Die distale intraartikuläre Humerusfraktur beim alten Menschen

BACKGROUND

Intra-articular distal humerus fractures are relatively uncommon. Due to osteoporosis in elderly patients, stable fixation still remains a problem despite new implants providing angular stability.

MATERIAL AND METHODS

The treatment of choice is open reduction and plate fixation requiring an extended approach with olecranon osteotomy often combined with additional postoperative immobilisation in a long arm cast. We describe a technique using closed reduction and percutaneous osteosynthesis with cannulated screws combined with external fixation. Morbidity due to surgical exposure and potential risks are diminished while functional results are comparable to open reduction and internal fixation . In contrast to plasters or casts, the use of an external fixator allows stable and safety protection of the elbow joint, preserving wrist function as well as forearm rotation and increasing the patient's comfort during immobilisation.

RESULTS

We have used this technique on ten patients aged 76.2 years (range 67-88 years). According to the AO classification, there were three B-1/B-2 fractures, four C-1 and three C-2/C-3 fractures without severe comminution. The duration of external fixation was 6.3 weeks (range 4-8 weeks) before fracture union was achieved. This allows the initiation of physiotherapy and motion of the elbow. There was only one revision caused by the necessary replacement of an aseptic loosened Schanz screw. At follow-up 3 months postoperatively, the range of motion of the elbow was 95 degrees (65 degrees-105 degrees ), average extension 25 degrees (10 degrees-35 degrees ) and mean flexion was 115 degrees (100 degrees-120 degrees ) with all patients exhibiting full pro/supination.

[A painless technique for reposition of anterior shoulder dislocation]

Acute shoulder dislocation is a common injury and characterized by an extremely painful lack of motion. The treatment objective after diagnosis is immediate reduction avoiding additional pain and complications. Various techniques have been described for more than 2000 years mostly using traction-countertraction, particularly combined with special positioning and leverage maneuvers. We report a reduction technique which is performed by a single person with the patient sitting on a chair and the physician standing behind him at the affected side. Positioning one fist in the anterior part of the axillary fossa for countertraction but avoiding direct pressure into the axillary fossa, the other hand uses traction grasping the patient's forearm. Only gentle traction is maintained until muscle relaxation is achieved and reduction mostly happens in this moment. Otherwise slow external rotation of the fist placed in the axilla can relieve reduction pushing the humeral head laterally. Additional leverage maneuvers are not necessary. This technique was successful in 98 of 108 (90.7%) patients. Only in 16.3% was premedication (intravenous analgesics) used. In ten patients general anesthesia was required to achieve reduction. No complications occurred in any of the patients. The reported technique allows a gentle and painless reduction of acute anterior shoulder dislocation with a high success rate mostly avoiding premedication.

Spondylosis hyperostotica als Ursache von Dysphagie, Dyspnoe und Hals-Schulter-Schmerz

Anterior or seldom posterior hyperostosis of the spine (Forestier disease, "diffuse idiopathic skeletal hyperostosis") is a common finding in elderly patients but is rarely associated with clinical symptoms. In some cases there is a wide range of symptoms which may not lead primarily to the correct diagnosis. We report a case in which the diagnosis was first made based on an unusual combination of symptoms after ENT and neurological examinations revealed no evidence for the underlying cause.

Minimal-invasive Versorgung monokondylärer Tibiakopffrakturen

BACKGROUND

Treatment of displaced tibial plateau fractures is often complicated by high-energy trauma and soft tissue damage. Therefore, numerous techniques such as indirect or arthroscopically controlled reduction and percutaneous osteosynthesis have been described to reduce the additional surgical trauma.

MATERIAL AND METHODS

Twenty-three fractures (AO type 41-B2/3, Schatzker type II-IV) were treated with percutaneous, fluoroscopically guided reduction combined with small fragment osteosynthesis using a radius T-plate. In none of the patient was cancellous bone graft performed. Only in one case was arthrotomy necessary because of uncertain image intensification findings in an obese patient. One revision was done for a 4-mm step caused by an over reduced rim fragment. Fracture healing and full weight bearing were achieved after 8-12 weeks. Neither secondary displacement nor implant loosening was seen under primary functional treatment without immobilization.

RESULTS

Functional recovery showed a mean ROM of 114 degrees after 6 weeks and 121 degrees after 3 months. The radius T-plate offers enough stability to allow primary functional treatment due to early recovery of joint motion. Percutaneous reduction and small fragment osteosynthesis is a less invasive approach in the treatment of displaced monocondylar tibial plateau fractures.

Schmerzhafter Tumor am Kniegelenk: Kasuistik und Literaturübersicht

PURPOSE/BACKGROUND

Glomangiomas are perivascular tumours which, on the whole, are rare. They are most frequently located subungually on the fingers and toes. Diagnosis is difficult when they are atypically located at the knee joint. This may frequently result in a course of disease extending over many years.

MATERIAL AND METHODS

The case of a 75-year-old male patient with a tumour which had existed for two years, located at the knee joint, is reported.

RESULTS

Symptomatology, diagnostics, histology and therapy are presented and discussed in the context of the currently available literature relevant to this disease. In the case presented here, following removal of the tumour, the patient remained free of complaints and did not suffer a relapse.

CONCLUSION

Glomangiomas exhibit local, invasive growth, metastases have not been reported. The clinical picture is characterised by the classical trilogy of sensitivity to pain, pressure and temperature. In cases associated with the knee joint, misdiagnoses such as meniscus lesions or degenerative changes, are frequently made. Diagnostic procedures include sonography and magnetic resonance investigations. A resection of the tumour should be carried out well into the healthy tissue, as local relapse is a frequent occurrence in this disease.

[Infection of the hip joint following psoas abscess. Case report and literature review]

Infection of the hip joint following psoas abscess is uncommon. In fact, only two cases have been reported in the literature. The clinical aspect of psoas abscess is characterised only by unspecific back pain and hip pain, which are responsible for delayed diagnosis. MRT and culture of joint aspirate can permit early diagnosis. The preferred treatment is immediate surgical intervention with debridement, drainage and antibiotic therapy. Percutaneous drainage of psoas abscess alone only rarely is sufficient. In cases of infected hip joint, resection arthroplasty often cannot be avoided. Following complete decline of inflammatory parameters and certain absence of bacteria confirmed by repeated joint aspiration, prosthetic joint replacement is possible. This decision should be made on an individual basis, because Girdlestone hip also can lead to a satisfactory result concerning pain relief and functional outcome.

Elastisch stabile intramedulläre Nagelung (ESIN) von Klavikulaschaftfrakturen — Wandel eines Therapiekonzeptes?

Midshaft fractures of the clavicle are mostly treated conservatively. For the few cases in which stabilisation is needed, open reduction and plate fixation is the standard procedure. We report a minimally invasive technique of intramedullary stabilisation using a titanium nail carried out in 35 markedly displaced midclavicular fractures. Twelve fractures were simple and 23 consisted of more than two fragments. A total of 62.9% (22/35) of the patients presented additional injuries; 37.1% (13/35) with additional fractures. There were four ipsilateral scapular neck fractures. In 74.3% (26/35) of patients closed reduction was possible, whereas nine fractures required open reduction before the nail inserted from the sternal end of the clavicle could be introduced into the peripheral fragment. All fractures healed clinically and radiologically within 6 weeks. In contrast to conservatively treated fractures, length discrepancies of 1 cm or more, mainly shortening, could be avoided. Using a visual analog scale, significant pain relief (8.4-2.4 points) was already recorded on the first day after surgery. Patients with an isolated fracture of the clavicle showed a nearly normal range of motion only 1 week after surgery, whereas patients with associated scapular or rib fractures needed up to 3 weeks to reach normal shoulder function. No patient complications requiring interventional procedures occurred. Minimally invasive, elastic, stable intramedullary nailing of midshaft fractures of the clavicle should be recommended as an alternative to conservative treatment because of early pain relief, associated rapid functional recovery and anatomical restoration of the clavicle.

[Do fixed-angle T-plates offer advantages for distal radius fractures in elderly patients?]

In the treatment of distal radius fractures, plate osteosynthesis using fixed-angle T-plates has become more common. Higher stability often allows functional aftertreatment in metaphyseal and articular fractures. So far it remains unclear whether these advantages also apply to elderly patients who commonly suffer from osteoporosis and reduced cooperativeness. Therefore, we evaluated the radiological loss of correction during fracture consolidation in patients aged more than 70 years. Fixed-angle plates were used in 44 patients (mean age: 79.4 years) while conventional T-plates were used in 30 patients (mean age: 78.2 years). Postoperative immobilization for 6 weeks by plaster or external fixator was performed in all patients. The loss of correction was significantly lower for fixed-angle plates (4.6% vs 40.0%). As a result of this study, we have gradually reduced immobilization in favor of early functional treatment. In a recent study fixed-angle plates so far seemed to permit stable fracture fixation. Our results underline the advantage of stable fixation in displaced fractures of the distal radius even in osteoporotic bone of elderly patients.

[Rupture of the azygos vein by blunt thoracic trauma. A case report and literature review]

Blunt chest trauma is a common injury in traffic accidents. Thoracic vessel trauma frequently affects intercostal arteries, the aorta and less often the subclavian artery. Azygos vein injury is uncommon and has previously been described in only 19 cases. The 20th case of blunt azygos vein injury due to high energy trauma as a consequence of a traffic accident is reported with a review of the literature. Preoperative diagnosis was performed by computed tomography. Azygos vein injury is rare but potentially lethal (8/20, 40.0%). Chest radiograph with right hemothorax is reported consistently except for two cases. Fractures of ribs and/or thoracic spine (T3-5) were found in nine patients, while neither were found in 11/20 cases. Pathognomonic signs have not been described in the literature. Early resuscitation and immediate thoracotomy with recognition and treatment of azygos vein rupture is necessary to avoid a fatal outcome.