Biomedical subjects
Publications and source records attributed to J Poigenfürst.
After a fracture of the medial part of the clavicle cardiac arrest occurred. This complication can be explained by vagus irritation because of fracture haematoma. The patient survived and was, six months later, of best health.
A total of 131 fractures of the clavicle were operated on in 129 patients. There was no bony infection or infected pseudarthrosis. Four clavicles refractured after removal of the plate and five operations led to pseudarthroses which were successfully treated by reoperation. Radiological and clinical results in the majority of the re-examined patients were excellent. Indications, operative technique and causes of poor results are described.
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Unstable subcapital fractures and dislocation fractures of the humerus can usually be set by closed reduction. Stabilization of these fractures by intramedullary pins is a method which avoids damage to the soft tissues around the shoulder. Since 1985, elastic steel pins with special features have been in use. The last 20 mm of the tip of the pins is angulated at 15 degrees, and the distal end is curved in a special way for the last 20 mm. According to our experience, the results after using this method in the treatment of unstable fractures of the surgical neck (ASIF type A II/2) and dislocation fractures (ASIF type A III/2) are fair to very good. For unstable fractures (ASIF type C I/2) and other dislocation fractures (ASIF type C III/2), the method is only suitable if good reduction is possible. Between the end of February 1985 and the end of December 1990, 101 fractures of the proximal end of the humerus were treated by closed reduction and fixation with intramedullary pins. Following fractures in the anatomical neck, aseptic necrosis of the fragment of the head leads to unfavorable results. In two patients, pseudarthrosis with poor function developed. Disturbance of wound healing, postoperative hematoma, infection, myositis ossificans, or Sudeck's desease have not been observed.
In the care of pelvic injuries complications arise because of organizational and technical factors, some of which are described here. The following measures are important: autotransfusion, emptying the bladder and catheterization, checking and protection of the colon, correct management of the operation table, and prophylactic measures to avoid thrombosis. From an operational/technical point of view, it is most important that a larger with good exposure route be chosen that takes the anatomical structures into account. Of 123 cases, 20% were not ideally reduced. Twice massive bleeding occurred from the A. glutea superior, once the sacral dura was opened without any adverse effects, infection occurred 8 times and 10 times peroneal paralysis was observed.
25 fractures of the lateral end of the clavicle were treated during the last six years. 22 of them were unstable because of additional rupture of the coracoclavicular ligaments. Only in two patients conservative treatment was successful, in six cases conservative treatment was unsuccessful. Altogether 20 fractures had to be operated. Coracoclavicular screw fixation (Bosworth) is recommended for simple fractures and plating for multifragmental injuries. Operative methods using K-wires are frequently impaired by wire-migration and therefore require a longer period of external immobilization. Independent of the type of surgery objective and subjective results were equally good.
A case of simultaneous dislocation-fracture of both ends of the right clavicle in a 17-year old patient is being described. Treatment consisted in operative reduction of both injuries. The sterno-clavicular joint was stabilized by a transarticular K-wire, the acromioclavicular injury was treated by extraarticular tension-band-wiring. Healing was without complications and the result 37 months after injury was excellent.
Forearm diaphyseal fractures in children are commonly treated by conservative management. In about 5% of cases, however, unstable fractures occur and require surgical intervention. We prefer the intramedullary pinning procedure, which has already been published in a similar version in 1913 by Schöne and in 1947 by Bsteh. 41 patients were followed up between 1979 and 1988. One instance with a severe infection of a second-degree open fracture required two reoperations and was completely restored with a very good result. An overall assessment of our collective yielded 31 patients with findings rated as very good, four patients rated as good, five as satisfactory and one as moderate.
A series of 35 proximal humeral fractures treated with flexible intramedullary pins between 1986 and 1988 are presented. Special design features of the pins include a proximal 15 degrees angulated 20 mm tip and a 20 mm curve distally. The method is suitable for fractures in the surgical neck with displacement of bone width (AO-type A2/2). In cases of fracture-dislocation or three- or four-part fractures it is only suitable when the fragments can be reduced satisfactorily. Complications are minimal with 95 per cent bone union.
If the iliotibial band should have a satisfactory function in order to improve suture or replacement of the anterior cruciate ligament the best point of fixation for tractopexy is the slope from the lateral femoral condyle to the femoral shaft in its dorsal third. In addition the position of the knee joint at the time of fixation is of importance. The angle should theoretically be 43 degrees.
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We report on 2 cases with complications after implantation of Biorod. These seem to be the result of tissue reaction to the material. According to the manufacturer, such complications have been observed in 6 to 10% of the cases. These observations have not been published so far.
Oto-audiograms were taken from 50 patients following skull and brain injuries. 22 of them (44%) showed a deterioration of their hearing which was of traumatic origin with high probability. 10 of them (20%) had deterioration of their hearing which was most questionably caused by the trauma. Between 1 and 1 1/2 years later 19 from 22 respectively 9 from 10 patients were reexamined all together. There were 9 improvements, 5 deteriorations and 10 unchanged oto-audiograms. As many injured people do not realize a one-sided deterioration of their hearing, oto-audiograms should routinely be made after head and brain injuries. The secondary deteriorations observed, demonstrate the necessity of otologic aftercare.
Early results obtained in 23 Monteggia-type fractures were analysed. Osteosynthesis of the fracture of the ulnar shaft has to be carried out according to the art. Application of a plate on the radial or the ulnar side always leads to secondary angulation. If primary resection of the radial head is carried out poor results must be expected. The fractured radial head should be reconstructed, replaced by an implant, or at least left in place until the fracture of the ulna is consolidated. In Monteggia type-I/6 fractures the coronoid process must be reliably stabilized. Conservative treatment is inadequate for Monteggia-type fractures.
This report deals with the surgical technique and the results of stabilisation of 10 medial ankle fractures using Biofix C rods. They are cylindrical, biodegredable rods. Biorod is constructed of self-reinforced composite material. It consists of polyglycolide matrix with polyglcolide fibers. The bending strength of the material before operation is more than 200 MPa, exceeding 20-30 times the strength of cancellous bone. The material looses its mechanical strength in hydrolitic conditions during 5-6 weeks and dissolves totally during the following months. Our experience with a self developed guiding tool for the implantation of the Biorod is presented. All fractures healed without any notable complications. As of the 8th day full weight bearing was allowed in a below knee plaster cast for 6 weeks.
According to our results, permanent epidural anaesthesia was significantly superior to systemic opioid treatment in patients with serial rib fractures. The main advantages were not only continuous pain relief despite the fact that the nonepidural control group required more than twice the dosage of morphine derivatives; also, the respiratory and pain-related recovery time was reduced. Another advantage was the selective effect (due to the local application) on respiratory pain and therefore on respiration as a whole. Deep breathing and expectoration were easier, so that the use of respirators and other artificial breathing aids could be avoided or at least reduced in duration in some cases. This makes the method particularly suitable for use in the management of polytraumatized patients. The standard dose was a mixture of 3.3 mg morphine and 37.5 mg bupivacaine (= 1/3 ampoule morphine + 15 ml Carbostesin 0.25%) every 12 h. When morphine was temporary contraindicated (frequently the final diagnosis in the case of an "acute abdomen" delayed the administration of morphine) the use of bupivacaine alone provided a satisfactory result for a certain time (we never observed tachyphylaxis). Additional systemic pain relievers were only necessary when the patient was suffering from pain caused by other injuries beyond the area of effectiveness of the epidural catheter (the only obvious disadvantage of the local application technique). On the other hand, epidural anaesthesia enabled us to treat a patient's lower-leg fracture by interlocking nailing, while adding only 0.01 mg fentanyl (= 2 ml Fentanyl Janssen) and 1.2 mg flunitrazepam (Rohypnol).
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