[Distal femoral fractures]. / Distale Femurfraktur.

CLINICAL ISSUE: Fractures of the distal femur represent rare but serious injuries with a high 1­year mortality. An increasingly older patient population requires adapted treatment concepts. STANDARD TREATMENT PROCEDURE: Surgical treatment using angular stable plating and retrograde nailing is the standard procedure. Conservative treatment is only indicated in cases of low demands and high perioperative risks of the patient. TREATMENT INNOVATIONS: Primary double plate osteosynthesis and primary implantation of a distal femoral replacement represent new treatment procedures and show promising initial results in the collective of geriatric patients. DIAGNOSTIC WORK-UP: Conventional radiographs in 2 planes and computed tomography with multiplanar and 3D reconstructions should be performed to enable an adequate assessment of the indications and treatment planning. PERFORMANCE: Nonunion rates of plate and nail osteosyntheses range from 4% to 10%. No significant differences in long-term results can be observed. The results regarding double plate osteosynthesis and distal femoral replacement so far do not show any disadvantages compared to the existing procedures but there is still insufficient data for general recommendations. ASSESSMENT: Complex fractures with extensive reconstructive procedures and treatment by distal femoral replacement should be performed in specialized centers. PRACTICAL RECOMMENDATIONS: The gold standard is still surgical treatment by means of minimally invasive angular stable plate or retrograde nail osteosynthesis. Complex fracture forms require individual treatment planning considering all currently available treatment options.

[Emergency room activation due to trauma mechanism]. / Schockraumindikation nach Unfallhergang.

BACKGROUND: The quality of trauma care in Germany has been significantly increased due to the establishment of standards in the white paper on severe injury care and the S3 guidelines. A key issue of multiple trauma treatment is the trauma resuscitation unit (TRU)/emergency room management, which is associated with extensive material and human resources. From the very beginning of the introduction of structured care for the severely injured, the choice of the target hospital and the indications for TRU have been the focus of scientific research. Furthermore, a reduction of the TRU team for presumably less seriously injured patients is discussed. MATERIAL AND METHODS: The emergency room assignments of a level I trauma center (n = 686) were analyzed in more detail. Of the patients 235 were assigned with the TRU indications according to the cause of the accident (GoR B criteria) and compared with the collective of TRU patients admitted according to the severity of injuries or life-threatening signs, the so-called GoR A criteria (n = 104) during the corresponding period. In addition to basic data (age, sex), the injured region and severity (injury severity score, ISS), the length of stay in the intensive care unit (ICU) and hospital as well as the necessity for surgery and transfusion were compared. RESULT: Of the emergency room allocations at the trauma center 34% were due to the cause of the accident and the severity of the injuries in this patient group was almost half as high as that of the control group with an ISS of 11. Of the patients 74% were admitted to the IMC/ICU and stayed there for an average of almost 3 days. There were between 4% and 18% severe injuries (abbreviated injury scale, AIS 3) and 17.9% were characterized as polytrauma with an ISS ≥ 16 points. CONCLUSION: A significant number of patients admitted to a TCU due to the cause of accident (the so-called B criteria of the white book), have severe and potentially life-threatening injuries, which necessitate a prioritized and immediate treatment by a TCU team. Whether a reduced TCU team is sufficient in this situation needs to be critically examined.

[The Significance of Early Reposition in Patients with Visible Malposition of the Upper Ankle Joint]. / Stellenwert der frühzeitigen Reposition bei sichtbarer Luxation im oberen Sprunggelenk.

Background: Protracted dislocation of the upper ankle joint can lead to substantial damage to the surrounding soft tissue, possibly followed by local complications and longer hospitalisation. Although reposition is usually easy to conduct, it is commonly recommended that this should only be performed by an experienced specialist, as long as there is no neurovascular restriction. There are however no exact data or studies on this problem. The aim of the present study is to examine whether early reposition is of benefit for subsequent treatment. Methods: Retrospective study of all patients in a supra-regional trauma centre during the period from January 2009 to July 2015, with either prehospital reposition of the ankle joint because of visible malposition or documented visible malposition on arrival at hospital. Patients with relevant concomitant injuries elsewhere were excluded. Data on the duration of dislocation were matched with diagnostic findings at the time of hospital admission, the kind of primary care, local complications and the time of hospitalisation, using linear regression analysis and ANOVA calculations. Results: Of a total of 391 patients with a dislocation or a fracture dislocation of the ankle joint within this period, 132 fulfilled the inclusion criteria. These patients were divided into 5 groups on the basis of the time of dislocation. Time to reposition was less than one hour for 39 patients, between one and two hours for 29 patients, between two and six hours for 41 patients, between six and 24 hours for 13 patients and more than 24 hours for 10 patients, all with a visible dislocation. The results on admission showed a significant increase in skin bruises and tension bullae with increasing time of dislocation. A longer time of dislocation was associated with more two stage surgical procedures with external fixators and a decreasing number of single stage procedures. While there was immediate definitive treatment of 79.5 % of the patients in the first group, this figure decreased continuously to 10.0 % in the last group. The number of local complications increased significantly in every group with the duration of dislocation. In particular, the incidence of severe swelling, wound healing disorders, skin necrosis and the need for revision surgery and plastic reconstruction exhibit a significant linear increase within the groups (p < 0.05). The incidence of severe swelling rose from 10.3 % in the first group, to 31.0 % in the second group, to 100 % in the last group. The incidence of wound healing disorders rose from 7.7 to 13.8 to 80 % and the incidence of skin necrosis from 2.6 to 3.5 to 30.0 %. The duration of hospitalisation also exhibited a significant linear increase with group affiliation (p < 0.001), from 8.3 days in the first group to 12.5 days in the second group and 30.5 days in the last group. Conclusion: This study shows the importance of conducting reposition of the ankle joint as soon as possible if there is visible malposition, in order to avoid local complications and longer hospitalisation. If there is visible malposition of the ankle joint, the best procedure is immediate - ideally prehospital - reposition and in-axis splinting, in order to preserve soft tissue.