[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65]

In a prospective study 104 patients >or=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

Osteitis

Infections of the locomotive system appear in many different forms such as acute inflammation of joints or bone following injury or surgical or chronic processes, often lasting for years. They demand an exact treatment plan not only to remove necrotic tissue but also for reconstruction of defects. A special problem is infection following alloplastic reconstruction of joints or spine. Multiple surgical procedures are required to hinder reinfection, restore function, and assure acceptable patient quality of life.

Apparative Diagnostik im Schockraum

Opinions vary with regard to the equipment and structural furnishings required for adequate management of the trauma patient in the dedicated shock suite. In order to assess the current situation in Germany, we conducted a survey of the 76 centers participating in the Polytrauma Registry of the DGU. Fifty-one questionnaires were returned by centers representing all levels of care. Responses revealed, for example, that not all centers possess capabilities for conventional radiography in the shock suite (7/51). Only 20 centers had a fixed table; the remaining 24 hospitals used either an image converter or a mobile X-ray unit. A dedicated ultrasound scanner was provided for the shock suite in 39 of 51 centers responding. Dedicated computed tomography scanners were provided for the shock suite in only eight centers (one dedicated trauma center, three level 3 centers, four university hospitals). All eight scanners use helical CT technology; at least three of the units are 8- or 16-slice. Of 51 shock suites, 12 are air-conditioned in compliance with sterile criteria (and are officially designated as surgical suites), while the remaining 39 are not. In acute cases, emergency surgeries can be performed in the shock suite in 37 centers, but not in the remaining 14 shock suites. According to the survey, slightly less than half of the hospitals responding are un-satisfied with the shock suite infrastructure ( n=24) and, of these, 13 centers are actively planning changes (the necessary financial resources have been guaranteed in 10 centers). Fourteen centers desire changes but do not currently have the required money. Information provided by Philips and Siemens suggests that the cost of furnishing a new shock suite ranges between 1.4 and 1.7 million euros. Responses to our survey show that a large gap remains between wishes and reality in the technical infrastructure in many shock suites in Germany.

[Costs for acute, stationary treatment of polytrauma patients]

Are the costs required for a polytraumatised patient sufficiently paid by the health care companies?The study population consisted of 71 polytrauma patients. The treatment-costs were calculated and compared with the reimbursements. The mean patient age was 38.0 years with a mean injury severity score (ISS) of 23.0 points. The mean duration of hospitalisation was 25.9 days and the mean calculated cost per patient was Euro 21,866.30. The reimbursement was only Euro 16,863.03/patient. This leads to a financial deficit of approximately Euro 5,000/patient (Euro 167/polytrauma patient/hospital day) and nearly Euro 355,000 for all patients during the period of 1 year. The introduction of the DRG system endangers the high standard of polytrauma treatment because of insufficient reimbursement.It is necessary to consider the implementation of an additional polytrauma-reimbursement based on the injury severity and duration of hospitalisation. The concentration of the patients in trauma centres, where the optimum of therapy is guarantied, leads in these hospitals to a continuously increasing deficit. The latter may be deleterious for the concept of "trauma centers" in the future.

[Correction of complex deformities in infectious conditions]

Skeletal deformities do occur after conservative or operative fracture treatment, as a consequence of congenital growth disturbance and as sequlae after posttraumatic and haematogenous osteomyelitis. In postinfectious deformities the course of the bone and soft tissue infection plays a decisive role when choosing the appropriate operative technique. Even in non active situations with a closed soft tissues envelope and no draining sinus persistence of germs within the bone has to be anticipated. The biological quality of the bone and the soft tissue envelope is often reduced because of local changes and as a result of multiple local revisions. Consequently wide areas of scar tissue and sclerotic bone are often encountered. The apex of the deformity is in most cases identical with the focus of the active or non active infection. The correction of the deformity at the apex can therefore only be accomplished if the infectious bone is also resected. If a correction is not possible at the apex of the deformity, translation at the osteotomy site is necessary to achieve a correct mechanical axis. The later rather complex operative procedure necessitates intensive preoperative planning and an extensive experience with deformity corrections by external fixators.

[Correction of post-traumatic diaphyseal malalignment of the lower extremity]

Post-traumatic deformities do occur as a result of disturbed fracture healing with loss of bone stock, necrosis of fragments or the development of pseudarthrosis resulting in malunion or progressive malalignment. In the majority of the cases these disturbances can be related to technical problems of primary fracture treatment like insufficient reduction or implant failure. On the other hand, complex deformities with involvement of the adjacent joints may also be a result of injuries of the growth plate in childhood. In some cases primary correction is impossible because of critical conditions of the bone and the soft tissue envelope in the center of deformation. If a secondary correction is indicated, knowledge of all reconstructive techniques is essential to choose the appropriate method and carry out successful and exact correction of malalignment of the affected limb after detailed planning.

Atherosclerosis in the aorta of hypercholesterolemic rabbits and the influence of daltroban

These studies have examined aortic atherogenesis in cholesterol-fed rabbits and have correlated the effects of daltroban to the pathomechanism of the vessel wall lesions. After feeding a 0.5% cholesterol-enriched diet for 96 d atherosclerotic alterations were seen, which exhibited a proximo-distal pattern, to which the branching of the aorta contributed considerably. Depending on their localization and size a varying cellular constitution of the plaques was obvious. Large plaques, which were mainly seen in the aortic arch and the proximal descending thoracic aorta, consisted of numerous proliferating cells, masses of fibrillar ground substance, clusters of foam cells, and rarely contained cholesterol crystals and necroses. Emerging plaques mainly found in distal thoracic and abdominal aorta imposed as fatty streaks. Daltroban treatment, used in a clinically relevant doses of 10 mg/kg b. wt. per day, reduced extension and protrusional area of plaques to about 40%, which was evaluated using a newly developed computerized morphormetric method, in association with significant reductions in free cholesterol content within the aorta. The results suggest that daltroban inhibits the progression of atherosclerosis in cholesterol-fed rabbits. This effect may be related to its antagonistic interaction with the thromboxane A2 receptor and also to an inhibition of the cholesterol metabolism.