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PubMed1996

[Functional fracture treatment of the upper arm].

Using a functional brace, we treated 67 patients who had a fracture of the humeral shaft over a 5-year period from 1987 to 1992. We analysed several parameters of the fractures to discover those which influence healing. Desault, plaster cast or traction were used before applying a brace in an average time of 15 days. The osseous consolidation was 10 weeks in the average. The functional results were very good and good in 78.3%, acceptable in 18.3% and poor in 3.4% of the cases. Twelve humeral-shaft fractures were associated with a radial nerve palsy. Every patient recovered a full radial nerve function under the treatment with a functional brace. The retentive management of an operative treatment of humeral-shaft fractures associated with a nerve injury can be supported because of our experience.

Adult↗
PubMed1997

Wear in the upper and lower incisors in relation to incisal and condylar guidance.

The incisors of 85 patients were examined for tooth wear with the aim to evaluate possible association between the degree of wear and anterior guidance. Apart from clinical functional analysis electronic axiography using the system CADIAX was carried out. Anterior guidance in protrusive movement was marked on individually mounted plaster casts and scanned using a pantograph. The cephalometric analysis program CADIAS was used for the metric determination of the anterior guidance angle to the axis-orbital plane, and in order to relate the anterior guidance to the horizontal condylar inclination. The interincisal angle was included in the evaluation as a further functional angle and according to overjet and overbite there were classified typical incisor relations. Where both anterior guidance and incisor inclination and relation were in the normal range, there was an increase in incisal tooth wear in the group investigated. With reduced functional space, frequently found together with anterior deep bite, incisor wear was less extensive. While the occurrence of parafunction was shown not to be related to anterior guidance and incisor inclination and relation parafunctions were the decisive factor in the occurrence of severe incisor wear. Where anterior guidance and incisor inclination and relation are normal, the area of enamel under load is smaller and the space for bruxism larger. Parafunctional forces thus appear to result in a higher degree of wear than is found with the reduced functional space of a steep incisor position. Anterior guidance could not be evaluated as a parafunctonal inducing factor, but only as determining the wear pattern in the individual.

Adult↗
PubMed1986

Freeman-Sheldon syndrome: report of three cases and the anaesthetic implications.

The Freeman-Sheldon syndrome is a rare congenital myopathy and dysplasia. Fibrotic contractures of the facial muscles result in the characteristic "whistling face". Difficulties with intubation may be attributed in part to microstomia and micrognathia. In addition to other deformities, limb myopathy results in ulnar flexion contractures of the hand and equinovarus/valgus deformities of the feet. Intravenous access may be difficult because of limb deformities and thickened subcutaneous tissues. Limbs may be encased in plaster casts or splints limiting the available sites for venepuncture. Three case reports of children with Freeman-Sheldon syndrome are presented. The pathophysiology and anaesthetic problems encountered are discussed.

Anesthesia↗
PubMed1985

Anaesthetic management of posterior lumbar osteotomy.

Sixty-four cases of posterior lumbar extension osteotomy performed at the Toronto East General Hospital between 1969 and 1983 are reviewed. The anaesthetic management is presented. The procedure was performed with local infiltration anaesthesia, heavy sedation and a brief period of general anaesthesia induced with nitrous oxide, halothane or ketamine. Five stages in the anaesthetic management are distinguished, each in relation to a phase of the surgical procedure and drug usage. A method of supporting these deformed patients in the prone position in moulded plaster casts is described. Anaesthetic and surgical complications and postoperative psychological disturbances are described and discussed. It is suggested that caudal epidural opioid or local anaesthetic analgesia be explored as an aid in the management of these patients.

Adult↗
PubMed2003

The Grummons face mask as an early treatment modality within a class III therapy concept.

BACKGROUND AND AIM: An underdeveloped maxillary complex is a major cause of the problems underlying skeletal Class III cases. The efficiency of early orthodontic therapy is shown with reference to a treatment method acting primarily on the maxillary complex. PATIENTS AND METHOD: The collective comprised 21 patients whose orthodontic therapy at the age of 5 to 9 years was invariably started with a palatal expander. This was followed by further development of the nasomaxillary complex, using a Grummons face mask for a period ranging from 3 to 15 months. With reference to findings from plaster casts and lateral cephalograms, the efficiency of early treatment as an important part of the overall therapy concept was evaluated. RESULTS: The mean improvement in anterior overbite was 3.4 mm. The lateral cephalograms revealed a marked improvement in the distance between the upper first molars and the pterygoid vertical (+ 4.1 mm), in the convexity of A (+ 2.2 mm), and in the SNA angle (+ 2.3 degrees). CONCLUSION: Early treatment combining rapid maxillary expansion and Grummons face mask resulted in a decisive improvement in the sagittal-basal relations.

Cephalometry↗
PubMed2004

Rapid maxillary expansion with palatal anchorage of the hyrax expansion screw--pilot study with case presentation.

BACKGROUND: Rapid maxillary expansion (RME) with the appliance fixed at the crowns of the first premolars and molars leads not only to transversal expansion but also to tipping of the anchorage teeth and a risk of increased tooth mobility as well as of root and bone resorptions. These disadvantages were to be avoided by fixing the transversal screw directly to the hard palate. MATERIAL AND METHOD: Following preliminary experimental work to determine the extent to which the hard palate could be loaded with orthodontic implants, two female patients were treated for extreme transverse maxillary deficiency using a Hyrax expansion screw fixed on one side with an implant with the following dimensions: length 4.0 mm, diameter 3.5 mm, abutment diameter 5.00 mm (EO implant, Straumann, Freiburg i. Br., Germany), and on the other side with a bone screw between the roots of the second premolars and the first molars. Presurgical osteotomy according to Glassmann was followed immediately by loading, i. e. by expansion through activation of the screw several times per day. Additional anterior guidance of the right and left maxilla was provided by crossed segmented archwires and a tension coil spring for space opening in the incisor region. After adequate expansion by 8.0 mm and correction of the position of the buccal teeth, the Hyrax expansion screw and the osteosynthesis screw were removed. The implant served as orthodontic anchorage for a molar-to-molar transpalatal bar aimed at preventing relapse. RESULTS AND CONCLUSIONS: The tooth axis inclination measured on cut sections of the plaster casts made at the beginning and end of treatment was largely without transversal discrepancies. Direct fixing of the transversal screw in the palatal arch prevents buccal tipping of the posterior teeth, especially in patients with a small apical base. Compared with other direct procedures involving osteosynthesis plates, this technique offers adequate guiding stability and is minimally invasive.

Adult↗
PubMed2005

Epidemiology of Hoffmeister's genetically determined predisposition to disturbed development of the dentition in patients with true skeletal class III malocclusion.

AIM: The prevalence of symptoms of Hoffmeister's "genetically determined predisposition to disturbed development of the dentition" as studied in patients with true skeletal Class III malocclusion; results of the study were compared with those found in the scientific literature regarding samples from the normal population and from orthodontic patients. PATIENTS AND METHODS: The prevalence of 20 defined symptoms was evaluated in 120 patients with true skeletal Class III malocclusion. The patients were selected on the basis of a positive family history and on the presentation of typical characteristics of a skeletal Class III morphology in a lateral cephalogram. The mean age of the patients evaluated was 12.4 years. The patients' files, 1161 radiographs and plaster casts were analyzed. The prevalence of the individual symptoms was compared by means of the chi(2)-test (p < or = 0.05). RESULTS: 118 patients (98.3%) were found to have 292 symptoms of "genetically determined predisposition to disturbed development of the dentition". Increased distance between molar buds, atypical tooth bud position and atypical root shape were the symptoms recorded most frequently. With regard to the simultaneous existence of several symptoms, the combination of four such symptoms was most frequent (20.8%), followed by the combination of three symptoms (15.8%), and five symptoms (15.0%). Congenital hypodontia was found in 19.2% of the patients. CONCLUSION: It should be kept in mind for patients with true skeletal Class III malocclusion that this type of dysgnathia is most likely combined with other symptoms of disturbed development of the dentition. The higher prevalence of those symptoms found in patients with skeletal Class III malocclusion when compared with the normal population and other orthodontic patients renders orthodontic treatment of those patients more difficult and calls for comprehensive clinical and radiological examination prior to any treatment.

Adolescent↗
PubMed2005

[Partial midcarpal arthrodesis with excision of the scaphoid for the treatment of advanced carpal collapse].

OBJECTIVE: To eliminate painful arthrosis between the radius and scaphoid and between the lunate and capitate. Stabilization of the carpus with preservation of useful range of motion between the radius and the lunate. INDICATIONS: Painful arthrosis of radioscaphoid joint due to an old lesion of the scapholunate ligament or a long-standing scaphoid pseudarthrosis with loss of carpal height (advanced carpal collapse, stage II) and eventual additional midcarpal arthrosis (stage III). CONTRAINDICATIONS: More complex Damage of carpal ligaments. Arthrosis of radiolunate joint. Ulnar displacement of the lunate. Rheumatoid arthritis. Calcium pyrophosphate deposition disease (relative). SURGICAL TECHNIQUE: Dorsal approach. Excision of scaphoid. Removal of articular cartilage between capitate and lunate and between hamate and triquetrum. Repositioning of capitate in relation to the lunate. Osteosynthesis with several Kirschner wires. POSTOPERATIVE MANAGEMENT: Immobilization in a plaster cast for 8 weeks; then, early removal of the wires. RESULTS: From 1993 to 2001, 64 partial midcarpal arthrodeses with excision of the scaphoid were performed in 62 patients. 26 of the patients operated up to 1999 were followed up for 27 months and evaluated with the Cooney Score and the DASH Score. The Cooney Score significantly improved, from 46 points preoperatively to 76 points postoperatively. Postoperative DASH Score was 22. Postoperative range of motion, 64 degrees extension/flexion, had hardly changed compared with the preoperative value. Strength increased from 24 to 34 kg on average. Out of the 55 patients available for follow-up (29 interviewed by telephone) 35 were completely satisfied, 13 satisfied with reservations, and seven dissatisfied. 24 patients had no activity-related pain. Different degrees of activity related pain were reported by 28 patients, and pain during minor activities or at rest was reported by three patients.

Arthralgia↗
PubMed2005

[The dorsolateral approach to the ankle for arthrodesis].

OBJECTIVE: Bony fusion of the ankle in functional position. Restitution of a pain-free use of the limb. INDICATIONS: Joint destruction not amenable anymore to conservative treatment modalities. Chronic instabilities of diverse causes. CONTRAINDICATIONS: Severe general and metabolic diseases. Extensive scarring at the posterior aspect of the ankle. SURGICAL TECHNIQUE: Posterolateral approach to the ankle. Fibular osteotomy and resection of a 1 cm long bone block from its diaphysis. Removal of articular cartilage of tibia, talus, and lateral malleolus. Plantigrade positioning of the talus under the tibia in slight external rotation. Internal tibiotalar screw fixation. Fixation of the lateral malleolus to tibia and talus with screws. POSTOPERATIVE MANAGEMENT: Plaster cast for 2 weeks without weight bearing followed by partial weight bearing in an ankle-foot orthesis with a rocker-bottom sole until radiologic evidence of bony fusion. RESULTS: 26 patients (21 men, five women, average age 55 years (21-83 years) underwent a total of 29 ankle arthrodeses. Minimum clinical and radiologic follow-up of 1 year. All patients were able to bear full weight between the 2nd and 3rd postoperative month. All patients could be reached by telephone 1-14 years after surgery. Screws had been removed in six of the patients. The activities of daily living were assessed on a visual analog scale (0-10 points); they had improved from 2.5 points preoperatively to 8.3 points postoperatively. All patients stated they would undergo this operation again. 16 patients were physically active and participated in sports such as bicycling, hiking and swimming.

Adult↗
PubMed1997

[Reconstruction of thumb through continuous lengthening of the first metacarpus.].

GOAL OF SURGERY: Reconstruction of the amputated thumb through continuous distraction with an Ilizarov ring fixator. INDICATIONS: Traumatic loss of thumb at the level of the proximal half of the proximal phalanx. CONTRAINDICATIONS: Insufficient soft tissue coverage of stump. Stiff saddle joint. POSITIONING AND ANAESTHESIA: Tourniquet. Brachial plexus or general anaesthesia. SURGICAL TECHNIQUE: Installation of a ring fixator. Incomplete osteotomy at mid shaft of first metacarpus with chisel and completion through osteoclasia by twisting the chisel. Preserve palmar periosteum. Deepening of first web space if necessary after removal of external fixator. Use of Z-plasty and proximal transfer of adductor pollicis insertion. POSTOPERATIVE MANAGEMENT: After 1 week continuous lengthening 0.7 mm/day in 3 daily increments. After removal of fixator plaster cast for 2 weeks. POSSIBLE COMPLICATIONS: Improper installation of fixator. Incomplete osteotomy. Too rapid or too slow distraction. Pin tract infection. Deep infection. RESULTS: Over a 2 year period 10 lengthenings. Average follow-up 23 months (10 to 36 months). Average gain in length 38.1 mm. Average length of treatment 163 days. Deepening of web space in 7 patients. Force of grasp 64% of opposite side. Pin tract infection: 4, too early removal of fixator: 1, revision of scar: 1 and correction of stump: 1. All patients were satisfied with the result but for scar at web space.

English Abstract↗
PubMed1996

[Current status of treatment of Achilles tendon ruptures. Results of a nationwide survey in Germany].

In a standard questionnaire distributed nationwide, we questioned staff from 1307 clinics (surgical, trauma-surgical, orthopedic), of which 787 clinics (60.2%) answered by letter. In 698 clinics (88.7%), operation is considered the standard therapy. Seventy-five clinics (9.5%) use both conservative and operative therapy (average postoperative rate of complication 3.5%). Only 14 hospitals (1.8%) treat strictly conservatively. The average rate of reruptures is 1.6% in the operated group (77.7% postoperative plaster cast fixation) regardless of postoperative treatment; the conservative group (96.1% functional treatment) showed 2.7% reruptures. Thus, operation is the standard therapy for fresh ruptures of the Achilles tendon in Germany. However, there seems to be a trend towards conservative functional therapy.

Achilles Tendon↗
PubMed1998

[Closed rupture of the tendon of the anterior tibial muscle].

Closed rupture of the anterior tibial tendon is rare. Fewer than 50 cases have been reported in the literature, perhaps because the symptoms are often neglected by the patient as well as by the doctor. Most often the rupture occurs as a consequence of a sudden plantar flexion of the ankle and pre-existing degenerative changes of the tendon tissue due to systemic disease or iatrogenic local corticoid injections. Clinically, the tendon rupture presents as acute weakness of the ankle extensors without reddening, swelling or neurological signs. Differential diagnoses such as anterior tibial syndrome and peroneal nerve palsy can thus be excluded. During the clinical examination the distal stump and the discontinuity of the anterior tibial tendon are often palpable. The clinical diagnosis can be confirmed by an ultrasound examination. An operation may be undertaken up to 3 months after the injury. Preferred procedures are end-to-end anastomosis and transosseous refixation of the tendon, followed by a plaster cast for 6 weeks post-operatively. High-risk patients can be treated conservatively, but the functional results are less satisfactory. We describe a case of an acute closed rupture of the anterior tibial tendon. A yet unpublished method of osseous reinsertion of the tendon is presented.

Ankle Injuries↗
PubMed2000

[Surgical vs. conservative treatment of fractures of the thoracolumbar transition].

A total of 86 patients suffering from fractures of the thoracolumbar spine were followed up after an average time period of 57 months (12-98). Of these patients, 56 were treated operatively and 30 conservatively. According to the AO/ASIF classification, 66% of the operated group were fractures of type A, 29% of type B, and 5% of type C. All patients were operated on by means of dorsal locking instrumentation with pedicular fixation and, apart from six patients, with transpedicular cancellous bone grafting. The conservative group was treated according to the guidelines of Böhler with closed reduction, plaster cast, and rehabilitation program. All fractures in the conservative group were of type A. At follow-up of all operated cases, the local gibbus angle had improved by a reduction of on average 18.6 degrees and was followed by a loss of correction of 12.5 degrees ending in a final gain of 6.1 degrees at follow-up. At follow-up of the conservatively treated cases, the local gibbus angle showed an improvement of 11.1 degrees at reduction and a loss of correction of 14.9 degrees after reduction. The remaining result was -3.6 degrees, that means an increase of kyphoses compared to the x-ray at admission. In order to be able to compare two homogeneous groups only fractures of type A were used. Comparison of the two groups showed an improvement of the vertebral body angle of 70% (11.3 degrees) after reduction in the surgical group and 46% (6.1 degrees) in the conservatively treated group. The subsequent loss of correction was 19% (3 degrees) in the surgical and 34% (4.5 degrees) in the conservatively treated group. The remaining gain at follow-up was 51% (8.3 degrees) in the surgical and only 12% (1.6 degrees) in the conservative group. The local gibbus angle had improved on average by 17.1 degrees after reduction in the surgical and by 11.1 degrees in the conservatively treated group. Loss of correction was 71% (12.2 degrees) and 132% (14.9 degrees), respectively. The final result at follow-up showed a decrease of kyphosis of 4.9 degrees in the surgical and an increase of kyphosis of 3.7 degrees in the conservatively treated group. The difference was significant. Within the surgical group, 75% of the loss of correction was caused by the discs and 25% by the vertebral body. In the conservatively treated group it was 69% and 31%, respectively. Concerning loss of correction, no difference was seen between patients with and without intercorporal bone grafting. There was no relationship between radiological and clinical outcome. Whereas 15% of the patients of the surgical group were not satisfied or moderately satisfied with the result, all patients in the conservatively treated group were satisfied or very satisfied. Based on the good clinical results of the conservative treatment we can conclude that in stable fractures without severe deformity, and in patients who are in bad general condition, conservative treatment can considered as an alternative to surgical treatment.

Adolescent↗
PubMed2001

[Diagnostic steps in disk dislocations and other frequent illnesses of the temporomandibular joint].

Modern diagnosis of the temporomandibular joint (TMJ) consists of multiple steps, based on each other and amplifying one another. The first step is the clinical functional analysis, respecting general medical as well as specific dental aspects. If need arises electronic axiography, recording the movement of TMJ hingeaxis, is being added as well as occlusal analysis on mounted plaster casts. In case of open questions at this point of analysis, magnetresonance- and computer-tomographic imaging is brought in. The present paper is an overview describing the current step by step diagnosis of TMJ disorders, with special attention to luxation-reduction mechanism in the joints.

Diagnosis, Differential↗
PubMed2003

[Rachitic knock knees in children].

Knee malpositions, for example valgus or varus deformations or flexion contractures, were often cited in the historical literature. In earlier times, clinical pictures such as rickets were often the reason for this kind of deformity. A causal therapy did not exist until the twentieth century. In most cases of rickets, genu valgum was reported as the typical knee deformation. The differential diagnosis for genu valgum caused by rickets was genu valgum traumaticum, paralyticum, and inflammatorium. The most important reports on the pathogenesis of valgus deformation can be found in publications by Hueter and von Mikulicz. The causal therapy of rickets was introduced at the beginning of the twentieth century.Vitamin therapy and UV phototherapy were developed during this period. Using these therapies, rickets decreased dramatically. Kurt Huldschinsky, a pediatrician from Berlin,was one of the main inventors of UV phototherapy in Germany. At the end of the nineteenth century, the operative correction of knee deformities increased while conservative treatment continued to be applied. Plaster casts,orthoses, and osteoclast therapy were the main noninvasive therapeutic possibilities. Positive aspects of the conservative techniques were mostly the good results and easy, timesaving technique compared with the operative treatment. The operative therapy increased with the knowledge of antisepsis and asepsis as well as advances in anesthetic procedures. Operative treatment modalities, for example tibial and femoral osteotomies, were more precise, but connected with multiple complications and greater time expenditure. Sufficient vitamin prophylaxis rendered knee deformations caused by rickets a rarity.

Bone Malalignment↗
PubMed2003

[Conservative and functionally oriented treatment of idiopathic clubfoot].

The article describes current conservative treatment of idiopathic clubfoot, especially plaster cast manipulation, functional mobilization, and orthosis. New procedures such as mobilization of the foot on a continuous passive motion machine and the use of botulinum toxin are presented and discussed.

Casts, Surgical↗
PubMed2006

[Botulinum toxin therapy in orthopaedics].

Botulinum toxin A plays an important role in the conservative management of problems of the musculoskeletal system. The main indications for its use are disorders of muscle tone and spasticity of various origins, which makes botulinum toxin an important focal treatment in many neurological conditions. Nevertheless, every orthopaedic surgeon who is involved in the conservative management of muscular problems should be familiar with the indications as well as the pharmacology of the substance and its proper injection techniques. By a combination of botulinum toxin injections with a variety of other conservative measures, such as orthotics and plaster cast treatment, its effect can be enhanced and prolonged. Due to the reversibility of its action, exact dose adjustment to the individual is possible.

Botulinum Toxins, Type A↗
PubMed2005

Stress fractures in adolescent competitive athletes with open physis.

There have been no studies devoted exclusively to stress fractures in competitive athletes with immature skeletal systems so far. The object of this case series was to describe special features of stress fractures in athletes with immature skeletal systems, with special reference to sport-specific strain, diagnosis and treatment results. The study population was made up of 19 children and adolescents with a total of 21 stress fractures. The average observation period was 4.83 years [standard deviation (SD) 2.69] and the average age at diagnosis, 14.04 years (SD 4.7). The lower extremity was affected in most of our cases. In adolescent athletes, endurance sports appear to lead preferentially to stress fractures in the region of the metatarsal bones, while sports requiring sudden stops at high speed appear to increase the risk of fractures in the region of the tibial diaphysis (P=0.0322). Most (20 of 21) of the fractures in this study were treated conservatively with refraining from athletic activity and reduction of stress/weight-bearing for an average of 6.73 weeks (SD 2.91). In five cases the extremity was in addition immobilized in a plaster cast for 5.32 weeks (SD 2.21). Complete healing was achieved in 14 cases. In seven cases, however, the treatment did not lead to a satisfactory outcome. Most of the patients whose symptoms persisted over a long period had fractures in the tibia and were engaged in sports requiring frequent sudden stops. Our data suggest that stress fractures in athletes, whose skeletal systems are still immature, lead to a clinical picture that does not always culminate in a good outcome of treatment. We therefore recommend a thorough and early diagnostic investigation (including MRI) and consistent treatment whenever a patient's history and clinical picture give any indication that a stress fracture might be present.

Adolescent↗