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Osteosynthesis refers to various surgical procedures, closed or open, for the treatment of fractures of any age. To document and control the osteosynthesis and the healing process X‑ray controls of the affected skeletal segment are performed during the operation and at regular intervals. To assess the quality of an osteosynthesis or to identify a complication, a comprehensive and systematic image review is useful. This includes the assessment of the restoration of the functional anatomy, the position of the material in relation to the surrounding structures, an evaluation of the stability as far as this is possible, and a control of the bone healing in a functionally correct position.Unter Osteosynthesen versteht man verschiedenste Operationsverfahren, geschlossen oder offen, zur Versorgung von Frakturen in jedwedem Alter. Zur Dokumentation und Kontrolle der Osteosynthese und des Heilverlaufs werden im Operationssaal und im Verlauf in regelmäßigen Zeitabständen Röntgenkontrollen des betroffenen Skelettabschnitts angefertigt. Zur Beurteilung der Güte einer Osteosynthese oder zur Feststellung einer Komplikation ist eine umfassende und systematische Bildbetrachtung sinnvoll. Hierzu gehören die Beurteilung der Wiederherstellung der funktionellen Anatomie und der Lage des Materials in Relation zu den umgebenden Strukturen sowie, falls möglich, der Stabilität sowie eine Kontrolle der Knochenheilung in funktionsgerechter Stellung.

Numerous predisposing factors are known for patellar dislocations but the extent to which these or the trauma cause the dislocation is often unclear.This study investigated whether the analysis of the accident mechanism and anatomical predisposition in juvenile patellar dislocations enables a conclusion as to the causality.Retrospective cohort study, evidence level III. In-house employers' liability insurance association (BG) cases with the diagnosis of patella dislocation in patients under 18 years were descriptively evaluated with respect to demographic and predisposing aspects as well as regarding accident information. The accident mechanisms were sorted into subgroups: direct impact, trivial trauma, fall, torsional trauma.A total of 54 patellar dislocations were identified with a patient age of 14 years (range 9-18 years). A mild valgus configuration was found in 39% of the cases, on average normal torsion, a tibial tuberosity-trochlea groove (TTTG) distance of 17 mm (range 8-24mm), with 41% a high proportion of patella alta and a trochlear deformity in 57%. Only 20% of the children had no relevant predispositions. The trivial traumas showed the highest proportion of recurrent dislocations with 50% and in the other accident categories the proportion of first dislocations was75%. In the fall cohort the rate of children without relevant predisposition was highest.The predisposition rate in infantile patellar dislocations is high; however, falls are always significant accident events as well as medial direct impact. Torsional trauma is also a significant causative factor, unless high-grade trochlear dysplasia is present, whereas trivial traumas are not.HINTERGRUND: Für Patellaluxationen sind zahlreiche prädisponierende Faktoren bekannt. Ob diese oder das Trauma die wesentliche Ursache sind, ist häufig unklar.Untersucht wurde, ob die Analyse von Unfallmechanismus und anatomischer Prädisposition bei kindlichen Patellaluxationen eine Aussage zur Ursächlichkeit erlaubt.Retrospektive Kohortenstudie, Evidenzlevel III. Betrachtet wurden hausinterne Berufsgenossenschafts(BG)-Fälle mit der Diagnose Patellaluxation bei ≤18-Jährigen, und deskriptiv bzgl. demografischer und prädisponierender Gesichtspunkte sowie Unfallinformationen ausgewertet. Die Unfallhergänge wurden in Subgruppen unterteilt: Direktanprall, Bagatelltrauma, Sturz, Verdrehtrauma.Es wurden 54 Patellaluxationen identifiziert, bei einem Patientenalter von 14 Jahren (Range 9–18 Jahre). In 39 % der Fälle fanden sich eine milde Valgusachse, im Mittel normwertige Torsionen, ein Tuberositas-tibiae-Trochleagrube(TTTG)-Wert von 17 mm (Range 8–24 mm), mit 41 % ein hoher Patella-alta-Anteil und zu 57 % eine Trochleadeformität. Lediglich 20 % der Kinder wiesen keine relevanten Prädispositionen auf. Die Bagatelltraumata zeigten den höchsten Anteil der Redizivluxationen mit 50 %, bei den übrigen Unfallkategorien betrug der Anteil der Erstluxationen75 %. In der Sturzkohorte war die Rate der Kinder ohne relevante Prädisposition am größten.Der Prädispositionsanteil bei kindlichen Luxationen ist hoch. Stürze sind jedoch immer wesentliche Unfallereignisse, ebenso der mediale Direktanprall. Das Verdrehtrauma ist, sofern keine hochgradige Trochleadysplasie vorliegt, ebenfalls wesentlich ursächlich, Bagatelltraumen hingegen nicht.

Simple elbow dislocations in childhood are rare. Nevertheless, they have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed.The purpose of the study was to review the literature and to derive a recommendation for the best treatment concept.A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified (initially nonspecific for age) and evaluated in a stepwise approach. Of these publications four met the inclusion criteria of the authors. The analysis was carried out descriptively and in a meta-analysis.The 4 publications included described simple elbow dislocations in 81 children (≤16 years). The weighted average age was 9.9 years with a gender ratio of 3.8 (boys:girls). The median follow-up was 49 months. Posterior and posterolateral dislocations were the most common with 73%. In 69 children the treatment was conservative and of these 66 were immobilized for longer than 2 weeks after closed reduction. The 12 children who had surgical treatment suffered dislocations that had not been reduced for longer than 3 weeks. The success rate of the conservatively treated immobilized group was 88%, of the conservatively treated non-immobilized group 70% and of the surgical group 42%. The differences between the success rates of the treatment methods was significant (p = 0.032).Simple elbow dislocations in children are rare. They most commonly occur in posterior and posterolateral directions. The prognosis is favorable; however a timely diagnosis and correct reduction are relevant for a good outcome.

Kindliche und adoleszente Schaftfrakturen an der unteren Extremitat sind keine seltene Verletzung. Der Unterschenkel ist haufiger betroffen als der Oberschenkel. Zur Behandlung der Femurschaftfrakturen finden sich deutlich mehr Empfehlungen als zur Behandlung der Unterschenkelschaftrakturen. Die Femurschaftfrakturen im fruhen Lebensalter sind eine Domane der konservativen Therapie, fur Ober- und Unterschenkel wird bis zu einem Korpergewicht von 50 kg als operatives Verfahren haufig die elastisch stabile intramedullare Nagelung (ESIN) verwendet. Die Plattenosteosynthese stellt aber eine ernste Alternative dar. Vorteile der ESIN sind die kleinen Zugange und die schnellere Belastbarkeit. Fur einfache Querfrakturen ist die intramedullare Stabilisierung klar uberlegen. Nachteil der ESIN ist die hohe intraoperative Strahlenbelastung. Auch die Plattenosteosynthese kann minimalinvasiv durchgefuhrt werden, langere Trummerzonen lassen sich damit gut uberbrucken.

BACKGROUND: Fracture of the distal humerus is a fairly rare injury and makes high demands on the treating surgeon. Prerequisites for a good outcome are anatomical reconstruction and osteosynthesis stable enough for exercises. A method permitting early restoration of function is especially important for patients with osteoporosis. The extensive surgical approach necessary for open reduction is associated with a high number of wound healing disorders and infections with a frequency of 11% being reported in the literature. Although open reduction and internal fixation in double-plating technique is unavoidable for complex intraarticular fractures, an alternative, minimally invasive and, consequently, tissue-preserving procedure is desirable for simpler fractures. OBJECTVE: To investigate this issue further an angular stable nail system developed for the distal radius was implanted as a stabilizer and the construct tested biomechanically as part of a feasibility study. METHODS: Distal humerus fractures were stabilized by insertion of a distal radius nail, namely, the Targon DR (Aesculap, Tuttlingen) and a K-wire. To test the hypothesis six cadaveric bones fixed in formalin were tested biomechanically for displacement, implant failure, and stiffness. Displacement was determined by means of an ultrasound-based system. RESULTS: An average displacement of 1.6 mm ± 0.7 was recorded at a maximum compression force of 100 N in extension and an average displacement of 1.4 mm ± 0.9 in flexion. Implant failure was not observed for any of the constructs. CONCLUSIONS: The study presented here permits the conclusion that a minimally invasive procedure is possible at the distal humerus and does ensure adequate stability. Although the nail was not specifically designed for the humerus, current findings form the basis for a promising approach that will be pursued further after modification of the nail design.

PURPOSE OF THE STUDY Various spine disorders are regularly treated by orthoses, and success of treatment depends on wearing these devices. In this study we examined the compliance, wear comfort, subjective stabilization and side effects associated with spinal orthoses using an individualized questionnaire and the Compact Short Form-12 Health Survey (SF-12). MATERIAL AND METHODS In this prospective pilot study of randomized cross-over design, twelve healthy volunteers with a mean age of 31.2 years wore three different types of orthoses, each for one week: A hyperextension brace (HB), a custom-made semirigid orthosis (SO) and a custom-made rigid orthosis (RO). The daily duration of wearing the orthosis was defined as primary endpoint; contentment was measured using an individualized questionnaire and the standardized SF-12. RESULTS In the study population calculated probability of wearing the HB and RO was between 0.2 und 38.5% (95% confidence interval). No volunteer wore the SO orthosis for the predefined time. The SO and RO each displayed high subjective stabilization, while the RO was more often associated with side effects like skin pressure marks than the SO. The need for rework due to discomfort was mainly necessary with the RO. We observed no substantial differences in feeling compression and sweating. Noteworthy, eight of 12 subjects complained of uncomfortable sternal pressure due to the upper pad of the HB. The SF-12: scores ranged from 52.1 to 48.6 on the physical (PCS), and from 53.7 to 50.8 on the mental component score (MCS), demonstrating an influence on QoL. DISCUSSION AND CONCLUSIONS The design as well as the orthosis itself influence the compliance of wearing and exert a moderate negative, but acceptable impact on QoL. The SO appeared to correlate with the best overall compromise between comfort and subjective stabilization. Further investigations are necessary in patients with spinal diseases, for whom the effect of orthosis wearing may surpass the potential discomfort. Key words: thoracolumbar spine, orthoses, SF-12 - Quality of Life - QoL, comfort, compliance.

Hintergrund der Arbeit Dislozierte Frakturen des Radiuskopfchens und -halses stellen aufgrund der komplexen funktionellen Anatomie des Ellenbogengelenks und den haufig mehrfragmentaren Fraktursituationen mit destabilisierenden Begleitverletzungen nach wie vor eine grose Herausforderung fur den behandelnden Chirurgen dar. Detaillierte Kenntnisse von Anatomie und Biomechanik sind eine wichtige Voraussetzung fur Analyse, Verstandnis und Therapieplanung. Ziel der differenzierten Therapie ist das Wiederherstellen einer moglichst anatomiegerechten Stellung und Gelenkkinematik, einer stabilen und schmerzfreien Gelenkfunktion sowie das Verhindern/Verzogern von posttraumatischen Gelenkveranderungen. Grad der Dislokation, Stabilitat der Fragmente, Grose und Anzahl der frakturierten Gelenkflache und assoziierte knocherne und ligamentare Begleitverletzungen mit entsprechender Instabilitat mussen in das Therapieregime einfliesen. Es gibt nach wie vor keine klaren Therapieempfehlungen mit hoher Evidenz, insbesondere fur die Frakturtypen III–IV in der Klassifikation nach Mason-Johnston, auch sind Expertenmeinungen und Studienlage teilweise kontrar.

Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.

The Enchondroma is a common, benign, cartilage forming tumour. They usually occur as a single, asymptomatic lesion. Occasionally patients present with multiple enchondromas which is generally defined as enchondromatosis. This entity encompasses several different subtypes including Ollier disease and Maffucci syndrome (enchondromatosis associated with soft tissue haemangiomas) as the most commons. Some of them have a complicated clinical course when malignant transformation occurs. This malignant progression is a well known fact especially in enchondromatosis, but up to now there is still a lack of recommendations concerning the follow up. The aim of this article is to review the clinical and imaging features of patients with solitary enchondroma and enchondromatosis focusing on the development of secondary chondrosarcoma and the follow up.

Purpose To evaluate influence of variation in spatio-temporal resolution and scan-rescan reproducibility on three-dimensional (3D) visualization and quantification of arterial and portal venous (PV) liver hemodynamics at four-dimensional (4D) flow MRI. Methods Scan-rescan reproducibility of 3D hemodynamic analysis of the liver was evaluated in 10 healthy volunteers using 4D flow MRI at 3T with three different spatio-temporal resolutions (2.4 × 2.0 × 2.4 mm3, 61.2 ms; 2.5 × 2.0 × 2.4 mm3, 81.6 ms; 2.6 × 2.5 × 2.6 mm3, 80 ms) and thus different total scan times. Qualitative flow analysis used 3D streamlines and time-resolved particle traces. Quantitative evaluation was based on maximum and mean velocities, flow volume, and vessel lumen area in the hepatic arterial and PV systems. Results 4D flow MRI showed good interobserver variability for assessment of arterial and PV liver hemodynamics. 3D flow visualization revealed limitations for the left intrahepatic PV branch. Lower spatio-temporal resolution resulted in underestimation of arterial velocities (mean 15%, P < 0.05). For the PV system, hemodynamic analyses showed significant differences in the velocities for intrahepatic portal vein vessels (P < 0.05). Scan-rescan reproducibility was good except for flow volumes in the arterial system. Conclusion 4D flow MRI for assessment of liver hemodynamics can be performed with low interobserver variability and good reproducibility. Higher spatio-temporal resolution is necessary for complete assessment of the hepatic blood flow required for clinical applications. Magn Reson Med 72:477–484, 2014. © 2013 Wiley Periodicals, Inc.

Die Humeruskopffraktur ist eine haufige Verletzung, insbesondere des alteren weiblichen Patienten. Im Rahmen der Osteosynthese lassen sich in der Regel gute klinische Ergebnisse erzielen. Probleme werden jedoch weiterhin bei den die varisch dislozierten Humeruskopffrakturen, insbesondere wenn die mediale Saule zerstort ist, beobachtet. Hier sind eine anatomische Reposition des Kalottenfragments sowie ein medialer Knochenkontakt fur ein gutes Operationsergebnis unentbehrlich. Ansonsten lasst sich ein sekundarer Varuskollaps und/oder ein Implantatversagen vorhersehen. Weitere Herausforderungen bilden die intraartikularen Frakturformen sowie die initial ischamen Humeruskopffrakturen. Die Indikation zur Frakturprothese ist immer dann gegeben, wenn keine stabile Osteosynthese in adaquater Reposition erzielt werden kann. Inverse Frakturprothesen stellen eine zunehmend verbreitete Therapieoption dar. Sie sollten jedoch den alteren Patienten >75 Jahren vorbehalten bleiben.

Hintergrund Die Spondylodese der Wirbelsaule mittels autologem Beckenkammspan ist ein Standardverfahren der Wirbelsaulenchirurgie. Zielsetzung dieser Untersuchung war die radiologische Evaluation der knochernen Einheilung von autologen Beckenkammspanen und bovinen Spongiosablocken nach Spondylodese anhand eines standardisierten Scores.

Kombinationen von Frakturen des Femurschafts mit einer huftnahen Komponente stellen eine Herausforderung fur den behandelnden Unfallchirurgen dar, da es sich um unterschiedliche Frakturentitaten mit jeweils eigenen Behandlungskonzepten handelt. In einer retrospektiven Untersuchung wurden Inzidenz, Behandlungsstrategie und Outcome dieser Verletzung ausgewertet. Vom 01.01.2001–31.07.2007 wurden alle Patienten mit Femurfrakturen erfasst, die in einem Traumazentrum der Stufe I behandelt wurden. Insgesamt wurden 1935 Patienten in die Studie eingeschlossen, wovon 21 Patienten 22 Frakturen als Kombination aus Schaftfraktur mit huftnaher Komponente erlitten (1,1%). Unter zusatzlicher Berucksichtigung der Kombination von Femurfrakturen mit Kniegelenkbeteiligung und des Acetabulums mit Femurschaftfrakturen ergab sich ein Anteil an Kettenverletzungen des Femurs von 3,1%. Der Anteil an polytraumatisierten Patienten bei Vorliegen von Kombinationsfrakturen des Femurschafts und des proximalen Femurs betrug 64%. Der uberwiegende Anteil dieser Patienten von 73% konnte mit einem einzigen Implantat zur Behandlung beider Frakturanteile versorgt werden. Die fuhrende Verletzungskomponente war in 8 Fallen die huftnahe Fraktur, hier kam es in einem Fall zur Ausbildung einer Pseudarthrose des Schenkelhalses, ansonsten konsolidierten alle Frakturen nach durchschnittlich 4,7 Monaten. Alle Verletzungen wurden bei der Primardiagnostik erkannt, wobei der Anteil an durchgefuhrten Ganzkorper-CT 73% betrug. Eine primar definitive operative Versorgung erfolgte bei 59% der Patienten. An Komplikationen ergaben sich 2 korrekturbedurftige Rotationsfehler sowie eine problemlos ausbehandelte postoperative Infektion. Die Behandlung der Kombinationsfraktur des Femurs aus schaft- und huftnaher Komponente bleibt eine Herausforderung, wobei sich die diagnostische Sicherheit durch den regelhaften Einsatz der Ganzkorper-CT im Rahmen der Polytraumadiagnostik verbessert hat und mit dem langen PFN und dem AFN zwei exzellente Implantate zur Verfugung stehen, die den Anforderungen beider Verletzungskomponenten gerecht werden.

Perioperative hemorrhage after total hip arthroplasty is a rare but life-threatening complication. The aim of the current retrospective analysis of five cases was to answer the question of whether bleeding can be controlled by angiography and catheter embolization.A retrospective analysis of five patients with perioperative bleeding complications after hip surgery was done. Bleeding occurred in one case after implantation of an acetabular revision cup, in three cases in association with implantation of a bipolar prosthesis, and in one case in conjunction with a Girdlestone procedure due to septic femoral head necrosis. In four cases we detected arterial bleeding with angiography, all of which were controlled during angiography; one case was complicated by bleeding after a few days. One patient died from multiorgan failure after control of peracute hemorrhage. Subacute hemorrhage after hip surgery can be controlled by angiography. In peracute situations clamping of the external iliac artery is an alternative procedure.

Whole-body computed tomography is accepted as the standard procedure in the primary diagnostic of polytraumatised adults in the emergency room. Up to now there is still controversial discussion about the same algorithm in the primary diagnostic of children. The aim of this study was to survey the participation of German trauma-centres in the care of polytraumatised children and the hospital dependant use of whole-body computed tomography for initial patient work-up.A questionnaire was mailed to every Department of Traumatology registered in the DGU (German Trauma Society) databank.We received 60,32% of the initially sent questionnaires and after applying exclusion criteria 269 (53,91%) were applicable to statistical analysis. In the three-tiered German hospital system no statistical difference was seen in the general participation of children polytrauma care between hospitals of different tiers (p = 0.315). Even at the lowest hospital level 69,47% of hospitals stated to participate in polytrauma care for children, at the intermediate and highest level hospitals 91,89% and 95,24% stated to be involved in children polytrauma care, respectively. Children suspicious of multiple injuries or polytrauma received significantly fewer primary whole-body CTs in lowest level compared to intermediate level hospitals (36,07% vs. 56,57%; p = 0.015) and lowest level compared to highest level hospitals (36,07% vs. 68,42%; p = 0.001). Comparing the use of whole-body CT in intermediate to highest level hospitals a not significant increase in its use could be seen in highest level hospitals (56,57% vs. 68,42%; p = 0.174).According to our survey, taking care of polytraumatised children in Germany is not limited to specialised hospitals or a defined hospital level-of-care. Additionally, there is no established radiologic standard in work-up of the polytraumatised child. However, in higher hospital care -levels a higher percentage of hospitals employs whole-body CTs for primary radiologic diagnostics in polytraumatised children.

Background Although minimally invasive posterior spine implant systems have been introduced, clinical studies reported on reduced quality of spinal column realignment due to correction loss. The aim of this study was to compare biomechanically two minimally invasive spine stabilization systems versus the Universal Spine Stabilization system (USS). Methods Three groups with 5 specimens each and 2 foam bars per specimen were instrumented with USS (Group 1) or a minimally invasive posterior spine stabilization system with either polyaxial (Group 2) or monoaxial (Group 3) screws. Mechanical testing was performed under quasi-static ramp loading in axial compression and torsion, followed by destructive cyclic loading run under axial compression at constant amplitude and then with progressively increasing amplitude until construct failure. Bending construct stiffness, torsional stiffness and cycles to failure were investigated. Results Initial bending stiffness was highest in Group 3, followed by Group 2 and Group 1, without any significant differences between the groups. A significant increase in bending stiffness after 20’000 cycles was observed in Group 1 (p = 0.002) and Group 2 (p = 0.001), but not in Group 3, though the secondary bending stiffness showed no significant differences between the groups. Initial and secondary torsional stiffness was highest in Group 1, followed by Group 3 and Group 2, with significant differences between all groups (p ≤ 0.047). A significant increase in initial torsional stiffness after 20’000 cycles was observed in Group 2 (p = 0.017) and 3 (p = 0.013), but not in Group 1. The highest number of cycles to failure was detected in Group 1, followed by Group 3 and Group 2. This parameter was significantly different between Group 1 and Group 2 (p = 0.001), between Group 2 and Group 3 (p = 0.002), but not between Group 1 and Group 3. Conclusions These findings quantify the correction loss for minimally invasive spine implant systems and imply that unstable spine fractures might benefit from stabilization with conventional implants like the USS.

Femoral shaft fractures are severe injuries and are often associated with a high impact trauma mechanism, frequently seen in multiple injured patients. In contrast an indirect trauma mechanism can lead to a complex femoral shaft fracture especially in elderly patients with minor bone stock quality. Hence management of femoral shaft fractures is often directed by co-morbidities, additional injuries and the medical condition of the patient. Timing of fracture stabilization is depended on the overall medical condition of the patient, but definite fracture fixation can often be implemented in the early total care concept in management of multiple injured patients. The treatment of choice is intramedullary fracture fixation. Further development of existing intramedullary nailing systems now offer comfortable handling and different locking options. Ipsilateral fractures of the neck and shaft are therefore facilitated in management. Then again increasing numbers of obese patient are representing a new patient group with challenging co-factors in fracture management. Sufficient preoperative planning is helpful to choose the most adequate fixation device. Correct reduction of the fracture and perioperative control of the axis and rotation is mandatory to avoid postoperative malrotation, which still represents the most frequent complication.

To improve patient safety and quality in joint arthroplasty a certification of arthroplasty centers (EndoCert©) and a German arthroplasty register (EPRD) have been implemented. This should guarantee a long-term improvement in documentation of arthroplasty in the future. Although the stages of operations in elective and trauma-associated joint arthroplasty are comparable, the surgical preconditions are often quite different. As required by the German Society of Trauma Surgery (DGU) this study analyzed the current situation with respect to the proportion of fracture-associated joint arthroplasties among the total volume carried out in Germany.A uniform internet-based questionnaire was sent to all listed trauma centers in Germany by the central office of the DGU. In addition any information regarding hip joint arthroplasty in 2011 was collected from the Federal Statistical Office of Germany.The questionnaire was returned by 324 (47 %) out of 690 of the trauma centers contacted. A total of 34,135 total hip arthroplasties (THA) and 26,753 total knee arthroplasties (TKA) were carried out in 2011 by these clinics. The absolute numbers for total endoprosthesis replacement cited by the trauma centers were 5718 THAs and 3829 TKAs. According to the data from the Federal Statistical Office of Germany 131,966 hip fractures were registered in 2011, including 69,582 femoral neck fractures (patient age19 years) and 62,384 pertrochanteric fractures. From a total number of THAs of approximately 200,000 in Germany 47,695 (approximately 25 %) of these were associated with trauma.The data analyzed in this study and the results obtained from known literature sources demonstrate that THA is the most frequently performed procedure in trauma management of femoral neck fractures. Because of the ubiquitous and high incidence and the need for emergency treatment due to correlated risks and complications of delayed treatment, a high and standardized around the clock (24 h and 7 days a week) treatment option is mandatory. Long waiting times to treatment or transfer are inacceptable due to the increased mortality and complications.

The incidence of diffuse idiopathic sceletal hyperostosis (DISH) is described in men more than 50 years old up to 25% and in wom-en up to 15%. Even little trauma in patients with DISH often leads to injuries of the spine, especially the cervical spine. In many cases MRI is necessary to find the injury in this an-atomically modified spine. It is often difficult to detect the injury by plane radiographs or even CT.Based on two cases of cervical spine frac-tures in patients with DISH we will describe the difficulties and specialities in the diag-nostics and surgical treatment of injuries of the cervical spine in patients with DISH. In the one case we stabilized a patient with an odontoid fracture type Andersson II, the oth-er case was a traumatic spondylolisthesis C4/C5. Both cases were treated operatively, the odontoid fracture was stabilized by a single screw, the spodylolisthesis by a ventral plate.If there are modifications in the spinal anatomy by degenerative diseases like DISH or spondylitis ankylosans, it is important to perform an intense search for injuries of the spine. In many cases MRI is indicated to de-tect the injury because plane radiographs and CT are not sensitive enough.For the planning of the operation it is im-portant to meet concerns to the thick ante-rior longitudinal ligament and to use screws, that are long enough because the use of standard instruments is often not successful.

The patellar bone is involved in repetitive, load bearing motion sequences every day and functions as a vectorial force translator. A fracture rate of 1% of all skeletal fractures is reported and surgical treatment often required. beside a direct trauma mechanism, indirect mechanism but as well as fatigue fractures after reconstructive knee surgery are published. The fracture management is dependent on the soft tissue condition and a variety of surgical options are known. new generation of low profile plates show promising results but the conventional cerclage wiring technique with K-wires is widely preferred. best functional results with sustainable stability are biomechanically seen after a combined fixation technique using anterior cerclage wiring with cannulated screw fixation. A definite algorithm of treatment of patellar bone fractures is yet not defied but a review of classification and surgical techniques should give assistance in decision making.

Femoral shaft fractures in children are a common injury. Operative treatment is recommended for children above 3 years of age. The question of this investigation was the current clinical standard for the treatment of femoral shaft fractures in children under 3 years old.An e-mail questionnaire was sent to all clinics and hospital departments of the members of the German Society for Trauma Surgery and the German Society of Pediatric Surgery.Out of 775 clinics and departments, 121 participated in the survey (16 %). From 2011 to 2012 overall 756 femoral shaft fractures of children 3 years and younger were treated of which 375 (50 %) were stabilized with elastic stable intramedullary nailing (ESIN), 183 (24 %) with an overhead extension, 178 (23 %) with a plaster cast and 9 (1 %) with external fixation. Finally, operative treatment was used in 51 % compared to 49 % with conservative treatment.Obviously, operative treatment of femoral shaft fractures in children younger than 3 years is routinely used despite the fact that there is no evidential basis for this approach. There are good arguments for and against operative and conservative forms of treatment. Indications for operative treatment include multiple trauma, open fractures, body weight over 20 kg, child already free walking and lack of stable fixation with conservative treatment. To achieve more evidence for the existing recommendation of the American Academy of Orthopaedic Surgeons (AAOS) and the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, Working Group of the Scientific Medical Specialist Societies), further investigations are needed.

In this review the aetiology, clinical signs, diagnosis and therapy of the acute compartment syndrome of the limb is discussed. It is a limb- and untreated life threatening emergency. For good results, early detection is necessary. It is important to educate those taking care of patients of risk, especially in the early symptoms and signs. In uncooperative, unconscious and sedated patients pressure monitoring is recommended. The critical level of the absolute intracompartmental pressure is unclear. It is recommended to use a delta p pressure of 30 mm Hg. Below this pressure in the presence of clinical signs a fasciotomy of all compartments is the treatment of choice.

Winkelstabile Stabilisierungssysteme sind seit dem Fixateur externe allgemein bekannt. Besonders bei den Plattensystemen hat sich das winkelstabile Prinzip in den letzten Jahren sehr rasch verbreitet. Von der Winkelplatte uber die HWS-Platte, den PC-Fix mit „limited contact“ und das LIS-System wird die Entwicklung der winkelstabilen Plattenosteosynthesen erlautert. Die Platten haben dabei das klassische Prinzip der Stabilitat durch Friktion verlassen und konnen eher als Fixateur interne bezeichnet werden, da ein direkter Kontakt mit dem Knochen bei der neuesten Plattengeneration nicht mehr erforderlich ist. Die winkelsteifen Platten zeigen biomechanische Vorteile, die sich in der praktischen Anwendung bereits bewahrt haben. Wissenschaftliche Studien fur die verschiedenen klinischen Anwendungen werden zum jetzigen Zeitpunkt an vielen Kliniken durchgefuhrt. Nicht zuletzt davon wird abhangen, ob sich die Systeme bei deutlich hoheren Kosten fur den allgemeinen Gebrauch durchsetzen werden.

Background: The treatment of displaced Colles-type fractures of the distal part of the radius remains a challenge. Two procedures for closed reduction and Kirschner wire osteosynthesis of these fractures were compared in a prospective randomized study. Methods: One hundred consecutive patients with a Colles fracture of the distal part of the radius (AO classification 23-A2, 23-A3, or 23-C1) were treated over an eighteen-month period. One group was managed with the conventional method, described by Willenegger and Guggenbuhl in 1959, in which two Kirschner wires are introduced into the styloid process of the radius. The other group was treated with the Kapandji method, as modified by Fritz et al., in which two Kirschner wires are inserted into the fracture gap and a third is placed through the styloid process. Postoperative care was standardized for both groups and carried out according to a strict procedure. Forty patients who had been operated on according to the modified Kapandji method and forty-one treated with the Willenegger technique were available for follow-up, for a follow-up rate of 81%. The follow-up assessment was performed with a modified version of the Martini score. Results: The median time to follow-up was ten months (range, six to twenty months). The results as assessed with the Martini score were, on the average, good to very good for the patients treated with the Kapandji method and satisfactory to good for the patients treated with the conventional Kirschner wire fixation. The duration of radiographic exposure was significantly shorter with the Kapandji method than with the Willenegger technique. Conclusions: Conventional Kirschner wire fixation remains a good method of osteosynthesis for the treatment of displaced fractures of the distal part of the radius. We found both the functional and radiographic outcomes of the Kapandji method to be significantly better than those of the Willenegger technique. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

The importance of emergency medical treatment for avalanche victims in the pre-clinical and clinical sector is still real. Based on new investigations, guidelines for triage have been endorsed by the International Commission of the Alpine Rescue Services (ICAR) to reduce secondary deaths following the successful extrication of victims from the avalanche mass. Although hypothermia plays a secondary role in the total mortality of avalanche victims, the most important task if extrication lasts 35 min or more is the professional treatment of hypothermia. Avalanche emergencies in the southern part of the Black Forest are quite rare. In February 2002 one avalanche victim in this region survived despite a statistically bad prognosis. Based on the current literature, we provide an algorithm which conforms with the ICAR guidelines for emergency personnel and describe the possibilities and standard stage dependent treatment in cases of accidental hypothermia.

The scapho-capitate fracture syndrome is a rare but severe injury of the carpus. It is characterized by a rotation of the proximal fragment of the capitate bone of 90 or 180 degrees and a fracture of the navicular bone in the intermediate third. This injury is caused by a fall on the outstretched and dorsiflected hand. The scapho-capitate fracture syndrome was firstly described in 1956 by Fenton. There are 31 cases described in literature but none of these involves both hands. Here we describe the first case of scapho-capitate fracture syndrome in both hands, in a 21 year old woman who jumped out of a window with suicidal intentions. She was treated operatively by Herbert-screws and K-wires.

Bei offenen Frakturen mit schwerem Weichteilschaden und grosem Weichteildefekt muss zur Sicherung der Knochenbruchheilung und Infektvermeidung eine rasche Weichteildeckung erfolgen. Verbreitet sind Verfahren der lokalen Lappenplastiken sowie der freien mikrovaskular gestielten Lappentransfers. Die kontinuierliche Weichteildistraktion wird dagegen in der Traumatologie zum Verschluss von kleineren Weichteildefekten wie zum Beispiel nach Kompartmentspaltungen eingesetzt. Grose Weichteildeckungen mit Hilfe der kontinuierlichen Weichteildistraktion sind allerdings selten angewandt worden. In der vorliegenden Arbeit wird eine Technik zur Weichteildistraktion unter Zuhilfenahme des Fixateur externe vorgestellt. Die zu distrahierenden Hautrander werden uber Redon-Drainagen geknupft und die Faden danach an den Gleitrohren des Fixateur externes befestigt. Nachfolgend kann in Abhangigkeit der Hautspannung kontinuierlich distrahiert werden, in dem die Tube-to-Tube-Verbindungen gelost und die Gleitrohre distrahiert werden. Somit ist es moglich auch grose Weichteildefekte sicher zum spannungsfreien Verschluss zu bringen, was anhand von vier Fallberichten demonstriert wird. Es wird hier erstmals das vorhandene Fixateursystem (Synthes™) als Hilfsmittel vorgestellt, mit welchem auf einfache Weise eine dynamische Hautdistraktion zur sicheren Deckung von grosen Weichteildefekten durchgefuhrt werden kann. The therapy of open fractures with severe soft tissue injuries, and large soft tissue defects, focuses on the need for rapid bone coverage to avoid complications like infection, delayed bone healing and pseudarthrosis. Common procedures for obtaining coverage are local sliding flaps and free microvascular pediculated flaps. This paper describes a method to achieve wound closure by utilizing skin traction to increase soft tissue surface area. This technique is often be used for covering smaller defects such as fasciotomies. In the treatment of extensive soft issue injures this procedure would rarely be used. The present article demonstrates a new technique for soft tissue expansion which utilizes the external fixateur. To accomplish soft tissue distraction, multiple sutures are first placed over drainage tubes about the skin periphery which will then function as traction units. External fixateur rods are placed parallel to the wound. The sutures are then placed on the rod opposite, such as, right wound sutures to left rod, left sutures to right rod. The rods are periodically distracted, as determined by the tactile feedback provided to the surgeon by the rod/suture harness. Sequential adjustments maintain the necessary tension and consequent tissue migration. Wet dressings are used to prevent desiccation during the process of soft tissue expansion. When the skin margins are approximated the sutures are tied and wound coverage is complete. This technique allows for a tension free closure of large soft tissue defects. The method is demonstrated here in the treatment of four patients. As shown in this article, the existing external fixateur (Synthes™) can be configured to function as a device which continuously expands soft tissue permitting a simple, safe closure of large posttraumatic soft tissue defects.

Rotator cuff ruptures are the most common degenerative tendon injury and occur mainly in older patients as multifactorial disorders manifesting the main symptoms of pain and restricted range of motion. Thorough clinical examination of the shoulder includes testing the function of the rotator cuff and leads to a tentative clinical diagnosis that is the prerequisite for diagnostic imaging procedures. Sonography of the shoulder gives rapid access to a very good sensitive overview of the rotator cuff. Conventional radiological imaging permits differential diagnosis since a reduced acromiohumeral interval is understood as a direct sign of rotator cuff rupture. The gold standard in imaging diagnostics is MRI because it not only delivers images of rotator cuff defects, but also permits interpretation of degenerative changes in the musculature. Significant pain relief can be achieved by conservative therapy such as analgesia, manual therapy and physiotherapeutic exercises and leads to improvements in the active range of motion. Persistent pain or progressive pain during conservative therapy are indications for surgical intervention. Arthroscopy-assisted treatment is tissue friendlier than open surgery and is today considered the standard for surgical treatment of rotator cuff rupture because of higher patient acceptance. Recent studies report that surgical rotator cuff repair leads to significant improvement in function, pain relief, and greater patient satisfaction. The principles of postoperative care after surgical rotator cuff repair are immobilization and gradual loading with passive and active exercises.

Esophageal perforation after cervical spine surgery is a rare complication. Based on the case of a 77-year-old female patient with a late, asymptomatic esophageal perforation after a ventral spondylodesis of the cervical spine, the symptoms, diagnostics, and therapy of this complication are discussed. The therapy of choice is the operation. Nonoperative therapy should only be chosen--like in our case--for special indications. An esophageal perforation with symptoms should be treated operatively. Our patient was treated conservatively in consideration of her age and missing symptoms.

The ideal treatment for dislocated fractures, especially three and four part fractures according to the classifications ofCodman and Neer, is still the center of scientific debate. In many cases the stabilization of this fractures is complicated by a low quality of bone because of osteoporosis. Many different implants have been tested and investigated, thus demonstrating lack of sufficient results. Over the last years the development of angle stable, locking implants started and clinical studies demonstrated encouraging results. In our clinic the locking proximal humerus plate (LPHP®) advanced to the implant of choice for treatment of dislocated proximal humerus fractures.

Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system.A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study.A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p = 0.0014) and CT scanners were located closer to the resuscitation room (p 0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p 0.05).Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..

There is no consensus on optimal treatment strategy for Mason type II-IV fractures. Most recommendations are based upon experts' opinion.An OVID-based literature search were performed to identify studies on surgical treatment of radial head and neck fracture. Specific focus was placed on extracting data describing clinical efficacy and outcome by using the Mason classification and including elbow function scores. A total of 841 clinical studies were identified describing in total the clinical follow-up of 1264 patients.For type II radial head and neck fractures the significant best treatment option seems to be ORIF with an overall success rate of 98% by using screws or biodegradable (polylactide) pins. ORIF with a success rate of 92% shows the best results in the treatment of type III fractures and seem to be better than resection and implantation of a prosthesis. For this fracture type the ORIF with screws (96%), biodegradable (polylactide) pins (88%) and plates (83%) showed the best results. In the treatment of type IV fractures similar results could be found with a tendency of the best results after ORIF followed by resection and implantation of a prosthesis. If a prosthesis was implanted, the primary implantation seems to be associated with a better outcome after type III (87%) and IV (82%) fractures compared to the results after a secondary implantation.Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence.IV.

Treatment of tibial shaft fractures is still discussed controversial. In the present study current literature was reviewed with the objective to demonstrate current recommendations concerning tibial shaft fractures. Tibial shaft fractures are often caused by high-energy trauma with severe concomitant soft-tissue injuries. Solid bone union without hypertrophy, fast mobilization and full range of motion without further soft-tissue damages are the aims of the therapy. Non-displaced tibial shaft fractures in patients with good compliance can be treated conservatively. Deep venous thrombosis, compartment syndrome, soft tissue injury and chronic regional pain syndrome are the major risks of conservative treatment and need to be required. Operative treatment can be performed with several different implants. Intramedullary nailing with a huge biomechanical stability seems to be the implant of choice. Only rare indications for plate osteosynthesis can be found. The use of external fixation has declined even though external fixation is still the implant of choice in first line treatment of multiple trauma according to the damage control principles. Open fractures with precarious blood supply and weak soft tissue covering are vulnerable to complications and remain a challenge for every treating surgeon. Reconstruction of axis, length and rotation is essential for a good outcome. The choice of technique depends on fracture localization, type of fracture, history of concomitant disorders and soft tissue damage.

Open transosseous rotator cuff reconstruction (RCR) still plays a prominent role in current treatment of rotator cuff tears. This study aimed to examine mid-term and long-term results of clinical outcome, determine influencing factors and analyze complications.This retrospective cohort study included 104 Patients following standardized open transosseous RCR. After a mean follow-up period of 38.3 months (range 12-71 months) 88 Patients (89 shoulders) were available for examination. The mean age of Patients at surgery was 57.1 years (range 29-83 years). Standardized clinical examination included sonography and assessment of the absolute, relative and intra-individual constant scores (CS(abs), CS(rel), CS(intra)), Oxford shoulder score (OSS), American shoulder and elbow surgeons' score (ASESS) and single assessment numeric evaluation score (SANES). The level of significance for analysis of variance (ANOVA) was set at p0.05 (95% confidence interval).Mean values and standard deviations (σ) were: CS(abs) = 71 points (σ: 20.3), CS(rel) = 76 points (σ: 20.7), CS(intra) = 86 % (σ: 19.5), OSS(mod) = 77 points (σ: 20.6), ASESS = 73 points (σ: 23.3) and SANES = 72 % (σ: 22.0). Clinical results were superior when the complaints were initiated by trauma (p0.05). Patients with massive tears showed inferior results relative to all outcome measures (p0.05). Concomitant pathologies even without surgical relevance were associated with inferior outcome (p0.05). The factors surgeon, suture material and acromioplasty did not exert a significant influence. Revision surgery was required in 12 out of 89 (13.5 %) cases and re-ruptures occurred in 19.1%.Objective and subjective clinical results following open transosseous RCR were comparable to those of previously described open and arthroscopic techniques. Results were superior when the complaints were initiated by trauma. Massive tears and concomitant pathologies even without surgical relevance were associated with inferior clinical outcome. Open or arthroscopic acromioplasty did not add further benefits. A standardized operative procedure led to reproducible results irrespective of the factor surgeon.

We describe a case of the rare entity of a persistant ossicle on the top of the odontoid process. In a short review of the literature, we show developmental abnormalities of the odontoid process and its ethiologies.The terminal ossicle (Bergmann) plays an important role in the differential diagnosis of a fracture of the odontoid process type I in adults using the classification of Anderson and D'Alonzo. If fracture and instability is excluded by plain radiographs,computed tomography and/or MRI, there is no need for additional therapy.

The SCIWORA-syndrome was firstly described by Pang and Wilberger in 1982 [11]. It is characterized by a neurological injury without radiological appearance. Since the standardized use of MRI in spinal cord diagnosis, the number of the "real" SCIWORA-syndromes decreases. By the case report of a 14 years old boy falling down from a wall of 2 meters height with a complete paraplegia from Th12 without radiographic abnormality (even in MRI) we will give a short review of the literature.

Fractures of the proximal humerus commonly affect elderly patients. The vast majority of proximal humeral fractures result from low-energy trauma in presence of osteoporosis. Incidence of proximal humeral fractures dramatically increased over the last decades. Recent epidemiological studies expect a rather stagnant incidence. Diversity of fracture types attenuates reliability of available classification systems. Even though, predictive morphologic criteria have been detected enabling a prognostic assessment. A short or absent metaphyseal head extension and disruption of the medial periosteal hinge reliably predict ischemia of the humeral head fragment. Still, humeral head necrosis may be prevented in early reduction and fixation. The range of treatment options consists of non-operative therapy, minimal-invasive osteosynthesis, open reduction and plate fixation, intramedullary nailing and primary arthroplasty. Most proximal humeral fractures in the elderly are stable injuries and can be successfully treated by non-operative means. Operative treatment of displaced, unstable fractures should resort to the least invasive procedure providing adequate reduction and fixation stability. To date, open reduction and locking plate osteosynthesis represents the standard operative procedure in displaced three- and four-part fractures. However, a number of risk factors may promote fixation failure or impair functional outcome, most important low local bone mineral density, residual varus displacement of the humeral head, insufficient restoration of medial calcar support, humeral head ischemia and insufficient fracture reduction. Innovation of fixation techniques (e. g. angular stable locking systems and bone augmentation) will further expand indications for operative fracture treatment. Outcome of hemiarthroplasty is closely related to anatomical tuberosity healing and restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients, rotator cuff dysfunction or failure of first-line treatment. Choice of treatment should be individualized and base on careful evaluation of patient-specific, fracture-specific and surgeon-specific aspects.

The primary care system, especially emergency rooms, seems to be an ideal location for the implementation of brief interventions for secondary prevention of alcohol use disorders. The present study examines whether a brief intervention can both lead to a reduction in alcohol quantity and consumption frequency as well as to an increased contact with alcohol counselling services.The brief intervention for patients with alcohol consumption consisted of an interview about the alcohol drinking patterns and the delivery of a flyer from the local counselling services. One month later a follow-up interview was conducted.A total of 64 patients participated in the study; 37 patients gave their consent for follow-up. Patients with harmful/dependent alcohol use significantly reduced their alcohol amount (p0,001) and consumption frequency (p0,02). Patients who linked the injury to the consumed alcohol reduced their drinking frequency significantly more than those who did not (p=0,01). The intervention had no influence on the contact rate with counselling services.Promising evidence was found, which needs confirmation in the form of randomized controlled trials with focus on long-term effects.

Fractures of the proximal humerus are commonly seen especially in the elderly population. High-energy trauma in young people can be distinguished from low-energy trauma in the elderly resulting from falls of a low height which are typically characterized by osteoporosis. A precise analysis of fractures is essential for a good understanding of the fracture and an individual therapy for which the LEGO-Codman classification provided by Hertel is recommended. Nonsurgical therapy is commonly performed and widely accepted not only for simple fractures. For osteosynthesis angular stable implants became the gold standard but are frequently associated with a high rate of complications some of which can be lowered by an improved surgical technique. Even today varus dislocated fractures are challenging, especially in combination with destruction of the medial column. In those cases where stable osteosynthesis can no longer be achieved arthroplasty is indicated. The clinical results of anatomic fracture arthroplasty are strongly related with correct ingrowth of the tuberosities. Reverse fracture arthroplasty may be considered but indications should be interpreted with caution and preferably used in patients older than 75 years.