Intraoperative assessment of the spinal canal during dorsal instrumentation for vertebral fractures which narrow the canal is facilitated by myelography. However, the flow of contrast medium around a displaced fragment may result in an erroneous interpretation of canal patency. By performing myelography prior to instrumentation and reduction of the fracture, a chance in myelography-findings after reduction can clearly be caused only by successful repositioning of the displaced fragment. The possibility of an incorrect interpretation of the investigation can thus be reduced.

Fracture Fixation, Internal↗

PubMed1992

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

Adolescent↗

PubMed1992

[Fractures of the proximal humerus. Classification and treatment principles].

The therapeutical strategy for fractures of proximal humerus is pointed out both by Neer's and by AO classification. Thus closed functional treatment is indicated in case of all undislocated or minimally displaced fractures. Conservative management is indicated for all reducible fractures as well. Severe and irreducible bone lesions i.e. three and four part fractures with or without dislocation are to be handled primarily by operation. Dislocated fractures require an emergency procedure. The operative strategy has to be suitable for the type of fracture. Stable T-plate osteosynthesis is preferred for simple fractures (i. e. Type A2 or A3 according to the AO classification). Serious bifocal and articular bone lesions are sufficiently managed by minimal internal fixation (osteosynthesis) especially in regard to the biological aspects. The sincere contact of bone fragments accompanied by sufficient anatomical axis should be the aim of the operative strategy. Manifold expedients for reduction like temporarily applied Steinmann pins are necessary. Larger lesions of spongiosa can mostly be substituted by autoclaved spongiosa transfer. As minimal osteosynthesis led rarely to necrosis of the humeral head it is preferred especially in case of severe fractures. According to our therapeutical draft head preserving procedure had the priority to primary humeral prosthetic arthroplasty.

Follow-Up Studies↗

PubMed1992

[Significance of ligamentotaxis for internal fixator osteosynthesis in fractures of thoracic and lumbar vertebrae].

Between 1985 and 1990 104 operations on the lower thoracic and lumbar spine using the AO-internal spinal fixation system were performed. The preoperative computed tomography (CT) scans as well as either the postoperative CT scans or the CT scans taken after implant removal of 41 cases were available for evaluation of the narrowing of the spinal canal and the subsequent fracture reduction by means of computer-aided planimetry. It is shown that a near normal reduction of the spinal canal through ligamentotaxis is achieved for a fracture between T 12 and L 2, whereas for fractures between L 3 and L 5 an incomplete reduction is observed. A correlation between the neurologic deficit and the degree of narrowing of the spinal canal could not be established. Obviously, the damage to the spinal cord is determined primarily through the dynamic forces of the impact. Also no statistical correlation could be demonstrated in our cases of the time interval between accident and operation to the degree of reduction of the fracture achieved.

Humans↗

PubMed1992

[Osteosynthesis in dislocated fractures of the humerus head].

The operative treatment of displaced fractures of the proximal humerus has changed during the last few years. Minimal osteosynthesis takes into consideration to a great extent the biological aspects of these fractures and provides sufficient stability for early functional therapy. Neer's classification has proved very useful for both the indication for and the choice of an operative procedure. The high necrosis rate of the operatively stabilized humeral head has considerably influenced the operative strategy. This is shown in two separately controlled patient groups. From 1970 to 1980, 65 patients and from 1983 to 1987, 30 patients with displaced fractures of the proximal humerus were treated operatively. Within the first group, in more than half the cases a T-plate osteosynthesis was performed, a minimal osteosynthesis being performed in only 1 out of 5 patients. In the second group, we exclusively performed minimal osteosynthesis. More favourable results were achieved in fractures with two or three fragments, in younger patients and in isolated shoulder injuries than with four-fragment fractures or luxated fractures, in older and in polytraumatized patients. Using minimal osteosynthesis instead of plate osteosynthesis in four-fragment fractures, functional results were achieved which, in 75%, were satisfactory or better. The necrosis rate of the humeral head also declined. We conclude that head-preserving methods seem advisable in these severe forms of humeral fractures.

Adolescent↗

PubMed1992

[Early and late results of 200 DHS osteosyntheses in the reconstruction of pertrochanteric femoral fractures].

We have treated more than 600 cases of trochanteric fractures by internal fixation with the dynamic hip screw. Between 1986 and 1988 we treated exactly 200 patients in this way, who were subsequently observed over follow-up times averaging 24 months. In 1% of this group we performed early revision osteosynthesis because of incorrect positioning of the lag screw; deep infections occurred in 2.5%; and in 6% revision interventions were necessary because of local hematomas. Late complications were necrosis of the femoral head (1%) and pseudarthrosis after head necrosis (0.5%). No reinterventions were necessary because of implant failure.

Aged↗

PubMed1992

[Initial results with the ball joint fixator].

The ball-joint fixator is a one-plane external fixator system that allows correction of the reduction postoperatively. Dynamic axial loading is made possible by a telescoping device. Between January 1987 and June 1991, 312 external fixators were applied in the Department of Trauma of the Surgical University Clinic in Freiburg/Breisgau. In 25 of these cases the ball-joint fixator (Unifix) was used. The study includes 16 open and 8 closed tibial fractures and 1 open femoral fracture. The pin-tract infection rate was 14%. In 16 patients a cast was necessary for a short time after the fixator had been removed, and 3 other patients needed intramedullary nailing. The long-term complications observed were osteitis pseudarthrosis and refracture (in 1 case each). The ball-joint fixator is a device that can be applied very easily and quickly. It can be used to advantage in the treatment of multiple trauma patients with open tibial fractures. Because of the fixed distance between the pin clamps there is no advantage over the original AO fixator in fractures where the telescoping mechanism cannot be used.

Adolescent↗

PubMed1991

Monitoring the response to injury.

Tissue trauma leads to a severity-dependent activation of plasma and cellular systems. This response can be recorded by determining parameters which represent the activation state of these systems. In severely injured patients with multiple trauma three out of 14 parameters measured at the time of admission proved to be indicators of subsequent septic complications with a high degree of accuracy: Fibrinopeptide A (FPA--the first split product of fibrinogen), the C3 split product C3a, and the elastase-alpha 1 proteinase inhibitor-complex (E alpha 1 PI). In a second series of multiple-injured patients with femoral fractures who did not develop clinical sepsis (N = 25) these parameters were measured continuously to evaluate the influence of injury severity and of therapeutic strategy on the further course. We found a strong correlation between injury severity (ISS) and the degree of activation. The signs of activation decreased rapidly following immediate operative fixation, and remained elevated or even increased after primary femoral traction and secondary stabilization. The operative procedure did not cause any additional activation. Complications such as infection or the formation of haematomas were reflected by raised parameter levels.

Adolescent↗

PubMed1991

[Traumatology in the elderly. Treatment concept in per- and subtrochanteric fractures in the elderly].

The aim of treatment of trochanteric fractures in the elderly patient is a prompt procedure, which allows early load bearing. Between 1986 and 1988 272 patients were treated with per- and subtrochanteric fractures: pertrochanteric fractures were stabilised by means of the dynamic hip screw (DHS), subtrochanteric fractures via the 95 degree condylar plate. With both methods an early mobilisation of the patients is possible. In 70 per cent of cases treated with DHS, early load bearing could be achieved within one week. 80 per cent of the patients were operated on within the first 24 hours after trauma. Complications of the methods (incorrect position of the lag screw, plate protrusion) were seen in one case in each group. The overall infection rate was 2.2 per cent. Hospital mortality was 10 per cent. On reviewing the results obtained, we approved of the concept of treatment.

Aged↗

PubMed1991

[Does covered tibial intramedullary nailing promote formation of a compartment syndrome? Perioperative and intraoperative continuous monitoring of compartmental pressure in covered tibial intramedullary nailing].

Between October 1988 and October 1989 we performed a continuously pressure monitoring with the infusion technique in the tibialis anterior and deep posterior compartment of the lower leg during the nailing of the tibia in complete fractures of the lower leg in 16 patients. We set up 2 groups of patients because of different pathophysiological conditions: patients, who were operated on a few days after trauma (Group A) and patients operated on months after the trauma (Group B) because of non-union of the tibia. The effects of the preoperative, intraoperative, and postoperative manipulations were recorded. In no case we saw a beginning compartmental syndrome, although very high pressures of 100 mmHg in Group A and 55 mmHg in Group B in the deep posterior compartment during reduction of the fracture were registrated. The registrated pressures correlated very well with the manipulations during the operation and were absolutely reversible after the ending of these manipulations. In our observation the closed tibia nailing does not favorize the development of a compartmental syndrome, if not done during the vulnerable phase after the first days after trauma, in blunt multiple trauma patients and during bleeding complications.

Adult↗

PubMed1991

[Osteosynthesis of the clavicle. Indications, surgical technique, results].

The osteosynthesis of the clavicle should be the exception and should only be indicated in the case of complicated fractures. The high rate of pseudoarthrosis given in medical literature, is due to errors in indication, selection of implants and in surgical techniques. Procedures like intramedullar wiring, axial screwing and single cerclage-wire suture are unsuited for osteosynthesis of the clavicle. After osteosynthesis of the clavicle we have found exceptional positive results, with respect to functional, radiological and after subjective evaluation, at a low rate of complication without any consequences occurring in the years to come. These results show, that mainly good or even excellent success can be achieved, at a limited indication, combined with careful surgery and a standardized surgery procedure of osteosynthesis of the clavicle.

Adolescent↗

PubMed1991

[Experimental studies of the stability behavior of the coxal end of the femur after montage and removal of DHS implants in the intact cadaver femur].

After experimental implantation in non-fractured cadaver femora, the ASIF dynamic hip screw system supported the femoral neck and the lateral proximal femur and prevents deformation, depending on the vector of the resultant force. Three positions of weight-bearing were simulated: near-axial loading of the femoral neck, standing on one leg and standing on two legs. After removal of the metal the bone breaking point was markedly lowered.

Biomechanical Phenomena↗