Der Unfallchirurg
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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.
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In an overview the clinical and academic problems of this kind of fractures are described and their treatment is discussed. The most important problem is the pseudarthrosis that can happen in the framework of a conservative treatment of displaced fractures, rarely after operative treatment with K-wires. A rather academic problem is the obligatory growth disturbance of a partial stimulation of the lateral part of the growth plate. ⋯ Pseudarthrosis, varus and fishtail deformity are a result of increasing instability of primarily or secondarily displaced fractures. All three problems can be avoided by metaphyseal compression osteosynthesis with an AO small-fragment screw with an additional axial K wire in the trochlea. Our own long-term results are shown and compared with the results of other procedures in the literature.
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Comparative Study
[Prognosis of proximal radius fractures in the growth period].
Fractures of the proximal radius in children may lead to deformities of the radial head and functional disturbance of pro- and supination. However, traumatization is not only caused by the injury itself, but may also occur secondary to surgical reduction, manipulation of fracture fragments and excessive physiotherapy. In a prospective long-term follow-study (2-20 years after trauma) of 38 children with displaced proximal radius fractures we found functional disturbances in 11% of children only. ⋯ Functional impairment was mainly seen after open reduction or secondary growth disturbances. On follow-up radiographs all conservatively treated fracture angulations up to 60 degrees had corrected themselves spontaneously. In view of the high complication rates after open reduction and the poor functional results, as well as the inconvenience for the pediatric patient and the economic aspects, we recommend a primary conservative treatment concept of proximal radius fractures in children.
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Between 1982 and 1993, 65 amputation and amputation-like injuries in the upper arm (n = 18), proximal and middle forearm (n = 32) and distal forearm and wrist level (n = 15) were treated in our institution. The overall survival rate in our series was 92.3% (60/65). In 3 of 65 cases early secondary amputation because of vascular failure was necessary. ⋯ Taking grades I and II results together, a "functional extremity" could be reconstructed at the upper arm level in 25%, proximal forearm 30%, and the distal forearm in 58%. The main advantage of replantation/revascularization of the upper limb is the possibility of restoring some sensitivity to the hand in addition to partial motor recovery, which always provides twice as much individual motor function as is offered by any type of prosthesis currently available. The higher cost and number of operations needed, as well as the longer postoperative care and longer disability time after replantation/revascularization are nevertheless justified by the significant increase in quality of life.
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Review Case Reports
[Must the accident victim be protected from the emergency physician?].
Quality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. ⋯ Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17% of all documented patients. According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.