Der Unfallchirurg
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Review Comparative Study
[Management of polytrauma patients in an international comparison].
Worlwide there will be an increase in polytraumatized patients. The number of death after trauma will increase from 5.1 Mill. to 8.4 Mill. The reason is the technical progress in the third world. ⋯ The Trauma register in Germany contents till now 2.069 polytraumatized patients. The lethality is 18.6% (ISS 21 +/- 13), comparing to MTOS (ISS 12.8 +/- 11.3, lethality 9.2%). The differences in injury pattern show in the US three times more penetrating injuries than in the German Traumaregister (21.1% versus 7.2%).
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The purpose of this paper is to outline the treatment protocol for the first time traumatic anterior shoulder dislocator, with options including conservative, arthroscopic and open surgical treatment. Regarding the subclassification of the first time traumatic anterior dislocater, it is imparitive to differentiate between the unidirectional dislocator with and without hyperlaxity. This subclassification takes into account the structural quality of the stabilizing ligamentous structures of the glenohumeral capsule. ⋯ Surgical stabilization of primary anterior traumatic dislocation is indicated if the following strict criteria are met: adequate trauma, no self reduction, unidirectional instability without hyperlaxity, Hill Sachs lesion, age below 26 years, high level of sport activity and the special situation of luxatio erecta. Post primary stabilization is indicated for persistent subluxation, subjective instability or demonstrated pathologic instability tests. Rotator cuff tears due to traumatic dislocation in the elderly population require surgical repair.
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Pseudoarthrosis and cubitus valgus as main complications following displaced fractures of the radial condyle in children can be prevented by open reduction and fixation by K wires. However, delayed union and stimulation of the radial physis with condylar overgrowth and varisation of the elbow as well as fishtail deformities of the distal end of the humerus are reported nevertheless. To prevent those growth disturbances all primary and secondary (4-day X-ray control) displaced fractures of the radial condyle, i.e. those with a central gap of more than 2 mm, were prospectively treated by open reduction and osteosynthesis with a metaphyseal lag screw beginning 1974. Sixty-six patients (41 boys, 25 girls) with an average follow-up of 10 years (2-22 years) sustained 28 primary and 6 secondary displaced fractures. In 5 cases a K wire fixation was performed in view of the smallness of the fragment. Two children with conservative treatment following overlooked displaced fractures showed condylar overgrowth and varisation of the elbow. Screw osteosynthesis led to symmetric elbow angles and function in all cases, whereas fishtail deformities could be observed in 8 of 27 children, probably as a consequence of the remaining central fracture instability. ⋯ Open reduction and osteosynthesis with a metaphyseal lag screw prevents condylar overgrowth in displaced fractures of the radial condyle by guaranteeing fracture healing in anatomic position within 3-4 weeks. However, fishtail deformity can not be prevented by metaphyseal compression only.
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Blunt chest trauma is the leading cause of thoracic injuries in Germany, penetrating chest injuries are rare. Hereby, single or multiple rib fractures, hemato-pneumothorax and pulmonary contusion represent the most common injuries. The early management of thoracic injuries consists of detection and sufficient therapy of acute life threatening situations like tension pneumothorax, acute respiratory insufficiency or severe intrathoracic bleeding. ⋯ Early intubation and PEEP-ventilation, alternate prone and supine positioning of multiple injured patients with lung contusion and differentiated concepts of volume- and catecholamine therapy represent the basic therapeutic principles. Additionally, the entire early trauma management of multiple injured patients must focus on the presence of pulmonary contusion. Every additional burden on their pulmonary microvascular system like microembolisation during femoral nailing, the trauma burden of extended surgery or mediator release in septic states may cause rapid decompensation and organ failure and therefore, has to be avoided.