Der Unfallchirurg
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According to our results, permanent epidural anaesthesia was significantly superior to systemic opioid treatment in patients with serial rib fractures. The main advantages were not only continuous pain relief despite the fact that the nonepidural control group required more than twice the dosage of morphine derivatives; also, the respiratory and pain-related recovery time was reduced. Another advantage was the selective effect (due to the local application) on respiratory pain and therefore on respiration as a whole. ⋯ When morphine was temporary contraindicated (frequently the final diagnosis in the case of an "acute abdomen" delayed the administration of morphine) the use of bupivacaine alone provided a satisfactory result for a certain time (we never observed tachyphylaxis). Additional systemic pain relievers were only necessary when the patient was suffering from pain caused by other injuries beyond the area of effectiveness of the epidural catheter (the only obvious disadvantage of the local application technique). On the other hand, epidural anaesthesia enabled us to treat a patient's lower-leg fracture by interlocking nailing, while adding only 0.01 mg fentanyl (= 2 ml Fentanyl Janssen) and 1.2 mg flunitrazepam (Rohypnol).
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Some of the peculiarities of the anatomy of the talus are of special interest: the lack of muscle insertions, the vulnerability of the blood supply, and the fact that about 60% of the surface is covered by hyaline cartilage. This implies that most of the fractures are intra-articular. In 1983, the results of 262 talus fractures were published. ⋯ Absence of subchondral atrophy in the early months and then later density of the dead bone and atrophy of the surrounding bones imply avascular necrosis. Dislocations around the talus without fractures are classified into three types: talocrural dislocation (i.e., luxatio pedis cum talo), subtalar dislocation (i.e., luxatio pedis sub talo), and the extremely unusual total dislocation of the talar body. The dislocations should be reduced promptly to avoid breakdown of the skin and distal circulatory compromise.
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Maintenance therapy of the traumatized foot by partial amputation, in contrast to lower-leg amputation with subsequent artificial leg adjustment, should always be attempted if there is any possibility of shaping a stump that is independent of the prosthesis. As in former years, the disarticulation technique is performed; however, today the technique has been modified to obtain more functional results and to conserve tissue, which may mean that transosseous amputation is practicable. The quality of the soft-tissue flap and stability are the determining factors in the quality of the stump. These prerequisites mean that the operative technique must be adapted to the requirements of the patients; the soft tissue must be preserved and procedures used that will permit reconstructive procedures later.
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A mathematical torso-neck-head model was used to simulate frontal and lateral head impact. The model consisted of nine rigid bodies representing the torso, the seven vertebrae, and the head. The external force acting during impact was described by a triangular force-time function. ⋯ The computer simulations produced linear and angular head accelerations, which were compared with the tolerance level for injury and used to determine the tolerance curves which discriminate between "safe" and "unsafe" acceleration. For the linear head acceleration, the tolerance level was 1000 as defined by the Head Injury Criterion, and for the angular head acceleration the tolerance level was 1800 rad/s2. Our results showed that the risk of head injury was lower for linear head acceleration than for angular head acceleration, and it was lower for frontal impact than for lateral impact.