Der Unfallchirurg
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Nearly 80 years ago in the autumn of 1939 Gerhard Küntscher successfully stabilized a patient with the first intramedullary nailing surgery. As a result, the research interest in osteosynthesis significantly increased. ⋯ The study showed the eminent impact that the close cooperation between Küntscher and Pohl had on the success of the intramedullary nail. The synergy of Küntscher's medical expertise and Pohl's ingenuity found solutions for problems other people could not solve. World War II interrupted this close interaction but at the same time helped to disseminate the technique globally which in turn contributed to the advancement of the idea.
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The technique of fracture treatment by minimally invasive plate osteosynthesis (MIPO) is today part of the treatment repertoire of any experienced trauma surgeon. The minimization of any additional iatrogenic damage to the tissues and the preservation of the osteogenic fracture hematoma are the decisive differences to open reduction and internal fixation (ORIF). The MIPO technique is particularly applied in metaphyseal and diaphyseal fractures, which cannot be treated with intramedullary nails as well as in fractures with critical soft tissue covering and complex fractures with metaphyseal extension fractures. ⋯ The minimally invasive approach by the trauma surgeon in MIPO fracture treatment is mainly defined by the selected gentle reduction technique. Because the fracture zone cannot be directly viewed, good knowledge of the anatomy and careful surgical planning including reduction on an adequate image basis are of decisive importance. This article introduces the principles of the reduction techniques in minimally invasive plate osteosynthesis and their practical application is described in detail.
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Intramedullary nailing was originally conceived for the stabilization of shaft fractures of long bones. Due to new nail designs and multiple interlocking possibilities, the spectrum of nailing has significantly increased. Nailing of fractures beyond the isthmus is technically challenging because fractures need to be reduced before the nailing procedure starts. ⋯ Blocking screws create an artificial isthmus in the metaphyseal area and force the guide wire in the desired direction. Blocking screws help to avoid axial malalignment during nail insertion. Interlocking of the nail with screws coming from different directions prevents secondary dislocation.
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The development of emphysema after intramedullary nailing can represent an easily manageable complication but in the differential diagnostics it could, however, be a life-threatening infection with Clostridium perfringens. This is a report about the case of an extensive subcutaneous and retroperitoneal emphysema, which developed after intramedullary nailing of a pertrochanteric femoral fracture and where such an infection was suspected.
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Special and specialized instruments help perform reduction more effectively and in a tissue-preserving manner. In addition to other articles, the application and advantages of the following instruments are presented: colinear reduction forceps, cerclage, cerclage passer, distal radius reduction clamp, modular external fixator, extension table, distraction frame, joystick, manipulators, distractor and assistance of reduction with elastic nails.