[Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures]. / Management vorbestehender Antikoagulation zur zeitgerechten Versorgung von hüftnahen Frakturen.

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients a prolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides a way to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

[Thoracolumbar spinal fractures in the elderly : Classification and treatment]. / Thorakolumbale Wirbelsäulenfrakturen beim alten Menschen : Klassifikation und Therapie.

Thoracolumbar fractures in the elderly are frequently associated with osteoporosis. Osteoporosis can cause fractures or be a significant comorbidity in traumatic fractures. The OF classification is based on conventional X­ray, computed tomography (CT) scan and magnetic resonance imaging (MRI). It is easy to use and provides a clinically relevant classification of the fractures. Therapeutic decisions are made based on the clinical and radiological situation by using the OF score. The score takes the current clinical situation including patient-specific comorbidities into consideration. The treatment recommendations are based on an expert consensus opinion and include conservative and operative options. If surgery is indicated, vertebral body augmentation, percutaneous stabilization and even open surgery can be used.

[The new treatment procedure of the German statutory accident insurance: From the perspective of a community hospital]. / Die neuen Heilverfahren der DGUV: Aus der Sicht eines Städtischen Krankenhauses.

The requirements of the German statutory accident insurance (DGUV) for the new treatment procedure were presented on 1 January 2013 in a new catalogue. The implementation of the certification of hospitals for the very severe injury procedure (SAV) by the DGUV should have been completed by 2014. These requirements placed high demands on trauma-oriented hospitals because of the high structural and personnel prerequisites. The background to the new organization was the wish of the DGUV for quality improvement in patient treatment in hospitals for patients with very severe occupational and occupation-related trauma by placement in qualified centers with high case numbers. No increase in income was planned for the hospitals to cope with the necessary improvements in quality. After 2 years of experience with the SAV we can confirm for a community hospital that the structural requirements could be improved (e.g. establishment of departments of neurosurgery, plastic surgery and thoracic surgery) but the high requirements for qualification and attendance of physicians on duty are a continuous problem and are also costly. The numbers of severely injured trauma patients have greatly increased, particularly in 2015. The charges for the complex treatment are not adequately reflected in the German diagnosis-related groups system and no extra flat rate funding per case is explicitly planned in the DRG remuneration catalogue. The invoicing of a center surcharge in addition to the DRG charges has not been introduced.

[Osteoporotic fractures of the proximal femur. What's new?]. / Osteoporotische Frakturen des proximalen Femurs. Was gibt es Neues?

Proximal femoral fractures in the elderly are still increasing and are almost always associated with osteoporosis. Especially the over 80-year-olds are increasing and at risk in this respect. In the treatment of these patients new knowledge has been achieved over the last years. An interdisciplinary, multimodal approach with early involvement of internists, geriatricians, anesthetists, osteologists, social workers, care facilities and outpatient trauma and orthopedic surgeons seems to generate a better outcome with fewer complications. In cases of suspected proximal femoral fracture diagnostic imaging should include a computed tomography scan of the posterior pelvic ring to detect commonly occurring fragility fractures of the lateral mass of the sacrum. Early surgery within the first 48 h has a significant positive effect with respect to general and local complications and early mortality. Medical and organizational barriers to an early operation, such as anticoagulant medication, limited capability of communication due to mental dysfunction and lack of operation capacity are continuously declining and subsequently complication rates are decreasing annually in Germany. Endoprosthetics are still associated with higher perioperative mortality than osteosynthesis (4.4 % versus 5.8 %). The innovations in the field of implants and surgical technique also contribute to these lower complication rates. While endoprosthetic treatment is still the gold standard for severely dislocated femoral neck fractures, non-dislocated or slightly dislocated fractures should be fixed with a stable extramedullary implant. For pertrochanteric fractures extramedullary stabilization can only be recommended for stable types of fractures. Every instable trochanteric fracture should be fixed with an intramedullary implant. The use of third generation nails has implicated a significant reduction of complication rates regarding cut-out and reoperations. Rotational fixing of the head-neck fragment with angular stable blade systems and the option of polymethyl-methacrylate (PMMA) cement augmentation are promising advantages that still remain to be clinically tested. Endoprosthetic treatment of pertrochanteric femoral fractures still has 3 times higher complication rate and is implemented only in exceptional situations.

[Traumatic dissection of the internal carotid artery following whiplash injury. Diagnostic workup and therapy of an often overlooked but potentially dangerous additional vascular lesion]. / Traumatische Dissektion der A. carotis interna nach HWS-Beschleunigungstrauma. Diagnostik und Therapie einer häufig übersehenen aber potenziell gefährlichen Begleitverletzung.

We report on the case of a 33-year-old male patient who was brought to the emergency room of our hospital after suffering a high-energy trauma due to an automobile accident. Besides a scaphoid fracture there were no signs of any neurological deficits. After several hours without clinical symptoms the patient developed dysarthria as the first manifestation of local cerebral ischemia based on a traumatic dissection of the internal carotid artery. Under systemic high-dose heparin therapy, fast and complete remission of all neurological disorders could be achieved. In the course of time a dissecting aneurysm developed. Temporary anticoagulation with phenprocoumon was started in the meantime and no further complications have appeared up to now. Besides presenting this absorbing case, this article highlights the diagnostic and therapeutic regime in cases of a traumatic dissection of supra-aortal arteries for rapid and adequate management of this rare but potentially dangerous complication.

[CT-findings in penetrating captive bolt injuries to the head and brain: analysis of the trauma-related CT-findings and review of the literature]. / CT-Befunde bei penetrierenden Kopfverletzungen durch Bolzenschussgeräte--Analyse der verletzungsspezifischen CT-Befunde und eine Übersicht über die relevante Literatur.

Penetrating gunshot injuries to the head and brain are rare in Germany and the rest of Western Europe. Due to the small number of cases over here no consistent diagnostic and therapeutic standards exist in this respect. Thus these kinds of injuries present a great challenge to the attending physicians. Most of these violations are a result of a suicidal attempt or an accident. Beside violations by firearms also penetrating injuries to the head and brain due to captive bolt devices, as used in slaughtery business for the "humane" killing of animals, occur from time to time. The impact on the head differs from that caused by firearms because no projectile is leaving the barrel and the used bolt, as a fix part of the device, does not remain in the affected tissue. That implies characteristic results within the radiological imaging that might be pathbreaking for the further treatment, because the origin of such a head injury is often unknown during primary care. Consequently the knowledge of these specific findings is central to the radiologist to make the appropriate diagnosis. Based on some clinical examples the trauma-related CT-findings are introduced and a short overview of the relevant literature is also given.

[Trochanteric femoral fractures: anatomy, biomechanics and choice of implants]. / Pertrochantäre Femurfrakturen: Anatomie, Biomechanik und Wahl der Implantate.

The objective of any surgical care of a trochanteric femoral fracture should be the achievement of a stable osteosynthesis that allows early full weight-bearing mobilisation of the patient, because long-term immobilisation soon becomes a vital threat to the affected patients who are usually elderly with correlating comorbidities. The anatomical references of the proximal femur and the structure of the hip joint contain some specifics that play an essential role in the incurrence of a trochanteric femoral fracture and the planning of the osteosynthesis as well. With reposition and fracture stabilisation particular importance must be attached to the collo-diaphyseal and the antetorsion angle so that they do not interfere with the functional interaction of the hip and knee joint. Uncomplex trochanteric fractures ordinarily stabilise sufficiently after reposition so that even an extramedullary implant can ensure full weight-bearing stability. With evermore distal fracture course and intertrochanteric comminution zone, rotational instability and pivot transfer of the fracture area to lateral and caudal are followed by an increase of the dislocating forces. These kinds of fractures (A2 and A3 according to the AO/ASIF classification) profit from an intramedullary and rotationally stable osteosynthesis. Basically primary total hip arthroplasty is a potential option for surgical care of a trochanteric fracture in elderly patients with relevant coxarthrosis. However this procedure can only be recommended in cases of a stable uncomplex fracture. The more the medial interlocking of the proximal femur is destroyed the more difficult it will be to primarily implant a total hip prosthesis with good offset and without a varus and rotational failure in the fracture zone.The current studies in the main show disadvantages due to increased complications in these patients, so that in cases of an unstable trochanteric fracture a primary osteosynthesis should be performed followed by total hip arthroplasty after fracture consolidation has occurred.

Fractures of the femoral neck.

The ideal treatment of the intracapsular fracture of the femoral neck still is subject of discussion. The demographic development of the population in Europe with fractures of the neck of femur being typical in the older patient, requires conclusive and stringent concepts of treatment. Adequate and patient oriented therapy should be promoted, regional differences and provisional deficiencies need to be adjusted in order to minimize the rate of complications. The guideline "Schenkelhalsfraktur" of the German board of trauma surgeons, the 'Deutsche Gesellschaft für Unfallchirurgie', and the article at hand are meant to serve as a manual for the trauma surgeon. Based on evaluated data it simplifies rational decision-making for treatment of fractures of the proximal femur. Moreover, secondary prophylaxis as well as the subsequent outpatient treatment and the social reintegration of the patients recovering from fractures of the femoral neck remains vital- ly important. After all, even with ideal treatment of the fracture more than half of the patients are impaired for a long time and one out of four permanently depends on nursing assistance.

[Balloon kyphoplasty in the treatment of osteoporotic vertebral fractures: indications - treatment strategy - complications]. / Ballonkyphoplastie zur Behandlung osteoporotischer Wirbelfrakturen: Indikationen - Behandlungsstrategie - Komplikationen.

BACKGROUND: Considering the demographic changes in the populations of Germany and Europe as a whole, the field of geriatric traumatology is gaining more and more importance within the specialty of orthopedic and trauma surgery. The high prevalence of osteoporosis in this specific group of patients poses a special challenge, with vertebral compression fractures being the by far most common osteoporosis-related fractures. These fractures present with acute as well as chronic back pain leading to severe consequences for the affected patients. Mobility and quality of life are often heavily impaired. Furthermore, higher morbidity and mortality as well as higher risk for further fractures have been proven in these patients. METHOD: Balloon kyphoplasty has become a more frequently used therapy and is now offered broadly. This treatment addresses stable fractures not involving the posterior margin of the vertebrae. With increasing application of this surgical procedure the number of complication reports is also rising. The following article gives an overview of the technique, indications and the possible complications by giving several examples from the daily practice and reviewing the relevant literature. RESULTS: Cement leakage of the treated vertebrae is the most common complication associated with balloon kyphoplasty. In almost all cases this occurs due to too early application of the cement, not having reached its optimum in viscosity. Literature research shows a percentage rate of about 9% for cement leakage. Thus, balloon kyphoplasty provides more safety for the patient than vertebroplasty, for which cement leakage rates of up to 41% are reported. Other studies report cement leakage ratios of 4-10% for kyphoplasty versus 20-70% for vertebroplasty. Overall the percentage of cement leakage is clearly increased in osteoporotic fractures compared to non-osteoporotic fractures, with the cement leaking mainly into the spinal disc space. So far, valid data in order to further explore the consequences of intradiscal cements are lacking. Most relevant for everyday practice are cement leakages that have become symptomatic. Depending on the localisation they present with dysaesthesia culminating in radicular pain or even paraplegia. Cement leakage into vessels can, depending on the amount of cement, lead to embolism of pulmonary arteries. Complications due to the surgical technique, postoperative infections, bleeding or cardiovascular complications are rare with less than 1%. The probability for symptomatic cement leakage averages about 1.3% for balloon kyphoplasty. Another discussion, for which at present there is no evidence-based verification, is concerned with the higher risk for adjacent vertebral fractures after cement augmentation of an osteoporotic vertebral compression fracture. At present the degree of osteoporosis and more important the number of osteoporosis-related fractures must be the relevant predictor for adjacent fractures of neighbouring vertebrae. CONCLUSION: Balloon kyphoplasty is a highly standardised and widely used minimally invasive procedure for stabilising and augmenting painful osteoporotic fractures of the vertebral body. When surgery is indicated carefully and is carried out subtly, the risk of complications is reasonable and the outcome is promising. Viscosity of the used cement has to be adequate and it must not be inserted with too high a pressure. A causal connection between cement viscosity and risk of cement leakage has been proven in experimental studies. During application of PMMA cement a thorough fluoroscopic monitoring must take place in order to detect cement leakage at an early stage and if necessary stop application. These procedures should be reserved for clinical centres and surgeons who are able to surgically handle possible complications such as compression of the spinal cord. On the basis of our own experience we also recommend treatment in a hospital with an integrated osteoporosis centre and consecutive treatment in specialised outpatient care. Standards in primary care as well as after treatment can be introduced thereby. Also communication with practitioner concerned with outpatient care is simplified, which leads to enduring therapeutic outcome.

[Marjolin's ulcer: malignant transformation of a crural ulcer due to posttraumatic chronic osteomyelitis]. / Das Marjolin-Ulkus : Maligne Transformation eines Ulcus cruris auf dem Boden einer posttraumatischen chronischen Osteomyelitis.

We report on the case of an 81-year-old female patient who developed a squamous cell carcinoma in a long-lasting therapy-resistant crural ulcer of the lower leg due to posttraumatic chronic osteomyelitis. Eventually the lower leg had to be amputated because of massive destruction of soft tissue and the tibia bone. Based on the desolate wound conditions plastic reconstruction by a pivoted muscle flap and surgical covering with mesh graft plastic was also necessary.The amputation stump had completely healed 6 months after surgery and the patient is fitted with an artificial limb ensuring independent mobility even outside the home. Up to the present there is no evidence of any tumor recurrence or progression.