. Displaced three and four part fractures of the proximal humerus in the elderly patient]. / Die primäre inverse Frakturprothese. Behandlung dislozierter 3- und 4-Fragment-Frakturen des proximalen Humerus beim älteren Patienten.

The treatment of comminuted three and four part fractures of the proximal humerus in elderly patients with degenerative rotator cuff tears is challenging. Primary reverse total shoulder arthroplasty (RSA) is an alternative; however, functional outcome is still unclear due to a lack of study results. The aim of this study was to examine the functional results of RSA and to compare them with the results after reconstruction and locking plate osteosynthesis 1 year after surgery.In this study 24 patients (mean age: 77.9±9.1 years) underwent RSA as primary treatment for three and four part fractures of the proximal humerus with either head split or rotator cuff tears >Bateman type II. The results obtained at 3, 6 and 12 months follow-up included shoulder range of motion (ROM), Constant score, age-adjusted and gender-adjusted Constant score and as a percentage when compared to the uninjured side. Data were compared to patients of matching age, gender and fracture pattern from a prospectively collected database of 526 patients treated by locking plate osteosynthesis.The mean shoulder ROM 1 year after surgery was 105±29° flexion, 99±31° abduction, 22±23° external rotation and 65±26° internal rotation. In 6 patients flexion-abduction was >130°. The mean Constant score (CS) 1 year postoperatively was 62.4±14, age and gender normalized CS was 79.2±20.5, CS compared to the uninjured side was 76.1% and there were no significant differences to matched individuals treated by open reduction and internal fixation using locking plates (p=0.360). There were no infections, dislocations, vascular or neural disorders and surgical revision was not necessary in any patient. RSA should be considered as an appropriate alternative for the primary treatment of comminuted three and four part fractures of the proximal humerus with head split or large rotator cuff tears in elderly patients. Although RSA can provide immediate shoulder stability for elderly patients with severe shoulder injuries, primary RSA needs investigation with regards to long-term outcome.

Footprint reconstruction in a rotator cuff tear associated cyst of the greater tuberosity: augmented anchorage.

Tears of the rotator cuff (RC) complicated by bone cysts at the footprint might represent a challenge for the shoulder surgeon. This might be additionally aggravated in elderly patients with inferior bone quality due to osteopenia or osteoporosis. In this report we present a technique for open repair of RC tears by augmenting the cystic lesion at the greater tuberosity using bone void filler in combination with a double row anchor reconstruction technique. Despite disadvantageous position and size of the cyst, using this technique the footprint can be restored by obtaining an anatomical position of the supraspinatus tendon. The application range of this technique is not limited to defined bony defects and presents a promising novel surgical approach. Level of evidence V.

Tension band wiring of the olecranon: is it really a dynamic principle of osteosynthesis?

The tension band principle as applied to transverse olecranon fractures fixed by tension band wiring is based on the premise that distraction forces on the outer cortex of the ulna during elbow flexion are converted to compression forces on the articular surface of the olecranon at the fracture site. In view of some clinical outcomes, where hardware failure and secondary dislocations occur, the question arises if the dynamic compression theory is correct. Compressive forces during active flexion and extension after tension band wiring of a transverse osteotomy of the olecranon were measured in 6 fresh frozen human cadaveric models using a pressure-sensor in the osteotomy gap. We could collect 30 measurements during active flexion and 30 during active extension. Active flexion did not cause any compressive forces in the osteotomy gap. Extension with the humerus in an upright position and the elbow actively extended causes some compression (0.37-0.51 MPa) at the articular surface comparing with active flexion (0.2 MPa) due to gravity forces. Posterior, there was no significant pressure difference observed (0.41-0.45 versus 0.36-0.32 MPa) between active flexion and extension. The tension band wiring principle only exists during active extension in a range of 30-120° of flexion of the elbow. Postoperative exercise programs should be modified in order to prevent loss of compression at the fracture site of transverse olecranon fractures, treated with tension band wiring when the elbow is mobilised.

Attachment sites of the coracoclavicular ligaments are characterized by fibrocartilage differentiation: a study on human cadaveric tissue.

We analyzed the immunohistochemical labeling patterns of the extracellular matrix of the coracoclavicular ligaments (CCL) in order to relate the molecular composition of the attachment sites to their mechanical environment. Ligaments were exposed from 12 fresh-frozen human cadaveric samples (four males, mean age: 48.6 ± 12.1 years). Cryosection of methanol-fixed and decalcified tissue was cut and sections were labeled with a panel of monoclonal antibodies directed against collagens, proteoglycans and proteins of vascular components. Attachment sites of both ligaments showed characteristic fibrocartilaginous labeling of collagen type II, aggrecan and link protein in all samples. Labeling for type II collagen was most conspicuous at the insertion of the coracoid process. Morphometry of adjacent samples revealed a fibrocartilage zone of 10-15% in relationship with the ligament proper, where labeling for type II collagen, aggrecan and link protein was negative. The presence of fibrocartilage at both entheses of the trapezoid and conoid ligament suggests that the CCL complex is subject to shear/compression forces. A variable fibrocartilage differentiation at the entheses of both ligaments may be related to the marked change in loading and insertion angle that the ligaments undergo during shoulder movement.

[Comparison of regional distribution of cancellous bone in osteoporotic and non-osteoporotic distal radii]. / Vergleich der lokalen Spongiosadichte osteoporotischer und nichtosteoporotischer distaler Radii.

BACKGROUND: In cases of distal radius fractures information about the regional distribution of cancellous bone is essential for adequate fixation of osteosynthesis material. MATERIALS AND METHODS: Using quantitative computed tomography (qCT) measurements 12 distal radii were divided into 2 groups (good and bad bone quality). High-resolution CT scans were obtained at 13 locations (1-40 mm distant from radial styloid processes). The resulting cross-sections were divided into 4 quadrants and the cancellous bone density was assessed in each of them. RESULTS: In both groups regional cancellous bone density was highest immediately beneath the joint surface and decreased towards the metaphyseal region. Comparing the radial with the ulnar quadrants significant differences were found between distances of 4 mm and 12 mm from the joint surface in both groups. The comparison of the palmar and the dorsal quadrants resulted in an almost identical cancellous bone distribution. CONCLUSION: In osteoporotic distal radii cancellous bone density decrease occurs homogeneously in all regions and is least pronounced beneath the joint surface. Comparing the regional cancellous bone density (radial versus ulnar and palmar versus dorsal) significant differences were mainly found near the joint surface in both groups.

Use of the fulcrum axis improves the accuracy of true anteroposterior radiographs of the shoulder.

In 100 patients the fulcrum axis which is the line connecting the anterior tip of the coracoid and the posterolateral angle of the acromion, was used to position true anteroposterior radiographs of the shoulder. This method was then compared with the conventional radiological technique in a further 100 patients. Three orthopaedic surgeons counted the number of images without overlap between the humeral head and glenoid and calculated the amount of the glenoid surface visible in each radiograph. The analysis was repeated for intraobserver reliability. The learning curves of both techniques were studied. The amount of free visible glenoid space was significantly higher using the fulcrum-axis method (64 vs 31) and the comparable glenoid size increased significantly (8.56 vs 6.47). Thus the accuracy of the anteroposterior radiographs of the shoulder is impaired by using this technique. The intra and interobserver reliability showed a high consistency. No learning curve was observed for either technique.

[Acromioclavicular (AC) joint cyst. A case report and review of literature]. / Die Akromioklavikulargelenkzyste. Eine Kasuistik und Zusammenfassung der Literatur.

The acromioclavicular (AC) joint cyst is a rare sequela of complete supraspinatus tendon rupture and arthritis of the AC joint. It appears as a swelling on the AC joint and must be distinguished from tumours of the shoulder and neck region. Besides physical examination, magnetic resonance imaging is the most useful tool for correct diagnosis. As reported in the literature, therapeutic procedures include observation, aspiration, excision of the cyst with or without resection of the AC joint, and repair of the underlying supraspinatus tendon rupture. All procedures should be based on consideration of the comorbidity and recurrence of the cyst. Combinations of cyst excision and rotator cuff repair or AC resection seem to be the most promising therapeutic options. We report on a 75-year-old patient with a painless swelling over the AC joint who had suffered shoulder trauma 15 years previously.

Stage-dependant management of septic arthritis of the shoulder in adults.

Diagnostic and therapeutic standards relating to septic conditions of the shoulder are rarely documented in the literature. For this study, patients suffering from septic shoulder arthritis were prospectively enrolled. Staging was based on the criteria of Gächter (Stutz et al., Knee Surg Sports Traumatol Arthrosc 8:270-274, 2000), and assessment of functional outcome was based on a self-assessed Constant score (Boehm et al., Unfallchirurg 107:397-402, 2004). Patients were separated into three groups according to the CEBI-classification reported by Pfeiffenberger and Meiss (Arch Orthop Trauma Surg 115:325-331, 1996). Forty-three patients were enrolled. Group I contained 21% of patients, while 23% were assigned to group II, and 56% to group III. Staphylococcus aureus was found in 71%. Eight patients were treated arthroscopically, and 35 received open surgery. None of the implants could be preserved. The mean self-assessed Constant score after 26 +/- 7 months was 74 +/- 9 points in group I, 63 +/- 14 points in group II, and 53 +/- 14 points in group III. Diagnostic work-up consisted of laboratory analysis including CRP and joint aspiration. Arthroscopic procedures can be effective when implemented early. With regard to implants and chronic symptoms, primary removal should be critically reconsidered.

Cerebrospinal s100-B: a potential marker for progressive intracranial hemorrhage in patients with severe traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is associated with cerebrovascular dysfunction and changes of the blood-brain barrier (BBB) function. Although knowledge about the function of the BBB would be of high interest, non-invasive neurodiagnostic tools are still lacking. In this context it has been shown, that the astrocytic protein S100-B is a significant parameter for neuronal damage. However, there is only poor knowledge about the dynamics of S100-B in cerebrospinal fluid (CSF) and serum of patients with severe TBI. Therefore, the aim of this study was to analyze intrathecal and systemic concentrations of S100-B in patients with severe TBI in correlation to the development of progressive intracranial hemorrhage (PIH) as well as to the CSF/serum albumin ratio (Q subsetalb), as functional parameter of the BBB. PATIENTS AND METHODS: In patients, suffering from severe TBI (GCS =or<8pts) and respectively healthy control patients, albumin for calculating the CSF/serum albumin ratio (Q subsetalb) as well as S100-B protein were analyzed in CSF and serum. Samples were collected immediately after placement of a ventricular catheter and 12h, 24h, 48 h and 72 h after TBI. S100-B was quantified using Elecsys S-100 superset assay (Roche superset Diagnostics; Mannheim, Germany). Volume measurements of focal mass lesions based on CT images taken during the first 72 h after TBI were obtained according to the Cavalieri's Direct Estimator method. RESULTS: 21 TBI-patients and respectively 10 healthy controls were enrolled. In patients exhibiting a mean ICP >15 mmHg (n = 15) CSF levels of S100-B were significantly increased on admission (819 +/- 78 pg/ml) compared to patients with ICP =or<15 mmHg (n = 6, 175 +/- 12 pg/ml) as well as to the control group (n = 10, 0.8 +/- 0.09 pg/ml). In the group with ICP >15 mmHg 8 patients developed PIH A positive correlation was found between CSF S100-B and ICP (r2 = 0.925, p<0.001). Furthermore a positive correlation between serum S100-B and Q subsetalb was found for each sampling point (r superset2 = 0.793, p<0.001). CONCLUSIONS: The cerebrospinal and serum concentration of S100-B in patients with severe TBI was evaluated. Monitoring cerebrospinal S100-B might help to prospectively identify patients with PIH.

Cerebrospinal IL-10 concentration is elevated in non-survivors as compared to survivors after severe traumatic brain injury.

OBJECTIVE: The intrathecal posttraumatic inflammation contributes to secondary brain damage as well as to the induction of neuroreparative mechanisms. In this context release of interleukin-10 (IL-10) has been reported to play a major role. However, initial IL-10 concentration in CSF remains incompletely characterized. Therefore, the aim was to analyze Il-10 in CSF and serum of patients early after TBI. METHODS: For control, 10 volunteers receiving spinal puncture were enrolled. In patients with severe TBI (GCS<8 pts.), CSF and serum was drawn within 90+/-45 min after intraventricular catheter insertion (0 h), as well as 12 h, 24 h and 48 h after TBI. Albumin for assessing Blood-Brain-Barrier (BBB) function and IL-10 (IMMULITE, DPC Biermann, Bad Nauheim, Germany) were analyzed. RESULTS: 23 patients were enrolled. 15 survived and 8 deceased within 24h. In controls, CSF IL-10 was below detection limit (<5 pg/ml). In contrast, IL-10 was elevated significantly in non-survivors at 0 h vs. survivors and controls (30+/-6 vs. 9+/-1 vs. <5 pg/mL). This was accompanied by a significant increase of serum IL-10 in both groups at 0 h vs. controls (survivors: 30+/-6 pg/mL, non-survivors: 48+/-8 pg/mL, controls: 10+/-7 pg/mL, p<0.001). Survivors revealed signs of a mild BBB dysfunction during the entire observation period. In contrast, non-survivors presented a severe BBB breakage. CONCLUSIONS: We demonstrated an analysis of IL-10 CSF and serum concentration after TBI. These data support an intrathecal IL-10 synthesis. Although the significant increase of IL-10 might indicate a bad outcome of TBI, responsible mechanisms still have to be elucidated.

[Bilateral clavicular fractures occurring at different times. Conservative vs operative therapy using intramedullary nailing--a case report]. / Zweizeitige bilaterale Klavikulafraktur. Konservative vs. operative Therapie mittels intramedullärer Osteosynthese--Fallbericht.

In this case report we present treatment strategies and the functional and cosmetic outcome in a case of midclavicular fractures. A 20-year-old patient suffered from nearly identical fractures of the left and right clavicle with a time interval of 2 years following snowboard falls. The first fracture was treated conservatively leading to an unsatisfactory course and result. This was the reason why 2 years later the contralateral fracture was treated by intramedullary nailing using an elastic titanium nail. The functional and cosmetic outcome of this treatment was excellent. In cases of clavicular fractures elastic stable intramedullary nailing (ESIN) is a minimally invasive technique leading to fast analgesia resulting in a high level of mobility and ultimately a pleased patient. If the indication is right, intramedullary nailing can be a helpful operation technique which complements the already established procedures (conservative and plate osteosynthesis) in cases of dislocated clavicular fractures.

[Traumatic posterior shoulder dislocation : diagnosis and therapy]. / Diagnostik und Behandlungsregime der traumatischen dorsalen Schulterluxation : Fallserie und Diskussion der Literatur.

In contrast to anterior dislocations, traumatic dorsal shoulder dislocation is a rare complication of upper extremity injuries. If the diagnosis is overseen and treated incorrectly, severe mobility restrictions might be the consequence for the injured individual. Hence, the aim of this article is to demonstrate the adequate diagnostic and therapeutic management and to critically discuss the literature.

Operative treatment of greater tuberosity fractures of the humerus--a biomechanical analysis.

BACKGROUND: Fractures of the greater tuberosity of the humerus present with increasing frequency. However, no biomechanical data about the optimal fixation technique of greater tuberosity fractures is available. This biomechanical cadaver study compares the stability of three standard fixation techniques used for the treatment of greater tuberosity fractures of the proximal humerus. METHODS: In 21 fresh frozen proximal humeri, standardized fractures of the greater tuberosity were created. The specimens were randomly assigned to one of three operation techniques: wire tension banding, two cancellous screws and transosseous sutures. These constructs were mechanically tested by applying an increasing force to the supraspinatus tendon. Load to 5mm displacement (load to 5mm yield point) and load to failure (maximum stretch strength) were measured in Newton (N). FINDINGS: Load to 5mm yield point values showed no significant differences between tension banding (498 N, SD 153) and two cancellous screws (400 N, SD 174) (P>0.01). Both techniques showed significantly higher values than transosseous sutures (185 N, SD 132) (P<0.01). Load to failure values were significantly higher for tension banding (1054 N, SD 125) than screws (842 N, SD 140) and sutures (480 N SD 101) (P<0.01). The difference between screws and sutures was also significant (P<0.01). INTERPRETATION: Tension banding and two cancellous screws provided the strongest fixation for isolated fractures of the greater tuberosity.

[Treatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures]. / Die winkelstabile Osteosynthese am proximalen Humerus mit der PHILOS-Platte. Darstellung von 225 dislozierten Frakturen.

BACKGROUND: Proximal fracture of the humeral head is the third most frequent fracture in humans. Most (70%) of those affected are over 60 years old. It is hoped that advanced locking medullary screws or plates will reduce the risk of secondary dislocation of screws or fracture segments when the bone of the humeral head is osteoporotic. METHODS: From January 2002 to August 2005, 225 displaced humeral head fractures in 223 patients aged on average 66+/-15 years were treated with a new locking proximal humeral plate. RESULTS: In 176 patients in whom follow-up was possible, the average Constant Score after 9 months was 70+/-19 points (raw data), or 81+/-22% in the normalized score. No significant difference was detected between the younger group up to 65 years of age (73% points) and those over 65 years of age (80% points). Axial deviations by more than 30 degrees were noted in 11 (5%), and of 159 displaced tubercles, malreduction by more than 5 mm was noted in 14 (9%). Two infections and two haematomas had to be treated so far. Primary screw perforations were seen in 24 (11%) cases as well as further implant dislocations in 3 (1,7%). Plate dislocations out of the shaft existed in 4 (2,4%) and 14 collapses of the humeral head with secondary screw perforations were recorded. All other complications arose out of technical faults, such as 24 screw perforations (11%) into the glenohumeral joint and 3 (1.7%) cases of secondary implant dislocation from the humeral head and 5 (3%) from the shaft, and 14 (8%) sinterings with glenohumeral screw perforation. So far, in addition to 1 case of pseudarthrosis with a broken plate, 5 (3%) cases of total and 9 (5%) of partial avascular humeral head necrosis have been observed. CONCLUSION: The new implant provides superior stability in the fixation of humeral head fragments and has proved its worth in everyday clinical practice when additional indirect fixation of the tubercle is needed, as it frequently is in elderly patients.