Unfallchirurgie
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In spite of surgical, intensive, and hyperbaric oxygen therapy, the gas gangrene is still one of the most dangerous surgical infections. In recent literature, the average mortality is about 50%. The patients die within a few days because of general intoxication. ⋯ An early diagnosis of the gas gangrene is of primary importance. As early as a gas gangrene is suspected because of typical local findings and clinical symptoms, therapeutic measures are immediately necessary (surgery, intensive treatment and hyperbaric oxygen therapy). A transport of more than six hours with prolonged interruption of the treatment will decrease the chances of success even in a "gas gangrene therapy centre".
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With its judgement of May 11, 1982, the Bundesgerichtshof (Federal Court of Law) has decided that it is primarily up to the doctor to choose the therapy method by which a person injured during an accident has to be treated. The patient must be informed only if there are different risks for him involved in different methods, e.g. if the doctor wants to apply a method criticized again and again in the literature. An information that a smaller hospital doesn't eventually correspond to the standard of a specialized hospital is only necessary if adequate treatment and care is not possible in the hospital where the patient is admitted.
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There are still gradually and even fundamentally different opinions about the most favorable moment for the definitive treatment of lesions of extremities in persons with multiple injuries. The immediate definitive treatment or primary treatment within the first 24 to 48 hours is opposed to a therapy method applying a graduated definitive treatment of the lesions of extremities taking into consideration the individual extent of the injury. During the period from January 1st, 1975 to December 31st, 1979, 321 persons with multiple injuries of degrees 2 and 3 have been treated at the Hospital for Accident Surgery of the University of Frankfurt/Main. 290 fractures were treated in 225 surviving persons with lesions of the extremities. ⋯ All femur fractures in surviving persons with multiple injuries were surgically stabilized, with the exception of several cases of isolated fractures of the shank diaphysis who received conservative treatment. Although we consider an early surgical treatment of femur fractures in persons with multiple injuries as the most favorable basis for a continuous and uninterrupted recovery, which we also strive for, the experiences made by us hitherto do not demand a general indication of immediate surgical treatment (within the first 24 hours) of closed femur fractures in persons with multiple injuries. We shall continue to apply a graduated therapy method, considering each individual case, for final treatment of fractures of extremities in persons with multiple injuries.
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The circulatory and acute generalized failure of the circulation, in particular of the lesser peripheral circulation, and may possibly but not necessarily be accompanied by a decrease in blood pressure and damage to the tissue due to a lack of oxygen. The main question concerning the causal pathogenesis of shock is still unsettled, but an interaction between a lack of oxygen as well as of other factors, like endotoxin, complements and vasoactive amines, and the presence of a microthrombosis must be held responsible for the appearance of this condition. In modern intensive medicine the lung must be considered as the preferential area for the manifestation of shock. ⋯ The pathology of shock lung shows two phases and has its onset in exudative alveolitis followed by alveolar fibrosis which can be hardly be controlled by therapy. The early phase of shock lung manifesting itself by exudative alveolitis is decisive with regard to diagnosis and further therapeutic measurements. If the condition can be brought under control at this stage there is a chance that the patient may survive.
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Indications and operative technics of problematic situations in the shoulder region are discussed. Methods which are commonly used at the "BG"-Accident-Hospital, Duisburg, are described in detail. Operative methods under question are arthroplasty, resection-arthroplasty and arthrodesis. ⋯ It should be limited exclusively to older patients. Details of the operative technic for various operations are described. Apart from the common resection of the humoral head these are technically difficult; they require a surgeon who is experienced in traumatology and orthopedics.