C. Gekle

Which labral lesion can be best reduced with external rotation of the shoulder after a first-time traumatic anterior shoulder dislocation?

IntroductionImmobilization in external rotation after a first-time traumatic anterior shoulder dislocation has been shown to improve the position of the labroligamentous lesion relative to the glenoid rim. The purpose of the present study was to evaluate the effect of the external rotation position of the shoulder on different types of labroligamentous lesions in patients with first-time traumatic anterior shoulder dislocation by using MRI.Patients and methodsWe performed a standardized MRI in internal and external rotation of the shoulder after initial reduction in 34 patients with a first-time traumatic anterior shoulder dislocation. Labroligamentous lesions were classified as Bankart, Perthes, or nonclassifiable. Four distinct grades were used to classify the amount of plastic deformation of the anterior labroligamentous structures. The position of the labrum was defined relative to the tip of the glenoid rim by measuring the dislocation and separation.ResultsIn all patients, dislocation and separation of the labrum relative to the rim of the glenoid were significantly improved in shoulders in the external rotation position compared to those in the internal rotation position. We observed 15 Bankart, 15 Perthes, and 4 non-classifiable lesions. No HAGL or GLAD lesions were found. Fourteen patients showed a plastic deformation grade I, 16 showed grade II, 3 showed grade III, and 1 showed grade IV. In regression analysis, the odds ratio was 1.100 for the type of lesion and 1.660 for the grade of plastic deformation. Perthes lesions (with an intact anterior scapular periosteum) and grade I plastic deformations showed the best labral reduction on the external rotation MRI.ConclusionPlacing the shoulder in external rotation after a first-time traumatic shoulder dislocation, significantly improves the position of the labroligamentous lesion on the glenoid rim. Perthes lesions that showed a low grade of plastic deformation displayed better reduction in external rotation and then compared to Bankart or other lesions that showed a high grade of plastic deformation. In conclusion, immobilization of the shoulder after a first-time traumatic shoulder dislocation is most effective in patients with Perthes lesions that show low grade plastic deformation.

Neue Biomaterialien am Skelettsystem

Summary. The increasing number of biomaterials for the skeletal system requires mote and move their distinct clinical application. To guarantee useful therapeutic results the characteristics of the biomaterials have to be matched with the characteristics of the implantation site. Recently developed biodegradable polymers with a slow degradation process and longer stability are being increasingly clinically applied with a low complication rate. The development of new remodelable bone cements for bone-defect filling revives the idea of cement-metallic implant constructs. Finally, recombinant human bone growth factors are currently under controlled clinical examination with first promising results. Long-term results allowing common clinical use of these factors are still to be expected.Zusammenfassung. Die zunehmende Anzahl unterschiedlicher Biomaterialien zur Anwendung im Skelettsystem erfordert immer mehr eine differenzierte Anwendung in der Klinik. Um ihren sinnvollen therapeutischen Einsatz zu gewährleisten, müssen die jeweiligen Biomaterialeigenschaften mit den Implantatlagereigenschaften abgestimmt sein. Weiterentwickelte biodegradierbare Polymere mit langsamer Umbaurate und länger anhaltender Stabilität werden bei deutlich verminderter Komplikationsrate zunehmend erfolgreich eingesetzt. Im Bereich der keramischen Knochenersatzstoffe läßt die Entwicklung neuartiger umbaubarer Knochenzemente neben der Möglichkeit der Defektauffüllung die Idee der „Verbundosteosynthese“ wieder aufleben. Eine weitere vielversprechende Gruppe sind die rekombinant humanen Knochenwachstumsfaktoren, die zur Zeit in der klinischen Erprobung sind. Eine allgemeine erfolgreiche Anwendung mit verwertbaren Langzeitergebnissen steht noch aus.

Anterior Sternoclavicular Dislocation Caused by Indirect Compression Trauma

AbstractBackground:Anterior dislocation of the sternoclavicular joint is extremely rare because the ligamentous connections surrounding the joint are strong. Since there is a very low complication rate, conservative treatment can be justified in most cases. Nonetheless, lack of reduction or, in case of re-dislocation, conservative treatment, is often associated with cosmetic asymmetry of the sternoclavicular joints due to ventral protrusion of the medial end of the clavicle. Furthermore, chronic pain, periarticular calcifications with ankylosis and progressive deformity may result. In cases of unsuccessful closed reduction and/or repeated re-dislocations despite corrective bandages, open reduction and fixation is indicated. An optimal, standardized operative procedure has not yet been established because of the small number of cases. The applied procedures include wire osteosynthesis, plate osteosynthesis, pin fixation with resorbable materials, complex capsular ligament reconstructions with displacement of tendons, resection of the medial end of the clavicle and arthrodesis of the sternoclavicular joint.Case Study:We report about a patient who sustained an anterior dislocation of the sternoclavicular joint as a result of a road traffic accident. Initially, conservative treatment was implemented with closed reduction and a correction bandage. After repeated re-dislocation, despite the bandage, we decided to stabilize the reduction surgically using PDS cord for fixation in a transosseous tension band technique which aligned the anteriorly dislocated medial end of the clavicle with the sternal articulating surface. 1 year after operation, the patient is symptom-free. She is very satisfied with the cosmetic result. No further dislocation has occurred.

Indirekte Reposition und Retention der Bankart-Fraktur in Außenrotation

The treatment of anterior glenoid rim fractures depends on the size of the fracture and the articular surface involved. The operative treatment is open or arthroscopic refixation. In cases with small fragments and a stable shoulder nonoperative treatment is recommended. In patients with a primary shoulder dislocation immobilization in external rotation has been showed to improve the position of the displaced labrum on the glenoid rim. However, whether external rotation can reduce displaced glenoid rim fractures is not known. With the use of CT the repositioning of a glenoid rim fracture in a single patient in external rotation is evaluated.A 26-year-old patient with an anterior glenoid rim fracture after a primary shoulder dislocation was referred to our shoulder service. After initial reduction a CT scan in internal and external rotation of the involved shoulder was performed. In the external rotation CT the glenoid rim fracture was reduced in anatomic position. The patient was immobilized in a 30 degrees external rotation brace for 4 weeks. Six weeks after trauma the internal rotation CT showed the fracture healed in the anatomic position. At the 1-year follow-up the Constant Score and the Rowe Score were 100 points each. In patients with anterior glenoid rim fractures immobilization of the shoulder in external rotation seems to allow a reduction of the fracture. A study with a large number of patients is under way to evaluate long-term results.

Sigmaperforation mit lokaler Peritonitis durch indirektes Trauma – Fallbericht und Literaturübersicht

ZusammenfassungSigmaperforationen ereignen sich sowohl akut als auch protrahiert. Im 1.Fall fließt der Darminhalt in die freie Bauchhöhle. Es entsteht eine generalisierte, fäkulente, lebensbedrohliche Peritonitis mit ungünstiger Prognose.Bei der protrahiert verlaufenden Form wird die Rupturstelle vom Peritoneum und den angrenzenden Organen bereits vor dem Durchbruch abgedeckt. Es entsteht ein Abszess, der in ein benachbartes Hohlorgan oder zur Hautoberfläche durchbrechen kann.Häufig resultiert eine innere oder äußere Fistel.Der Auslöser für eine Sigmaperforation kann eine spontane Ruptur ohne vorangegangenes Trauma durch einen vorgeschädigten Darm sein. Als häufige Vorerkrankungen sind hier die Divertikulitis, die Kolitis,Karzinome und Nekrosen zu nennen. Auch ein erhöhter Darminnendruck durch verstärkte Bauchpresse oder Kotsteine können zu einer nichttraumatischen Ruptur des Colon sigmoideum führen. Häufige Ursache für eine traumatische Läsion des Sigmas stellen diagnostische Verfahren wie z.B.Rektoskopie und Kontrasteinläufe dar.Perforierende Verletzungen der Bauchhöhle durch Stich, Schuss oder Pfählung können auch das Sigma betreffen und sein Lumen eröffnen. Fremdkörper führen ebenfalls häufig zu traumatischen Verletzungen im rektosigmoidalen Übergang. Indirekte Traumata hingegen stellen eine ausgesprochene Rarität dar. Wir berichten über den seltenen Fall einer indirekten traumatischen Ruptur des Kolons im Sigmabereich. Es handelt sich um eine 62-jährige Patientin mit vorbestehenden Briden nach konventioneller Cholezystektomie, die bei einem Treppensturz auf das Gesäß eine Ruptur des Colon sigmoideum mit lokaler Peritonitis erlitt.Die Patientin wurde laparotomiert und der Einriss übernäht.AbstractInjuries to the sigmoid occur either as acute or protracted events. In the first case, enteral contents discharge into the abdominal cavity and a generalized, fecal, life-threatening peritonitis with a bad prognosis develops. In the protracted form, the rupture is covered by peritoneum and adherent organs before perforation.The ensuing abscess formation may lead to perforation into contiguous visceral organs or the cutis.Frequently an intestinal or cutaneous fistula results.The trigger for a sigmoid perforation can be a spontaneous rupture in an already vulnerable intestine.Common precursory diseases are diverticulitis, colitis, carcinomas, and necroses. Also, elevated intestinal pressure invoked by increased bearing down or coproliths may cause disruption. Diagnostic procedures such as rectoscopy and rectal contrast instillation are frequent idiopathic causes of traumatic injuries to the sigmoid.Perforating injuries of the abdominal cavity by stabbing, gunshot, or impalement may affect the sigmoid and open its lumen.Foreign bodies often lead to traumatic injuries of the rectosigmoid junction. In contrast, indirect trauma as a cause of sigmoid perforation, which is described in the following case, is very rare. A 62-year-old woman,who had a cholecystectomy and adhesive strangulation of intestine in her history,was admitted to our clinic after falling down stairs and landing on her bottom.She suffered a sigmoid rupture and peritonitis.Laparotomy and suturing of the sigmoid defect were performed.

Primäre Schulterendoprothetik nach Trauma

ZusammenfassungDie primäre Frakturendoprothetik der Schulter ist in den letzten Jahren aufgrund der verbesserten Osteosyntheseverfahren mit kleinfragmentären, winkelstabilen Plattensystemen eher rückläufig. Die Schwierigkeit bei der 4-Fragment-Fraktur bei erhaltener Kopfkalotte liegt in der Reposition und Retention der Tuberkel in anatomischer Position. Diese Problematik wird durch die Frakturprothetik nicht gelöst. Bei kompletten Head-Split-Frakturen ist der Ersatz der Kalotte durch eine Prothese indiziert. Das Problem der stabilen Tuberkelrefixation und knöchernen Integration bleibt jedoch bestehen. Neue Prothesendesigns verbessern die Tuberkelrefixationsmöglichkeit und die korrekte Positionierung der Prothese. Eine anatomische Frakturrekonstruktion ist immer primäres Ziel und sollte nicht zu früh verlassen werden.AbstractIndications for primary shoulder prosthesis in displaced four-part fractures has decreased in recent years due to new techniques in fracture reconstruction using angle-stable plate osteosynthesis. The challenge of four-part fractures with an intact head fragment is the anatomic reconstruction and fixation of the tuberosities. Using a fracture prosthesis does not solve this problem. In complex head-split fractures arthroplasty is indicated, but the difficulty of tuberosity refixation and healing remains. New prosthetic designs improve tuberosity fixation and healing, as well as correct placement and orientation of the prosthesis. Anatomic fracture reconstruction should always be the goal and this goal should not be abandoned too easily.

Tuberculous rice body synovitis of the shoulder joint

ZusammenfassungDas Krankheitsbild der Reiskornsynovitis findet sich bei einigen wenigen systemischen Erkrankungen als Begleitmanifestation innerhalb von Gelenken oder in gelenkassoziierten Bursen. Ein 79-jähriger Patient stellte sich vor, der seit längerer Zeit über Schmerzen und Schwellung in der linken Schulter klagte. In der Sonographie konnten innerhalb des Gelenkergusses multiple spindelförmige Gelenkkörper festgestellt werden. Die Magnetresonanztomographie zeigte einen ausgedehnten Befund von reiskorngroßen Präzipitaten mit Gelenkerguss und Massenruptur der Rotatorenmanschette an der linken Schulter. In der histologischen Untersuchung zeigte sich eine für die Tuberkulose spezifische Entzündungsreaktion mit Riesenzellen und epitheloidzelligen Granulomen und molekularbiologischem Nachweis von Mycobacterium tuberculosis. Nach chirurgischer Entfernung der „Reiskörper“ aus dem Gelenkraum und den Bursen an der Schulter kam es innerhalb weniger Monate zu einem Rezidiv mit abermaliger Ergussbildung und Notwendigkeit einer erneuten chirurgischen Entfernung der intraartikulären Gelenkkörpermasse. Wir beschreiben den seltenen Fall eines Patienten mit einseitiger muskuloskelettaler Manifestation der Tuberkulose in Form einer Reiskornsynovitis des linken Schultergelenks und der angrenzenden Bursen mit beschleunigter Wachstumstendenz ohne bekannte Tuberkuloseerkrankung in der Anamnese oder Nachweis anderer Tuberkuloseherde. Zusätzlich erfolgt eine kurze Literaturzusammenfassung.AbstractThe clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

Tuberkulöse Reiskornsynovitis des Schultergelenks

ZusammenfassungDas Krankheitsbild der Reiskornsynovitis findet sich bei einigen wenigen systemischen Erkrankungen als Begleitmanifestation innerhalb von Gelenken oder in gelenkassoziierten Bursen. Ein 79-jähriger Patient stellte sich vor, der seit längerer Zeit über Schmerzen und Schwellung in der linken Schulter klagte. In der Sonographie konnten innerhalb des Gelenkergusses multiple spindelförmige Gelenkkörper festgestellt werden. Die Magnetresonanztomographie zeigte einen ausgedehnten Befund von reiskorngroßen Präzipitaten mit Gelenkerguss und Massenruptur der Rotatorenmanschette an der linken Schulter. In der histologischen Untersuchung zeigte sich eine für die Tuberkulose spezifische Entzündungsreaktion mit Riesenzellen und epitheloidzelligen Granulomen und molekularbiologischem Nachweis von Mycobacterium tuberculosis. Nach chirurgischer Entfernung der „Reiskörper“ aus dem Gelenkraum und den Bursen an der Schulter kam es innerhalb weniger Monate zu einem Rezidiv mit abermaliger Ergussbildung und Notwendigkeit einer erneuten chirurgischen Entfernung der intraartikulären Gelenkkörpermasse. Wir beschreiben den seltenen Fall eines Patienten mit einseitiger muskuloskelettaler Manifestation der Tuberkulose in Form einer Reiskornsynovitis des linken Schultergelenks und der angrenzenden Bursen mit beschleunigter Wachstumstendenz ohne bekannte Tuberkuloseerkrankung in der Anamnese oder Nachweis anderer Tuberkuloseherde. Zusätzlich erfolgt eine kurze Literaturzusammenfassung.AbstractThe clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

Reduction of glenoid rim fractures after primary shoulder dislocation in external rotation

The treatment of anterior glenoid rim fractures depends on the size of the fracture and the articular surface involved. The operative treatment is open or arthroscopic refixation. In cases with small fragments and a stable shoulder nonoperative treatment is recommended. In patients with a primary shoulder dislocation immobilization in external rotation has been showed to improve the position of the displaced labrum on the glenoid rim. However, whether external rotation can reduce displaced glenoid rim fractures is not known. With the use of CT the repositioning of a glenoid rim fracture in a single patient in external rotation is evaluated.A 26-year-old patient with an anterior glenoid rim fracture after a primary shoulder dislocation was referred to our shoulder service. After initial reduction a CT scan in internal and external rotation of the involved shoulder was performed. In the external rotation CT the glenoid rim fracture was reduced in anatomic position. The patient was immobilized in a 30 degrees external rotation brace for 4 weeks. Six weeks after trauma the internal rotation CT showed the fracture healed in the anatomic position. At the 1-year follow-up the Constant Score and the Rowe Score were 100 points each. In patients with anterior glenoid rim fractures immobilization of the shoulder in external rotation seems to allow a reduction of the fracture. A study with a large number of patients is under way to evaluate long-term results.

Tuberkulöse Reiskornsynovitis des Schultergelenks@@@Tuberculous rice body synovitis of the shoulder joint

ZusammenfassungDas Krankheitsbild der Reiskornsynovitis findet sich bei einigen wenigen systemischen Erkrankungen als Begleitmanifestation innerhalb von Gelenken oder in gelenkassoziierten Bursen. Ein 79-jähriger Patient stellte sich vor, der seit längerer Zeit über Schmerzen und Schwellung in der linken Schulter klagte. In der Sonographie konnten innerhalb des Gelenkergusses multiple spindelförmige Gelenkkörper festgestellt werden. Die Magnetresonanztomographie zeigte einen ausgedehnten Befund von reiskorngroßen Präzipitaten mit Gelenkerguss und Massenruptur der Rotatorenmanschette an der linken Schulter. In der histologischen Untersuchung zeigte sich eine für die Tuberkulose spezifische Entzündungsreaktion mit Riesenzellen und epitheloidzelligen Granulomen und molekularbiologischem Nachweis von Mycobacterium tuberculosis. Nach chirurgischer Entfernung der „Reiskörper“ aus dem Gelenkraum und den Bursen an der Schulter kam es innerhalb weniger Monate zu einem Rezidiv mit abermaliger Ergussbildung und Notwendigkeit einer erneuten chirurgischen Entfernung der intraartikulären Gelenkkörpermasse. Wir beschreiben den seltenen Fall eines Patienten mit einseitiger muskuloskelettaler Manifestation der Tuberkulose in Form einer Reiskornsynovitis des linken Schultergelenks und der angrenzenden Bursen mit beschleunigter Wachstumstendenz ohne bekannte Tuberkuloseerkrankung in der Anamnese oder Nachweis anderer Tuberkuloseherde. Zusätzlich erfolgt eine kurze Literaturzusammenfassung.AbstractThe clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.