Scaphoid fracture and scaphoid pseudarthrosis

Summary Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixtion. The operative treatment of non- unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.      

Nonunion of the isolated capitate waist fracture

 We report a patient with nonunion of an isolated fracture of the capitate. A male 17-year-old high school student directly hit the dorsal aspect of the carpal with the wrist in flexion position against another player's shoulder during a rugby football game. Radiographs did not show a fracture of the capitate on the day after the injury, but nonunion was distinct across the waist at the middle one-third of the capitate 4 months later. The fixation using two cannulated Herbert-Whipple screws with iliac cancellous bone graft led to sound union of the capitate and the patient's ability to return to sporting activities. Although the initial plain radiographs do not show a fracture of the capitate, we should consider the capitate fracture and check the patient by repeated physical examinations and radiographs if the patient suffers from persistent localized pain and tenderness over the capitate. Received: December 6, 2001 / Accepted: May 27, 2002     

The contribution of soft-tissue trauma and/or bone fracture to depressed immunity following hemorrhagic shock in an experimental setting

Summary Bone fracture, soft-tissue trauma and hemorrhagic shock are frequent complications in trauma patients, and these patients are known to be immunocompromised. Nonetheless, it is difficult to differentiate the effect of soft-tissue trauma plus hemorrhage from that of bone fracture and hemorrhage on host immune function in the clinical setting. To determine this experimentally, closed bone fracture (right lower leg) and/or soft-tissue trauma (2.5 cm midline laparotomy) were induced prior to hemorrhagic shock (mean arterial BP of 35 ± 5 mm Hg for 90 min) in male C3H/HeN mice. All animals were killed at 72 h after initiation of the experiment and the spleens were collected aseptically. More significant depression of splenocyte IL-2 and IL-3 release occurred with the combined insult than after bony injury or tissue trauma alone with hemorrhage. The present study suggests that different traumatic insults, i. e. bone fracture as well as soft-tissue trauma in conjunction with hemorrhagic shock, produce comparable depression of host immune function. Moreover, combination of closed bone fracture and soft-tissue trauma prior to hemorrhagic shock leads to even more compromised immunity. This indicates that different mechanisms of immune depression may be involved following soft-tissue trauma or bony injury coupled with hemorrhage. The markedly depressed immune function following bony injury, soft-tissue trauma and hemorrhagic shock may contribute to the increased susceptibility of severely injured patients to sepsis and the ensuing multiple organ failure in the clinical situation.      

Total instability of the pelvic ring as a result of increasing unsufficiency fractures

Summary We report a case of a 64-year old female patient, who developed a total instability of the pelvic ring within one year as a result of increasing insufficiency fractures. A minor trauma of the pelvis was assumed to be the trigger of this process retrospectively. The radiographic appearance of the multiple pseudoarthrosis simulated a metastatic disease. The differential diagnosis and the typical pattern of sacral insufficiency fractures (SIF) are described.      

Endoscopic controlled splitting of the diaphragm. A minimal invasive approach for the treatment of thoraco-lumbar fractures of the spine

Summary On 90 patients with 93 unstable fractures of the thoracic spine and the thoracolumbar junction we treated by a minimal invasive procedure between may 1996 and april 1998, in 46 patients an endoscopic splitting of the diaphragm was performed. The diaphragma was dissected at its attachment at the spine and the adjoining costal base. After partial corporectomy and discectomy, a tricortical bone graft has been inserted. An additional stabilization was done by using a plate and screw system. The incision of the diaphragm was closed by suturing or using an universal endostapler. Controlling the postoperative results a complete closure of the incision was documented by X-ray and CT-scan. There was no conversion to the open procedure or postoperative infection. Splitting the diaphragma opens also the thoracolumbar junction to a minimal invasive treatment and stabilization of fractures.      

Prospective comparison of MR imaging and direct magnification radiography in occult scaphoid fractures

Summary The diagnosis of occult fractures of the scaphoid bone is even more challenging than that of conventional fractures of the scaphoid. This study aimed to compare prospectively the gold standard method (plain radiographs in four projections, after about 14 days) and the primary findings with direct magnification radiography (DIMA) and magnetic resonance imaging (MRI). Primary MRI showed much higher diagnostic power than plain radiography at 10–14 days in occult scaphoid fractures and in detection of associated carpal injuries. This may lead to a decreasing time of disease. DIMA was inferior in detecting occult fractures of the scaphoid.      

Vascular injuries complicating osteosynthesis in proximal femur fractures

While there are quite a number of reports on vascular injuries complicating hip arthropasty by acetabular component screw fixation, retractor tip pressure or extruding bone cement, the incidence of deep femoral vessel injuries in operative fixation of proximal femoral fractures is comparatively seldom described. We report on two patients with per- and subtrochanteric femoral fractures who sustained injuries of deep femoral artery branches during the implantation of a dynamic hip screw (DHS) and a dynamic condylar screw (DCS), which resulted in a massive thigh hematoma and a fist-size pseudoaneurysm respectively and necessitated surgical intervention in either case. We blame these vascular injuries on the pressure of Hohmann retractors exposing the femoral bone or on the drilling of boreholes for plate attachment. After discussing various operative procedures, we conclude that intramedullar implants are safer than plates with regard to potential vascular complications.     

Fractures of the proximal humerus

Summary Proximal humeral fractures are common particularly in the elderly. The decision of the optimal treatment is dependent on many factors. On the one hand the biological age of the patient and the bone structure plays a key-role, on the other hand the living conditions and individual needs are of importance. Most fractures with minimal displacement respond satisfactorily to simple conservative treatment including short sling immobilisation and functional aftertreatment under supervision of the physiotherapist. Most recently there is a trend towards more aggressive surgical intervention with percutaneous insertion of cannulated screws also in the slightly displaced fracture situation. This protocol allows for earlier functional and less painful aftertreatment, less risk of displacement of the fracture fragments and better outcome. In severely unstable fractures with marked displacement of the fragments an operative stabilisation is advocated by most surgeons. Again there is a trend from plating towards cannulated screw fixation combined with tension absorbing (resorbable) sutures. In special cases which are described in detail a minimal invasive percutaneous screw technique with less stripping of bone and therefore preservation of the crucial blood supply of the humeral head is recommended. Instead of percutaneous pinning using K-wires only, cannulated screws are inserted today. Plating of proximal humerus joint fractures is the exception in our days, only the subcapital unstable fracture of the elderly would be an indication. LC-condylar plating seems to yield better stability than the conventional T-plate-system. In the most severe fractures of the proximal humerus (4-segment-fractures and dislocation fractures according to Neer, respectively C-2- and C-3-fractures according to the AO-classification) there is still controversy on the best management. Most authors prefer hemiarthroplasty in this situation whereas the other group of orthopaedic surgeons try open reduction and internal fixation particularly in the younger individuals. This stabilisation provides the orthopaedic surgeons with a formidable challenge and requires a lot of experience in this field. Also the understanding of the fracture morphology is needed for optimal results. In spite of good stabilisation techniques often partial or total humeral head necrosis occurs in the most severe fractures. Surprisingly enough results with reasonable function can be obtained even with partial avascular necrocis of the humeral head. A crucial part of the management is team work with the physiotherapist and an individual program for each fracture situation, depending on the stability of the fixation. Close contact between these two professions is of utmost importance. Finally it can be stated that the management of proximal humeral fractures is fairly standardised but it is always dependent on the experience and resources of the attending surgeon and must be tailored to the individual needs of the patient.      

Late development of a brachial plexus lesion after fracture of the clavicle

Summary Neurological complications in clavicle fractures are rare. As a primary lesion, it is caused by the trauma itself. More often however, the neurological symptoms develop later by large callus formation that encroach on the costoclavicular space. A case report is presented of delayed injury to the brachial plexus due to clavicular fracture with non-union and callus formation.      

Injuries of the cervical spine in children

Summary Injuries of the spine in children rarely occur. They amount to about 0.2 % of all fractures and dislocation and to 1.5 to 3 % of all lesions of the spine. The younger an injured child is, the more likely it has sustained a lesion of the upper cervical spine. This spinal segment in comparison to adults is concerned more often and accounts for 50 % of all C-spine injuries. Important differences between the adult spine and the spine in the child disappear with the age of 10 years. Later diagnostics, classification and treatment correspond widely with the principles valid in adults. The knowledge of the normal shape and development of the spine are crucial in avoiding misinterpretations of X-ray films. Typical examples include the confusion of synchondrosis with fractures or of subluxations of the atlas and the C2/C3 segment with “true” instabilities. Relevant lesions always are accompanied by clear clinical symptoms. Specific injuries of the growing axial skeleton are lesions of the cartilaginous endplates and “fractures” of the synchondrosis. Atlantooccipital dislocations (AOD) occur typically in children. According to our experiences with 16 AOD we propose – dependent on the direction of dislocation of the occipital condyles – a simplified classification in anterior, posterior and completely unstable AOD. In one boy in our series we treated the lesion successfully by temporary interal fixation. He presented a massive improvement of initially subtotal neurologic symptoms. Injuries to the synchondrosis of the dens represent another typical lesion in childhood. Four out of 5 children treated in our clinic were involved as back seat passengers in head-on motor vehicle accidents. Three of them were restrained by 4 point children's seat harnesses. For conservative treatment we prefer a halo and plaster-vest for 12 weeks after closed reduction. We recommend operative treatment in cases of major dislocation with greater instability where it may be impossible to maintain alignment with halo fxation. Surgical equipment and techniques correspond in detail to those used in adults. Three of the five children mentioned have been stabilized successfully by anterior screw fixation. Atlantoaxial dislocations (AAD) are devided into translatory and rotatory instabilities. Sagittal dislocations of the atlas in children also need to be fixed by a fusion between C1 and C2. Rotatory instabilities in the acute phase are easy to reduce and are treated with a halo-fixator. According to our experiences in two delayed cases anatomical reduction is also possible after months partly by open, partly by closed means. For the lower C-spine lesion with encroachment of the spinal canal and above all ligamentous injuries represent a clear indication for operative treatment because, similar to the adult spine, they do not become stable after close management.      

Bilateral comminuted fracture of the proximal humerus with posterior dislocation treated by hemiarthroplasty and arthrodesis

Summary Functional recovery after bilateral comminuted fractures of the humeral head with posterior dislocation is poor. When reposition and internal fixation fail, the remaining alternatives are (hemi)arthroplasty and/or arthrodesis. In a 50-year-old patient, we treated the dominant shoulder by arthrodesis; a Neer prosthesis was inserted at the other side. Using this strategy, the advantages of both techniques were combined with an acceptable functional recovery, which ist especially important for young and active patients.      

Treatment of III B open tibial fractures with early osteosynthesis and local muscle flaps

Summary From 1986 to 1994 18 patients with 19 IIIB open tibial fractures were treated following similar therapeutic management. This included early and radical primary debridement, early and whereever possible immediate internal fixation of the bone and coverage with a local muscle flap (hemisoleus or gastrocnemius). At the time of follow-up all fractures had consolidated clinically as well as radiographically. The mean time to bony union was 7 months (3–20). Twelve patients did not have any severe pain and were able to walk for more than 4 km. The time to return to work averaged 8 months. In 2 cases a permanent disability of 50 % was established. Fourteen of 18 patients were satisfied with the function of the leg. On the other hand, 9 didn't like the aesthetic appearance and were inhibited because of it. The following complications occurred within a period of 2 years: non-union (3), flap necrosis (2), osteomyelitis (2), delayed union (4). The mean number of reoperations was 3 (0–8). In no case did an amputation have to be performed.      

The efficiency of ultrasound guided spinal fracture reposition

Summary To calculate canal compromise and decrease of midsagittal diameter caused by retropulsion of fragments into the spinal canal we analyzed the pre- and postoperative computed tomographies of 32 patients with unstable thoracolumbar burst fractures treated by USS (universal spine system). Our intention was to examine the efficiency of ultrasound guided repositioning of the dispaced fragments which was performed in all 32 cases. We found a clear postoperative enlargement of canal area (ASP preoperatively 55 %, postop. 80 %) and midsagittal diameter (MSD preop. 58 %, postop. 78 %). 10 of 13 patients presented a postoperative improvement of neurological deficit, no neurological deterioration occured. Fractures with neurological deficit showed more canal compromise (52 %) and less midsagittal diameter (MSD compromise 51 %) than those without (40 % or 39 %). There was no correlation between the percentage of spinal canal stenosis and the severity of neurological deficit. Below L 1 the spinal canal is greater than between Th 11 and L 1, so a more important spinal stenosis is tolerated. In case of unstable burst fractures with neurological deficit the ultrasound guided spinal fracture reposition is an effective procedure concerning the necessary improvement of spinal stenosis: an additional ventral approach for the revision of the spinal canal is unneeded. In fractures without neurologic deficit the repositioning of the displaced fragments promises an avoidance of long-term damages such as myelopathia and claudicatio spinalis.      

Definition of complex trauma and general management principles

Summary Complex joint trauma is a term reserved for specific and severe injuries that include two or more structural elements of the joint. These structural elements are the articulating bones, the major ligaments of the joint, the local soft tissue envelope and the neurovascular structures. Complex joint trauma has a high risk for complications and requires a special treatment algorhythm. A staged surgical protocol with initial soft tissue debridement, closed joint reduction and external fixation of the extremity followed by secondary recontructive surgery after soft tissue recovery is suggested.      

Retrograde intramedullary nailing in humeral fractures with new implants. Analyse of 120 consecutive cases

Summary Since 1993, 120 fractures of the humerus were treated by retrograde unreamed nailing. Operations were performed on simple, complex, compound and pathological fractures of the proximal three quarter of the humerus. On the proximal humerus, displaced two-part-fractures and occasionally three- or four-part-fractures were stabilized. In 110 cases a prototype of an unreamed humeral nail with deployable fins for proximal locking was employed. In another ten cases the new solid interlocking nail of the AO/ASIF was used. The operative procedure, rehabilitation program, complications and functional and radiological results are presented. Retrograde nailing offers a high patient comfort and good functional results (Constant-Score on average 87 % of the opposite side). Complications were nail migration (8.3 %), instability (3.8 %), nonunions (5.8 %) and iatrogenic fractures (5.8 %). Patients with high grade osteoporosis, small proximal fragments and poor compliance have an increased rate of complications.      

Late results after fracture of the femoral head

Summary The dislocation fracture of the femoral head is the result of high speed trauma. Most of the patients have additional injuries. The prognosis of this kind of fracture of the femoral head depends on the type of fracture, the additional injuries and the age of the patients. The diagnosis and the specific treatment are most important, since most of the patients with this injury are of a younger age. The reposition of the fracture has to be performed within 6 hours. In our opinion, this should be done by surgery if possible. For the operation some routine pelvic X-rays and a CT of the pelvis should be prepared. The therapy depends on the type of fracture. In patients with Type I and II fractures the broken head fragments should be refixed by only taking out small parts of bone which are not elementary for the pressure zone of the femoral head. Younger patients with Type III fractures should always receive the possibility of a screw fixation of the neck of femur, whereas total hip replacement should generally be achieved in the older patient. An exact reconstruction of the dorsal acetabulum must be performed in Pipkin Type IV fractures. The usual approach for Type I–III fractures is the ventrolateral Smith-Peterson and lateral Watson-Jones, for Type IV fractures, the dorsal Kocher-Langenbeck approach. We suggest indometacine as a prophylaxis for ossifications due to high tissue damage. Several scores for the evaluation and documentation of the outcome of this kind of fracture are useful: the clinical results according to Merle d'Aubigne, social status scored by the Karnofsky Index and X-ray results using Brooker and Helfet to classify the heterotopic ossification and post traumatic joint changes.      

Functional Treatment of Acute Achilles Tendon Rupture. A Histological, Immunohistological and Ultrasonographic Analisis in the Experiment

Summary In 105 rabbits the course of healing was examined at 1, 2, 4, 8 and 12 weeks (21 rabbits per group) after an experimental Achilles tendon rupture. The following treatment modalities were compared: a. operative functional treatment (resorbable suture, Kleinert technique) b. operative functional treatment with fibrin glue c. primary functional treatment. For the functional (after)-treatment a special orthosis was applied. A 7,5 MHz Ultrasound probe was used for the ultrasonographic evaluation. The histological specimens were stained after Masson-Goldner with Azan. Collagen Type III was depicted immunhistologically with polyclonale antibodies. A semiquantitative fibrocytes count was performed. The histological results showed a smooth healing in the prim. functional treatment group, reaching parallel orientation of collagen fibers at 12 weeks. In the fibrin glue-group the fibrin was resorbed after 4 weeks without essential influence to the course of healing. In the suture-group a secondary gapping of the tendon stumps was detectable. At 12 weeks the histological evaluation in all groups showed approximately normal tendon pattern. Immunohistochemically all groups showed cell-associated positive reactions for type III-collagen after 1 week with a maximum after 2 weeks. The semiquantitative fibrocyte count in the primary funct. group showed a maximal number after 1 week, in the fibrin glue- and suture-groups the maximal number could be found after 2 weeks. Sonographically an increase in tendon thickness was detectable up to the 4th weeks in all groups. The secondary gapping of the tendon stumps in the suture group could be detected sonographically. The echogenicity of the tendon during the course of healing showed increasing homogeneity and parallelism in all groups. At 12 weeks the echogenicity was comparable in all groups. The experiment could prove the equivalence of the primary functional treatment to operative therapy in Achilles tendon rupture.      

Influence of primary plate-osteosynthesis of femur fractures on complications in multiple trauma patients with or without thoracic injuries

Summary Primary intramedullary nailing of femoral fractures is well known to increase the risk of pulmonary complications, especially in multiple-trauma patients with severe thoracic injuries. Aim of this study was to investigate the influence of primary plate ostesynthesis of femur fractures on maior complications after trauma. This retrospective study based on the records of 325 multiple trauma patients (Injury severity score ISS > 18, no letal brain injury, age 16–65). According to the abbreviated injury scale of the Thorax (AIS T) patients were divided in groups without (AIS T < 3, “N”) or with relevant thoracic injury (AIS T > = 3, “T”). Both groups were additionally divided in subgroups without severe trauma to the extremities (AIS E< 3, “0”) or primary plate-osteosynthesis of femur fractures (< 24 h, “I”). 4 groups were performed: N0 (n = 39, ISS 25 ± 1, pneumonia 10 %, ARDS 5 %, lethality 10 %); NI (n = 55, ISS 27 ± 1, pneumonia 4 %, ARDS 5 %, lethality 4 %); T0 (n = 137, ISS 28 ± 1, pneumonia 21 %, ARDS 15 %, lethality 16 %); TI (n = 94, ISS 31 ± 1, pneumonia 21 %, ARDS 17 %, lethality 15 %). Primary plate-osteosynthesis of femur fractures did not increase lethality or incidence of pulmonary complications in patients with or without severe thoracic injuries. Also complication rate after primary plate-osteosynthesis was less compared to published results after intramedullary nailing. For this, primary plate-osteosynthesis is recommendable in case of multiple trauma with thoracic injuries.      

Surgical management of type III thoracic shotgun injury

Summary Reporting the case of a short-range severe thoracic shotgun injury the differentiated management of this trauma is discussed. Indication for operative exploration under emergency conditions is hemorrhagic shock, perforation of esophagus/stomach and pericardial tamponade. Even under a toxicological point of view there is no indication for emergency revisions.