Marcus Schiltenwolf

Further investigations of the intraosseous pressure characteristics in necrotic lunates (Kienböck's disease)*

To confirm the hypothesis that venous congestion plays a role in idiopathic lunate necrosis (Kienböcks disease), intraosseous pressure in 12 normal and 12 necrotic lunates was measured. Intraosseous pressure in the capitate of 12 healthy subjects served as reference measurement. The intraosseous pressure was recorded in neutral position and 60 degrees extension of the wrist under normotensive conditions and during venous stasis. In all groups, the mean intraosseous pressure rose significantly with extension of the wrist, with the largest increase being 92.3 mmHg for necrotic lunates, followed by 40.3 mmHg for normal lunates, 6.9 mmHg for normal capitates and during venous stasis, 26.6 mmHg for necrotic lunates, 26.1 mmHg for normal lunates, and 5.9 mmHg for normal capitates. In some necrotic lunates, the intraosseous pressure during extension exceeded the arterial blood pressure, which can be explained by mechanical deformation of the bone. In neutral position, no significant differences in pressure were found between normal lunates and capitates. A significant difference was found for venous stasis and extension. The intraosseous pressure rise in the normal lunate in extension was slightly higher than the pressure found during venous stasis. The intraosseous pressure differed significantly (by 56.9 mmHg) between normal and necrotic lunates in extension. These data support the hypothesis that impairment of venous drainage plays a role in lunate necrosis and that the lunate can be considered as a venous bone at risk.

Begutachtung der HWS-Distorsion

The assessment of cervical spine injuries is not a problem - provided full evidence of primary physical damage can be ensured. MRI examinations of the cervical spine carried out soon after the accident provide the best evidence. The assessment is more difficult if only clinical abnormalities are documented by the doctors after the accident in the diagnosis of cervical spine distortion, as functional results of this type are not specific and are also common in the general population. The legal rules of evidence must be taken into account in the summary assessment of the consequences of cervical spine injuries. Testing schemes are available which allow structured assessment of cervical spine injuries and help to avoid incorrect assessments.

Begutachtung chronischer muskuloskeletaler Schmerzen: Aktualisierung der Leitlinie zur Begutachtung von Menschen mit chronischen Schmerzen

Medicolegal assessments of claimants with chronic muskuloskeletal pain conditions are frequent. The first German guideline published in 2005 for the medicolegal assessment of claimants in chronic pain is now available in its 4th version (AWMF register number 094 - 003). It gives recommendations for the procedure and serves to ensure the quality of expert opinions when complaints about chronic pain are the leading symptom. In the current version, the indications for ordering medical assessments in pain syndromes have been reformulated, the assessment criteria have been adapted to ICF specifications, and an unequivocal distinction has been introduced between questions of state and causal assessment. A separate chapter on symptom validity assessment has been engrafted.

BK 2108 – Die Berechnung der normierten relativen lumbalen Bandscheibenhöhe: Gutachtliche Vorgehensweise in der standardisierten Beurteilung der Chondrose

The assessment of the medical conditions (liability-compliant causality) of the BK 2108 is a frequent assessment, which poses a challenge to the medical expert in orthopaedics and trauma surgery. In assessing the load-consistent damage pattern, defined changes in the intervertebral discs as well as the adjacent vertebral bodies must be comprehended in a standardised manner. Of several technical measuring methods, three practicable methods are discussed and their application explained. Thus, methods are provided which allow the medical expert to calculate the normalised relative disc height. In this way, the specifications of the consensus recommendations can be met in order to define the damage profile.

Begutachtung des OPS-Codes 8-918 Multimodale Schmerztherapie

Interdisciplinary multimodal pain therapy is the gold standard in the treatment of chronic pain. Due to an overall increase in case numbers, the number of MDK examinations leading to the assessment of primary incorrect occupancy is also increasing. This results in a multitude of social court disputes in which medical assessments are required. With knowledge of the legal norms and relevant guidelines or other recommendations, the expert can take this topic step by step. The starting point here is the evaluation of the patient file, followed by the examination of the medical indication, the implementation of the therapy and, finally, the answers to the questions of proof. A test scheme based on the Schröter concept can further simplify this process.

A NEW CLASSIFICATION OF LUNATE NECROSIS

The classifications of lunate necrosis used by Decoulxet al. (1957)3 and Lichtmanet al. (1977)7 and Lichtman and Degnan (1993),6 respectively, do not refer to early changes in MRI nor to changes to the carpal architecture, but do attribute the onset of the disease to the presence of a fracture. A recent publication of Lichtman and Ross (1994)8 did not solve the problem of a precise description of the disease. This necessitates a new, reliable classification based on the true natural course of the disease. In a prospective study of 49 patients and in a retrospective analysis of 125 lunate necrosis, the findings obtained prove the regular natural course of the disease. It starts with normal x-ray appearance but the intensity of the signal in T1-weighted MRI is decreased; a fracture line is part of the latter course and not the beginning. It precedes the collapse of the lunate, followed by the collapse of the carpus and the arthritis of the wrist.