[The value of sonography in traumatology and orthopedics : Part 2: emergency diagnostics in blunt abdominal and thoracic trauma]. / Stellenwert der Sonographie in Traumatologie und Orthopädie : Teil 2: Notfalldiagnostik beim stumpfen Bauch- und Thoraxtrauma.

Ultrasound examinations in trauma patients should be done in the emergency department using curved-array (3.5-7.5 MHz) probes. Blunt trauma of the abdomen and thorax must be regarded as a single organ injury. Sonography is the imaging technique of first choice and has completely replaced peritoneal lavage. Paramount advantages are its ability to provide rapid information and reproducible results at short intervals and in a noninvasive manner. The sensitivity and specificity of sonography in detecting intraabdominal fluid are 97-100% and 80-90%, respectively. To achieve such good results, though, adequate education in ultrasound and state-of-the-art devices is crucial. Clinical experiences prove that standardized sonography must be part of polytrauma management and should be integrated in advanced trauma life support courses. Technical improvements with better image quality and miniaturization of hardware will contribute to increase the use of this technique. However, ultrasound does not replace computed tomography for follow-up in answering more sophisticated questions in multiple injured patients.

[Significance of sonography in traumatology and orthopedics: part 1: ultrasonography of the musculoskeletal system]. / Stellenwert der Sonographie in Traumatologie und Orthopädie :Teil 1: Sonographie des Bewegungsapparats.

A wide variety of modern ultrasound systems - including linear probes (7.5-15 MHz) and curved array probes (3.5-7.5 MHz), with color Doppler and duplex as well as harmonic imaging are used in trauma surgery and orthopedics to image and investigate almost all regions of the body. It is generally possible to assess all joints by ultrasonography. Valid procedures for ultrasonographic examination of the elbow, hip, knee, and ankle joints have been described in the literature. In the clinical setting, the use of ultrasound to examine the Achilles tendon and joints such as the shoulder and knee is particularly well documented. An important feature of ultrasound is that it allows dynamic examinations and side-to-side comparisons. Because ultrasonography is a very widely used imaging modality, it is a useful tool for screening and monitoring and especially for investigating venous thrombosis and diseases and injuries of the tendons and muscles.

Polyetheretherketone--cytotoxicity and mutagenicity in vitro.

The results of the incubation of polyetheretherketone (PEEK) fibre material with seven different genotype variants of salmonella bacterium showed with and without an external metabolic activation system (S9) with no mutagenic or cytotoxic activity of the test material. In the so-called "plate incorporation test" in which the PEEK raw material is finely cut and applied direct to the agar plate without the addition of solvent there was, as expected, no evidence of cytotoxic or mutagenic effects. In the HPRT test there was a significant increase in the number of mutants per dish, both after addition of N-acetylaminofluorene and N-methyl-N'-nitro-N-nitrosoguanidine (with and without an external metabolic activation system = +S9), but not after treatment of the cells with PEEK-DMSO-eluate. This means that the PEEK material under study did not release any substances that cause V79 cells to mutate. The investigation of the toxic reaction on the material under study revealed that the number of surviving colonies per 10(5) surviving cells lay within the range of or below the solvent control even in the presence of high PEEK concentrations (5.0 microg/ml). Therefore, in summary, the study produced no evidence of cell damage caused by PEEK.

Serum cholesterol is elevated in patients with Achilles tendon ruptures.

Forty-one patients were analyzed after surgical treatment of Achilles tendon ruptures. The following parameters served as the outcome measure: (1) duration of wearing cast, (2) length of hospital stay, (3) outpatient treatment, (4) time of absence from work, (5) complications, (6) re-rupture rate, (7) subjective evaluation by patients, (8) scar condition, (9) ability to stand on tiptoes, (10) Thompson test, (11) movement of talocrural joint, (12) circumference data of lower extremity, (13) radiographs, (14) power measurement of the ankle (in kg), (15) ultrasound examination, (16) blood cholesterol levels, (17) scoring by Trillat's score. Surgical treatment achieved an excellent or good outcome in 91% of patients as evidenced by the Trillat score. Furthermore, cholesterol levels were found to be elevated in 83% of patients. Given the good results, surgical treatment of Achilles tendon ruptures is recommended, but patients of status post-Achilles tendon rupture should be checked for high cholesterol levels. In the future, controlled, prospective trials need to prove a correlation between Achilles tendon rupture and a pathological blood lipid status.

[Attempted suicide--a challenge for the trauma surgeon?]. / Der Suizidversuch--eine Herausforderung für den Unfallchirurgen?

The data from 767 patients after a suicide attempt or suicide were analyzed retrospectively. Skeletal damage was present in 52% of the patients. This was also the highest percentage in the breakdown of the injury patterns, followed by damage of the central nervous system (26.6%). Injuries to parenchymatous organs (20.1%) took third place. Extensive soft tissue injuries were diagnosed in 18.1% and relevant vascular lesions in 16% of suicide cases. At the same time, the high percentage of multiple trauma patients (22.9%) reflects the severity and the extent of injuries suffered in the application of "violent methods". Injuries of suicide cases involving violence often resemble those of serious road traffic accidents. In contrast to unselected patients, the injury pattern of suicide cases with multiple trauma is dominated by jumps from a great height and being run over by a train. However, when unusual suicide techniques are used, the surgeon's experience may soon become insufficient. To our knowledge, special traumatology wards provide the best available diagnosis and emergency care for these patients unless they have suffered purely trivial injuries.

[Etiology of cerebral perfusion disorder in patients with severe craniocerebral trauma]. / Ursachen zerebraler Perfusionsstörungen bei Patienten mit schwerem Schädel-Hirn-Trauma.

In 53 patients with severe head injury, a decline of the cerebral perfusion pressure (CPP) was distinguished related to its cause, i.e., by a rise in intracranial pressure (ICP), a decline in the mean arterial pressure (MAP) or both. The mean Glasgow Outcome Scale (GOS) was 1.6 in patients with elevated ICP, 3.8 in those with decreased MAP and 2.7 when impaired CPP was due to both. It is concluded that in cases of decreased CPP, elevated ICP is the main cause of secondary brain injury and poor outcome, independent of the circulatory condition, whereas an isolated decline in the MAP does not show any influence on functional outcome.

[Perioperative antibiotic prophylaxis in hip operations. Penetration into bone, capsule tissue and cartilage exemplified by cefuroxime]. / Perioperative Antibiotikaprophylaxe bei Hüftoperationen. Penetration in Knochen, Kapselgewebe und Knorpel am Beispiel Cefuroxim.

The most serious complication of accident surgery is postoperative osteitis. At the same time, perioperative antibiotic prophylaxis is generally recommended in order to reduce the rate of infection in joint surgery. The criteria for the suitability of a substance as prophylaxis include inter alia the activity spectrum with respect to the expected microorganisms, its retention time in the body and its ability to penetrate the endangered tissue. In the present study, the systemic and local activity levels after a single i.v. dose of 1500 mg cefuroxime was investigated in relation to the time of administration in 30 patients who had to undergo total hip replacement owing to a medial fracture of the neck of the femur. The tissue and serum samples were analyzed by high pressure liquid chromatography (HPLC). The results show that the tissue levels of the intermediary cephalosporin after an i.v. single shot dose are on average still several times higher than the minimum inhibitory concentration (MIC) of the most frequent bacterium. Staphylococcus aureus, as late as 4 hours after application. The optimal time for the administration form selected was immediately prior to the operation and the concentrations measured suggest that several repeat doses of cefuroxime for short-term prophylaxis are not necessary.

[Self-induced injuries--surgical aspects]. / Selbstverletzungen--Chirurgische Aspekte.

So far, psychiatric-psychoanalytic theories have been able to explain the phenomenon "self-injury" only unsatisfactorily. Moreover, the patients do not turn to a psychiatrist in the first place, but to surgeons, dermatologists, gynecologists or general practitioners. This is therefore an interdisciplinary problem. Since general medical knowledge is relatively unhelpful in diagnosing self-inflicted disease and its treatment, these patients often do not receive adequate psychiatric co-management or further care or indeed often get the chance to delegate the act of self-injury to the physician. In view of the sustained tendency for the disorder to chronify, this frequently results in severe, partly irreversible and sometimes iatrogenically co-induced physical impairments. In the final analysis, it also leads to enormous financial burdens for the agencies which bear the costs.

[Rotator cuff rupture. Vascular supply and collagen fiber processes as pathogenetic factors]. / Die Rotatorenmanschettenruptur. Gefässversorgung und Kollagenfaserverläufe als pathogenetische Faktoren.

Light and polarization microscopic appraisal of the pathways of fibers and blood vessels in the region of the rotator cuff shows branches of the suprascapular artery. These initially radiate into the insertion tendon parallel to the muscle fibers. They do not continue there, i.e. the vessel branches have blind endings, or they branch and anastomose with each other. Outliers of the transverse branch of the anterior circumflex artery of the humerus come from lateral (from the direction of the deltoid muscle). They pass from the bony insertion of the supraspinatus tendon into the tendon plate, but only run together with the fibers for a short distance. Consequently, a zone low in vessels or free of vessels can be constantly demonstrated under a magnifying glass in the course of the supraspinatus and to a small extent also of the infraspinatus in the fetus or neonate as well as in the adult in the region of the zone of interweaving of the tendinous muscle outlier with the capsule at length magnification. In the genesis of rotator cuff rupture, the presence of hypovascularity must be considered to be a predisposing factor which is present from birth onwards. It affects the clinical course during the process of aging as the point of least resistance in consequence of arteriosclerosis, collagen degeneration physiological wear and tear friction at the lower surface of the acromion and inflammatory swellings of the subacromial bursa.

[Intracranial pressure monitoring in patients with severe craniocerebral injury]. / Hirndruck-Monitoring bei Patienten mit schwerem Schädel-Hirn-Trauma.

After severe head injury intracranial pressure (ICP) must be measured continuously for management to assess and maintain the cerebral perfusion. Therefore in our hospital epidural transducers are used. To prove the efficiency of this method in a 12-month period the clinical courses of 23 patients with intracranial pressure transducers were analysed retrospectively. Eighteen patients survived, 5 of them without residuals, 13 with residuals and 2 remained in coma. In 14 patients secondary rises of intracranial pressure were observed between days 3 and 6 post injury. The mean ICP value of the survivors revealed 25 mm Hg. whereas the expired showed 60 mm Hg. In 17 patients the measurements were considered as reliable, 6 measurements were not reliable, which included 1 of the 5 patients who died. One transduce was displaced, another one showed a hemorrhage at the drill hole. There was no infection.

[Measuring epidural intracranial pressure in patients with severe craniocerebral trauma]. / Epidurale Hirndruckmessung bei Patienten mit schwerem Schädel-Hirn-Trauma.

In 30 patients with severe head injury (SHI), intracranial pressure (ICP) was monitored using epidural transducers. In 22 patients, the measurements were reliable, with average values of 19.4 mmHg in the survivors and 64.6 mmHg in those who died. It is concluded that epidural measurement of ICP provides a helpful method for the management of SHI and to control the indication for CT scans.

[Detection of the tendon of the musculus plantaris longus--diagnostic imaging and anatomic correlate]. / Nachweis der Sehne des Musculus plantaris longus--bildgebende Diagnostik und anatomisches Korrelat.

Using ultrasound as well as magnetic resonance imaging (MRI) and computed tomography (CT), the plantaris tendon can be identified between the top of the calcaneus and the upper third of the lower leg in cross sections. Due to the surrounding fat tissue, the best proof of plantaris tendon existence and diameter can be obtained on sections at the level of syndesmosis and ankle joint. This allows to avoid unnecessary incisions during plastic and reconstructive surgery using this tendon as an autologeous transplant. For the experienced examiner ultrasound seems to be the easiest way to show plantaris tendon existence; in case of doubt, MRI or CT will give further information.

[Electromyography studies of surgically managed knee ligament ruptures. A retrospective analysis of defined injury patterns]. / Elektromyographische Untersuchungen operativ versorgter Kniebandrupturen. Eine retrospektive Analyse definierter Verletzungsmuster.

In 52 patients (5 groups, average age 32.8 years) with operative treatment of knee ligament injuries cutaneous electromyograms (EMG) under dynamic and isometric conditions (100 N, 200 N, 300 N) were performed in an average of 61.2 weeks postoperatively. The subgroups consisted of 13 patients with operative reconstruction of the anterior cruciate ligament (ACL), 12 after reconstruction of the medial collateral ligament (MCL), 21 after combined ACL and MCL reconstruction and 6 patients with autologous or alloplastic ligament replacement, respectively. The control group consisted of seventeen young adults without a history of knee joint injuries. The intensified and filtered analogous signals of 8 investigated thigh muscles were digitalized and analysed with help of a specially developed computer program. In summary, group specific EMG-criteria reveal distinct ligamentomuscular inhibitory reflexes and, vice versa, EMG activities of thigh muscles may indicate tendencies for group specific criterion after operatively treated knee ligament injuries.

[Experiences with the classic nail in management of per-/subtrochanteric femoral fractures in elderly patients]. / Erfahrungen mit dem Classic-Nagel bei der Versorgung von per-/subtrochanteren Femurfrakturen beim alten Menschen.

In the department of trauma and reconstructive surgery at the University Hospital of Hamburg-Eppendorf (UKE) the surgical treatment of unstable per- and subtrochanteric femoral fractures (AO 31A2 and 31A3) in elderly patients with severe osteoporosis includes the implantation of dynamic hip screws (DHS) and gamma nails, as well as the straighter "classic nails". Using 43 short and 15 long classic nails, 58 fractures in seven women and 51 men, respectively, with an average age of 85 years (65-98 years) were stabilized over the last 2 years with good results (98.3% primary full weight bearing). In order to facilitate implantation of the longer nails, additional antetorsion of the femoral neck screw and improvement of the distal interlocking have been developed by the manufacturer.

Prevalence of human immunodeficiency virus in the trauma emergency room.

Over 55,000 human immunodeficiency virus (HIV)-infections had been reported to the German Federal Health Council as of December 1992. More than 60% of a total of over 9000 overt AIDS cases has arisen in the five largest urban areas. Patients with open wounds represent a daily risk of contamination for emergency room personnel. In addition to surgical treatment and after written informed consent, we conducted HIV-antibody studies on patients with open wounds in the trauma emergency room of the University Hospital Eppendorf over a period of 6 months. Of 286 patients 220 (77%) consented to the study, and 6 HIV infections were found, corresponding to a prevalence of 2.7%.

[Solitary bone cysts. Morphologic variation, site, incidence and differential diagnosis]. / Solitäre Knochenzysten. Morphologische Variationsbreite, Lokalisation, Häufigkeit und Differentialdiagnose.

Analysis of 402 solitary bone cysts demonstrates the wide morphological variation of this cystic lesion with regard to histology and radiology. Aside from metaphyseal location in femur (33%) and humerus (23%), solitary bone cysts are also often located in calcaneus (11%), tibia (11%) and pelvis (10%). Most patients are in the second decade of life. Differentiation between this benign lesion and malignant bone tumors is very important in daily clinical routine. The diagnosis cannot be based solely on radiological findings because of the variation of solitary bone cysts and the special forms, such as calcifying solitary bone cyst. Therefore, exact histological diagnosis is of particular importance.

[Diagnosis and therapy of cruciate ligament injuries in childhood. Clinical results]. / Diagnostik und Therapie von Kreuzbandverletzungen im Kindesalter. Klinische Ergebnisse.

In 19 years 21 children were operated upon anterior or posterior ligament ruptures. Follow-up based on policlinical data and 12 out of 21 patients were tested on follow-up (average follow-up time: 5.5 years). We made notes of the clinical data of an examination with the knee-arthrometer KT-1000 as well as of radiologic and sonographic methods. The subsequent scoring revealed mostly good to very good results. Still, in the long run it would be desirable to perform a prospective multicenter study to obtain statistically relevant data to give advice for ideal surgical treatment of ligamentous knee injuries in children.

[Is there an increased risk of infection in trauma surgery emergency admission for medial personnel by unknown HIV-positive patient status?]. / Besteht in der unfallchirurgischen Notaufnahme ein erhöhtes Infektionsrisiko für das medizinische Personal durch unbekannt HIV-positive Patienten?

In the trauma emergency room 212 patients were asked--according to German law--for a blood sample for HIV-testing. Nine (4.2%) victims rejected the test, another 3 (1,4%) did not meet the study criteria since they were previously known to be HIV-positive or suffering from AIDS disease. None of the finally tested 200 patients was HIV-positive. On an anonymous questionnaire that was handed out additionally, 64% of the patients said they would accept HIV-testing without consent prior to operative treatment. 49% would reject HIV-testing without consent in non-operative treatment.

[Examinations with the KT-1000 knee arthrometer in injuries of the posterior cruciate ligament in comparison with stress roentgen images in the Scheuba positioning device]. / Untersuchungen mit dem KT-1000-Kniearthrometer bei Verletzungen des hinteren Kreuzbandes im Vergleich zu Stressröntgenaufnahmen im Scheuba-Halteapparat.

Eighteen patients with surgically treated ruptures of the posterior cruciate ligament were tested on follow-up 2 to 13 years with KT-1000 Kneearthrometer and radiologically according to Scheuba to objectify the clinical results and to compare the 2 methods. It could be shown that both methods are highly specific and do correspond in 89%. In 11% a borderline difference between a "+" posterior drawer and a "++" posterior drawer in the classification by Hughston et al. [5] was detected. Since the Scheuba test does involve radiation, the KT-1000 Knee-arthrometer testing device represents a safe alternative to objectify a posterior drawer.