Biomedical subjects
Publications and source records attributed to T Rüedi.
Ten cases seen over the last eight years were reviewed by clinical and radiological re-examination one year after injury. The results encourage us to continue treating young patients with critical soft-tissue injury, compartmental syndrome, open fracture and multiple injury by this technique.
Abdominal tuberculosis is a rare disease in Western countries and remains difficult to diagnose. The most frequent symptoms are abdominal pain, weight loss, fever, vomiting, constipation and/or diarrhea. Clinical findings include abdominal tenderness, a palpable mass (often in the right fossa due to ileocecal infection), paleness, cachexia and ascites. Suggested radiological investigations include plain abdominal film, upper GI-series and barium enema. Chest X-rays often show signs of either active or inactive tuberculosis. Sputum and gastric juice should be cultured. Coloscopy serves to sample specimens for histology and bacteriology and may help to confirm the diagnosis, which is, however, not ruled out by negative findings. The same holds good for peritoneal biopsy and laparoscopy. Bowel perforation and ileus are frequent complications and always require surgery, whereas uncomplicated cases can be treated by drugs only.
Within the context of modern fracture fixation, buttress plates have traditionally played an important role in stabilizing both intraarticular and extraarticular displaced metaphyseal fractures. While plating has substantially improved the assurance of union and functional recovery in these fractures, there is some interference with physiologic blood supply to the regions of the fracture and, consequently, to the biological elements of healing. This article outlines alternative methods of treatment for these fractures using screws and wiring systems with little, if any, loss of stability. Patients must be selected carefully and must have large fracture fragments and normal or near normal mineralization of their bones. When screw and wiring methods can be used, there is less tissue dissection and, consequently, less interference with the physiologic fracture healing process.
The treatment of comminuted intra-articular fractures of the distal radius often requires an operative fixation. Beside the recently recommended external fixator, the support plate fixation offers a helpful alternative to treatment. Between 1980 and 1986, 30 wrists in 29 patients with intra-articular fractures of the distal radius were stabilized with a buttress plate an the Kantonsspital Chur, Switzerland. The mean follow-up-time was 15 months. These follow-ups showed that the buttress plate in treatment of complicated intra-articular fractures allows a satisfactory reduction and stabilization with restoration of the articular congruity and the possibility for early active assisted motion. Buttress plate fixation still remains a demanding technique, which in complicated cases, should be reserved for the experienced surgeon.
33 children with displaced SFH were all treated operatively by open reduction and internal fixation or closed reduction and percutaneous pinning. A follow-up study was performed on average 29 (range 3-63) months after the injury. In 18% of the cases an initial injury of the neurovascular structures was observed and documented during the operation. 32 times open reduction and internal fixation by K-wires was performed, only once, closed reduction and percutaneous pinning was attempted. In the presence of a preoperative neurologic deficit, the nerves were always visualised, never, however, a nerve suture was necessary. In one case we had to reconstruct both the arteria brachialis and radialis because of intima lesions with total obstruction of the vessels. The average time of hospitalization was 9 days, which includes the time for removal of the pins, which was usually performed about 4,5 weeks later simultaneously with the removal of plaster. Using Innocenti's criteria, 27 of 30 reviewed patients had an excellent result, 3 had a good result. Early complications due to the operation such as wound healing problems, infection or nerve lesions did not occur. 3 patients could not be reached any more. We recommend for the management of the displaced SFH open reduction and internal fixation by K-wires as the method of choice. Percutaneous pinning is a valid alternative when closed reduction succeeds easily at the first attempt.
The new AO universal tibia nail with interlocking possibility has several new features. The wall thickness has been increased from 1.0 to 1.2 mm. In order to give the stiffer nail smoother insertion properties and better cortical contact, the overall design has been altered with the help of computer calculation. Proximally there are 3 holes for locking purposes in the frontal plane, while distally we find two holes in the frontal and one in the sagittal plane to accommodate the locking bolts. The new nail has been applied in 17 clinical cases with overall good results. The indications were deliberately pushed to the extremes and even 5 open fractures were nailed after minimal remaining. There were 2 major perioperative complications: one proximal blow-out of the anterior cortex due to a wrong point of insertion and several other technical mistakes. The situation was salvaged with an external fixator. In an 85-year-old multiple injured lady with a 3-degree open tibia, the initial fixateur externe was replaced after 3 weeks by a 10 mm universal nail. Due to severe porosis and rather proximal extensive cortical comminution, the locking bolts and therefore the nail did not find a good hold in the tibia plateau. After uneventful healing of the soft tissues and additional splinting, the fracture, however, consolidated within 4 months. There were two superficial soft tissue infections early postoperatively, but no cases of osteitis. Healing of the fractures seems to progress without delay.(ABSTRACT TRUNCATED AT 250 WORDS)
Depending on the choice of fixation and implant, the aftercare of fractures has to occur in different manners. Postoperatively the CPM-machines have taken the place of conventional supports, and there is a distinct tendency to even earlier mobilisation of fracture patients. Except for comminuted, intraarticular fractures, partial weight bearing with 10 to 15 kg (toe-touch) is encouraged as of the first postoperative week. Since the introduction of the locked nail for shaft fractures, we have to get used to look at X-rays with hardly reduced fragments and abundant callus formation. This contrasts to what we are used to from the conventional plate fixations. In case of stable plating, the old rules remain valid: anatomic reconstruction and direct fracture healing without visible callus.
We report our experience with 11 patients treated with an external fixator that was dynamized at some stage of the treatment. In 7 patients bone union occurred without any other measures, 2 patients were protected in a cast after the external fixator removal, while 2 patients developed a non union that was plated and subsequently healed. According to these experiences, dynamization of an external fixator seems to be a reliable and elegant way to treat simple open shaft fractures, the method is however not advocated for more complex or comminuted fractures.
Non operative management of humeral shaft fractures is well recognized as the standard of care for uncomplicated injuries. Operative treatment of humeral fractures may be performed when limited indications are present as in patients with multiple trauma including ipsilateral forearm injuries, arterial injury or primary radial nerve palsy. 18 patients with humeral shaft fractures underwent open reduction and internal fixation (ORIF) using the AO plating technique at the Kantonsspital Chur from 1980 to 1986. Follow-up was available for 17 patients of whom 16 suffered from multiple injury trauma. The broad DC plate combined with lag screws was used in most cases. Two brachial artery transections were repaired at the time of primary osteosynthesis by the same surgeons with full functional recovery. Concomitant nerve injuries were repaired primarily in one case and postprimarily in 3 more cases. The overall result was excellent in 9 patients, good in 5 patients, fair in 2 patients and poor in one patient with complete brachial plexus injury. Bone healing was uneventful in all 17 patients. No infection and no delayed union or pseudarthrosis has been observed.
This study presents the follow-up of 187 patients with 194 diaphyseal fractures of the tibia (20% open), which were operated upon between 1980 and 1984 at our institution. We were mainly interested in the question of refractures after implant removal. The majority of fractures (98.79%) had no complications after removal of the implants, but 2 patients (1.03%) sustained another fracture of the same leg between 4 and 19 months after plate removal. Both are considered to be "true" refractures, as the new fracture occurred at the original fracture site. In one case the plate was removed far too early (9 months after the initial ORIF) and no warning or additional cast was given. Two other patients sustained a new fracture at different sites 4 and 7 years after the original surgery, respectively. The possible reasons for refractures as well as the best way to prevent them are discussed.
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