[Humeral shaft fractures]. / Humerusschaftfraktur.

There is still no gold standard for the treatment of humeral shaft fractures. This might be attributed to the fact that several commonly used treatment methods have shown good clinical results. A bimodal age distribution of humeral shaft fractures with frequency peaks between 20 and 30 years old and above 60 years old is reported. Decision making for conservative or operative treatment depends not only on the injury pattern but is also dependent on individual patient needs. Currently available operative techniques include antegrade and retrograde interlocking medullary nailing as well as the use of longer proximal humeral nails. Plate osteosynthesis can be performed as open reduction and internal fixation (ORIF) or as minimally invasive plate osteosynthesis (MIPO). There is currently insufficient evidence for a clear superiority of either of the methods. Radial nerve palsy is the most typical complication of humeral shaft fractures but an improved outcome is not achieved by an emergency revision of the nerve.

Aspects and assessment of delirium in old age. First data from a German interdisciplinary emergency department.

BACKGROUND: The prevalence of delirium in hospitalized patients is high, but delirium is frequently not identified by treating physicians in emergency departments (EDs). Although the number of elderly patients admitted to EDs is increasing, no data on prevalence, identification and outcome of delirious elderly patients in German EDs exist. OBJECTIVES: To evaluate the prevalence and identification of delirium in elderly patients in a German ED and to identify characteristics of delirium in elderly ED patients. METHODS: Evaluation of data from a prospective single-center observational study. The study was conducted in the interdisciplinary ED of an urban university-affiliated hospital receiving approximately 80,000 visits per year. The shortened Confusion Assessment Method (CAM) was used to screen 133 consecutive ED patients, aged 75 years and older, for delirium. Comorbid conditions were ascertained by patient interview and review of medical records. Data concerning patient mortality and current living status were collected 28 days after the ED visit in a structured telephone interview. RESULTS: A positive CAM result was recorded in 14.3 % of cases; 68.4 % of these CAM-positive patients were not identified as being delirious by the ED physician. The 28-day mortality was higher among patients with delirium. Dependency on external help, polypharmacy, pre-existing cognitive or mobility impairments and the presence of any care level were strongly associated with delirium. CONCLUSION: Elderly patients with known risk factors should be routinely assessed for delirium in the ED with a standardized assessment tool such as the CAM.

Considerations for the development of an undergraduate curriculum in geriatric medicine.

BACKGROUND: Although the number of older patients is increasing in almost all medical specialties, the interest of medical students in geriatrics as a career is still low. Because quality of medical education and educators strongly influences student career decisions, it is important to develop curricula that motivate students to become self-directed, lifelong learners in the field of geriatric medicine. OBJECTIVES: We evaluated training aspects in terms of time, core content of teaching goals, and quality of undergraduate geriatric education in medical schools in Austria and Germany. METHODS: A standardized paper questionnaire was sent to all 36 German and 4 Austrian medical faculties to evaluate quantitative aspects, content, and quality of pregraduate medical education in geriatrics. Results were compared to the recommendations of the Geriatric Medicine Section of the European Union of Medical Specialists (UEMS). RESULTS: A total of 33/36 (92 of the German medical faculties) and 4/4 (100 of the Austrian medical faculties) responded to the questionnaire. In most of the faculties, geriatric medicine was taught as an independent discipline in the core curriculum, with learning objectives absent in almost one third of the faculties. A medical student's first contact with geriatric medicine occurred on average during the second clinical year (median 8th semester). Although the content of geriatric curricula strongly varied among the faculties, core knowledge as recommended by the UEMS was integrated into most of the curricula. Teaching strategies regarding the development of attitudes and skills also recommended by the UEMS were identified in the curriculum of only some faculties. CONCLUSIONS: Geriatrics seems to be an established subject in most German and Austrian faculties. However, the current data clearly indicate highly variable quality in geriatric pregraduate training at German and Austrian universities. Because curricula should prepare young people using competence-based training and assessment methods, room for improvement remains not only in terms of structure, but also regarding quality of training to develop self-directed lifelong learners.

[Hemiarthroplasty for femoral neck fracture in the elderly--an operation suitable for teaching?]. / Ist die Versorgung der Schenkelhalsfraktur mittels Duokopfprothese beim alten Menschen ein geeigneter Ausbildungseingriff?

BACKGROUND: Hemiarthroplasty is a common procedure for treating femoral neck fractures in orthogeriatrics. For training purposes the operation may also be performed by supervised residents. Our study aims at evaluating the rates of early surgical complications after hemiarthroplasty in different age groups, comparing operations performed by consultants and residents. METHODS: All patients treated with hemiarthroplasty between December 2006 and July 2011 at our municipal, maximum-care-providing hospital were included in a retrospective cohort. The Excia® stem with a self-centering bipolar head (Aesculap, Tuttlingen) was used in all patients. Educational level of the operator (consultant vs. resident) and operation time were noted as well as early complications including luxation, infection, haematoma, seroma, and early periprosthetic fractures (e.g., intraoperative lesions of the greater trochanter). The complication rates were evaluated and compared by the chi-square test. RESULTS: 241 of 729 hemiarthroplasties were performed by supervised residents. Neither the overall complication rate nor the rates of specific complications differed significantly between the patients operated by consultants and those operated by residents. The result was still true if comparing the different age groups. On average operation time was 8 minutes longer in teaching operations. CONCLUSIONS: Focusing on early surgical complications, the teaching of hemiarthroplasty does not seem to increase the risk to patients of any age. We conclude that the hemiarthroplasty procedure is suitable for teaching younger colleagues in orthogeriatrics. As age is just one of several potential risk factors, additional studies on this topic should be undertaken.

Is proximal femoral nailing a good procedure for teaching in orthogeriatrics?

BACKGROUND: Proximal femoral nailing is a common operation in orthogeriatrics and a highly standardized procedure. For teaching purposes, this operation is often performed by residents and supervised by attending physicians. The objective of this study is to investigate if teaching this operation influences the surgical in-house complication rate. PATIENTS AND METHODS: All patients who received a proximal femoral Targon PF nail (Aesculap AG, Tuttlingen, Germany) for trochanteric fractures were included in a cohort at our urban academic teaching hospital between 1998 and 2010. To evaluate potential effects of patient age, we separately analyzed several age groups. Complications including wound infection, hematoma, intraoperative malreduction or implant malpositioning causing revision, pain, cut-out and readmission due to nonunion were recorded. RESULTS: Our collective consists of 1,516 patients (m/f: 410/1,106). The mean age was 78.7 years (range: 19-103 years). The overall complication rate was 7.9 %. In 857 cases operated by attending physicians, the complication rate was 6.9 %. However in the 659 operations performed by residents, we found a higher complication rate of 9.3 %. Further investigating this difference by χ(2) test, we found no significance (p = 0.09). Whilst analyzing the complication rates for the different age groups, we did not find a statistically significant difference except in the age group between 71 and 80 years, for which the odds ratio indicated a 2.6-fold increased complication risk for operations performed by residents (p = 0.01). Further analysis revealed that this increased complication rate was mainly due to increased numbers of cut-out. CONCLUSION: We conclude that proximal femoral nailing is an operation suitable for teaching purposes. However, patients between 71 and 80 years of age seem to be at an increased risk for cut-out if operated by a resident.

"N-active": a new comanaged, orthogeriatric ward: observations and prospects.

The incidence of hip fractures increases with increasing age. Besides the actual trauma, it is mainly the comorbidities and an increased postoperative complication rate in old patients that lead to increased mortality in this patient population. Around 25% of patients who had previously been living independently continue to need long-term care after a hip fracture. Given this situation, the comanaged orthogeriatric unit "N-active" was opened at the Nuremberg Hospital in December 2010. The following article describes implementation of the ward and preliminary data. These show a positive impact of comanagement in terms of patient outcome, staff satisfaction, and also financial aspects.

[Seventy-seven-year old patient with Recklinghausen's disease (neurofibromatosis)]. / 77-jähriger Patient mit Rückenschmerzen. Der "Rucksack" war ein Neurofibrom.

In this article, the case of a 77-year old patient who went to his physician complaining of increasing dizziness, unsteady gait and backaches is described. During the physical examination, a monstrous skin tumor was found on the back of the patient. MRI showed cerebellopontine angle tumors in the area of the trigeminal nerve and the beginnings of hydrocephalus. A diagnosis of neurofibromatosis type 1 was made on this basis. This disease, which is also called Recklinghausen's disease, belongs to a group of diseases called phakomatosis. It can develop due to the inheritance of an autosomal dominant trait, but can also arise through new mutations. Treatment varies with the symptoms. In the present case, the tumor was surgically removed without complications.

Complications and failure of MPFL reconstruction with free tendon grafts in cases of patellofemoral instability.

BACKGROUND: Reconstruction of the medial patellofemoral ligament (MPFL) using free tendon grafts has become a widespread treatment option for patellofemoral instability. As the numbers of cases gradually grow, so do the reports of possible peri- and postoperative complications following this procedure. OBJECTIVE: The present review summarizes all known complications of MPFL reconstruction with regard to postoperative outcome and seeks to highlight possible pitfalls that may occur during treatment. CONCLUSIONS: MPFL reconstruction generally has to be regarded as a safe procedure today due to low patellar re-dislocation rates. Complication rates however are not trivial owing to the complexity of the underlying pathology. Complications can arise from graft fixation or femoral tunnel placement. Postoperative flexion deficits and medial knee pain have been described as predominant complaints. Anatomical preconditions as the grade of trochlear dysplasia, axis or torsion of the lower extremity have to be considered in search of causes for possible graft failure as well as in the thorough preoperative planning of the procedure.

Stage D1 adenocarcinoma of prostate.

The natural history of Stage D1 adenocarcinoma of the prostate remains unclear. In a series of 50 patients with positive pelvic lymph nodes at the time of staging lymphadenectomy, metastatic disease developed in 43 per cent of the patients treated for cure within the period of time of follow-up. Several series from the literature confirm those findings. Positive pelvic lymph nodes most probably represent systemic disease, and the patients are incurable by current surgical and radiotherapeutic modalities.

[Retrograde intramedullary nailing for periprosthetic fractures of the distal femur]. / Retrograde Marknagelung bei periprothetischen Frakturen des distalen Femurs.

OBJECTIVE: Intramedullary stabilization of periprosthetic distal femoral fractures by interlocking nailing. Closed reduction by retrograde nail can be combined with the use of transmedullary support screws (TMS principle of Stedtfeld). INDICATIONS: Supracondylar fractures above stable knee arthroplasty (Rorabeck types I and II), femoral shaft fractures ipsilateral of stable hip and/or knee arthroplasty, contraindications for antegrade nailing CONTRAINDICATIONS: Closed box design of femoral implant, intercondylar distance of the femoral component smaller than nail diameter, more than 40° flexion deficit of the knee, inability to place two bicortical distal interlocking screws. Relative contraindication: insufficient overlap with proximal implants SURGICAL TECHNIQUE: Supine position and knee flexion of approximately 45°. Fluoroscopy should be possible between the knee and hip. Longitudinal skin incision into the pre-existing scar over the patellar tendon which is then split. The nail entry point is located in the intercondylar groove at the deepest point of Blumensaat's line, often predetermined by the femoral arthroplasty component. Reaming is rarely necessary. Transmedullary support screws may correct axial malalignment during nail insertion. Static interlocking in a direction from lateral to medial by the aiming device. Insertion of locking cap. POSTOPERATIVE MANAGEMENT: Retrograde nailing normally allows full weight bearing. Range of motion does not need to be restricted. RESULTS: Out of 101 fractures treated between 2000 and 2013 with a Targon RF nail (Aesculap, Tuttlingen, Germany) 10 were periprosthetic, all were classified as Rorabeck type II and of these 6 fractures were metaphyseal and 4 were diaphyseal. In four cases proximal implants were present. The mean operative time for periprosthetic fracture fixation did not significantly differ from that for normal retrograde femoral nailing. There were no postoperative infections, fixation failures or delayed unions. There was one revision for secondary correction of maltorsion.

Proximal third humeral shaft fractures -- a fracture entity not fully characterized by conventional AO classification.

INTRODUCTION: The retrospective study was made to evaluate the fracture patterns at the proximal humeral shaft for which the long version of a standard proximal humeral nail (PHNLV) has been used. The indication has been decided by the individual surgeons. PATIENTS AND METHODS: Over a five year period 72 consecutive PHNLV cases of an acute fracture were identified and were included in the study. Mean patient age was 68.9 years. Gender ratio was m/f=22/50. 86.1% of the patients fractured their humerus by a fall, the rest by a high velocity accident. We analysed patient comorbidity, ASA score, osteoporosis, social status before accident, additional injuries affecting local soft tissues or other anatomic regions. We analysed the expansion of the fractures, dividing the humerus into five zones. Fracture morphology was categorized according to the standard AO/ASIF classification (if applicable). RESULTS: Comorbidities were found in 76.4% of the patients. Almost all patients (93.1%) had been living independently at home before the accident. 47.2% of patients had osteoporosis in their medical history. Five patients (6.9%) had a primary palsy of the radial nerve. Six fractures chosen for PHNLV fixation were clearly restricted to the humeral head. The remaining 66 fractures were located in the humeral shaft (AO region 12). There were 5 segmental fractures. Of the remaining 67 fractures affecting the proximal third of the humeral shaft 49.3 percent extended into the humeral head. 98 percent of these fractures displayed spiral morphology. DISCUSSION: Proximal humeral shaft fractures are amazingly similar to subtrochanteric and distal tibial shaft fractures: Spiral fracture types with different grades of comminution are absolutely dominant; a great proportion of the fractures extend into the humeral head with growing tendency of displacement if located closer to the humeral head. Diverging traction of deltoid and pectoralis muscle causes typical displacement if the fracture line runs in between their attachments substantiating the term 'intermuscular fracture'. A distinct classification system for proximal humeral shaft fractures seems meaningful and is proposed. CONCLUSIONS: There is clear evidence of specific characteristics which differentiate proximal third humeral shaft fractures from those of midshaft and distal third. They explain the specific problems of reduction and fixation. If disrespected they will lead to higher rates of therapeutic failure.

The Targon PH(®) nail for distal femoral fracture fixation in disabled children. A report of three cases.

UNLABELLED: Recommendations for distal femoral fracture treatment in children with neuromuscular disease are various, including conservative, plating, nailing, and ESIN. All methods have disadvantages. Retrograde femoral intramedullary nailing using a statically interlocked Targon PH nail was performed in three cases. A right nail was used for a right femur (and vice versa). A short nail was used for supracondylar fractures, a long nail for distal femoral shaft fractures. Closed reduction was performed in all cases. Despite osteopenia, small bone dimensions and muscle dystrophy, no intraoperative or postoperative complications occurred. All cases achieved primary stability, allowing immediate rehabilitation. Bone healing occurred uneventfully within four months. No deterioration of functional status or range of motion was seen. There were no peri-implant fractures or hardware removal need over a two-year-period. Retrograde femoral nailing with the Targon PH nail seems to be a reasonable treatment concept for these rare and demanding cases. LEVEL OF EVIDENCE: IV.

[Correlation of patients age on length of stay and admission rate in a German emergency department]. / Auswirkungen des patientenalters auf aufenthaltszeiten und stationäre aufnahmen in einer deutschen interdisziplinären notaufnahme.

BACKGROUND: This study aimed to examine correlations between patient age, length-of-stay (LOS) in the emergency department (ED), admission rate for various medical disciplines and probabilities of admission in a German interdisciplinary ED. PATIENTS AND METHODS: In a retrospective cohort analysis, 7937 patients of the ED were evaluated for age, gender, ED-LOS and admission rate. Rank correlation coefficients were calculated in order to analyze the influence of patient age for each discipline. Statistical tests were performed to evaluate explorative hypotheses on specific discipline influence of patient age. RESULTS: Patients age significantly differed between the disciplines. There was a strong correlation between patient age and LOS for trauma surgery, visceral surgery and ophthalmology. The correlation between patient age and admission rate was highest in patients with problems regarding internal medicine, trauma surgery and neurology. CONCLUSION: There is a correlation between patients age, LOS and admission rate in the ED.

[Management of metaphyseal nonunions of the femur with retrograde nailing]. / Behandlung metaphysärer Femurpseudarthrosen durch Retrogradnagelung.

We report on the therapy of two hypertrophic, metaphyseal nonunions of the distal femur by retrograde nailing. Two patients with an old nonunion were successfully treated only by interlocking the retrograde nail according to the principle of transfixation. Both cases illustrate that an angular stable fixation might be critical to bony consolidation in the metaphyseal region. If toggling of the nail within the medullary cavity is limited by interlocking at appropriate positions, retrograde intramedullary nailing will provide angular stable fixation.