Sebastian Manegold

[Shock trauma room diagnosis: initial diagnosis after blunt abdominal trauma. A review of the literature].

ZusammenfassungFragestellung.Das stumpfe Abdominaltrauma tritt meist im Rahmen eines Polytraumas auf und stellt neben dem SHT die häufigste Ursache für das frühe Versterben des schwerstverletzten Patienten dar. Daher ist eine unverzügliche Diagnostik abdomineller Verletzungen von entscheidender Bedeutung.Methodik.Klinische Studien wurden über systematische Literatursuchen (Medline, Cochrane und Handsuche) und Klassifikation nach Evidenzgüte (Level 1–5 nach Oxford-Schema) zusammengetragen.Ergebnisse.Die alleinige klinische Untersuchung des Abdomens zur Diagnostik einer intraabdominellen Verletzung ist nicht verlässlich. Die Sonographie des Abdomens, insbesondere das alleinige Screening nach freier Flüssigkeit (FAST) ist nicht ausreichend sensitiv. Die Computertomographie des Abdomens stellt dagegen derzeit den Goldstandard dar. Die diagnostische Peritoneallavage (DPL) findet trotz nachgewiesener hoher Sensitivität nur in Ausnahmen Anwendung. Beim persistierend kreislaufinstabilen Patienten und Nachweis von freier Flüssigkeit im Abdomen sollte ohne Verzug die Notfallaparotomie erfolgen.Schlussfolgerungen.Nach Abdominaltrauma sollte im Schockraum zunächst eine Abdomensonographie zum Nachweis freier Flüssigkeit und Screening auf Organläsionen erfolgen. Unabhängig davon ist nach stumpfem Abdominaltrauma beim ausreichend kreislaufstabilen Patienten zur sicheren Diagnostik einer intraabdominellen Verletzung eine Computertomographie des Abdomens durchzuführen.AbstractObjective.Blunt abdominal trauma is most common in the polytraumatized patient and beside neurocranial trauma one major determinant of early death in these patients. Therefore, immediate recognition of an abdominal injury is of life-saving importance.Methods.Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).Results.Clinical examination is not reliable for evaluation of abdominal injury. Abdominal ultrasound, especially if only focusing on free fluid (FAST) is not sensitive enough. Today, CT-scan of the abdomen is the gold-standard in diagnosing abdominal injury. Diagnostic Peritoneal Lavage (DPL) has a high sensitivity but in our region only is used in exceptional cases. The patient with continuing hemodynamical instability after abdominal trauma and evidence of free intraperitonial fluid has to undergo laparotomy.Conclusion.After blunt abdominal trauma, initially ultrasound investigation should be performed in the emergency room. This should not only focus on free intraabdominal fluid but also on organ lesions. Regardless of the findings from ultrasound or clinical examination, the hemodynamically stable patient should undergo a CT-scan of the abdomen in order to proof or exclude an abdominal injury.

Schockraumdiagnostik: Initiale Diagnostik beim stumpfen Abdominaltrauma

ZusammenfassungFragestellung.Das stumpfe Abdominaltrauma tritt meist im Rahmen eines Polytraumas auf und stellt neben dem SHT die häufigste Ursache für das frühe Versterben des schwerstverletzten Patienten dar. Daher ist eine unverzügliche Diagnostik abdomineller Verletzungen von entscheidender Bedeutung.Methodik.Klinische Studien wurden über systematische Literatursuchen (Medline, Cochrane und Handsuche) und Klassifikation nach Evidenzgüte (Level 1–5 nach Oxford-Schema) zusammengetragen.Ergebnisse.Die alleinige klinische Untersuchung des Abdomens zur Diagnostik einer intraabdominellen Verletzung ist nicht verlässlich. Die Sonographie des Abdomens, insbesondere das alleinige Screening nach freier Flüssigkeit (FAST) ist nicht ausreichend sensitiv. Die Computertomographie des Abdomens stellt dagegen derzeit den Goldstandard dar. Die diagnostische Peritoneallavage (DPL) findet trotz nachgewiesener hoher Sensitivität nur in Ausnahmen Anwendung. Beim persistierend kreislaufinstabilen Patienten und Nachweis von freier Flüssigkeit im Abdomen sollte ohne Verzug die Notfallaparotomie erfolgen.Schlussfolgerungen.Nach Abdominaltrauma sollte im Schockraum zunächst eine Abdomensonographie zum Nachweis freier Flüssigkeit und Screening auf Organläsionen erfolgen. Unabhängig davon ist nach stumpfem Abdominaltrauma beim ausreichend kreislaufstabilen Patienten zur sicheren Diagnostik einer intraabdominellen Verletzung eine Computertomographie des Abdomens durchzuführen.AbstractObjective.Blunt abdominal trauma is most common in the polytraumatized patient and beside neurocranial trauma one major determinant of early death in these patients. Therefore, immediate recognition of an abdominal injury is of life-saving importance.Methods.Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).Results.Clinical examination is not reliable for evaluation of abdominal injury. Abdominal ultrasound, especially if only focusing on free fluid (FAST) is not sensitive enough. Today, CT-scan of the abdomen is the gold-standard in diagnosing abdominal injury. Diagnostic Peritoneal Lavage (DPL) has a high sensitivity but in our region only is used in exceptional cases. The patient with continuing hemodynamical instability after abdominal trauma and evidence of free intraperitonial fluid has to undergo laparotomy.Conclusion.After blunt abdominal trauma, initially ultrasound investigation should be performed in the emergency room. This should not only focus on free intraabdominal fluid but also on organ lesions. Regardless of the findings from ultrasound or clinical examination, the hemodynamically stable patient should undergo a CT-scan of the abdomen in order to proof or exclude an abdominal injury.

Treatment strategy for talus fractures

Fractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively. The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.ZusammenfassungTalusfrakturen sind seltene Verletzungen, stellen aber eine therapeutische Herausforderung dar. Die gängigen Frakturklassifikationen beruhen auf der konventionellen Radiographie, das CT ist jedoch bei jeder Fraktur obligat. Offene Frakturen, Luxationen oder Talusextrusionen müssen notfallmäßig reponiert und stabilisiert werden. Alle dislozierten Talusfrakturen stellen eine absolute Operationsindikation dar. Die Zugangswahl wird vom Frakturtyp und dem Weichteilschaden bestimmt. Die anatomische Reposition der Gelenkflächen und der Talusform und die Stabilisierung mit Zugschrauben stellt meistens die Methode der Wahl dar.Das Ergebnis wird vom Dislokationsgrad bzw. dem Weichteilschaden, aber oftmals auch von der unzulänglichen Versorgung determiniert. Verzögerte Konsolidierungen, Pseudarthrosen und sekundäre Fehlstellungen sollten möglichst frühzeitig gelenkerhaltend korrigiert und notwendige Arthrodesen auf die betroffenen Gelenke beschränkt werden.AbstractFractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively.The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.

Increased unilateral tendon stiffness and its effect on gait 2-6 years after Achilles tendon rupture

Achilles tendon rupture (ATR) alters tissue composition, which may affect long‐term tendon mechanics and ankle function during movement. However, a relationship between Achilles tendon (AT) properties and ankle joint function during gait remains unclear. The primary hypotheses were that (a) post‐ATR tendon stiffness and length differ from the noninjured contralateral side and that (b) intra‐patient asymmetries in AT properties correlate to ankle function asymmetries during gait, determined by ankle angles and moments. Ultrasonography and dynamometry were used to assess AT tendon stiffness, strain, elongation, and rest length in both limbs of 20 ATR patients 2–6 years after repair. Three‐dimensional ankle angles and moments were determined using gait analysis. Injured tendons exhibited increased stiffness, rest length, and altered kinematics, with higher dorsiflexion and eversion, and lower plantarflexion and inversion. Intra‐patient tendon stiffness and tendon length ratios were negatively correlated to intra‐patient ratios of the maximum plantarflexion moment and maximum dorsiflexion angle, respectively. These results suggest that after surgical ATR repair, higher AT stiffness, but not a longer AT, may contribute to deficits in plantarflexion moment generation. These data further support the claim that post‐ATR tendon regeneration results in the production of a tissue that is functionally different than noninjured tendon.

Periprosthetic Fractures in Total Ankle Replacement: Classification System and Treatment Algorithm

BACKGROUND Despite progress in implant design and surgical technique, the reported number of periprosthetic ankle fractures following total ankle joint replacement continues to increase. A treatment-oriented classification of these fractures has not yet been reported. The purpose of this study was to evaluate the prevalence, cause, and location of periprosthetic fractures and the stability of the associated prosthetic components after total ankle replacement and to develop a method of classification. METHODS Data regarding 503 total ankle replacements with a mean follow-up of 14.7 months were reviewed. The prevalence, location, and possible cause of the fractures as well as prosthesis stability were analyzed and a systematic method of classification based on these factors was developed. RESULTS Twenty-one patients (4.2%) with a periprosthetic fracture were identified. The fracture was intraoperative (Type 1) in eleven patients (2.2%) and postoperative in the remaining ten (2.0%). Two of the latter fractures were traumatic (Type 2) and eight were stress fractures (Type 3). Two-thirds (fourteen) of the twenty-one fractures occurred in the medial malleolus. CONCLUSIONS The prevalence of periprosthetic fractures following primary total ankle replacement was relatively low. We propose a classification system for these fractures that is based on more than 500 cases. We believe that this classification can facilitate therapeutic decision-making, as it allows for differential analysis of the cause and guides the choice among operative and nonoperative treatment options.

Therapiestrategie bei Talusfrakturen

Fractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively. The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.ZusammenfassungTalusfrakturen sind seltene Verletzungen, stellen aber eine therapeutische Herausforderung dar. Die gängigen Frakturklassifikationen beruhen auf der konventionellen Radiographie, das CT ist jedoch bei jeder Fraktur obligat. Offene Frakturen, Luxationen oder Talusextrusionen müssen notfallmäßig reponiert und stabilisiert werden. Alle dislozierten Talusfrakturen stellen eine absolute Operationsindikation dar. Die Zugangswahl wird vom Frakturtyp und dem Weichteilschaden bestimmt. Die anatomische Reposition der Gelenkflächen und der Talusform und die Stabilisierung mit Zugschrauben stellt meistens die Methode der Wahl dar.Das Ergebnis wird vom Dislokationsgrad bzw. dem Weichteilschaden, aber oftmals auch von der unzulänglichen Versorgung determiniert. Verzögerte Konsolidierungen, Pseudarthrosen und sekundäre Fehlstellungen sollten möglichst frühzeitig gelenkerhaltend korrigiert und notwendige Arthrodesen auf die betroffenen Gelenke beschränkt werden.AbstractFractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively.The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.

Fracture severity of distal radius fractures treated with locking plating correlates with limitations in ulnar abduction and inferior health-related quality of life

Introduction/background: The operative treatment of distal radius fractures has significantly increased after the introduction of locking plates. The aim of the present study was the evaluation of health-related quality of life, functional and radiological outcome of patients with distal radius fractures treated with the locking compression plate (LCP). Materials and methods: In the present study 128 patients (130 fractures) that were operatively treated with the LCP (2.4 mm/3.5 mm, Synthes®) were retrospectively evaluated. Mean follow-up was 22.7 months (SD 10.6). The fractures were radiographically evaluated (radial inclination, palmar tilt, ulnar variance) pre-, postoperatively and at the last follow-up visit. Range of motion (ROM) was documented. Grip strength was assessed with the use of a JAMAR dynamometer. The score for disabilities of the arm, shoulder and hand (DASH) and the Gartland-Werley score (GWS) were evaluated. Health-associated quality of life was assessed with use of SF-36 Health Survey. Results: Postoperative reduction was excellent; at the last follow-up visit only minimal reduction loss was observed. Except for pronation, a statistically significant decrease of ROM was present; in most cases that was not disturbing for the patients. The injured side achieved 83.9% of grip strength of the intact side. Mean DASH was 18.9 and mean GWS was 3.5. Health-associated quality of life was generally not compromised. However, limitations in ulnar abduction correlated with inferior quality of life. Fracture severity correlated with inferior quality of life, despite the absence of correlation with the functional and radiological outcome. Complication rate was low. Conclusions: Fracture severity seems to affect ulnar abduction and therefore patient quality of life, despite almost anatomical reduction; the objective and subjective scores were in most cases excellent. Modern everyday activities, such as keyboard typing, could be associated with the present results.

Functional and radiological outcome of periprosthetic fractures of the ankle

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA). A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically. A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%. There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively. A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Short-term functional assessment of gait, plantarflexor strength, and tendon properties after Achilles tendon rupture

BACKGROUND Although early functional rehabilitation (EFR) has been suggested to yield rapid functional recovery after Achilles tendon rupture (ATR) compared to conventional rehabilitation (CR), most quantitative assessments occur long after rehabilitation has been completed. Few data exist regarding the short-term functional gains during the healing period post-ATR. It remains unclear if EFR allows for an objectively faster return to function. The aim of this study was to examine EFRs effect on gait, plantarflexor strength, and tendon properties in early post-operative follow-ups. METHODS Fourteen patients received either EFR (n = 6) or CR (n = 8) after percutaneous ATR repair. Functional gait analysis, maximal voluntary isometric contractions (MVICs), and Achilles tendon properties were assessed at 8 and 12 weeks post-op. RESULTS Comparison of EFR against CR yielded no statistically significant differences in ankle kinematics or kinetics, Achilles tendon properties or MVICs on the injured (INJ) ankle at either time point. During gait, only CR patients demonstrated significantly lower plantarflexion moments on INJ at 8 weeks (0.817 ± 0.151 N·m/kg vs. 1.172 ± 0.177 N·m/kg, p = 0.002). All patients exhibited deficits in plantarflexor moment at 8 weeks and eversion moment at 12 weeks on INJ during gait that had effect sizes of note when compared to CON. SIGNIFICANCE ATR patients, regardless of rehabilitation, exhibit deficits in gait, AT properties, and single-limb strength at 8 weeks. Though AT properties and single-limb plantarflexor isometric strength remain at a deficit at 12 weeks, bipedal plantarflexion moments are comparable between INJ and CON. Though effect size calculations suggested clinically significant differences, clear benefits of EFR compared to CR were not found.

Alterations in structure of the muscle-tendon unit and gait pattern after percutaneous repair of Achilles tendon rupture with the Dresden instrument

BACKGROUND Functional deficits after Achilles tendon (AT) ruptures are observed. The relationship between musculotendinous structural alterations and functional outcome is not clear. METHODS Kinematic analyses (level walking, stair climbing), patient-reported outcome measures (PROMs), calf atrophy (maximum calf circumference (MCC)), and AT length were evaluated in patients after percutaneous AT repair with the Dresden instrument (n=20min. FOLLOW-UP 24 months). RESULTS Patients achieved good results in PROMs. However, MCC decreased significantly and AT length increased significantly postoperatively. Side-to-side MCC differences over 2cm resulted in significantly lower PROMs. AT lengthening correlated with increased dorsiflexion and decreased plantarflexion. CONCLUSION Calf atrophy and AT lengthening after minimally invasive AT repair resulted in inferior ankle kinematics and PROMs.