Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients.

BACKGROUND: Although the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear. OBJECTIVE: To compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients. METHODS: A multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher's exact tests, Mann-Whitney U-tests and adjusted analysis of variance (ANOVA). RESULTS: Forty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17-86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up. CONCLUSIONS: Our findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.

[Intramural duodenal hematoma after blunt abdominal injury in childhood. Case report]. / Intramurales Duodenalhämatom nach stumpfem Bauchtrauma im Kindesalter. Fallbeschreibung.

Gastrointestinal injuries after blunt abdominal trauma in childhood are seldom. In 30% of the patients, the site of injury is the duodenum. In 60% associated injuries including other abdominal or extraabdominal lesions are found. Most frequently duodenal damage consists in parietal haematoma, seldom in duodenal laceration. Duodenal haematoma can be resolved non-operatively in 50%. Operation is recommended for children in whom there is no evidence of partial resolution of the obstruction after 10-14 days or in cases with development of a parietal laceration with peritonitis and/or retroperitonitis. For diagnostic computed tomography is the examination of choice.

[Current status of therapy for gastroduodenal ulcer]. / Heutiger Stand der Therapie des perforierten Gastroduodenalulkus.

Over the last 25 years there has been a considerable decrease in the prevalence of peptic ulcer worldwide. Since the introduction of potent anti-ulcer drugs the number of elective operations for peptic ulcer (PU) has decreased considerably, whereas the number of emergency operations has remained largely unchanged. The current incidence of PU perforation is 4-10 per 100,000 population. Perforation accounts for 40-50% of emergency operations for PU. Currently one third to over one half of patients presenting with PU perforation are aged over 65, with an increasing percentage of female patients and gastric ulcer perforations. There appears to be a correlation between PU perforation and ingestion of non-steroidal antiinflammatory drugs (NSAIDS), especially in women over the age of 65. About 50% of patients presenting with perforation of PU do not report a previous history of ulcer dyspepsia or treatment with anti-ulcer drugs. Many authors think the lack of a PU history reported by many patients is unreliable and may lead to erroneous conclusions in about half of patients. Mortality of PU perforation is currently 10-20% in most series, with a higher mortality of 10-40% for perforated gastric ulcer (GU) compared to duodenal ulcer (DU), for which mortality rates of 0-10% are currently reported. A number of centers report an increase in PU perforation mortality: this is due to an increased number of elderly patients in whom ulcer perforation mortality is enhanced by preexistent or concomitant diseases of other organs and systems. In the treatment of PU perforation the discussion centers around the choice between simple closure of the perforation and definitive ulcer surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Monteggia injury in childhood: a frequent cause of chronic dislocation of the head of the radius]. / Monteggia-Verletzung im Kindesalter: eine häufige Ursache der chronischen Radiusköpfchenluxation.

Two cases of chronic dislocation of the radial head after Monteggia lesions in children are described. The late reconstruction with open reduction of the radial head combined with osteotomy of the ulna is mentioned as the therapy of choice before skeletal maturity, because the pathophysiology of the lesion is best considered. The operative procedure in detail is given. Finally, alternative procedures are presented and discussed.

[Giant cell tumor--an unusual cause of pathologic fracture of the femoral neck]. / Riesenzelltumor--eine ungewöhnliche Ursache einer pathologischen Schenkelhalsfraktur.

The uncommon giant cell tumors of bone are generally benign but locally aggressive with tendency for local recurrence. They are located in the epimetaphysis of the long bones, predominantly in the distal femur, proximal tibia and distal radius; the location in the proximal femur is very rare. Because of their location and the high local recurrence, therapy, mainly of the rare pathological fractures, is difficult and controversial. We are presenting a well documented case with joint salvage and good outcome.

[Multiple organ removal from the viewpoint of the non-transplanting hospital. Cost, yield, problems]. / Die Multiorganentnahme aus der Perspektive des nicht-transplantierenden Spitals. Aufwand, Ertrag, Probleme.

Our algorithm is an example of the way in which multiple organ donation can be organized in a hospital which does not perform transplants. We describe problems which arise during evaluation of the donor and pending explanation. In conclusion we call for better coordination and support from transplantation centres.

[Multi-organ procurement from the perspective of a hospital not involved in transplantation. Requirements, implementation, problems]. / Die Multiorganentnahme aus der Perspektive des nicht-transplantierenden Spitals. Aufwand, Ertrag, Probleme.

Our algorithm is an example in which way the multiple organ donation can be organised in a hospital, which doesn't perform transplantations. We are showing problems which occur during the evaluation of the donor and till the explantation can be performed. In the conclusion we are demanding for better coordination and better support from the transplantation centers.

[Analysis of the "user friendliness" of the AO classification of fractures]. / Analyse zur "Anwenderfreundlichkeit" der AO-Klassifikation für Frakturen.

The AO-classification of long bone fractures has been introduced as a universal system and depends mainly on morphological characteristics and fracture-location. It includes the fracture severity and outcome and should be a basis for treatment. To evaluate the AO-classification in the "daily use", we were interested if this system is really userfriendly, where the problems of coding occur and which is the agreement in different codings of several surgeons in relation to segment, type, group and subgroup. 58 fractures were classified, totally we got 456 classifications. The agreement in relation to segment was 95%, to type 79%, to group 63% and to the subgroup only 45%. Endsegment-fractures had a better agreement than shaft fractures. Common mistakes are discussed and some "user-guidelines" are given.

[Combined "percutaneous and minimal" osteosynthesis for dislocated intra-articular calcaneus fractures]. / Kombinierte "perkutane und minimale" Osteosynthese für dislozierte, intraartikuläre Kalkaneusfrakturen.

41 displaced intraarticular fractures of the calcaneus were treated with open reduction, limited internal screw fixation, bone grafting and percutaneous pinning, using an extensile postero-lateral approach. Despite early functional after treatment all fractures healed without secondary displacement in an average time of 8 weeks. At follow-up (average 4.2 years) there was a strict correlation between the clinical results and the severity of articular comminution. A satisfactory outcome seems to depend on the ability to restore the best possible articular congruency and extra-articular alignment of the os calcis. Results and advantages of our method are discussed.

[Complex distal radius fracture: value of spongiosa-plasty in combination with external fixator treatment]. / Komplexe distale Radiusfraktur: Nutzen der Spongiosaplastik in Kombination mit der Fixateur-externe-Behandlung.

22 Patients with complex fracture of the distal radius (Fernandez III/Frykman VII-VIII/AO 23.C) underwent treatment with external fixation and auxiliary autologous bone grafting in purpose to reconstruct and stabilize the radiocarpal articular surface, reset the radius length, obtain a quicker bone healing and avoid secondary radius shortening after removing of the external fixation. In spite of reassessment of radius length in 80% and reconstruction of the radiocarpal articular surface in 75%, late control showed the development of radiological signs of radiocarpal arthritis. 50% of the patients have a moderate loss of strength and motility in the wrist; this seems to be a good result for a very negative selection of complex fractures of distal radius. We recommend autologous bone grafting in treatment of complex fractures of the distal radius with external fixation.

[Quality of life and the subjective well-being after successful kidney transplantations]. / Die Lebensqualität und das subjektive Wohlbefinden nach erfolgter Nierentransplantation.

The quality of life following kidney transplantation is examined. For this reason a total of 38 patients were questioned. There were three subgroups: 18 adults and 10 children with excellent kidney function and 10 patients in whom nephrectomy had to be performed after rejection of the transplanted organ. The extent and importance of the changes of various criteria considered essential for judgement of the quality of life are illustrated. Adults and children alike consider the improvement of drinking and eating habits, improvement of physical fitness and of the capability to deal with psychological problems as the essence of their greater joy in life. For children there are added advantages at school and in the choice of their occupational activity. In conclusion there is a definite improvement of the quality of life following renal transplantation.