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Type II fractures of the odontoid process of the axis are the most common injury of the cervical spine in elderly patients. Only little evidence exists on whether elderly patients should be treated conservatively or surgically. The mortality and survival probability of 51 patients were determined in a retrospective study. The range of motion, pain and the neck disability index were clinically investigated. Of the 51 patients 37 were treated surgically and 14 conservatively. The conservatively treated group showed a higher mortality (64 % vs. 32 %). Kaplan-Meier analysis revealed a median survival of the conservatively treated group of 29 months, whereby during the first 3 months of treatment this group showed a higher survival probability and afterwards the surgically treated group showed a higher survival probability. The clinical examination of 20 patients revealed limited range of motion of the cervical spine. Additionally, moderate levels of pain and complaints were recorded using the neck disability index. Fractures of the odontoid process pose a far-reaching danger for elderly patients. A balanced assessment of the general condition should be carried out at the beginning of treatment of these patients. In the early phase following trauma no differences were found with respect to survival rates but for long-term survival the operatively treated group showed advantages; however, these advantages cannot be causally attributed to the choice of therapy.

Hyperextension injuries of the subaxial cervical spine are potentially hazardous due to relevant destabilization. Depending on the clinical condition, neurologic or vascular damage may occur. Therefore an exact knowledge of the factors leading to destabilization is essential. In a biomechanical investigation, 10 fresh human cadaver cervical spine specimens were tested in a spine simulator. The tested segments were C4 to 7. In the first step, physiologic motion was investigated. Afterwards, the three steps of injury were dissection of the anterior longitudinal ligament, removal of the intervertebral disc/posterior longitudinal ligament, and dissection of the interspinous ligaments/ligamentum flavum. After each step, the mobility was determined. Regarding flexion and extension, an increase in motion of 8.36% after the first step, 90.45% after the second step, and 121.67% after the last step was observed. Testing of lateral bending showed an increase of mobility of 7.88 %/27.48 %/33.23 %; axial rotation increased by 2.87%/31.16 %/45.80 %. Isolated dissection of the anterior longitudinal ligament led to minor destabilization, whereas the intervertebral disc has to be seen as a major stabilizer of the cervical spine. Few finite-element studies showed comparable results. If a transfer to clinical use is undertaken, an isolated rupture of the anterior longitudinal ligament can be treated without surgical stabilization.

The aim of this study was the evaluation of patient-oriented outcome scores for shoulder function and residual complaints after diaphyseal clavicular fractures with respect to shortening deformities. The analysis was based on data of 172 adult patients (mean age 39 +/- 14 years) with healed clavicular fractures treated operatively (n = 104) or conservatively (n = 67). The control population consisted of 35 healthy adults without shoulder problems and 25 patients with nonunion after conservative treatment. The subjective estimation of the level of pain was collated on a visual analog scale (VAS 1-100 points), together with the relative Constant and Murley score, the Cologne clavicle score, the disabilities of the arm, shoulder and hand (DASH) score and a bilateral comparison of the length difference of the clavicles. Patients with a clavicular length difference of > 2 cm had significantly (p < 0.001) more pain, a greater loss of mobility and significantly lower values in the scoring system of Constant and Murley, the DASH and Cologne clavicle scores compared to patients with clavicular length differences < 0.5 cm and healthy controls (p < 0.001). The results of this study showed that shortening deformities after clavicular fractures in adults have a large impact on the functional result and patient-oriented outcome scores. The aim of the therapy of diaphyseal clavicular fractures should therefore concentrate on reconstruction of the anatomical length of the clavicle.

Background: Placing transpedicular screws in the cervical spine is a special challenge for spine surgeons, due to the anatomical features of this part of the spine. During the last 15 years, computer-aided navigation systems have been developed to facilitate this procedure and to make it safer for patients. One option is navigation by intraoperatively acquired data sets with the use of an 3D C-arm. Patients/Material and methods: Our retrospective study evaluates transpedicular screws in the cervical spine placed by 3D C-arm navigation, within a 6 year period in a level 1 trauma centre. We recorded epidemiological data, operation time and especially general adverse events, as well as revision surgery, including reasons for revision. We used a C-arm Arcardis Orbic 3D (Siemens, Munich), connected to a navigation system (VectorVision, Brainlab, Munich). Results: Between July 2007 and July 2013, 207 transpedicular screws were placed in 58 patients. The main indications were trauma (69%), rheumatic diseases (20.7%) and tumour (8.6%). The most commonly instrumented cervical spine segments were C2 (53.5%)%), C7 (10.3%) and C5 (8.6%). In nearly 95% of the cases, we performed an intraoperative 3D scan after screw or k-wire placement to control the screw position. We found unacceptable malposition in 7.2% of patients. This was corrected at once. Ten patients had to be revised: seven times due to wound problems, twice because of implant failure and once for treatment of CSF leakage. Three screws (1.5%) led to injuries of the vertebral artery, once with a lethal outcome. Analysis of these cases showed that the 3D scan gave reduced data quality, due to reduced bone density or anatomical factors. Conclusion: Intraoperative 3D C-arm navigation seems to be a reliable option for transpedicular screw placement in the cervical spine. Complication rates were comparable to published values. 7.2% of all screws were corrected intraoperatively after a control scan. Therefore possible revisi

Background: Treatment of type II fractures of the odontoid process is still controversial. Besides conservative treatment, there are surgical options, including anterior screw fixation, as first described by Bohler and Magerl, or procedures using a dorsal approach. Many authors prefer dorsal fusion of C1 and 2, due to the reliable, biomechanical stability. In this context, pedicle screw fixation, as described by Harms, and transarticular screw fixation of the atlantoaxial joints, as described by Magerl, have to be mentioned. With the use of intra-operative fluoroscopic navigation, the risk of neurovascular lesions caused by abortive drilling or malposition of screws has been significantly decreased. In 1993, Eysel and Roosen established a subclassification of type II fractures of the odontoid process and gave treatment recommendations for each of the three subtypes. While there was an outcome for type A and B fractures treated by anterior screw fixation, the authors recommended performing dorsal stabilisation at type C fractures. Indication: In accordance with the recommendations of Eysel and Roosen, an 82 year old man, suffering from a type II C fracture of the odontoid process, underwent navigated, transarticular screw fixation of C1 and C2. Method: Once the 3D-fluoroscopy scan had been performed, the correct drilling direction in the axial, coronary and sagittal views of C1 and 2 was found using the navigated drillguide. After K-wires had been inserted in this direction on both sides, a second 3D-scan was performed to recontrol placement of the K-wires. Cannulated screws were introduced and the rods were installed, bearing the atlas hook to fixate the posterior atlas. Conclusion: In summary, dorsal, transarticular fusion of C1 and C2 is a successful treatment option, rarely leading to complications and is accompanied by reduced radiation exposure to the operating team.

To compile an evaluation system (score) for post-treatment outcomes of midclavicular fractures, 172 patients were studied on average 15 months post-injury. As a control group 45 healthy volunteers were examined. The most relevant elements were filtered out for use in a new classification system, the Clavicle Score (CS). The CS is based on a system of three partnered objective/subjective items as well as radiographic assessment of fracture healing. For the partnered items, subjective responses with the most significant correlation to the specific objective parameters were selected. Total score cutoff values (very good, good, moderate, poor) were established to keep interpretation simple. To validate the system, linear regression analysis was performed comparing the CS to two established assessment systems (Constant Score and the DASH Score). The correlation coefficients R=0.756 (Constant) and R=0.687 indicated that the conclusions were comparable and therefore valid. The reliability coefficient Cronbach's alpha was calculated at 0.8241, indicating high reliability. The CS is a simple, valid and reliable instrument to assess outcomes post-midclavicular fracture.

Patella fractures are rare and account for approximately 1% of all fractures. They are classified regarding their localization (proximal, distal) and appearance. The aim of any treatment is reconstruction of the extensor mechanism and joint surface. If dislocation and cartilage steps are less than 2 mm, conservative treatment may be indicated. Operative treatment is only necessary if a dislocation is more than 2 mm or when the extensor mechanism is unstable. Depending on the shape of the fracture, tension band wiring, interfragmentary screw fixation and combinations are the main techniques. Because patellectomy has functionally the worst result it should be avoided. Sleeve fractures (children) need exact reconstruction of the joint surface. In elderly patients conservative treatment or surgical patella-enclosing wiring techniques for stabilization are the best options due to low bone quality.

After operative correction of a clavicle fracture using an elastic stable intramedullary nail the patient presented signs of delayed fracture healing after 2 months. During the sixth postoperative month the 28-year-old obviously pain-ridden female patient showed dystonia of the shoulder girdle and allodynia surrounding the operation field. Upon these findings, we decided - as a result of the complex regional pain syndrome that had not been previously described in this location - to treat the patient by administering bisphosphonates, multimodal analgetic therapy, physiotherapy and occupational therapy. Fourteen months after surgery, the patient showed no remaining symptoms, and the fracture had consolidated at that time.