Offene Stabilisierung mit Kapselverschiebeplastik und Bankart-analoger Refixation bei posttraumatischer vorderer Schulterinstabilität

Background

Recurrent posttraumatic glenohumeral instability with hyperlaxity and glenoid bone deficiency are risk factors for postoperative failure after surgical stabilization. Methods. This study enrolled 60 patients including 48 men (80?%) and 12 women (20?%) with posttraumatic unidirectional anterior instability. Of the patients 37 (61.7?%) showed accompanying hyperlaxity grade II or higher, 14 (23.3?%) showed intact glenoid bone and 42 (76.7?%) had a glenoid bone deficiency of up to 20?% of the anteroposterior (AP) diameter. The average number of dislocations before surgery was 9.1?±?2.0 (range 1–100). All patients underwent open stabilization with reconstruction of the capsulolabral ligamentous complex with capsular shift.

Results

Until the first follow-up after 3.6 years (minimum 2 years) 3 patients (5?%) had a redislocation after adequate trauma. The average postoperative Rowe score (RS) was 88.7 with no significant differences between the trauma cases and the hyperlaxity patients which was the same using the Constant score (CS, 89.4?±?9.0 % vs. 87.8??±?8.6 % with without hyperlaxity, respectively). Of the patients 55.2?% had an excellent result according to the RS, 34.5?% a good result and 10.3?% a satisfactory result. The average external rotation on the adducted operated arm was reduced by 3.9° and 11° on the abducted arm compared to the contralateral side. At the final follow-up after 12.8 years the average RS was 86.2 (range 50–100) with a recurrence rate of 6.7?% and a follow-up rate of 88?%.

Conclusion

This study shows a comparable recurrence rate of open surgical stabilization with capsular shift in a high risk population with recurrent posttraumatic dislocations and accompanying hyperlaxity and glenoid bone deficiency of less than 20?% of the AP diameter when compared to non-selected patient groups in the literature.     

Bypass bei chronisch kritischer Extremitätenischämie

The value of infrainguinal bypass surgery for critical limb ischaemia (CLI) in elderly patients is being scrutinised more as medical resources decline. Despite technically successful revascularisation, patient quality of life seems impaired by delayed wound healing and repeated hospitalisation for interventions and operations. Therefore it is questionable whether these frail patients benefit from bypass surgery with respect to their health-related quality of life. This review examines current evidence of patients with CLI and summarises the effect of bypass surgery on their own quality of life assessments. All in all, patients benefit from the revascularisation because ambulation status improves and independence is preserved. From a patient’s perspective these improvements in quality of life justify an aggressive approach towards revascularisation for CLI.     

Häufigkeit der traumatischen und chronischen skapholunären Bandläsion bei distaler Radiusfraktur

BACKGROUND: Early diagnosis and appropriate treatment of acute scapholunate dissociation (SLD) is crucial for obtaining a favorable result in fractures of the distal radius. The aim of this study was to determine the incidence of acute SLD in a prospective study and to differentiate this entity from chronic SLD. PATIENTS AND METHODS: A total of 120 patients with unilateral distal radius fractures were prospectively evaluated for SLD. Stress radiographs were obtained for all patients on the injured side after fixation of the distal radius fractures. In cases of SLD the unaffected side was examined to rule out chronic, bilateral SLD. RESULTS: Acute SLD was detected in 13 patients (11%), 11 (9.1%) of whom had stage 3 injury. Chronic SLD with bilateral asymptomatic instability was seen in three patients (2.5%). CONCLUSION: When treating fractures of the distal radius, acute SLD has to be ruled out and to be discriminated from chronic SLD. While acute SLD requires appropriate treatment, immediate treatment of chronic SLD is not indicated.     

Anästhesie bei Patienten mit chronisch obstruktiven Lungenerkrankungen

Chronic obstructive pulmonary disease (COPD/pulmonary emphysema) is a common disease with a high incidence and a medico-economical impact which should not be underestimated. Pathophysiologically it is defined as expiratory obstruction due to increased airway resistance. The extensive comorbidity of COPD patients as well as the impairment of the respiratory system make COPD a key challenge for anesthesiologists. Besides basic drug therapy, differentiated ventilation support represents a hallmark of perioperative management. This article includes the current recommendations of the German national care guidelines for COPD as well as the COPD guidelines of the American Thoracic Society.     

Fehleinschätzung bei vorderer Beckenringfraktur im höheren Lebensalter

Clinical outcome following pelvic ring fractures of AO/OTA type-A in the elderly is often unsatisfying because the posterior pelvic ring fracture is underdiagnosed and patients with type B fractures were conservatively treated like patients with type A fractures. This so-called "A-B" problem was systematically analyzed in our patients with pelvic ring fractures. 183 patients were treated with pelvic ring fractures. Primarily, the injuries were classified as follows: 81 type A, 38 type B, and 64 type C. The diagnosis was changed from type A to type B injury in seven patients. Parameters of investigation included fracture type, duration of symptoms, treatment, and outcome score according to the German Multicenter Study Group Pelvis. Persistent pain in the sacral area over an average of 2 (1-6) weeks was found in all patients. The CT scan revealed in all patients a transalar sacral impression fracture in the sense of an internal rotationally unstable injury of type AO/OTA B 2.1. The treatment consisted in a supra-acetabular external fixator for an average of 3 weeks. After 4 weeks the mean pelvis outcome score was 9 (7-10) points. In cases of persistent pain for more than 2 weeks after transpubic pelvic ring fractures in the elderly further investigation by CT scan should be recommended to exclude a concomitant sacral fracture, which then could be safely treated by a supra-acetabular external fixator.     

Verhaltensbezogene Notfälle bei Erwachsenen. Abklärung und Behandlung

Background

Behavioral emergencies are frequent occurrences in the emergency room setting. They are associated with an increased risk of harm to patients and staff, and specific training is needed to ensure proper assessment and treatment, including verbal de-escalation techniques, medications, and restraints.

Objectives

The objective of this study was to define behavioral emergencies, review causes and assessment of them, and to discuss treatment strategies based on a systematic review of the literature.

Methods

Publications in PubMed from 1980–2015 were accessed using key terms of behavioral emergency, agitation, aggression, psychiatric emergencies, restraints, and delirium.

Results

A review of definition, diagnosis, and treatment of behavioral emergencies is provided. New treatment approaches which include the use of standardized agitation scales to objectively measure agitation, verbal de-escalation techniques, and focusing on oral medications rather than parenteral medications are detailed.

Conclusions

Utilizing verbal de-escalation techniques in the emergency room setting is quick and often prevents further escalation of behaviors. Second generation antipsychotic medications are as effective as first generation antipsychotics without cardiac and extrapyramidal side effects and are to be favored in most cases of acute agitation. Oral medications are preferred to parenteral if possible.The German full-text version of this article is also available at SpringerLink under dx.doi.org/10.1007/s10049-016-0159-4.

     

Diagnostik und Therapie der frischen und chronischen hinteren Kreuzbandläsion

Zusammenfassung. Rupturen des hinteren Kreuzbandes geh?ren zu den schwerwiegenden Bandverletzungen des Kniegelenks. Problematisch ist hier eine oft unzureichende Einsch?tzung und versp?tete Diagnostik der Verletzungsschwere als auch der Begleitverletzungen. Zus?tzlich ist die Versagerquote der bisherigen Rekonstruktionsverfahren unbefriedigend hoch. Das Ziel dieser übersichtsarbeit ist es, auf der Basis der eigenen Erfahrungen und dem Wissen aus dem internationalen Schriftum, einen umfassenden Einblick in die Anatomie und Biomechanik, die Unfallmechanismen und die Pathobiomechanik zu geben. Ein weiterer Schwerpunkt liegt in der Kl?rung diagnostischer Schwierigkeiten. Zur ad?quaten Berücksichtigung der Begleitverletzungen, wie z. B. der posterolaterale rotatorische Instabilit?t oder zus?tzlichen Verletzungen des vorderen Kreuzbandes wird ein differenziertes Therapiekonzept vorgestellt, um das konservative und perioperative Management zu optimieren, mit dem Ziel die hohe Quote unbefriedigender Ergebnisse weiter zu reduzieren.      

Diagnostik und Therapie der isolierten proximalen Bizepsläsion

Pathologies of the long head of the biceps tendon are a frequent cause of pain and restricted shoulder function. In most cases the anamnesis and clinical examination with a combination of specific tests for the biceps tendon lead to the diagnosis. Magnetic resonance imaging (MRI) especially with intraarticular contrast medium enables differentiation of the different biceps pathologies and additional disorders, such as rotator cuff tears. Radiological examination can rule out other bone pathologies. In cases of unclear persistent shoulder disability, diagnostic arthroscopy remains the gold standard which allows a precise diagnosis as well as direct operative treatment of the underlying pathologies. Conservative treatment consists of adaptation of physical activity, anti-inflammatory drugs as well as injections with local anesthetics. Physical therapy can further address concomitant contractures of the capsule or dyskinesia of the scapula. After failed conservative treatment, the surgical procedure depends on the underlying pathology including debridement or refixation of the biceps anchor, tenotomy or tenodesis of the biceps tendon as well as treatment of concomitant pathologies, such as rotator cuff tears.     

Transfer des Processus coracoideus bei rezidivierender vorderer Instabilität am Schultergelenk

Objective

Full arthroscopic treatment of severe anterior shoulder instability due to glenoid bone loss, Hill–Sachs lesion and irreparable ligament damage.

Indications

Recurrent anterior dislocations or subluxations, previously failed Bankart repairs; patients with anterior glenoid bone loss, Hill–Sachs defect; patients with irreparable damage to soft tissues of labrum, capsule and ligaments; patients with chronic humeral avulsion of glenohumeral ligament (HAGL lesion); combinations of lesions above; young contact sport athletes, where Bankart repairs have high failure rates.

Contraindications

Presence of (arthroscopically confirmed) good preconditions for Bankart repair: good quality of labrum, capsule and ligament, labrum still present, no or minimal bone loss of glenoid, no engaging Hill–Sachs. Lack of requirements for complex arthroscopic procedure (e.g., special instruments and skills).

Surgical technique

Diagnostic arthroscopy. Removal of anterosuperior and superior capsule, middle glenohumeral ligament, anterior labrum. Preparation of glenoid neck, debridement. Opening of rotator interval. Preparation of coracoid process and conjoint tendons. Subdeltoid preparation of anterior coracoid with arthroscope moved to anterolateral portal. Tenotomy of pectoralis minor. Arthroscopic split of subscapularis tendon via deep anteromedial portal. Predrilling of 2 holes through coracoid, insertion of 2 special washers into predrilled holes (“top hats”). Arthroscopic osteotomy of coracoid at base. Mounting of coracoid to special coracoid cannula. Manipulation of coracoid/conjoint tendon through subscapularis to glenoid neck, prefixation with wires. Fixation of coracoid after drilling with cannulated special screws.

Postoperative management

Immobilization in a sling on postoperative day 1; pain-controlled active range of motion without limit starting postoperative day 2. Sling during the night for 4 weeks.

Results

Between 2007 and June 2013, 210 operations were performed. No intraoperative conversion to open operative technique. Revision required in 10 patients with postoperative complications. No intraoperative or neurovascular complications.     

Empfehlungen zu Diagnostik und Begutachtung der traumatischen Rotatorenmanschettenläsion

Traumatic rotator cuff lesions are a very rare condition. However, this article represents a comprehensive survey according to current knowledge on anatomy, biomechanics, and pathogenesis of rotator cuff pathology. Because of the relatively high prevalence of degenerative changes with increasing age, including partial and complete rotator cuff tears, it may be difficult to demonstrate the causality of an acute traumatic rotator cuff tear. Therefore, a catalogue of potential adequate and inadequate trauma mechanisms is proposed. Emphasis is also placed on posttraumatic diagnostic steps following persistent rotator cuff deficient shoulder function (e.g., ultrasound, MRI). From a legal aspect (e.g., private accident insurance, workers compensation claim), different minor and major criteria are defined, which could help experts to judge the causality of posttraumatic rotator cuff deficiency. These criteria mainly refer to distinct details concerning patients' history, trauma mechanism, primary clinical appearance, and diagnostic findings.     

Ueber Läsion des Nervus ulnaris bei Verletzungen am Ellbogengelenk

Ohne Zusammenfassung (Mit 4 Abbildungen.)     

Iatrogene Läsion des Nervus accessorius bei der cervicalen Lymphknotenbiopsie

The majority of lesions of the spinal accessory nerve occur as an iatrogenic injury after lymph node biopsy in the posterior cervical triangle (trigonum colli laterale). In most cases the accessory nerve palsy is not recognised immediately after the injury. Therefore surgical repair is often performed too late to regain sufficient function of the paralytic trapezius muscle. Later than 6 months after the injury, reconstruction seems to be hopeless. However, "timely" reconstructions often have poor results. Exact knowledge of anatomy, postoperative check of the trapezius muscle and, if an accessory nerve injury has occurred, early reconstructive procedures (neurolysis, reconstruction of nerve continuity) may on the one hand prevent iatrogenic lesions of the nerve and on the other hand improve the reconstructive result. A series of 6 patients with an injury of the spinal accessory nerve after lymph node biopsy is reported. In 2 cases primary coaptation, in 3 cases interpositional nerve grafting and in 1 case neurotization was performed. Clinical recovery was achieved in 3 of the 6 cases.     

Spätfolgen und Behandlungsstrategien der distalen Radioulnardissoziation nach unerkannter Essex-Lopresti-Läsion

The Essex-Lopresti lesion, a combination of radial head fracture and distal radioulnar dislocation, rarely occurs but nevertheless represents a frequently unknown result after forearm fracture. The responsible physician soon has to initiate surgical treatment to prevent his patient from permanent pain of the wrist. Previously unrecognised distal radioulnar dislocation remains to be an unsolved problem. A generally accepted management concept does not exist. Since rupture of the membrana interossea nearly ever occurs, resection of the radial head is followed by radial shifting and seems to be obsolete under these circumstances. An exemplary case is presented and surgical management in this situation is discussed.     

Unfallhäufigkeiten und Verletzungswahrscheinlichkeiten bei Flugunfällen

Introduction

Accident analysis in aviation is generally performed very thoroughly to avoid a re-occurrence with similar causes and to develop new strategies for accident prevention. Furthermore, relevant data for emergency medicine can be obtained. The goal of this study was to evaluate probabilities for severe and/or fatal injuries sustained in German general aviation (GA) aircraft accidents between 1993 and 2007.

Material and methods

Using official data from the 1993–2007 Federal Office for Aviation Accident Investigations (BFU) annual reports, the total number of GA accidents, the number of GA accidents with severe or fatal injuries as well as the number of severely or fatally injured persons were obtained for a 15-year period. Data were assigned to subgroups (according to the aircraft category) for detailed analysis. Analysis focused on the average number of injured (ANI) and average number of killed (ANK) persons in accidents involving severe or fatal injuries and the probabilities of sustaining severe (POS) or fatal (POF) or both (POS/F) injuries in a GA accident. Data were corrected for double counts (accidents with both severe and fatal injuries). STATISTIKA® and SPSS® were used for statistical analysis.

Results

A total of n=5,259 GA accidents were analyzed. The average number of injured (ANI) and average number of killed (ANK) persons correlated with the size and capacity of the aircraft (p<0.05). Most accidents occurred in the categories gliders (n=1,930, 36.7%) and single piston engine with a maximum take-off weight (MTOW) less than 2 tons (n=1,929, 36.7%). The highest probability of sustaining severe injuries (POS) was found for hot air balloons (in 72.9% of all accidents), gliders (POS=15.18%) and helicopters (POS=12.02%). The highest risk of sustaining fatal injuries (POF) was found for aircraft with a MTOW between 2 and 5.7 tons (POF=23.08%), helicopters (POF=17.05%) and aircraft with MTOW less than 2 tons (POF=13.95%).

Conclusions

Although underlying reasons are multi-factorial and hard to identify, conclusions can be drawn for the Emergency Medical Service (EMS) management of aviation accidents. Most accidents occurred with single-engine piston airplanes and gliders (a total of 70–80% of all cases) and foremost during take-off and landing (62% of all cases). Accordingly, EMS dispatch should expect 1–2 injured and/or killed persons if the aircraft category is known.     

Analgesie und Anästhesie bei Kindernotfällen

Background

Pediatric emergencies are not very common, but analgesia is often necessary in these patients. Thus, induction of general anesthesia in children is a particularly rare event for any emergency physician.

Analgesia

Intranasal administration of fentanyl using a nebulizer provides early, effective analgesia, without intravenous or intraosseous access. If necessary, a subsequent puncture can be prepared under intranasally administered sedation. For intravenous or intraosseous analgesia, the familiar non-opioids and opioids can be used. A method to assist in estimating drug doses (e.g., Broselow tape) should be used for patient safety.

Anesthesia

The induction of anesthesia with administration of sedatives, relaxants, and analgesics is performed as a modified rapid-sequence induction with pressure-limited mask ventilation. The sequence of action should be set beforehand and trained. Because of its high risk, endotracheal intubation of infants and toddlers is not the gold standard—alternatives include supraglottic airway devices. Universal exit strategy is the pressure-limited mask ventilation.