Der Orthopäde
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The precise preoperative clinical and electrophysiological evaluation of the brachial plexus as well as an exact radiological evaluation are the keystones for the treatment of traumatic injuries of the brachial plexus. Furthermore, surgical management and prognosis of traction injuries of the brachial plexus depend on the accurate diagnosis of root avulsion from the spinal cord. Myelography, myelo-computed tomography and recently magnetic resonance imaging are the main radiological methods for preoperative diagnose of cervical root avulsions. ⋯ However in 15% of the cases preoperative exact radiological diagnosis is unfortunately not reliable. In these special cases intraspinal surgical exposure of the cervical roots will provide the accurate diagnosis of root avulsion. Accurate clinical evaluation and exact assessment of intraspinal root avulsion simplify enormously the decision concerning the choice of donor nerves for transplantation and/or neurotization during brachial plexus surgery.
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Low back pain is the most expensive condition in industrialized countries. Approximately 65-80% of the population will be afflicted with low back pain at some point during their life. Low back pain has many causes and can originate from any of several pain-sensitive foci, among which are facet joints, sacroiliac joint, muscle and ligaments. ⋯ If used, their potential benefit for the individual case needs to be carefully weighed. They should be used to facilitate more aggressive conservative care and not as an isolated treatment. Certainly, if response to corticosteroids does not occur after the first injection, no further administration of corticosteroids is indicated.
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The presence of psychological co-morbidity and difficulties in coping with chronic low-back pain are indications for the application of psychological therapy procedures. In the treatment of patients with chronic pain, the aim of therapy as well as the technique of the traditionally employed psychotherapeutic procedures need to be modified. What is of immediate importance is to promote an active pattern of coping with pain and discourage pain-related inactivity and reduce feelings of helplessness and hopelessness. ⋯ Relatives should be integrated in the planning and possibly also in carrying out of the treatment. Symptom-specific group therapy might motivate patients to undergo treatment and to change their habitual ways of life. A multimodal treatment approach incorporating orthopaedic, sports medicine, physiotherapeutic, psychological and socio-therapeutic procedures have proved to be more effective in the treatment of chronic pain than one employing monocausal treatment modalities.
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Nail, plate and external fixator are since decades the most frequently and stabilizers for the surgical treatment of dia- and metaphyseal fractures. These elements are still present today. ⋯ Beside an overview about the current discussion of unreamed and reamed nail insertion new trends, techniques and nails are presented for the different long bones (retrograde nails, spiral blade, flex-nail humerus and a distal aiming device (DAD) for interlocking screws). In addition, new approach techniques for nailing (stab incision) and minimally invasive percutaneous plate osteosynthesis (MIPO) for metaphyseal fractures of the proximal and distal femur and proximal tibia are described including the necessary techniques for control of axes and rotation.
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Radiography is still the basic imaging method in traumatology and orthopedics. However, technical improvements and new imaging modalities may partially replace the conventional diagnostic imaging strategies. This review describes actual indications of x-ray examination, computed tomography (CT), ultrasonography and magnetic resonance imaging (MRI). New developments and future aspects in digital radiology, CT and MRI, two- and three-dimensional reconstruction techniques and image guided therapies are demonstrated.