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Ein neuartiges Antisepticum auf Biguanidbasis zeigt im Vergleich zu anderen Antiinfectiva in vitro eine verbesserte Bactericidie bei guter Gewebevertraglichkeit. In einer prospektiv-randomisierten, kontrollierten Doppelblindstudie wurden Patienten mit bakteriell kontaminierten Weichteilwunden vom Typ 2–4 mit feuchten Kompressenverbanden 0,2 %iger Lavasept-Losung (n = 45) im Vergleich zu Ringer-Losung (n = 35) behandelt. In keiner Gruppe traten Wundheilungsstorungen auf. Durch die Lavaseptbehandlung kam es auf den Wundoberflachen zu einer schnelleren und signifikanten Reduktion grampositiver Keime. Die Gewebevertraglichkeit von Lavasept wurde signifikant besser als Ringer-Losung beurteilt.

Physical methods became recently more important as an alternative to anticoagulation for prophylaxis of thromboembolism and were studied for their efficacy. The AV-impulse-system proved efficient in reducing thromboembolic complications in patients undergoing hip surgery by increasing the return of venous blood in the deep veins of the leg. In a preclinical trial we studied the influence of the AV-impulse-system and of active forefoot movement on venous blood return in 12 lower extremities of 6 healthy individuals immobilized in below the knee plaster casts. Our results show a significant increase in venous blood flow caused by the AV-impulse-system (p < 0.05) and by active forefoot movements (p < 0.05). Prevention of thromboembolic complications in trauma and orthopaedic patients immobilized in plaster cast seems possible by using the AV-impulse-system which significantly increases the venous blood flow independent from patient compliance.

In the treatment of posttraumatic contracture of the elbow joint, arthrolysis is a proven procedure. We used a stepwise operative approach starting laterally and including an additional medial and dorsal incision if needed. A total of 91 patients with arthrolysis of the elbow could be followed-up on average 44 months (range 9-102 months) joint after operative (58, 63.7%) and non-operative (33, 36.3%) fracture treatment. The mean preoperative range of motion (ROM) in flexion/extension was 49 degrees (SD +/- 38 degrees), while in pronation/supination it was 89 degrees (SD +/- 66 degrees). Postoperatively, the ROM was on average 94 degrees (SD +/- 27 degrees) in flexion/extension and 129 degrees (SD +/- 52 degrees) in pronation/supination. Using our own grading system, it became evident that most patients had a functional benefit from the procedure, although the quality of the improvement differed. For example, postoperatively 59.3% of the patients were grade I (or = 90 degrees) in flexion/extension compared with 16.5% preoperatively. Although the rest also showed improvements, their functional benefit was less. The earlier the release of the joints was performed, the better was the functional outcome (p0.05). The importance of an intensive early rehabilitation programme is emphasised while indications for this procedure should only be seen in compliant patients.

The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights > 4 m. 211 patients with an injury severity score (ISS) > 17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 ± 1; A: 30 ± 1), ventilation time (I: 16 ± 2; A: 15 ± 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27 %), fractures of lumbarspine (I: 34; A: 15 %), pelvis (I: 51; A: 38 %), lower leg (I: 47; A: 20 %), pilon (I: 15; A: 5 %), and os calcis (I: 17; A: 9 %). Liver lacerations occured more often after intentional fall (I: 16; A: 6 %). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A (I: 1; A: 8 %). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69 %) or related to brain-injuries (I: 35; A: 19 %). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.

Out of 95 ligamentous lesions of the thumb metacarpophalangeal joint, those with an isolated bony rupture of the ulnar collateral ligament were chosen. Of these, 15 patients treated with Lengemann suture and 16 with screw fixation were followed-up on average 27.3 and 26.4 months, respectively, after operative treatment. Under only "good" and "very good" clinical results, the statistical analysis of the objective and subjective parameters showed no significant difference, except for the measurement of the soft-tissue circumference (p < 0.01) between either procedure. Although both procedures have a low rate of complications, screw fixation is preferable since implant removal is not necessary.

Multiple injuries in children are responsible for a great part of childhood mortality. Remaining handicaps after injuries have a social and economic significance. In this study, the characteristics of polytrauma in childhood are evaluated by comparison with severely injured adults. The two groups of multiple trauma patients (117 children between 3 and 15 years of age and 1159 adults between 16 and 59) were equal in the overall severity of all injuries. Children were mainly hurt as pedestrians, whereas adults had an accident more often as car passengers. The most frequently injured region were in both groups fractures of the extremities. The greatest injury severity represented head injuries in each group. Complications were seen more often in adult patients. Multiple organ failure and isolated liver failure were exclusively seen in the adult group, pneumonia and lung failure occurred significantly more often. The duration of artificial ventilation and the duration of hospital stay were prolonged in the adult group. In summary, children with multiple injuries have a lower mortality rate than adults. The main cause of death are cerebral injuries. Remaining handicaps in surviving children are most often caused by fractures of the lower extremities.

The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of this retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients sustaining flail chest with and without pulmonary contusion.The hospital records of 405 patients with multiple trauma (Injury Severity Score17) between 1988 and 1994 were reviewed. Forty-two patients sustained flail chest. Twenty of these underwent operative chest wall stabilization for the following indications: 1) flail chest with indication for thoracotomy due to intrathoracic injury (n = 6); 2) flail chest without pulmonary contusion (n = 9); 3) paradoxical movement of a chest wall segment in the weaning period from the respirator (n = 3); and 4) severe deformity of the chest wall (n = 2). For the purpose of analysis the patients were separated into groups: group 1: operative chest wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with pulmonary contusion (n = 10); group 3: flail chest without pulmonary contusion and without chest wall stabilization (n = 18); group 4: flail chest with pulmonary contusion and without chest wall stabilization (n = 4). Data were coded for time of operation, duration of ventilatory support, and complications.There were no significant differences in age, severity of injury, and extent of injury between groups 1, 2, and 3 (p0.42). Group 4 was excluded for statistical analysis because of the small number of patients. Patients in group 1 required a shorter ventilatory support time compared to patients in group 3 (6.5+/-7.0 versus 26.7+/-29.0 days) and group 2 (p0.02). In group 2 (ventilator time 30.8+/-33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturbance of gas exchange. All patients in group 1 survived; deaths in group 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure.In patients with flail chest and respiratory insufficiency without pulmonary contusion, operative chest wall stabilization permits early extubation. Patients with pulmonary contusion do not benefit from chest wall stabilization. Secondary operative chest wall stabilization in these patients is indicated when progressive collapse of the chest wall is evident during weaning from the ventilator.

Die Versorgung polytraumatisierter, alterer Patienten ist aufgrund vielfaltiger Probleme besonders aufwendig und mit einer hohen Letalitat bei diesen Patienten verknupft. Der Verlauf und die Prognose alterer polytraumatisierter Patienten sollte durch Vergleich mit jungeren Patienten untersucht werden. Dazu wurden 2 Gruppen gebildet: Gruppe J: 16 – 64 Jahre, n = 1022, Gruppe A: 65 – 94 Jahre, n = 132. Altere Patienten wurden haufiger als Fusganger (69%), jungere Patienten vor allem als PKW-Insassen (41%) verletzt. Die Verletzungsschwere im ISS (J: 28±1, A: 27±1) war in beiden Gruppen gleich. Im Verlauf traten ARDS (J: 10%, A: 11%), MOV (J: 6%, A: 9%) und Pneumonien (J: 17%; A: 21%) in beiden Gruppen gleichhaufig auf, wahrend septische Komplikationen bei den alteren Patienten signifikant haufiger beobachtet wurden (J: 19%, A: 27%). Altere Patienten verstarben signifikant haufiger (J: 16%, A: 58%) an der Sepsis (J: 15%, A: 31%), jungere Patienten dagegen haufiger an den Folgen des Organversagens (J: 54%, A: 29%). Die Intensiv-(J: 19±2, A: 18±1) und Beatmungsdauer (J: 17±1, A: 14±2) war bei den alteren Patienten nicht verlangert. Zusammengefast haben altere Patienten nach schweren Unfallverletzungen bei vergleichbarer anatomischer Verletzungsschwere eine deutlich hohere Letalitat als jungere Patienten, wobei diese auf der Entwicklung septischer Komplikationen beruht.

Treatment costs of emergency therapy, surgery and intensive care were analysed in 20 randomly chosen, representative patients with severe multiple trauma (mean ISS 32 p). For an average stay of about 22.5 days in the ICU, the total costs were DM 106,924.36 (about $70,000), which breaks down as DM 39,635.88 (= 37%) for physicians and nurses, DM 67,289.08 (= 63%) for materials, X-rays, laboratory investigations, drugs and blood components. The whole treatment caused daily costs of DM 4,752.22, or DM 3.30 per min. The first emergency diagnostic procedures and emergency therapy take a mean of 451.9 min from admission to the beginning of the ICU treatment and itself generates costs of about DM 12,325.99. In Germany a new system of compensation by diagnosis-related group was introduced in 1996. Therefore, these data indicate that treatment of severe multiple trauma is very expensive and trauma care could be economically by damaging for smaller hospitals. We conclude that treatment of multiply injured patients (ISS > 16 p) should be concentrated in selected trauma centres and compensated by payment of a special daily amount of about DM 5,000 (about $3,500).

Accident proceedings and injuries were investigated in a consecutive series of 70 patients (65.2% male, 34.8% female, age: 18 +/- 9 years) presented to the emergency department after in-line skate falls. 52.7% wore no protective equipment. 41.8% used knee pads, 27.3% wrist guards, 12.7% elbow pads, and 5.5% each helmets and gloves. The most common cause of fall were obstacles/irregularities (32.7%) on a dry and plain surface. The upper extremity (67.9%) and the head (12.8%) were the most commonly injured body parts. 47.8% in-line skaters sustained fractures. The distal radius (51.5%) was most commonly injured body parts. 47.8% in-line skaters sustained fractures. The distal radius (51.5%) was most commonly fractured. Injuries to novice skaters were more often severe. Advanced freestyle and jumping in-line skaters sustained even injuries of the trunk. Life-threatening injuries of the abdomen and the head may occur. The use of a complete personal protection equipment is recommended.

From 87 patients who underwent anterior cruciate ligament (ACL) surgery with an alloplastic ligament (Trevira hochfest) the radiographs of 77 patients were examined by 2 physicians, who were not involved in the operation. They evaluated the increase of degenerative osteoarthritis according to the classification by Holz [12] finding a significant increase of degenerative osteoarthritis after surgery with a mean follow-up of 41.2 months. The ligament reconstruction was performed in 50 fresh ACL tears by reinsertion plus synthetic ligament protection and in 27 chronic instabilities with several failed previous operations by using the alloplastic ligament as an ACL prosthesis by means of a salvage procedure. Both investigators found a significant increase of degenerative osteoarthritis in both groups, but the chronically instable knees had a higher initial value. Patients with concomitant meniscus and/or posterior cruciate ligament (PCL) ruptures showed the highest increase of osteoarthritic changes; isolated ACL tears were found with very low degeneration. Considering the special profile of our collective, the factors that were found to as a risk of osteoarthritis and the comparison with the literature we could not find any indication for a relevantly increased risk of osteoarthritic progression using the Trevira hochfest ligament.

We have used total hip replacement combined with cemented intramedullary nailing to treat a selected group of nine patients with pathological fractures of the proximal femur and impending fractures of the shaft due to metastases. One patient died from cardiopulmonary failure on the third postoperative day, but the others were able to walk within the first week after operation. Complications included one recurrent dislocation of the THR and one fracture of an osteolytic lesion of the femoral shaft during nail insertion. Both were managed successfully. The hybrid osteosynthesis which we describe is an alternative to the use of tumour or long-stem prostheses; it has the advantage of preserving bone stock and muscle attachments.

Anteroposterior X-ray views of both acromioclavicular (AC) joints with 10-kg weights held in each hand are the generally accepted procedure for diagnosis of Tossy I-III grades of AC joint separation. An analogous diagnosis can be made by standardized ultrasound examination. Ten individuals with Tossy-I, 11 with Tossy-II and 8 with Tossy-III instability were examined both radiographically and by B-mode ultrasound. The degree of AC joint separation was uniformly determined on the basis of a calculated index (AC Index = AC joint width of uninjured side/AC joint width of injured side). The mean AC Index for Tossy-I instability determined by ultrasound was 1.0; mean indices of 0.49 and 0.5 were determined for Tossy-II injury by ultrasound and X-ray, respectively, and of 0.21 and 0.2, respectively, for Tossy-III instability. Statistical analysis showed significant differences between the mean AC indices of all three groups (P < 0.0001). We conclude that the reliability of ultrasound examination of AC joint instability is equal to that of radiographic measurement. Standard X-rays of the shoulder remain mandatory only to exclude fracture. The indication for operative stabilization of the AC joint can be established on the basis of the grade of AC joint instability measured by the side-effect-free and cost-effective method of ultrasound examination (AC Index < 0.3 equivalent to Tossy-III instability).

From 1981 to 1993, 21 patients received intercalary bone allografts for reconstruction of the extremity after en bloc tumor resection (15 malignant and 6 benign tumors). The allografts were collected from multiorgan donors and cryopreserved at -70 degrees C. The mean follow-up was 4.4 (range 1-13) years. The fate of the grafts was followed by conventional radiography, bone scintigraphy, and functional assessment. The overall survival rate of the 7 patients with high-grade malignancies was 86%. Solid union of the graft-host sites in less that 15 months occurred in 85%. An increased isotope uptake of the graft indicates that incorporation at the osteotomies as well as remodelling is still continuing at 9 years after operation. The overall complication rate was 43%; 3 patients had two or more complications. Complications were related to the allograft in 6 (infection or fatigue fracture in 1 and delayed healing in 4 cases) and to the osteosynthesis in 3 patients. The definitive results after treatment of complications show that satisfactory results have been obtained in all but 2 patients: 62% had excellent, 19% good, and 10% fair results. Intercalary allografts therefore provide a valuable solution for large skeletal defects after resection of bone tumors.

An 18 Kaninchen wurde eine Stichinzision von definierter Grose am Musculus supraspinatus vorgenommen und das kernspintomographische Signalverhalten dieses Muskels bis zum 64. Tag nach Lasion bestimmt. Wahrend bei der Betrachtung der MRT-Bilder keine Auffalligkeiten zu erkennen waren, konnte eine charakteristische Verlaufskurve der kalkulierten T2-Zeiten (ein rechnerisches Verfahren der MRT-Software) beobachtet werden. Die kernspintomographischen Ergebnisse sind mit den histopathologischen Vorgangen nach Muskelverletzung vereinbar. Die kernspintomographische Untersuchung ermoglicht durch den Nachweis von Flussigkeitsverschiebungen mittels kalkulierter T2-Zeiten die Beurteilung von Schaden der Muskulatur auch nach Minimalverletzungen.

Plaster cast immobilisation following trauma is a major risk factor for the development of deep vein thrombosis. In our controlled, randomized and prospective study in patients with minor injuries the incidence of deep vein thrombosis was 4.3% in conservatively treated outpatients with plaster cast immobilisation of the leg (n = 163 control group without prophylaxis). By application of low molecular weight heparin once daily the number of deep vein thrombosis in the prophylaxis group (n = 176) was reduced to 0% (p = 0.006). No severe side effects of low molecular weight heparin were observed. Subcutaneous injections were self-applicated by 89% of males and 72% of females. We conclude that thromboprophylaxis with low molecular weight heparin once daily is effective to reduce the risk of deep vein thrombosis in outpatients with plaster cast immobilisation of the leg.

Thirty-one salvage cases of chronically unstable previously operated knees were stabilized by an anterior cruciate ligament prosthesis of polyethyleneterephthalate (Trevira hochfest) and additional repair of concomitant lesions. The patients were followed up at yearly intervals. For the final follow-up after 4.4 years 27 patients could be evaluated clinically, radiologically and by several scores. The pre-operative Lysholm score was 59.8 (+/- 16.7). It was raised significantly by the operation to 75.4 (+/- 18.9) after 1 year, but then gradually decreased to 71.4 (+/- 19.6) at the final examination. Similar values were reached for the other scores (OAK, IKDC, VAS). The degree of activity (as estimated by the Tegner activity scale) increased from 2.0 (+/- 2.1) to 3.1 (+/- 1.9). Pre-operative anterior translation revealed a side-to-side difference of 7.5 (+/- 3.4) mm. The stability, which was restored by the operation, gave way a little in the first 2 years up to a side-to-side difference of 2.1 (+/- 2.5) mm, but then remained constant and was measured 2.3 (+/- 2.9) mm after 4.4 years. On the whole, the patients gained a significant improvement from the operation in all investigated parameters. Major complications included 5 ruptures of the synthetic ligament (1 by material fatigue), 1 avulsion of a staple, 1 supracondylar fracture due to 3 closely located staples, 4 cases of arthrofibrosis and 1 case of chronic knee irritation. The gradual deterioration of the operated knees within the follow-up period is mainly caused by the pre-existing chronic degenerative changes, which progress in spite of a sufficient stabilization of the central pivot.

In a prospective clinical study of 54 patients with acute anterior cruciate ligament instability, 56 artificial ligaments made of polyethylene terephthalate (Trevira hochfest) were implanted to restore knee stability. The average follow-up of these artificial knee ligaments was 40.2 (12-79) months; five implants (10%) had to be explanted due to failure after an average of 17.8 (6-50) months. All explants were examined by histological and ultrastructural methods in a device retrieval analysis. With regard to short- and medium-term artificial ligament failure in the human knee joint, a non-isometric surgical implantation technique, inappropriate strain during rehabilitation and implant fatigue and wear were responsible for ligament failures.

In a prospective controlled study, carpal tunnel tissue pressures were determined in a group of 56 patients with distal dislocated fractures of the radius at initial presentation, immediately prior to and after reduction, and 1, 2, 4, 12, and 24 h after reduction. Depending on the severity of the trauma and delay to presentation at the hospital, initial measurements revealed raised pressure averaging 23 mm Hg, which further increased during reduction to 44 mm Hg. After 4 h the average pressure was 37 mm Hg, and it then dropped to 26 mm Hg after 12 h. For anatomical reasons the median nerve is quite vulnerable in the region of the wrist joint. Chronic pressure here may cause carpal tunnel syndrome. Acute pressure in the carpal tunnel, which according to our investigations represents a distinct compartment, results in an overt compartment syndrome. The possibility of a direct relationship between markedly elevated tunnel pressure and the development of Sudeck's dystrophy is discussed.

Belastungsrontgenaufnahmen unter 10 kg Zug sind das Standardverfahren zum Nachweis der Schultereckgelenk-instabilitat. Aber auch die quantitative sonographische Messung der Schultereckgelenkinstabilitat in Anlehnung an die Radiographische Klassifikation nach Tossy ist moglich. Zehn Probanden ohne AC-Gelenkinstabilitat der Gruppe Tossy I, elf mit Tossy-II- und acht mit Tossy-III-Verletzungen wurden radiographisch und sonographisch untersucht. Die AC-Gelenkweiten wurden unter Bildung eines Index (AC-Index=AC-Gelenkweite unverletzte Seite/AC-Gelenkweite verletzte Seite) einheitlich berechnet. Fur die Tossy-I-Gruppe betrug der AC-Index sonographisch im Mittel 1,0, bei Tossy-II-Verletzung sonographisch im Mittel 0,49 und radiographisch 0,5, und bei Tossy-III-Verletzung sonographisch 0,21 sowie radiographisch 0,2. Die Varianzanalyse ergab signifikante Unterschiede dieser Indexwerte (p

ZusammenfassungIn einer prospektiven, randomisierten Untersuchung zur Thromboseinzidenz bei gipsimmobilisierten Patienten ohne besondere Risikofaktoren ergab sich ein Thromboserisiko in Abhängigkeit von der Verletzungslokalisation zwischen 2,9% (Unterschenkelgips) und 9,5% (Oberschenkelgipstutoren). Die Thromboseprophylaxe mit niedermolekularem Heparin führte zu einer signifikanten Senkung des Thromboserisikos (p

Knocherne Verletzungen der Handwurzel sind trotz verbesserter Nachweisverfahren immer noch ein Hauptproblem in der Primardiagnostik. Das neuartige Verfahren der digitalen Lumineszenzradiographie (DLR) ermoglicht die Darstellung traumatologisch relevanter Strukturen im Bereich der Handwurzel. An 39 Patienten mit Verdacht auf knocherne Handwurzelverletzungen waren die uns zur Verfugung stehenden, individuell nachbearbeiteten DLR-Ausspielungen sowohl der Standardausspielung der digitalen Lumineszenzradiographie als auch den konventionellen Film-Folien-Rontgenaufnahmen in der Beurteilbarkeit knocherner Merkmale uberlegen. In konventionellen Rontgenaufnahmen nicht erkennbare knocherne Verletzungen der Handwurzel konnten mit den zur Verfugung stehenden Speicherfolien bisher nicht diagnostiziert werden. Die Skelettszintigraphie erscheint uns weiterhin als die sicherste Methode zum Frakturausschlus an der Handwurzel nach Ausschopfung konventioneller und digitaler bildgebender Verfahren.

170 patients who had suffered trauma to bones or soft tissues were examined by a digital and a conventional film/screen technique. In addition to "standard" and edge-enhanced images, post-processing was carried out and compared with conventional radiographs. Four radiologists and two surgeons evaluated the compacta, spongiosa, soft tissues, fractures and osteo-synthetic materials as shown on the two systems. The "standard" digital images are inferior to film images, but edge-enhanced images showed definite advantages for demonstrating soft tissues. Evaluation of osteo-synthetic material is limited by the creation of artifacts. Recognition of detail can be significantly improved by using post-processing with optimized parameters.

Physical methods became recently more important as an alternative to anticoagulation for prophylaxis of thromboembolism and were studied for their efficacy. The AV-impulse-system proved efficient in reducing thromboembolic complications in patients undergoing hip surgery by increasing the return of venous blood in the deep veins of the leg. In a preclinical trial we studied the influence of the AV-impulse-system and of active forefoot movement on venous blood return in 12 lower extremities of 6 healthy individuals immobilized in below the knee plaster casts. Our results show a significant increase in venous blood flow caused by the AV-impulse-system (p0.05) and by active forefoot movements (p0.05). Prevention of thromboembolic complications in trauma and orthopaedic patients immobilized in plaster cast seems possible by using the AV-impulse-system which significantly increases the venous blood flow independent from patient compliance.

We compared the motion-stable wire suture by Towfigh (MSWST) with a modified Kessler suture (MKS) by following up flexor tendon repairs (MSWST, n = 21/39 digits; MKS, n = 20/31 digits). For MSWST we found 31 (79.5%) “excellent”, 3 (7.7%) “good”, and 5 (12.8%) “fair” results, when using the scoring system of Buck-Gramcko. In 3 (14.3%) patients the MSWST had to be removed owing to local irritation. In a further 3 (14.3%) patients, this was done when secondary tenolysis was necessary. The latter was also performed in 4 (20.0%) patients in whom the MKS was used. Here we found 23 (74.2%) excellent, 7 (22.6%) good, and 1 (3.2%) fair result. The statistical evaluation of the data concerning the patients’ age, sex, the involved zone, the side, and the functional outcome did not reveal a significant difference (P < 0.05) between both groups and the chosen type of repair. The results of MSWST and MKS are similar, but MSWST allows early motion therapy without a splint or rubber-band protection.

A novel antiseptic biguanide has been shown to be more bactericidal and tissue compatible in vitro than other antiseptics. In our controlled, prospective and randomized double-blind study on patients with bacteria-contaminated wound types 2-4, one group (n = 45) was treated with humid cotton swab dressings of 0.2% Lavasept solution compared with Ringer solution (n = 35). No deterioration of wound healing was observed in either group. Lavasept treatment resulted in faster and significant reduction of gram-positive germs. The tissue compatibility of Lavasept was evaluated as significantly better than Ringer solution.

Schon bei der praklinischen oder klinischen Notfallversorgung frischer Handverletzungen soli ten die Wunden mit einem sterilen Schutzverband bedeckt und verbunden werden, von einschnurenden Verbanden muss Abstand genommen werden. Bei schweren Handverletzungen mit geschlossenen oder offenen Frakturen oder Verrenkungen mussen Schienenverbande in Funktionsstellung der Hand und mit Einschluss des Unterarmes so angelegt werden, dass einerseits durch die Ruhigstellung und Vorbeugung unwillkurlicher Bewegungen die Schmerzen weitgehend ausgeschaltet sind und andererseits Erschutterungen wahrend des Transportes dem Patienten keine zusatzliche Schmerzen bereiten. Geeignet sind neben den handelsublichen, beugeseitig angelegten Schienen v. a. pneumatische Schienen, welche nicht nur die Hand, sondern den ganzen Arm einschliesen. Bei starken, auch arteriellen Blutungen kann die Blutstillung immer durch einen Kompressionsverband erreicht werden, zumal es bei arteriellen Blutungen durch Einrollung der Intima bald zu einem spontanen Blutungsstop kommen wird.

Unfractionated heparins in high dosage are well known to cause side effects in fracture repair and bone remodeling. Low molecular weight heparins, which have gained importance in antithrombotic therapy over the last decade, have not yet been investigated in regards to their possible effects on fracture repair. In a standardised rabbit bone defect model the effect of high doses of unfractionated heparin (UFH,n=10), low molecular weight heparin (LMWH,n=10) and 0.9% NaCl (control, n=10) on bone repair after 6 weeks of application were studied by fluorescence, light and electron microscopy. The results of this blind investigation revealed significantly increased bone defects in the UFH group (p 0.05). Cell structures and bone matrix in the UFH showed degenerative changes only in the UFH group. We conclude from these findings that high-dose UFH can cause a relevant delay in bone defect healing after 6 weeks, whereas LMWH in high dosage did not show such effects. Osteoblast dysfunction seems to be a possible explanation for this effect and should be investigated further.

Bei Frakturen der gelenkbildenden Strukturen des proximalen Unterarms ist stets mit einer Beteiligung beider Gelenkkorper und der stabilisierenden Bandverbindungen bis zum Vollbild der Luxationsfraktur zu rechnen. Die Arbeitsgemeinschaft fur Osteosynthesefragen berucksichtigt in ihrer auf M.E. Muller zuruckgehenden Klassifikation diese pathomechanischen Zusammenhange (Muller et al. 1992). Unterschieden werden extraartikulare Frakturen eines oder beider Knochen (A), intraartikulare Frakturen eines Knochens ohne oder mit extraartikularer Beteiligung des Nachbarknochens (B) oder intraartikulare Frakturen beider Knochen (C; Abb. 3.1).

10 % aller handchirurgischen Operationen mussen wegen Infektionen durchgefuhrt werden. Aufgrund ihrer unterschiedlichen Genese werden sie in 3 Gruppen unterteilt: 1. Auftreten des Infektes ohne nachweisbare Hautlasion: Furunkel oder Karbunkel im Bereich der behaarten Hautflachen der Hand konnen zu Infekten der Hand fuhren. Zu dieser Gruppe werden auch alle Infekte gerechnet, die in durchblutungs-, stoffwechsel- oder trophisch gestorten Geweben der Hand entstehen oder sich aus nekrotisch zerfallenen Tumorinfiltraten (maligne Lymphome) entwickeln. 2. Handinfektionen durch kontaminierte Hautverletzung (Gelegenheitswunde): Solche Hauteroffnungen konnen punktformige und kleinste Verletzungen (Stichverletzung, Nagelpflege) sein oder im Rahmen von offenen Frakturen bis hin zur schweren Kombinationsverletzung einer Hand reichen. Die Erreger konnen dabei durch die verletzte Haut eindringen oder werden bei der Verletzung in die Tiefe verschleppt (Katzenbissverletzung als Punkturwunde). 3. Hamatogene Handinfektion: Erreger erreichen Weichteile oder Knochen der Hand auf dem Blutweg.

Verrenkungen des Ellenbogengelenks stellen nach den Schulterluxationen die zweithaufigste Luxationsform dar. Die hochste Inzidenz ist unter den 20- bis 30-jahrigen zu beobachten.

Atiologisch liegt der Epikondylitis eine funktionelle Uberbeanspruchung im taglichen Leben verbunden mit Mikrotraumatisierung und degenerativen Veranderungen des Sehnengewebes zugrunde (Abb. 7.1).

Severe posttraumatic lung injury is characterized by impairment of gas exchange and pulmonary densities. The influence of intermittent prone positioning on pulmonary gas exchange and parenchymal densities was investigated prospectively in patients with pulmonary injury after multiple trauma with blunt chest trauma.A six-bed trauma intensive care unit in a university hospital.Prospective, descriptive study.Twenty-two consecutive patients with pulmonary injury after multiple trauma with blunt chest trauma and acute lung injury (n = 11) or severe acute respiratory distress syndrome (ARDS) (n = 11) according to the definitions of the consensus conference on ARDS.Pulmonary densities were calculated planimetrically from computed tomographic scans of the chest before the first and after the last cycle of prone positioning. Indications for prone positioning were a) mechanical ventilation with FIO20.5 at positive end-expiratory pressure10 cm H2O for24 hrs; or b) pulmonary densities in two or more quadrants being constant or increasing within 48 hrs. Arterial blood gas analysis was performed every 2 hrs. Intrapulmonary right-to-left shunt (Qs/Qt) and alveolar-arterial PO2 difference were calculated 2 hrs after the beginning and end of every prone and supine cycle, respectively. Patients were ventilated in the prone position for 8 hrs each day.Every single posture change from the supine to the prone position resulted in a significant average increase in the oxygenation index of 28+/-8 torr (3.7+/-1.1 kPa) (p.0001). There was a significant improvement in oxygenation (4.3+/-0.8 torr [0.57+/-0.11 kPa]) with time between two consecutive measurements in the prone as well as the supine position (p.0001). Alveolar-arterial PO2 difference and Qs/Qt showed a significant decrease of 25+/-7 torr (3.3+/-0.9 kPa) and 1.1+/-0.46%, respectively, for every cycle of prone positioning. Statistical analysis revealed no significant alteration of gas exchange within every prone and supine cycle. Total static lung compliance improved significantly over time (p.001). However, ventilation of patients in the prone position demonstrated a mean decrease in compliance of 2.1+/-0.72 mL/cm H2O. The response to prone positioning was similar in patients with ARDS and acute lung injury and revealed no significant difference. In both groups, the course of the oxygenation index and Qs/Qt over time was almost parallel. Posture changes were continued for 9.0+/-1.1 days. The oxygenation index showed an overall increase of 129+/-20 torr (17.2+/-2.7 kPa) from baseline supine at the end of prone positioning (p.0001). Pulmonary densities were reduced significantly from 31.1+/-2.5% to 3.8+/-0.81%, Qs/Qt was reduced from 24.9+/-1.5% to 11.7+/-0.32%, and FIO2 was reduced from 0.43+/-0.04 to 0.26+/-0.02 (p.01). Gas exchange improved in all patients, and no patient died immediately as a result of respiratory failure.Repeated prone positioning recruits collapsed lung tissue and improves gas exchange in trauma patients with blunt chest trauma and severe ARDS as well as in trauma patients with acute lung injury.

The aim of this study was to investigate the direct influence of lung contusion on pulmonary surfactant in multiple trauma patients.Prospective, nonrandomized study.University hospital, trauma intensive care unit.Eighteen multiple trauma patients with unilateral lung contusions and Injury Severity Scores19 were studied prospectively.Bronchoalveolar lavage was performed daily until either day 7 or extubation. Samples from the side of lung contusion (n = 62) and the contralateral, uninjured side (n = 62) were obtained at the same time in 14 patients. Total phospholipids, total phospholipid classes, and surfactant apoprotein A were quantified. Additionally, surfactant function was measured with a pulsating bubble surfactometer in four patients. All data are presented as mean +/- SEM. Statistical analyses were performed using programs of SPSS for Windows 6.1.3 (SPSS Inc., Chicago, IL) (Student's t-test; p.05).Total phospholipids were significantly increased on the side of lung contusion (contusion side, 40+/-7 microg/mL; contralateral side, 21+/-3 microg/mL; p = .004). The percentage contents of phosphatidylcholine (contusion side, 87.1%+/-1.0%; contralateral side, 84.3%+/-1.0%; p = .04) and sphingomyelin (contusion side, 2.9%+/-0.3%; contralateral side, 1.9%+/-0.2%; p = .004) were significantly higher. In contrast, the percentage content of phosphatidylglycerol was significantly decreased (contusion side, 4.1%+/-0.1%; contralateral side, 6.9%+/-0.6%; p = .001). No alterations were found for the relative contents of phosphatidylethanolamine (contusion side, 2.4%+/-0.2%; contralateral side, 2.2%+/-0.2%; p = .47), phosphatidylinositol (contusion side, 3.5%+/-0.4%; contralateral side, 4.6%+/-0.5%; p = .06), and surfactant apoprotein A (contusion side, 7177+/-1404 ng/mL; contralateral side, 4513+/-787 ng/mL, p = .10). There was no statistical difference for minimal surface tension measured with the pulsating bubble surfactometer after 5 mins of oscillation (contusion side, 29.5+/-2.3 mN/m; contralateral side, 23.7+/-2.1 mN/m; p = .08).Direct damage of lung parenchyma by lung contusion alters the composition of surfactant. No additional changes in surfactant function were observed that would argue in favor of functional compensation.

The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights4 m. 211 patients with an injury severity score (ISS)17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 +/- 1; A: 30 +/- 1), ventilation time (I: 16 +/- 2; A: 15 +/- 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27%), fractures of lumbarspine (I: 34; A: 15%), pelvis (I: 51; A: 38%), lower leg (I: 47; A: 20%), pilon (I: 15; A: 5%), and os calcis (I: 17; A: 9%). Liver lacerations occurred more often after intentional fall (I: 16; A: 6%). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A(I: 1; A: 8%). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69%) or related to brain-injuries (I: 35; A: 19%). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.

Out of 95 ligamentous lesions of the thumb metacarpophalangeal joint, those with an isolated bony rupture of the ulnar collateral ligament were chosen. Of these, 15 patients treated with Lengemann suture and 16 with screw fixation were followed-up on average 27.3 and 26.4 months, respectively, after operative treatment. Under only "good" and "very good" clinical results, the statistical analysis of the objective and subjective parameters showed no significant difference, except for the measurement of the soft-tissue circumference (p0.01) between either procedure. Although both procedures have a low rate of complications, screw fixation is preferable since implant removal is not necessary.

OBJECTIVE To study whether the endotoxin responsiveness of peripheral blood mononuclear cells correlates with the severity of injury in trauma patients. DESIGN Prospective, observational study. SETTING University trauma center. PATIENTS Fifty-nine patients with blunt trauma (Injury Severity Score [ISS] 4 to 57 points). INTERVENTIONS Standard emergency department care, surgical care, and postoperative intensive care unit treatment. MEASUREMENTS AND MAIN RESULTS Whole blood and serum were obtained 94+/-89 (SD) mins post trauma (day 0) and during a 14-day period postinjury. Endotoxin-induced tumor necrosis factor-alpha (TNF-alpha) synthesis of peripheral blood mononuclear cells ex vivo was tested using a whole blood assay. Serum samples were assayed for TNF-alpha concentrations. A reduced capacity of whole blood to produce TNF-alpha ex vivo with endotoxin treatment was found to be closely correlated with the ISS. The capacity to produce TNF-alpha on endotoxin stimulation of whole blood from patients with an ISS > or =16 points was depressed immediately after trauma and did not reach normal values during the observation period. In patients with an ISS >22 points, maximum depression of the capacity of whole blood to produce TNF-alpha occurs within 100 mins post injury. In contrast, in patients with an ISS

Multiple injuries in children are responsible for a great part of childhood mortality. Remaining handicaps after injuries have a social and economic significance. In this study, the characteristics of polytrauma in childhood are evaluated by comparison with severely injured adults. The two groups of multiple trauma patients (117 children between 3 and 15 years of age and 1159 adults between 16 and 59) were equal in the overall severity of all injuries. Children were mainly hurt as pedestrians, whereas adults had an accident more often as car passengers. The most frequently injured region were in both groups fractures of the extremities. The greatest injury severity represented head injuries in each group. Complications were seen more often in adult patients. Multiple organ failure and isolated liver failure were exclusively seen in the adult group, pneumonia and lung failure occurred significantly more often. The duration of artificial ventilation and the duration of hospital stay were prolonged in the adult group. In summary, children with multiple injuries have a lower mortality rate than adults. The main cause of death are cerebral injuries. Remaining handicaps in surviving children are most often caused by fractures of the lower extremities.

Ninetten consecutive patients with bone and soft tissue tumors of the shoulder girdle were treated with interscapulothoracic resection (Tikhoff-Linberg procedure) over a 10-year period. Twelve patients were alive with no evidence of disease at a mean follow-up of 6.3 (1-11) years and one patient is alive with local recurrence and pulmonary metastases after 15 months. Six patients died due to pulmonary metastases. Despite these complications, the Tikhoff-Linberg procedure proved to be a valuable operation for extended tumors of the shoulder girdle in terms of functional and oncological outcome and is clearly superior to forequarter amputation.