Der Unfallchirurg
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Using anatomic specimens from 58 fixed femurs, we analyzed the point of insertion and junctional variations of the gluteus medius, minimus and vastus lateralis over the greater trochanter. On six specimens the physiological muscle cross-section Q was determined for the muscles inserting at the greater trochanter. The results showed that the gluteus medius and minimus, as well as the vastus lateralis generally insert at the lateral and ventral surfaces of the greater trochanter. ⋯ An operating technique for the implantation of tumor prostheses using this muscle sling is introduced. Hereby the greater trochanter and inserted musculature remain intact and are placed hoodlike on the implanted tumor prosthesis. Postoperatively, the procedure results in good muscle function with early exercise tolerance.
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Intra-articular fractures of the distal end of the humerus are severe injuries because stable anatomic reduction is difficult to achieve even operatively. They are often accompanied by nerve lesions and often lead to heterotopic para-articular ossifications. Functional recovery is only rarely complete. ⋯ In immediate operations we observed fewer infections, less ossification, and better functional results than after delayed operative treatment. We therefore recommend careful examination for nervous deficits, immediate stable internal fixation of the fractures displaying the ulnar nerve, and handling the soft tissue as gently as possible to avoid additional damage. Postoperative physiotherapy should also be started immediately.
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1566 patients with fractures of the pelvis were treated at the Department of Traumatology of the Hannover Medical School between 1972 and 1990: 1350 patients had fractures of the pelvic ring, 216 isolated acetabulum fractures, 398 combinations of pelvic ring fractures and acetabular involvement; 718 of these patients were admitted with severe polytrauma. For 1254 patients a complete file was available for clinical and radiological evaluation of fracture distribution, classification (Tile and anatomical location) and concomitant injuries. During the observation period, significant increase in the severity of the trauma, the severity of the pelvic fractures and the rate of internal stabilization, especially of the posterior pelvic ring was observed. ⋯ Adapted small fragment implants ("local osteosyntheses") can be applied, with an unilateral longitudinal dorsal incision providing an excellent overview over the fracture line. For internal fixation of sacral fractures, involvement (penetration by screws, transfixation) of the sacroiliac joint is avoided whenever possible. In our experience early open reduction and internal fixation of pelvic fractures facilitates the management of these severely injured patients.
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Complex pelvic traumas are pelvic fractures accompanied by pelvic soft tissue injuries. Mortality in major pelvic fractures with associated soft tissue injuries is high, and these injuries can pose a more complex range of therapeutic problems. Uncontrolled bleeding and septic complications are the main causes of death. ⋯ It leads to important therapeutic steps after brief clinical, ultrasonic and radiological assessments. The major questions in the flow chart take the pelvic ring and hemodynamic instability into account. Immediate laparotomy, surgical control of hemorrhage, and open reduction and internal fixation of an unstable pelvic ring represent the most important requirements for successful treatment.
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One hundred patients with multiple injuries (mean ISS 37 patients) were prospectively evaluated over a period of 14 days following trauma. Significant differences in the blood levels of PMN elastase, cathepsin B, lactate, neopterin, C-reactive protein (CRP) and antithrombin III (ATIII) were found in non-survivors and in survivors with and without organ failure. ⋯ The prognostic value of these factors was comparable to trauma scores regarding organ failure and better with respect to death. Biochemical parameters may be helpful in estimating the severity of the injury and prognosis and in monitoring the ICU course of such patients.