[Percutaneously navigated balloon fracture reduction in a displaced acetabular fracture]. / Perkutane navigierte Ballonreposition einer dislozierten Acetabulumfraktur.

Kyphoplasty is a well proven surgical procedure for osteoporotic fractures in spine surgery. Anatomic reconstruction of the joint is the primary aim in the treatment of acetabular fractures. To achieve this, extensive approaches with entry related morbidity are usually needed. Percutaneous stabilisations are still limited for non- or minimally displaced fractures.For displaced acetabular fractures, there are percutaneous procedures described with intraoperative CT control or by the use of a 3D C-arm. The case of an anterior column posterior hemitranverse fracture with an articular step in the weight bearing area is presented. In this case, a kyphoplasty balloon was placed by use of 3D C-arm navigation. After 2D C-arm controlled fracture reduction, the supra-acetabular screw was inserted percutaneously using the previous 3D navigation data set.With the combination of kyphoplasty technique, intraoperative 3D C-arm control and 3D C-arm based navigation, this displaced acetabular fracture could be reduced and fixed percutaneously. Anatomic reconstruction of the joint remains the primary aim.

Three-dimensional ultrasonography of bone and soft tissue lesions.

BACKGROUND: The aim of this study was to investigate feasibility and potential applications of three-dimensional (3D) ultrasonography in the evaluation of musculoskeletal disorders. METHODS: 3D ultrasonography was performed in 83 patients with bone (n = 50) or soft tissue lesions (n = 33). Volume data were obtained using two volume probes (1-8.5 and 8.5-12 MHz) and a 3D ultrasound unit. The results of 3D ultrasonography were compared to two-dimensional ultrasound and radiological imaging. RESULTS: The system enabled acquisition of 3D ultrasound data in diagnostic quality. 3D image-processing permits to analyse ultrasound data interactively in three orthogonal planes (section mode) or in realistic 3D views (rendering mode). Compared to conventional ultrasonography 3D image analysis improved assessment of details, provided better spatial orientation and facilitated image interpretation in 23, 44 and 49 cases, respectively. Additional findings that had significant influence on patient management were obtained in 16 of 83 patients (19%). Multiplanar reformating provided additional scan planes and increased the comparability of follow up examinations by standardized display and measurement. 3D surface reconstructions were very helpful to understand the morphology of bone lesions e.g. tortuous fracture lines. CONCLUSION: Our preliminary experience shows that 3D ultrasonography of musculoskeletal disorders is feasible. The ability to assess previously unattainable scan planes and lifelike surface projections may be particularly valuable for imaging of bone lesions. Further studies will be required to assess the exact role of this new technique for the evaluation of musculoskeletal disorders.

[Mechanical behavior of Ilizarov ring fixators. Effect of frame parameters on stiffness and consequences for clinical use]. / Mechanisches Verhalten von Ilizarov-Ringfixateuren. Einfluss der Gestaltparameter auf die Steifigkeit und Konsequenzen für den klinischen Einsatz.

Using a mechanical testing procedure, various fixator constructs were tested in vitro. In addition, the influence of the passive soft tissue structures on the fixation stiffness was determined. An increased number of Schanz' screws or Kirschner wires led to a comparable increase in stiffness than that observed with an increasing screw or wire diameter. In consequence, larger diameters should be preferred over an additional screw or wire where clinically applicable. With diaphyseal telescoping rods only the axial stiffness decreased. As expected, large ring diameters as well as titanium wires reduced stiffness components. Bracing the outer rings caused a reduction of the overall stiffness. Asymmetric pre-tensioning of the K-wires resulted in a significant reduction of tension in the neighboring wire. Removal of the soft tissues reduced stiffness to a similar extend as experienced in a fibula defect situation. The study demonstrates the correlation between design parameters, passive soft tissues and fixation stiffness and presents guidelines for an optimized fixator design.

Nonunion of the humerus following intramedullary nailing treated by Ilizarov hybrid fixation.

A case of a posttraumatic humeral shaft nonunion, after intramedullary stabilization with a Seidel nail, is presented. Severe osteoporosis, an oligotrophic nonunion, subclinical infection, and adhesive capsulitis of the glenohumeral joint were present. Due to the subclinical infection and severe osteoporosis, other major invasive therapeutic options such as intramedullary nailing or compression plating and bone grafting were not applicable. Nonoperative treatment was also not indicated secondary to the pain and disability present. External fixation with the Ilizarov hybrid fixator seemed to offer a minimally invasive treatment modality without the need of additional bone grafting. After fourteen weeks of "callus massage," consisting of closed alternating compression and distraction with an Ilizarov hybrid fixator, osseous consolidation was achieved. Eight months after Ilizarov treatment the patient had returned to work as a mechanic. At the one-year follow-up examination, the patient presented pain free and with near normal shoulder and elbow motion, with stable osseous consolidation of the humerus. In some cases of nonunion of the humerus shaft, when standard treatment options are not recommended, external fixation with an Ilizarov hybrid fixator may offer a salvage procedure with a successful clinical outcome.

[Retrograde intramedullary nailing in proximal fracture of the humerus in the elderly patient. Results of a minimally invasive management concept]. / Die retrograde Markdrahtung bei proximaler Humerusfraktur des alten Patienten. Ergebnisse eines minimal-invasiven Versorgungskonzeptes.

Retrograde intramedullary fixation of proximal humerus fractures with flexible wires was evaluated in a prospectively documented study. Seventy-four fractures in 73 patients with unstable proximal humerus shaft or neck fractures were fixed with 3-11 flexible intramedullary wires. The age of the patients averaged 72 years (42 females, 31 males). In nine fractures additional implants (screws, cerclages) were used to fix dislocated fragments through an anterior approach to the shoulder. Complications associated with the procedure especially in osteoporotic bone were secondary loss of reduction (16%) and wire migration (21%) which lead to revision surgery in 14% of patients within 6 weeks. A minimum follow-up of 12 months (average 16.5 months) could be obtained in 61 patients (84%). According to the Neer- and Constant-scores 60% showed good or excellent results, 30% had a satisfactory and 10% had an unsatisfactory or poor result.--Retrograde intramedullary, flexible wire fixation can provide an overall satisfactory outcome in unstable proximal humerus fractures of the elderly. However, the high incidence of secondary wire dislocations especially in marked osteoporosis appears to be an unsolved problem of this treatment modality.

[Supportive composite-hybrid fixation of percutaneous screw fixation of tibial head fractures]. / Supportive Composite-Hybridfixation perkutan verschraubter Tibiakopffrakturen.

Recent operative techniques with percutaneous screw fixation of the tibial plateau require a high level of patient compliance. Geriatric, non-cooperative patients and fractures with severe soft tissue injury have had to be excluded so far from this therapeutic regimen. Since September 1993, composite hybrid fixation, as a combination of ring fixation of the epimetaphyseal tibia with monolateral AO fixation of the tibial shaft, has been performed in 12 patients. The data were collected prospectively. Fractures were classified according to the AO and Moore classification; soft tissue damage was classified according to Tscherne and Gustilio. Fixation was performed with the cannulated AO system, 2.0 mm titanium K wires and 5.0 mm AO Schanz screws. In five patients, additional arthroscopic control of the reposition was performed. Average removal of the external fixator was 16 weeks postoperatively. Pin-tract infections occurred in all patients, mainly in the metaphyseal region. In one patient, a knee infection resulted from a subchondral intra-articular pin, which was treated by repetitive arthroscopic synovectomy. In two patients, a secondary loss of reposition (5-7 degrees varus) occurred. Despite a high rate of soft tissue damage (8/12), no osteitis or non-union occurred. As an alternative to extensive methods of ORIF, supportive composite hybrid fixation offers a new perspective of early functional treatment, weight bearing and a rare loss of reposition. It is favored in geriatric, non-cooperative patients and in fractures with severe soft tissue damage.

[Combination of the Ilizarov ring fixator with the unilateral AO tube fixator. Initial clinical experiences with the hybrid system]. / Kombination des Ilizarov-Ringfixateurs mit dem unilateralen AO-Rohrfixateur. Erste klinische Erfahrungen mit dem Hybridsystem.

Ring fixation of the tibia is difficult because of soft tissue transfixation and the size and weight of the external fixator. To increase the patients comfort K-wire and half-pin fixation are combined in a new hybrid configuration. The Ilizarov ring fixator with K-wire or Schanz screw fixation is combined with the unilateral AO fixator. This configuration has so far been used in 17 cases: in the proximal and intraarticular tibia in 7 cases, in the distal tibia in 8 cases and in the femur in 2 cases. As experience with the hybrid system widens indications accepted are metaphyseal and intraarticular fractures of the tibia with severe soft tissue damage, open fractures, segmental defects and fractures of the tibia that cannot be nailed. Loosening of the hybrid construction requiring an additional operative procedure has not occurred. The hybrid system is minimally invasive and allows early weight-bearing. It has the advantages of less transfixation of the soft tissue, an easy operative technique and more comfort with higher patient compliance, and the options for corrective procedures are the same as with the conventional Ilizarov technique. Our preliminary first experience with this system is encouraging; it is especially useful for problematic epi- and metaphyseal fractures with severe soft tissue damage.

Unrecognized pneumothorax as a cause of intraspinal air.

STUDY DESIGN: This is a case report. OBJECTIVE: A case of intraspinal air in a polytraumatized patient with unrecognized pneumothorax after blunt chest trauma is reported. SUMMARY OF BACKGROUND DATA: In most cases, intraspinal air is associated with degenerative disc disease, epidural abscess, or synovial cyst, or it follows iatrogenic manipulation. Scialdone and Wagle first reported a case of intraspinal air due to a laceration of the right main bronchus. No previous case of intraspinal air after a simple unsuspected pneumothorax following blunt chest trauma has been reported. METHODS: During routine x-ray and computed tomography examination of a polytraumatized patient, an unsuspected pneumothorax due to a rib fracture was detected in a thorax computed tomography scan. Computed tomography scans of the cervical spine showed a collection of intraspinal air. RESULTS: The computed tomography examination of a polytraumatized patient with an unsuspected pneumothorax after blunt chest trauma showed the embolization of air in the paravertebral vein plexus and in the intraspinal canal. CONCLUSION: These observations suggest a wider indication for computed tomography scans of the thorax in blunt chest trauma. Also, whenever intraspinal air is found in the diagnostic course of a traumatized patient, a hidden pneumothorax should be suspected and ruled out.

Double dislocation of the fifth metacarpal.

A case of traumatic, simultaneous, double dislocation of the fifth metacarpal bone is presented. Closed reduction was easily achieved and held with transarticular, crossed Kirschner wire fixation.

[Clinical experience with collagenous wound dressing in severe traumatic soft tissue injuries]. / Klinische Erfahrungen mit einem kollagenhaltigen Wundverband bei schweren traumatisch bedingten Weichteilverletzungen.

We treated 34 patients during 1987-1990 with a collagen wound dressing. Eleven patients had traumatic soft tissue defects, 10 patients had 3 degrees-grade open fractures, 7 patients had infected soft tissue wounds and 6 patients had deep 2 degrees and 3 degrees-degree burns. Our clinical experience confirmed the excellent clinical experimental results of collagen wound dressings. In all cases after 4 until 6 days of treatment good granulation and vascularisation of the wound bed was obtained, so that a skin transplant could be performed, which in all cases healed primarily. Moreover, the wound dressing had a good antibacterial effect and integrated actively in the wound healing process.

[True Madelung's deformity and traumatic pseudo-Madelung. An exemplary differential diagnosis of the deformity in the forearm of children]. / Echte Madelung und traumatische Pseudomadelung. Eine beispielhafte Differentialdiagnose der Deformität des kindlichen Unterarmes.

This article describes the differential diagnosis between hereditary Madelung's deformity and acquired posttraumatic Pseudo-Madelung's deformity. Three cases of posttraumatic Pseudo-Madelung's deformity were reported. Aspects of aetiology, clinical radiological appearance of hereditary Madelung's deformity and acquired Pseudo-Madelung's deformity are discussed. Differential diagnostic criteria for the discrimination between both forms are also discussed. A rare case of acquired posttraumatic "reversed" Madelung's deformity is also reported.

[Perforation of a duodenal stress ulcer in a 7-year-old polytraumatized boy]. / Perforation eines Duodenal-Stressulkus bei einem siebenjährigen polytraumatisierten Jungen.

This is a report of a seven-year-old polytraumatised boy with perforation of a duodenal stress-ulcer. Aspects of the etiology and pathogenesis were discussed. The main therapeutical efforts by stress-ulcer risk patients consist in an early sufficient shock therapy and adequate stress-ulcer prophylaxis to prevent the origin of stress-ulcers and their complications like bleeding and perforation.

[Light and electron microscopy of the human, anterior cataract capsule]. / Licht- und Elektronenmikroskopie der humanen, anterioren Kataraktkapsel.

Forty-three anterior lens capsules and epithelium from cataract patients extracted during extracapsular cataract surgery were examined by light microscopy and morphometry. An additional 15 lens capsules were examined by transmission electron microscopy. Morphometric examination revealed a positive correlation between age and the lens capsule thickness of 0.08 micron/year. The medium lens-capsule thickness of a 65-year-old human being was 8.65 microns. Light microscopy of cataractous anterior lens capsule and epithelium demonstrated proliferative changes with a multilamellar arrangement of the lens epithelial cells and an increase in the pleomorphic appearance of the cell and nucleus. Examination of the lens capsule revealed intracapsular foamy and vacuolic deposits with a localized splitting of the lens capsule. Transmission electromicroscopy established certain aspects of the lens capsule and epithelium. We found intracytoplasmatic single cilia and fibrillar intracytoplasmatic structures, with a diameter of 12-20 nm arranged in a pseudocrystalline fashion. The anterior lens capsule demonstrated similarly localized deviations from the normal homogeneous structure of type IV collagen, resulting in intracapsular deposition of fibrillar material. These observations suggest that cataractogenesis is associated with ultrastructural metaplastic and degenerative alteration of the lens epithelium and capsule.