T.M. Frangen

The undiagnosed Essex-Lopresti injury

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist. Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.

The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity.

BACKGROUND The timing of stabilization for thoracic spine injuries is discussed controversial. Although early repair of long bone fractures is known to reduce complications, few studies investigate this issue in spine trauma. METHODS We retrospectively investigated 160 patients (January 2000 to March 2003) with spine fractures from Th1 to L1, which were stabilized. Patients were divided into two groups: early stabilization within 72 hours or later. Other subgroups were analyzed for the relationship of neurologic status, injury severity, and incidence of preoperative lung failure. RESULTS : Severely injured patients (Injury Severity Score >or=38 pts) with early stabilization had a significantly shorter intensive care unit-stay (14 days [1-34 days] vs. 20 days [1-39 days]; p < 0.05) and overall shorter hospital stay (56 days [9-147 days] vs. 108 days [11-198 days]; p < 0.05). Similar patterns were seen for patients with Frankel A deficits (Frankel Score) and preoperative lung failure. The clinical course of less severe-injured patients was not influenced at all. CONCLUSIONS Our data provide further evidence that early stabilization of spine injuries is safe. In severely injured patients, it does not impair perioperative lung function and results in a reduced overall intensive care unit and hospital stay.

Traumatic manubriosternal dislocation

Manubriosternal dislocation is an extremely rare occurrence, especially as the result of an indirect compression injury. Manubriosternal dislocations are divided into two types: In a Type I dislocation, the body of the sternum is displaced in a dorsal direction; in Type II dislocation, the body is displaced to the ventral side of the manubrium. A manubriosternal dislocation may be caused by direct or indirect trauma. Direct injury is generally a collision injury occurring in the context of a road accident. Resulting may be in either a Type I or Type II dislocation. Indirect trauma always leads to a Type II dislocation due to a flexion-compression mechanism in the region of the spine. Rheumatic arthritis and obvious kyphosis are predisposing factors in manubriosternal dislocation due to the indirect compression injury. Non-operative treatments after reduction, e.g. correction tape or plaster bandage, symptomatic pain treatment, application of ice, and several weeks without sports, are associated with a not inconsiderable rate of subluxations or reluxations, especially due to insufficient patient compliance. These disorders can lead to chronic pain, periarticular calcification with ankylosis, and progressive deformity. It has not been possible to establish an optimal, standardized operative procedure so far because of the small number of cases. We have achieved very good, postoperative long-term outcomes after plate osteosynthesis of manubriosternal dislocations in two patients.

[Spine fractures in patients with ankylosing spondylitis: an analysis of 129 fractures after surgical treatment].

INTRODUCTION The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

Wirbelsäulenfraktur bei ankylosierender Spondylitis

INTRODUCTION The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

Local application of basic fibroblast growth factor increases the risk of local infection after trauma: An in-vitro and in-vivo study in rats

Introduction Local application of growth factors to stimulate wound and fracture healing is attracting increasing interest. We studied the effect of local application of a potent angiogenic growth factor, basic fibroblast growth factor (bFGF), on resistance to local infection after soft tissue trauma. Methods For in-vitro and in-vivo experiments, we used recombinant human bFGF. The in-vitro investigations were performed by isolation of human leukocyte fractions, cytokine analysis, phagocytosis assay, flow cytometry, and LDH assay. For the in-vivo investigation, a paired comparison of infection rates was carried out on Sprague-Dawley rats after standardized, closed soft tissue trauma and local, percutaneous bacterial inoculation of different concentrations of Staphylococcus aureus (2 × 104 to 2 × 107 colony-forming units (cfu)). The lower leg was treated with 1, 10 or 100 ng bFGF (16 animals for each concentration) and without bFGF (16 animals). Results Cytotoxic reactions due to the concentrations of bFGF used could be excluded in the in-vitro tests since incubations of isolated peripheral blood mononuclear cells (PBMCs) with increasing concentrations of bFGF for 24 h did not lead to an increase in the release of lactate dehydrogenase in the culture supernatants compared to corresponding control incubations without any bFGF added. A significant increase in cytokine release was observed after the co-incubation of PBMCs with 100 or 200 ng of the same bFGF that was used for the animal experiments. Furthermore, the capacity of phagocytes in whole blood to phagocytose bacteria was suppressed in the presence of 100 ng exogenously added bFGF. We found continuously reduced granulocytic phagocytosis in FGF-supplemented blood compared to non-supplemented blood. In the in-vivo investigation, the infection rate for the group without bFGF was 0.25. In the groups with 1, 10 and 100 ng bFGF, the infection rates were 0.5, 0.7 and 0.8, respectively. A dose-dependent increase in infection rate was observed after local application of bFGF, compared to the untreated control group. The difference in infection rates for the groups in which 10 and 100 ng bFGF was used, relative to the group without bFGF, was statistically significant. Interpretation If these initial results are confirmed for other potent angiogenic growth factors, then the local use of growth factors for stimulation of wound and bone healing—a main focus of current research in traumatology—will have to be reconsidered and preceded with a strict evaluation of the risks and benefits.

Pathophysiologie der posttraumatischen Osteitis

ZusammenfassungIn den letzten Jahrzehnten gelang es durch Etablierung neuer Operationstechniken und -taktiken, durch an das Infektionsrisiko adaptierte Indikationsstellungen, durch Chemotherapeutika und durch neue Implantatentwicklungen die posttraumatische Infektionsrate deutlich zu minimieren. Hierbei waren neue Erkenntnisse über die pathophysiologischen Mechanismen der posttraumatischen und postoperativen Osteitis wegweisend. Trotzdem ziehen posttraumatische Infektionen weiterhin oftmals erhebliche gesundheitliche und ökonomische Folgen nach sich.In diesem Artikel werden die wesentlichen pathophysiologischen Mechanismen der posttraumatischen Infektionsentstehung zusammengefasst. Es wird versucht, neue Denkanstöße zur posttraumatischen Osteitisprophylaxe und -therapie zu geben.AbstractOver the last few decades, significant reduction of post-traumatic infections could be attained by establishing novel surgical techniques and tactics, by adapting surgical decisions to the risk of infection, by employing chemotherapeutic agents, and by developing new implants. Here a novel understanding of the pathophysiologic mechanisms of post-traumatic and postoperative osteomyelitis were directive. Nevertheless, post-traumatic infections later cause significant physical and economic sequelae.This article sums up the fundamental pathophysiological mechanisms of post-traumatic infection. New ideas about post-traumatic prevention and therapy of osteomyelitis are discussed.

Elevated Systemic Interleukin-18 in Multiple Injured Patients Is Not Related to Clinical Outcome

Interleukin-18 (IL-18) is a pleiotropic proinflammatory cytokine with the ability to induce interferon-gamma production in T-helper cells type 1 and natural killer cells. To investigate the role of IL-18 after severe trauma we measured plasma levels of IL-18 in 229 multiple injured patients [mean age of 39 +/- 16 (range 11-81) years, injury severity score (ISS) of 31 +/- 10 (range 16-66) points; 55 women and 174 men] and correlated these with demographics, clinical course, and routine laboratory parameters. IL-18 plasma levels were significantly increased in polytraumatized patients compared to healthy donors (p < 0.001). Survivors presented significantly (p < 0.05) higher IL-18 plasma median values (n = 193, median 98 pg/mL) compared to nonsurvivors (n = 36, median 63 pg/mL). Patients >60 years old (n = 35) had significantly lower plasma levels of IL-18 (median 45 pg/mL) compared to younger ones (n = 194, median 92 pg/mL). In the subgroup of nonsurvivors (n = 12) elderly patients had the lowest plasma levels of IL-18 (median 45 pg/mL). Patients with an ISS >25 had significant higher IL-18 plasma levels compared to the group with an ISS <or=25 (p < 0.001). Our data demonstrate elevated plasma levels of IL-18 after severe trauma.

Wirbelsäulenfraktur bei ankylosierender Spondylitis@@@Spine fractures in patients with ankylosing spondylitis: Eine Analyse von 129 Frakturen nach operativer Versorgung@@@An analysis of 129 fractures after surgical treatment

INTRODUCTION The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

Versorgung medialer Schenkelhalsfrakturen im Alter

ZusammenfassungAufgrund der demografischen Bevölkerungsentwicklung sehen wir uns mit einer jährlichen Zunahme medialer Schenkelhalsfrakturen betagter Patienten konfrontiert. Im vorliegenden Beitrag werden die Behandlungsmodalitäten der Frakturen des koxalen Femurendes geriatrischer Patienten insbesondere mittels Duokopf- und Totalendoprothese anhand der vorliegenden Literatur und unter Betrachtung der für die Therapie der Schenkelhalsfraktur des Erwachsenen vorliegenden Leitlinien der Deutschen Gesetzlichen Unfallversicherung (DGU) diskutiert. Auch die Frage der Verwendung zementierter oder zementfreier Schäfte bei der endoprothetischen Versorgung dieser Verletzungen wird aufgegriffen und reflektiert.AbstractDue to demographic changes in the population, we are facing an annual increase in femoral neck fractures in geriatric patients. The paper discusses the treatment modalities of hip fractures in this patient group, with particular regard to bipolar and total hip alloarthroplasty according to the current literature and taking the existing guidelines of the German statutory accident insurance (DGU) into consideration. We also discuss the use of cemented or cementless stems in the endoprosthetic care of these fractures.