Historical and current treatment of calcaneal fractures.
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Calcaneus↗
Biomedical subjects
H Zwipp
Publications and source records attributed to H Zwipp.
[Effect of logistic and medical emergency resources on fatal outcome of severe trauma].
122 cases of patients who died in sequel of an accident (recruitment period 1993/94, mean ISS 40 +/- 19) in reach of air rescue base Dresden, Germany, were examined. Data were assessed from autopsy protocol and the protocol of the physician who treated on scene. We analyzed the time course of the emergency, the scheduled emergency medical service and the quality of prehospital diagnosis and therapy by the emergency team. The mean response time was 8.1 +/- 5.9 min, the mean distance between EMS bases und incident location 5.9 +/- 5.7 km. In 94.4% of all cases a mobile intensive care unit--with an emergency physician as crew member--was on scene, in 5.6% a paramedic car. Air rescue by helicopter, including an emergency physician, was performed only in 8.7% of all cases although a helicopter was available in 54% of all accidents. Mechanisms of injury were traffic accident (71.4%), fall (14.3), 5.9% accident on building site, shot and stab injuries (5.9%) and burns (1.7%). 82 patients reached the emergency room alive (67.2% mean ISS 37 +/- 18). Only 26% of all patients were transported directly to a level I trauma center. Mean survival time of all 122 patients was 146 +/- 30.4 h. Severe head injury described by autopsy protocol was diagnosed on scene in 82%. Preclinical treatment was:intubation and ventilation (63%), O2 insufflation (17.4%), no specific treatment (19.6%). Severe thoracic trauma was diagnosed in 54%. Preclinical treatment was:intubation and ventilation (64.8%), O2 application (18.8%), no specific treatment (16.2%). Severe thoracic trauma with hemato-pneumothorax (n = 26) was recognized by the emergency physician in 65.6%, specific therapy (application of chest drain) was performed in 7.1%. Preclinical diagnosis rates concerning abdominal trauma were 29% and 27.8% in case of unstable pelvis fracture. Hemorrhagic shock related to these injuries was found in 44.2%, mean resuscitation volume applicated in these cases was 960 +/- 610 ml. Typical faults in diagnosis and treatment were underestimating of severe trunk trauma and non-consistent use of invasive treatment procedures. Primary transport of the severely injured patient to a level I trauma center by helicopter was performed only rarely.
Adult↗
[Fatal aorto-esophageal fistula as a late complication of traumatic aortic rupture].
We report on a case of a 23 years old man who was polytraumatized in a car accident. He survived with excellent clinical outcome, but 113 days after the accident he collapsed, massive bleeding out of the mouth started and the patient died within a few minutes. A gastric ulcer bleeding was assumed, but autopsy showed the break-in of a posttraumatic aortic aneurysm into the esophagus. The difficulties of in time diagnosis of thoracic aorta lesions are discussed.
Adult↗
[Distal radius fracture--is non-bridging articular external fixator a therapeutic alternative? A prospective randomized study].
A randomised prospective study was carried out to compare non-bridging external fixation using a small A0 external fixator with percutaneous Kirschner wire fixation and plaster in the treatment of distal radial fractures (A2/A3 in the A0 classification). The study involved 40 patients, 20 in each group. The advantages of the non-bridging fixation are: (1) early functional therapy of the wrist, (2) simplified reduction of the fracture, and (3) considerable less restriction of wrist mobility in day-to-day situations. Although the final examination 6 months after treatment showed almost identical functional results, the patients treated with the external fixator benefited from the fact that use of the wrist was virtually free throughout the entire treatment period.
External Fixators↗
[Injuries of the tibialis posterior tendon: diagnosis and therapy].
Complete traumatic rupture of the tibialis posterior tendon is absolutely rare. From the scarce case reports in the medical literature a extreme pronation-abduction or pronation-external rotation mechanism according to the Lauge-Hansen classification can be presumed, leading to a malleolar fracture because of forced pronation, external rotation and dorsiflexion of the foot. With primary suture the prognosis is favorable. Traumatic dislocations, mostly with luxatio pedis sub talo, are treated by atraumatic reduction and refixation of the retinaculum. Again, the prognosis is favorable. Incomplete traumatic rupture of the tibialis posterior tendon with development of posttraumatic pes plano valgus, according to case reports and our own experience result from severe pronation-external rotation-soft tissue injuries as well as with pronation-abduction or pronation-external rotation-type ankle fractures. In these cases no macroscopic rupture of the tendon is evident, however occult interstitial micro-ruptures can occur because of excessive stretching, which can be determined histologically. If conservative measures fail, a modified Evans osteotomy to lengthen the lateral foot column is indicated. Degenerative complete and incomplete ruptures of the tibialis posterior tendon are predominantly seen in women more than 42 years old. Staging of this entity can be achieved with clinical tests (muscular force, external rotation), ultrasound, weight-bearing x-rays, CT and MRT. According to the degree of decompensation of tendon function, treatment consists of augmentation, modified Evans procedure or triple arthrodesis of the hind-foot.
Adolescent↗
[Injuries of the pelvic girdle. The pathway to exact diagnosis: which imaging methods are indicated? Synopsis of information].
Synopsis in diagnosis of pelvic ring fractures begins with the help of our senses while taking the history, inspecting and palpating the patient. It is continued with urological, gynecological and neurological assessment of the whole extent of peripelvineal injury. The picture is completed by ultrasonography, standard X-rays and special views, two- and three-dimensional CT and finally MRI. To minimize radiation damage to the patient and to lower the costs for radiologic assessment the standard ap view of the pelvis has to be analysed carefully to avoid numerous special views. Horizontal lines drawn perpendicular to the L5-Sacrum-Symphysis axis are helpful in discriminating rotational and translational instability, quantifying the extent of dislocation and controlling the quality of reduction and internal fixation. In order to avoid missing fractures of the os sacrum, the arcuate lines have to be inspected carefully.
Diagnostic Imaging↗
Bilateral adrenal hemorrhage in blunt abdominal trauma.
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Abdominal Injuries↗
Vascularized double barrel ribs combined with free serratus anterior muscle transfer for homologous restoration of the hindfoot after calcanectomy.
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Accidental Falls↗
Avascular necrosis after minimally displaced talus fracture in a child.
This is a case report of a delayed diagnosis in a 5 year old child who sustained a minimally displaced fracture of the proximal or posterior aspect of the talar neck of the left foot with no subluxation at the subtalar or ankle joint of his left talus. Avascular necrosis (AVN) appeared 6 months after the injury. The further course was protracted with another 12 months of non-weight bearing. The case was followed until 36 months after the injury with nearly full functional recovery. An extensive literature review revealed a calculated incidence of AVN after reportedly non-displaced talus fractures in children of 16 per cent which is considerably more than is reported in adults. Nearly half of all reported cases occurred after the fracture had been missed initially. 8 of 11 cases with reported age occurred between 1 and 5 years. No child was older than 9 years, which indicates that the immature talus may be more prone to AVN. Some possible causes for the higher incidence of AVN in children with non-displaced talus fractures are discussed. Prolonged non weight-bearing cannot be recommended, since it reportedly does not alter the course of the disease.
Ankle Joint↗
[Injuries of the inferior tibiofibular syndesmosis].
The incidence of isolated distal tibiofibular syndesmotic ruptures in acute ankle sprains lies between 1% and 11%. These injuries are frequently overseen or misdiagnosed as anterolateral rotational instability of the ankle and often become apparent through protracted courses. Although the pathomechanics and extent of syndesmotic injuries have been systematically described by Lauge-Hansen and Weber, no generally accepted guidelines exist as to when these complex injuries are to be treated surgically to ensure sufficient and stable healing of the syndesmosis besides correct alignment of the distal fibula. So far, systematic follow-up regarding syndesmotic injuries in ankle fractures is missing, although it has long been recognized that tibiofibular diastasis secondary to chronic syndesmotic instability leads to external rotation of the talus. In combination with a valgus position of the talus, this instability leads to a decrease in the contact area which results in posttraumatic arthritic changes. This paper reviews the standard diagnostic and therapeutic procedures for acute syndesmotic ruptures in fracture dislocations of the ankle. Among the few corrective procedures advocated for chronic syndesmotic insufficiency are tibiofibular arthrodesis, synthetic ligament substitutes, and tenodesis with the peroneus brevis tendon. A sufficient reconstruction must restore the stability of the ankle mortise and alignment of the fibula in the tibiofibular incisura to ensure limitation of talar rotation. Therefore, a tenodesis was developed which substitutes the three important ligaments of the syndesmotic complex. The Casting procedure for chronic syndesmotic insufficiency was modified with reconstruction of the interosseous tibiofibular ligament in addition to the anterior and posterior tibiofibular ligaments. The resulting three-point fixation of the distal fibula appears more anatomically, physiologically, and biomechanically advantageous. The operative procedure is given in detail. Distal tibiofibular syndesmosis. Persistent instability of the distal syndesmosis. Ankle fractures. Syndesmotic screw.
Ankle Injuries↗
[Significance of selenium in regulation of inflammatory response by transcription factors in polytrauma patients. A clinical study].
The authors have investigated the relationship between selenium and transcription factors (NF-kappa B and AP-1) in the field of pathogenesis of polytrauma. Correlations between plasma selenium content and transcription factor binding activity have been found. The measured connecting capacitances of transcription factors have been associated with the severity of disease. To harden the results of this research a randomized double blind study with sodium selenite substitution is necessary next. This study will be to establish the therapy with sodium selenite in the treatment of polytrauma.
APACHE↗
[Low T3 syndrome in multiple trauma patients--a phenomenon or important pathogenetic factor?].
BACKGROUND: Many nonthyroidal illnesses, such as major trauma, severe burn injury, sepsis or immune deficiency are associated with a reduced T3 concentration without increased serum TSH secretion. The pathopysiologic meaning of this phenomenon was controversely discussed since its investigation 20 years ago. The identification of the Type I 5-iodthyronine-deiodinase as a selenoenzyme brought many new aspects into this discussion. PATIENTS AND METHODS: To investigate the correlation of T3 blood levels and the selenium concentrations in consideration of the severity of the nonthyroidal illness 20 patients with major trauma where included in this study. In all these patients frequently T3, T4, fT3, fT4, TSH, Se (whole blood), Se (plasma) and Glasgow-Coma-Scale (GCS), APACHE II and MOF-Score where measured until the 28th day of illness. RESULTS: Five patients (20%) died during the study until the 8th day of measurement. Survivors and nonsurvivors initial showed a low T3 and fT3 level in serum. While the T3 serum concentrations of nonsurvivors remained on a low level the thyronine concentrations of survivors distinctly increased. The measured thyroid hormone concentrations were significantly correlated with MOF-score, APACHE II and inversely with GCS. There was no significant correlation between low T3/fT3 blood levels and low selenium concentrations in all observed patients. CONCLUSION: The selenium deficiency in all patients with major trauma seems to be not the single cause of the low T3 syndrome. The distinctly suppression of TSH could be caused by the action of various cytokines such as IL-6 and TNF-alpha. Further investigations should improve the effectivity of substitution of selenium and/or thyroid hormones in the therapy of patients with severe nonthyroidal illness.
APACHE↗
[Arthrodesis - non-union of the ankle. Arthrodesis failed].
Non-unions after fracture dislocation of the ankle joint are extremely rare with predominantly operative treatment. In contrast, after fractures of the tibial plafond (pilon fractures) infections are seen in the literature in 37 % and non-unions are seen in 27 % after open reduction and internal fixation, requiring secondary ankle arthrodesis in about one quarter of all cases. In contrast to aseptic non-union or arthrosis, which can be salvaged with screw arthrodesis, with prevailing infection and severe osteoporosis external fixation (either one- or two-sided) is the treatment of choice. In isolated non-unions of the malleoli, either plate osteosynthesis with 3.5 low-contact dynamic compression plate or tension banding with autologous bone graft interposition, or alternatively sliding graft technique, is performed with good results.
Ankle Injuries↗
[Treatment of recurrence of fibular ligament rupture. Results of a prospective randomized study].
Previous studies concerning ruptures of the lateral ligaments of the ankle dealt with acute first ruptures. There are a few articles about chronic instability of the ankle but no prospective investigations have been reported concerning the treatment of recurrent ruptures. Good results were obtained following after non-operative treatment of acute ruptures of the fibular ligaments of the ankle joint. This prospectively randomized study was commenced to test whether recidivations of the rupture of the lateral ligaments can also be treated non-operatively or if they are in need of operative repair. The second question to be answered was whether these injuries should be treated differently depending on the treatment of the first rupture. From December 1986 to November 1989, 109 patients with a recidivation of a rupture of the ankle joint lateral ligaments were included in this prospective trial at the Department of Trauma Surgery, Hannover Medical School. They were divided into two groups depending on the therapy used to treat the first injury: The relapse was classified as a second-stage-rupture in cases where treatment of the first ligament rupture did not involve an operation and as a rerupture if the initial rupture was surgically repaired. Half of each group was treated randomly either with surgical ligament repair or without. A total of 100 patients (92%) at an average age of 24 years (11 to 49 years) was seen for follow-up examination one year after the relapse: The follow-up included the patient's subjective assessment, a clinical examination, and stress radiography. A 70 point score was used for evaluation of the total result. Two wound infections requiring reoperation were observed in the operative treatment groups. The follow-up examination revealed better results in both operative treatment groups (A and C), which was statistically significant (P < 0.05). Patients with a second-stage-rupture showed a significantly higher (P < 0.001) stability by stress radiography after surgical treatment (group A) in contrast to non-operative treatment (group B). In addition, the subjective and clinical results indicated a tendency towards better results which were not statistically significant (P < 0.09 and P < 0.07). In cases of rerupture the patient's subjective assessment revealed significantly more (P < 0.05) complaints after non-operative treatment (group D). Clinical results were comparable, and radiologic assessment showed a tendency towards higher joint stability after surgical treatment (group C), although it was not statistically significant (P < 0.07). Based on the results presented, the authors recommend the surgical repair of ankle joint ligaments in cases of second-stage- or rerupture.
Adolescent↗
[Fractures of the foot region of car drivers and passengers. Occurrence, causes and long-term results].
During 1973 and 1989, 6,378 car accidents with 8,931 injured persons were evaluated in the area of Hannover. 3,267 car drivers and passengers sustained fractures overall and 148 (4.5%) fractures of the foot. A major role in the etiology of the foot fractures evolves from the deformation of the foot room. Driver and front seat passenger showed similar injuries. Among the 286 single fractures, the forefoot was affected most often (45%), followed by ankle (38%), midfoot (11%) and hindfoot (6%). 5% were open fractures. The long term results were estimated upon the limitation of working ability caused by the foot injury in relation to the entire working ability. The evaluation concludes that the foot fractures especially in combination with other injuries were frequently not recognized within the primary examination and therefore underestimated. The long-term outcome leaded to a high degree of impairment due to foot fractures.
Accidents, Traffic↗
[Lisfranc arthrodesis after malunited fracture healing].
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Arthrodesis↗
[Lisfranc arthrodesis after malunited fracture healing].
The causes of residual deformity with posttraumatic painful arthritis after tarsometatarsal (Lisfranc) fracture-dislocation with the need for correctional arthrodesis are in our experience (22 cases over 5 years) overseen injuries in one third, closed reduction and immobilisation or inadequate fixation technique with K-wires in another two thirds of cases. Foot malalignment and residual instability is assessed with weight-bearing radiographs of both feet, adduction/abduction stress films and CT scans for complex deformity. Correction is carried out via two longitudinal dorsal incisions, strict epiperiosteal preparation and debridement of the Lisfranc joint of all remaining cartilage, sclerosis and fibrous tissue. Reorientation begins, in the same manner as primary open reduction, with anatomical alignment of the second metatarsal base to the second cuneiform. Defects are filled with autologous bone grafting, stable fusion can be achieved with 3.5 mm cancellous compression screws. Full weight bearing is allowed in a modelled plaster shoe for 6 to 8 weeks. The functional medium-term results are convincing with 15 of 17 patients seen after 13 months of follow-up working full time. The Maryland Foot Score improved from 38.9 to 76.8 points in these patients.
Adult↗
[The Charcot joint].
Charcot foot in its original sense is equivalent to stage 4 of hereditary motor and sensory neuropathy (HMSN) which is known as Charcot-Marie-Tooth disease since 1886. This entity, which can be subdivided into 3 groups including subgroups, predominantly begins during childhood and progresses slowly. The first symptom, often unnoticed by the patient for a long period, is weakness of the intrinsic foot muscles with consecutive hammer-toe formation and mobile pes cavus. Progredient atrophy of the peroneal, extensor, tibialis posterior and finally triceps surae muscles leads to fixed pes cavus varus excavatus with severe varus deformity of the hindfoot, secondary varus position of the talus at the ankle level and subsequent arthrosis of the medial compartment. Permanent varus deformity of the ankle almost invariably leads to stress fractures of the malleoli because of repetitive microtrauma (stage 5 of HMSN). Early detection of the disease with nerve conduction studies at clinical suspicion allows tibialis posterior transfer, correctional osteotomy of the hindfoot or arthrodesis of Chopart's or Lisfranc's joint and can postpone or prevent the otherwise inevitable triple arthrodesis which has a less favorable long-term prognosis. At stage 4 (manifest Charcot foot) and stage 5 (neuropathic fracture of the ankle) a reorientating ankle arthrodesis is advocated, with additional subtalar pathology correctional double arthrodesis becomes necessary. In diabetic arthropathy of the ankle (Type IV according to Sanders and Frykberg), which is often referred to as "Charcot Ankle", tibiocalcanear arthrodesis is indicated. In case of supervening infection or extensive necrosis a modified Pirogoff amputation is carried out as a salvage procedure. Doubled periods of non weight-bearing, immobilization and brace protection of the ankle help to reduce the frequently observed implant failure in both forms of osteoarthropathy. In addition to stable implants retrograde calcaneotalotibial transfixation with a Steinmann pin may help to protect the achieved result despite prolonged bone consolidation.
Adult↗