The Swiss workers' compensation law prescribes experience rating. Successful efforts of an employer to reduce the risk of accidents through adequate preventive measures on one hand, and on the other hand to keep subsequent costs of still occurring accidents low with quick, consistent and generous measures of rehabilitation, will therefore result in a lower insurance rate. The motivating influence and success of this self-responsibility is pointed out with the figures of a trading company who had been detached from a large risk-community due to bad results. The success with accident prevention and the very favourable ratio achievable of costs for medical treatment (as a measure for the severity of the injuries) to daily payments and costs for permanent disabilities is shown with the example of a construction machinery company. What relations and consecutive costs result from (partly conscious) neglect of rehabilitation is demonstrated with the figures of a construction company.
In the paper we present the result of an epidemiological study we conducted upon injuries due to road accidents in Canton Ticino. We reviewed 1471 injured patients during two periods: in 1982 we examined all patients evaluated in the Emergency Room and admitted - if required - in all the Canton Ticino Hospitals. In 1985 we reviewed only patients seen at Ospedale Civico Lugano and patients seen by the police department (SIR) because the lesions were life-threatening. 106 (8%) patients died, 206 (15%) were seriously injured (87 patients with chronic infirmity) and 1062 had slight injuries. The total lesions were 2900 and 839 surgical operations were necessary. These patients needed a 7804 days of hospitalization (677 days in the intensive care unit). Motorcycles represented 46.5% of the involved vehicles. The major risk groups by age are: 14-17 years old (motorcyclist), 18-29 years old (automobilists and motorcyclists), up to 13 and over 60 years of age (pedestrians). The percentage of the total road accidents which occur at the week-end is of 49.4%. At rush/hours (5.00 pm) the percentage of accident is 8.1% (115 accidents) and in the early morning hours the percentage is 5.5% (74 accidents). The annual hospitalization costs amounted to 3,200,000 sFr., whereas the real costs corresponding to production loss, social expenditures (25.737 were the days of disability) and in- and out patient care are as high as 100 million francs.
In a retrospective study 275 femoral-shaft fractures and 652 tibial respectively fibular fractures of the growing skeleton were evaluated. A posttraumatic limb length difference was present in 70% after femoral fractures and in 40% following fractures of the lower leg. In the control group of 822 examined persons we found an idiopathic difference of the length of the limb in 25%. Following femoral fractures the limb length difference was in average 10 mm. However following fractures of the tibia and fibula it was 7 mm. There is no evidence that an established difference in length will improve in course of growth. Factors influencing the alteration of length are discussed. It could be shown that there is no primary therapeutic way of influencing the alteration of length and that the so called prophylactic "shortening" at time of consolidation cannot prevent future lengthening. Also we could prove that rotational deformities of the femur show a good prognosis regarding spontaneous correction. Deformities of the lower leg however do not show spontaneous correction and ought to be corrected primarily. The incidence and degree of future alteration of length of the lower limb can only be influenced indirectly by early definite stabilisation of the fracture without leaving an axial deformity behind. For stable non-dislocated fractures the plaster of cast treatment is sufficient. However for unstable, dislocated (displaced) fractures which need anaesthesia for primary treatment, the unilateral external fixator is proposed as the method of treatment. Functional follow up examinations to evaluate possible posttraumatic alteration of the length of the lower limb, have to be performed at least for two years after the accident.
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.
Between 1979 and 1988, 119 children with 123 femur shaft fractures were treated in the Department of Traumatology of the university-hospital of Freiburg. Traffic accidents were the reason in half of the cases. 19 children had multiple trauma and serious cranio-cervical traumata. In the case of 14 further children, additional limb fractures could be diagnosed, four of which were contralateral femur shaft fractures. More than half of the children with femur shaft fractures were treated by internal fixation. Only internal fixation by plate was employed. 32 children were operated upon at the day of the accident (49%). Children with solitary injuries could be treated as outpatients after 13 days. The implanted material could be removed after an average of 8.4 months. At the moment a reexamination of 31 operated cases (altogether 65 children with 69 fractures are operated) is performed. 30 children have excellent (18 patients) or good (12 patients) results. The healing process was complicated by delayed healing of the fracture (1 patient), plate fracture after 2 months (1 patient) and subcutaneous haematoma (2 patients). Osteitis did not occur.
In adolescents dynamic-compression-plate osteosynthesis is an excellent modality for treating femoral shaft fractures. It provides anatomical stabilisation as well as short hospitalisation and rehabilitation. In contrast, fractures of the tibial shaft are usually treated with casts or by extension. Primary operation is rarely necessary, for example in cases of an impaired neurovascular system. In third degree open fractures we usually recommend external fixation. In our department clinical and radiological late-term controls are performed over a period of at least two years for tibial and four years for femoral shaft fractures.
Childhood accidents of any kind do not present any particular problems to Swiss third party liability insurers. However, such claims call for an active handling by the claims adjusters as well as intense contacts between claims adjuster, responsible physician, and parents in order to prevent any long term complications.
Shaft fractures in young children have certain characteristics that are related to the type of accident and bony structure of this age group, the rapid healing process, and the long subsequent growth period. 1. Due to the high incidence of falls, green-stick, compression, and torsion fractures predominate. 2. Reduction and immobilization can nearly always be achieved by conservative treatment or simple osteosynthetic procedures. 3. The intensive remodelling process makes precise reduction unnecessary. Tolerance is greatest for side-to-side displacement and least for rotational deformities, especially in the forearm and leg. 4. The most common consequence of fracture healing is overgrowth of the fractured extremity, the intensity of which increases in proportion to the degree of spacing in the fracture area. 5. Complications are uncommon and are due mainly to overlooked rotational deformities, repeated manipulations, erroneous indications, or inappropriate internal fixation. 6. Anticipation of further growth is never an acceptable excuse for leaving an improperly aligned fracture to be "outgrown". 7. When certain basic precepts peculiar to this age group are observed, the treatment of shaft fractures in young children nevertheless carries a favorable prognosis.
The authors illustrate an original method of osteosynthesis concerning shaft fractures in children: Stable Elastic Nailing. They elaborate the physiopathological basis and specify all details of this technique. The results of this treatment as well as its limits are considered through personal experience of 217 femurs, 42 tibias, 36 humerus, 84 fore-arms and 96 supracondylar fractures of the humerus. We essentially proceeded for a comparative analysis with other methods of osteosynthesis or conservative treatment, illustrating the net superiority of stable elastic nailing in their indications according to the recommended technique.
In a series of 329 children treated for fractures of the femur between 1968 and 1982 a comparison was made between the results of mere extension treatment against operative compression plate treatment. The follow-up shows that conservative methods suffer from high rate of axial deviation, particularly antecurvature, while operative treatment has the negative effect of a higher, incidence of persistent leg lengthening and of re-fracture. The advantages of operative management, namely precise positioning of fracture, low damage to soft tissue and - above all - unimpaired motility of the young patient justify its preferred use in the treatment of femur fractures in children - except for long oblique fractures.
This paper presents a special reaction of long tubular bone to a singular compression or bending stress. The characteristics of this special type of reaction to injury are exposed on the basis of bibliographical data and experiences in 12 own patients. Traumatic bowing in the forearm and shank leads to loss of function respectively to delayed union. Up to the age for ten years spontaneous correction by further growth is possible. Beyond this age treatment consists in sensitive correction in general anesthesia and plaster fixation.
Previous examinations using computed tomography have shown that no geometrical changes in the cross-section was induced by the plate fixation; bone density was slightly reduced (10% in average) in the entire cross-section and not only next to the plate. A tomographic analysis is presented here about the quality and the amount of bone in the affected leg, compared to the contralateral one.
Early full weight bearing in femoral trochanteric fractures is an important problem. It seems to us to be imperative because the very old aged population (about 80 year old average) concerned by that type of fractures. That attitude reduces hospitalisation and rehabilitation time. The authors propose an original 95 degrees angular-plate rendered by a stay. A complete experimental study proved that material able to support the immediate weight bearing. A clinical application on 207 cases confirmed the experimental hypothesis.
By the autologous blood-transfusion we understand the dose of own blood in contrary to strange blood. The advantageous of the method are well-known. But nevertheless the own-transfusion is rarely realized. By the immune infirmity AIDS this method is of pressing importance at the present time. In orthopaedics and the traumatology of the movement mechanism especially selected operations and delayed emergency-operations are qualified for the autologous blood-transfusion. Regarding a ten years positive experience we introduce a simple and safe method which is also commonly used in the regional hospital in Langenthal since summer 1986. It is a combination of a pre-operative own-blood-transfusion and the "isovolumic" actual blood-dilution. 158 patients have been analysed which have been treated by this method. The most frequently operation has been the total hip replacement 85% of the analysed persons could be operated without any strange blood and totally 426 times autologous blood donation could be received within 26 months. That safe and simple method can be managed in the hospital by an engaged but moderate display and it is recommended especially for average and small hospitals.
The prehospital emergency treatment of craniocerebral trauma tries to avoid secondary cerebral lesions by controlling respiration and circulation. The therapy consists of heavy sedation with Midazolam, analgesia with morphine, artificial hyperventilation, PaO2 over 12 kPa and average arterial pressure above 80 mmHg. Our series of 46 patients recovered between 1982-1988 had a hospital mortality of 23%. 46% of the patients were polytraumatized. A normal neurologic state 6 months from the accident was registered in 86.4%. For 13.6% it was slightly pathological and no vigilant coma state was reported. The most effective rehabilitation method at the site of the accident has to secure the cerebral oxygen supply and reduce potential increase in intracranial pressure for avoid secondary cerebral lesions.
The first carpal row acts as an important functional unit. The position of the lunate and scaphoid and their relationship within the wrist are wellknown. On the lateral radiography they are easily recognized so that one is able to define and measure accurately their relative position. The position of the triquetrum and its relationship to the adjacent bones have not been previously very well defined. However, it is possible to consistently identify the axis of the pisotriquetral joint on the lateral radiography. From this line the position of the triquetrum can be inferred. We measured the axis of the pisotriquetral joint in a random sample of 102 cases (40 men and 62 women), and compared it to the axis of the radius. Thus, using the pisiform axis as a marker, the position of the triquetrum can be accurately defined. Its movement correlates well with that of the adjacent bones.
Infected tibial nonunions, with bone loss and extensive soft tissue damage, often require long multistage treatment. Epidermo-fascial osteoplasty according to Umiarov allows the removal of important bone loss without previous sterilization of purulent foci or coverage of the soft tissues. The results obtained in 5 cases treated by Umiarov technique are very satisfactory and allow to consider this method as a valid alternative to the traditional treatments.
In tibia and fibula fractures the classification of Weber for malleolar fractures is not valuable. Very rare are fractures of the lower leg (tibia and fibula) together with a ruptured syndesmosis. But it exists, the surgeon has to know it, if the patient complains in addition of pain in the region of the lateral malleolus. One typical case is reported. In 4760 documented tibia fractures we had 39 cases with ruptures of ligaments. Lesions of the syndesmosis were seen in 11 cases and fractures of the Volkmann triangle in 4 cases.
