External fixation of lower limb fractures in children.

26 children with 29 lower limb fractures, between the age of 2 and 15 years, were treated with an external fixator. The average time to union and removal of the fixator was 71 days for femoral and 73 days for tibial fractures. Complications included pin problems in nine cases, two devices had to be replaced with a cast and one refracture. Leg length discrepancies were noted in five children and radiological malalignment in three. We recommend external fixation for all femoral shaft fractures and all open or dislocated tibial and tibia and fibula fractures beginning at the age of three to adolescence.

Complications in the use of diathermy.

Electrical burns in diathermy rarely occur but are not always recognized as such or thoroughly investigated. The literature has proved to be very sparse in terms of reference to complications, although prolonged courses of treatment are required in individual cases. This paper analyses and discusses the problems of burns associated with diathermy that occurred in seven patients.

[An unusual case of gunshot wound to the head]. / Ein besonderer Fall einer Kopfschussverletzung.

We are going to present a special case of head injury caused by a gunshot. In this case it resulted in a fracture of the skull, but the bullet did not penetrate the skull. It was deflected by the bone, leaving the body at an angle. But bone fragments, acting as secondary bullets, penetrated the brain. In spite of a massive cerebral trauma and brain injury, no retrograde amnesia could be diagnosed. The patient recovered to such an extent, that he could return to his former job. Special characteristics of head injuries caused by bullets will be referred to.

Lower infection rate after interlocking nailing in open fractures of femur and tibia.

Between 1975 and 1987 91 patients with Types I and II open lower extremity fractures (66 tibia and 25 femur) have been treated surgically with interlocking nailing at the I University Clinic of Traumatology, and the Trauma Department of Wilhelminenspital, Vienna. Our infection rate of 1.2% was found to be lower than figures cited in the literature. Conscientious indication of the interlocking nail in these circumstances cannot claim all the credit for these results, the appropriate preoperative management with preventive antibiotics together with excellent operative technique have to be taken into consideration as well. Reviewing these results, we have adopted the opinion that the interlocking nail, when selectively used in the hands of an expert, can be recommended not only in closed fractures but also in Types I and II open fractures of the femur and tibia, provided that the special principles of treatment in a particular case are not neglected.

[Primary stabilization of open fractures of the lower extremity with the interlocking nail--the results of a study of 91 patients]. / Die primäre Stabilisierung offener Frakturen an der unteren Extremität mit dem Verriegelungsnagel--Ergebnisse einer Untersuchung an 91 Patienten.

The authors report on a series of open fractures (Type I and Type II) on the lower extremities of 91 patients, treated at the I. University Clinic of Traumatology, Vienna and at the Traumatologic Department of Wilhelminenspital, Vienna from 1975-1987. There were 25 open femoral- and 66 open tibial fractures. We have seen 60% Type I and 40% Type II fractures on the femur as well as on the tibia. 74% of the patients were male. The patients' ages ranged from 15 to 92 years with a median of 32 years. The main fracture type was the comminuted fracture with over 50%. In contrast to the references in the literature (9, 11, 21) we noticed an infection rate of only 1.2%. 96% of the operated and checked up patients received bone union with the interlocking nail. We cannot in any way attribute these results solely to the used implant. Conscientious indication in the application of the interlocking nail, an exact preoperative management with prophylactic antibiotic as well as an excellent operative technique are also taken into consideration. The choice of the static interlocking nail (73%) after the closed reduction (80%) of these open fractures is supposed to be a measure against infection. Due to these results we are of the opinion that the interlocking nail when selectively used in the hands of an expert can be recommended not only in closed fractures but also in Type I and II open fractures of the femur and the tibia as long as the special principles of treatment are not neglected.

[Tendon injuries of the knee joint extensor mechanism]. / Sehnenverletzungen des Kniegelenkstreckapparates.

Diagnosis, aetiology and therapy of injuries to the extensor mechanism of the knee joint are presented. 22 cases of ruptures and discisions of the lig. patellae or the quadriceps tendon could be reexamined. All cases but one, with operation within the first week after injury, suturing with absorbable or non absorbable material, immobilisation for 6 weeks and following physical therapy, had a good functional result. No rerupture occurred. In one case a limitation of the range of movement had to be seen afer an open discision of the lig. patellae. After transposition of the tuberositas tibiae, discission of the scares and functional therapy a good result could also be achieved.

[Subtotal lateral foot dislocation with osseous fracture of the posterior syndesmosis]. / Luxatio pedis subtalo lateralis cum Exfract. ossea syndesmosis posterioris.

This case was interesting because of the type of injuries--combination luxation of the talocrural and subtalar joint, endochondral fracture of the talus, and severe injury to the soft tissue. Although a careful study of the literature was made, nothing was found that dealt with similar injuries, including fracture of the posterior syndesmosis. The pathomechanism included motion phases that interfered with one another and merged. This injury is caused by a combination of luxation of the talocrural and subtalar joint, with forces acting in both radial and tangential directions. We worked out the pattern of injury, decided upon the treatment of choice, and summarize here some of the information found in the literature.

[Initial experiences with a new mounting system for AO external fixation]. / Erste Erfahrungen mit einer neuen Montageanordnung für den AO-Fixateur externe.

The advantage of the herewith presented v-shaped unilateral external fixator lies in the combination of the stability characters of the v-shaped mounting with the convenience of the unilateral lay-out. The combination of the advantages of two mounting schemes that have already been clinically tested, suggest that these should be integrated into a single construction system. Both, the surgery procedure and the dynamics of the system have been described in detail. The clinical case studies document the first experience with this new mounting scheme.

[Surgical stabilization of femoral fracture following implantation of straight shaft prostheses]. / Die operative Stabilisierung der Oberschenkelfraktur nach Geradschaftprothesen-Implantation.

Fractures of the shaft of the femur at the level of a hip endoprosthesis may cause serious problems in regard to operative stabilization as well as to bony union. The therapeutic procedure and the clinical course are described in two patients. The technical procedure is demonstrated on a plastic femur model. The advantages of cementless implantation of the femoral shaft are discussed in view of this complication.

[Occipitocervical fusion in metastasis to the dens]. / Okzipitozervikale Fusion bei Densmetastasierung.

Metastasis of the cervical spine or pathological fracture respectively presents a demanding therapeutical task. Pain and threatening, neurological deficit require an active action, even if curative treatment is unlikely. The remaining survival time after appearance of osseous metastasis is on the average nine to twelve months and justifies an operation, especially in view of psychosocial consequences for the patient. We are describing the unique case of cervical spinal manifestation after liver transplantation because of primary hepatic cancer.

[Prevention of thromboembolism in accident surgery--angiospastic complications with DHE-heparin. A multicenter study]. / Thromboembolieprophylaxe in der Unfallchirurgie--angiospastische Komplikationen bei DHE-Heparin. Eine multizentrische Erhebung.

In immobilized patients different drugs are used for thromboembolism prophylaxis. Arterial vasospastic complications have recently been reported after Heparin-DHE. In our clinical observation five of these cases were treated. A multicenter study was performed in 82 Austrian trauma units investigating the incidence and outcome of complications of Heparin DHE prophylaxis. 147,290 patients had different drugs for thromboembolism prophylaxis. 61,092 got Heparin-DHE. Complications could be observed at 142 patients but only in the group receiving Heparin DHE. 135 cases were treated conservatively (amputation of limbs became necessary in seven patients). In seven other cases immediate operative exposure of the vessels and balloon catheter dilatation was successfully performed. Vasospasm occurred only in patients with Heparin DHE prophylaxis. It is important to realize this possibility, so that early therapeutic measurements can be taken to avoid unnecessary permanent ischaemic damages and limb amputation.

[Static stress of tibiofibular syndesmosis]. / Zur statischen Belastung der Syndesmosis tibiofibularis.

The tension-patterns of the tibiofibular syndesmosis during stance and push-off phases of gait are still unknown. Therefore a strain-gauge study was done, using an anatomically prepared human leg with the syndesmosis removed and the gauges fixed on the bone, avoiding bending influences. Syndesmotic tension forces measured under sequential axial loading up to 500 N in neutral ankle position were 6.5 N for anterior and 10 N for posterior ligaments under maximum load. With 10 degrees ankle dorsiflexion and no load applied about 5 N of tension were measured in each of the anterior and posterior ligaments. Application of axial load under same conditions resulted in a decrease to negligible tension in the anterior ligament and an increase of tension in the posterior ligament. In evaluating the load tests, which were done in 10 degrees dorsiflexion and the so-called neutral-zero-position of the ankle, we found that our data correlated well with the elasticity and tearing resistance, measured by Sauer. According to the pathomechanics of trauma exact measurements of these forces in the weightbearing ankle are of interest for postoperative treatment of ankle fractures.

[Management of combination injuries of the femur shaft and femoral neck fractures with a locking nail. Multicenter study of 26 cases from 4 trauma clinics]. / Versorgung von Kombinationsverletzungen von Femurschaft- und Schenkelhalsfrakturen mit Verriegelungsnagel. Multizentrische Studie von 26 Fällen aus vier Unfallkliniken.

Twenty-six patients with femoral shaft- and ipsilateral neck-fracture, treated in four different hospitals, have been analysed. The majority of these fractures was treated by a distally locked dynamic nail and fixation of the femoral neck by two or three lag-screws. In some cases a "contralateral" nail with a proximal locking screw in the femoral neck was used. Results are excellent without non-union or mal-union. Only one case of avascular necrosis occurred in an 68 years old patient. Interlocking intramedullary nailing certainly has its place in the treatment of associated femoral shaft- and neck-fractures. This closed method presents a stable fixation and permits early mobilisation and joint-function.

[Study of the stability of current plaster substitutes]. / Stabilitätsuntersuchung aktueller Gipsersatzstoffe.

In connection with company independent test series the clinically required usefulness of four different modern plaster substitutes were examined. A comparison of breakage resistance, deformation and relation of price versus stability of plaster bandages were considered. The advantage of using these materials, especially in case of prolonged cast immobilization, is-despite of higher financial costs - more appropriate because of lower weight, increased durability and hygienical comfort for the patients.

[Comparative study of stability following the nailing of fractures of the femur shaft. An experimental study with cadaver bones]. / Vergleichende Stabilitätsuntersuchung nach Nagelung von Frakturen des Oberschenkelschaftes. Eine experimentelle Studie am Leichenknochen.

Intramedullary osteosynthesis is preferred for shaft fractures of the long bones of the lower extremities because it generally results in early weight-bearing stability, allowing full function of the leg and rapid rehabilitation. Only transverse and short oblique fractures near the middle of the medullary cavity can be sufficiently stabilised using intramedullary nails alone. Additional stabilising aids such as cerclages or interlocking nails must be used for all other types of shaft fracture. There are no previous studies of stability that make a comparison between conventional intramedullary nails and interlocking bolts with or without cerclages. This paper set out to clarify therapeutically relevant questions in the light of a comparative study of stability. To this end a comparative experimental investigation was carried out using femora from human cadavers to determine whether or not either method of intramedullary osteosynthesis attained the stability of the intact bone. The study also set out to establish the relevance of the type of fracture, localisation and mode of fitting to the resulting stability of the osteosynthesis. A comparison was also made of the stability in the bone-implant complex of two different commercially available interlocking nails. Finally, the question was raised as to the clinical conclusions that can be drawn from the present investigation. The bone-implant complex represented by a fracture of the femur secured by an interlocking nail is a complex mechanical system. An optical measuring arrangement was developed so as to ensure that this system was not subject to any interference resulting from the method of measurement. This consisted of a laser light source which projected a beam of light parallel to the axis of the femur shaft across the fracture onto a mirror system attached to the bone. The rays of light reflected from the mirrors were recorded as dots of light on measuring screens. A load of up to 1000 N was gradually applied along the bearing axis, and the resulting changes in the position of the parts of the osteosynthesised fracture relative to one another indicated by the deviation of the beams of light. The axial tilt and rotation of the pieces of bone could be determined from the coordinates of the dots of light. The stability of nailed transverse femoral fractures (n = 6), short oblique fractures (n = 6), long oblique fractures (n = 6) and comminuted fractures (n = 6) was determined and compared with the deformation of intact femora. The stability of all types of osteosynthesis was several times less than that of the intact bones.(ABSTRACT TRUNCATED AT 400 WORDS)

[Stress to the lateral ankle joint ligament complex in confined imaging with an a.-p. radiation path]. / Die Belastung des lateralen Sprunggelenkbandkomplexes bei gehaltenen Aufnahmen im a.-p. Strahlengang.

Physical definition and laws of rotating systems will be stated. The application for supination in ankle joint shows, that lever action increases the force applied up to four times in case of stress X-rays in the a.-p. view. As quoted in literature, the test power of up to 25 kp means a loading of the lateral collaterals up to 100 kp. An additional iatrogenic rupture of already traumatically partially sprained structures seems possible. The critical judgement of five different methods producing stress X-rays of the ankle joint shows the weak points of this test system. Beck's method seems sufficient for precise statements and judgement of the stress X-ray tests without endangering ligaments so far unsprained.

[Arterial spasm caused by administration of DHE-heparin in a tibial fracture]. / Arterienspasmus unter Gabe von DHE-Heparin bei Unterschenkelfraktur.

A 38 years old white woman suffered a tibial fracture which was primarily managed by traction therapy. 3 X 5000 IU Heparin DHE was given as prophylaxis against thromboembolism. 6 days after administration of the drug a severe arterial spasm (documented by arteriography) with high-grade ischaemia of the left leg occurred. Successful arterial dilatation with a Fogarty catheter within the entire infragenual region down to the foot arteries was performed and consecutively during the same anaesthesia the intramedullary stabilisation using an interlocking nail was also performed. 8 months later the patient was free from symptoms, the fracture had healed, and the function was unrestricted. All pulses were palpable and the ultrasound Doppler index was greater than 1. In conclusion, we recommend in arterial spasm during heparin DHE therapy, immediate operative exposure of the vessel--if possible under local anaesthesia--and adequate vascular surgery as balloon catheter dilatation.