[Hand replantation: differences in functional outcome considering patient age and sociomedical aspects]. / Handreplantation: Unterschiede im funktionellen Ergebnis in Anbetracht von Alter und sozialmedizinischem Aspekt.

By presenting 2 cases of successful hand replantation with similar trauma mechanism, level of amputation and ischaemia time of an 18-year-old female patient and a 48-year-old depressive male patient, the influence of age and sociomedical status on the postoperative outcome is discussed. DASH- (disabilities of the arm, shoulder and hand) score and Biometrics E-LINK power and sensitivity measurement were used to evaluate the outcomes.

[Musculosceletal reconstruction in bilateral forearm transplantation]. / Muskuloskelettale Rekonstruktion bei bilateraler Unterarmtransplantation.

BACKGROUND: Improvement of motor function of the upper extremity was investigated in a patient following bilateral forearm transplantation. PATIENTS AND METHODS: Following an electric shock injury with amputation of both forearms at the proximal level a bilateral allotransplantation was performed 2003 in a 41-year-old male patient. Missing and insufficient muscles were replaced by donor units. For use of myoprothesis in case of transplant failure remnants of BR, ECRL, ECRB and ECU remained at the recipient. 3.5 mm DCP plating was used without bone grafting to stabilize the forearm bones. PT, FCR, FDS, PL of the donor was fixed to the medial epicondyle of the humerus, ECU and EDC to the periosteum of the ulna. FCU, BR, ECRL; ECRB of the donor were sutured to the corresponding fascia of the recipient muscles. For motor function NIA; NIP and the motor branches of the median nerve for PT, FCR, FDS, PL were coapted. The ulnar nerve was coapted distally to the motor branch for the FCU. Following induction therapy today IS consist of tacrolimus (trough level 8 ng/ml), everolimus (trough level 6 ng/ml) und Prednisone (5 mg/day). RESULTS: Both grafts are vital at FU of 6 years and 1 month. During the first 3 years episodes of graft rejection, opportunistic infection and transient metabolic disorder occurred which could be treated successfully by systemic, topical agents and change of IS. Bone healing appeared normal. TRM of the upper extremity improved from 32.7% before surgery to 74.6% of normal, with gain of wrist motion/forearm rotation of 8.7% and finger motion of 33, and 2%. The moderate muscle power (M4/5) of the deep flexors, the extensors and the intrinsic muscles is considered to be due to the long distance of reinnervation, a pre-existing electric damage to the nerv and repeated rejection episodes. CONCLUSION: Range of motion of the upper extremity improved primarily by extrinsic muscle function. Muscle strength and grip are moderate. The patient described the following to be most beneficial: the better range of motion, the possibility to perform tasks without visual control, the availability of his range of motion 24 h a day and a new sense of body integrity.

[Dorsolateral dislocation of the proximal interphalangeal joint: closed reduction and early active motion versus static splinting]. / Dorsolaterale Dislokation des proximalen Interphalangealgelenkes: Geschlossene Reposition und frühe aktive Mobilisation oder Gipsruhigstellung.

In this follow-up examination, the outcome of two conservative treatment regimens (immobilisation versus early active motion) were evaluated in 50 patients with dorsolateral dislocation of the proximal interphalangeal joint after a mean follow-up time of 7.9 years. The aim of this study was to prove whether early mobilisation results in better clinical outcome compared to prolonged immobilisation. In group A, 25 patients were treated by static splinting in a cast for four weeks. At follow-up, 21 patients were free of pain, three patients complained of pain following maximum loading and one patient experienced permanent pain. The mean range of motion was 89.4 degrees, the mean lack of extension was 12.7 degrees and the mean joint circumference was 3.4 mm thicker than the uninjured side. Pinch power was reduced to 78 % of the uninjured side. All joints were clinically stable. Degenerative arthritis was seen in five patients. In group B, 25 patients were treated by dorsal block splinting of the interphalangeal joint. The patients were allowed to extend their finger and to perform daily active exercises of the injured joint. At follow-up, eighteen patients were pain free, five experienced pain after maximum loading and two patients complained of permanent pain. The mean range of motion was 96.6 degrees, the mean limitation of extension was 5.3 degrees and the mean joint circumference was 4.1 mm thicker than on the uninjured side. Pinch power was reduced to 85 % of the uninjured side. All joints were clinically stable. Degenerative arthritis was seen in six patients. Early active motion following dorsolateral dislocation of the proximal interphalangeal joint leads to significantly superior results regarding the active range of motion and pinch power.

[Acceptance of patient-related evaluation of wrist function following distal radius fracture (DRF)]. / Zur Akzeptanz der patientenbezogenen Bewertung der Handgelenkfunktion nach distaler Radiusfraktur (DRF).

INTRODUCTION: Outcome evaluation after distal radius fractures is mainly based on wrist function and radiological parameters, while measuring patient satisfaction seems to be more difficult. The purpose of this study was to assess different subjective features with regard to patient satisfaction for wrist healing, activity and participation. MATERIALS AND METHODS: A questionnaire combining items from the established PRWE (Patient related wrist evaluation), wrist-specific items from the DASH (Disability of Arm, Shoulder and Hand) as well as the ICF questionnaire (international classification of function, health and disease) was created, and then distributed to patients without wrist injuries (group 1) and patients following a distal radius fracture (group 2). Analysis of answered questions was performed with regard to response rate, valid content, mean differences between the two groups, correlation with radiology features in the patient group and age. RESULTS: Of 510 individuals with non-relevant wrist injuries, 96.7 % of the questions were answered, while of 133 distal radius fracture patients, 92.2 % of the questions were answered, rendering a total response rate of 95.5 %. Frequency of not responding to questions varied between 1.4 % to 14.4 %, and remained < 5 % for 17 questions. Internal consistency of the questionnaire with regard to wrist function was high in both groups (Cronbach alpha index for patients with non-relevant wrist injuries 0.9836, for distal radius fracture patients 0.9881). All questions were deemed specific for wrist function (discriminatory power > 0.7), and highly significant (p < 0.01) for ascertainment of subjective comfort after distal radius fracture in comparison with non-relevant wrist injuries. Fourteen of 25 questions (56 %) were correlated significantly (p < 0.05) with radiological features of malunion. For ages 30 to 49, and > 70 years, wrist function was deemed worse in the distal radius fracture patients vs. the non-injured wrist group. For ages 50 to 69, a significant difference was found only for 5 of 25 (20 %) questions. CONCLUSION: All questions were of a high validity and significance to determine subjective outcome after distal radius fractures. Patient acceptance was significantly different for questions, and subjective wrist comfort depended on age. For ages 50 to 69, additional questions in terms of employment situation and recreational function could be incorporated. Only about half of the questions correlated with radiological parameters of distal radius malunion. Eight questions showed both high acceptance and high correlation with radiology. Standardised measurements of range of motion and power, as well as radiology features and subjective questions of high acceptance and radiology relevance are essential for a wrist-specific questionnaire.

[Long-term results after a modified Sauvé-Kapandji procedure. Report on 105 post-traumatic cases]. / Langzeitergebnisse nach modifizierter Sauvé-Kapandji- Operation. Bericht über 105 posttraumatische Fälle.

A modified Sauvé-Kapandji procedure was performed on 105 patients for a painfully limited range of motion and arthritis of the distal radioulnar joint following distal fracture of the radius ( n=81), the radius and ulna in the distal one-third ( n=18) and of the forearm shaft ( n=6). After an average of 8 years all patients were followed up clinically (motion, strength, pain) and radiographically (union of the arthrodesis, carpal translation, radioulnar distance). Rotation of the forearm had been improved by 53%. The amount of strength lay by 70% in comparison to the contralateral side. In 97% of the patients pain could be reduced. In all cases the arthrodesis had fused completely. An ulnar drift of the carpus was observed in 5% of the patients, and 74% of the patients showed radiological signs of approximation of the proximal ulnar stump to the radius. This reduction of the radioulnar distance amounted to less than 3 mm in 65% of the patients and lay between 3 and 5 mm in 29% of the patients. In none of the cases was direct contact between the ulna and the radius encountered.

[Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism]. / Distale Radiusfrakturen und Begleitverletzungen - Experimentelle Untersuchungen zum Pathomechanismus.

Since Colles (1814) first described a distal radius fracture and the publication by Dupuytren (1834), the frequency of and problems surrounding these fractures were increasingly recognised. Not only the treatment but also the formation and type of fracture were repeatedly analysed. The various theories concerning the pathomechanism led to names such as: "tear fracture", "bend fracture", "thrust fracture", "compression fracture", "snap fracture" and others. In our experimental studies we attempted to simulate the pathomechanism of distal radius fractures and present them pictorially. With the help of a materials testing machine, 63 prepared cadaver arms were hyperextended in the wrist joint until a radius fracture occurred. The concomitant lesions were registered radiologically and by dissection. Moreover, additional cadaver arms were deep-frozen and examined by means of computer tomography and cryosection according to Kathrein. Through experimental hyperextension it was possible to generate dorsal, central, and palmar types of fractures. We produced 42 dorsal, 14 central and 7 palmar fractures. Fundamentally, it seems that the fracture depends on the extent in which the carpal bones of the proximal row are pressed against the dorsal, central or palmar part of the articular surface of the distal radius. The subsequent dissection showed in 40 cases (63 %) mostly multiple concomitant lesions and in 23 cases (37 %) none of these. The reason for concomitant lesions may be the proportion of bone stability to the strength of ligaments. Most frequently (27 cases, i.e. 43 %), we found a destabilisation of the articular disk with or without a bony avulsion fragment (fracture of the ulnar styloid). We also commonly found ruptures of the interosseous ligaments between scaphoid and lunate (20 cases, i.e. 32 %) and lunate and triquetrum (11 cases, i.e. 18 %). It is difficult to apply knowledge gained from experimental studies on preserved cadaver arms clinically. There are of course no physiological reflexes and the slow fracture process must be taken into consideration. This holds true not only for concomitant lesions but also for the type of fracture. On the other hand, in these experimental studies it was possible to generate many realistic types of fractures with their concomitant lesions.

Arthroscopic chondrectomy as a treatment of cartilage lesions.

Although favorable effects of débridement with chondrectomy and drilling or abrasion have been reported in treating of cartilage lesions in the knee joint; however, in most cases an additional intervention is generally performed during arthroscopy. We studied 53 consecutive patients with solitary chondral lesions in the weight-bearing part of the knee and treated 86 cartilage lesions by arthroscopic débridement, including a detailed removal of damaged or undermined cartilage. We evaluated the postoperative course by questionnaire (mean follow-up 6.5 years, response rate 83%). All patients reported a positive effect of chondrectomy: 69% considered the knee considerably better or cured and 77% regarded the effect as permanent. There was no complication of the arthroscopies performed, and no patient noted any deterioration in the condition. We therefore recommend routine chondrectomy of cartilage lesions when these are found during an arthroscopy.

[Dorsal dislocation of the proximal interphalangeal joints of the finger. Results after static and functional treatment]. / Dorsale Luxation der PIP-Gelenke der Finger. Ergebnisse nach statischer und nach funktioneller Behandlung.

In a follow-up examination of 30 patients who had sustained dorsal dislocations of the PIP joint, the results of two conservative therapy regimens, either immobilisation or early motion were investigated. In Group A, 15 patients were treated by closed reduction and immobilisation with a forearm cast for four weeks. Nine patients showed normal range of motion, whereas a limitation of extension of ten degrees and more was seen in six cases. All PIP joints were stable. Nine patients were satisfied. Three patients complained of a limitation of extension, two of a limitation of extension and pain and one of swelling. In Group B, 15 patients were treated by dorsal block splinting of the PIP joint following reposition. The finger was released in extension with daily active exercise of the PIP joint. Only two of 15 patients showed limitation of extension, whereas 13 cases showed normal range of motion. Instability of one collateral ligament was seen in two cases. Palmar instability did not occur. Eleven patients were satisfied. One patient complained of instability, pain and lack of extension, one of pain in combination with instability, one of pain and one of swelling of the joint.

[Late sequelae of fractures of the distal third of the forearm during the growth period]. / Spätfolgen nach Frakturen im distalen Unterarmdrittel im Wachstumsalter.

Fractures to the distal third of the forearm are the most common fractures of the upper extremity, with the majority occurring between the age of ten and 14 years. With the exception of the rare epiphyseal fractures, they have a favourable prognosis. The present study investigates the frequency and extent of potential clinical and radiological late sequelae of fractures in the distal third of the forearm during growth. Of the patients treated at the Innsbruck University Department of Traumatology from 1980 to 1992, 220 patients of a growing age with 232 closed fractures in the distal third of the forearm were followed up. The radius alone was affected in 60% of these cases; the radius and the ulna in 40%. Fractures of the ulna alone were not present. The mean age of the patients at the time of injury was nine years (range one to 16 years) and the mean time of follow-up ten years (range five to 16 years). In addition to the patient's subjective assessment, the right and left sides were compared with regard to mobility of the wrist and rotational movement of the forearm. Based on standard X-rays, the frontal (radio-ulnar) and lateral (dorso-palmar) radial joint angle as well as the difference in the radio-ulnar plane were compared with the contralateral side. Clinical and radiological findings were summarised into an overall result. 19% of the patients reported pain in the injured wrist. Mobility of the wrist in the sagittal and/or frontal plane was limited in 5% of patients and rotation of the forearm was limited in 16% of patients. A statistically significant accumulation of limited rotation was seen after physeal fractures of the ulna ("one-way" ANOVA-test, p = 0.0033). A difference between the left and right side in regard to the frontal radial joint angle was seen in 6% of patients and a difference in the lateral radial joint angle was registered in 2% of patients. A difference in the radio-ulnar plane was observed in 37% of patients. In the presence of relative ulna-plus variance, 75% of patients complained of pain in the ulnocarpal compartment of the wrist. In these patients, dynamic magnetic resonance tomography revealed a compression of the ulnocarpal disk between the proximal carpal bones and the head of the ulna, as well as degeneration in the central portion of the disk. The overall outcome was very good in 72%, good in 19%, moderate in 6% and poor in 3% of patients. The younger the children had been at the time of injury, the more favourable were the results (chi-square test, p = 0.009). Children older than ten years of age with an angulatory deformity of more than 20 degrees and/or fragment dislocation over half of the breadth of the shaft at fracture consolidation showed the poorest results. Further factors having a negative influence on the outcome were repeated reduction manoeuvres and an additional fracture of the ulna.

[Monteggia injuries in childhood]. / Monteggia-Verletzungen im Kindesalter.

The Monteggia-fracture dislocation is a characteristic combined injury of the forearm with fracture of the ulna and dislocation of the head of the radius. Monteggia- and equivalent injuries are rare. In the present study, we attempt to clarify the concept of therapy and observe the influence of this injury on the growth of the forearm bones. Between 1977 and 1996, 27 patients (three to thirteen years) with a Monteggia or a Monteggia-equivalent injury were treated. We present clinical and radiological long-term results of 20 patients, two to 21 years following the injury. Group I includes 12 patients with a classic Monteggia injury, five patients were treated conservatively, seven patients surgically. Ten patients were free of pain and had no loss of motion. In one patient there was a loss of pronation following an accompanying injury of the distal radius. Primary paresis of the radial nerve has a good prognosis. One patient presents a persisting dislocation of the radius head with a loss of flexion in the elbow joint, and a secondary persisting paraesthesia of the median nerve. Group II includes eight patients with a Monteggia-equivalent injury; all of them were treated surgically. The results in this group showed more loss of motion in elbow function, forearm rotation, and dislocation of the axis in the elbow joint. Monteggia and Monteggia-equivalent injuries in childhood have good functional results if correct reduction of the fracture of the ulna and the head of the radius is performed. If this is not possible conservatively, patients need open reduction and internal fixation.

The use of a graft from the second extensor compartment to reconstruct the A2 flexor pulley in the long finger.

A 10 mm wide ring graft from the second extensor compartment with periosteum from the floor of the sheath was used to correct bowstringing in six patients who sustained an isolated rupture of the A2 pulley. It was attached to the lateral rims of the sheath. Periosteum was used for additional graft fixation. Bowstringing was assessed by magnetic resonance imaging and ultrasound preoperatively and 19.5 months after surgery. It was corrected in five patients and improved in one. Pain was reduced from 35 to 7 points on a visual analogue scale. Digital circumference decreased from 76 to 71 mm. Flexion at the PIP joint increased from 88 degrees to 116 degrees. Pinch grip improved from 28 to 56 N.

[Tibial growth after isolated femoral shaft fracture in the growth stage]. / Das Tibiawachstum nach isolierter Femurschaftfraktur im Wachstumsalter.

The aim of the present study is to investigate the growth of the tibia after femoral shaft fractures in children. We were able to follow up 44 patients (32 male and 12 female) after a mean of 8 years (range, 5 to 15 years). The age in the time of injury was 3 till 13 years (mean 7 years). The length of the femur, tibia and leg was measured on X-rays of the entire leg, and the measurements were compared with the contralateral side. A statistically significant number of tibial elongations were observed in fractures that had healed in considerable malalignment (at least 1 cm shortening, dislocation of at least a half of the breadth of the femoral shaft, angular deformity of more than 10 degrees) (p = 0.003) and in fractures that were subjected to manipulation (secondary reduction, change of treatment or traction weight) during the healing process (p = 0.007). Furthermore, all 7 patients who had infection requiring treatment at the tibial plateau extension had more pronounced tibial growth. No significant difference was found between tibial growth and the age of the child at the time of injury, the type of fracture, the location of fracture and the mode of treatment. The following factors were evaluated as being clinically relevant: primary, largely anatomic reduction, avoidance of secondary manipulation and prevention of infection at the tibial plateau extension.

Chronic Achilles tendinopathy in athletic individuals: results of nonsurgical treatment.

We report the results of nonsurgical treatment of chronic Achilles tendinopathy in 22 patients with a follow-up of 33 to 72 months. Immediately after the treatment period, 70% of the patients were either improved or cured. At follow-up, 65% were improved or cured, and 35% failed treatment or had a poor long-term result. In these patients, early surgery might have been considered, but only one patient received a peritendinitis operation in the follow-up period. In athletic individuals with chronic Achilles tendinopathy, nonsurgical treatment with emphasis on active training is recommended. Surgery should be considered if the athlete has been treated for 3 to 6 months without progress.

The interosseous membrane and its influence on the distal radioulnar joint. An anatomical investigation of the distal tract.

From the interosseous membrane of the forearm a tract extends to the dorsal capsule of the distal radioulnar joint. The structure and function of this tract have been investigated. The tract originates from the radius 22 mm proximal to the distal dorsal corner of the sigmoid notch. Central fibres are attached there with fibrous cartilage and superficial bundles mix with the periosteum. The tract is 8 mm wide, 31 mm long and 1 mm thick. Distally it inserts at the capsule of the distal radioulnar joint between the tendon sheaths of extensor digiti minimi and extensor carpi ulnaris. Deep fibres insert directly at the triangular fibrocartilage. The tract of the interosseous membrane is taut in pronation and loose in supination. It strengthens the dorsal capsule of the distal radioulnar joint. During pronation the tract protects the ulnar head in a sling. Its attachment at the triangular fibrocartilage influences the distal radioulnar joint. Its insertion at the triangular fibrocartilage and the support of the weakest part of the dorsal capsule are of interest.

[Acute compartment syndrome of the lower leg after ankle joint sprain. A case report]. / Akutes Kompartmentsyndrom des Unterschenkels nach Sprunggelenkdistorsion. Ein Fallbericht.

In the field of traumatology, compartment syndromes of the lower extremity are often seen after fractures and direct injuries, or after ischaemia. Other causes include over-exertion and non-traumatic causes such as acute rhabdomyolysis, drug-induced myositis and eosinophilic myositis. This paper describes the clinical and MR course of a compartment syndrome following an ankle sprain.

Osteochondritis dissecans of the femoral condyle treated with periosteal transplantation. Poor outcome in 14 patients followed for 6-9 years.

We evaluated 14 consecutive periosteal transplantations to treat osteochondritis dissecans lesions of the femoral condyle. 1 year postoperatively, 9 knees were pain-free, but with 6-9 years follow-up, only 2 knees were pain-free. Formation of hyaline-like cartilage, assessed in 12 knees, was documented in 1 patients and assessed as possible in 1 more, but in 10 patients the tissue formed in the defects was not or probably not hyaline cartilage. 6 knees had developed arthrosis.

[Hand and wrist injuries. A study of 50.272 injuries]. / Hånd- og håndledsskader. En undersøgelse omfattende 50.272 skader.

This study reports the causes, characteristics and treatment of injuries to the hand and wrist presented to five accident and emergency departments in a two-year survey of 13% of the Danish population. The rate of injury to the hand or wrist was 28.6% of all injuries, or 3545 per 100,000 inhabitants per year. Thirty-four percent of the accidents were domestic, 35% were leisure accidents, 26% were occupational and 5% were traffic accidents. Only 2% of the patients were admitted to hospital for further treatment or observation and 13% were referred to a hospital as out-patients. The most frequent causes for admission were fractures (42%), tendon lesions (29%) and wounds (12%).

[Referrals to an emergency unit before and after changes in the practitioner-on-call system]. / Skadestuehenvendelser før og efter aendring af vagtlaegeordningen.

Attendance at the casualty department of the Central Hospital in Naestved was investigated during two similar periods before and after changes were made in the practitioner-on-call system. The total number of patients admitted (either via casualty or referred from a practitioner) were registered. A total of 4454 attendances took place during the two periods, 2330 of these being before the changes and 2123 after the changes in the practitioner-on-call system. In the present material there were 1673 orthopaedic and 136 medical patients before and 1552 orthopaedic and 133 medical patients after the reorganization. No changes in medical specialities of the attendances in the two periods could be pointed out. 2110 patients were admitted to hospital in the first period, 2299 in the second period. The study concludes that no changes in the pattern of attendance at the casualty department could be shown after the reorganization in general practice.

The social and economic consequences of finger amputations.

120 patients with amputation of at least 1 of the 4 ulnar fingers were admitted to hospital. In none was replantation considered to be possible because of serious damage to the soft tissues and bone. 12 (3-18) years after the accident 80 percent of the patients assessed their condition as good or fair, even those with proximal amputation or loss of 2 or 3 fingers. Our observations do not support replantation when only one of the second-to-fifth fingers have been amputated.