Scintimetric evaluation of remodeling after bone fractures in man.

In a review of bone scans of 2000 post-trauma patients, the following rules of bone remodeling after fracture were found: different bones behave differently; lesions in the vicinity of joints show an early and high accumulation of the tracer within the first days after the trauma, whereas fractures of the axial skeleton and shafts of long bones sometimes need up to 12 days to appear on scan; all except skull fractures demonstrate a steady rise of accumulation intensity compared to normal bone for 2-5 wk; the steepness of increase and time of maximum differ significantly for different fracture sites. Calculating a ratio 24:4 hours after injection helps differentiate fractures from soft tissue lesions since fresh fractures show a ratio > 1:1. We found no clinically relevant dependence on sex and age. The scintigraphic/scintimetric behavior of fractures is reproducible and predictable, adding specificity to the well-known high sensitivity of bone scans.

[Clinical relevance of whole body skeletal scintigraphy in multiple injury and polytrauma patients]. / Die klinische Relevanz der Ganzkörperskelettszintigraphie bei mehrfachverletzten und polytraumatisierten Patienten.

The provision of care to polytraumatised patients is a particular diagnostic and therapeutic challenge. The examination data of 162 polytraumatised patients were retrospectively investigated to determine the diagnostic gain provided by skeletal scintigraphy with 99mTc-HMDP. It was found that every fresh fracture (with the exception of fractures to the skull) led to a scintigraphically clearly demonstrable remodelling reaction within ten to 14 days. The timing of the examination was of decisive importance for the information yield. Not until about the tenth to 12th day did also those fractures that showed a delayed uptake show adequately signal-intensive areas of uptake in the scintigram. Typical examples were additional fractures of the spine and pelvis in patients immobilised by fractures of the limbs. At this time, with the aim of skeletal scintigraphy, an additional fracture was found in half of all patients, and was subsequently verified radiologically. Additional diagnostic information is independent of the ability of the patient to cooperate. This was of particular importance in the case of the very severely injured and old patients. Skeletal scintigraphy can be employed with equal efficacy to reliably exclude bone injuries. Thus, skeletal scintigraphy if of particular significance in the determination of the extent of bone injury in polytraumatised patients. This applies in particular to the preparation of an expertise. Thus, as in the case of staging of malignomas, the additional performance of bone scanning twelve to 14 days after traumatisation should form part of routine care offered to polytraumatised patients.

[The age dependence of traumatically induced bone remodeling as studied in the bone scintigram]. / Untersuchungen zur Altersabhängigkeit der traumatisch induzierten ossären Umbaureaktion im Skelettszintigramm.

Two independent groups of patients were studied by bone scintigraphy to demonstrate age-dependent changes in the appearance time of fractures: 83 patients with 123 fractures of the spine showed neither by multiple regression analysis nor by separation into two subgroups (younger and older than 55 years) a clinically significant difference by scintimetric evaluation. A second group of 162patients with multiple trauma demonstrated no age dependence of the rate of additional bone lesions shown by scintigraphy. Instead a clear dependence on the site of the lesion and the time after trauma was found: fractures of the shafts of long bones and fractures of the pelvis and spine showed up significantly later than fractures in the neighbourhood of the distal joints. 12-14 days after a trauma all fractures may be detected with a high accuracy independently from the fracture site (except for fractures of the skull which did not show up at all in most cases). Thus, the differences in the appearing time of fractures are not age- but site-dependent.

[Experiences with the Spotorno expansion acetabulum]. / Erfahrungen mit der Expansionspfanne nach Spotorno.

At 53 hip joints a cupshell developed by L. Spotorno was practiced as replacement for the acetabular joint surface. This cementless CLS expansion-shell was always in combination with an also cementless femoral prosthesis applied in case of medial femur neck fractures, coxarthrosis, or the exchange operation to implantation. The concept of this prosthesis-shell performs the elastic- and mechanical structures of the bone around the joint. The primary stability is guaranteed by cramp points, which penetrate in the bone layer under the cartilage. Secondary the bone, which grows in the surface of the titanium shell takes, over the durable stability. Our experiences up to now with relation to the technique of implantation and the check ups after one till two years of functional weight-bearing are looking foreward to a time which confidences in the results with regard to the regeneration of bone and the cramp-stability.

[The effect of inactivity-induced osteoporosis on the scintigraphic image of bone lesions of the wrist]. / Der Einfluss der Inaktivitätsosteoporose auf die szintigraphische Darstellung knöcherner Verletzungen im Bereich des Handgelenks.

In addition to its established oncological indications the sensitivity of bone scintigraphy is of steadily increasing significance in traumatology. Inactivity-induced osteoporosis plays a major role during the immobilization period in the plaster cast. In the region of the joints remodelling intensity may reach such a high level that the non-injured bone shows a higher rate of accumulation than the fracture. This process already begins between the third and fourth week of immobilization. The highest uptake is found after fracture of the scaphoid bone at the end of twelve weeks of immobilization. Control scintigraphies at intervals of several days are indicated to differentiate between various clinical conditions (pseudoarthrosis, activated osteoarthrosis, algodystrophy in case of doubtful x-ray results).

VariDyne--new standards in postoperative wound drainage.

Conventional wound drainage systems operate at the beginning of the drainage procedure with a unilateral pressure of -0.9 bar. The system becomes static in case of no or only little secretion per unit of time. The pressure which is then unphysiologically high influences the microcirculation of the wound edge. A dynamic source of low pressure, which can be adapted to the individual requirements by varying its pressure, is coming from America.

[Medical peculiarities and social effects of accidents with motorcycles]. / Medizinische Besonderheiten und soziale Auswirkungen der Unfälle mit motorisierten Zweirädern.

During the period 1976 until 1982, 133 accident patients with two-cycle motor vehicles were treated at the traumatological Department of the Dr. Horst Schmidt Hospital. 80% of those patients were below or 21 years of age, 58.5% were undergoing training for professional work. 23.3% had suffered severe injuries (according to the Gögler scheme), 6.8% died as a result. Six out of nine dead patients were caused by severe head injuries, five of whom did not wear protective helmets. 37.7% cover all head injuries 5% more than injuries of the lower extremities (thigh and shins). The result of these accidents causes an enormous impact on those concerned as well as on the society. 32.3% interruptions and extensions of training periods and change of training for the youth became necessary. Treatment after admissions as in-patient (for minor injuries costs ca. DM 1000, for major injuries DM 20,000) costs about DM719,368,000 excluding costs for rents and auxiliary requirements which have not been taken into consideration. The invaluation of treatment of 133 accident cases with motorcycles has resulted in the following consideration: 1. Yearly publication of motor cycle accidents and its death tolls including cost sustained or prospective costs involved. 2. Strict rules concerning covering clothing. 3. Rigorous accident theching during driving lesions. 4. Security measures and its execution enforced by law to control the construction of motorized two cycle in consideration of optical and technical performance criteria. 5. Severe criticism of advertisers in usage of words like speed, performance and freedom which influence the youth without indicating the risks of the two-cycle vehicles.

[Detection of ischemic muscle necroses using 99mTc perfusion scintigraphy of traumatized extremities]. / Der Nachweis von ischämischen Muskelnekrosen mittels der 99mTc-Perfusions-szintigraphie an traumatisierten Extremitäten.

In the Dr. Horst-Schmidt Kliniken Wiesbaden 19 patients with trauma of the inferior legs have been examined by means of perfusion-scintigraphy with regard to a compartmental syndrome. In the control group there were twelve Patients without trauma. The employed method of computer assisted analysis of function of blood supply of the extremities in connection with the verification of the 99mTC-MDP amassment in the soft tissues seen in follow-up X-rays allows a differentiation between a normal-blood stream raising caused by a traumatic reparation (C = 1.7 +/- 0.6) and the significant higher blood stream as a result of the development of ischemic muscle lesions (C = 3.8 +/- 1.5). This non-invasive method is not very exert for the patient and is practicable with little expense in a nuclear medicine department. It may not be considered as a routine analysis because the clinical signs are sufficient to show the necessity of an immediate operative intervention in order to avoid a compartmental syndrome.

[Contributions of Max Bürger to the development of sports medicine]. / Das Wirken von Max Bürger für die Entwicklung der Sportmedizin.

The paper describes and appreciates the merits of Max Bürger who--as a clinician--realized very early the preventive and health-promoting role of regular physical training which can be principally carried out, from his point of view, up to the older age. He proved this opinion over more than 3 decades by numerous results of examinations especially in the field of the cardiopulmonary system and metabolism. Max Bürger became in several ways one of the forerunners of modern sports medicine by his important publications (among others "Normale und pathologische Physiologie des Blutkreislaufes bei sportlichen Anstrengungen", "Die Methodik der körperlichen Leistungsprüfungen mit Einschluss der Eignungsprüfungen für Beruf und Sport") by influencing the development of new research apparatuses and the installation of a larger performance diagnostic unit within his hospital as well as by the understanding between his aging research and sports medicine promoted by him and by his inititative to invite interested sports physicians to the foundation session of a "working group for sports medicine" the 13th and 14th November 1954.

[Complications in drug prevention of thromboembolism]. / Komplikationen während der medikamentösen Thromboembolieprophylaxe.

The possibility of complications during the thrombembolic prophylaxis with heparin-dihydroergotamine requests the observance of the application and the contraindications. The information of the patients and the continuous clinical control are absolutely necessary. The thrombembolic prophylaxis with less risk is given in a sufficient medication with Heparin in connection with early active exercising and correct positioning of the patient.

Measurement of knee-joint instabilities in the anterior-posterior plane.

The documentation of instabilities of the knee joint in sagittal direction by X-rays is usually inexact and incomplete by lack of rotational exertion. With a simple appliance instabilities of the knee joint in sagittal direction can be measured in mm within the examination. The difference between the injured and uninjured knee may show the importance of an instability of the knee joint.

[Fracture of the base of metatarsus V--conservative or operative treatment?]. / Die Fraktur der Basis des Metatarsale V--konservative oder operative Behandlung?

A follow-up study is given of 138 fractures of the base of the metatarsale V. In the years 1976-1980 124 of these fractures were treated conservatively, 14 operatively. In 1982 all patients were examined personally to find out the treatment with the best results. According to these results the authors consider the conservative treatment the preferable method.

[Malrotation following intramedullary nailing of the femur]. / Rotationsfehler nach Marknagelung des Oberschenkels.

77 patients with previous intramedullary nailing of the femur underwent detailed clinical and roentgenographical examination designed to show the frequency and extent of malrotation following this type of osteosynthesis. In 29% of the cases, more than 10 degrees of torsion deviation was detected on the roentgenogram using the Rippstein technique. An average outward rotation of three degrees was found after nailing. Most of the cases of malrotation occurred after fractures involving the proximal or distal third of the femoral shaft, or when there were more than two large fragments. Transverse and short oblique fractures of the mid-shaft showed superior results. Additional causes of malrotation included the nail being too thin or intraoperative fixation of the fragments occurring in the wrong torsional position. Torsion deviations were the same after using Küntscher- or AO-nails.

[Muscular changes caused by suction drainage. Scanning electron microscopy, transmission electron microscopy, light microscopy and morphometric studies of dorsal muscles of the rat (Rattus rattus) using drainage]. / Muskelveränderungen durch Saugdrainagen. Eine rasterelektronenmikroskopische, transmissionselektronenmikroskopische, lichtmikroskopische und morphometrische Untersuchung an mit Drainagen behandelter Rückenmuskulatur der Ratte (Rattus rattus).

Changes in the dorsal muscles of 22 rats (Wistar), resulting from surgical drain, have been studied under different morphological aspects. The lumen of drains were obstructed after a short time. In the drains without using low pressure, erythrocytes and fibrin network were seen by scanning microscopical investigation. Patent muscle fibres could be analyzed in the lumen of drain using negative pressure. They prevent the functional drain system. By the effect of surgical drains the fibres of dorsal muscles had become swollen. This fact could be analyzed by morphometrical technique. Some changes in fibres have been demonstrated by histological methods.

[Combined malleolar lesion in the growing skeleton]. / Die kombinierte Malleolarverletzung des wachsenden Skeletts.

Some examples are given in order to describe the combined lesion of the ankle joint in the growing skeleton after a supination trauma. This lesion in the growing skeleton is similar to the basic type A of luxation fractures according to Weber[4]: lateral ligament rupture or lysis of the fibular zone of bone growth, respectively, combined with fracture of the medial malleolus and involvement of the tibial zone of bone growth. In some cases, anteroposterior radiographs are necessary in order to establish a complete diagnosis. The pictures should always be compared with those of the uninjured side. Skeletal dysplasia as well as joint instability can be avoided by a differentiated therapy depending on the initial findings.

[Therapy of hand joint fractures using the external fixator. Experiences - results]. / Zur Therapie der Handgelenkfraktur mit dem äusseren Festhalter. Erfahrungen - Ergebnisse.

In the treatment of multi-fragment fractures of the base of the radius plate osteosynthesis using the small-fragment instrument set is preferred to conservative treatment due to the superior results achieved. However, one still cannot dispense with an additional immobilization of the fracture in a plaster cast. The extension of intra-articular comminuted fractures of the base of the radius is a technically relatively simple procedure and does not require a supporting plaster cast. In this paper we report the results of the treatment of twenty-seven wrist-fracture patients who were treated by external fixator. We also describe the indications and operative techniques. The results are reported by functional and radiological findings. For a great number of cases the results were quite good. We can highly recommend this procedure in the treatment of wrist injuries due to the simplicity of the operative technique employed and minimal follow-up treatment needed in conjunction with the good results achieved.

[Disturbances in surgical wound drains--principles and means of correction (author's transl)]. / Störungen in chirurgischen Wunddrainagen--ein Prinzip zu ihrer Beseitigung.

Hydrodynamic studies of surgical drains are done in abundant quantities of isotropic liquids. In order to emulate the environment within the surgical wound one has to use a changeable or inhomogenous system. Consideration has to be given to the consistency and amount of wound secretion as well as to the size and shape of the wound itself. These specifications are almost fully met by the spiral-drain. Additional advantages are gained through the small diameter and exact construction of the spiral drain. Clinical use of the drain in about 3.800 cases did not show and disadvantages in comparison to other widely used drains. No complications were observed. The painlessness during manipulation of the drain was acknowledged by all patients, especially those who had previous experience with perforated drains.