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.

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.

The floating shoulder: ipsilateral clavicle and scapular neck fractures.

In ipsilateral mid-clavicular and scapular-neck fractures, the mechanical stability of the suspensory structures is disrupted and muscle forces and the weight of the arm pull the glenoid fragment distally and anteromedially. To prevent late deformity we recommend internal fixation of the fractured clavicle by a plate and screws. We treated seven patients with this unusual injury; all achieved an excellent functional result without deformity.

Treatment of supracondylar-intracondylar fractures of the femur using the dynamic condylar screw.

Forty-nine distal femur fractures were treated with the Dynamic Condylar Screw (DCS) between 1982 and 1985. The results in 35 fractures were reviewed in 32 patients with an average follow-up of 27.5 months. Functional results were graded using a stringent traumatic knee rating scale and Schatzker's criteria. The overall results were seen to be excellent to good in 71%, and excellent to good to fair in 83% of the cases. Using Müller's fracture classification, the less comminuted fractures were found to have better results than those with more comminution. Ease of insertion, the ability to obtain good fixation even in osteoporotic bone, and the capability of revising non-unions with a simple plate exchange are distinct advantages of the DCS over the 95 degree condylar blade plate. Medially placed iliac crest bone grafting should be performed if there is proximal extension of the fracture.

Esophagectomy without thoracotomy: is there a risk of intramediastinal bleeding? A study on blood supply of the esophagus.

In transhiatal blunt esophagectomy there is surprisingly little bleeding if no adjacent great vessels are torn. This prompted an investigation by new injection techniques and corrosion on the human esophageal vasculature three-dimensionally. The three main arterial sources were confirmed: the superior thyroid artery, bronchial arteries at the level of the carina, and the left gastric and splenic artery. Two facts became obvious that were not appreciated hitherto. All major vascular trees divide into minute branches at some distance from the esophagus. Those branches go on to form a dense submucosal interconnected network. It appears that such small extraesophageal branches, when torn, will have the benefit of contractile hemostasis. Previous claims made that essential nutritional vessels arise from intercostal phrenic arteries or the aorta directly could not be confirmed. These findings would confirm blunt esophagectomy for tumors within the wall of the organ as a relatively safe procedure in terms of bleeding hazards.

The operative treatment of elbow dislocation in the adult.

Operative treatment of traumatic dislocation of the elbow joint is indicated when there is proved gross instability or osteochondral fractures and loose bodies, or both. We performed a capsule-ligament repair in twenty-eight patients, and no cast was applied postoperatively. Satisfactory results were achieved with an average follow-up of two and one-half months. In all patients postoperative assisted range-of-motion exercise was begun after the operative wound and healed. The functional outcome depended on the osseous lesions involving the articular surface and on the time interval between the accident and the operation.

The operative treatment of intra-articular fractures of the lower end of the tibia.

Intra-articular fractures of the lower end of the tibia are an interesting challenge. The best functional results in the past series were observed in patients treated according to the following 4 sequential principles: (1) reconstruction of the correct length of the fibula; (2) anatomical reconstruction of the articular surface of the tibia; (3) insertion of a cancellous autograft to fill gaps left by impaction and comminution; (4) stable internal fixation of the fragments by a plate placed on the medial aspect of the tibia. Seventy-five cases had a good or excellent late result (on average 6 years postoperatively) in 70% as compared to 43% to 55% in cases treated by closed and/or open methods.

Results after internal fixation of comminuted fractures of the femoral shaft with DC plates.

A series of 131 comminuted fractures of the femoral shaft in 123 patients were externally fixed by the ASIF plating method. Of the 126 fractures in 118 patients, that could be reviewed one to 3 years postoperatively, 115 of 92% presented a good functional result. The most common complication was a fatigue fracture of the plates which, however, only occurred after biomechanically faulty application, without medial buttress of the bone, and in the absence of a cancellous autograft. The application of a bone graft therefore appears mandatory in all fractures of the femoral shaft that are fixed by a plate.

[Traumatic hemobilia. A case report (author's transl)]. / Posttraumatische Hämobilie. Ein kasuistischer Beitrag.

A case of traumatic hemobilia is reported. After ligation of the left hepatic artery and additional dearterialisation a third bleeding period occured due to a porto-hepatic communication, diagnosed by a transumbilical portography. A left hepatic lobectomy was finally necessary to achieve hemostasis. This case demonstrates that a selective artery ligation for the treatment of hemobilia is only successful if a complete dearterialisation is performed at the first operation. Furthermore a porto-hepatic communication may require partial hepatectomy.