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Background: A preoperative informed consent discussion is an essential element of surgical treatment. Suspected errors in informed consent are frequently the subject of medical liability cases. To ensure a comprehensive documentation of the informed consent discussion, commercial documentation forms are available. Thanks to their comprehensiveness, they are increasingly replacing conventional, typically self-designed forms. In this study, the quality of informed consent discussions was evaluated based on the retrievable knowledge of the informed patients. Informed consent discussions based on self-designed forms were compared with those based on a commercial form., Materials and Methods: A monocentric, prospective, randomised, controlled, clinical longitudinal study was performed with 261 patients. Study participants were randomised into two groups. Informed consent discussions held in group A were documented using a self-designed form, while a commercial form (Thieme Compliance) was used for group B. Data collection was conducted through interviews using a standardised questionnaire, which each participant completed twice: once immediately after the medical informed consent discussion, and again on the morning of the surgery. The average time interval between the informed consent discussion and the surgery was 19 days., Results: In both groups, the results were approximately the same. Overall, 98% of the respondents felt well or very well informed after the informed consent discussion and were satisfied with the manner of communication and the time frame. Accordingly, 77% of the respondents were not or only slightly nervous about the upcoming surgery. 85% of the participants correctly stated their diagnosis, and 80% correctly identified the planned surgery. However, 24% of the respondents were unable to actively name any of the complications mentioned in the discussion. Preoperatively, this percentage increased to 35%. Following the informed consent discussion, 44% of the respondents were able to list one to two complications, 27% were able to list three to four, and 5% were able to list five or more. Patients in group A tended to perform slightly better., Conclusion: Similar results can be achieved even if different consent forms are used. Patients are well-informed immediately before hand surgery procedures. High patient satisfaction can be achieved through individualised design and documentation., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Bite injuries cause contaminated wounds with a high risk of infection. It is a progressive process. The prognosis depends less on the extent of the surface area but more on the depth of penetration. Due to the close spatial relationships the structures in the hand are particularly at risk from bite injuries. This study evaluated the dynamics of the disease progression based on the extent of injury and the timing of treatment initiation. A total of 332 bite injuries were treated and retrospectively analyzed. The severity of injuries was classified into five grades based on the affected compartments. The evaluation of the treatment was conducted according to the timing in four groups. The infection rates increased with the severity of the injury and the elapsed time. On the day of the accident 11% of patients showed signs of infection, rising to 72% the following day under conservative treatment, and 93% if no treatment was initiated by then. Patients treated conservatively elsewhere also showed similar levels. The average number of interventions also increased with the interval between the bite and the start of treatment. Not all bites are equal. The extent matters. Cutaneous injuries show signs of infection in 23% of cases but can mostly be treated conservatively. All deeper injuries require surgical treatment with debridement, immobilization and antibiotics. After immediate surgical treatment revision was necessary in 4% of cases., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

There is an emergency indication for the treatment of open fractures. Fracture stabilisation and soft tissue care are equal prerequisites for an uncomplicated course of treatment and a good functional result. However, challenges arise in cases of extensive wound contamination and compromised perfusion, limiting options for stable osteosynthesis in emergency situations. Furthermore, resource constraints may pose a challenge to adhering strictly to the six-hour time window. This prompts deliberations on whether, under certain circumstances, a deviation from the conventional approach is feasible by exploring the possibility of prioritising immediate surgical wound care during emergencies, with definitive fracture care deferred to a later point in time. Between 2019 and 2021, 301 patients with open fractures of the hand skeleton were treated (median age 44 years, 85% male, 15% female). Definitive treatment was carried out as a primary emergency procedure in 215 patients (group A), whereas it was performed at an interval after an average of 3 days in 86 patients (group B), who had received surgical wound care, splint placement, and antibiotic coverage on the day of the injury. In a retrospective study, the following criteria were analysed: comorbidities, injury patterns, injury location, timing of treatment, number of follow-up procedures, infection rate, and duration of hospitalisation. The course was complicated by infection in six patients (1.9%). Five of these patients were in group A (infection rate 2.3%), and only one patient was in group B (infection rate 1.1%). All six infections occurred after crush injuries, all at the fingertip or end joint. These numbers underscore the relevance of soft tissue trauma and primary stump formation. Comorbidities were not statistically significant in our study with a view to the occurrence of infection. In conclusion, it can be stated that, with antibiotic protection, definitive treatment of an open fracture in an interval is possible if it is preceded by initial emergency surgical wound care with subsequent immobilisation., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Bony defects in finger injuries and infections impose high demands on their treatment due to the close anatomic relationships. Ideally, the injuries are entirely treated in emergency care. Due to the mechanism of the accident, contaminated and compromised soft tissues are often present and set limits to single-stage treatment. We present the long-term subjective and functional results after two-stage reconstruction of bony finger joint defect injuries., Patients and Methods: Over a period of 15 years, a total of 40 patients with 43 fingers were treated due to a defect injury in the phalanges. Initially, the finger was stabilised with Kirschner wires after debridement. After consolidation of the soft tissue, the bone was reconstructed in a subsequent operation by interposition of an iliac crest graft. Complications occurred in 9 patients. Twenty-five patients with 27 fingers were followed up for 10.3 years. Range of motion, length of the affected finger, and grip force, each in relation to the contralateral extremity, were recorded. In addition to a subjective assessment of the global result, the daily function was determined by means of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire., Results: Significant differences compared with the contralateral extremity (p<0.05) were found in length (70 mm; 91.0%) and total mobility of the affected finger (95°; 46.0%), hand span when the thumb was involved (202.5 mm; 93.4%), and power grip when one of the fingers was injured (30 kg; 84.1%). The DASH score was 4.2 points (0-55.8). Subjectively, 88% of patients were satisfied with the treatment outcome., Conclusion: In case of contaminated and compromised soft tissues, the two-stage treatment of bony defect injuries in finger joints by arthrodesis of the joint is a reliable treatment strategy. In the long run, it results in a very satisfactory function of the hand in everyday life although significant differences have been measured compared with the contralateral extremity., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Denervation is a surgical option in ankle arthrosis when conservative therapy has failed. Sectioning all joint branches is essential for its success. The locations of the articular branches of the saphenous (Sa), tibial (Ti), sural (Su), superficial (Ps) and deep peroneal (Pp) nerves are specified., Methods: In 16 cryopreserved specimens, the courses of the nerves were prepared. Their articular branches were identified, and their respective locations documented by using a new reference system., Results: The articular branches to the ankle ranged from 5 to 30 cm measured from the foot sole. The Sa should be transected at 22.5 cm, the Su at 20 cm, and the Pp at 15 cm. The Ti should be skeletonized up to 25 cm. Epifascial dissection of the Ps is to be performed below 15 cm., Conclusion: The study specifies the joint branches of the ankle in an intraoperatively reproducible reference system and thus minimizes the required skin incisions., Competing Interests: Declaration of interest None., (Copyright © 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Two key positions have been defined for the in-house management of patients in the context of a terrorism-related mass casualty incident (Terror-MASCAL). The senior triage coordinator (LArS) categorizes the injured according to injury severity using algorithms. The central operational and medical coordinator (ZONK) disposes and prioritizes the injured for treatment measures, considering the injury severity and the available treatment capacities. The dynamics and complexity of a Terror-MASCAL combined with the high number of patients requires comprehensible documentation., Material and Methods: The evaluation of an incident exercise of a Terror-MASCAL revealed deficits in its documentation. Based on the deficits identified, requirements have been defined. The article presents the management and documentation aids of a German national trauma center., Results: The hospital with its currently available resources is abstractly represented via the Trauma Tactics Board (TTB). Patients with their individual injuries are represented by identification cards on the TTB. The ZONK can prioritize and dispose further treatment based on the information about the available resources and the patient-specific injury pattern. The patient registry continues to document the patient's other medical findings. Important external and internal information is noted in an event register. The entire documentation process on the TTB is documented by camera., Conclusion: Documentation aids are required to fulfil the core tasks of the ZONK. By using the documentation aids, a hospital can prepare for a Terror-MASCAL within a short time. Lack of daily practical application of the documentation aids should be compensated for by regular practice and interdisciplinary exchange of experience., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: A rare but typical perioperative complication in the surgical treatment of pediatric forearm fractures is injury to the extensor pollicis longus (EPL) tendon. This article presents the long-term results after reconstruction of the EPL tendon with transposition of the extensor indicis (EI) tendon in children and adolescents after surgically treated forearm fracture., Patients and Methods: Over a period of 15 years, 22 children up to the age of 16 were treated with EI transposition analogous to adult care. In a follow-up examination, the range of motion of the finger and thumb joints, retropulsion of the thumb and index finger, abduction and opposition were examined. In addition, hand span and strength in the gross, key, and point grasp were measured. Subjective complaints were questioned and the DASH score was assessed., Results: Rupture of the EPL tendon is a rare complication, accounting for 1% of all surgically treated paediatric forearm fractures. 15 patients with an average age of 10.9 years could be followed up for an average of 66.5 months after transposition of the EI tendon. Significant differences were found in reduced mobility of the metacarpophalangeal joint of the thumb, isolated extensor strength of the index finger, a reduced span between the thumb and index finger in palmar abduction, and reduced strength in the pointed grip. Subjectively, the differences between the sides were not noticed by the patients and their parents in everyday life., Conclusions: Transposition of the EI tendon for reconstruction of a ruptured EPL tendon as a rare complication after paediatric forearm fracture does lead to a measurable and significant reduction in index finger mobility on the affected side in the long term, but without subjective limitations of the children., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: Diaphyseal ulnar shortening osteotomy (USO) as surgical treatment of ulnar impaction syndrome is standardized nowadays with good to very good results. In contrast, a wide spectrum of different postoperative treatment regimens can be found in the current literature. The results after USO with modern, angular stable implants with immobilization for 2 weeks are presented., Patients and Methods: A retrospective database analysis identified 49 patients (31 women, 18 men, mean age 37.6 years) with a total of 51 USO over a 13-year period and were followed up for 73.5 (15.9-192.9). All USO were obliquely sawed and stabilized with palmar locking implants. The wrist was immobilized postoperatively in 30° extension in a dorsal forearm splint for 2 weeks., Results: All USO showed load-stable consolidation signs after an average of 7.0 (SD 1.9; 4.9-14.1) weeks. Wrist range of motion was significantly improved in extension/flexion from 107.6° (60-155) preoperatively to 123.7° (80-160) postoperatively and in ulnar/radial deviation from 55.1° (25-90) to 60.8° (30-90) (p<0.05). Pain level was significantly reduced from 3.2 (0-8) to 0.1 (0-2) at rest and from 7.3 (4-10) to 1.2 (0-9) under weight bearing (p<0.01). A total of 5 complications (9.8%) were noted. Nonunion was not found., Conclusion: By using angular stable implants to stabilize a USO, the duration of immobilization can be reduced to 2 weeks without compromising bone healing., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Distal interphalangeal joint (DIPJ) arthrodesis is a well-proven therapy for osteoarthritis in the DIPJ. Since the upper limb is effectively a linked chain which is moved by interlinked, joint-overlapping muscle-tendon units, impacts on movement and force patterns are expected to occur in response to arthrodesis. In this context, a real-time quantitative analysis has not been performed to date., Material and Methods: Finger motion and force development during grasping were dynamically measured and quantitatively analyzed in 19 healthy volunteers with a simulated DIPJ arthrodesis using a TUB (Technische Universität Berlin) sensor glove during fist closure and evaluating two types of force grips compared with the physiological grip., Results: Typical motion patterns were found. During physiological fist closure, the average flexion angle was 71.5° in the metacarpophalangeal joint (MPJ), 76.8° in the proximal interphalangeal joint (PIPJ) and 37.3° in the distal interphalangeal joint (DIPJ). With DIPJ arthrodesis, the flexion angle decreased to 49.6° in the PIPJ, whereas it increased slightly to 77.3° in the MPJ. During force grip I, the average physiological flexion angles were 18.3° in the MPJ, 39.6° in the PIPJ and 42.6° in the DIPJ. With simulated DIPJ arthrodesis, the flexion angle in the MPJ increased to 28.4°, whereas it decreased to 25.2° in the PIPJ. Force grip II yielded physiological flexion angles of 30.9° in the MPJ, 36.6° in the PIPJ and 29.0° in the DIPJ. In response to simulated DIPJ arthrodesis, the angle in the MPJ increased to 34.4° while it decreased to 23.3° in the PIPJ. The forces measured with force grips were almost equally distributed under physiological conditions. In response to simulated DIPJ arthrodesis, the average decrease in the measured force of a finger was no more than 1.4%., Conclusion: This study was the first to introduce a quantitative analysis of grasping with simulated DIPJ arthrodesis. Based on this analysis, the study demonstrates the dynamic interaction of the finger joints as well as force patterns on the individual finger rays of the hand in real-time., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: In this study, the results after corrective osteotomy of the base of the first metacarpal bone are presented., Patients and Methods: There were 24 malunion following a fracture of the base of the first metacarpal, these included 19 Bennett's fractures, 3 Rolando fractures, and 2 Winterstein fractures. The time between the corrective osteotomy and the initial trauma averaged 16 (range, 4 to 66) weeks. The Bennett and Rolando fractures had an average step-off of 2.3 (range, 0 to 4) mm, as well as gaps between 0.9 and 5.4 mm in the basal articular surface of the first metacarpal. There was a subluxation in 16 patients. Patients with Rolando or Winterstein fractures showed an axis deviation of the first metacarpal ranging from 31° to 57°. Two of the patients with Rolando fracture showed a step-off of the articular surface of 1 and 3 millimetres, respectively. Screw osteosynthesis was carried out 10 times, K-wire osteosynthesis 13 times, and once, both procedures were combined. One osteotomy was performed with use of a plate osteosynthesis., Results: The corrective osteotomy in patients with Bennett's fracture improved the radial abduction on average from 37° to 49° and the palmar abduction on average from 37° to 47°. Thirteen patients presented a congruent articular surface postoperatively. A step-off in the articular surface between 0.5 and 2.2 millimetres remained in 6 cases. In one patient the subluxation could not be completely corrected. In two cases a trapezectomy was required due to the remaining displacement in the joint and a post-traumatic osteoarthritis. The mobility after Rolando and Winterstein fractures improved on average from 31° to 41° for radial abduction and from 32° to 43° for palmar abduction. Congruent joint surfaces as well as repositioning of the first metacarpal was seen in all patients, only one patient showed a persisting axis deviation of 35° postoperatively. All patients returned to work., Conclusion: The study shows that posttraumatic malunion of the base of the first metacarpal can be treated effectively by corrective osteotomy resulting in good outcomes, if degenerative changes have not occurred, while alternative treatment methods remain to be performed., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Depressed fractures of the base of the middle phalanges are problematic because of frequent subluxations and centrally depressed fragments. There are two minimally invasive procedures available: 1) the less known intramedullary padding technique according to Hintringer and 2) the widely used distraction fixator of Suzuki. This article describes the technique and outcome of these two procedures., Methodology: The follow-up collective included 42 patients after treatment of a depressed fracture of the base of the middle phalanx. An intramedullary padding with percutaneous Kirschner wire retention was performed 28 times (group A) and treatment with a Suzuki fixator 14 times (group B). The study examined the hand function, the radiological results and the subjective pain level., Results: According to the American Society for Surgery of the Hand (ASSH) classification 81% of the patients in group A achieved a good result but in group B the same result was achieved by only 50% of the patients. The median range of movement in the proximal interphalangeal joint was 82.5° after intramedullary padding and 47.5° after Suzuki fixator. In median, the impression was reduced from 2.35 mm to 0.5 mm in group A, but only from 1.6 mm to 1.15 mm in group B. Pain was a limiting factor in 2 out of 28 patients in group A and 1 out of 14 patients in group B., Conclusion: The intramedullary padding technique according to Hintringer enables good treatment of depressed fractures of the base of the middle phalanx of the finger. Repositioning of dorsal subluxations can be performed and centrally impressed fragments can be reduced better than by using the Suzuki dynamic fixator. In addition, the radiological course assessments can be assessed better than with the distraction fixator.

Background: Secondary reconstructions of flexor tendons are nowadays seldom - due to developments in primary repairs of flexor tendon. They are however indicated in complex cases. The results of a tertiary, supraregionally operating hand centre are presented. The results are compared with recent and historic published results., Patients and Methods: During a period of 11 years and with a total of 644 flexor tendon repairs, there have been 52 secondary flexor tendon reconstructions: 7 single staged reconstructions, 16 tendon transpositions and 29 two staged reconstructions. A total of 39 patients have been evaluated retrospectively using the system of Buck-Gramcko., Results: Excellent to good results have been achieved in 60 % of the single staged reconstructions. Functional = excellent to good results are found in 75 % of the transpositions. 50 % of the two staged reconstructions obtained a functional result. In total 58.5 % of the secondary flexor tendon reconstructions achieved a functional result according to the system of Buck-Gramcko., Conclusions: Secondary flexor tendon reconstructions make up about 7.5 % of all flexor tendon injuries. The functional results have changed little during the last decades and relevant improvement appears to be impossible. In comparison to primary suture of flexor tendons, the results are disappointing. The objective is to further optimize the primary repair of flexor tendons and consequently to reduce the need for secondary reconstructions., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Injuries to the flexor tendons in children are less common than in adults. The clinical examination and diagnostics require extensive experience. Leaving flexor tendons untreated will result in growth disorders of the affected finger. Therefore, the indications for operative exploration of any type of open injury in a child's hand should be liberally applied. As for adults the primary treatment of flexor tendon injuries as an emergency is rarely indicated. In the recent literature various tendon suture techniques and rehabilitation protocols have been differently assessed. According to the Ulm algorithm flexor tendon injuries in children are treated by a 2-strand core stitch technique followed by a continuous circular suture. Children under 6 years of age are postoperatively immobilized for 3 weeks with a fist bandage. Children older than 6 years are treated like adults with a dynamic aftercare as described by Kleinert for 5 weeks. The results are comparable with those of other aftercare protocols.

The purpose of this study was to analyse motion patterns of the finger joints dynamically while making a fist. 10 subjects were examined using the TUB-sensor glove, which was equipped with 14 joint angle sensors. The median time it takes the finger joints to complete flexion until reaching the state of a closed fist ranges between 0.5 to 1.0 s. A specific pattern can be seen for every finger. The PIP and DIP joints appear to be linked, with the DIP trailing the PIP joint. At the thumb the IP is trailing the MCP joint. The MCP joint shows more variation at the beginning of flexion: while in some cases it initiates movement in a finger, in other cases its flexion falls behind the PIP joint movements. The completion of flexion is achieved by the MCP joints, with the PIP and DIP joints reaching their end of motion first. The range of motion (ROM) at the MCP joints shows a finger-dependent median of 79-97°. At the PIP joints the median lies between 87° and 90°, at the DIP joints between 52° and 68°. At the thumb it is 21° for the MCP and 24° for the IP joint. The linkage between PIP and DIP joints can also be seen when analysing the ROM. The coupling ratio amounts to 0.77 at the index finger, 0.75 at the middle and ring finger and 0.57 at the small finger., (© Georg Thieme Verlag KG Stuttgart · New York.)

The present study analyses force distribution patterns during primary grips. 10 subjects were examined using the TUB-sensor glove, which was equipped with 10 pressure sensors. 5 proximal sensors at the MCP joints and 5 distal sensors at the DIP joints were attached palmarly. 9 different gripping motions were examined: the cylinder grip using 4 different objects, the pinch grip and 4 different kinds of precision grips. The force distribution patterns can be clearly divided into 2 groups. On the one hand there are the "power grips", in which the force is distributed over the proximal and distal sensors. On the other hand there are the "precision grips", which only show a force distribution at the distal sensors. Therefore Napier's concept of the existence of primarily 2 gripping patterns, which is based on visual analysis, can be verified objectively. For the "power grips" the force distribution is shifted further distally with increasing size of the objects. In conclusion, their distribution pattern shifts towards the pattern of the "precision grips". At the small finger the distal sensor is already dominant during the "power grips" of smaller objects. The thumb plays a subordinate role during the "power grip" of smaller objects, since these grips are similar to the "closing fist motion" and the objects can be held between the fingers and the palm of the hand. However, with increasing object sizes the thumb gains more importance, since its opposing movement is now required to accomplish the grip., (© Georg Thieme Verlag KG Stuttgart · New York.)

Blunt chest trauma impairs the outcome of multiply-injured patients. Lung contusion induces inflammatory alterations and Fas-dependent apoptosis of alveolar type 2 epithelial (AT2) cells has been described. The Fas/Fas ligand (FasL) system seems to exhibit a proinflammatory potential. We aimed to elucidate the involvement of the Fas/FasL system in the inflammatory response after lung contusion. Chest trauma was induced in male rats by a pressure wave. Soluble FasL concentrations were determined in bronchoalveolar lavage fluids and alveolar macrophage (AMΦ) supernatants. Alveolar macrophages and AT2 cells were isolated to determine the surface expression (FACS) of Fas/FasL, the mRNA expression (reverse transcriptase-polymerase chain reaction) of Fas, FasL, TNF-α, IL-6, and IL-10 and to measure the release of IL-6 and IL-10 after culture with or without stimulation with FasL. After chest trauma, FasL concentration was increased in bronchoalveolar lavage fluid, and AMΦ supernatants and Fas and FasL protein were downregulated on AMΦs and unchanged on AT2 cells. The mRNA expression of Fas was increased in AMΦs and AT2 cells and that of FasL only in AMΦs isolated after lung contusion. Fas ligand stimulation further enhanced IL-6 and suppressed IL-10 release in AMΦs after trauma.The results indicate that the Fas/FasL system is activated after chest trauma, and FasL is associated with the inflammatory response after lung contusion. The proinflammatory response of AMΦs is enhanced by FasL stimulation. Both AMΦs and AT2 cells seem to contribute to the mediator release after lung contusion. These results confirm the importance of the Fas/FasL system in the inflammatory response after chest trauma.

A new experimental setup dedicated to the measurement of soft-x-ray magnetic absorption spectroscopy and soft-x-ray resonant magnetic reflectometry (soft-XRMR) is presented. XRMR is the combination of standard x-ray reflectometry with x-ray magnetic circular dichroism which provides chemical and magnetic depth profiles of layered thin-film samples. This new diffractometer is optimized for a broad variety of sample systems. Therefore a balanced design focusing on high magnetic fields, low temperatures, and full freedom of rotation has been realized in UHV. First experimental results obtained on a NiCoO/Co bilayer sample are presented showing the potential of the setup.