Management of dabigatran-induced bleeding: expert statement

The interdisciplinary group of experts has compiled a clinical guidance for manifest dabigatran-induced haemorrhage and envisaged invasive interventions on patients under dabigatran. It recommends an escalation of treatment measures as summarized in a pocket guide (see electronic supplementary material online and insert in the print issue).

[Diagnosis and treatment of ligament injury of the thumb base joint. Results within the scope of follow-up]

Distortions and ruptures of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb represent 6% of hand injuries in alpine skiing and 8% in ski-skating. 155 patients who had been treated for ligamentous rupture (88), for osseous rupture with dislocation of the fragment (42) and for osseous rupture without any dislocation (25) wer reviewed: in 106 patients with conservative treatment 64 had stable joints and 42 showed a ligamentous instability. After surgical treatment in 49 patients 44 had ligamentous stability; 5 joints (10%) showed a radial instability. Summarizing the results we found instability after conservative treatment in 40%, but only in 10% of surgically treated patients. Recommendations for the treatment of this frequent hand injury are given.

[Ulnar head resection--indication and treatment results]

A follow-up of 52 patients with a history of Darrach's procedure between 1961 and 1989 was carried out 16 years after surgery. 92% of those with trauma of the forearm, wrist, and distal radio-ulnar joint reported hardly any pain at all with marked improvement of forearm rotation and wrist mobility. The only drawback to surgery was an average strength loss of 50%.

[Roentgenological parameters of the fibular incisure of the tibia in fractures of the lateral malleolus. Results in the framework of a follow-up study]

In order to check the correct position of the fibula in the Incisura fibularis tibiae by means of X-ray, four radiological parameters could be distinguished in patients with surgically or conventionally treated fractures of lateral malleolus. In spite of easy access, inserting the fibula into the incisure can be difficult in the case of bony or ligamentous injuries of the distal tibiofibular syndesmosis. With the help of these easily measurable X-ray parameters, an incongruence in the distal tibiofibular syndesmosis, which have to be corrected in any case, can easily be detected. The clinical relevance of these results could be verified in 105 patients.

[The fibular incisure of the tibia. The cross-sectional position of the fibula in distal syndesmosis]

The ligamentous structure of the distal tibiofibular syndesmosis has been described by numerous authors. Yet the bony part, i.e. the fibular incisure of the tibia and the relationship of the fibula to this joint surface have hardly been dealt with. For this reason, we decided to investigate and typify the bony structures and the surrounding areas of the syndesmosis on 25 frozen cadaver feet. We found these could be divided into three groups: about 75% had concave surfaces, 16% convex surfaces, and in 8% typification was not possible because of irregular forms. In addition, measurements were taken that reflect the position of the fibula in the distal tibiofibular syndesmosis. These data are useful on X-ray examination of the ankle and are therefore of practical clinical significance.

[Development and forms of post-traumatic carpal instability]

Posttraumatic carpal instabilities may be caused either by fractures or by rupture of the ligaments and originate mostly from a sudden fall on the hand risen in defense. In this case forced dorsiflexion, supination and ulnarduction will be developed in the wrist joint and intracarpal region. The injury takes its course in four stages. According to the localisation we differ between radial carpal instabilities, which develop especially in the stages I and II, ulnar instabilities, which develop in the stages III and IV. Furthermore there exists a third kind of instability: the proximal carpal instability, which is localised in the radiocarpal joint. In addition to that we differ static and dynamic instabilities. For treatment in recent injuries the continuity of the ligaments and the shape and the size of the carpal bones are restored. In delayed cases it will be necessary to restore the ligaments by grafting, to perform intracarpal arthrodesis or osteotomy to correct the bony configuration.

[Ligaments of the wrist and their clinical significance]

The ligaments of the wrist joint were dissected on ten hands of corpses fixed with formalin. A two and a half magnifying lens was used during the dissection. The following structures could be discerned: a radial and an ulnar collateral ligament and the dorsal radiocarpal ligament, which are all capsular ligaments. Furthermore the intracapsular palmar group of ligaments, which could be divided into five different parts, and the intracarpal (interosseous) ligaments, which stabilize the bones of the proximal and distal carpal row. The exact knowledge of the anatomic standards and proportions in the wrist joint will be a fundamental step to improve the present treatment of the carpal instability.

[Perilunar dislocations and dislocation fractures--evaluation of treatment results using the newest data on carpal instability]

Between 1956 and 1984, 196 patients with perilunate fracture dislocations were treated at the Unfallkrankenhaus Wien-Meidling. The authors were able to examine 56 of these patients on average 12.5 years after the accident looking specifically at carpal instability. The results showed three patients with dynamic and 21 patients with static instability of the wrist. After having examined the X-rays of all the patients we formulated the following plan: If the dislocation is adequately reduced by closed manipulation, conservative management is successful. But if there remains a pathological radiolunate, scapholunate, or capitolunate angle, operative treatment is indicated.

[Bilateral palmar instability with dislocation between the capitate and lunate bones]

Bilateral palmar instability of the wrist with subluxation between capitate and lunate bone. A stable wrist requires intact ligaments as well as a normal shape and size of carpal bones. While the reasons for bony changes are mainly posttraumatic, degenerative diseases and congenital laxity of ligaments as well as traumatic ruptures may cause an insufficiency of the ligaments. The following article deals with a theoretical discussion of carpal instability considering diagnosis, progress, development, and treatment of congenital bilateral palmar carpal instability which caused painful subluxation between the capitate and lunate bone.

[Use of a fascia flap of the forearm in soft tissue defects of the extremities]

The forearm flap can be used as a free fascial flap alone, thereby avoiding the displeasing scar arising at the donor site which has been covered in split-skin grafting. A case of a free fascial flap in a burn injury of the lower leg is demonstrated.

[Femoral shaft fractures in early childhood]

30 infants, one to three years old, with femoral shaft fractures were follow-up examined 12 years after the accident. In all those case it led within the described treatment to a beloadable healing of the fractures within six weeks. In 73% overgrowth could be noticed, which was on average of 13 mm. As factors which exercise an influence on the overgrowth the localisation of the fracture and the shortening during the healing-process can be called. Failures of the axes up to 15 degrees were completely corrected. Based on the clinical results a spontaneous correction of rotation failures can be accepted.