Search

Intraosseous lipomas represent a small number of benign bone tumors with incidence rates of approximately 0.1%. In about 15% these neoplasias are localized within the calcaneus, mostly at Ward's triangle. The tumors usually remain clinically inapparent and diagnosis is often obtained incidentally. Although CT scan and MRI provide specific and sensitive diagnostic tools that can distinguish morphology and dignity, surgical treatment is not standardized yet. In conjunction with a case report, we summarize and critically compare current treatment strategies.

Isolated fractures of the os triquetrum are a very rare condition, since they are usually combined with other fractures of the carpus. An undetected isolated fracture of the os triquetrum in a 28-year-old pieceworker revealed an osseous consolidation with a misalignment of the joint surface on presentation 6 months after his primary injury. During the whole time he was unable to work due to the severely painful restricted range of movement of his wrist. There are no general guidelines for treatment. Instead of correction of the anatomy of the os triquetrum, we decided to perform a subperiosteal pisiform excision according to Palmieri. As early as 6 weeks later, the patient was able to go back to work and demonstrated a pain-free full range of movement of his wrist. We encourage this procedure not only for degenerated joint disease but also for posttraumatic lesions in the early onset of painful blocking of the joint between the os triquetrum and os pisiforme.

From 1990 to 1997, callus distraction of the first metacarpal bone was performed on 34 patients with a traumatic amputation of the thumb, if replantation was not possible. After a period of 7 +/- 11 months (range, 1-48), a corticotomy and continuous distraction with an external fixator was carried out. Of the patients, 31 (91%) were reviewed after treatment. The follow-up period range was 41 +/- 32 months. With this method, the average lengthening of the thumb was 78% in comparison to the uninjured side. Complications were rupture of the callus in one case, four patients suffered a superficial wound infection, and seven patients showed pin tract infection without osteitis. At follow-up examination, 20 patients (64.5%) showed excellent, 9 (29%) good and 2 patients (6.5%) unsatisfying results.

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.

An iatrogenic avulsion of the greater trochanter occurring during prosthetic hip replacement after a fracture of the neck of the femur is a rare complication. The need for maximum internal rotation of the limb during the operation imposes serious mechanical stress on the greater trochanter in patients who are often elderly and whose bones are osteoporotic. Two case reports illustrate that a conservative management--without internal fixation--combined with early mobilisation is successful. Our view is based on the current, international opinion that conservative management with early mobilisation is preferable for isolated traumatic avulsion of the greater trochanter, even if there is wide displacement.

Among the various procedures to restore flexor tendon function after failed or omitted primary suture flexor tendon grafting is the most frequently applied technique. It can be performed in a one-stage procedure using a palmaris- or plantaris graft in cases with less scarring or in a two-stage procedure for cases in unsuitable conditions. The main purpose for using silicone rods is to prepare an artificial tendon sheath to avoid adhesions of the tendon graft. The disadvantage of two operations seems to be justified by better results. We performed this technique in 168 zone-II-lesions. According to the Buck-Gramcko score we achieved excellent results in 30.9% and good results in 25.6%. In 76 fingers we applied the combination of the Paneva-Holevich technique of using a pedicled superficialis tendon with Hunters method without obtaining better results (22.4% and 32.9% respectively). The various techniques of grafting are described as well as indication and technique of tenodesis and alternatively staged procedure for isolated profunda lesions.

Avulsion fractures of the ischial tuberosity are rare. They are often caused by a typical "splits"-like accident. In general the patients feel sudden severe pain in the buttock with localized tenderness in the region of the ischial tuberosity, rarely in combination with sciatic nerve irritation. According to the functional anatomy, flexion of the knee and extension of the hip may be impaired. Roentgenograms often reveal no abnormality and show no evidence of fracture. Therefore, inadequate therapy because of missed diagnosis can result in avoidable persistent pain. We report on a 42-year-old man with an avulsion fracture of the ischial tuberosity. The epidemiology, symptoms, including irritation of the sciatic nerve, differential diagnoses, diagnostic procedures and therapy are presented in detail.

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.