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20 male professional divers underwent a total of 68 MR examinations of the shoulder, hip and knee joints with follow-up for 16 joint regions. Cerebral MR was performed additionally in 16 divers. 11 patients showed signal alterations of bone marrow which suggested bone infarct in 9 cases. One patient had unifocal demyelinisation of the left hemisphere. In conclusion, MR showed high sensitivity in detecting dysbaric osteonecrosis.

20 male professional divers underwent a total of 68 MR examinations of the shoulder, hip and knee joints with follow-up for 16 joint regions. Cerebral MR was performed additionally in 16 divers. 11 patients showed signal alterations of bone marrow which suggested bone infarct in 9 cases. One patient had unifocal demyelinisation of the left hemisphere. In conclusion, MR showed high sensitivity in detecting dysbaric osteonecrosis.

From 1980 to 1986 in 15 patients (16 lower leg fractures) with crush fractures of the lower limb, five had to be amputated primarily under emergency conditions, and four had successful reconstruction but required medical treatment for an average of one year. Seven secondary amputations were carried out because of infection of the bone, soft tissue and vascular occlusion. The level of amputation was at the proximal third of the tibia according to Dederich and Burgess. One leg was amputated 'through the knee'. The indication for amputation was based mainly on clinical findings, supplemented by bone X-rays, arteriography or arterial DSA. Doppler sonography was used for monitoring short intervals of blood flow in the emergency case unit, in cases of doubt.

Der Radiushalsbruch ist eine typische und haufige Frakturform des Kindes. Meist handelt es sich um metaphysare Frakturen, selten nur um Epiphysenverletzungen. Anlaslich der Nachuntersuchungsergebnisse konservativ behandelter Radiusfrakturen im Kindesalter werden therapeutische Alternativen diskutiert. — Das Vorgehen richtet sich nach dem Grad der Fragmentdislokation. Frakturen des Dislokationsgrades 1 und II nach Judet sollten uberwiegend konservativ behandelt werden. Dislozierte Frakturen des Schweregrades III sollten bei Repositionsschwierigkeiten, Frakturen des Schweregrades IV weitgehend ausnahmslos notfallmasig operiert werden

Von 1975–1979 wurden von 93 Oberarmschaftfrakturen 79 im Hanging-cast und 14 operativ behandelt. OP-Indikationen waren zweit- und drittgradig offene Bruche, Gefas- und/oder Nervenlasionen, Serien- oder doppelseitige Frakturen, Pflegeerleichterung bei Greisen und Polytraumatisierten. Von 79 konservativ Versorgten wurden 12 wegen verzogerter Bruchheilung nach 8 Wochen sekundar operiert. Von 67 im Hanging-cast zu Ende behandelten wiesen nach 1–5 Jahren 62 (93 %), inklusive Querfrakturen, ein sehr gutes und gutes, sowie 5 (7 %) ein schlechtes Ergebnis auf.

Die operative Knochenbruchbehandlung mit intra- und extraossaren Krafttragern sowie die Knochentransplantation setzen eine genaue Kenntnis der Gefasversorgung und des Verhaltens des ossaren Gefassystems nach operativen Eingriffen voraus.

Die Bruckenkallusbildung als Komplikation nach Unterarmfrakturen bedingt eine erhebliche Einschrankung der Drehbewegungen der Hand. Ursachlich ist eine Verknocherung, die ihren Ursprung am Frakturspalt hat und sich in Faserrichtung der Membrana interossea auf den gegenuberliegenden Knochen hin entwickelt. Die Membrana interossea verfugt uber eine grose Potenz zur Verknocherung. Der Grund ist in ihrer Ontogenese zu suchen. Die Therapie bereitet wegen der Rezidivneigung grose Schwierigkeiten. In der Resektion des Bruckenkallus und der gedoppelten Interposition eines breiten Kutisstreifens sehen wir eine erfolgreiche Therapiemoglichkeit. Drei Patienten sind auf diese Weise erfolgreich operiert worden.

Auf Grund toxikologisch gewonnener Befunde bei frischen Unfallverletzten wird auf die Bedeutung der Einnahme von Medikamenten auf die Verkehrstuchtigkeit hingewiesen. Die Zahl der Unfallverletzten, bei denen kurz nach dem Unfall toxikologisch Medikamente nachgewiesen wurden, die in der Lage waren, die Verkehrstuchtigkeit zu beeintrachtigen, ist mit 68% erschreckend hoch. Die Ergebnisse zeigen, das der unkontrollierten Medikamenteneinnahme bei Verkehrsteilnehmern weit grosere Beachtung geschenkt werden mus als bisher.

Das Verfahren der Wahl in der Behandlung der offenen Frakturen ist die primare operative Versorgung: An erster Stelle steht die mechanische Reinigung, die Spulung und die Wundausschneidung; danach folgt die Stabilisierung der Fraktur durch eine gewebeschonend durchgefuhrte Osteosynthese. Nachuntersucht wurden 307 operativ stabilisierte offene Frakturen aus dem Zeitraum 1973 bis 1979 durchschnittlich ca. drei Jahre nach dem Unfall. Die Knocheninfektrate betragt bei den offenen Unterschenkelfrakturen durchschnittlich 8,5%, bei den offenen Frakturen der ubrigen Lokalisation 4,9%. Am Unterschenkel wird die Osteitisrate bei Anwendung des Fixateur externe seit 1977 bei den zweit- und drittgradig offenen Frakturen auf 5,5% gesenkt. Wegen verzogerter Frakturheilung bei alleiniger Anwendung des Fixateur externe ziehen wir bei den zweit-und drittgradig offenen Unterschenkelfrakturen die sogenannteKombinationsosteosynthese vor: Die Fraktur wird zunachst exakt reponiert und mit Zugschrauben, gelegentlich auch durch eine Zweilochplatte unter Kompression gesetzt. Danach wird zusatzlich der Fixateur externe angebracht. Auserdem empfielt es sich bei den offenen Unterschenkelfrakturen grundsatzlich, eine autologe Spongiosa-Transplantation durchzufuhren, um die haufig verzogerte Frakturheilung zu beschleunigen.

A computer tomographic method is described for measuring tibial torsion in vivo. The basis of the method depends on transverse scans of the tibia through the knee and ankle joint region by means of which it is possible to establish normal values and abnormal posttraumatic or in congenital torsion. Traumatologists, as well as orthopaedic surgeons, require reproducible measurements, since a detorsion operation may rectify deformities which would lead to degenerative joint changes. A review of previously available methods with torsiometer or conventional radiography shows the limitations of these methods.

In der vorliegenden Arbeit wird der Einflus von postoperativen Ossifikationen der Syndesmose auf die Arthroseentstehung am oberen Sprunggelenk untersucht. Durch die computertomographische Bestimmung der tibiofibularen Beweglichkeit last sich in vivo die Veranderung der Biomechanik feststellen. Eine bislang in der Literatur vermutete Verstarrungsarthrose konnte anhand der computertomographischen Befunde belegt werden. Posttraumatische und postoperative Veranderungen der tibiofibularen Beweglichkeit konnen mit dem vorliegenden Verfahren bestimmt und im Hinblick auf eine Arthroseentehung bewertet werden.

In Erganzung zu den radiologischen Befunden (siehe Teil I) zeigt sich, das die histologischen Regenerationsvorgange bei Segmentdefekten an Rohrenknochen von der Markhohle ausgehen. Es wird ein endostales Geflechtknochen-Gerust gebildet, an der proximalen Resektionsstelle in starkerem Umfang als an der distalen. Die Knochenneubildung im Defekt ist gebunden an die Revaskularisierung durch medullare Gefase. Die starkere Osteogenese an der proximalen Resektionsstelle entspricht der starkeren Gefasneubildung in diesem Bereich. Die Vaskularisierung und Auffullung von Segmentdefekten an Rohrenknochen wird beschleunigt, wenn zur Stabilisierung anstelle einer Doppelplatten-Osteosynthese nur eine Metallplatte und ein gegenuberliegender autologer Kortikalisspan verwendet werden. Der Span verbindet sich innerhalb von 12 Wochen durch Bildung eines Geflechtknochen-Gerustes an den Anlagerungsstellen mit dem Wirtsknochen. Der stabil befestigte autologe Kortikalisspan wird von Knochen- und Weichteillager her revaskularisiert. Darauf folgen Osteolyse und gleichzeitig Osteogenese, wodurch der avitale Kortikalisspan innerhalb von ca. 40 Wochen durch neugebildeten Knochen weitgehend ersetzt wird. Der dabei entstehende Stabilitatsverlust gefahrdet die Osteosynthese nicht.

Because of the anatomical and functional peculiarities of the astragallus surgical and conservative treatment of central fractures are often unsatisfactory. A follow-up study of 40 patients with 42 central talus fractures were performed over an average of 9 years after the initial trauma. The number of poor results was extremely high; only primary surgical or conservative treatment showed good or fair results. Best results were obtained by primary surgical treatment whereas fractures operated at later stages showed worse results. Therefore fresh central astragallus fractures should be operated upon, fractures older than 1 day should be treated conservatively. If a satisfactory reduction cannot be obtained, the fracture should be operated upon in order to prevent arthrosis in the upper ankle joint.

In part I of this paper the radiological findings in segmental defects of long bones were discussed. The histological regeneration originates from the marrow cavity. An endostal framework of bone is formed; this is more pronounced on the proximal resection place than on the distal one. The new bone formation within the defect depends on the revascularization through medullar blood vessels. The increased osteogenesis on the proximal site of resection is due to the increased formation of vessels in this area. The vascularization and the filling of segmental defects in tubular bone occurs faster, if only one metal plate and on the opposite side an autologous bone graft (cortical bone) is used in order to stabilize the bone. This method is superior to the use of a double-plate osteosynthesis. The graft unites with the underlying bone within twelve weeks by forming a trabecular network of new bone. If the autologous bone graft has become stable, it is vascularized from the bone and from the sorrounding soft tissue. Afterwards an osteolysis and at the same time an osteogenesis take place. The dead bone graft is replaced by newly formed bone within about 40 weeks. The loss of stability which occurs does not endanger the osteosynthesis.

A computer tomographic method is described for measuring tibial torsion in vivo. The basis of the method depends on transverse scans of the tibia through the knee and ankle joint region by means of which it is possible to establish normal values and abnormal posttraumatic or in congenital torsion. Traumatologists, as well as orthopaedic surgeons, require reproducible measurements, since a detorsion operation may rectify deformities which would lead to degenerative joint changes. A review of previously available methods with torsiometer or conventional radiography shows the limitations of these methods.

Ectopic ossifications occassionally occur after stable osteosyntheses. The literature and our own observations indicate that osseous bore-chips probably favour these ossifications, especially after intermedullary nailing. Experiments determined the weight of osseous bore-chips which occur in intermedullary nailing of femur and in plate osteosynthesis of radius and ulna. Conclusions drawn from these findings should be considered when performing osteosynthesis.

Because of the anatomical and functional peculiarities of the astragallus surgical and conservative treatment of central fractures are often unsatisfactory. A follow-up study of 40 patients with 42 central talus fractures were performed over an average of 9 years after the initial trauma. The number of poor results was extremely high; only primary surgical or conservative treatment showed good or fair results. Best results were obtained by primary surgical treatment whereas fractures operated at later stages showed worse results. Therefore fresh central astragallus fractures should be operated upon, fractures older than 1 day should be treated conservatively. If a satisfactory reduction cannot be obtained, the fracture should be operated upon in order to prevent arthrosis in the upper ankle joint.

The indication and surgical procedure of mesh skin grafting with mesh graft dermatoma II after Tanner-Vanderput concerning avoidable failures are shown. In order to avoid therapeutic complications of skin grafting in extremities it is of great importance to have a well granulating transplantation ground and to spread out the mesh graft equally. Even in regions of joints good results can be achieved.

Between 1975 and 1979 93 upper arm fractures were treated: 79 by hanging cast, 14 by surgery. The indications for operation were second or third degree compound fractures, vessel or nerve lesions, serial fractures in both arms and for easier nursing of the aged and polytraumatised. Out of 79 conservatively treated patients 12 required secondary surgery after 8 weeks due to prolonged fracture healing. 62 (93%) out of 67 fractures treated solely by hanging cast showed very good and good results 1-5 years after the accident--transverse fractures included--and only 5 (7%) poor results.

Die pertrochantere Oberschenkelfraktur stellt den Hauptanteil aller huftgelenknahen Bruche des alten Menschen dar. Nach Ender liegt das Durchschnittsalter bei 80 Jahren. Bemerkenswert ist die Tatsache, das mit zunehmendem Alter meist ein Sturz aus innerer Ursache der Fraktur vorausgeht. Exogene Gewalteinwirkungen sind in der Minderzahl.

The infection rate of open lower leg fracture is extremely high. Surgical treatment guarantees a reduced risk of infection when compared with conservative treatments. But even osteosynthetic methods such as screw or compression plate fixation show unsatisfactory results because of the additional traumatization of the primarily injured soft tissue combined with a reduction of blood circulation. From July 1973 till September 1976 we treated 57 2nd and 3rd degree open shank fractures with osteosynthetic methods: 46 with compression plate osteosynthesis and 11 primarily or secondarily with external fixation. The osteitis-rate was 14%, in addition to that there was a soft-tissue infection rate of 5%. In order to change our therapeutical procedure we stabilized 2nd and 3rd degree open lower limb fractures and lower leg fractures complicated by soft-tissue damages consequently by external fixation. From October 1976 till May 1978 we treated 39 open shank fractures; 24 of them were 2nd and 3rd degree open fractures. They were treated by external fixation. This change in our surgical treatment resulted in an osteitis-rate of 2.6%, there was no case of soft-tissue inflammation. These results underline the superiority of treating 2nd and 3rd degree open lower leg fractures and fractures combined with soft-tissue injuries consequently and chiefly with AO external fixation.

Subject of this investigation is the influence of postoperative tibio-fibular ossification on the development of arthrosis of the ankle. Changes of the biomechanics of the joint can be evaluated by computed tomography. Posttraumatic and postoperative changes of the mobility of the fibular in relation to the tibia may be quantified by CT investigation and evaluated with respect to the development of arthrosis.

12 patients (mean age: 81 +/- 9 years) undergoing total hip replacement because of transcervical femoral fractures were studied intraoperatively by two-dimensional transoesophageal echocardiography (TEE). The purpose of this study was to evaluate the ability of this new technique for detection of embolic events in the right heart by intraoperative 2D-TEE monitoring during hip surgery. In all patients (pts) we observed a transient increase of contrast intensity in the right atrium immediately after insertion of the acetabulum prosthesis ("snow flurry"). Contrast was maximal 15-20 seconds after insertion and persisted for approximately 2 min. While contrast intensity decreased in the minutes thereafter, in 3 pts contrast became more heterogeneous:we detected structures like "flakes" passing the right heart, sometimes circulating for some seconds in the right atrium respectively the right ventricle. Detected embolism was followed by a transient decrease of arterial pO2 (greater than 10 mmHg) in 5 pts. However, haemodynamic responses occurred infrequently; 4 pts experienced no changes at this moment. During insertion of the femoral prosthesis the contrast events were even more pronounced and persistent. In all pts we observed the appearance of "flake"-like structures passing the right atrium and the right ventricle, some measuring up to 6 cm in length. This was accompanied in 10 pts with a decrease (greater than 10 mmHg) of arterial pO2 and in 8 pts with a decrease (greater than 5 mmHg) of endtidal CO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Der Traumatologe wird tagtaglich mit den unterschiedlichsten Wunden konfrontiert. Entsprechend der Vielfalt der prasentierten Wunden sind auch die Behandlungsprinzipien vielfaltig.

Primary operative care with debridement and the soft tissue protective osteosynthesis is the method of choice in the management of open fractures. A follow-up study of 307 so treated fractures was performed over an average of 3 years after the initial trauma. The overall rate of osteomyelitis was 8.5% in below knee compound fractures and 4.9% in all other areas. During the past two years while using the external fixation device in 2nd and 3rd degree compound fractures in the lower leg the osteomyelitis rate was reduced to 5.5%. In the 2nd and 3rd degree compound crural fractures due to the delayed bone healing with the external fixation method alone we recommend the so called "combination osteosynthesis" in which a screw or a AO-2-hole-plate is employed additionally. Furthermore it seems essential to perform an autologous cancellous bone graft in these fractures to reduce the long healing time.

In fruheren experimentellen Untersuchungen beim Hund wurden 2 cm lange Kontinuitatsdefekte am Femurschaft durch Plattenosteosynthese und autologe Kortikalistransplantation uberbruckt (Schottle et al. 1979,1980). Der Kortikalisspan wurde vom gegenseitigen Femur entnommen und als Widerlager zur Platte mit Schrauben stabil fixiert. Der Kortikalisspan heilte in diesen Experimenten in 11 von 12 Fallen innerhalb von 12 Wochen komplikationslos ein. (Abb. 1).

Analyses of blood coagulation in a defined group of patients before, during, and after trauma-surgery confirms an intraoperative trigger-mechanism, that causes postoperative thromboembolic complications. They also proof the correlation between extent of tissue-lesion and extent of triggering, this was previously presumed from the postoperative incidence of thromboembolic complications. Apart from the usual blood coagulation tests the following parameters where analysed: Factor VIII: C, Ristocetin-Co-factor, Factor Xa, AT III, TAT, Reptilase-time, tPA, D-dimers, and FPA. Simultaneously, it was shown, that a preoperative prophylaxis of thrombosis can prevent an intraoperative increase of Factor Xa, that plays a key role in postoperative thromboembolic complication. The increased intraoperative turnover of coagulation factors, which is necessary for physiologic blood coagulation, is not prevented.

A follow-up study concerning arthrotic, ischemic and functional results was performed in 20 patients with subtalar luxations over an average of 13 years after the initial trauma. 13 patients showed good, 7 poor results according to Weber. 4 of these 7 patients were free of any complaints but showed reasonable arthrosis in both ankle joints as well as pathological scintigrams. Three cases operated upon showed poor functional results, two of them were primarily open, in one case the tendon of m. tibialis post. forced us to reduct openly. The best results could be obtained by immediate reduction and conservative treatment.

In childhood fractures of the head of the radius are typical and frequent. Generally these fractures are in the metaphysis, but a few cases are in the epiphysis. In the follow-up of conservatively treated fractures of the radial head in childhood, the therapeutic alternatives are discussed. The therapeutic procedure must take into account the degree of fragment displacement. Fractures of type I and II according to Judet are treated conservatively, predominantly by means of exact reduction and fixation in a plaster cast. If reduction fails for type III, however, type III and type IV fractures must be operated on at once for sufficient results.

Die gewebeschonende Osteosynthese ist das Verfahren der Wahl bei der Behandlung offener Frakturen. 3307 offene Bruche wurden durchschnittlich 3 Jahre nach dem Unfall nachuntersucht. Durch die vermehrte Anwendung des Fixateur externe bei zweit- und drittgradig offenen Unterschenkelfrakturen sank die Osteitisrate von 10% auf 5,5%. Wegen verzogerter Bruchheilung wurde oft bei der Fixateur-exteme-Behandlung eine Kombinationsosteosynthese mit einer Schraube oder 2-Loch-Platte durchgefuhrt. Bei offenen Unterschenkelfrakturen empfiehlt sich auserdem eine autologe Spongiosaplastik zur Beschleunigung der Bruchheilung.