The aim of the present systematic literature review is to give an overview of ruptures of the plantar fascia. For this purpose, a detailed description of the patient collective is provided. However, the focus of this analysis is based on the current therapy concepts. Based on the results the authors propose a standardized therapy concept. A systematic literature review was performed using the PubMed database using the terms: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis"). All articles published in the PubMed database until 07.11.2018 were included. The articles were evaluated with regard to three research question: (1) Which patients are affected by a rupture of the plantar fascia? (2) Which therapy concept was used to treat rupture of the plantar fascia? And (3) which result was achieved and how was this measured? A total of 78 studies were identified, of which the full text of 17 were analysed. 12 publications were cases reports, 5 studies were retrospective analyses. Data from 124 patients could be included. The average age of patients was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. 94.4% of all patients were treated conservatively. The average duration of immobilization in a rigid walker was 2.6 weeks. In the majority of cases, pain-adapted weight-bearing was allowed in the rigid walker. There are few available studies concerning the rupture of plantar fascia. The quality of data is poor. The maximum duration of immobilization of 3 weeks in a rigid walker with pain-adapted weight-bearing appears to be the most applied therapy concept. Further studies are needed to evaluate the efficacy of the therapy and to optimize the therapy concept.

Introduction Surgical treatment of supracondylar femoral fractures can be challenging. An additional wire cerclage is a suggested way to facilitate fracture reduction prior to plate osteosynthesis. Denudation to the periosteum remains a problematic disadvantage of this procedure. This study analyzed the effect of an additional wire cerclage on the load to failure in plate osteosynthesis of oblique supracondylar femoral shaft fractures. Materials and methods On eight pairs of non-osteoporotic human femora (mean age 74 years; range 57–95 years), an unstable AO/OTA 32-A2.3 fracture was established. All specimens were treated with a polyaxially locking plate. One femur of each pair was randomly selected to receive an additional fracture fixation with a wire cerclage. A servohydraulic testing machine was used to perform an incremental cyclic axial load with a load to the failure mode. Results Specimens stabilized with solely plate osteosynthesis failed at a mean load of 2450 N (95% CI: 1996–2904 N). In the group with an additional wire cerclage, load to failure was at a mean of 3100 N (95% CI: 2662–3538 N) ( p = 0.018). Compression deformation with shearing of the condyle region through cutting of screws out of the condylar bone was the most common reason for failure in both groups of specimens. Whereas axial stiffness was comparable between both groups ( p = 0.208), plastic deformation of the osteosynthesis constructs differed significantly ( p = 0.035). Conclusions An additional wire cerclage significantly increased the load to failure. Therefore, an additional cerclage represents more than just a repositioning aid. With appropriate fracture morphology, a cerclage can significantly improve the strength of the osteosynthesis.

BACKGROUND:The aim of the present systematic literature review is to give an overview of ruptures of the plantar fascia. For this purpose, a detailed description of the patient collective is provided. However, the focus of this analysis is based on the current therapy concepts. Based on the results the authors propose a standardized therapy concept.MATERIAL AND METHODS:A systematic literature review was performed using the PubMed database using the terms: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis"). All articles published in the PubMed database until 07.11.2018 were included. The articles were evaluated with regard to three research question: (1) Which patients are affected by a rupture of the plantar fascia? (2) Which therapy concept was used to treat rupture of the plantar fascia? And (3) which result was achieved and how was this measured?RESULTS:A total of 78 studies were identified, of which the full text of 17 were analysed. 12 publications were cases reports, 5 studies were retrospective analyses. Data from 124 patients could be included. The average age of patients was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. 94.4% of all patients were treated conservatively. The average duration of immobilization in a rigid walker was 2.6 weeks. In the majority of cases, pain-adapted weight-bearing was allowed in the rigid walker.CONCLUSION:There are few available studies concerning the rupture of plantar fascia. The quality of data is poor. The maximum duration of immobilization of 3 weeks in a rigid walker with pain-adapted weight-bearing appears to be the most applied therapy concept. Further studies are needed to evaluate the efficacy of the therapy and to optimize the therapy concept.

Heel pain is one of the common reasons why patients consult orthopaedic surgeons in an outpatient setting. The dorsal heel pain is often caused by a Haglund’s deformity which is an exostosis of the posterior superior calcaneus. It often leads to Haglund’s syndrome with calcaneal bursitis and Achilles tendinosis. This study aims to investigate the roll of MRI in diagnosis of Haglund’s syndrome and its influence on therapy.

Das Vorliegen von Abdominalverletzungen hat einen großen Einfluss auf die Mortalität schwerverletzter Patienten. Bei operationspflichtigen Verletzungen gilt die Laparotomie als Therapie der Wahl im Rahmen der frühen operativen Versorgung. Allerdings gibt es zunehmend Hinweise, dass die Laparoskopie eine Alternative im Rahmen der Polytraumaversorgung darstellen kann. Die vorliegende Arbeit analysiert das Verletzungsmuster, die Häufigkeit durchgeführter Laparoskopien sowie das Outcome schwerverletzter Patienten mit Abdominaltrauma. Es wurde eine retrospektive Analyse von 12.447 Patienten auf Basis der TraumaRegister DGU® (TR-DGU) durchgeführt. Einschlusskriterien waren ein Injury Severity Score (ISS) von ≥9 und ein Abbreviated Injury Scale (AIS; [Abdomen]) ≥1. Die Patienten wurden entsprechend der Therapieform in die Gruppen (1) Laparoskopie, (2) Laparotomie und (3) nichtoperatives Management (NOM) unterteilt. Anschließend wurden die Basisdaten der einzelnen Gruppen beschrieben und das Outcome analysiert. Die Mehrheit der Patienten wurde mittels NOM (52,4 %, n = 6069) behandelt, gefolgt von der Laparotomie (50,6 %, n = 6295) und der Laparoskopie (0,7 %, n = 83). Die meisten Laparoskopien wurden bei Patienten mit einem AIS [Abdomen] ≤ 3 (86,7 %) durchgeführt. Der ISS der Laparoskopie-Gruppe war signifikant geringer als in der Laparotomie-Gruppe und der NOM-Gruppe (ISS: 23,4 vs. 34,5 vs. 28,2; p ≤ 0,001). Die standardisierte Mortalitätsrate (SMR) war in der Laparoskopie-Gruppe geringer als in der Laparotomie-Gruppe und der NOM-Gruppe (SMR: 0,688 vs. 0,931 vs. 0,932; p-Wert = 0,2128), ohne das statistische Signifikanzniveau zu erreichen. Obwohl die Laparoskopie nicht häufig eingesetzt wurde, weisen die Daten auf die Effektivität dieses Verfahrens in der frühen operativen Versorgung schwerverletzter, hämodynamisch stabiler Patienten mit einem (AIS; [Abdomen]) ≤ 3 hin.

BACKGROUND Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls. RESULTS Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well. CONCLUSIONS Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.

Background: The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment.Methods: We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016.Results: The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo-dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized.Conclusion: The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.

INTRODUCTION:Hemorrhagic shock remains one of the most common causes of death in severely injured patients. It is unknown to what extent the presence of a blood bank in a trauma center influences therapy and outcome in such patients.MATERIAL AND METHODS:We retrospectively analyzed prospectively recorded data from the TraumaRegister DGU® and the TraumaNetzwerk DGU®. Inclusion criteria were Injury Severity Score (ISS) ≥ 16, primarily treated patients, and hospital admission 2 years before or after the audit process.RESULTS:Complete data sets of 18,573 patients were analyzed. Of 457 hospitals included, 33.3% had an in-house blood bank. In trauma centers with a blood bank (HospBB), packed red blood cells (PRBCs) (21.0% vs. 17.4%, p < 0.001) and fresh frozen plasma (FFP) (13.9% vs. 10.2%, p <0.001) were transfused significantly more often than in hospitals without a blood bank (Hosp0). However, no significant difference was found for in-hospital mortality (standard mortality ratio [SMR, 0.907 vs. 0.945; p = 0.25). In patients with clinically apparent shock on admission, no difference of performed transfusions were present between HospBB and Hosp0 (PRBCs, 51.4% vs. 50.4%, p = 0.67; FFP, 32.7% vs. 32.7%, p = 0.99), and no difference in in-hospital mortality was observed (SMR, 0.907 vs. 1.004; p = 0.21).DISCUSSION:In HospBB transfusions were performed more frequently in severely injured patients without positively affecting the 24h mortality or in-house mortality. Easy access may explain a more liberal transfusion concept.

Following the establishment of the first trauma networks in 2009 an almost nationwide certification could be achieved. Despite the impressive number of 46 certified networks, little is known about the actual improvements and the satisfaction of the participating hospitals. This article aims to give a first representative overview of the expectations and actual achievements. An online survey with a total of 36 questions was conducted in 884 hospitals. The questionnaire could be filled out online, sent by post or fax to the AKUT- Office. Descriptive statistical analyses were performed with Microsoft Excel. With 326 responses, a response rate of 48.9 % of all active hospitals was achieved. Of the participating hospitals 64.1 % (209) were certified and had taken part in the project for an average of 3.9 years. The average score for satisfaction was 2.3, 72.4 % (236) felt that there was a need for improvement in the care of severely injured patients and 46.6 % (152) in the transfer of patients. In 47.2 % (142) no improvement in cooperation with the ambulance service could be determined, 25.2 % (82) documented an increase in the number of severely injured patients since participating in the trauma network (TNW-DGU) and 93.9 % (306) of all hospitals wanted to participate in the trauma network in the future. It could be shown that important goals, such as simplification of patient transfer or general improvement in cooperation have been achieved. Overall there was a high level of satisfaction among the participating hospitals; however, the survey has identified some points which need to be improved by further intensive work.

Background. In recent years, there has been an ongoing improvement in the treatment and structural aspects of acute trauma care. Because of the definition of rehabilitation as a post-acute part of the treatment of traumatic injuries, especially in multiple injured patients, there is need to improve the interaction and cooperation between acute care hospitals and rehabilitation clinics. This article gives a survey of the current state of rehabilitation in Germany. Materials and methods. Based on a directory of rehabilitation clinics and an internet search, all rehabilitation clinics were identified and included in the analysis for clinic location, structural and equipment attributes. Results. In total 551 rehabilitation clinics with expertise in the treatment of traumatic and orthopedic injuries were identified. In detail, broad differences between the federal states could be observed. The number of rehabilitation clinics per state ranged from 1 to 136 and the number of beds from 70 to 18040. The average catchment area covered by a rehabilitation clinic is 648 km(2) (range 149-2106 km(2)) with an average of 1584 patients per clinic per year. Of the clinics 68% can treat patients with methicillin-resistant Staphylococcus aureus (MRSA) infections and 62.1% are able to deal with patients who need renal dialyses. Almost all clinics provide an x-ray facility (96.4%) while computed tomography (CT) and magnetic resonance imaging (MRI) are available in 52.6% and 50.3%, respectively. Conclusion. The number of rehabilitation clinics available seems to be adequate for all patients with traumatic injuries but there are enormous differences between the federal states. Because rehabilitation is important for the outcome of multiple injured patients, a further improvement of the quality and integration into the regional trauma network seem to be necessary.

Nach der Etablierung der ersten TraumaNetzwerke im Jahr 2009 ist mittlerweile eine fast flächendeckende Zertifizierung gelungen. Trotz der beeindruckenden Anzahl von 46 zertifizierten Netzwerken ist nur wenig über die tatsächlich erzielten Verbesserungen und die Zufriedenheit bekannt.

INTRODUCTION:The distal radial fracture is a common fracture and frequently seen in geriatric patients. During the last years, volar plating has become a popular treatment option. While the application of locking screws at the distal fragment is widely accepted, there is no evidence for their use at the radial shaft.MATERIALS AND METHODS:In six osteoporotic pairs of matched human cadaver radii an extra-articular model creating an AO 23-A2.1 fracture was employed. Osteosynthesis were performed using the APTUS 2.5 Adaptive TriLock Distal Radius System (Medartis AG) with locking (LS) or non-locking screws (NLS) for proximal fixation. Biomechanical testing was performed in a staircase fashion: starting with 50 cycles at 200N, the load was continuously increased by 50N every 80 cycles up to a maximum force of 400N. Finally, load to failure was analyzed with failure defined as sudden loss of force measured (20%) or major deformation of the radii (10mm).RESULTS:At 200N, 250N, 300N, 400N and load to failure, the NLS group showed a higher degree of elastic modulus. In contrast, the LS group showed higher elastic modulus at 350N. Maximum force was higher in the LS group without reaching statistical significance. Reasons for loss of fixation were longitudinal shaft fractures, horizontal peri-implant fractures and distal cutting out. No difference was seen between the two groups concerning the development of the above mentioned complications.CONCLUSION:Our study did not show biomechanical superiority for distal radius fracture fixation by using locking screws in the proximal holes in an osteoporotic cadaver study. At load to failure, longitudinal shaft fractures and peri-implant fractures seemed to be a more relevant problem rather than failure of the proximal fixation.

Background: A precise understanding of glenohumeral anatomy is required to optimize preoperative planning in shoulder joint arthroplasty, which is difficult in the presence of degenerative disease. In unilateral disease, the contralateral shoulder can be used as a representation of normal anatomy; however, intrasubject differences in shoulder morphology have not been investigated.Methods: A retrospective study of all patients aged >65 years who received whole body computed tomography at our trauma center from 2010 through 2014 was conducted. Right and left shoulder computed tomography scans were examined, and the following anatomic parameters were measured: humeral head diameter in anteroposterior and axial views, glenoid diameter in anteroposterior and axial views, glenoid surface, scapula neck depth, neck-shaft angle, glenoid inclination, glenoid/head ratio, and glenoid version. Patients with inadequate scan quality, osseous lesions, pre-existing anatomic abnormality, or metallic implant at the shoulder region and significant osteoarthritis were excluded.Results: The study analyzed 102 shoulders of 51 patients. Mean age was 71.4 +/- 8.2 years. Humeral head and glenoid diameters, scapula neck depth (right, 36 +/- 8 mm; left, 36 +/- 7 mm; P = .684), glenoid/head ratio (right, 0.6 +/- 0.1; left, 0.6 +/- 0.0; P = .961), and glenoid surface (right, 790 +/- 152 mm(2); left, 754 +/- 134 mm(2); P = .215) showed no significant side-related differences. In addition, no significant difference was found regarding the neck-shaft angle (P = .211) and glenoid anteversion or retroversion (right, 65% [n = 33] anteversion and 35% [n = 18] retroversion; left, 69% [n = 35] anteversion and 31% [n = 16] retroversion; P = .417).Conclusion: There are no significant side-dependent differences in the osseous anatomy of the glenohumeral joint. In patients with unilateral shoulder degeneration, the contralateral shoulder can provide reference values during the planning of shoulder replacement surgery.Level of evidence: Basic Science Study; Anatomy; Imaging (C) 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Profound knowledge of variations in shoulder anatomy is gaining relevance in daily clinical work. In our study, we examine age-dependent variations of glenohumeral parameters in healthy individuals.

Introduction: Despite the importance of rehabilitation in the treatment of patients with severe trauma or even of severely injured patients, the cooperation between acute and rehabilitation hospitals is often inadequate. The present study aims to identify factors that make it probable that a severely injured patient requires inpatient rehabilitation following the acute treatment.Material and methods: A retrospective analysis of 75.357 cases from the TraumaRegister DGU (R) (TR-DGU) was performed. All cases from 2002 until 2013 with an ISS >= 9, who were taken to the ICU were included. Regarding the discharge destination the subgroups "at home" and "rehabilitation hospital" were analyzed in detail. Finally, we performed a multivariate regression analysis based on the parameters previously collected.Results: 24.208 patients (32.1%) were transferred to a rehabilitation clinic. In the multivariate regression analysis the most relevant independent parameters for discharge in a rehabilitation hospital were age (18-54: OR 1.65; 55-74: OR 2.86 and 75 and older: OR 5.07, all p <= 0.001), AIS pelvis >= 2 (OD 1.94), AIS legs (OR 2.02), AIS spine (AIS 4: OR 5.78 and AIS 5-6: OR 6.36) and the AIS head (AIS 3: OR 1.88; AIS 4: OR 3.11 and AIS 5-6: OR 7.55) (all p <= 0.001). The length of stay in the ICU (3-7 days: OR 1.88; 8-28 Days: OR 5.42 and 29 and more days: OR 14.7, all p <= 0.001) was also a relevant parameter. The overall ISS presented no relevant influence with an OR of 1.02 (p = 0.03).Discussion and conclusion: Knowing independent factors for a required inpatient rehabilitation helps the treating physicians to identify the patients at an early stage in acute hospitals. So the transfer to a rehabilitation clinic can be organized faster and more selective in future. (C) 2016 Elsevier Ltd. All rights reserved.

Background: Persons who sustain severe traumatic injury, i.e., those with an Injury Severity Score (ISS) of 16 or above, go on to suffer major physical, emotional, and socio-economic consequences. It is important to know the incidence of severe trauma so that these patients can be cared for optimally.Methods: Data from the year 2012 on severely injured persons with an ISS of 16 or above were obtained from the trauma registry of the German Society for Trauma Surgery (DGU) and analyzed. Further information was obtained from the database of the DGU trauma network. The annual incidence of severe trauma was estimated from these data in three different ways.Results: An extrapolation of hospital-based data to the German population yielded a figure of 16 742 severely injured persons per year. A population-based estimate from the German federal state of Bavaria yielded a figure of 16 514/year, while an area-based extrapolation using data from 17 established networks yielded a figure of 16 554/year. We added 10% to each of these figures as a correction for assumed underreporting. We conclude that the number of persons who sustained a severe traumatic injury in Germany in 2012 lay between 18 209 (95% confidence interval [CI]: 17 751-18 646) and 18 416 (95% CI: 18 156-18 695). This corresponds to an incidence of 0.02% per year.Conclusion: Data from a prospectively maintained nationwide trauma registry were used for the first time to calculate the annual incidence of severe traumatic injury in Germany: the expected number of severely injured persons per year is 18 200-18 400. Previous extrapolations yielded values in the range of 32 500-35 300. A high variability of documentation practices among supraregional trauma centers may have distorted the estimate, along with other factors. The figures were not normalized for age or sex.

Die Anzahl der (schwer)verletzten Kinder ist 2011 erstmalig wieder angestiegen. Ziel der vorliegenden Studie war es, neben der Analyse der Unterschiede im Vergleich zum Polytrauma des Erwachsenen, auch die Versorgungsrealität abzubilden.