[Posttraumatic AV fistula in the upper arm region following a foreign body injury. Sonographic diagnosis - a case report]. / Sonographischer Nachweis einer posttraumatischen AV-Fistel am Oberarm nach Fremdkörpereinsprengung.

This paper reports on the sonographic localisation of a metallic foreign body in the upper arm region and its topographic anatomic position as well as the sonographic diagnosis of an AV fistula due to a lesion of the brachial blood vessels. Ultrasonography is the method of choice for the evaluation and diagnosis of foreign body injuries and possible subsequent complications.

Subluxation of the ulnar nerve in the elbow region--ultrasonographic evaluation.

Chronic ulnar nerve subluxation out of its sulcus in the elbow region may be a rare reason for undefined chronic disorders in the medial elbow aspect. We present two cases, a 38-year-old male patient complaining of a recurrent painful disorder including paresthesia of the 4th and 5th fingers and a 12-year-old boy presenting with a palpable band in the medial elbow region without pain. Ultrasonography was performed using a high frequency linear probe in the longitudinal and horizontal planes including dynamic examination. In both patients, the ulnar nerve was completely identified, both in the transverse and longitudinal planes. The sonomorphology and echogeneity of the nerve were the same as in the contralateral limb. Ulnar nerve subluxation was diagnosed in elbow joint flexion, in both cases. It is possible through dynamic ultrasonographic examination to diagnose and document ulnar nerve subluxation for further (surgical) treatment.

[Ultrasound detection of dislocation of the ulnar nerve from the sulcus of the elbow joint]. / Sonographischer Nachweis der Subluxation des Nervus ulnaris aus dem Sulcus am Ellbogengelenk.

BACKGROUND: Chronic ulnar nerve subluxation out of the sulcus in the elbow region may be a rare reason for undefined chronic disorders in the medial elbow aspect. METHODS: We report two cases: A 38 years old male patient reports recurrent painful disorders including paresthesia of the 4th and 5th fingers. A 12 years old boy shows a palpable band in the medial elbow region without pain. RESULTS: In both patients, the ulnar nerve was completely identified, both in transverse and longitudinal planes. Sonomorphology and echogeneity were the same as in the controlateral limb. Ulnar nerve subluxation could be diagnosed in elbow joint flexion, in both cases. CONCLUSION: Dynamic ultrasonographic examination is able to diagnose and document ulnar nerve subluxation and determine further (surgical) treatment.

[Ipsilateral femoral fracture and anterior hip dislocation in a 15-year-old girl: case report]. / Ipsilaterale Oberschenkelschaftfraktur und vordere Hüftgelenkluxation bei einem 15-jährigen Mädchen.

Operative management of concomitant ipsilateral femur fracture and anterior hip dislocation has not been previously described in the literature. We report the case of a 15-years-old girl who was injured in a motorcycle accident and presented with a femoral shaft fracture and a concomitant ipsilateral anterior hip dislocation. Operative management consisted of an attempted closed reduction of the femoral fracture, which was unsuccessful; thus, an external fixator was temporarily applied. Subsequently, the hip dislocation was treated by open reduction through an anterolateral approach. Finally, the femoral fracture was securely stabilized using an unreamed femoral intramedullary nail. The postoperative course was uneventful. MRI follow-up after 6 weeks did not reveal any sign of mangled vascularization of the femoral head and radiographs demonstrated normal bony healing of the shaft fracture. Due to the fact that there is no definitive surgical strategy for this rare combination of injuries, concomitant ipsilateral femoral fracture and anterior hip dislocation is an interesting and challenging situation for the trauma surgeon which requires a subtle and exact surgical technique in order to achieve satisfying results.

The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study.

he anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Student's two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury.

[Ultrasound diagnosis in shoulder trauma]. / Die Sonographie beim Schultertrauma.

In cases of injuries to the shoulder region, ultrasonography is an ideal supplement to clinical and radiologic examination, including dynamic functional evaluation. The advantages of the method in children and adults are mainly the reduction of conventional radiographs and thus a minimum exposure to radiation. Despite the growing experience of clinicians and the development of high-resolution sonographic technology, primary conventional radiology cannot be dispensed with. Moreover, sonographic examination is rather time-consuming. Evaluation of the subacromial space and the glenohumeral joint itself is impossible in adults, and diagnosis of lesions to the labrum and the articular capsule requires a great deal of experience on the part of the clinician. Ultrasonography has gained increasing importance in the evaluation and follow-up of shoulder trauma in adults and children.

[Ultrasound diagnosis in hip trauma]. / Die Sonographie beim Hüfttrauma.

The Question is: What are the indications for ultrasonography of the hip joint following trauma, except the investigation in children, and in which cases does ultrasonography provide a useful improvement within the diagnostic cascade? Considering the limitations in evaluation of boney structures and also soft tissues (due to anatomic topography) and if CT and MRI is not available, the moin indications are: Suspected soft tissue lesions (articular effusion, bursitis, muscle tears etc.) and vascular disorders (deep venous thromboses, vascular tears and occlusions). Both in preoperative planning and in postoperative follow up, ultrasonography provides useful information (e.g. after shunt surgery or as a screening method for venous thrombosis). There is also tho option for sonographically guide punction, drainage or even treatment (e.g. block anaesthesia). Performed by an experienced clinician, ultrasonography of the hip joint has a lot of indications to gain quick information. Using this non-invasive technique, demanding and invasive diagnostic investigations (for example phlebography) may even by saved.

[Ultrasound diagnosis of the Achilles tendon]. / Sonographische Achillessehnendiagnostik.

Due to the superficial position of the Achilles tendon and the development of high-resolution probes with 7.5, 10, and more MHz, which allow the exact depiction of even very small structures, ultrasonography is the method of choice for the diagnosis of acute and chronic Achilles tendon disorders. Using sonography, both chronic achillodynia (disorders of the tendon itself, peritendinous tissue, bursa, and insertion of the tendon at the calcaneus) and ruptures of the Achilles tendon are exactly diagnosed. By sonographic examination, depiction of changes of the tendon itself (rupture, calcification, thickening) and evaluation of the peritendinous soft tissue with dynamic assessment of the gliding sheath are possible. The risk for the less experienced clinician using ultrasonographic assessment of the locomotor system is not to miss pathologic findings, but to overestimate them, due to artifacts. Sufficient knowledge of ultrasound physics as a reason for typical artifacts and the use of a standardized examination technique are necessary. However, by using high-resolution small ultrasound probes, the depiction of "problem areas" (e.g., musculotendinous junction, insertion of the tendon on the calcaneus) has become easier and more accurate.

[Ultrasound diagnosis in knee and foot trauma]. / Die Sonographie beim Knie- und Fusstrauma.

Subsequent to clinical and radiologic examination, ultrasonography is an important diagnostic method in knee and foot trauma, especially to assess pathologic conditions of the periarticular soft tissue. The main indications for ultrasonographic assessment of the knee region are fluid conglomerations, injuries of tendons, ligaments, and muscles, and vascular diagnosis. The indications for ultrasonography in the foot region are diagnosis of foreign bodies, dislocation of the peroneal tendons, lesions to the flexor and extensor tendons, and osseous capsular and ligamentous avulsions. Changes of the soft tissues include articular effusion, fluid conglomeration, ossification, and vascular lesions. Fractures involve the base of the fifth metatarsal, navicular and sesamoid bones, and epiphysiolysis. Rare indications are the search for free articular bodies and free air and the depiction of cartilaginous lesions and fractures of the knee region.

[Ultrasonic anatomy of pediatric joints]. / Sonoanatomie der kindlichen Gelenke.

The radiological work-up of joint injuries in young children can be very tedious due to the absent ossification of secondary ossification centers, which cannot be seen directly on plain X-ray images in this age group. Cartilaginous joint structures therefore cannot be distinguished from joint gaps using X-ray images in young children. High-resolution ultrasound scanning probes facilitate ultrasound studies of cartilaginous joint structures and growth plates in young children, thus providing a new and rewarding option for imaging of traumatic alterations of growing joints, especially in children whose secondary ossification centers have not yet undergone calcification processes. The use of ultrasound for evaluation of joint injuries avoids the shortcomings of ionizing radiation, contralateral joints can be examined for comparison, and functional dynamic studies can be obtained easily.

[Ultrasonography in trauma]. / Sonographie beim Trauma.

The aim of this paper is to report on the possibilities of ultrasonography of the musculoskeletal system following traumatic injuries. Subsequent to clinical and radiologic examination, ultrasonography is able to confirm the primary diagnosis by dynamic comparison with a minimal expenditure of time and costs. The size, extent, and anatomic topography of tissue lesions are depicted. This paper focuses especially on the diagnosis of fluid within joints and soft tissues, the identification of foreign bodies, the diagnosis and follow-up of fractures, the diagnosis of infections (possibility of sonographically guided puncture), and musculotendinous injuries. Furthermore, the use of ultrasonography for the evaluation of postoperative pain and complications, the preoperative planning of metal removals, and its performance during spinal surgery are discussed. This paper deals with indications and technical tips for sonography as well as methodological limitations and sources of error in the evaluation of ultrasonographic findings.

[Ultrasonographic imaging of pneumarthrosis of the knee joint--case report and experimental cadaver study]. / Sonographischer Nachweis von Luft im Kniegelenk - eine experimentelle Studie und klinischer Fallbericht.

In case of penetrating injuries near to the knee joint showing only a small skin lesion and no damage to tendons and neuro-vascular structures, opening of the joint cavity has to be taken into consideration. Besides surgical revision of the penetration canal, radiological depiction of free intraarticular air may be useful. We report the cases of two patients, who suffered from intraarticular effusion and pain two, respectively three days after a penetrating injury. In both of them, free intraarticular air in the suprapatellar region could be depicted by ultrasonographic assessment. Subsequent evaluation of radiographs showed intraarticular air already being there at the day of admittance. Performing an experimental study in fifteen cadaver knee joint specimens, the reliability of this technique was evaluated and documented. Using an injection needle, air was insufflated into the knee joints with or without previous instillation of fluid. Afterwards sonographic assessment was performed using 7,5 - 13 MHz linear probes and Siemens (Elegra) equipment. Ultrasonographic detection of pneumarthrosis of the knee joint was possible early and reliably in both of the patients reported. With sufficient experience of the clinician and adequate equipment, even singular intraarticular air blisters are detectable, especially in cases of concomitant intraarticular effusion. By ultrasound it was possible to detect pneumarthrosis with at least 0,5 ml, by X-ray with at least 2 ml. Ultrasonography proved to be a reliable diagnostic tool for the detection of free intraarticular air within the knee joint. This fact should be considered in the differential diagnosis of unclear knee joint disorders after penetrating injuries.

Sonographic evaluation of the normal hypothenar compartment musculature.

PURPOSE: We propose a standardized sonographic examination technique to evaluate the muscles of the hypothenar region and describe their normal sonographic appearance. METHODS: The hypothenar region was studied with sonography in 20 healthy volunteers using 5-12-MHz linear-array transducers. The assessment included dynamic testing. RESULTS: All hypothenar muscles could be identified in all subjects and their courses followed entirely. In addition, their function could be assessed by scanning during active and passive movements. CONCLUSIONS: Knowledge of the normal sonographic anatomy of the hypothenar region is essential for evaluation of pathologic conditions.

[Ultrasound anatomy of the shoulder joint during the growth period]. / Sonoanatomie des Schultergelenks im Wachstumsalter.

AIM OF STUDY: It is the aim of this investigation to describe the normal ultrasonographical appearance of the glenohumeral joint in childhood. METHODS: Ultrasound investigation was performed in 20 healthy children aged between 6 weeks and 19 years (median: 6 years) using 12 MHz linear probes. A dynamic examination of both shoulders was carried out. Probe positions according to standard planes were used, and attention was paid to visualise the growth regions. RESULTS: Ultrasound images of the periarticular soft tissue in children do not differ markedly from those in adults. However, there are basic structural differences of the epiphyseal and apophyseal regions. In the newborn period the proximal humeral epiphysis mainly consists of cartilage and changes to the adult shape after the appearance of three secondary ossification centers and growth plates. Interestingly, the chondral buds of the acromion or coracoid process offer additional imaging facilities for ultrasound examination in children. CONCLUSIONS: Ultrasound examination of the glenohumeral joint in children offers a more precise evaluation when compared to adults, due to the presence of additional ultrasonographical "windows" and depiction of parts of the humeral epiphysis. This imaging technique is well tolerated by children.

Primary ulnar head prosthesis for the treatment of an irreparable ulnar head fracture dislocation.

We report the case of an irreparable fracture - dislocation of the ulnar head with a concomitant fracture of the radius (Galeazzi lesion), treated by implantation of a Herbert Ulnar Head Prosthesis((R)). A stable distal radio-ulnar joint was achieved by careful dissection of a posterior soft tissue flap and accurate reduction of the radius.

[The distal radius and surrounding soft tissues--ultrasound anatomy and ultrasound pathology in the adult and child]. / Der distale Radius und seine umgebenden Weichteile--Sonoanatomie und Sonopathologie beim Erwachsenen und beim Kind.

BACKGROUND: The aim of the study was to evaluate the ultrasonographic anatomy of the distal forearm (i.e. distal radius and surrounding soft tissue) and the typical changes occurring during growth, in adults and children. MATERIAL AND METHODS: The ultrasonographic anatomy was evaluated in 10 healthy adults aged between 20 and 60 years, and 20 healthy children aged between 2 and 18 years. Particular attention was paid to dynamic examination comparing both limbs, and isolated investigations of functional tendon. RESULTS: An anatomical description of the tissues of the distal forearm was possible at all ages. During growth, secondary ossification centres and the transitional osteochondral region of the growth plate need particular consideration. DISCUSSION AND CONCLUSION: Both in children and adults, ultrasonography can provide valuable information in the evaluation of acute trauma, follow-up of fractures and osteosynthesis, suspected osteomyelitis and chronic disorders. In children, special attention must be paid to the development of the epiphyseal region, as reflected by ossification centre, growth plate and articular cartilage.

Capsular attachment to the distal radius for extracapsular placement of pins.

The aim of this study was to evaluate the anatomy of the wrist joint capsule on the distal radius. As such the extent of the joint capsule and the limits of attachment in relation to the articular surface were determined. Furthermore, the study also determined whether there was any reflection of the capsule onto the distal radius. Fifty cadaveric specimens, preserved according to Thiel's method, were assessed. After careful dissection the distance between the chondral line of the carpal articular surface and three defined points on each of the palmar and dorsal aspects of the radius were measured. In none of the specimens was there any variation in the course and extent of the joint capsule. Using external fixators for managing fractures of the distal radius, pins and wires can be placed subchondrally close to the articular capsule. The risk of intraarticular infection, due to pin tract infection in intraarticularly positioned pins, is very low.

[Diagnostic value of conventional roentgen image, computerized and magnetic resonance tomography in acute sprains of the foot. A prospective clinical study]. / Diagnostische Wertigkeit von Nativröntgen, Computer- und Magnetresonanztomographie beim akuten Hyperflexionstrauma des Fusses. Eine prospektive klinische Studie.

In order to gain satisfying results in the treatment of acute hyperflexion trauma to the foot, it is absolutely necessary to achieve an exact primary diagnosis because injuries to the tarsometatarsal joint are frequently missed primarily. Aim of this prospective clinical study was to evaluate the diagnostic reliability of conventional radiography, CT and MRI compared to each other. 75 consecutive patients after hyperflexion trauma to the foot were included. There were 47 males and 28 females with a mean age of 38 years. After admittance, pa-, lateral and 45 degrees oblique radiographs were taken as well as stress views in comparison to the contralateral foot. Furthermore, CT and MRI were performed in any patient. By conventional radiography, 48 metatarsal and 24 tarsal fractures were diagnosed as well as 17 cases of malalignment of the Lisfranc joint. Stress radiographies were not able to provide a more accurate diagnosis. By CT scans, however, 86 metatarsal and 74 tarsal fractures were detected. Moreover, we found malalignment in 31 and bony avulsions of Lisfranc's ligament in 4 patients. By MRI, finally, 85 metatarsal, 100 tarsal fractures and 31 cases of malalignment were diagnosed. Additionally, partial or complete tears of Lisfranc's ligament were depicted in 22 patients. The present study could clearly show the superiority of CT and MRI to conventional radiography in diagnosis of bony and ligamentous disorders of the Lisfranc joint. Therefore, extended diagnosis has to be demanded in all cases of hyperflexion trauma to the foot.

Sonographic evaluation of the thenar compartment musculature.

The thenar region was studied with ultrasonography in 10 healthy volunteers. All thenar muscles could be identified and their course followed entirely. In addition, their function could be assessed by scanning during unresisted or resisted active movements. Standard approach, normal appearance, and dynamic tests for each muscle are described.