E. Markgraf

Die proximale Humerusschaftfraktur als Komplikation nach der Schlüssellochplastik

Six weeks after operative treatment of a rupture of the long head of biceps brachii using keyhole tenodesis on the left arm in a man 69 years old a fracture of the upper arm happened. The reason seems to be the localization of keyhole osteotomy being probably to much distal.ZusammenfassungEin 69 jähriger Patient zog sich sechs Wochen nach der operativen Versorgung einer proximalen Bizepssehnen-ruptur des linken Arms mittels der Schlüssellochplastik eine proximale Humerusschaftfraktur infolge eines Bagatelltraumas zu. Als Ursache dafür muß eine zu weit distal gelegene Schlüssellochosteotomie angenommen werden.AbstractSix weeks after operative treatment of a rupture of the long head of biceps brachii using keyhole tenodesis on the left arm in a man 69 years old a fracture of the upper arm happened. The reason seems to be the localization of keyhole osteotomy being probably to much distal.

Die offene Arthrolyse der posttraumatischen Ellenbogensteife

BACKGROUND The incidence of relevant posttraumatic functional deficits in the sense of elbow stiffness with less than 30 degrees in extension or flexion less than 120 degrees , is unknown. A differentiation can be made between intraarticular, extraarticular and combined causes. An open procedure is indicated in elbow stiffness after correct analysis of the situation and failure of conservative treatment. MATERIALS AND METHODS An open procedure was carried out on 35 patients between March 1995 and November 2001, 10 (3-24) months after the trauma. The mean age of the 24 men and 11 women was 45 (range 17-75) years. Of the patients 15 had distal humerus fractures, 10 radius head or neck fractures and 12 proximal ulnar fractures. RESULTS Of the patients 11 (31%) had an excellent result in the Cauchoix and Deburge score, 15 (42%) a good, 4 (11%) a fair, 4 (11%) a bad and 1 (3%) a very bad result after a mean follow-up of 21.5 (range 9-60) months. Of the patients 11 (31%) had an excellent result in the Mayo elbow performance score, 14 (40%) a good, 5 (14%) a fair and 5 (14%) a poor result. CONCLUSION Open arthrolysis for severe posttraumatic elbow stiffness carried out 10 months (range 3-24 months) after the accident led to good results in most cases with a clear improvement in functional mobility.

Traumatic peripheral vascular injuries

Summary2–4 % of vascular injuries need operative reconstruktion. In polytraumatized patients the rate is even 10 %. Arterial vascular repair should precede venous reconstruction and orthopaedic stabilization due to limb threatening ischemia. Penetration or blunt vascular trauma result either in acute blood loss, ischemia or compartmental compression. Reperfusion syndrom leads to vital threat of patient. Clinical assessment, measurement of limb pressures using a Doppler device and use of duplex ultrasonography are reliable adjuncts in the rapid evaluation. Arteriography is rarely indicated and should be spared for patients with abnormal physical examination. Minimizing ischemia (6–8 h) is an important factor in maximizing limb salvage. Vascular repair include direct anastomosis or lateral suture repair mostly combined with primary shortening of the extremity. In most cases autogenous vein graft is required. Rethrombosis, arteriovenous fistula and pseudoaneurysms are possible complications. Stabilisation of the fracture has priority over vascular reconstruction. The initial steps to success are surgical debridement, adequate bony stabilization mostly by external fixation, revascularisation of vascular injury, immediate fascial decompression and early soft-tissue reconstruction. The best results are obtained when a multidiciplinary approach is used combining expertise in orthopedic surgery, vascular surgery and plastic surgery.ZusammenfassungDie rekonstruktive Versorgungspflicht betrifft 2–4 % der Gefäßverletzungen, bei Mehrfachverletzungen 10 %. Die Wiederherstellung der arteriellen Strombahn hat das Primat, da die Extremitätengefährdung durch Venenverletzung wesentlich geringer ist. Die akuten Verletzungen entstehen durch scharfe oder stumpfe Gewalteinwirkungen. Der Gefäßschaden führt entweder zum akuten Blutverlust oder zur Ausbildung von extremitären Kompressionssyndromen, die über zunehmende Perfusionsstörungen den Gliedmaßenerhalt in Frage stellen können, darüber hinaus aber durch die Reperfusionsphänomene eine vitale Bedrohung des Verletzten darstellen. Die Diagnostik stützt sich auf die klinischen Phänome und wird apparativ heute im wesentlichen durch die cw-Dopplersonographie oder die farbcodierte Duplexsonographie ermöglicht. Die Angiographie ist nur noch für bestimmte Ausnahmefälle reserviert. Die Wiederherstellung der Gefäßstrombahn steht unter der Prämisse, daß die Ischämietoleranzzeit nutritiver Gefäße nur 6–8 h beträgt. Begleitet die Gefäßverletzung Frakturen, insbesondere dislozierte Formen, so ist die primäre Frakturstabilisation wegen der Distanzvorgabe wichtig. Die Osteosynthese erfolgt in der Regel mit einem Fixateur externe. Sie muß in kurzer Zeit erfolgen, und möglichst stabil sein. Die direkte Gefäßanastomosierung gelingt selten, gegebenenfalls bei Verkürzung der Extremität. In der Regel wird eine autologe Vene interponiert. Rethrombosierung, Infektion, Aneurysmen und arterio-venöse (AU-) Fisteln sind Komplikationen oder Spätfolgen von Gefäßverletzungen.

Komplexe osteoligamentäre Verletzungen des Ellenbogens

BACKGROUND Hinged external fixation is a recognized method to treat instabilities after complex dislocations and fracture-dislocations of the elbow. The hinged external fixator allows stabilization of the elbow while preserving flexion and extension. METHODS Eighteen patients with an average age of 47 years (range 35-67) were treated with a hinged external fixator between April 2001 and March 2006 for 6 weeks. In 11 patients an internal fixation had to be done; six were treated initially with an AO fixator. After 8 days (3-14), we changed to a hinged external fixator. RESULTS At 39 months (12-71) of follow-up, all 18 elbows were stable. One stress-fracture of the ulna after pin removal occurred. The mean Mayo Elbow Performance Index (MEPI) was 78 points. Five (28%) patients had an excellent result, six (33%) a good result and seven (39%) a fair result. The average DASH score (disabilities of the arm, shoulder and hand) was 18 points, which indicates a discrete impairment. CONCLUSION The treatment outcome of complex instabilities treated with a hinged external fixator using our technique is comparable to outcomes from other studies.

Das maligne „Marjolin Ulcus“ als seltene Komplikation eines thermischen Traumas an der oberen Extremität

ZusammenfassungAls„Marjolin Ulcus“ bezeichnet man maligne Transformationen chronischer Wunden insbesondere nach Verbrennungstraumen. Die Latenzzeit zwischen dem Primärtrauma und der malignen Transformation beträgt etwa 30 Jahre. Das„Marjolin Ulcus“ zeichnet sich durch ein aggressiveres Verhalten gegenüber anderen Plattenepithelkarzinomen aus. In einem Fall eines 65 jährigen Patienten mit der Läsion am rechten Handrücken und regionalen Lymphknotenmetastasen berichten wir über die kombinierte Strahlen- und chirurgische Therapie. Der ausgedehnte Weichteildefekt nach entsprechend breiter lokaler Exzision wurde mit einem retrograd gestielten A. radialis-Lappen gedeckt.SummaryThe ,,Marjolins ulcer” is a malignant lesion which is developed especially at chronic wounds after burn trauma. The latency from primary trauma to the malignant transformation is about 30 years. The lesion is more aggressive than other squamous cell carcinomas. We report on the combined radiation and surgical therapy of an 65-year-old patient with this lesion on the right hand and regional lymph node metastases. The extensive tissue defect after wide excision was reconstructed with a reversal radial forearm flap.

Open arthrolysis of posttraumatic elbow stiffness

BACKGROUND The incidence of relevant posttraumatic functional deficits in the sense of elbow stiffness with less than 30 degrees in extension or flexion less than 120 degrees , is unknown. A differentiation can be made between intraarticular, extraarticular and combined causes. An open procedure is indicated in elbow stiffness after correct analysis of the situation and failure of conservative treatment. MATERIALS AND METHODS An open procedure was carried out on 35 patients between March 1995 and November 2001, 10 (3-24) months after the trauma. The mean age of the 24 men and 11 women was 45 (range 17-75) years. Of the patients 15 had distal humerus fractures, 10 radius head or neck fractures and 12 proximal ulnar fractures. RESULTS Of the patients 11 (31%) had an excellent result in the Cauchoix and Deburge score, 15 (42%) a good, 4 (11%) a fair, 4 (11%) a bad and 1 (3%) a very bad result after a mean follow-up of 21.5 (range 9-60) months. Of the patients 11 (31%) had an excellent result in the Mayo elbow performance score, 14 (40%) a good, 5 (14%) a fair and 5 (14%) a poor result. CONCLUSION Open arthrolysis for severe posttraumatic elbow stiffness carried out 10 months (range 3-24 months) after the accident led to good results in most cases with a clear improvement in functional mobility.

Complex osteoligamentary injuries of the elbow. Treatment with a hinged external fixator

BACKGROUND Hinged external fixation is a recognized method to treat instabilities after complex dislocations and fracture-dislocations of the elbow. The hinged external fixator allows stabilization of the elbow while preserving flexion and extension. METHODS Eighteen patients with an average age of 47 years (range 35-67) were treated with a hinged external fixator between April 2001 and March 2006 for 6 weeks. In 11 patients an internal fixation had to be done; six were treated initially with an AO fixator. After 8 days (3-14), we changed to a hinged external fixator. RESULTS At 39 months (12-71) of follow-up, all 18 elbows were stable. One stress-fracture of the ulna after pin removal occurred. The mean Mayo Elbow Performance Index (MEPI) was 78 points. Five (28%) patients had an excellent result, six (33%) a good result and seven (39%) a fair result. The average DASH score (disabilities of the arm, shoulder and hand) was 18 points, which indicates a discrete impairment. CONCLUSION The treatment outcome of complex instabilities treated with a hinged external fixator using our technique is comparable to outcomes from other studies.

Amputationsverletzungen der oberen Extremität—Frühkomplikationen nach Replantation und Revaskularisation

ZusammenfassungIn einem Zeitraum von zehn Jahren wurden bei 144 Patienten 95 Replantationen und 102 Revaskularisationen durchgeführt. Bei 26 Patienten waren Revisionsoperationen wegen arterieller oder venöser. Thrombosen erforderlich. Bei 46% unserer Patienten kam es bereits in den ersten 24 Stunden zu vaskulären Frühkomplikationen. Die Thrombosehäufigkeit stieg mit dem begleitenden Weichteilschaden und somit mit der Schwere der Verletzung. Avulsionsverletzungen hatten naturgemäß die schlechteste Prognose. Nach Feststellung eines Gefäßverschlusses im Replantat sollte so schnell wie möglich eine Revision der Anastomosen erfolgen. In zwei Fällen konnten wir durch arterielle Applikation von Urokinase eine Wiederherstellung der Zirkulation auch ohne Revision oder Neuanlage der Anastomose erreichen. Mit einer subtilen Anastomosentechnik und ausreichenden venösen Drainagen (mindestens zwei Venenanschlüsse pro Arterie im Fingerbereich) konnten wir die Thromboserate senken und damit auch die Ergebnisse deutlich verbessern. ab|Within a time of ten years 144 patients with difficult injuries on their hands were operated. These were 95 replantations and 102 revascularizations. 26 patients hat to be operated again because of arterial and venour thrombosis. 46% of our patients had early vascular complications already within 24 hours. The frequency of thrombosis was increasing with the accompanying soft tissue injury and therefore with the gravity of the trauma. Avulsion injuries had of course the worst prognosis. After diagnosis of vascular occlusion within the replanted finger there should be a quick surgical revision of the anastomosis. With the help of application of urokinase into the artery we could create the circulation without any new production of the anastomosis in two cases. With a subtile technique of the disposition of the anastomosis and two venous connections to one artery with the replanted fingers we could reduce the rate of thrombosis and improve the results.Within a time of ten years 144 patients with difficult injuries on their hands were operated. These were 95 replantations and 102 revascularizations. 26 patients had to be operated again because of arterial and venous thrombosis. 46% of our patients had early vascular complications already within 24 hours. The frequency of thrombosis was increasing with the accompanying soft tissue injury and therefore with the gravity of the trauma. Avulsion injuries had of course the worst prognosis. After diagnosis of vascular occlusion within the replanted finger there should be a quick surgical revision of the anastomosis. With the help of application of urokinase into the artery we could create the circulation without any new production of the anastomosis in two cases. With a subtile technique of the disposition of the anastomosis and two venous connections to one artery with the replanted fingers we could reduce the rate of thrombosis and improve the results.

Funktionelle Knochenbruchbehandlung am Oberarm

Using a functional brace, we treated 67 patients who had a fracture of the humeral shaft over a 5-year period from 1987 to 1992. We analysed several parameters of the fractures to discover those which influence healing. Desault, plaster cast or traction were used before applying a brace in an average time of 15 days. The osseous consolidation was 10 weeks in the average. The functional results were very good and good in 78.3%, acceptable in 18.3% and poor in 3.4% of the cases. Twelve humeral-shaft fractures were associated with a radial nerve palsy. Every patient recovered a full radial nerve function under the treatment with a functional brace. The retentive management of an operative treatment of humeral-shaft fractures associated with a nerve injury can be supported because of our experience.ZusammenfassungIn einer retrospektiven Studie von 1987 bis 1992 erfolgte die Auswertung von 67 frühfunktionell mit dem Brace nach Sarmiento behandelten Patienten mit Humerusschaftfrakturen. Zur Vorbehandlung vor Anlage des Brace kamen Extension, Binden-Desault und Gipslonguette für durchschnittlich 15 Tage in Anwendung. Nach durchschnittlich zehn Wochen war die Fraktur nach röntgenologischen Kriterien durchgebaut. Die funktionellen Ergebnisse nach der Wasmer-Klassifikation waren in 78,3% sehr gut und gut, in 18,3% befriedigend und in 3,4% schlecht. Die zwölf primären Radialisparesen im Krankengut restituierten sich vollständig. Somit kann die operative Zurückhaltung von Humerusschaftfrakturen mit Radialisparesen befürwortet werden.AbstractUsing a functional brace, we treated 67 patients who had a fracture of the humeral shaft over a 5-year period from 1987 to 1992. We analysed several parameters of the fractures to discover those which influence healing. Desault, plaster cast or traction were used before applying a brace in an average time of 15 days. The osseous consolidation was 10 weeks in the average. The functional results were very good and good in 78.3%, acceptable in 18.3% and poor in 3.4% of the cases. Twelve humeral-shaft fractures were associated with a radial nerve palsy. Every patient recovered a full radial nerve function under the treatment with a functional brace. The retentive management of an operative treatment of humeral-shaft fractures associated with a nerve injury can be supported because of our experience.

Study of late results of flexor tendon injuries in the hand with examination of 119 patients

SummaryIn the care and further treatment of patients with hand injuries, a necessary requirement of the hand surgeon is that he be able to cope with the interlocking factors that are no longer influential, for example, the type and extent of the trauma or the age of the patient; the influential factors are a thought-out care plan, atraumatic action with regard to optimal restoration of the hand. This also showed a retrospective analysis of results and post-examination from flexor tendon injuries in the hand of 298 patients, who were surgically cared for from 1984 to 1994 at the surgical clinic of the University of Jena. Of the 298 patients 119 patients with 198 flexor tendon injuries (165 fingers and 33 thumbs) were followed up. For objective assessment of the treatment results, the assessment scheme Buck-Gramcko was used.ZusammenfassungVersorgung und Weiterbehandlung handverletzter Patienten verlangt von dem Handchirurgen immer wieder, das Ineinandergreifen von nicht mehr beeinflußbaren Faktoren wie Art und Ausdehnung des Traumas, Alter des Patienten und beeinflußbaren Faktoren wie durchdachter Versorgungsplan, atraumatisches Vorgehen hinsichtlich einer optimalen Wiederherstellung der Einheit Hand zu bewältigen. Dies zeigte auch eine retrospektive Analyse über Resultate und Nachuntersuchungsergebnisse nach Beugesehnendurchtrennungen im Hand- und Fingerbereich bei 298 Patienten, die von 1984–1994 an der Chirurgischen Universitätsklinik Jena operativ versorgt wurden. Von den 298 Patienten konnten 119 Patienten mit 198 Beugesehnendurchtrennungen (165 Langfinger und 33 Daumen) nachuntersucht werden. Zur objektiven Bewertung der Behandlungsergebnisse wurde das Bewertungsschema von Buck-Gramcko angewendet.