Versorgung von Kreuzschmerzen

Notfall + Rettungsmedizin -     

Versorgung von Humeruskopffrakturen

Objectives

Placement of a proximal humerus locking plate through a percutaneous transdeltoid approach bears the advantages of a minimally invasive approach but may compromise the anterior branches of the axillary nerve. This anatomic study aimed to develop a risk profile for 6 types of modern proximal humerus locking plates as to their interference with the axillary nerve.

Materials and methods

In this study six different implants (Arthrex®, DePuy®, Königsee®, Smith & Nephew®, Stryker® and Synthes®) were placed on the intact proximal humerus of 33 embalmed cadaveric upper extremities and the relative positioning between the axillary nerve and the screw holes was determined.

Results

All locking plates displayed an area of risk which concerned 3 out of 7 (Arthrex®), 4 out of 10 (DePuy®), 2 out of 9 (Königsee®), 3 out of 11 (Smith & Nephew®), 3 out of 11 (Stryker®) and 6 out of 12 (Synthes®) screw holes of the plate.

Conclusions

Using the anterolateral percutaneous deltoid splitting approach the relative position of the axillary nerve to the holes of a specific implant is of relevance for avoidance of iatrogenic lesions to the nerve.     

Versorgung von Schwerverletzten

Die Anaesthesiologie - Im Jahr 2011 ist die erste interdisziplinäre S3-Leitlinie zur Versorgung von Schwerverletzten publiziert worden. Nach intensiver Überarbeitung dieser Leitlinie...     

Das medizinisch-ethische Dilemma von Reanimationsentscheidungen bei Notfallpatienten

Despite established structures for consultation regarding clinical ethics, emergency physician often faces the problem of making decisions in cases of emergencies in a very short time without knowing the patient’s preferences, because a clinical–ethic consultation, such as an ethics committee, is not possible in an emergency department. Resuscitation represents a special situation. The emergency physician in this case cannot rely on valid medical data, since on the one hand—as in the work presented here—there are currently no reliable studies (long-term studies) investigating survival after resuscitation and on the other hand, the studies for futility, that means hopelessness of life-prolonging measures, are very heterogeneous. In various works, authors therefore demand that the professional make an individual decision. In the present work, it is argued that an individual treatment decision involves moral values of the physician and therefore ethical aspects enter the decision. Today’s medical ethics, which is based on the four principles of modern bioethics (welfare, non-harm, autonomy, and justice), includes the need of valid medical “input” on the benefits or harm of the proposed treatment method and thus survival option or “futility” in the given situation. But proper evidence-based data are currently not available. Thus, the logical argumentation in this paper is a vicious circle from which there is currently no way out. This means that even ethics can offer no solutions here, because application of the four leading principles requires precisely those medical data which are currently not yet available. The task of the present work is to draw attention to this problem and to stimulate discussion on how to make treatment decisions in this context and how to judge them.     

Operative Versorgung von Achillessehnenverletzungen

Rupture of the Achilles tendon is typically associated with sportive activities with increasing tendency; it occurs most commonly in the third to fourth decade of life with a male-to-female ratio of 5–10:1. Ruptures are caused predominantly by a sudden, unexpected overextension of the tendon while direct trauma is less frequent. The recommended treatment of the injury remains controversial. In Germany, due to the good functional results, the open surgical repair represents the standard therapy since many years. The open suture technique offers the advantage of a lower re-rupture rate but is associated with the risk of wound-related complications including infection. By percutaneous suture techniques a significant decrease in the rate of infections and complications in wound healing could be achieved by minimal-access with reduced soft tissue trauma; on the other hand an increased rate of lesions of the sural nerve is reported. Dynamic imaging assessment of ultrasound or MRI allows a more accurate localisation of the ruptured ends of the tendons which is the prerequisite for the non-operative primary functional treatment of Achilles tendon ruptures. This conservative treatment regime is recommended when adaptation of the ends of the ruptured tendon is possible in 20° plantar flexion of the foot. Moreover, the desired level of daily activity and the patients’ degree of compliance has to be considered. Operative management should be avoided in the elderly patient or patients with risk factors like immunosuppressive therapy, diabetes mellitus, steroid use or failure to comply.     

Chirurgische Versorgung von Leberrupturen

Zusammenfassung. Von Januar 1979 bis August 1996 wurden an der Chirurgischen Universit?tsklinik Ulm 178 Patienten aufgrund eines Lebertraumas chirurgisch versorgt. Es handelte sich dabei zu 91,6 % um stumpfe und nur zu 8,4 % um penetrierende Traumen. Bei 110 F?llen (62 %) handelte es sich um leichte Verletzungen der Schweregrade I und II, w?hrend sich bei 68 Patienten (38 %) schwere Traumen der Grade III, IV und V fanden. Die Letalit?tsrate wird vom Schweregrad der Leberruptur und der Begleitverletzung bestimmt. Die Gesamtletalit?t lag bei 32 % (57 Patienten). Davon sind 28 Patienten an den Folgen der Leberverletzung verstorben. Dies bedeutet, die reine Sterblichkeit aufgrund der Leber betrug 15,7 %. Keiner der Patienten mit einer penetrierenden Verletzung ist verstorben. Die Komplikationsrate lag bei 55 %, wobei die H?matombildung die am h?ufigsten beobachtete Komplikation darstellte (12,9 %), an zweiter Stelle folgte die Nachblutung mit 9,6 %. Die Absce?rate lag bei 2,8 %. Bei einem kreislaufstabilen Patienten sollte grunds?tzlich die konservative Therapie angestrebt werden, sofern er die gegebenen Voraussetzungen erfüllt. Bei kreislaufinstabilen Patienten ist ein operatives Vorgehen unumg?nglich. Das chirurgische Vorgehen h?ngt vom Schweregrad der Leberverletzung ab. Bei leichter Blutung steht die „einfache“ Versorgung durch Coagulation oder Naht im Vordergrund. Liegt eine schwere Blutung vor, so empfiehlt sich die Hepatotomie, die gezielte Blutstillung und Débridement (Pachters Vorgehen). Ist die Blutung nicht unter Kontrolle zu bringen, ist die perihepatische Bauchtuchtamponade das Mittel der Wahl.      

Operative Versorgung von HWS-Verletzungen

The three most frequent sources of complications in the treatment of cervical-spine injuries are the indications adopted, the access route used, and the implant selected and its application . The management of complex injuries can be significantly facilitated if it is implemented with due consideration for the basic premises of spinal surgery: the operator must be familiar with the biology and mechanics of the vertebral column and with the potentials and limitations of the implants available for selection and must have analysed the actual instability in each case. There are also critical segments that have different biomechanical characteristics from the other sections of the spine. Some pathologic conditions also involve problems peculiar to themselves in addition to such anatomical characteristics, and these thus affect the choice of surgical procedure. In such situations (fractures associated with ankylosing spondylitis, unstable fractures at the cervicothoracic junction, insufficient anterior support with dorsal instrumentation, stabilization with incomplete reduction, multisegmental instability) excessive strain on the implant must be expected, which entails the risk of early implant failure, especially if the associated biomechanical condition is misinterpreted.     

Versorgung von frischen Beugesehnenverletzungen

The aim of acute flexor tendon repair is to establish a strong and stable suture, which enables a smooth gliding of the tendon and early mobilization to prevent postoperative adhesion formation. This is especially important in fingers which have fibrous tendon sheaths. The evolution of different suture techniques in the past decades provides an abundance of surgical options for primary flexor tendon repair. In vitro studies have shown that multistrand core sutures have enhanced biomechanical properties compared to two-strand core sutures. This achievement, however, was not demonstrated in clinical studies as there was no statistically significant difference when looking at the outcomes of rupture rate and function between two-strand and multistrand core sutures. The published literature supports the use of a strong core suture and circumferential epitendinous suture to minimize complications; however, so far there has not been a consensus on the optimal suture technique or material for primary flexor tendon repair.     

Chirurgische Versorgung von Leberrupturen

Von Januar 1979 bis August 1996 wurden an der Chirurgischen Universit?tsklinik Ulm 178 Patienten aufgrund eines Lebertraumas chirurgisch versorgt. Es handelte sich dabei zu 91,6 % um stumpfe und nur zu 8,4 % um penetrierende Traumen. Bei 110 F?llen (62 %) handelte es sich um leichte Verletzungen der Schweregrade I und II, w?hrend sich bei 68 Patienten (38 %) schwere Traumen der Grade III, IV und V fanden. Die Letalit?tsrate wird vom Schweregrad der Leberruptur und der Begleitverletzung bestimmt. Die Gesamtletalit?t lag bei 32 % (57 Patienten). Davon sind 28 Patienten an den Folgen der Leberverletzung verstorben. Dies bedeutet, die reine Sterblichkeit aufgrund der Leber betrug 15,7 %. Keiner der Patienten mit einer penetrierenden Verletzung ist verstorben. Die Komplikationsrate lag bei 55 %, wobei die H?matombildung die am h?ufigsten beobachtete Komplikation darstellte (12,9 %), an zweiter Stelle folgte die Nachblutung mit 9,6 %. Die Absce?rate lag bei 2,8 %. Bei einem kreislaufstabilen Patienten sollte grunds?tzlich die konservative Therapie angestrebt werden, sofern er die gegebenen Voraussetzungen erfüllt. Bei kreislaufinstabilen Patienten ist ein operatives Vorgehen unumg?nglich. Das chirurgische Vorgehen h?ngt vom Schweregrad der Leberverletzung ab. Bei leichter Blutung steht die „einfache“ Versorgung durch Coagulation oder Naht im Vordergrund. Liegt eine schwere Blutung vor, so empfiehlt sich die Hepatotomie, die gezielte Blutstillung und Débridement (Pachters Vorgehen). Ist die Blutung nicht unter Kontrolle zu bringen, ist die perihepatische Bauchtuchtamponade das Mittel der Wahl.     

188. Versorgung von Skalpierungsverletzungen

Zusammenfassung Zur Versorgung von Skalpierungsverletzungen gibt es verschiedene Methoden. Replantation, Hautplastik, Rotationslappen, freie Lappenplastik. Als primär am günstigsten wird heute die sofortige Replantation angesehen, um eine retitutio ad integrum zu erzielen. Spalthautdeckung wird bei vorhandenem Periost nur als temporäre Erstversorgung durchgeführt. Die freie Lappenplastik ist zur endgültigen Versorgung bei nicht vorhandenem Skalp oder nach fehlgeschlagener Replantation indiziert, da sonst durch ständige Uleerationen der Untergrund instabil ist.     

Minimalinvasive Versorgung von thorakolumbalen Wirbelfrakturen

Minimally invasive surgery for vertebral fractures means less approach-related morbidity, decreased postoperative pain and rapid mobilization of patients. Such procedures can be performed even in elderly patients. However, along with the many advantages, minimally invasive procedures are technically demanding, require sophisticated tools and there is a learning curve for surgeons. Intraoperative visualization is often possible only radiologically and implants are generally much more expensive. Using the data from some 1,000 vertebral fracture cases treated over the past 3.5 years, we have developed a differentiated treatment concept, depending on the age of the patient and the fracture characteristics, which are presented here. Unstable fractures with involvement of the posterior edge are stabilized from a posterior approach, percutaneously with a fixator. In patients under 60 years, monoaxial screws with inserted rods (top loading) are used with which distraction and restoration of lordosis are also possible. Patients over 60 years are treated percutaneously with a polyaxial sextant system with rods inserted to avoid avulsion of the pedicle screws from the vertebral body. To avoid cutting through the vertebra, the fenestrated screws can be augmented with cement. If a vertebral defect remains after posterior treatment, anterior fusion can also be performed endoscopically with an iliac crest bone graft and an anterior plate if necessary. In older patients, often kyphoplasty is sufficient here. For recent, stable osteoporotic fractures with enhancement of the short time inversion-recovery (STIR) T2 sequence on magnetic resonance imaging and severe pain despite analgesics kyphoplasty is performed. This is possible even in high thoracic fractures to T3 using thinner balloons. In 0.34% (2 out of 564) of cases post-operative neurological deficits were observed after cement extravasation.     

Die laparoskopische Versorgung von Morgagni-Larrey-Hernien

Three patients with Morgagni-Larrey hernias are reported who underwent successful laparoscopic repair between 1992 and 1998. The hernia was closed by direct suturing in one case; in the two other cases a polypropylene mesh was used because of the size of the hernia in one case and in the other because of muscle atrophy in a patient with Charcot-Marie-Tooth disease. There were no complications, and the patients were discharged 3-4 days after surgical treatment. The current follow-up is between 10 months and 6 years; there have been no hernia recurrences and all patients are asymptomatic. We consider laparoscopic repair to be a suitable and safe procedure for treatment of Morgagni hernias. We discuss the two different techniques, direct suturing or using polypropylene mesh by reviewing the results of the current literature.     

Die operative Versorgung von Unterarmschaftfrakturen

Zusammenfassung In der Chirurgischen Universitätsklinik München kamen in den Jahren 1961 bis 1969 195 Unterarmschaftfrakturen zu stationären Behandlung. An Hand einer umfassenden Nachuntersuchung wird die Problematik der verschiedenen Osteosyntheseverfahren diskutiert. Es kann gezeigt werden, daß die Druckosteosynthese mit schmaler Platte nach AO gegenüber den weniger stabilen Osteosyntheseverfahren wie Rush-pin oder Drahtung oder konservativer Behandlung wesentlich bessere funktionelle Endresultate gewährleistet. Um eine Vollstabilisierung zu erreichen, muß nach Möglichkeit die Länge des Implantates so gewählt werden, daß jeweils 3 Schrauben im frakturfreien Fragment zu liegen kommen. Auch in der Behandlung von Pseudarthrosen hat sich die Druckplattenosteosynthese bewährt. So konnten 19 Falschgelenkbildungen mittels Druckosteosynthese mit schmaler, langer Platte und in 5 Fällen mit zusätzlicher Spongiosaplastik zur Ausheilung gebracht werden.

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Summary In 1961 to 1969 in the Surgery-University-Hospital of Munich 195 cases of fractures of the forearm were stationary treated. By means of comprehensive examination the problems of various methods of osteosynthesis are discussed. There can be demonstrated that compression osteosynthesis with narrow plate following AO grants essential better functional results than less stable methods of osteosynthesis such as rush-pin or wire fixation or conservative treatment. To achieve full stability, the length of the implant has to be chosen, if possible, such as to place 3 screws in the fracture-free fragment. Also in pseudarthrosis treatment the compressure-plate-osteosynthesis has proved true. In this way we have been able to cure completely 19 false joints by means of compressure-osteosynthesis with narrow, long plates, and 5 cases with additional spongy substance plastic operation.

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Resumé En 1961–1969, il y avait 195 thérapeutiques stationnaires de fractures d'avantbras du Département de Chirurgie, Cliniques Universitaires de Munick. On discutera les problèmes de différentes méthodes d'ostéosynthèse au moyen de larges examens. On peut démontrer, que l'ostéosynthèse compressive avec une plaque mince d'après AO représente contre les méthodes d'ostéosynthèse moins stables comme rush-pin ou par fil métallique ou traitement conservatif, des resultats fonctionneaux énormément mieux. Pour achever une stabilisation complète, il faut choisir autant que possible la longueur de l'implantation tellement qu'on peut placer toujours trois vis dans le fragment sans fracture. L'ostéosynthèse á plaque compressive a justifié sa réputation aussi dans la thérapeutique des pseudarthroses. Tel il était possible de guérir complètement 19 fausses articulations avec ostéosynthèse compressive en longues plaques minces et 5 pseudarthroses avec une opération plastique avec tissu spongieux en plus.

     

Der Zwei-Inzisions-Zugang in der Versorgung von Acetabulumfrakturen

Objectives

To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures.

Intervention

The first TIMI incision is performed using a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held back using a retraction system. After fracture reduction and fixation by isolated screws a conventional reconstruction plate is inserted for fracture neutralization.

Results

Since January 2008 we have performed the TIMI method in 88 cases with good results. Recently we have published the data of a first series with 26 patients that were seen at least 12 months after surgery. The mean operative time was 109±30 min and all incisions showed primary healing. Postoperative radiological examination revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft tissue complications and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The average Harris hip score (HHS) was 86.6±8. Quality of life was comparable to control persons in the same age group.

Conclusions

The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited number of incisions a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in patients with a higher risk for postoperative soft tissue complications.