We report a truck driver with severe soft tissue contusion of both legs who developed atypical heparin-induced thrombocytopenia (HIT) after a thrombosis prophylaxis with unfractionated heparin; despite a thrombosis the patient showed a systemic allergic reaction to heparin in combination with elevation of thrombocytes and positive heparin-dependent antibodies. Six days after the initial trauma deep vein thrombosis of the left lower leg was diagnosed and fasciotomy was performed, preventing an imminent compartment syndrome. Another 5 days later the patient developed exanthema of the trunk and upper extremities and urticaria on his face, as well as severe headache. His platelet count increased from 134,000/microliter to 258,000/microliter. After exclusion of other causes for these symptoms, a reaction to heparin-dependent antibodies (heparin-platelet-factor 4 complex) was demonstrated 2 days later. Thrombosis prophylaxis was changed to hirudin (Refludan) and elevation of thrombocytes to 445,000/microliter was noted. Shortly after rinsing of an intravenous line with less than 50 IE unfractionated heparin at day 36 after trauma the patient developed an anaphylactic shock, which could be managed with cortisone. We suggest that in HIT the thrombocytopenia may represent only one form of an allergic reaction to heparin. The cause of the thromboembolic event is an antigen-antibody reaction to heparin taking place on the surface of the thrombocyte. This is similar in all forms of systemic reaction to heparin application, even though the symptoms may vary. As thrombocytopenia may not be the main symptom of a heparin-induced antibody reaction--in our hospital only 5 of 10 patients with HIT--the disease should rather be named "heparin allergy". We suggest a new classification of different pattern of heparin allergy types I-IV. The new types I and II are similar to HIT types I and II. Type III is the reaction of antibodies without decrease of thrombocytes, and type IV the reaction of antibodies associated with systemic allergic symptoms.

For unstable fractures of the distal radius, the dorsal plate requires exposure of the fragments, frequently spongioplasty, and usually removal of the implant later on. However, with the palmar approach for the reconstruction of the articular surface and restoration can easily be achieved with the T-plate. In the Traumatology Department of the University at Göttingen, we have gained experience in the treatment with the palmar T-plate in more than 400 patients. In a prospective study, we investigated the functional and radiological results after palmar T-plate osteosynthesis in Colles fractures. From September 1994 to December 1998 we treated 200 patients with the palmar T-plate (AO, 3.5 mm, titanium). 166 patients (83%), mean age 59 years, could be followed up >18 months. AO classification: A2:10, A3:45, B1:18, B2:10, C1:24, C2:40, C3:19. We compared group 1 (younger than 60 years, n=88) vs group 2 (older than 60 years, n=78). The patients' evaluation of the usability of the hand was normal in 56% and in 26,5% slightly reduced. 12,5% felt handicapped and 5% felt severely handicapped. 5% of the patients changed the domain hand, 15,4% at least partly. Function according to Lidström: 23% excellent, 58% good, 15% fair and 4% poor results. Radiological results according to Lidström were excellent and good in 88,3% and fair in 11,7%. Gartland and Werley score was excellent in 66%, good in 24%, fair in 6% and poor in 4%. There was no significant difference between group 1 and group 2 in the age-depending results. The secondary dislocation, the average dorsal tilt was 3 degrees, the mean shortening of the radius was 1,5 mm. We saw steps in the joint surface from 0,5-1 mm in 10%. An algodystrophy occurred in 5%. 12% of the patients complained of limited sensitive irritations of the medianus nerve most likely originating in the formerly used approach close to the medianus nerve. After changing this approach, we saw no irritation of the Nervus medianus among 50 patients so far. Evaluation of the functional and radiological investigations: The palmar T-plate has produced reliable and good results in the treatment of unstable distal fractures of the radius without angle-stable screws up to now. This type of osteosynthesis is stable for exercise and ensures early mobilization with good functional results even in elderly patients.

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6%) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Type B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20.7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13.6% of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.

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Zusammenfassung OperationszielReposition und Rekonstruktion des Schultereckgelenks durch Naht des zerrissenen Kapsel-Band-Apparates und temporäre Retention der Klavikula mit Balser-Platte zur Wiederherstellung der Form und Funktion des Schultergürtels. IndikationenPrimäre Schultereckgelenkzerreißungen vom Typ Tossy III oder Rockwood III bei körperlich belasteten Patienten. Ausgedehnte Schultereckgelenkzerreißungen mit zusätz-lichen Muskel-oder Nervenläsionen vom Typ Rockwood IV-VI. Alte Schultereckgelenkzerreißungen ohne Arthrose mit anhaltenden Schmerzen unter Berücksichtigung der kör-perlichen und beruflichen Belastung des Verletzten. Laterale Klavikulafrakturen mit Verletzung des Bandapparates der Klavikula. Kontraindikationen Schlechte lokale Hautverhältnisse sowie Wunden. Symptomatische und röntgenologisch mäßige bis deutliche arthrotische Veränderungen des Akromioklavikulargelenks. Hohe allgemeine Operationsrisiken. Schlechter Allgemeinzustand. Kein Behandlungswunsch, keine ästhetischen Ansprüche. Operationstechnik Vorderer Zugang medial des Schultereckgelenks durch sä-belhiebförmigen Schnitt. Einkerben des Musculus deltoideus an dessen Ansatz zur Darstellung der Bänder des Akromioklavikulargelenks. Vorlegen von U-Nähten in den zerrissenen korakoklavikulären Bändern. Refixation des intraartikulären Diskus an der lateralen Klavikula durch Naht. Knochennahes, subakromiales Einführen des Hakens der individuell ausgewählten Platte und Positionierung dorsal des Akromioklavikulargelenks. Röntgenkon-trolle der Platten-und Hakenlage sowie der Stellung des Akromioklavikulargelenks. Fixieren der Balser-Platte mit Kortikalisschrauben. Knoten der vorgelegten Bandnähte. Adaptierende Nähte des akromioklavikulären Bands, der Gelenkkapsel und begleitender Weichteilläsionen. Drainage. Wundverschluss. WeiterbehandlungKeine Ruhigstellung. Frühe, funktionelle Nachbehandlung unter Einschränkung der Abduktion bis 90°. Implantatentfernung nach 12 Wochen. Physiotherapie. ErgebnisseIm Zeitraum von 9/94-12/97 wurden 57 von 68 operierten Patienten (62 Männer, sechs Frauen, Durchschnittsalter 40,3 [19-84] Jahre) in einer prospektiven Studie nach 12-49 (durchschnittlich 24,6) Monaten klinisch und sonographisch nachuntersucht. Das Implantat wurde nach 12 Wochen entfernt. 50 Patienten wiesen eine uneingeschränkte, schmerzfreie Beweglichkeit der Schulter auf. Im Seitenvergleich fand sich sonographisch auf der operierten Seite ein minimaler Klavikulahochstand von durchschnittlich 0,3 mm ohne Belastung und 0,6 mm unter 10 kg Belastung. Einschränkungen beim Sport beklagten sieben Verletzte. Ein sehr gutes bis gutes subjektives Ergebnis erreichten 50 Patienten. VorbemerkungenBalser [2] beschrieb 1976 erstmals seine leicht bogenförmige 4-Loch-Formplatte mit Z-förmigem Haken am lateralen Plattenende als Prototyp der gelenküber-brückenden Klavikulaplatten. Der Haken gibt bei korrekter Position dorsal unter dem Gelenk die Reposition vor. Andere Platten wurden von Ramanzadeh (Tiedke et al. [19]), Aderhold [1] sowie Wolter & Eggers [21] entwickelt....