[A penetrating volar foreign body: a wooden splinter beneath the flexor tendons]. / Fremdkörper in der Hohlhand - Holzsplitter unter den Beugesehnen.

Hand injuries are among the most common injuries seen in general practitioner (GP) consultation hours and emergency departments and are most often affecting the dominant hand. We report on a case of unsuccessful primary exploration of the volar hand for a foreign body by the GP. In regard to detailed history of the injury mechanism, we performed the clinical examination and an additional ultrasound evaluation of the hand, suggesting evidence for a foreign body and a laceration of one of the flexor tendons. Figures are illustrating the mechanism of the injury and emphasize the need for determining the kinematics and course of the injury. The suspicion of a foreign body within the hand requires the consultation of a trained hand surgeon to adequately treat the injury and provide the after-care.

[Management of bicondylar fractures of the tibial plateau with unilateral fixed-angle plate fixation]. / Versorgung von bikondylären Tibiakopf-Frakturen mit einem unilateral platzierten winkelstabilen Plattensystem.

BACKGROUND: This study was initiated to evaluate early results of a locked screw plate for unilateral fixation of bicondylar fractures of the tibial plateau. Emphasis was laid on malreduction, secondary loss of reduction, union rate, and infection. MATERIAL AND METHODS: A case series of patients with AO/ASIF 41-C type fractures treated with the less invasive stabilization system for the proximal lateral tibia (LISS PLT) were prospectively followed up until 11-13 months after surgery. Malreduction and malalignment were defined as an intra-articular step-off of 2 mm or more or as a malalignment in the frontal or sagittal plane of more than 5 degrees. RESULTS: Sixty-eight patients with 69 fractures were involved. Fourteen fractures were open. Primary bone grafting was performed in 13 patients. Significant malreduction was seen in 16 patients. Sixty-two (91%) patients returned for follow-up. All but one fracture healed eventually. The number of infections was low (4 superficial, 1 deep). Nine patients had a significant loss of reduction. Of 54 patients outcome scores were good to excellent in 47 patients on the Lysholm score (average 87.2) and in 44 patients on the Rasmussen score (average 26.7). CONCLUSION: We concluded that unilateral locked screw plating is a good alternative in the treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.

[New surgical treatment procedures in fractures of the distal tibia (LCP, MIPO)]. / Neue Stabilisierungsverfahren bei distalen Tibiafrakturen (LCP, MIPO).

All along the operative treatment of distal tibial fractures is a difficult procedure. In most cases the clinical situation is characterized by small distal fragments in combination with crucial soft-tissue conditions. That's why complications as primary or secondary displacements, mal unions, delayed or non unions and as well as a high rate of deep wound infection are often seen. Thus internal fixations with traditional implants (standard screws and plates) could consider inevitable this crucial biology and biomechanics only insufficiently. The nowadays available internal fixators with optional angular-stable screws expand the possibilities of internal fixation in these severe situations. Their minimal invasive application (MIPO, Minimally Invasive Plate Osteosynthesis) takes care of the soft tissue and reduces the surgical trauma furthermore. With the variety of their possible applications (combination of angular stability with standard application) also the demands increase, however, both onto the surgeons, but also onto the general practitioners in the aftercare. The combination of most different tactics in one implant results in the consequence, that at the same bone simultaneously direct and indirect bone healing will be expected. The radiological differentiation between desired and unwanted healing processes becomes thus difficult. Pre- and perioperative procedures require from the trauma surgeon a huge infrastructure and a high measure of biomechanical and biological experience. In the postoperative management of these injuries an unlimited cooperation between traumatologists and general practitioners is indispensable for a further successful course.

Fulkerson's modified Elmslie-Trillat procedure for objective patellar instability and patellofemoral pain syndrome.

Twenty two knees were either operated for objective patellar instability (Group A: 14 patients) or patellofemoral pain syndrome (Group B: 8 patients) using Fulkerson's modified Elmslie-Trillat procedure. The objective of this retrospective study was to evaluate the results of this method and to detect whether or not there were differences in the outcome comparing the two groups. Twenty knee joints (Group A: 13; group B: 7) were available for clinical and radiographic examination after an overall mean follow-up of 63 months. Duration of pre- and postoperative physical therapy was significantly longer for group B, the activity level increased significantly for these patients and the Q-angle could be corrected significantly in this group comparing pre- and postoperative values. The overall outcome (Turba score) detected no statistically significant difference between the groups, only good and excellent results were obtained. No signs of osteoarthritis were found radiologically. A pathological patellar congruence angle could be corrected significantly by this method. We conclude that Fulkerson's modified Elmslie-Trillat operation is an excellent treatment method with a very low morbidity for patients with patellofemoral malalignment after failed conservative treatment.

[Isolated coracoid fracture--open reposition and osteosynthesis--report of 3 cases]. / Die isolierte Coracoid-Fraktur--offene Reposition und Osteosynthese--Bericht über drei Fälle.

UNLABELLED: Usually coracoid-fractures are "chain-injuries" in association with complex shoulder injuries. Isolated fractures of the coracoid process are uncommon. In the literature there is no consensus about the treatment. The conservative method is generally advocated. For better recognizing the particularities of coracoid-anatomy and fracture-analysis we performed dissections on cadaver shoulders and also evaluated a useful radiologic technique for diagnosis. Between 1995 and 1997 three patients with isolated displaced coracoid-fractures had open surgical repair. The postoperative course was very good in all three cases with complete recovery of shoulder function. DISCUSSION: We believe that isolated coracoid-fractures with infero-lateral dislocation and loss of function should sustain open reduction and internal fixation with functional after treatment.

[Pneumatic tourniquet as a repositioning aid in closed intramedullary nailing]. / Pneumatische Manschette als Repositionshilfe bei geschlossener Marknagelung.

The use of an extrawide pneumatic tourniquet as a reduction aid for closed intramedullary nailing is described, even in combination with the distractor. The principle is similar to that applied in fracture bracing as described by Sarmiento: the reduction of the fragments is achieved by ligamentotaxis (traction on the limb) combined with gentle concentric soft tissue compression exerted by the inflated tourniquet. We have applied the simple, non-invasive technique in over 30 fractures with good results. Implementation of the method with an unreamed tibia nail (utn) is described as an example.

[Computer-assisted prospective wound infection monitoring. 1: Ideas and principles]. / Computerunterstützte prospektive Wundinfektionsüberwachung. Teil 1: Ideen und Prinzipien.

The prospective recording of nosocomial infections can be regarded as a quality control measure whereby exact data collection and analysis will improve recognition of the individual aspects of hygiene deficiency in the hospital and thus reduce the incidence of nosocomial infections. Wound infections will be recorded on the basis of the CDC definitions for nosocomial infections (1988) and according to three categories of cleanliness for all operations: aseptic, contaminated, infected. A computer program is recommended for data collection and exact analysis--if possible, combined with an internal hospital communication system.

[High grade liver rupture--is nonsurgical therapy feasible?]. / Die höhergradige Leberruptur--ist sie für eine nicht operative Therapie geeignet?

Although well accepted in pediatric patients, the nonoperative management of severe blunt hepatic trauma in adults remains controversial. On the basis of 3 cases with major liver injury, the rationale and prerequisites for a successful nonoperative treatment are discussed.

[Distal radius fractures: conservative or surgical treatment?]. / Die distale Radiusfraktur: konservative oder operative Behandlung?

The "classical" Colles fracture of the distal radius is the most common fracture in the adult. In order to reduce the still rather high rate of permanent disability, this fracture involving a functionally important joint requires accurate reduction. The AO-fracture classification introduced by Müller not only defines the severity of an injury, but also allows for decision-making as to the most adequate treatment. Besides the purely conservative management by closed reduction and plaster cast for the type-A fractures, we have a number of other treatment modalities for the more complex-B and C-type fractures, such as closed reduction and percutaneous K-wire application or the use of the small external fixator as well as open reduction and internal fixation by plates and screws for a few selected indications.

Tibial fractures treated with the AO unreamed tibial nail.

During the last 2 years 20 fractures of the tibial shaft have been treated with the new, 'unreamed' solid AO tibial nail (UTN). There were 13 open fractures, while four of the seven closed fractures had severe soft tissue injuries. There were nine fractures classified as 'complex' or type C according to the AO classification. All UTNs were introduced without reaming but with proximal and distal interlocking. In all, 12 fractures (five of them open) were stabilized primarily by 'unreamed' nailing, whereas the first eight (open) fractures of the series were fixed initially by an external fixator and then nailed after about 14 days. In our series no intraoperative complications occurred, and no major soft tissue problems or infections were observed. The functional results were generally good; however, fracture healing appeared to be delayed in six cases. One patient had a further operation because of non-union. Intramedullary nailing, without reaming, seems to be a reliable and safe treatment for closed and open fractures with severe soft tissue injuries as an alternative to external fixation. The use of a thin, solid nail combined with interlocking allows the stabilization even of complex fractures. Contrary to initial assumptions, the UTN can be used as a definitive implant with no need for further stabilization in the majority of cases.

[Initial results with the unreamed AO tibial nail]. / Erste Erfahrungen mit dem unaufgebohrten AO-Tibianagel (UTN, unreamed tibial nail).

It is generally accepted that intramedullary nailing in combination with reaming should be avoided in treating open fractures. However, the use of an unreamed, solid nail combined with interlocking also allows stabilization of open and complex fractures. 20 tibia fractures (65% open, 45% complex fractures) have been treated by the AO unreamed tibial nail (UTN), 12 (5 of them open fractures) by direct nailing and 8 after initial stabilization by an external fixator. In our series no intraoperative complications, no soft-tissue healing problems and no infections occurred. Thus, treatment of both open and comminuted fractures by UTN appears to be safe and generally needs no secondary stabilization.

[Initial experiences with the unreamed AO tibial nail]. / Erste Erfahrungen mit dem unaufgebohrten AO-Tibianagel (UTN, unreamed tibial nail).

It is generally accepted that intramedullary nailing in combination with reaming should be avoided in treating open fractures. However the use of an unreamed, solid nail combined with interlocking allows stabilization also of open and complex fractures. 20 tibia fractures (65% open, 45% complex fractures) have been treated by the AO unreamed tibial nail (UTN), 12 (5 of them open fractures) by direct nailing and 8 after initial stabilization by an external fixator. In our series no intraoperative complications, no soft-tissue healing problems and no infections occurred. Thus, treatment of both, open and comminuted fractures by UTN appears to be rather safe and generally needs no secondary stabilization.

[The initial traumatic shoulder dislocation. Prospective study]. / Erstmalige traumatische Schulterluxation. Prospektive Studie.

The goal of this prospective study was to investigate possible factors which might prevent the recurrence of dislocation after a first time traumatic shoulder dislocation. Of the 504 patients initially recorded, 376 were followed up clinically and radiologically after 1 year, and 324 were followed up after 5 years. 20% (64/324) of the patients examined after 5 years sustained a recurrent dislocation of the shoulder. We can confirm age dependency in the occurrence dislocations (50% of the patients > 30 yrs; 15% > 30 yrs). However, we were unable to find a relationship between the duration of immobilization and the incidence of recurrence redislocation (20% recurrence for 0, 1, 2, 3, > 3 weeks of immobilization). A simultaneous avulsion fracture of the tuberculum majus seems to improve the prognosis for recurrent shoulder dislocation (3/114 = 3%), whereas other bony injuries detected using conventional radiology do not appear to influence the incidence of recurrence. A shoulder stabilisation operation had to be carried out in a total of 10% of the follow-up cases. Based on our experience, we recommend a sufficiently long immobilization period of the freshly injured shoulder. In young patients, extensive and invasive procedures (arthro-MRI, pneumo-arthro-CT, shoulder arthroscopy) should be carried out after the first redislocation.

Long-term results with the uncemented thrust plate prosthesis (TPP).

The long-term clinical results of a novel concept for total joint replacement called the Thrust Plate Prosthesis (TPP) are presented. Only a restricted number of patients were provided with this new prosthesis (115 at the Orthopedic Department, Canton Hospital, Chur, and 47 at the Department of Orthopedic Surgery, University of Zurich). All patients have undergone clinical and radiological follow-up covering a period from 1980 to 1991. The basic feature of the Thrust Plate Prosthesis is the direct load transfer to the medial cortical bone of the femoral neck, and this has been unchanged since 1978. Titanium alloy has been used since 1986. The good clinical and radiological results are confirmed by a histological examination of an 8-year-old implant: In the crucial area of load transfer newly formed bone can be seen in direct contact with the thrust plate without fibrous tissue in between. The clinical results and histological findings have confirmed the validity of the biomechanical principle of the TPP. The TPP is therefore to be considered a true alternative to the conventional hip prosthesis. In contrast to the conventional intramedullary anchored stem prosthesis the TPP requires the removal of a minimum amount of bone stock, which is certainly important in young patients.

Five years' follow-up of severely injured ICU patients.

We conducted a 5-year follow-up study of a group of 461 consecutive trauma patients treated in our Intensive Care Unit from 1980 to 1983. The entry criteria (initial survival and severe injury: ISS greater than or equal to 18) were fulfilled by 233 patients with a mean ISS of 29.3 and mean age of 35.6 years. Data on prehospital care, type and timing of surgery, and hospital and ICU stay were recorded during hospital discharge. The protocol strictly asked for a personal interview and a physical examination. Mailed questionnaires or phone interviews were not allowed. The areas of medical sequelae, aftercare, missed injuries, occupation, insurance, social integration, economics, legal aspects, and traffic involvement were covered. We were able to gather final information from 223 (95.6%) of the 233 cases. Forty-three patients (18.4%) died in the hospital, 13 patients (5.6%) died later, and 167 (76.5%) were eventually seen. Only 10 patients (4.4%) were lost to follow-up. Outcome was judged using the Glasgow Outcome Scale (GOS), which was compared with a GOS value given prospectively at the time of hospital discharge. Eighty-nine percent of the survivors were healthy or slightly disabled (GOS 5 and 4), 9% were severely disabled, and only 2% were in a persistent vegetative state. Outcome after 5 years was better than tentatively prognosed at the time of hospital discharge. Ninety-one patients with severe head injuries (AIS 4-5) were additionally tested using the Mini Mental State instrument. This test revealed normal mental functions in 77% and dementia, mostly of a minor degree, in 23% of the head-injured patients. Almost all the early deaths and two thirds of the late deaths were related to severe head injury. Seventy-nine percent of the survivors were working after 5 years. During the post-trauma period, patients experienced reduced social well-being and also changed professional and recreational activities. There appears to be extensive room for improvement in the posthospital recovery phase. We conclude that survivors of critical trauma have a very good chance, after 5 years, of regaining a high quality of life. All efforts at improving trauma survival and quality of trauma care are therefore worthwhile and deserve high priority.

[Surgical stabilization of juvenile lower leg fractures using the external fixator. Retrospective analysis of 10 cases]. / Operative Stabilisierung kindlicher Unterschenkelfrakturen mit Fixateur externe. Retrospektive Analyse von 10 Fällen.

Ten cases seen over the last eight years were reviewed by clinical and radiological re-examination one year after injury. The results encourage us to continue treating young patients with critical soft-tissue injury, compartmental syndrome, open fracture and multiple injury by this technique.