[Creutzfeldt-Jakob disease in a dura transplant recipient: first observation in Austria]. / Creutzfeldt-Jakob-Krankheit bei einem Dura-Transplantat-Empfänger: Erstbeobachtung in Osterreich.

Dura mater grafts can lead to Creutz-feldt-Jakob disease (CJD) as late complication (dura-CJD). So far 61 dura-CJD cases have been described worldwide. We report here the first dura-CJD case in Austria. A 50-year-old man had a traumatic open frontobasal skull fracture with tearing of dura mater in 1977. Reconstructive surgery used Lyodura (braun Melsungen AG, BRD). Lyodura was derived from pooled cadaveric dura. Ten years after the dural transplantation, the patient developed gait ataxia, paresthesia of both legs, myoclonus and visual disturbance. CT was unremarkable. EEG showed diffuse unspecific changes. The patient died 5 months after onset of disease. Neuropathological examination showed typical histopathology of CJD. Immunocytochemistry detected typical type prion protein (PrP) deposits and scattered PrP plaques in cerebral and cerebellar cortex, basal ganglia and spinal cord. Cerebellar white matter contained numerous PrP miniplaques. This pattern is unusual for sporadic CJD, but is similar to that in CJD after human growth hormone treatment. In our patient and 13/19 earlier described cases with dural graft covering the cerebrum ("central inoculation"), cerebellar disturbance was the initial symptom. Therefore, cerebellar signs are characteristic as initial symptoms in iatrogenic CJD, irrespective of central (cerebral dura mater graft) or peripheral inoculation (e.g., human growth hormone treatment). These data do not support the hypothesis that primary cerebellar symptoms in iatrogenic CJD after peripheral inoculation reflect migration of the infectious agent from the periphery via spinal cord and cerebellum to the cerebrum.

[Frequent injuries of the shoulder joint]. / Häufige Verletzungen des Schultergelenkes.

This article tries to identify the most frequent osseous lesions in the shoulder complex found in the all day routine of a trauma center or trauma unit. It discusses the clinical diagnosis, the most typical radiological findings and the current concepts of treatment. This report is designed mainly to help the general practitioner outside the hospital community.

Septic focus localized by determination of arterio-venous difference in neopterin blood levels.

We describe a case of a 38-year-old female accident victim who was admitted to the trauma hospital with an ISS of 66. Successful emergency treatment (including amputation of the left leg) and 4 weeks of intensive care led to an overall improvement so that the patient was extubated on day 29. Throughout this period neopterin was measured routinely 3 times a week and correlated well with the clinical course. At the end of the fifth week massive lung impairment and all clinical signs of sepsis appeared. Neopterin values increased dramatically up to 200 nmol/L. However, no abnormal findings were revealed by X-ray, contrast fluoroscopy, or sonographic imaging. To examine the amputation site more closely, simultaneous determination of neopterin in samples from the vena and arteria femoralis was performed. We found a 50% higher level in the venous blood (300 vs. 200 nmol/L). This was regarded as evidence for a hidden focus. Immediate surgical intervention revealed an abscess, which proved to be Pseudomonas aeruginosa positive. After adequate treatment the patient recovered quickly. In this case neopterin was not only helpful in monitoring the septic episodes of the patient, but proved essential for the detection of a septic focus and the risk of explorative relaparotomy could be omitted.

[Simultaneous dislocation-fracture of both ends of the clavicle]. / Simultane Luxationsfraktur beider Schlüsselbeinenden.

A case of simultaneous dislocation-fracture of both ends of the right clavicle in a 17-year old patient is being described. Treatment consisted in operative reduction of both injuries. The sterno-clavicular joint was stabilized by a transarticular K-wire, the acromioclavicular injury was treated by extraarticular tension-band-wiring. Healing was without complications and the result 37 months after injury was excellent.

Injuries to the cervical spine causing vertebral artery trauma: case reports.

In four patients with lesions of the vertebral artery resulting from cervical spine injury, two were due to unilateral facet dislocation and two to fractures of the dens. There was one arterial occlusion with minor vertebrobasilar symptoms, and an arterial lesion with thrombosis causing embolic occlusion of the basilar artery with lethal outcome. In one patient a fresh fracture of the dens caused dislocation of C1/2 with reversible occlusion of the left and stenosis of the right vertebral artery, resulting in unconsciousness. In a patient with pseudarthrosis of the dens an aneurysm of the vertebral artery could be detected. Cerebellar or cerebral symptoms associated with cervical spine injury should be investigated by vertebral angiography because vertebral arterial injury may be more common than suspected and may simulate traumatic brain damage.

[Thrombosis prevention with heparin/dihydroergotamine versus heparin/Sintrom in Ender nailing of pertrochanteric fractures]. / Thromboseprophylaxe mit Heparin/Dihydroergotamin versus Heparin/Sintrom in Ender-genagelten pertrochanteren Frakturen.

The effect of either (randomized) Heparin/Dihydroergotamine (HDHE) or heparin-acenocoumarin (Hep/S) on the incidence of deep-vein thrombosis in the legs was studied in 212 women of more than 60 years of age with hip fractures. All patients were screened with the 125-I-fibrinogen uptake test (FUT) confirmed by a bilateral ascending venogram upon positive FUT. This revealed good sensitivity and specificity (85/84%) for the FUT. Deep vein thrombosis developed in 37.6% of the HDHE group and in 59.1% of the Hep/S group which was significantly different (p less than 0.005). The calculated thrombosis risk was significantly diminished (by 38% - p less than 0.005) in the HDHE group. Therefore we conclude that in traumatology Heparin/Dihydroergotamine seems to be the prophylaxis of choice.

Thromboembolic prophylaxis in hip fracture.

The effect of either heparin-dihydergot or heparin-acenocoumarin on the incidence of deep-vein thrombosis in the legs was studied in 181 women undergoing Ender nailing for intertrochanteric fracture of the femur. All the patients were screened with the 125-I-fibrinogen uptake test, confirmed by a bilateral ascending venogram. Deep-vein thrombosis developed in 40 per cent of the heparin-dihydergot group and in 61 per cent of the heparin-acenocoumarin group (p less than 0.015).

[Post-traumatic hemarthrosis of the knee joint--determination of the cause by arthroscopy (author's transl)]. / Der posttraumatische Haemarthros des Kniegelenkes--arthroskopische Abklärung der Ursachen.

Between December 1977 and February 1981, a series of 70 patients was examined because of an unclear hemarthrosis, the source of hemorrhage was determined by arthroscopy. In our opinion a hemarthros of the knee joint is not clear if the lateral ligaments are stable, no drawer can be loosened at an angle of 90 degrees, and if the X-ray radiograph does not clearly show a fresh fracture. In most cases, the symptom of uncertain hemarthros was provoked by a banal trauma hardly to reconstruct. Due to the violent pain caused by the thick effusion, the patients consulted the doctor early and had partly been pre-examined by several doctors. In all cases, the joint was described to possess stable ligaments and X-ray examination did not show any clear fracture sign. The thorough examination under anesthesia made by the author resulted in a suspicion of a ligament in 43% of the examined joints, however, the subsequent arthroscopy showed a rupture of the anterior cruciate ligament in 70%. A cartilage/bone lesion was found in 30%, a rupture of the posterior cruciate ligament, however, only in 5,7%. In two cases (3%), the hemorrhage was caused by a fatty body lesion or the rupture of an adhesion. In 41% of the patients we found severe combined lesions of the anterior cruciate ligament and the meniscus or cartilage lesions. In 56 patients, i.e. 80%, the lesion was so severe that they had to be treated by surgery. In 11%, we thought an immobilization by plaster cast to be sufficient. Only six patients i.e. 9%, had neither to be operated nor immobilized. The hemarthros of the knee joint which occurs even after small accidents is caused by severe inner lesions of ligaments and cartilages. In more than 50% of all cases, these lesions cannot be diagnosed even by careful clinical examination under anesthesia and special X-ray examination methods. With adequate skill and experience, however, arthroscopy allows an exact diagnosis in almost 100% of all cases. It is therefore the patient's interest to clarify by arthroscopy every case of unclear hemarthrosis.

Anterior plate stabilization for fracture-dislocations of the lower cervical spine.

In fracture-dislocations of the cervical spine with associated injury to the supporting posterior elements, anterior interbody bone block or dowel fusion does not give sufficient stability to the involved area. Additional fixation using an H- or HH-ASIF plate has been employed over the past 2 years in 26 cases. All patients had achieved solid fusion of the involved region of the cervical spine without recurrence of the deformity. None has required additional external plaster fixation. In 21 patients with neurologic involvement, recovery (complete, marked, or partial) occurred in 14; there was no recovery in four; deaths in three patients were late and in two were not related to their operations.

[Splenectomy for traumatic rupture of the spleen in childhood and its sequaelae]. / Splenektomie im Kindesalter aus traumatischer Ursache und ihre Folgen

This study was undertaken in order to assess the clinical and immunological consequences of splenectomy for traumatic reasons in childhood. Immunological testing of 22 persons 1 to 20 years subsequent to removal of the spleen for traumatic rupture between the ages of 3 and 6 revealed diminished or absent agglutinins in 10 cases and diminished or absent opsonins to E. coli in 16 cases. All patients were in good health and no clinical evidence of increased susceptibility to severe infections was found postoperatively. It is, therefore, assumed that the diagnosed defects had been compensated for by other immunological mechanisms. In contrast to the opinions of other authors, it is concluded that splenectomy in childhood between the ages of 3 and 6 does not appear to carry greater risks than in later years.