[Reconstruction of distal fingeramputations using palmar fingerflaps and the dorsal eponychial flap]. / Versorgung von fingerkuppendefekten mit palmarer Lappen- und dorsaler Eponychiumplastik.

Reconstruction of fingertip amputations, especially if they involve more than half of the fingernail require the surgeon to determine whether the fingernail should be removed. However, aside from aesthetic aspects the fingernail has functional purposes - stabilisation of the pulp and enhancement of sensibility - and should therefore be preserved. Since November 2004 we have been using the technique of combining palmar finger flaps with dorsal eponychial plasty in reconstructing complex distal fingertip defects in 12 patients. All flaps had an uneventful healing. One patient with insufficient bone support after a failed operation developed an onychogryphosis. The remaining patients were satisfied with the result. With a simple technique augmenting the palmar reconstruction of complex fingertip defects by the dorsal eponychial flap plasty we can achieve a better support for the pulpa and also a better cosmetic result.

Magnetic resonance imaging of anterior cruciate ligament tears: evaluation of standard orthogonal and tailored paracoronal images.

PURPOSE: To evaluate the three standard orthogonal imaging planes and a paracoronal imaging plane for anterior cruciate ligament (ACL) tears. MATERIAL AND METHODS: Ninety patients (91 knees; 29 F and 61 M) aged between 15 and 84 years (mean 36.9 +/- 16.4 years) underwent magnetic resonance imaging (MRI) of the knee prior to arthroscopy. At surgery, 32 knees had an intact ACL, 4 a partial tear, and 55 a complete ACL tear. In all patients, axial, sagittal, coronal, and paracoronal T2-weighted turbo-SE images were acquired. The ACL was classified as intact, partially, or completely torn. Partial and complete tears were combined for statistical evaluation. RESULTS: Partial ACL tears (four cases) were not correctly diagnosed at MRI except in one knee by one observer on coronal images. Sensitivity in detecting ACL tears was 95%/63% (reader1/reader2) in the axial, 93%/95% in the sagittal, 93%/86% in the coronal, and 100%/93% in the paracoronal plane. Specificity was 75%/81% in the axial, 72%/81% in the sagittal, 78%/94% in the coronal, and 78%/88% in the paracoronal plane. CONCLUSION: ACL tears can be diagnosed accurately with each of the standard orthogonal planes. Based on reader confidence and interobserver agreement paracoronal images may be useful in equivocal cases.

[Ipsilateral knee and hip joint dislocation]. / Ipsilaterale Knie- und Hüftgelenkluxation.

Knee and hip dislocations are often serious injuries with an uncertain outcome. Simultaneous ipsilateral dislocation of the knee and hip joints is very rare; consequently, there is an inadequate amount of literature on the subject. In this case report we present a 35-year-old male patient with this combination of both injuries and discuss it in comparison with the available literature. This case report shows, that a methodical and sequential treatment can lead to good results in spite of this complex combination of injuries.

Functional donor-site morbidity during level and uphill gait after a gastrocnemius or soleus muscle-flap procedure.

BACKGROUND: There is only limited objective information about functional donor-site morbidity after harvest of one head of the triceps surae muscles to cover a severe soft-tissue defect of the leg. The purpose of the present study was to investigate whether a functional deficit is present during level and uphill walking after such a procedure. METHODS: Five subjects who had completely recovered from the initial injury were studied with use of comprehensive gait analysis during free level, fast level, and uphill walking on a ramp at a 10 degrees inclination. RESULTS: Gait analysis revealed no relevant donor-site morbidity affecting level gait at a free walking speed (mean, 1.27 m/sec; range, 1.18 to 1.40 m/sec). When the subjects walked at a higher velocity (mean, 1.89 m/sec; range, 1.58 to 2.43 m/sec), an asymmetry of the ground-reaction forces was seen. The second vertical peak force during push-off was reduced by a mean of 7.3% (range, 0.94% to 12.24%), and the impulse in the direction of progression was reduced by a mean of 8.7% (range, 0.13% to 17.87%) on the affected side (p = 0.04). During uphill walking, a compensatory strategy to reduce the demand on the posterior calf muscles was seen in all subjects-that is, they shortened the length of the step on the contralateral side by a mean of 3.9 cm (range, 2.2 to 6.2 cm), which corresponded to a mean side-to-side difference of 5.6% (range, 2.18% to 6.18%) (p = 0.04). A calcaneal motion pattern, denoted as increased ankle dorsiflexion, was seen in three of the five subjects during uphill walking as a sign of decreased function of the posterior calf muscles. Two of them (both with a soleus flap) also had a calcaneal pattern during fast gait. CONCLUSIONS: We concluded from this study that the functional donor-site morbidity after harvest of one head of the triceps surae muscles is mild in subjects who have had a complete recovery from their initial injury. Normal level gait is possible. However, deficits are seen in more demanding tasks such as fast walking or uphill walking.

Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique, results.

BACKGROUND: The surgical treatment of complex unstable proximal femur fractures from the trochanteric region to the middle shaft area is difficult and often highly invasive, especially in older patients with osteoporotic bones. METHODS: In 1993, we began to treat all unstable proximal femur fractures from the trochanteric region to the middle third of the shaft with the long gamma nail (LGN) and allowed the patients immediate full weightbearing after surgery. Perioperative, postoperative, and follow-up data were analyzed. RESULTS: During a 3-year period, we treated 37 patients with unstable proximal femur fractures with the LGN. Five of the patients had sustained pathological fractures, and four patients had sustained multiple trauma. The 37 operations were performed by 22 different surgeons with varying degrees of experience. The LGN implantations through maximal 40-mm skin incisions were performed in a mean skin-to-skin operation time of 125 minutes (range, 65-200 minutes) without any further complications. Thirty-one of the 37 patients were allowed immediate full weightbearing after the second postoperative day. The six patients who were not allowed full weightbearing were the ones who had multiple trauma (4) and those who were unable to walk before surgery (2). Three postoperative complications were as follows: one deep infection 4 months after surgery, one superficial infection 3 weeks after surgery, and one deep vein thrombosis 2 weeks after discharge. All three complications occurred in the group of patients who had sustained only one trauma. All traumatic fractures (n = 32) healed without any bone grafting, which means a union rate of 100%. Although immediate full weightbearing was allowed, there were no implant dislocations, implant failures, or other problems. The 30-day mortality was 0%. The follow-up examinations after a mean time of 6 months were very satisfying. All traumatic fractures were healed. The patients had symmetrical functional findings to the opposite side or before surgery, respectively, except for two patients with a leg shortening of 2 cm, two patients with an external malrotation of 10 degrees, and one patient with a hip extension deficit of 10 degrees after a pathological fracture. CONCLUSION: The LGN is, after appropriate introduction and training, a safe and easy implant for the treatment of complex proximal femur fractures from the trochanteric region to the middle shaft area. The minimal invasive technique with low risks and minimal complications and the possibility of immediate full weightbearing sets a new standard, especially for older patients with osteoporotic bones.

[Distal biceps tendon ruptures--experiences with soft tissue preserving reinsertion by bone anchors]. / Distale Bizepssehnenrupturen--Erfahrungen mit der weichteilschonenden Reinsertion mittels Knochenankern.

The repair of the distal biceps tendon rupture with bone anchors achieves excellent results. The important function of the M. biceps brachii as a powerful supinator and flexor can be reestablished and the soft tissue can be protected. We describe the repair of the rupture of distal biceps tendon by an anatomic refixation of the tendon to the tuberositas radii with bone anchors through a single anterior incision. In a four year period we treated eight patients with this technique. All patients were men with a mean age of 50 years. In each case the mechanism of injury was a single traumatic event with a large load on the flexed elbow. In average surgery was performed within five days and the patients stayed in the hospital for two days. Clinical follow up after almost two years showed no nerve damage or heterotopic bone formation. The range of motion and isometric muscle testing were almost symmetrical. All patients were able to return to preinjury activity level without any limitations.

[Inline skating, an old sport, newly discovered: harmless or a potential danger with socioeconomic effects?]. / In-line Skating, eine alte Sportart, neu entdeckt: Harmlos oder ein Gefahrenpotential mit sozioökonomischen Auswirkungen?

Over a period of one year, all accidents associated with in-line skating (ILS) were surveyed. Sport-specific data was recorded with a standardized questionnaire. The study comprised 66 patients with 75 injuries (48 upper limb, 16 skull, eight lower limb, three trunk). We were looking after 42 male and 24 female patients with an average age of 20 years (5-53 years). Twenty-seven patients (40%) had to be treated as inpatients. Overall, the most frequent injury (one third of all injuries) was forearm fracture close to the wrist (21 radius fractures, four radioulnar fractures). It had to be reset in 20 cases. Additional internal fixation was required in 10 cases (Kirschner wire osteosynthesis, intramedullary nailing or plate osteosynthesis). Only five patients could be treated with plaster cast fixation alone. Most patients with injuries in the vicinity of the wrist were not wearing a wrist protector at the time of the accident. The most frequent reasons given for not wearing protectors was forgetfulness or the high price of protectors. However, there were also two distal radius fractures and a disc injury in the wrist in patients who had been wearing wrist protectors. In most cases, ILS accidents lead to appreciable damage requiring a healing period of several weeks to months (average period of loss of work 41 days). The bfu (advisory center for accident prevention) reckons with 60,000 ILS cases annually in Switzerland. These injuries are thus of great socioeconomic importance. In the future, better risk behavior must be achieved by informing the population (wearing protectors, especially for the wrist and head, attendance of training courses).

[Management of unstable shaft fractures of the lower extremity in children using the external fixator]. / Versorgung instabiler kindlicher Schaftfrakturen der unteren Extremität mit dem Fixateur externe.

METHOD: Since 1993 we have treated 30 children between 2 and 15 years with 31 unstable tibial and femoral shaft fractures. We perform closed reduction und X-ray control and stabilize the fracture using the monotube-fixator, system Howmedica. The advantages of this system are based on the self-drilling, self-cutting screws and the simple dynamization. DISCUSSION: The treatment of dislocated, instable fractures of the tibial and femoral shaft in children using traction method is related with a long hospital stay in an uncomfortable position. The traction method leads to bone healing, but with a high rate of deformity after reposition. We treat the shaft fractures of the lower extremity using the external fixation. This method allows to reach early weight bearing mobilisation, it is related to a shorter hospital stay. The child is already one day after initial treatment allowed to walk with full weight bearing. The treatment with the external fixation is a modification of the traction method. CONCLUSION: We think to have a good concept of treatment using external fixation in children with unstable fractures of the femur and tibia shaft. The disadvantages namely pin tract infections, general anesthesia for removal and difficulties with the reduction are overruled by the advantages as short hospital stay, early weight bearing mobilisation and early return of the child to his own environment.

[Admission documentation of multiple trauma patients using the Zurich Trauma Protocol--initial experiences]. / Eintrittsdokumentation polytraumatisierter Patienten mit dem Zürcher Traumaprotokoll--Erste Erfahrungen.

A new protocol to document multiply injured patients in presented. It consists of 23 pages and is indexed on the right side. The pages are structured according to the Abbreviated Injury Scale (AIS): head/neck, face, thorax, abdomen, extremities/pelvis and integument. Different checklists on the right side of each page help to enter data efficiently; schemes and templates on the left side provide further support to visualize and classify the injuries. Summaries for diagnosis, therapies and for further investigations provide a standardized overview of the patient. The experiences of 22 residents were analyzed after one year of the protocol use. The trauma protocol was shown to be easy to learn, it was well accepted, and it increased the exchange of information between the emergency room and the intensive care unit. However, some residents considered this data entry to more laborious compared with the traditional medical record system. The trauma protocol was designed for prospective data acquisition of intensive care patients; it provides also a uniform structure for retrospective analysis and is therefore a helpful tool to increase quality control and quality assurance.

[Osteosynthesis of subcapital humerus fractures with unconventional use of implants]. / Osteosynthese subkapitaler Humerusfrakturen mit unkonventionell applizierten Implantaten.

The osteosynthesis of subcapital humerus fractures with the commonly used plates is often critical because of the little space subacromial, the irritation of the blood supply by the broad plates and the poor proximal anchorage without angle stability. The osteosynthesis with blade plates (children hip plate or blade plates for small adults) for isolated subcapital fractures or a blade plate like modified DC-plate for subcapital fractures with a shaft component or severe osteoporosis is thought to be a reliable alternative. We treated 34 patients aged between 18 and 85 years (mean 44 years) with blade plates. 33 patients had a good fracture healing and subjectively free shoulder motion after 3 months. One patient had distal implant loosening because of insufficient medial contact. The fracture healed after refixation.

[Intramedullary nailing of the humerus shaft fracture]. / Die Marknagelung der Humerusschaftfraktur.

The current retrospective study refers to 61 fractures and nonunions of the humeral shaft that were treated operatively between 1980 and 1990 in the Department of Surgery of the University of Zürich Medical School. All fractures were stabilized with thin noninterlocking AO tibial nails. The follow-up included 48/61 patients. The predominant fracture localization was the middle third of the humeral shaft (52 consecutive cases), and most of these fractures were of the simple transverse type A3 according to the AO classification (29 cases). The incidence of initial radial nerve palsy was 9/61 and that of postoperative palsy 1/61. No preoperative evaluation of radial nerve function was obtained in 4 multiply injured patients. Upon follow up, the function was found to have returned to normal in 8 patients. No infectious complications were observed. In 4/56 patients the final result was nonunion. In 41/48 a good result was obtained in terms of shoulder function. There were 7 patients (5 of them multiply injured) with poor shoulder motion with less than 100 degrees in abduction and anteversion.

[Bilateral anterior shoulder dislocation fracture after an epileptic seizure. A case report]. / Bilaterale anteriore Schulterluxationsfraktur nach epileptischem Anfall. Ein kasuistischer Beitrag.

Fractures can occur during violent muscular violence such as occur in the course of epileptic seizures, though this is rare (0.3%). The proximal part of the humerus is most frequently affected. The typical lesion is bilateral posterior dislocation or fracture-dislocation. We present a rare case of bilateral anterior fracture-dislocation of the shoulder sustained as the result of an epileptic fit. The treatment given was open reduction, refixation of the anterior labrum and screw fixation of the fragments. A review of the literature revealed only 18 cases of bilateral anterior dislocations caused by convulsive seizures.

[Patient management in polytrauma with injuries of the cervical spine]. / Versorgungskonzept beim Polytraumatisierten mit Halswirbelsäulenverletzung.

Complex unstable cervical spine injuries in polytraumatized patients are stabilized ventro-dorsally in a two-stage procedure. The ventral stabilization is a day-one surgery with the goal to get primary stability for intensive care, early spinal decompression and protection against secondary damage of the spinal cord. The additional dorsal stabilization allows early functional treatment or in case of spinal cord lesions early neurorehabilitation. The combination of severe brain injury and unstable cervical spine injury is especially demanding concerning diagnostic and therapeutic procedures.

[Distraction spondylodesis of the sacrum in "vertical shear lesions" of the pelvis]. / Distraktionsspondylodese des Sakrums bei "Vertical-shear-Läsionen" des Beckens.

The sacroiliac region is the link through which the weight of the trunk is transmitted to the legs and a region frequently indicated by patients as the site of back pain. Sacral fractures often remain undiagnosed and untreated and frequently result in neurologic symptoms and deficits. Since a systematic approach is used to analyse the pelvic ring fractures with CT scans, the surgical management of sacral fractures had become a focus of interest. Stabilization is important for survival of the patient and may improve the long-term functional results of treatment of such injuries. Specific treatments aimed at neurologic problems are available and may allow the patient functional recovery. Previous attempts to achieve internal fixation for sacral stabilization have used lag screws, sacral bars and plates in a compression mode. We present a new type of stabilization for vertically unstable sacral fractures in zones II and III (Denis). The aim of our suggested stabilization is a stable fixation without compression on the fracture side to protect the neural structures. We perform a transfixation from L5 to the pelvic rim with an internal fixator. Our instrumentation allows decompression (fracture reposition, sacral laminectomy, sacral foraminotomy) of the neural structures and stable fixation without compression. Five multiply traumatized patients with sacral fractures as a component of vertical shear injury of the pelvis had the sacroiliac region stabilized with the internal fixator. The preliminary results are presented.

[Computerized tomography follow-up in the acute phase after craniocerebral trauma]. / Computertomographische Verlaufskontrollen in der Akutphase nach Schädel-Hirn-Traumen.

Because of methodological reasons, within the first day after a head trauma, CT scan often does not demonstrate all the pathological consequences of brain injury. Additionally, secondary sequelae are frequent events. In our series of 129 patients the findings on subsequent CT scans done during the posttraumatic course were worse compared to the initial CT in 45% of patients. This deterioration on the CT scan was seen irrespective of the initial GCS score and the initial diagnosis of circumscribed or diffuse injury. The event observed most often was bleeding into a preexisting contusion or even bleeding into a region which had looked normal on the first CT scan. In the vast majority of cases, this happened within the first 2 weeks after the initial trauma. We conclude that an initially pathological CT should be repeated early in the posttraumatic period even in patients with mild to moderate head injury. In particular, we recommend that patients having sustained diffuse brain injuries should be transferred to neurotraumatology units for specialised management, even when there may not be immediately obvious indications for surgical intervention.

[Combined fractures of the femoral neck with femoral shaft fractures]. / Kombinierte Frakturen des Schenkelhalses mit Femurschaftfrakturen.

Ipsilateral fractures of the femoral neck and shaft presents diagnostic difficulties and complex choices as to treatment. The surgeon is often faced with a multiply-injured patient with an obvious fracture of the femoral shaft. The accompanying femoral neck fracture can be overlooked (20-50%). Most frequently, the missed fracture is a minimally displaced vertical fracture of the femoral neck. Reviewing the literature on the subject offers little guidance of managing this fracture combination. Our present protocol for this double fracture is treatment with immediate internal fixation: 1. ISS < 25: Interlocking nailing for the shaft fracture and supplementary screws for the neck fracture, 2. ISS > 25: Plating for the shaft fracture and screwing for the neck fracture. The aseptic necrosis of the femoral head is not frequent.

[Necrotizing soft tissue infections]. / Nekrotisierende Weichteilinfekte.

Necrotizing soft tissue infections are a group of life- and limb-threatening infections. They are caused by aerobic and anaerobic bacteria occasionally in a synergistic polymicrobial combination. The literature describing necrotizing soft tissue infections is controversial and often contradictory. Depending on their clinical appearance, tissue level and microbiological findings, necrotizing soft tissue infections are classified into two major groups, infections within the subcutaneous/fascia niveau and within the muscle level. Necrotizing infections of the subcutaneous level are further differentiated in hemolytic streptococcal gangrene, necrotizing fasciitis, clostridium fasciitis, and anaerobic nonclostridium fasciitis. In particular, necrotizing fasciitis is a rapidly progressing process, which is characterized by suppurative fasciitis, following by vascular thrombosis and cutaneous gangrene and is often accompanied by severe systemic toxicity, seen as septic-toxic shock and progressive (multi-) organ failure. Nineteen cases of necrotizing soft tissue infections were treated at the Department of Surgery, University Hospital of Zurich, between 1989 and 1992. These infections originated from "neglected trauma" in 9 (9/19), drug injections in 4 (4/19), acute infections in 3 (3/19), operative wounds in 2 (2/19) and perforation of the intestine in 1 case (1/19). Most of the patients (13/19) suffered from chronic debilitating diseases and were compromised by a suppressed immune system. We treated two groups of patients, one with septic-toxic clinical course and the other without. Eleven patients (11/19) belonged to group one and four of them, showing necrotizing fasciitis of the trunk, died as a result of multiorgan failure (MOF). Furthermore, three patients in this group had a limb amputated. In the other group without septic-toxic signs, no one died or lost a limb. The two groups differed also in length of hospital stay, an average of 60 days in group one (23 days intensive care) and 25 days in group two. Our results suggest that prompt recognition and treatment of necrotizing soft tissue infections are essential for the patient's survival. Often the full extent of the infections is underestimated initially, resulting in delayed surgical therapy. To control the rapidly spreading necrosis, early diagnosis and radical debridement of the affected tissue are essential and should be done without compromise, even if the affected limb must be amputated.

[Unstable spinal injuries in cranio-cerebral injuries]. / Die instabilen Wirbelsülenverletzungen beim Schädelhirntrauma.

Estimates of the incidence of injury to the cervical spine among patients suffering blunt trauma to the head vary widely. In an attempt to quantify the risk, the records of 593 consecutive patients with blunt craniocerebral injuries admitted to our trauma center in 1991 were reviewed. The overall incidence of cervical spine injuries was 5.8% and for unstable cervical spine injuries 2.9%. In the management of head trauma with associated cervical spine injuries realignment and immobilization of the spine and surgery of the head were carried out as first step, followed by decompression and stabilization of the affected segment in the same session. In patients with altered consciousness there is always loss of cooperation and early spinal stabilization for optimal treatment in the intensive care unit and in the wake-up-phase is important.

[Unstable spinal injuries in craniocerebral trauma]. / Die instabilen Wirbelsäulenverletzungen beim Schädelhirntrauma.

Estimates of the incidence of injury to the cervical spine among patients suffering blunt trauma to the head vary widely. In an attempt to quantify the risk, the records of 593 consecutive patients with blunt craniocerebral injuries admitted to our trauma center in 1991 were reviewed. The overall incidence of cervical spine injuries was 5.8% and for the unstable cervical spine injuries 2.9%. In the management of head trauma with associated cervical spine injuries realignment and immobilisation of the spine and surgery of the head were carried out as first step, followed by decompression and stabilisation of the affected segment in the same session. In patients with altered consciousness a loss of cooperation is always present and an early spinal stabilisation for the optimal treatment in the intensive care unit and in the wake-up-phase is important.

[Results of intramedullary nailing in humerus shaft fractures]. / Ergebnisse der Marknagelung bei Humerusschaftfrakturen.

We present an analysis of a retrospective study of 61 humeral shaft fractures, stabilized with a thin AO tibial nail. All fractures were analysed according to the AO-classification. Follow-up included 48/61 patients and averaged 82 months. Local complications were postoperative radial nerve palsy in 1/61, infection in 0/61 and non-union in 4/56. A good result in shoulder function was obtained in 41/48 cases.