[Trauma to the thoracic spine and chest]. / Trauma an Brustwirbelsäule und knöchernem Thorax.

BACKGROUND: The assessment of traumatic lesions to the chest and thoracic spine can pose a challenge for the emergency radiologist. Collaboration with the treating clinicians and knowledge of the patients' history and the trauma mechanism are essential. STANDARD RADIOLOGICAL METHODS: In case of minor trauma, digital radiography may be sufficient for diagnosis. For the diagnostic work-up of polytrauma patients, multidetector computed tomography (MDCT) is the most important modality due to its broad availability and higher sensitivity. The chest has to be completely contained within the scan volume to be able to adequately analyze the bony structures and thoracic spine. Reconstruction in three planes and multiplanar reconstruction are prerequisite for a correct diagnosis and further therapy planning. PERFORMANCE: Magnetic resonance imaging (MRI) serves as a third level diagnostic modality in special cases. MRI can demonstrate bone marrow edema of vertebral bodies or other bones. In addition, the myelon and the epidural space are best assessed with MRI. RESULT: In this article, the most relevant knowledge for the diagnostic work-up of traumatic lesions of the bony chest and the thoracic spine is summarized.

Mid-term results of conservative, conventional and endovascular treatment for acute traumatic aortic lesions.

BACKGROUND: To analyze our results after conservative, conventional and endovascular treatment for acute traumatic aortic lesions during the last decade. METHODS: From June 1993 to September 2004, a total of 19 patients with traumatic aortic lesions were referred to our department. All patients sustained injuries from blunt deceleration trauma. In hemodynamically stable patients, initial evaluation was by multi-slice CT scan. The diagnosis of traumatic aortic injury was confirmed and an individual treatment strategy was determined. In hemodynamically unstable patients, emergency thoracotomy was performed. RESULTS: An emergency thoracotomy was performed in seven (37%) patients. Mortality in this group was 100%. In the remaining group of 12 (63%) patients without hemodynamic instability at time of admission, in-hospital mortality was 0%. Treatment was surgical in five patients (26%), endovascular in five (26%) and conservative in two patients (11%). Mean follow-up was 63 months (5-108 months). No patient died during follow-up. In patients treated by endovascular stent-graft placement no signs of endoleaks could be detected. CONCLUSIONS: Hemodynamic stability and an individual treatment strategy are prerequisites for survival of acute traumatic aortic lesions. Endovascular stent-graft placement has emerged as an innovative and minimally invasive therapeutic option in this polytraumatic high-risk patient cohort.

Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases.

OBJECTIVE: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. DESIGN: Retrospective. SETTING: Four Level I trauma centers. PATIENTS: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. OUTCOME MEASUREMENTS: Clinical and radiographic analysis. METHODS: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. RESULTS: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). CONCLUSIONS: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

[Fatigue stability of locking screws for unreamed tibial intramedullary nailing]. / Ermüdungsfestigkeit von Verriegelungsbolzen für die unaufgebohrte Tibianagelung.

Unreamed nailing with solid tibial nails is an accepted method of treatment for open tibial shaft fractures up to grade III and of closed tibial fractures with severe soft tissue damage. However, fatigue failure of the distal locking bolts is a frequent complication. We report a mechanical study investigating the fatigue limit of six different types of locking bolts used in solid tibila nails (Biorigid Tibial nail/aap, UTN/ace, STN/Howmedica, TLN/Howmedica, delta R & T Tibial nail/Smith & Nephew, AO/ASIF UTN/Synthes). Our results prove a direct correlation between the bolt's diameter and mechanical properties. Further more we found that bolts with a continuing thread were weaker than bolts of the same diameter with only a short thread and an increased diameter at the nail's aperture. Our results suggest that mobilization with half of the average body weight (350N) allows osseous consolidation without fatique failure of any of the tested locking bolts. Some of the tested locking bolts may even withstand full wieght-bearing in a physiological walking cycle, but will not withstand the stress of a running cycle.

Unreamed nailing of tibial fractures with the solid tibial nail.

In 1993 a solid 7.5-mm tibial nail was developed and is composed of a wrought stainless steel alloy. In a preclinical testing series its static and dynamic mechanical properties proved to be superior to other small diameter nails. The clinical application of the Solid Tibial Nail in 70 cases of acute tibial diaphyseal fractures showed promising results. Neither severe intraoperative complications nor infections were observed. The entire series, including seven Grade I, eight Grade II, four Grade IIIA, and nine Grade IIIB open fractures, revealed a union rate of 95% at 6 months postoperative. After dynamization in one case and reaming and renailing in three cases, the fractures with delayed healing progressed to union within the following 3 months. There was no need for bone grafting in any of the cases. Locking screw breakage was observed in 10 (14%) cases 8 to 24 weeks postoperatively. This did not lead to any additional complications. No nail failures were observed. The excellent results of unreamed nailing with the Solid Tibial Nail consequently led to its use as the primary method of treatment for tibial fractures associated with soft tissue injury at the authors' institution.

[Borderline indications for locked intramedullary nailing of femur and tibia]. / Grenzindikationen der Verriegelungsnagelung am Ober- und Unterschenkel.

The borderline indications of locked intramedullary nailing of the femur and the tibia, based on Küntscher nailing, are defined by the location of the fracture, the associated soft tissue injury, the appearance of infection and the patient's pulmonary status. From 1975 to 1995 at the Department of Traumatology, Vienna University School of Medicine, 551 patients with 559 femoral fractures and 536 patients with 548 tibial fractures were stabilized using locked intramedullary nailing. A total of 135 (24%) proximal femoral fractures were stabilized using intramedullary locking nails in 54 cases, and using long gamma nails in 81 cases. Ninety-one distal femoral fractures (16%) were stabilized in 82 cases with intramedullary locking nails and in 9 cases using retrograde nailing. In open fractures predominantly a reamed technique was used. Fifty-two of these fractures were femoral fractures and 101 were tibial fractures. Seventy-two femoral fractures (13%) were associated with compromised pulmonary function and polytrauma. Procedural changes from external fixation to the intramedullary locking nail technique were performed in 21 cases of femoral fractures and in 21 cases of tibial fractures. Six tibial fractures diagnosed as having compartment syndrome were treated using unreamed nailing and fasciotomy. The overall infection rate of femoral fractures was 1.7% and 1.9% for all tibial fractures; the nonunion rate of both femoral and tibial fractures was 0.5%. Because of the success rate observed in the treatment of borderline indications for locked intramedullary nailing of femoral and tibial fractures and the improvement in equipment, training and techniques, we have expanded the indications for treatment of these fractures by intramedullary nailing.

Septic complications after interlocking nailing of the tibia.

Infection, the primary cause of nonunion and unsatisfactory results in operative fracture treatment, occurs with unsettling frequency in spite of modern surgical methods and antibiotics. In the literature we find infection rates after interlocking nailing (IN) of tibial fractures between 1% (Vécsei, 1981) and 6.3% (4.2% deep infections, Jenny, 1993). In this paper a retrospective study of 334 open and closed tibial fractures treated with Grosse & Kempf Nails (G & K Nails) is presented. There were 5 cases (1.5%) of manifest osseus infection. These cases are classified according to the type of infection, the visible site of infection and predisposing factors for infection. Possible reasons for the infectious process, our therapeutic guidelines and results in the treatment of septic complications of nailed tibia fractures will be discussed.