[Acute tibial tubercle avulsion fractures]. / Avulsionsverletzungen der proximalen Tibia.

BACKGROUND: The tear-off of the apophysis of the proximal tibia is a rare injury (< 1 % of all apophysal lesions). It mainly affects male adolescents (14,6 years). Main causes are concentric and eccentric stress during sport activity. Morbus Osgood-Schlater seems to be a predisposing factor. AIM: Up-to-date survey of pathogenesis, diagnostics and treatment strategies. MATERIAL AND METHODS: Literature research (level III and IV studies) as well as own results. RESULTS: The affected patients are mostly male (97 %), type III fractures are most frequently seen (48 %). Accompanying injuries are not to be missed (10 %). The treatment usually consists of surgery by means of an open reposition and internal refixation, recently also minimal invasi. The results are mainly very good to good, approximately 95 % reach their old level of activity again. Almost one third of the patients develop a mostly slight complication. CONCLUSION: The acute tear-off of the apophysis of the proximal tibia is an infrequent disease. In dislocated injuries the standard procedure is the open reposition and the internal fixation. Lesions within the knee are particularly to be expected in intraarticular fractures und must not be missed. A very good to good result is to be expected with correct treatment, momentous complications are all together rare.

Two Adult Patients with Ellis-van Creveld Syndrome Extending the Clinical Spectrum.

Ellis-van Creveld (EvC) syndrome is a rare autosomal recessive malformation syndrome with the main features cardiac defects, postaxial hexadactyly, mesomelic shortening of the limbs, short ribs, dysplastic nails and teeth, oral frenula and various other abnormalities while mental function is normal. We describe 2 adult EvC patients with the cardinal skeletal features of mesomelic short stature and severe, progressive genu valgum deformity, resulting from loss of function mutations in the EVC genes. While the genu valgum was the predominating and disabling feature in patient 1, patient 2 showed acroosteolyses in the distal phalanges and a symmetrical synostosis of metacarpals in his hands. Moreover, patient 2 developed synostoses in the additional fingers in adolescence which had not been present at the age of 12 years, suggesting a further progression of skeletal disease. Joint fusion of phalanges so far has not been reported in EvC syndrome. Our data further expand the phenotypic spectrum of EvC related skeletal malformations and contribute important new information on the clinical course of EvC syndrome with increasing age.

[Technique and diagnostic value of musculoskeletal ultrasonography in rheumatology. Part 6: ultrasonography of the wrist/hand]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik -- Teil 6: Sonographie der Hand- und Fingergelenke.

Sonography of the hands is especially helpful in the diagnosis of early arthritis. Sonography allows for a very sensitive detection of small joint-effusion, tenosynovitis and small erosive bone lesions earlier than conventional radiography. Musculoskeletal sonography is also helpful in morphological analysis of changes of the median nerve in patients with carpal tunnel syndrome. The following standard scans are suggested for the sonographic evaluation of the wrist: 1. dorsal longitudinal scan along the radio-carpal joint, 2) along the ulno-carpal joint, and 3) dorsal transverse scan along the wrist to detect joint fluid collection, synovitis, tenosynovitis, ganglia, irregularities of the bone surface in osteoarthritis, and erosions due to inflammatory disease, 4) volar longitudinal scan along the radio-carpal joint, and 5) along the ulno-carpal joint, and 6) volar transverse scan along the wrist to diagnose the same objective as the above mentioned scans and to evaluate the median nerve in cases of carpal tunnel syndrome. Optional scans are the following: 7) ulnar longitudinal 8) transverse scan along the ulnar joint space and the extensor carpi ulnaris muscle to detect tenosynovitis and caput ulnae syndrome, 9) radial longitudinal, and 10). transverse scan along the joint space to diagnose synovitis and tenosynovitis. The following standard scans are suggested for the sonographic evaluation of the fingers: 1) volar longitudinal, 2) volar transverse scan in extension along the finger joints to detect effusion and synovial proliferation, tenosynovitis, irregularities of the bone surface (osteophytes, erosions), 3) dorsal longitudinal scans in extension and flexion >70 degrees along the CMC I, MCP, PIP and DIP joints to evaluate effusion and synovial proliferation, tenosynovitis or tendinitis, irregularities of the bone surface (osteophytes, erosions), and 4) dorsal transverse scans along the finger joints to evaluate these structures in an additional dimension. Optional 5) scans include the following: medial longitudinal scan along the MCP I, II, PIP and DIP joints, and 6) lateral longitudinal scan along the MCP V, PIP and DIP joints to evaluate the erosive bone process and joint instability. A linear transducer with a frequency of between 7.5 and 12 MHz is recommendable. The anterior distance between the bone and the joint-capsule of the wrist is > or = 3 mm in probable and > or = 4 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left wrist is > or = 1 mm, and they are definite if the difference is > or = 2 mm. A carpal tunnel syndrome is probable with a cross-sectional area of the median nerve of > or = 12 mm(2).

[Technical aspects and value of arthrosonography in rheumatologic diagnosis. 4: Ultrasound of the elbow]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik. Teil 4: Sonographie des Ellenbogens.

Musculoskeletal ultrasonography is an important imaging technique in the diagnosis of rheumatic diseases especially for early manifestation. It allows sensitive detection of small joint fluid collections as well as differentiation of soft tissue lesions and bone lesions. The following standard scans are suggested for sonographic evaluation of the elbow: 1) anterior humeroradial longitudinal scan, 2) anterior humeroulnar longitudinal scan to detect effusions, synovial proliferation, loose joint bodies, bone lesions (osteoarthritis/arthritis), 3) anterior transverse scan over the trochlea to evaluate these structures in an additional dimension, 4) posterior longitudinal scan and 5) posterior transverse scan of the olecranon fossa with flexed/extended elbow to evaluate the same objectives as the above mentioned scans and additionally to detect olecranon bursitis, and optional 6) distal dorsal longitudinal scan to differentiate soft tissue lesions such as rheumatoid nodules or gout tophi, 7) anterior transverse scan over the radius head to evaluate lesions of the radius head, tendopathy, calcinosis, 8) lateral humeroradial longitudinal scan to evaluate epicondylitis, 9) medial humeroulnar longitudinal scan to evaluate calcinosis, epicondylitis, signs of compression of the ulnar nerve. A linear transducer with a frequency of about 5-7.5 MHz is recommendable. The anterior distance between trochlea and the capitulum of the humerus between the bone and the joint-capsule of the elbow is > or = 2 mm in probable and > or = 3 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between the right and left elbow is 1 mm, and they are definite if the difference is > or = 2 mm.

[Technique and diagnostic value of musculoskelatal ultrasonography in rheumatology. Part 5: Ultrasonography of the shoulder]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik -Teil 5: Sonographie des Schultergürtels.

Shoulder-related symptoms are very common in rheumatic diseases. For the evaluation of the diagnosis as well as for therapy and prognosis, an anatomic assignment is essential. Clinical investigations alone are often not capable to do this. Ultrasonography is a method to delineate bony surfaces as well as the soft tissues around the shoulder joints statically and even dynamically. For the purpose of rheumatic diseases, ultrasound standard scans help to detect the lesions at the biceps tendon, the bursae, the rotator cuff, the humeral head as well as in the acromial and sternoclavicular joints. Considering the limitations of the method (obesity, frozen shoulder, no findings under bony structures) and knowing the pitfalls and errors of the method, ultrasonography is a reliable, quick and low cost method for the diagnosis of rheumatic shoulder joint pathology. Compared to computer tomography and magnetic resonance imaging, ultrasonography should be used as a screening method. The following standard scans are suggested for sonographic evaluation of the shoulder: 1) anterior transverse scan and 2) anterior longitudinal scan at the bicipal groove to detect synovitis and tenosynovitis, 3) anterior transverse scan at the coracoacromiale window in the neutral position, 4) at maximal external rotation and 5) at maximal internal rotation to evaluate the rotator cuff, bursitis, synovitis and erosions, 6) anterior longitudinal scan at 90 degrees to the coracoacomiale window at maximal internal rotation to describe these findings in an additional dimension, 7) anterior-lateral longitudinal scan at the anterior lateral acromion to tuberculum majus to evaluate the distal part of the supraspinatus muscle, 8) posterior transverse scan at the fossa infraspinata lateral under the spina scapulae, 9) axillary longitudinal scan to evaluate synovitis, synovial proliferation, erosions at the humeral head, lesions at the glenoidale labrum, 10) anterior transverse scan at the acromioclavicular joint and 11) anterior oblique scan at the sternoclavicular joint to detect synovitis, synovial proliferation, erosion, osteophytes.

[Technique and value of arthrosonography in rheumatologic diagnosis--3: Ultrasound diagnosis of the ankle joint, foot and toes]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik--Teil 3: Sonographie der Sprunggelenke, des Fusses und der Zehen.

The clinical investigation of ankles, feet, and toes is frequently equivocal in rheumatology. Sonography can distinguish between underlying pathologies. We suggest following standard scans: 1) anterior longitudinal scan to diagnose effusions in the ankle and talonavicular joints, to display erosive and osteoarthrotic pathologies, and to diagnose tenosynovitis of the extensor tendons; 2) anterior transverse scan to document the findings in an additional dimension; 3) lateral transverse scan and 4) lateral longitudinal scan to diagnose tenosynovitis of the peroneus tendons; 5) medial transverse scan and 6) medial longitudinal scan to diagnose tenosynovitis of the flexor tendons; 7) posterior longitudinal scan and 8) posterior transverse scan to evaluate the Achilles tendon, the retrocalcaneal bursa, and the posterior recess of the ankle joint. Additionally we suggest optional scans: 9) plantar longitudinal scan for the plantar fascia and the plantar calcaneal surface; 10) distal anterior longitudinal scan to evaluate the midtalar joints; 11) distal anterior longitudinal scan to evaluate the toes; and 12) plantar, distal transverse scan to evaluate the flexor tendons of the toes. Additionally, the correlating longitudinal and transverse scans can be used to confirm the findings. The frequency of the transducer should be about 7.5 MHz for ankles and the peroneus, flexor, and extensor tendons. Ten to over 20 MHz are possible for more superficially located structures. Using modern equipment with higher resolution a hypoechoic border may be normal up to 3 mm in the ankle joints, the MTP joints, and around the peroneus tendons, and up to 4 mm around the tibialis posterior tendons.

[Shock wave therapy for recalcitrant plantar fasciitis with heel spur: a prospective randomized placebo-controlled double-blind study]. / Stosswellentherapie bei therapieresistenter Plantarfasziitis mit Fersensporn: eine prospektiv randomisiert plazebokontrollierte Doppelblindstudie.

AIM: Efficacy of low-energy shock wave therapy for recalcitrant plantar fasciitis. METHOD: 32 patients were randomly assigned into real and placebo ESWT groups, treatment comprised 1000 impulses of 0,08 mJ/mm 2 at 14 kV (OssaTron OSA 120, HMT AG, Switzerland) in 12 cases repeated after six weeks or placebo (energy-absorbing foil). Follow-up evaluation (19, 32 and 48 wks.) included specific questionnaire, clinical-functional examination and measurement of plantar pressure while walking (Emed AT-4. pedograph, Novel GmbH, Munich). Examiner and patients were blinded. RESULTS: 88 % of the treatment group were pain free or had good results. None of the placebo group were pain free, 33.3 % had good results (Roles and Maudsley Score). The treatment group showed significantly better outcome for morning and resting pain, pressure stamp-tolerance and walking ability. Pedography did not show a clear correlation between pain relief and load pattern. CONCLUSION: The results of this study corroborate the value of ESWT for recalcitrant plantar fascitis. As a non invasive technique with low side effects, it can complement the row of conservative treatments.

[Technique and value of arthrosonography in rheumatologic diagnosis. 2: Ultrasound diagnosis of the hip area]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik. Teil 2: Sonographie der Hüftregion.

The clinical investigation of the hips in patients with rheumatic diseases is often equivocal. Thus, ultrasonography of this region is very relevant for rheumatologists. We suggest following standard scans: 1) anterior longitudinal scan to detect synovitis of the hip joint, iliopectineal bursitis, irregularities of the bone surface in osteoarthritis, Perthes' disease, and erosions due to inflammatory disease, 2) anterior transverse scan to evaluate these structures in an additional dimension, 3) lateral longitudinal scan of the hip joint with the same objective as the above mentioned scans; 4) lateral longitudinal scan, and 5) lateral transverse scan of the greater trochanter to diagnose trochanteric bursitis and bone irregularities due to enthesiopathy, and 6) dorsal oblique scan (optional) to diagnose hip joint effusions and pannus that localize in the dorsal region. Rotation of the joint is necessary to detect small effusions. The transducers should have a medium frequency of 5 to 7.5 MHz. In obese or muscular patients, 3.5 MHz transducers may be necessary to increase penetration. The anterior distance between the bone and the joint capsule of the hip joint is > or = 7 mm in probable and > or = 8 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left hip is > or = 2 mm, and they are definite if the difference is > or = 3 mm.

[Technique and value of arthrosonography in rheumatologic diagnosis. 1: Ultrasound diagnosis of the knee joint]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik. Teil 1: Sonographie des Kniegelenks.

Within the last few years, ultrasonography (US) of joints has attained a firm position for the diagnosis of joint diseases. Degenerative as well as inflammatory changes can be recognized using this method. With new, higher resolution techniques even bone surfaces and tendon textures can be visualized in greater detail. The advantages of sonography are general availability and low costs. When used properly, as a non-invasive procedure US has no detrimental effects on patients. The disadvantages of this technique result from its physical limitations, such as high reflection of US on bone and the negative correlation between resolution and penetration which makes US imaging difficult in deeper regions. The current technical development of probes and imaging processing, however, promises better deep structure imaging in the future. The quality of ultrasound examination always depends on the technical equipment, as well as on the patients' individual tissue constitution and the experience of the physician. It is possible to avoid misinterpretation and to increase the diagnostic value of US by using a standardized technique and professional knowledge of the specific aspects of the method. The significance of qualified education and sufficient training of sonographers is to be stressed. The aim of this article is to deliver a basic contribution to the standardization and quality assurance of joint US and to indicate the value of this method. In addition to the overview the authors propose guidelines for performance and interpretation of joint US. Due to the major significance of the knee joint in rheumatology it was decided to begin the work in this area.

[Measuring the surface of the back. Value in diagnosis of spinal diseases]. / Oberflächenvermessung des Rückens. Wertigkeit in der Diagnostik der Wirbelsäulenerkrankungen.

X-ray study to verify clinical findings in patients with scoliosis and other deformities of the spine is associated with considerable radiation exposure as well as a variety of other problems, particularly as regards assessing disease progression. Hence, in the course of the past few years a number of alternative, supplementary spinal diagnostic procedures have been developed which are based on analysis of the surface of the back: Moiré topography, photogrammetry/raster stereometry, opTRImetric system, ISIS system, video raster stereometry (formetrics), ultrasound-guided spine analysis (Zebris) and ultrasound topometry. To assess the effectiveness of screening, diagnosis, and progression of scoliosis the formetric system of video raster stereometry and the Zebris system for ultrasound-guided spine analysis were tested. It was shown that the results of screening tests, diagnostic study, and progression evaluation of scoliosis and sagittal deformities were exact enough using these systems. Furthermore, the ultrasound-guided Zebris system offers the option of dynamic analysis of spinal movement. Limitations in measurement precision were found in obese patients, asymmetric muscle surfaces, and in patients who had undergone surgery, although in the latter group progression could be reliably monitored if the radiological angle was known. We can assume that surface analysis procedures will gain in importance clinically and in practice.

[2- and 3-dimensional correction of scoliosis by corset treatment. Optimized conservative therapy of idiopathic scoliosis with the improved Cheneau corset]. / Zwei- und dreidimensionale Korrektur von Skoliosen durch Korsettbehandlung. Optimierte konservative Therapie der idiopathischen Skoliose durch ein weiterentwickeltes Cheneau-Korsett.

It is generally accepted that the progression of an idiopathic scoliotic deformity with a Cobb angle of between 25 degrees and 40 degrees can be stopped by brace treatment alone provided that the generally acknowledged criteria for the treatment concerning skeletal growth of the individual are respected. In Europe, the Cheneau brace, which was originally designed as an active derotation orthosis, is widely in use and is constantly being improved. The biomechanical principle of this orthosis consists of a pressure vector that is applied laterally (with regard to the 3-point principle) to exert pressure on the peak of the curvature in the frontal and transversal planes. Thus, the thoracic, lumbar and pelvic body mass that was rotated out of normal body symmetry is transferred back to its original position via pressure and derotation. Therefore, an active back like the Cheneau orthosis must provide pressure surfaces and sufficient expansion spaces. Subtle insights into the actual effect of braces have furthered ongoing development to take into consideration the changes to the trunk in the sagittal plain and have respected the different states of expansion of the two halves of the trunk in the craniocaudal direction. The thoracic flat back and cyphosis of the lumbal spine, which were formerly ignored, actually provide a real challenge for the technical realization of the brace. The new generation of Cheneau braces potentially provides an effective means for the active correction of scoliotic spinal deformity in all three dimensions and thus fulfills the requirements of modern conservative scoliosis treatment.

Long-term results of Salter and Chiari hip osteotomies in developmental hip dysplasia. A survey of over 10 years follow-up with a new hip evaluation score.

When conservative treatment of developmental hip dysplasia (DDH) does not render satisfactory results, surgical methods are indicated to gain a maximum of joint posture and stability. To assess the efficiency of these surgical procedures, the long-term results of the most often used pelvic osteotomies were examined. As common evaluation scores do not apply for DDH, we developed a specific score system of 100 points to integrate subjective factors such as patient's complaints with objective functional and radiological findings after surgical intervention. Our survey with an average postoperative follow-up examination of 10 years indicated that Salter's innominate osteotomy can render long-term pain relief and enable normal hip development, whereas Chiari's capsular arthroplasty does not. Here, subjective patient complaints do not correlate with clinical and radiological findings, which leads to unsatisfactory results. Ideally, patients aged 2-3 years can undergo Salter's innominate osteotomy whereas the Chiari osteotomy should be considered for patients older than 15 years. Even under optimal surgical conditions, Chiari's osteotomy cannot significantly prevent the development of joint arthritis. Undoubtedly, late results of both surgical procedures are dependent upon the initial stage of DDH. Additional upper femoral correction osteotomies have no further influence on hip development.

[Diagnosis and follow-up of muscle injuries by means of plain and contrast-enhanced MRT: experimental and clinical studies]. / Diagnostik und Verlaufskontrolle von Muskelverletzungen mittels nativer und kontrastmittelunterstützter MRT--experimentelle und klinische Untersuchungen.

PURPOSE: To clarify the value of plain and contrast-enhanced MRI for the diagnosis and follow-up of muscle injuries, by means of experimental and clinical studies. METHOD: 24 Wistar rats were studied following standardized division of the calf muscles by means of MRI carried out on the first day, and also after one, two, three and four weeks. In addition, 16 patients with muscle injuries were examined (32 examinations), first between the first and fifth day of trauma, and subsequently over a period of two to seven weeks (average: four weeks). RESULTS: In the animal experiments, there was signal reduction of T1 and an increase of the T2-weighted signal during the acute inflammatory phase. During the subacute reparative phase, there was an increase of both the T1-weighted and T2-weighted signals. These became reduced during the chronic healing phase. Early differentiation between intramuscular haematomas and bleeding, surrounding oedema and recognition of the divided muscle fibres was possible only after the intravenous injection of an MR contrast medium (Gd-DTPA). Suture of the divided muscles resulted in more rapid healing without major defects. CONCLUSION: It is possible to follow up the healing process after muscle injuries by means of plain MR. Contrast-enhanced MR allows early evaluation of muscle abnormalities, and is particularly valuable for recognising the margins of the injured muscles.

Absence of nitric oxide synthase I despite the presence of the dystrophin complex in human striated muscle.

Recently, it has been shown that in human striated muscle the signalling enzyme, brain-type nitric oxide synthase I (NOS I), is associated with the sarcolemma and complexes with dystrophin and/or members of the dystrophin complex. In order to find out whether there exists a regular association between NOS I and the complex, muscle biopsies from patients with various muscle disorders were analysed by enzyme histochemistry and immunohistochemistry. In patients suffering from Duchenne muscular dystrophy, and to a lesser extent in those with Becker-type dystrophy, NOS I and dystrophin complex components were absent or drastically reduced in the sarcolemma region. In other dystrophies, as well as in metabolic and inflammatory myopathies, NOS I and dystrophin complex constituents were expressed normally, while in the case of neurogenic diseases leading to denervation atrophy and especially congenital idiopathic clubfoot, the immunohistochemical patterns of the distribution of the dystrophin complex constituents were normal, but NOS I activity and protein were deficient or dramatically diminished. The results can be interpreted as indicating that, in general, NOS I targeting to the sarcolemma is dependent on particular members of the dystrophin complex, such as alpha-1 syntrophin, yet the expression and/or positioning of NOS I may be under the control of further factors, probably of neurogenic origin. NOS I-associated diaphorase may thus be a useful complementary tool in the diagnosis of muscle disorders.

Endoscopic discectomy in pediatric and juvenile lumbar disc herniations.

Most herniated lumbar discs in children and adolescents respond to conservative treatment, but some young patients with persistent low back and neurological symptoms do not respond to noninvasive treatment and require operative treatment. Because the long-term results of disc surgery depend not only on the disc disease itself but also on the degree of surgical trauma, disc herniations in children and adolescents should be treated with minimally invasive procedures. We report our experience with four young patients aged 8-17 years with contained or small noncontained lumbar disc herniations who were treated by percutaneous endoscopic discectomy (PED). The clinical results were good to excellent in all four cases, with follow-up of 1 to 5 years. There were no complications, and the operation was tolerated well by the young patients. We recommend percutaneous endoscopic lumbar discectomy in patients with contained or small uncontained disc herniations who do not respond to conservative treatment.

[Diagnosis of changes in the knee joint of high performance athletes]. / Diagnostik von Veränderungen des Kniegelenkes bei Leistungssportlern.

Sport-associated knee-joint alterations are frequent. A correct and rapid differentiation between traumatic lesions, chronic degenerative changes, and adaptive processes is important with regard to therapy as well as training and competitive planning for athletes. After the case history and physical examination, X-ray images are an absolute necessity for more in-depth diagnostic procedures. Depending on the clinical symptoms, partial aspects of the knee-joint can be visualized by sonography as well as by conventional tomography and computed tomography. If, however, a comprehensive evaluation of all knee-joint structures is needed, magnetic resonance imaging of the knee-joint should be performed. As a rapid, noninvasive procedure with high diagnostic reliability for all essential knee-joint structures only magnetic resonance imaging presently fulfills the specific demands placed on a modern diagnostic procedure by doctors working in sports-medicine.

[Fractures of the proximal radius in the growth stage]. / Frakturen des proximalen Radius im Wachstumsalter.

From 1970 to 1985 in the Orthopedic University Clinic (Oskar-Helene-Heim Berlin) 116 children with fractures of the proximal end of the radius received medical treatment. The frequency of the remaining complications like restriction of movement, differences in elbow axis angle (carrying angle), disturbances of growth or nerve lesions are described. The cause of those complications and the facilities for treatment are discussed in regard to controversy recommendations for therapy in literature. Special reference is made to problems of dislocation ad latus and late operative treatment.

[Possibilities and limitations of knee joint sonography]. / Kniegelenkssonographie Möglichkeiten und Grenzen.

In case of arthrosonography the sonography of knee-joint has got more importance because of the prompt and reproduceable possibility of soft tissue imaging without incidental consequences. There is a limitation of conclusiveness because of overshadow of bone structures and the narrow joint space. The cruciate ligaments and the imaging of the menisci, whose evaluation is still in discussion, are especially concerned. The method is excellent useful for clarification of traumatic or other soft tissue alterations in popliteal as well as in medial and lateral but also in supra--and infrapatellar region. With improvement of the equipment, e.g. the transmissionsonography, this diagnostic method for knee-joint could get greater importance.