[Fractures of acetabulum and pelvic ring--epidemiology and clinical outcome]. / Epidemiologie und Nachuntersuchungsergebnisse operativ behandelter Beckenfrakturen.

From 1980 to 1995 inclusive we conducted a study on pelvic ring and acetabular fractures in Kantonspital Chur (KSC). 118 patients were studied and of these 51 had pelvic ring fractures and 67 acetabular fractures. Most of the patients with pelvic ring fractures had additional severe injuries and almost two thirds of them were polytraumatised and very shocked. One third of the acetabular patients were polytraumatised and about one fifth shocked. The length of the hospital stay was also noteworthy--an average of 47 days for the pelvic ring fractures and 30 days for the acetabular fractures. These injuries mainly affected patients in the active working age group (20-60 years of age). 56 of these had acetabular fractures and 39 had pelvic ring fractures. From 51 patients (76%) treated with acetabular fractures and 45 with pelvic ring fractures (88%) (i.e. of total 96 (81%)) we have summarised our results. About two thirds of the patients were followed up at one year and the AO documentation form completed. The remainder were sent a questionnaire. The results showed that 84% of the acetabular fracture group and 83% of the pelvic ring fractures had a good or excellent final result. Radiological complications noted in the acetabular fracture group were early signs of degenerative disease (18), a slight pelvic tilt (8), heterotopic ossification (7), early evidence of femoral head necrosis (3) and 1 definite pseudoarthrosis. Additionally 7 patients had significant motor or sensory loss. By comparison, those with pelvic ring fractures showed less in the way of radiological complications. 17 patients were seen to have a slight tilt, 9 showed initial signs of arthrosis and there was 1 pseudoarthrosis. Of the 5 patients in this group with neurological damage, 3 had difficulty in achieving an erection and 2 had urological problems. One patient who had a pelvic ring fracture had to have a caesarean section for a subsequent pregnancy.

[The floating joint injury of the lower and upper extremity--epidemiology, therapy and results in 40 extremities]. / Die Floating-Joint-Verletzung an der unteren und oberen Extremität--Epidemiologie, Therapie und Resultate bei 40 Extremitäten.

GOAL: Floating Joint Injuries (FJI) are resulting from high energy traumas and are often combined with additional neuro/vascular damage. The high incidence of severe open or closed soft tissue injuries is complicating the initial management and requires a broad surgical know-how also in minimal-invasive fixation techniques. In a retrospective analysis of our cases treated between 1980 and 1995, we try to find out some important therapeutical feedback for the future. MATERIAL AND METHODS: Of the 37 patients, 33 had a FJI of the lower (2 bilateral) and 7 patients of the upper extremity. 90% were road traffic injuries, 75% showed an open fracture situation and 25% an associated neuro-vascular injury. All fractures were stabilised within the first hours, femur, humerus and forearm in one step, the tibia in 33% in two steps (initial external fixator ...). 80% of the FJI have been reexamined after 1-2 y. RESULTS: Local complication: Femur: 4/33 (1 infection, 2 refractures, 1 non-union). Tibia: 11/33 (5 infections, 4 delayed/non-unions, 2 malalignements). Humerus: 0/7. Forearm: 1/7 (1 malalignement). 1-2 y-results: Very good-good: Femur: 26/27 (96%). Tibia: 23/27 (85%). Humerus: 4/5. Forearm: 3/5. DISCUSSION: FJI should be stabilised as soon as possible in a way allowing for early functional aftercare of the affected joint. Most complications are observed in the proximal tibia fracture because of the thin and therefore often severely (open or closed) injured soft tissue cover. Despite a staged procedure, there exists a high complication rate, which probably can be reduced in the future by the single-step use of the hybrid external fixateur.

New techniques in indirect reduction of long bone fractures.

The most important and demanding part of operative fracture treatment concerns the reduction and correct alignment of the fracture fragments, which must be gentle to the bone and surrounding soft parts to preserve the essential blood supply to all tissues. The so called indirect reduction techniques apply the principles of nonoperative fracture care (ligamentotaxis) in combination with surgical tools and a number of techniques, where by the exposure of the most critical fracture focus can be minimized. New implant designs, low contact plates, cannulated screws, unreamed nails, pinless and hybrid external fixators, are helpful adjuncts: however, the surgical technique remains of paramount importance. The essence of careful handling of the soft and hard tissues has been stressed time and again. With the introduction of biological or minimally invasive surgery, the techniques of indirect reduction have had a renaissance. A few examples are described.

[Elbow fractures in elderly patients]. / Ellenbogenfrakturen beim betagten Menschen.

Are the well established methods for operative treatment of fractures about the elbow and their results also applicable to elderly people with osteoporosis? In a retrospective study 23 of 32 patients with 33 operatively stabilized fractures of the distal humerus and the proximal radius and ulna, could be reviewed and personally questioned. The fracture type, the complications and the range of motion of the elbow were analysed and classified. Over 75% of the cases presented with a good to excellent range of motion with no increase of complications. 80% of the patients were satisfied with their result after surgical treatment of the fracture. Fractures of the elbow in elderly people with osteoporosis may be sucessfuly treated by ORIF. It appears important to start early with postoperative physiotherapy. Thereby good functional results can be expected without an increase of complications.

Thoracoscopic resection of an ectopic giant parathyroid adenoma: indication, technique, and three years follow-up.

We report on a case of a large mediastinal parathyroid adenoma resected successfully using a thoracoscopic approach. Apart from a slight hypocalcemia, which normalized within three days, the patient recovered quickly and was discharged with an excellent functional and cosmetic result. 36 months after the operation no symptoms of recurrency of hyperparathyroidism were evident and laboratory results were normal. Complete thoracoscopic removal of mediastinal parathyroid adenoma seems to be possible as demonstrated by this example.

Duration of antibiotic treatment in surgical infections of the abdomen. Blunt abdominal trauma.

Blunt abdominal trauma is associated with a low risk of injury to the microorganism-containing hollow viscera. Therefore, routine pre-operative administration of antibiotics is not necessary. Antibiotics are given intraoperatively, if laparotomy discloses transmural injury of a hollow organ and peritoneal contamination. If intervention is early (< 12 hours) and there is no evidence of purulent exudate in the abdominal cavity, the antibiotic should be considered prophylactic and not exceed one dose. Neglected injuries should be treated with antibiotics for a maximum of 5 days.

[Pneumatic tourniquet as a repositioning aid in closed intramedullary nailing]. / Pneumatische Manschette als Repositionshilfe bei geschlossener Marknagelung.

The use of an extrawide pneumatic tourniquet as a reduction aid for closed intramedullary nailing is described, even in combination with the distractor. The principle is similar to that applied in fracture bracing as described by Sarmiento: the reduction of the fragments is achieved by ligamentotaxis (traction on the limb) combined with gentle concentric soft tissue compression exerted by the inflated tourniquet. We have applied the simple, non-invasive technique in over 30 fractures with good results. Implementation of the method with an unreamed tibia nail (utn) is described as an example.

Severe skiing injuries: a retrospective analysis of 361 patients including mechanism of trauma, severity of injury, and mortality.

All ski accident patients requiring an inhospital treatment at our institute from 1984 to 1992 (n = 2,053) were analyzed retrospectively. The incidence, pattern, and severity of the injuries, as well as the 30-day mortality comparing two time slots (1984 to 1988 and 1989 to 1992) were analyzed for the 361 cases classified as "serious" injuries according to the following definitions and groupings: group 1, multiple trauma (Injury Severity Score > or = 18) and patients with multiple fractures (n = 179; group 2, abdominal or thoracic single trauma (Abbreviated Injury Scale (AIS) score > or = 2, n = 58); and group 3, isolated head injuries (AIS score > or = 2, n = 124). Serious injuries were observed in 19% in the first period compared to 16% in the second period (not significant). Two hundred thirty-eight of 361 patients injured themselves by just falling, while 117 collided with some sort of obstacle like other skiers (45), trees or rocks (27), posts, pylons, barriers (20), and moving objects (25) such as piste machines, ski lifts, automobiles, and in one case a helicopter. Six skiers were caught on the ski run by an avalanche. Comparing the two time periods, trauma circumstances did not change significantly. The number of most severe head injuries (AIS score > or = 4) increased from 11.6 to 19.3% (p < 0.05). The overall mortality increased from 2 to 7% (p < 0.05). Group 2 had the best prognosis with no mortality, while group 3 was rated worst with 8%. Skiing remains a major source of serious trauma in winter resort areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten-year follow-up after operative treatment for intra-articular fractures of the calcaneus.

Our first 16 patients with intra-articular calcaneal fractures that were managed by open reduction and internal fixation were originally reviewed on average 3 years after operation. We looked at the same patients again on average more than 10 years after surgery using the same evaluation system by the same physician. Seventy-five percent of the patients showed an excellent or good functional result. In no case was there an indication for a secondary arthrodesis. In spite of the fact that radiologically most patients showed a slowly progressing posttraumatic subtalar osteoarthritis, the subjective results (pain, capacity to work, and/or sports) at 10 years were clearly better than 3 years after surgery. These results may allow the conclusion that radiologic findings are only of limited value in the assessment of long-term results after operative treatment of calcaneal fractures. From a functional point of view and on the long-term follow-up most patients with intra-articular fractures of the calcaneus seem to profit from open reduction and internal fixation.

[Cystic lymphangioma of the mesenterial root as a rare cause of acute abdomen]. / Das cystische Lymphangiom der Mesenterialwurzel als seltene Ursache des akuten Abdomens.

Mesenteric lymphangioma is a rare, benign cystic tumor of the lymphatic system, which is commonly found in younger children and may in certain cases lead to an acute abdominal manifestation. The treatment of choice is surgical resection without damage to the blood supply of the bowel. The prognosis is generally favourable, but with increasing tumor size radical resection becomes more difficult and local recurrence more probable.

[Acute Leriche syndrome in a previously healthy woman: differential diagnosis of embolic occlusion]. / Akutes Leriche-Syndrom bei einer bisher gesunden Frau: die Differentialdiagnose zum embolischen Verschluss.

The case report describes an acute total ischemia of both legs in a young otherwise healthy woman. Based on the patient's history, the physical findings and further investigations, the differential diagnosis is discussed. The emergency procedure with a successful desobliteration of a strictly localized arteriosclerotic plaque by Fogarty catheter was followed by open thrombendarterectomy 10 days later because of a persistent stenosis. Finally the clinical manifestations of such rare occlusive disease of the aorta are discussed as well as the bilateral ischemic syndrome of the lower extremities originally described by Leriche in 1940.

[High grade liver rupture--is nonsurgical therapy feasible?]. / Die höhergradige Leberruptur--ist sie für eine nicht operative Therapie geeignet?

Although well accepted in pediatric patients, the nonoperative management of severe blunt hepatic trauma in adults remains controversial. On the basis of 3 cases with major liver injury, the rationale and prerequisites for a successful nonoperative treatment are discussed.

Osteosynthesis of 245 tibial shaft fractures: early and late complications.

A consecutive series of 245 fresh fractures of the tibial shaft, including 60 open fractures underwent operation in a 5 year period (1980-1984). Two hundred and forty-two (98.8 per cent) of these fractures were followed-up for an average of 79 months (6.5 years). Early and late complications as well as complications after implant removal were taken into account for closed and open fractures. In the 185 closed fractures, infection was observed in 1.7 per cent and delayed union in 6.8 per cent. More than 94 per cent of the closed fractures had an excellent or good late result. In open fractures (60 cases) infection was seen in 6.8 per cent, and plate fatigue with delayed union was seen in 10.3 per cent. However an excellent or good functional result was obtained in 93 per cent of the open fractures. After implant removal refractures occurred in 1.3 per cent and other minor complications in 0.9 per cent.

[Experiences with Ilizarov distraction osteogenesis with the AO spindle fixator]. / Erfahrungen mit der Distraktionsosteogenese nach Ilizarov mit dem AO-Spindelfixateur.

For correction of leg length discrepancies and for the treatment of segmental bony defects we used a modular AO-fixator knowing that the principle of the distraction osteogenesis is not dependent of a special fixation device. In our small series the AO-fixator proved to be a good alternative to the ring fixator of Ilizarov for the use on the tibia but not on the femur where we noticed a relatively high incidence of complications, especially deformities of the axis. The distraction osteogenesis has proved to be an efficient technique for limb lengthening and segmental bone transport but is high demanding for the patient and the surgeon.

[Blessings of technology? The severely injured skier--a result of technical equipment on the ski slope]. / Segen der Technik? Der schwerverletzte Skifahrer infolge technischer Einrichtungen auf der Skipiste.

In a retrospective manner we studied the injury pattern of 2053 patients following a skiing accident that required hospital admission in the year 1984-1992. Of these 361 or 18% were categorised as severely injured according to the AIS/ISS scoring system. 31% of these 361 skiers were injured by colliding at considerable speed with either a moving object (other skier, snow cat, ski-lift, etc) or fixed obstacles (trees, rocks, pilons, etc) along the ski slopes. As the most extensive injuries seem to result from collisions with the latter, fixed obstacles, it should be requested that more protective measures are being taken to prevent such severe accidents.

[Towards minimally-invasive osteosynthesis]. / Auf dem Weg zur minimal-invasiven Osteosynthese.

While the original techniques of open reduction and internal fixation have proved their efficacy during the last decades, the development of new implants and techniques is mostly based on the experience, that soft tissues and local blood supply are the most important factors for undisturbed fracture healing. Unreamed nails with interlocking plates with limited bone contact as well as soft tissue preserving techniques with minimal fracture visualization and indirect or closed reduction techniques determine the current progress in internal fixation on the way to a minimal access invasive or biological technique.

[What does the new solid unreamed tibia nail (UTN) contribute in open fractures?]. / Was bringt der neue solide Tibiamarknagel (UTN) ohne Aufbohren beim offenen Bruch?

In the field of trauma surgery open fractures of the lower leg remain an injury with a high complication rate. Bone and soft tissues must be treated carefully to avoid further damage, so that uncomplicated healing results. In the past, treatment of open fractures of the lower leg was done primarily by external fixation. Medullary nailing with reaming of the medullary canal has been widely used for shaft fractures without soft tissue damage, but when used in open fractures, the infection rate remained high. Intramedullary nailing without reaming required the development of new implants (i.e. the solid unreamed tibia nail (UTN) by AO). These new implants allow us to perform the nailing technique in open fractures of the lower leg with a low complication rate. This can be done primarily or secondarily after initial treatment with external fixation. Even patients with lower-leg open fractures may benefit from the advantages of early mobilization and partial weight-bearing after osteosynthesis with intramedullary nailing.

Tibial fractures treated with the AO unreamed tibial nail.

During the last 2 years 20 fractures of the tibial shaft have been treated with the new, 'unreamed' solid AO tibial nail (UTN). There were 13 open fractures, while four of the seven closed fractures had severe soft tissue injuries. There were nine fractures classified as 'complex' or type C according to the AO classification. All UTNs were introduced without reaming but with proximal and distal interlocking. In all, 12 fractures (five of them open) were stabilized primarily by 'unreamed' nailing, whereas the first eight (open) fractures of the series were fixed initially by an external fixator and then nailed after about 14 days. In our series no intraoperative complications occurred, and no major soft tissue problems or infections were observed. The functional results were generally good; however, fracture healing appeared to be delayed in six cases. One patient had a further operation because of non-union. Intramedullary nailing, without reaming, seems to be a reliable and safe treatment for closed and open fractures with severe soft tissue injuries as an alternative to external fixation. The use of a thin, solid nail combined with interlocking allows the stabilization even of complex fractures. Contrary to initial assumptions, the UTN can be used as a definitive implant with no need for further stabilization in the majority of cases.

[Initial results with the unreamed AO tibial nail]. / Erste Erfahrungen mit dem unaufgebohrten AO-Tibianagel (UTN, unreamed tibial nail).

It is generally accepted that intramedullary nailing in combination with reaming should be avoided in treating open fractures. However, the use of an unreamed, solid nail combined with interlocking also allows stabilization of open and complex fractures. 20 tibia fractures (65% open, 45% complex fractures) have been treated by the AO unreamed tibial nail (UTN), 12 (5 of them open fractures) by direct nailing and 8 after initial stabilization by an external fixator. In our series no intraoperative complications, no soft-tissue healing problems and no infections occurred. Thus, treatment of both open and comminuted fractures by UTN appears to be safe and generally needs no secondary stabilization.