[Extensor injuries at the zone I of the digits]. / Verletzungen des Strecksehnenapparats in der Zone I.

Injuries of the extensor tendon in zone I are frequently seen. If detected early and treated appropriately they are associated with good functional results. Open injuries are primarily treated surgically by suturing the injured tendon. Closed injuries without bone involvement are treated conservatively. In cases of bone involvement the treatment procedure is determined by the articulation and the extent of fragment displacement. This article presents the current state of knowledge on the diagnostics and treatment of extensor tendon injuries in zone I with the aim of providing treatment recommendations for the clinical routine.

[Etiology, diagnostics and classification of lunate bone necrosis]. / Ätiologie, Diagnostik und Klassifikation der Lunatumnekrose.

Kienböck's disease, also known as avascular necrosis of the lunate bone describes the slowly progressive osteonecrosis of the lunate bone with secondary development of osteoarthritis and carpal collapse. In order to emphasize the atraumatic origin of the disease, this is normally referred to as aseptic, idiopathic or avascular lunate necrosis. There are thought to be a number of factors predisposing to Kienböck's disease, such as ulnar negative variance, the shape of the lunate itself and various types of vascular anatomy. The ongoing development of radiographic techniques in recent years has contributed to a better understanding of the progression of the disease and led to a modification of the standard classifications. New sophisticated classification methods provide the basis for a differentiated treatment. This article provides an overview of the current state of knowledge about the etiology and pathogenesis as well as the clinically relevant diagnostic procedures and classifications.

[Current aspects of therapy of rhizoarthrosis]. / Aktuelle Aspekte zur Therapie der Rhizarthrose.

In patients with carpometacarpal osteoarthritis of the thumb, treatment strategies should be based on functional impairment and pain. Although X­ray imaging is an integral component of the diagnostics, it is of subordinate importance for the therapy algorithm. Conservative therapy is always the first step in the chain of treatment. The efficacy of non-operative treatment, including intermittent immobilization using splinting and the application of technical assist devices in the daily routine has been proven to achieve pain relief. The intra-articular injection of hyaluronic acid or glucocorticoids is still under debate as some good experiences in routine clinical applications are contrasted by the lack of effectiveness in randomized studies. The indications for operative treatment are fulfilled by persisting pain after exhausting all the options for conservative therapy. In this case isolated trapeziectomy is the method of choice. Suspension (interpositioning) arthroplasty is not associated with improved clinical results. More recent procedures which aim to avoid proximalization by tendon interposition, have not yet shown better clinical outcome compared to trapeziectomy alone.

[Fractures of carpal bones]. / Frakturen der Handwurzelknochen.

Fractures of the carpal bones are uncommon. On standard radiographs fractures are often not recognized and a computed tomography (CT) scan is the diagnostic method of choice. The aim of treatment is to restore pain-free and full functioning of the hand. A distinction is made between stable and unstable carpal fractures. Stable non-displaced fractures can be treated conservatively. Unstable and displaced fractures have an increased risk of arthritis and non-union and should be stabilized by screws or k­wires. If treated adequately, fractures of the carpal bones have a good prognosis. Unstable and dislocated fractures have an increased risk for non-union. The subsequent development of carpal collapse with arthrosis is a severe consequence of non-union, which has a heterogeneous prognosis.

[Correlation of Estimated and Factual Operation Time in Frequent Interventions in Traumatolgy]. / Korrelation geschätzter und tatsächlicher Operationsdauer bei häufigen Eingriffen in der Traumatologie.

BACKGROUND: The Surgical Safety Checklist (SSC) was introduced by the World Health Organization (WHO) in 2008 in order to analyse and reduce perioperative surgical morbidity. Preoperative estimation of the expected surgery time (EST) by the surgeon is an integral part of the SSC. OBJECTIVE: The aim of the present study was to correlate EST and factual surgery time (FST), to identify factors influencing the correlation between the two parameters and to collect more information about planning surgical capacity. MATERIAL AND METHODS: A retrospective analysis researched the EST and FST for plate osteosynthesis in distal radius fractures, intramedullary femur nailing or the implantation of duo head prosthesis in proximal femur fractures in our department between 06/2012 and 12/2013. RESULTS: 220 patients fulfilled the inclusion criteria and underwent further analysis (palmar plate osteosynthesis: n = 89, intramedullary femur nailing with joint involvement: n = 70, duo head prothesis: n = 61). Mean EST and FST exhibited no significant difference in any of the analysed surgical procedures. However, the correlation coefficients were comparatively low for individual surgical procedures (ρ = 0.60). The surgeon's experience had no influence on the correlation between EST and FST. CONCLUSIONS: In this study, the FST for palmar plate osteosynthesis, proximal intramedullary femur nailing and implantation of duo head prosthesis agreed well with the national average. Unexpected intraoperative complications may cause above average FST. In this case, the surgical team and coordinator must identify rapid individual solutions.

[Direct Screw Osteosynthesis of a Bennett's Fracture by Radiopalmar Incision after Gedda and Moberg]. / Direkte Schraubenosteosynthese einer Bennett-Fraktur über den radiopalmaren Zugang nach Gedda und Moberg.

BACKGROUND: Bennett's fracture is a partial intra-articular fracture, with two main fragments of the first metacarpal bone. Treatment should aim to rebuild the articular surface and to achieve early mobilisation of the thumb saddle joint. OBJECTIVE: To demonstrate the operation of direct screw osteosynthesis of a Bennet's fracture by a Gedda/Moberg radiopalmar incision in a video. PATIENT: During distortion of the thumb, a 31-year old patient suffered a Bennets's fracture, which was operated by direct screw osteosynthesis. CONCLUSION: Direct screw osteosynthesis is the method of choice to restore the articular surface and early mobilisation of the thumb saddle joint after Bennett's fracture.

Wrist motion analysis in scaphoid nonunion.

INTRODUCTION: The motion of human wrist is a complex and multidirectional process. The aim of this study was to develop a reliable and practicable method to measure motion impairment of the wrist in patients who incurred a scaphoid nonunion. A scaphoid nonunion in computed tomography as well as the consent in this study was required. METHODS: A total of nine patients with unilateral scaphoid nonunion accomplished maximal circumferential wrist movements. The wrist movements were measured with an electrogoniometer (Biometrics Ltd.). To quantify maximal wrist motion we constructed the maximal boundaries of the wrist motion from angular plots in flexion-extension (FE) and radio-ulnar deviation (RUD). We calculated the area of the circumduction envelope, the ranges of motion in FE and RUD and the main axis in wrist motion (dart-throwin-motion). The collected data were reconstructed with a custom-made MatLab program. We compared the impaired with the unimpaired side of each patient and analyzed with student's t test. RESULTS: A scaphoid nonunion significantly reduced motion ranges in flexion/extension but not in ulnar and radial deviation. The overall mobility as quantified by the area of the circumduction envelope, decreased significantly. The circumduction boundaries of the wrists showed a kidney-shaped configuration with an oblique axis from radial/extension to ulnar/flexion. CONCLUSION: Our results demonstrate that scaphoid nonunion without pain has motion deficits and may be poorly quantified with conventional manual goniometers.

Management algorithm for index through small finger carpometacarpal fracture dislocations.

PURPOSE: Injuries to the carpometacarpal (CMC) joints are rare. The most common CMC fracture dislocations occur in the ring and small finger CMC joints. The aim of this study was to review the structured diagnostic procedure and different treatment options. METHODS: We review the importance of early and correct diagnosis in CMC fracture dislocation, because it is needed to ensure pain-free hand function. Moreover, we contrast different therapeutic options, including non-operative and surgical therapy for CMC fracture dislocation. RESULTS: If a clinical suspicion for a CMC dislocation based on patient examination or radiographic findings exists, then a thin slice CT should be considered. Non-operative treatment is rarely indicated. Surgical treatment may include closed or open reduction efforts. In the case of most fracture dislocations, open reduction is recommended. Fracture fixation may be accomplished with K-wires, mini plates or screws. CONCLUSION: CMC fracture dislocations of the fourth and fifth CMC joints are uncommon and often overlooked. Primary goal of treatment is to restore normal function to the hand. Therefore, operative therapy might be the method of choice.

Uncommon carpal fractures.

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.

Treatment of a diaphyseal long-bone defect with autologous bone grafts and platelet-rich plasma in a rabbit model.

INTRODUCTION: Large bone defects are a therapeutic challenge to surgeons and are often associated with a high morbidity. The use of autologous cancellous bone graft represents an essential therapeutic option and is considered the gold standard. However, the use of platelet-rich plasma (PRP) for improving bone defect healing has been discussed controversially. The aim of this study was to evaluate the treatment of a diaphyseal long-bone defect in a rabbit model with a combination of PRP and autologous cancellous bone. MATERIAL AND METHODS: A monocortical long-bone defect in the radial diaphysis of 24 New Zealand white rabbits was filled either with autologous cancellous graft as a control group or with autologous cancellous graft combined with autologous PRP. Histomorphometrical and radiological analysis as well as quantification of platelets and growth factors were performed. The animals were euthanatized after three and six weeks according to the study arms. RESULTS: A significant improvement in bone healing was observed histomorphometrically in the PRP group in the central area of the defect zone (p <0.01) as well as the cortical defect zone (p <0.01). The radiological findings were in accordance with the histomorphometrical results. Comparing native blood and PRP, an enrichment of growth factors and platelets was detectable in the PRP. CONCLUSION: Within this animal study, the combination of PRP and autologous cancellous bone grafts improved bone healing significantly compared to the sole application of autologous bone. Therefore, further efforts should be initiated to establish the composite of PRP and autologous bone for bone healing disorders in clinical use.

Hyperbaric oxygen therapy improves angiogenesis and bone formation in critical sized diaphyseal defects.

Besides the use of autologous bone grafting several osteoconductive and osteoinductive methods have been reported to improve bone healing. However, persistent non-union occurs in a considerable number of cases and compromised angiogenesis is suspected to impede bone regeneration. Hyperbaric oxygen therapy (HBO) improves angiogenesis. This study evaluates the effects of HBO on bone defects treated with autologous bone grafting in a bone defect model in rabbits. Twenty-four New-Zealand White Rabbits were subjected to a unilateral critical sized diaphyseal radius bone defect and treated with autologous cancellous bone transplantation. The study groups were exposed to an additional HBO treatment regimen. Bone regeneration was evaluated radiologically and histologically at 3 and 6 weeks, angiogenesis was assessed by immunohistochemistry at three and six weeks. The additional administration of HBO resulted in a significantly increased new bone formation and angiogenesis compared to the sole treatment with autologous bone grafting. These results were apparent after three and six weeks of treatment. The addition of HBO therapy to autologous bone grafts leads to significantly improved bone regeneration. The increase in angiogenesis observed could play a crucial role for the results observed.

Fracture-dislocations of the carpometacarpal joints of the ring and little finger.

We report the functional and radiographic results of 16 patients with fracture-dislocations of the ring and little finger carpometacarpal joints and 23 cases with fracture-dislocations of only the little finger carpometacarpal joint treated between 2006 and 2012. The above two cohort populations of patients were treated with either open reduction and pin fixation or closed reduction and pin fixation. These patients were followed for a mean of 13 months (range 9 to 48). The DASH scores for patients with fracture-dislocations of the ring and little finger carpometacarpal joints were 6.0 and of the little finger carpometacarpal joint 7.2. We found no functional differences in term of DASH scores after treatment between patients with fracture-dislocations of only the little finger carpometacarpal joint and both the ring and little finger carpometacarpal joints.

[Giant cornu cutaneum - a grotesque manifestation of squamosus cell carcinoma in the palm]. / Cornu cutaneum giganteum - groteske Manifestation eines Plattenepithelkarzinoms in der Hohlhand.

Squamous cell carcinoma is the most common maligne primary tumour of the hand. It is almost always located on the dorsum of the hand, an occurrence in the palm is very rare. Usually these tumours are recognised early because of their clinical presentation and visible location. We report on a case in which the patient presented in our hospital only due to a massive mechanical impairment of his hand function through an oversized squamous cell carcinoma. On the basis of this case the therapeutic algorithm for large squamous cell carcinoma in the palm is illustrated and discussed.

[Therapy of triangular fibrocartilage complex lesions]. / Therapie von Läsionen des "triangular fibrocartilage complex".

The triangular fibrocartilage complex (TFCC) represents an important anatomical structure interposed between the ulnar carpus and the distal ulnar. Injuries and degenerative changes of the TFCC are of high clinical relevance and there are numerous treatment options available based on different concepts and which are being used to varying extents. The aim of this systematic review was to evaluate the effectiveness of different therapies for lesions of the TFCC. Studies on TFCC lesions were systematically reviewed, classified into evidence levels and selected according to predefined criteria. A total of 259 publications were identified as being potentially relevant and finally 35 studies could be included in the review. In addition, a survey was performed among German hand surgeons in order to identify commonly used procedures for TFCC lesions in Germany. The classification of Palmer is mostly used both in the literature and in Germany and therapeutic decisions are predominantly based on this classification. The systematic review revealed some common treatment strategies for traumatic and degenerative lesions. Generally, the level of evidence was poor for all identified publications. For this reason, evidence-based recommendations for the treatment of TFCC lesions could not be derived from the literature. There was broad consent between the results of the literature review and the survey.

[Interhospital transfer of severely injured patients in Germany. Evaluation of the DGU trauma register]. / Verlegungsrealität schwerverletzter Patienten in Deutschland. Eine Auswertung im TraumaRegister DGU.

BACKGROUND: The TraumaNetzwerk(D) DGU was founded 3 years ago and since then the majority of trauma centers have been registered and organized into regional trauma network services (TNW). Within these networks assessment criteria for transferring patients to higher level hospitals are defined. The purpose of this study was to evaluate the incidence, causes, implications and quality of care for patients with major trauma who were transferred for definitive treatment before implementation of the TraumaNetzwerk(D) DGU in Germany. PATIENT AND METHODS: The data of 19,035 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) >9 and a blood pressure documented on admission were included into the study. Data were allocated according to patients where therapy was performed completely in the primary hospital of admission (group I; n=16,033; 84.2%) and patients transferred after primary care from one hospital to another centre for definitive care (group II; n=3,002; 15.8%). Comparative parameters were the pattern and severity of injury, physiological state on admission and clinical outcome. RESULTS: Mean ISS and percentage of patients with an ISS ≥25 did not differ significantly between groups. Of the patients who were transferred to a higher level trauma centre (group II) 20.7% needed catecholamines on admission, 10.1% were in shock (blood pressure <90 mmHg) and 2.5% of the patients underwent resuscitation in the emergency department. Patients of group II had a considerably longer hospital stay (31.2±35.5 days) than patients of group I (24.8±27.1 days). Furthermore, treatment costs were significantly higher for group II (I: EUR 23,870; II: EUR 26,054). CONCLUSIONS: A relevant percentage of patients transferred from one hospital to another were hemodynamically and clinically unstable. To what extent the quality of patient transfer and therefore major trauma care is improved by the implementation of regional trauma networks in Germany remains to be seen over the next years.

[Intralesional sclerotherapy of venous malformations in the hand with methyl tetradecyl sulfate]. / Die intraläsionale Sklerosierung venöser Malformationen an der Hand mit Natriumtetradecylsulfat.

Congenital venous malformations (VM) at the hand are rare. VM consist of dysplastic venous vessels without progressive cellular proliferation. The therapy for VM is considerably different from that for vascular tumours (e. g., haemangiomas). Treatment options for vascular malformations are antithrombotic medication, local compression, resection of the VM, and obliteration of the lumina by percutaneous sclerosation. Here, the percutaneous sclerosation for the treatment of VM with sodium tetradecyl sulfate has been illustrated and discussed on the basis of 2 case reports.

[Current concepts in the treatment of mallet fractures of the distal phalanx]. / Aktuelle Konzepte in der Therapie der dorsalen Endgliedbasisfraktur.

Articular fractures of the dorsal part of the distal phalanx may result in a painful dysfunction and a bothersome deformity of the distal interphalangeal joint. For this injury multiple treatment procedures exist. We performed a survey among German hand surgeons and a review of the literature in order to present current concepts of treatment and to verify the feasibility of a randomized trial. There is a tendency to prefer conservative treatment options. The indication for operative treatment depends on size and displacement of the articular fragment as well as on subluxation of the joint. Operative techniques vary widely and the comparability of their results is restricted. Complications more often occur after operative treatment. The type of injury and the individual demands of the patient are the most relevant factors for the choice of treatment. From the results of the survey and the review of the literature, a randomized trial of conservative and operative treatment has to be considered as a challenge.

Flexor tendon repair using a new suture technique: a comparative in vitro biomechanical study.

INTRODUCTION: The purpose of this experimental study was to evaluate the biomechanical characteristics of two new four-strand core suture techniques for flexor tendon repair. MATERIALS AND METHODS: The two new suture techniques (Marburg 1, Marburg 2) are characterized by four longitudinal stitches which are anchored by a circular or semicircular suture. They were compared with three commonly used core suture techniques (modified Kessler, Tsuge, Bunnell). Fifty porcine flexor tendons were randomly assigned to one of the five core suture techniques. Outcome measures included ultimate tensile strength, maximum of lengthening, mode of failure and 1 mm gap formation force. RESULTS: The highest ultimate tensile strength was found for the modified Kessler technique (115 N). Both new techniques showed an ultimate load exceeding 50 N (57 N for Marburg 1, 54 N for Marburg 2). The Marburg 1 technique showed the highest gap resistance of all tested suture techniques. The Bunnell and Tsuge core suture techniques produced the poorest mechanical performance. CONCLUSION: From these experimental results, the new Marburg 1 core suture technique can be considered for flexor tendon repair in a clinical setting with the use of active motion protocols.