Zentralblatt für Chirurgie
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Comparative Study
[Treatment concepts and results in non-infected post-traumatic pseudarthroses of the femur and tibia].
Different methods of internal and external fixation are used to treat aseptic posttraumatic nonunion of the femur and tibia. The advantages and disadvantages of the different methods will be demonstrated by analysing the clinical course and the outcome of our patients. Utilizing these data, a therapeutic concept tailored to the individual situation is recommended. ⋯ Due to the good soft tissue coverage and vascularisation internal fixation is favored for the treatment of femoral nonunions. The fixator should only be used if distraction osteogenesis is necessary because of a bony defect. Due to the problematic soft tissue situation and poorer vascularisation on the external fixator is preferred in the treatment of tibial nonunions if a change of method is indicated. For this purpose, we currently use predominantly the Ilizarov-apparatus because of its biomechanical properties and the convincing results. Initial problems with its use could markedly be reduced with growing experience.
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Causes of septic multiple organ failure are endotoxin induced mechanisms, exotoxin induced mechanisms and sepsis associated immunosuppression. Pharmacological intervention is limited. ⋯ The prevention of systemic infections is mandatory. Approaches to new therapeutical concepts are outlined.
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In 212 patients after injury of the thorax (54 males, 158 females; penetrating (15), blunt (197), multiple trauma (128)) 158 cases demonstrated rib fractures and 103 radiological proven pneumo- or hematothoraces or sometimes both, 108 of 138 had to be drained. 96.5% of the effusions and 98% of the pneumothoraces were clinical confirmed. 93.5% of 97 pulmonary contusions (79 unilateral, 18 bilateral) were detected by bronchoscopy within 10 h, 72% by x-ray. Caused by anatomical problems or for additional diagnosis 4 patients underwent thoracic CT. ⋯ After CT we performed: 9 resections of the lower lobe, 1 pneumectomy, 1 decortication, 7 thoracotomies with drainage, 8 drainages. To detect a septic focus under treatment the CT proved being an important diagnostic tool in chest trauma and lung contusion.
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Emergency medicine is subjected worldwide to financial stringencies and organizational evaluations of cost-effectiveness. The various links in the chain of survival are affected differently. Bystander assistance or bystander CPR is available in only 30% of the emergencies, response intervals--if at all required by legislation--are observed to only a limited degree or are too extended for survival in cardiac arrest. ⋯ Efficiency of emergency physician activities can be demonstrated in polytraumatized patients or in patients with ventricular fibrillation or acute myocardial infarction, in patients with acute myocardial insufficiency and other emergency clinical pictures. Cost effectiveness is clearly in favor of emergency medicine. Future developments will be characterized by the consequences of new health care legislation and by effects of financial stringencies on the emergency medical services.
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In the Department of Traumatology and Reconstructive Surgery of Steglitz Medical Center, Berlin, a total of 1,323 patients with proximal femoral fractures were treated between 1978 and 1992. 988 patients were female and 335 male, age range 18-99 years, mean age 74 years. 479 fractures were classified as medial femoral neck fractures and 205 as lateral femoral neck fractures, further 461 pertrochanteric and 178 subtrochanteric fractures were seen. Based upon computerized data--especially regarding lethality and complication rates--the evolution of fracture treatment is outlined. ⋯ In older patients with medial femoral neck fractures the therapeutic standard today is the bipolar prosthesis, in younger patients osteosynthesis. In lateral femoral neck fractures as well as pertrochanteric fractures the most suitable osteosynthesis is the DHS, in subtrochanteric fractures the condylar plate. Whenever possible osteosynthesis should be preferred to total hip arthroplasty if patient condition and hip joint integrity allow this treatment. The more stable and biological procedure of osteosynthesis should be preferred.