Der Unfallchirurg
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Capsulolabral reconstruction (Bankart repair) is recommended as the first line treatment in young and functionally demanding active patients with anteroinferior shoulder instability, due to the high tendency to recurrent dislocation. This has become established both for arthroscopic and open primary shoulder stabilization with good clinical outcome; nevertheless, recurrence of dislocation is reported in up to 25% of patients. Risk factors for failed surgery are patient (e.g. young age, male gender and contact sports) and surgery (e.g. primarily underestimated glenoid bone loss, Hill-Sachs lesion, non-treatment of bipolar defects or malpositioned anchors) related. ⋯ Dislocation arthropathy is an underestimated complication as a result of frequent recurrent dislocations. After development of dislocation arthropathy, patients reported a painful restriction of range of motion rather than instability. Arthroscopic arthrolysis and comprehensive arthroscopic management (CAM procedure) are possible joint-preserving treatment options.
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Review Historical Article
[Structural damage after shoulder dislocation and development of surgical treatment from a historical perspective].
In the nineteenth century there was a high incidence of habitual shoulder instability caused by epileptic seizures and accompanied by therapeutic dilettantism, which led to socioeconomic problems in the working population. In the preradiography era the pathomechanism of shoulder dislocation was only known on the basis of cadaver studies and autopsy findings. The underlying structural disorders of habitual shoulder instability in the Bismarck era were published by Malgaigne, Broca and Hartmann. ⋯ At the beginning of the twentieth century Perthes introduced the anatomical reconstruction of the capsulolabral complex, which was copied in the English speaking area by Bankart. Surgical wrong tracks through extra-anatomical procedures, capsulorrhaphy and tendon transfer, were followed by bone block procedures according to Eden-Hybinette and a modification of this procedure by Lange. In the French speaking area Latarjet introduced the transfer of the coracoid process in the middle of the 1950s, which brought the advantage of simultaneous dynamic stabilization to bony augmentation of the glenoidacetabulum .
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In the current literature a consensus on the specific management of primary anterior traumatic shoulder instability has not been reached. While the steps of the initial diagnostic and therapeutic procedures are mostly well-defined, a variety of factors need to be considered for the planning of further treatment. ⋯ A well-structured treatment plan is essential for the initial management of primary anterior traumatic shoulder instability. A generally applicable algorithm for further management is not yet established. The treatment should therefore be individually planned based on patient-specific characteristics.
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Posterior shoulder instability has a markedly lower incidence than anterior shoulder instability. It has a wide spectrum of clinical symptom manifestations and the overwhelming number of patients lack a traumatic primary dislocation. In addition to a detailed medical history, a specific clinical examination with the help of standardized provocation tests is essential for the diagnostics. ⋯ Conservative therapy is useful in patients with scapular dyskinesis, voluntary dislocation and pathological muscle patterning. In isolated soft tissue pathologies, arthroscopic labrum fixation and capsule plication are the standard treatment. In the case of insufficient soft tissue relations or critical posterior glenoid defects, bony stabilization of the glenoid using an iliac crest bone graft is the recommended therapy.
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Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. ⋯ An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.