The 2-2-2-20-20 concept for supraacetabular schanz screw insertion without additional radiography.

PURPOSE: Application of supraacetabular Schanz screws is usually performed under image intensifier guidance. The aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre- and intraoperative fluoroscopy can be avoided. MATERIAL & METHODS: Insertion of the supra-acetabular Schanz screws was performed by two trauma surgery residents in a study sample of 14 human adult cadavers which had been embalmed by use of Thiel`s method. With cadavers placed in supine position, the anterior superior iliac spine (ASIS) was palpated. Starting from this landmark, 2 cm were measured in a distal and 2 cm in the medial direction. At this point, a 2 cm long oblique skin incision was performed. Through this approach, 150 mm Schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of 20° to distal as well as 20° to medial. Following screw application, combined obturator oblique-outlet views (COOO) were taken bilaterally in each specimen by use of an Arcadis© Orbic 3D C-arm to prove the screw position. Six of the specimens underwent a 3D-CT-scan. Images were evaluated concerning correct screw positioning by a further traumatologist. Skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (LFCN) or to the joint capsule were evaluated. RESULTS: The sample consisted of eight pelves from female and six pelves from male cadavers. During radiographic evaluation of the COOO-scans (14 specimens) and the 3D-scans (6 specimens), the Schanz screws were placed inside the supra-acetabular corridor in all specimens (14/14). During dissections, no intracapsular screw placements or LFCN lesions were found. CONCLUSION: According to the described anatomical data, we defined a 2-2-2-20-20 concept, starting with a 2 cm skin incision 2 cm distal and 2 cm medial to the ASIS with a drill angulation of 20° inferior and 20° lateral orientation. Using this technique, all Schanz screws could be sufficiently inserted without intraprocedural x-ray imaging.

[Pediatric pelvic trauma]. / Kindliches Beckentrauma.

The main injury mechanism of rare pelvic girdle injuries in children is high-energy trauma with a high rate of accompanying injuries and a mortality up to 6%. Anatomical features often result in complex pelvic trauma. Emergency treatment is based on established standards in adults. Definitive treatment is mostly conservative and implants adapted for children are increasingly used. Long-term consequences have to be considered, especially after unstable pelvic ring injuries. A correlation exists between clinical and radiological results. Due to the difficult radiological assessment, acetabular injuries are easily overlooked. The Salter-Harris classification appears to be prognostically useful. Most acetabular injuries can be treated conservatively. Considerable displacement or additional intra-articular injuries necessitate open reduction and internal fixation. Frequent follow-up examinations up to the end of the growth phase avoid posttraumatic acetabular dysplasia being overlooked.

Concussion in Sports - What Trauma/Orthopedic Surgeons Need to Know!

Concussion in sport is often underdiagnosed with the potential risk of long-term sequelae. This article presents the mechanisms, the underlying pathophysiology and typical primary signs and symptoms. The recognition and resulting medical measures including the present recommendations and decisions on return to play are described. The majority of patients with concussion present with clinical and cognitive symptoms only for short time intervals. As a rule a complete subjective recovery is observed within a few hours or days. Although neurocognitive impairments can persist in individual cases, they also show a good tendency to heal. Thus, after 1 year nearly all patients no longer have any relevant disorders. In a few cases long-term disturbances can occur in the presence of certain risk factors and/or after repetitive concussion. Unspecific symptoms and some cognitive impairments are the main reported problems; however, there is also a potential but individually unpredictable risk of developing neurodegenerative alterations and diseases.

[School re-integration after child brain dislocation : The trauma surgeon's role]. / Schulische Reintegration nach kindlicher Gehirnerschütterung : Die Rolle des Unfallchirurgen.

Concussion injury of the brain is still a frequently underestimated injury, which can be associated with long-lasting consequences. Compared to adults, the recovery phase is often prolonged in childhood. Primary treatment consists of symptom-dependent physical and mental activities. Re-integration into daily life is crucial. In childhood, the primary focus is therefore on returning to school. New symptoms, or an increased presence of symptoms must be detected, to avoid prolonged recovery courses. School restrictions have to be minimized. Corresponding concepts are already implemented in North America. Comparable concepts are not established in Germany. In addition to well-known standard return-to-play protocols for sport re-integration, it is urgently recommended to integrate gradual return-to-learn protocols.Thus, academic adaptations and support must be established as well as symptom-oriented organizational and teaching modules.

Proximal Femoral Fractures and Anticoagulation Therapy - When Is Surgery Safe?

Patients presenting with proximal femur fractures are at high risk of developing DVT and pulmonary embolism. Many of these patients suffer from additional anticoagulant treatment. Patients on anticoagulation treatment are complex to manage, especially regarding timing of surgery due to implemented quality control recommendations. The present review analyses the present data timing of surgery and perioperative surgical considerations on anticoagulation treatment in this patients group.

Standard Approaches to the Acetabulum Part 2: Ilioinguinal Approach.

The ilioinguinal approach is one of the standard approaches in the treatment of displaced acetabular fractures used during the last decades (9). The meta-analysis of Giannoudis et al. showed that 21.9% of acetabular fractures were historically treated using this approach (3). One of the disadvantages of this study was, that studies focussing especially on posterior wall stabilization and studies dealing with more complex fracture types treated by extended approaches were integrated. Thus, these fracture types were overrepresented. Re-analysis excluding these data lead to an increase of the rate of anterior approaches to 25.9%. More recent data (years 2005-2007) from the German multicenter study showed that presently in almost 45% of the cases the single ilioinguinal approach was used and only 38% of patients were stabilized via the KocherLangenbeck approach (11). Historically, the Smith-Peterson approach (15, 17) and the iliofemoral approach were used to treat acetabular fractures. In the 60ies, based on the work by Letournel and Judet, the ilioinguinal approach was developed for acetabular fracture fixation (9). It is an extrapelvic approach resulting in an indirect reconstruction concept of the acetabulum without direct visualization of the articular acetabulum. The ilioinguinal approach was the standard anterior approach during the last 30-40 years. An important advantage is the reduced soft tissue detachment of periarticular muscles with only a small risk of developing heterotopic bone formation. The aim of the second part of "Standard approaches to the acetabulum" is to report on the special topics indication, positioning, exposure, incision, dissection, the anatomical basis of osteosynthesis and present results using ilioinguinal approach.

Standard Approaches to the Acetabulum Part 1: Kocher-Langenbeck Approach.

Historically, standard approaches for surgical treatment of displaced acetabular fractures were the KocherLangenbeck approach, the ilioinguinal approach and the extended iliofemoral approach (12). Presently, several modifications of these approaches are accepted alternatives, especially anterior modifications based on the intrapelvic approach described by Hirvensalo (8). Single access approaches allowing visualization of one acetabular column are the posterior Kocher-Langenbeck approach and the anterior ilioinguinal approach (12) and the use of a single approach is favoured (9, 24). For more complex situations, in the 80s and 90s extended approaches (extended iliofemoral approach according to Letournel (12), its modification to Reinert (19) (Baltimore approach), and the Triradiate approach according to Mears (14)) were introduced. These approaches are presently rarely choosen due to the extensive soft tissue dissection and higher complication rates (28). Alternatively, the combination of an anterior and posterior standard approach was recommended (7, 21, 22) having the disadvantage of longer operating time and blood loss and showed no superior results compared to a single approach. The meta-analysis by Giannoudis et al. stated that 48,7% of patients were treated using the Kocher-Langenbeck approach, followed by 21,9% ilioinguinal approaches and 12,4% extended approaches (6). More recent data from the years 2005-2007, showed that anterior approaches are now predominantly used according to a higher number of acetabular fractures with anterior column involvement. Overall, more than 40% of all patients with acetabular fractures are still approached via the Kocher-Langenbeck approach (18). Therefore, the Kocher-Langenbeck approach is still a "working horse" in approaching displaced acetabular fractures. The Kocher-Langenbeck approach consists of two parts. In 1874 von Langenbeck described a longitudinal incision starting from above the greater sciatic notch to the greater trochanter, dissecting the gluteal muscles for treating hip joint infections (11). Theodor Kocher in 1911 described a curved incision starting from the posterior-inferior corner of the greater trochanter, running across the postero-superior tip of the greater trochanter passing oblique in line with the fibres of the gluteus maximus muscle in direction to the posterior superior iliac spine (10). The aim of the present analysis is the detailed anatomi - cal analysis of this standard approach, focusing on fracture indication, positioning of the patient, exposure, dissection, reduction techniques of special fracture types, approach modifications/extensions, complications and approach-specific results.

Standard Approaches to the Acetabulum Part 3: Intrapelvic Approach.

Introduction The intrapelvic approach was originally described by Hirvensalo et al. from Finland in the early 90ies (8) and a further comparable description was published shortly thereafter by Cole et al. (5). Since then, various modifications have been described. Whereas the ilioinguinal approach was used until then to treat acetabular fractures with relevant anterior column involvement from an extrapelvic view, the intrapelvic approach was developed to address the often accompanied central hip dislocation in these fracture types with relevant fractures of the quadrilateral surface. With this approach a complete different view to the antero-medial acetabular pathology was possible. The view from more medial allows a better direct access to joint structures "below" the pelvic brim in the true pelvis (intrapelvic) in contrast to the extrapelvic access with the ilioinguibnal approach. Meanwhile, the surgical technique has been described in detail and some modifications and tricks have been published (5, 8, 10, 13, 19). The intrapelvic approach offers several advantages compared to the ilioinguinal approach: • lower invasiveness without substantial muscle detachment, • direct view of the superior pubic rami from superior and medial, the inferior anterior column and the quadrilateral surface up to the posterior border of the posterior column at the greater sciatic notch, • reduction and fixation of the anterior column and the quadrilateral surface under direct visualization, • reduction of antero-superior marginal impactions under direct visualization, • low risk of heterotopic ossification, • low risk of lesions to the lateral cutaneous femoral nerve. The aim of the third part of "standard approaches of the acetabulum" is to report on the special topics indication, positioning, exposure, incision, dissection, the anatomical basis of osteosynthesis and present results using the via the intrapelvic approach.

Minimal Invasive Dorsal Plate Osteosynthesis of the Tibia--Are Nerves and Vessels at Risk? An Anatomical Study.

PURPOSE OF THE STUDY: Purpose of this anatomic study was to develop a new and safe technique of minimal invasive dorsal plate osteosynthesis for tibia shaft fractures. MATERIAL AND METHODS: Sixteen paired adult lower limbs of eight different cadaveric specimens were examined. Anatomical prebending for each plate was done. Plates were inserted percutaneously, following plate fixation the neurovascular bundle was dissected out. The distance between the neurovascular bundle (posterior tibial nerve, posterior tibial artery) and the plate was measured at two different positions. The distance to the origin of the flexor digitorum longus muscle and the arch of the soleus muscle was measured. RESULTS: The mean distance between the neurovascular bundle and the plate amounted 1.4 cm (±0,2 cm; 1.0-1.7 cm) at hole number six and 1.1 cm (±0.4 cm; 0.6-2.0 cm) at hole number ten. The nerve was never directly in contact with the plate. The flexor digitorum longus muscle had its origin along the plate and was between the plate and the neurovascular bundle in all cases. CONCLUSIONS: Dorsal percutaneous plate insertion is a safe and easy method for osteosyntesis of tiba shaft fractures. Especially in case of poor skin and soft tissue conditions this technique offers a good alternative.

Measurement of compartment elasticity using pressure related ultrasound: a method to identify patients with potential compartment syndrome.

PURPOSE OF THE STUDY Decision-making in treatment of an acute compartment syndrome is based on clinical assessment, supported by invasive monitoring. Thus, evolving compartment syndrome may require repeated pressure measurements. In suspected cases of potential compartment syndromes clinical assessment alone seems to be unreliable. The objective of this study was to investigate the feasibility of a non-invasive application estimating whole compartmental elasticity by ultrasound, which may improve accuracy of diagnostics. MATERIAL AND METHODS In an in-vitro model, using an artificial container simulating dimensions of the human anterior tibial compartment, intracompartmental pressures (p) were raised subsequently up to 80 mm Hg by infusion of saline solution. The compartmental depth (mm) in the cross-section view was measured before and after manual probe compression (100 mm Hg) upon the surface resulting in a linear compartmental displacement (Δd). This was repeated at rising compartmental pressures. The resulting displacements were related to the corresponding intra-compartmental pressures simulated in our model. A hypothesized relationship between pressures related compartmental displacement and the elasticity at elevated compartment pressures was investigated. RESULTS With rising compartmental pressures, a non-linear, reciprocal proportional relation between the displacement (mm) and the intra-compartmental pressure (mm Hg) occurred. The Pearson's coefficient showed a high correlation (r2 = -0.960). The intraobserver reliability value kappa resulted in a statistically high reliability (κ = 0.840). The inter-observer value indicated a fair reliability (κ = 0.640). CONCLUSIONS Our model reveals that a strong correlation between compartmental strain displacements assessed by ultrasound and the intra-compartmental pressure changes occurs. Further studies are required to prove whether this assessment is transferable to human muscle tissue. Determining the complete compartmental elasticity by ultrasound enhancement, this application may improve detection of early signs of potential compartment syndrome. Key words: compartment syndrome, intra-compartmental pressure, non-invasive diagnostic, elasticity measurement, elastography.

The risk of neurovascular injury in minimally invasive plate osteosynthesis (MIPO) when using a distal tibia anterolateral plate: a cadaver study.

PURPOSE OF THE STUDY: Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. The aim of this study was to analyze structures that are at risk during this approach. MATERIAL AND METHODS: Thirteen unpaired adult lower limbs were used for this study. Thirteen, 15-hole LCP anterolateral distal tibial plates were percutaneously inserted according to the recommended technique. Dissection was performed to examine the relation of the superficial and deep peroneal nerves and anterior tibial artery relative to the plate. RESULTS: The superficial peroneal nerve was found to cross the vertical limb of the LCP plate at a mean distance of 63 mm (screw hole five) but with a wide range of 21 to 105 mm. The neurovascular bundle (deep peroneal nerve and anterior tibial artery) crossed the plate at a mean of 76 mm (screw hole six) but also with a wide range of 38 to 138 mm. The zone of danger of the neurovascular structures ranges from 21 to 138 mm from the tibial plafond. In one specimen, a significant branch of the deep peroneal nerve was found to be entrapped under the plate. CONCLUSION: Caution is advised when using anterolateral minimally invasive technique for plate insertion and screw placement in the distal tibia due to great variability in the neurovascular structures that course distally in the lower leg and cross the ankle.

Femoral shaft fractures in adults: treatment options and controversies.

Antegrade reamed femoral nailing via the piriformis entry point is the technique of choice in treating femoral shaft fractures, with retrograde nailing as an alternative. The supine position is favored to reduce complications, especially rotational malalignment. With navigation and robotic assistance fracture reduction can be supported and the rate of rotational, axis and length malalignement can potentially further reduced. Careful reaming is the procedure of choice to optimize bony healing and reduce systemic and local complications. In multiply injured patients reamed nailing can be safely integrated in the DCO- or ETC-concept and can be performed in the majority of patients, even when additional severe chest and head injuries are present. Initial resuscitation should focus on general stabilization before definitive femur fixation. Plate osteosynthesis of the femur can be an option in selected patients.

[Basic knowledge on concussion in the German Ice Hockey League (DEL)]. / Wissensgrundlagen zur Gehirnerschütterung in der Deutschen Eishockey Liga (DEL).

OBJECTIVE: In professional ice hockey there is a high incidence of concussion. In order to implement preventative measures as well as to introduce a treatment concept it is necessary to analyse the basic knowledge about concussion of all participants and to identify aspects requiring additional educational measures. METHOD: By means of an internet-based questionnaire comprising 18 questions, trainers and co-trainers, sport directors, team physicians and team captains of all teams in the German ice hockey league were interviewed about their knowledge and impressions with regard to general knowledge, game-stop, protection, and training as well as their opinions about changing the penalty system. RESULTS: The response rate amounted to 57.8 %. Not only team physicians but also players, trainers and sport directors exhibited a good basic knowledge on concussion, duration of treatment and rehabilitation as well as possible long-term sequelae. There were only slight differences in knowledge between team physicians and not-medically trained personnel. This survey also revealed a broad support for educational measures about concussion and the possibility for rule changes to further protect the players. CONCLUSION: There appears to be an acceptable basic knowledge about concussion and its symptoms and no major underestimation of the problems. All participants were in favour of the provision of further information as well as the implementation of preventative measures.

Supraacetabular external fixation for pain control in geriatric type B pelvic injuries.

UNLABELLED: PURPOUSE OF THE STUDY: Pelvic ring fractures in the geriatric population are of increasing frequency. Often insufficiency fractures or occult fractures are described. With a classical injury mechanism the majority of these injuries are the result of a low energy trauma, typically a fall from standing or during walking.Clinically, many patients report immediate anterior groin pain but detailed clinical examination often shows significant posterior pelvic pain. CT evaluation often reveals posterior pelvic ring injury, in the majority of cases a sacral compression fracture. Despite adequate diagnostics, many of these patients suffer from persistent pain, which can be observed up to 8 weeks after injury. To asses the role of external fixator in pain relief and early mobilisation in this group of patients the study was performed. MATERIAL AND METHODS: From the database of all patients with pelvic ring and acetabular injuries 25 patients > 65 years with type B injuries stabilized by a supraacetabular external fixator were analyzed. Prospectively demographic data including sex, patient age, cause of injury, frequency and type of concomitant injuries and diseases, injury severity,fracture type and complications were recorded. For evaluation of the pain course, the visual analog scale was used. Preoperative and postoperative mobility and the type of post-treatment were evaluated. RESULTS: Stabilizing the pelvic ring with a simple external fixation procedure (supraacetabular one pin external fixator) allows immediate relief of pain, which allows early and successful mobilization of these patients. Normally, adequate mobilization is possible immediate after application of the fixator. CONCLUSIONS: This simple operative procedure, therefore, can be used for pain control and sufficient mobilization to avoid secondary medical complications.

Acetabular fractures in children: a review of the literature.

Injury to the acetabular growth plate is rare. Accordingly, data on the incidence in the literature are controverse. Other difficulties include the clear definition of a pediatric acetabular injury. The modified classification according to Salter-Harris described by Bucholz is used in immature patients. The majority of these injuries can be treated conservatively. In severely displaced injuries or in the presence of intra-articular pathologies open procedures are recommended. The main long-term complication is the development of posttraumatic acetabular dysplasia which should be early detected by regular check-ups until the completion of growth. Overall, the long-term results are satisfactory.

Transverse + posterior wall fractures of the acetabulum: epidemiology, operative management and long-term results.

UNLABELLED: PURPOUSE OF THE STUDY: Associated transverse and posterior wall fractures account for approximately 20% of all acetabular fractures. To asses the risk of these concommitant bone injuries on early joint failure despite a high rate of postoperative congruency. MATERIAL: The analysis of 104 surgically treated patients with associated transverse and posterior wall fractures showed that more than half of these patients had associated injuries. The mean age was 35 years, and > 75% of these patients were male. A high energy trauma was the trauma mechanism in 94.2%. The mean ISS was 26.3 points. The majority of patients showed a juxta- or transtectal fracture line. The mean articular fracture displacement was 13.5 mm. 87.5% of the patients showed a femoral head dislocation. An acetabular roof comminution was present in 16.3%. 20.2% of patients received a fracture related preoperative nerve injury to the sciatic nerve. METHODS: Osteosynthesis was performed 9.9 days after trauma. The Kocher-Langenbeck approach was used in > 90% for stabilization with a combination of plate and screw fixation in 71.1%. The mean operative time was 190 minutes with a blood loss of 855 ml. Postoperatively the hip joint was congruent in 90.3% with anatomical or near-anatomical joint reconstruction in > 90%. Iatrogenic nerve injury occurred in 12 patients (8.9%). RESULTS: 67 patients (67.7%) could be followed after a mean of 42.7 months. The average subjective Visual Analog Scale pain score was 42.7. Mild or no pain was seen in 58.2%. The mean Merle d'Aubigné score was 15.4 with 56.7% of patients having a functionally perfect or good result. 52.2% had no post-traumatic osteoarthritic changes of their hip joint. A joint failure was diagnosed in 32.8% of the patients. Analyzing only patients with anatomically reconstructed hip joints, patients showed comparable results with 61.3% having no or mild pain and 59.2% a good or excellent functional result. Posttraumatic arthrotic changes occur in only 26.5% of these patients. A joint failure was present in 32.7%. In this group, a joint failure was significantly more likely to be present with an additional acetabular comminution zone. CONCLUSION: Associated transverse and posterior wall fractures have a significant risk of early joint failure despite a high rate of postoperative congruency.

Evaluation tools and outcomes after osteosynthesis of unstable type B and C pelvic ring injuries.

The evaluation of present long-term studies on results after surgical stabilization of the pelvic ring is difficult, as different treatment concepts are used and the majority of these studies are not comparable regarding selected evaluation parameters. Additionally, no standardized measurement instrument exists to analyze the clinical and radiological result after pelvic ring injuries. Only short-term evaluations with a mandatorily recommended minimum follow-up time of one year are available. Medium-term analyses or real long-term analyses are missing. Present data show an increase of long-term sequelae from stable type A injuries to completely unstable type C injuries. Concomitant injuries of other injury regions around the body as well as additional injuries to the pelvic region (complex pelvic trauma) seem to influence the overall results. Therefore, in the future it is necessary to develop a sufficient pelvic outcome instrument which addresses these parameters. Additionally, results of treatment of specific fracture types depend on the chosen stabilization method. Overall, as single centres have only "limited" experience in treating pelvic ring injuries within a short period of time, and there is a wide range of completely different injury types and different treatment concepts, for future evaluation of long-term results after pelvic ring injuries prospective, multicenter outcome studies are recommended.

Conservative treatment of acetabular both column fractures: does the concept of secondary congruence work?

Complete separation of all bony fragments around the acetabulum in both column fractures can lead to extra-anatomical orientation of these fragments around the femoral head with the potential of a "secondary congruence". No long-term data are known in the literature. We could follow 35 patients were a both column fracture was treated non-operatively due to different reasons. Demographics, fracture type, additional fracture lesions (comminution, marginal impaction), the clinical and radiological result and joint failure (severe arthrosis, FHN, esc. THR) were analyzed. The mean age was 38 years, 27 patients were male, eight female. All but four were multiply injured with a mean ISS of 22 points. 16 patients had additional pelvic ring injuries The majority of patients showed a C1-fracture of the acetabulum (anterior column multifragmentary, posterior column simple). 31 patients healed in secondary congruence (88%). Primary displacement was half (11,4 mm, 3-27 mm) compared to patients without secondary congruence (20 mm, 17-22 mm). 80% of the patients had none or only slight pain and 77% had an excellent or good functional result (Merle d'Aubigné Score). The rate of joint failure due to non-union, femoral head necrosis, posttraumatic degenerative changes or pain was relatively low with 17% after a mean of 5 years following trauma. In selected patients, conservative treatment of both column fractures can lead to acceptable long-term results with a high rate of secondary congruence.

Management of hemodynamic unstable patients "in extremis" with pelvic ring fractures.

The hemodynamic status in patients with pelvic ring injuries is a major prognostic factor of an immediate mortality risk. Especially, patients "in extremis" are of high risk to die. This patient group is characterized by absent vital signs or being in severe shock with initial systolic blood pressure .70 mm Hg and/or requiring mechanical resuscitation or catecholamines despite >12 blood transfusions within the first two hours after admission. The sources of pelvic bleeding is in approximately 80-90% of venous origin and relevant arterial bleeding accounts for 10-20%. Important parts of the initial treatment treatment concept include mechanical pelvic ring stabilization combined with hemorrhage control concepts. Mechanical stabilization is performed non-invasively by pelvic binder application or invasively by classical anterior pelvic fixation or posterior pelvic C-clamp, depending on the local available resources. In patients "in extremis" the concept of direct extraperitoneal pelvic packing is recommended, whereas in moderately unstable patients or in patients where persistant hemodynamic instability occurs despite shock therapy and mechanical stabilization and pelvic packing, arterial injury is ruled out by angiography followed by selected embolization of pelvic vessels.