Surgical trainees and trauma emergencies.

An accident and emergency (A&E) training has been suggested as an essential part of the basic surgical training. The A&E curriculum should be divided into three sections: a critical curriculum, a core curriculum and a comprehensive curriculum. For instance, the critical curriculum contains topics that provide the opportunity to translate the ABCDE principles of trauma management into practice. Furthermore, a post in the A&E department provides the surgical trainee with significant exposure to the management of the polytrauma patient and to the management of other acute general surgical, urological and orthopaedic conditions. By presenting better educational programs and by reducing the non-medical tasks a trainee has to deal with, the education of surgical trainees during A&E attachment can be improved.

Medical liability in ancient times: a surgeon's view.

Even in ancient times, medical liability occupied man. Various civilizations had their own interpretation and solutions for this. Original writings are very rare and articles on the subject are equally hard to find. The only relatively trustworthy sources are of a legal nature with their origin in Roman law and Greek philosophy, which is still reflected in our modern western way of thinking and acting today. At a later stage, the influence of the Middle East gives a special view on what was important in other civilizations and their way of thinking. All this proves that medical liability originated in ancient times.

Some notes on medical liability in ancient times.

Already in ancient times did medical liability occupy mankind. Various civilizations did give their own interpretation on the subject and proposed solutions. Original writings are rare and articles concerning ancient medical liability equally are hard to find. The only relatively trustworthy sources are of legal nature and find their origin in Greek philosophy and Roman Law. At a later stage, Arabic philosophers gave a renewed view on the statements of these previous civilizations and added their own way of thinking. All these influences still reflect in our modern western way of medical acting. Some of these ancient customs concerning medical liability will be discussed in this article.

An algorithm for the surgical treatment of periprosthetic fractures of the femur around a well-fixed femoral component.

The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored. Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed. Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications.

Computer-aided planning of reconstructive surgery of the innominate bone: automated correction proposals.

OBJECTIVE: In cases of complex reconstructive surgery of the innominate bone, it is difficult to draw up a good surgical plan; manual planning of a 3D reconstruction is highly demanding and time-consuming. This paper presents and validates methodology to automatically generate 3D correction proposals for reconstructive surgery of the innominate bone, and illustrates its use with clinical applications. MATERIALS AND METHODS: The developed Matlab methodology starts from CT-based outer surface representations of the patient's bone, which allow straightforward mirror and matching implementations for automated reconstruction procedures. The validation on 9 cadavers was two-fold: the geometrical deviations of the intact original with respect to the reconstructed surface meshes were assessed, and the characteristics of both original and reconstructed acetabular cup regions were determined. RESULTS: Eighteen healthy and thus, it was assumed, spherical acetabula were automatically reconstructed with mean accuracies of 3.2 +/- 2.2 mm, 0.1 +/- 1.0 mm and 3.8 +/- 2.9 degrees for the hip joint centerpoint, joint radius and cup orientation, respectively. As a demonstration, a triflange cup acetabular implant was rapidly designed, starting from the correction proposal. CONCLUSIONS: A highly automated, computer-aided approach to surgical planning for pelvic bone defects was developed and sample applications demonstrated. Validation results for healthy acetabula were superior to those obtained in real surgery. The generated virtual correction proposals can be used as targets in surgical planning and cup navigation applications, or in the design of customized implants with complex shapes.

Quality of life after hip fracture surgery in the elderly.

As the world population ages, the prevalence of osteoporosis and the incidence of hip fractures will increase dramatically, being responsible for an increase of the health expenditure. On the other hand, there is the inescapable fact of scarcity creating the necessity of making difficult choices with regard to the allocation of human resources. So the question remains: should we carry on investing an important part of our health expenditure for the treatment of hip fractures in elderly people? To answer this statement, we compared 384 hip fracture patients of 70 years and older treated in our department between 1978 and 1983 with 1102 patients treated between 1998 and 2003. Both groups had a prospective follow-up of at least one year. There were no statistically significant differences: mortality rate 24% vs. 23%; good functional outcome 82% vs. 73%; and home going rate 60% vs. 66%. The factors influencing these results were studied. So we can conclude: The number of hip fractures treated nowadays has increased compared with twenty years ago; There is no significant improvement in mortality, nor in quality of life; Age is not a contraindication for hip fracture surgery.

Sterno-manubrial dislocation in a 9-year-old gymnast.

Dislocations of sternal segments in children are extremely rare lesions; only seven sterno-manubrial dislocations have been reported in the literature. We present a case of posterior sterno-manubrial dislocation in a 9-year old gymnast exercising on parallel bars. We preferred performing an open reduction and plate stabilization using an angular stable implant, because of pain and respiratory distress. This technique of stabilization has not been described in the literature before and present the advantage of combining a high stability with a reduced risk of iatrogenic retrosternal injury. The plate stabilization led to an immediate amelioration of symptoms. The plates could be removed 4 months after initial treatment. The boy rapidly regained his sporting capabilities.

[Trauma during pregnancy]. / Trauma während der Schwangerschaft.

In the past 60 years trauma has become the most important cause of morbidity and mortality in pregnancy. Motor vehicle accidents are the most common cause of abdominal trauma and lead to the highest mortality. The typical anatomical and physiological changes occurring during pregnancy demand a specific resuscitation procedure in which stabilization of the mother hemodynamically has to be done first. During the secondary survey the mother and fetus have to be examined thoroughly. The correct use of safety belts is an essential part of prevention.

From unstable internal fixation to biological osteosynthesis. A historical overview of operative fracture treatment.

The first techniques of operative fracture treatment were developed in the 19th century. In fact, these methods only consisted of an open reduction of the fracture followed by a usually very unstable fixation. This method gave rise to the combination of the disadvantages of the conservative and the operative fracture treatment: the fracture had to be opened with a real risk for (sometimes lethal) infection, the bone healing was disturbed, there was muscular atrophy and joint stiffness. The successes were very rare and catastrophes were often seen. Küntscher's endomedullary rods can be considered as the first useful implants in the treatment of diaphyseal fractures. Reaming of the medullary canal and the development of interlocking nails have enlarged the indications for intramedullary nailing. The classic Dynamic Compression Plates from the seventies were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates and reamed nails disturbed the vascularisation of the bone fragments, leading to a high infection rate (particularly in open fractures) and delayed union (particularly after plate and screw fixation). These insights lead to the development of the "biological osteosynthesis" : a terminology introduced to indicate a new type of osteosynthesis leading to a sufficiently stable fixation of the bone fragments allowing early mobilisation, but without major disturbance of the vascularisation. The unreamed nail can also be considered as a biological osteosynthesis and in a lot of cases it is the implant of choice for tibial and femoral shaft fractures, especially in polytrauma patients. Finally, some new devices contributing to the principles of biological osteosynthesis like locking plates and the LIS-System are gaining popularity.

Fractures of the distal radius: a contemporary approach.

The fracture of the distal radius is the most common fracture we treat. Although sometimes stated otherwise, the outcome of these fractures is not uniformly good regardless the treatment instituted. A thorough understanding of the anatomy and biomechanics of the wrist is a prerequisite when treating these lesions. The literature proves that there is a strict relationship between the quality of anatomical reconstruction and the long-term functional outcome. We try to clarify the complex functional anatomy of this region. No single treatment is the solution for every type of fracture in every kind of patient. Based on the functional anatomy, we analyze the actual treatment possibilities and try to develop strategies in the choice of treatment for different fracture types in different patient groups. Treatment aims should be to reconstruct the anatomy as good as possible, to guarantee that there is no loss of reduction and to allow for a functional after treatment as soon as possible.

Treatment of a metastasis of a rectal carcinoma in the greater trochanter with the AO/ASIF Proximal Femoral Nail. A case report.

A 48-year-old patient was referred to our department because of a solitary metastasis of a rectal carcinoma, localized in the left greater trochanter. Since the risk of pathological fracture was higher than acceptable for radiation therapy alone and because of the young age of the patient, radical debulking and reconstruction using the AO/ASIF Proximal Femoral Nail and cement augmentation was performed. Solitary bone metastases of colorectal adenocarcinomata are rare, as discussed. The prognosis of a primary colorectal carcinoma in the presence of a bone metastasis, even a solitary one, is poor. In patients with these metastases with poor overall prognosis, the treatment objectives, which we could define as 'safe, short and simple' are stringent, although there most certainly remains an indication for palliative surgery.

Notorious pitfalls in the care of multi-trauma patients.

In this review we elaborate on the more specific circumstances that are needed for adequate trauma care, such as the correct recognition and management of a tension pneumothorax, a tracheobronchial disruption, systemic air embolism and hypoventilation. Furthermore the trauma clinician must be aware of the different life threatening causes of haemorrhage and hypovolemia. Traumatic pericardial tamponade, myocardial contusion and a tension pneumothorax can all prove to be difficult diagnoses, but may all present with signs of hypotension with an increase in central venous pressure (CVP). In contrast, internal haemorrhage is most often accompanied by hypotension with a low CVP. Immediate evaluation and treatment of thoracic trauma, such as rupture of the aortal arch, is mandatory, as is the utilisation of the correct diagnostic strategy to evaluate the possibility of intra-abdominal and retroperitoneal injury. Both an unnecessary laparotomy and a delayed diagnosis must be avoided when dealing intra-abdominal injuries, such as kidney trauma. Furthermore, we stress the importance of the swift diagnosis and treatment of fractures of long bones and the pelvis, to prevent ongoing massive haemorrhage. Certain criteria should be met, in a hospital setting with sufficient day-to-day trauma experience, to be able to provide quality care for the multi-trauma patient. This will minimise the risk of errors and serious medical and judicial consequences.

The acute atraumatic peroneal compartment syndrome, a rare and therefore sometimes unrecognised entity.

Two cases of Acute Peroneal Compartment Syndrome, without history of trauma are presented. One case had a history of prolonged horse-riding with the wearing of tight boots, the other case had a history of prolonged walking. An Acute Peroneal Compartment Syndrome should always be considered in the differential diagnosis of pain in the peroneal region of the lower limb.

Impairment and return to work after intra-articular fractures of the calcaneus.

Intra-articular fractures of the calcaneus typically occur in individuals working on ladders, scaffolding or roofs. Male individuals in their productive age are most at risk. The functional problems that frequently persist are a well-known risk since they may obstruct a safe resumption of the former job. According to the data of the National Institute for Sickness and Invalidity Insurance the number of calcaneal fractures in Belgium have stabilised over the last ten years. These figures indicate the necessity for a better prevention policy. Scientific literature about the problem of impairment and disability in these cases is rare and lacks uniformity. A retrospective study was therefore performed on 65 private insurance compensation patients who were treated for intra-articular calcaneal fractures. The mean period of work incapacity was 260.5 days and the mean percentage of impairment was 12.3%. A large group (86.2%) were able to resume their former activities including the height workers. More than half of the patients (57%) needed a supportive device. Working at heights and falls from a height were a significant risk factor for long-term work incapacity. The figures are compared with the limited literature and further discussed.

Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results.

The percutaneous compression plate (PCCP) is a new implant for the minimally invasive treatment of pertrochanteric hip fractures that might reduce blood loss, wound problems and prevent devascularization of bone fragments. A quicker operation with minimal blood loss is better in the older patients. We performed a prospective, randomized clinical trial to compare the PCCP with the well-known dynamic hip screw (DHS). A total of 71 patients with an Evans type 1A-D pertrochanteric hip fractures were included. We measured the operation duration, blood loss, wound healing, complications, fracture healing and functional outcome. In total, 33 PCCP and 38 DHS were implanted. The mean operation times were 69.2 and 46.6 min for DHS and PCCP, respectively (P = 0.000). Blood transfusions were given in 24 DHS patients compared with six PCCP patients (P = 0.000). There were 27 haematomas in the DHS group and eight in the PCCP group (P = 0.000). There were no differences in fracture healing and the functional outcome between the two implants (P = 0.767, ns). Although this is a preliminary study with a relatively small number of patients and short follow-up, the PCCP seems similar to the DHS in relation to bone healing and stability, but with significant advantages for blood loss, soft tissue healing and operation time.

The use of the unreamed AO femoral intramedullary nail with spiral blade in nonpathologic fractures of the femur: experiences with eighty consecutive cases.

OBJECTIVE: To evaluate the unreamed femoral nail with spiral blade (UFN-SB) in the treatment of nonpathologic subtrochanteric and segmental femoral fractures. DESIGN: Prospective follow-up of eighty consecutive fractures in eighty patients still alive at least ten months after the operation. SETTING: Academic teaching hospital. PATIENTS: Eighty patients with a subtrochanteric or segmental femoral fracture. Excluded were patients with pathologic fractures and those who died within ten months of the operation. INTERVENTION: Unreamed femoral nail with spiral blade. MAIN OUTCOME MEASURES: Clinical and radiographic examination. RESULTS: In seventeen fractures, the UFN-SB failed before bony union (21 percent): bending of the spiral blade, five times; migration, nine times; and breakage, three times. Revision surgery was necessary in seven cases (9 percent). All complications except one were observed in elderly women with a Seinsheimer fracture type IIC or V. Nevertheless, all fractures healed within one year, including those that needed revision surgery. CONCLUSIONS: There is predictive value of the Seinsheimer classification as to outcome using UFN-SB. The UFN-SB is an option for the treatment of subtrochanteric or segmental fractures of the femur, especially in patients with a good quality of bone. The complications using this device are not caused by the learning curve, but by the characteristics of the implant and the type of fracture for which it is used. The implant should not be used in elderly women with a reversed oblique fracture or a subtrochanteric fracture with an intertrochanteric component.

Operative treatment of humeral shaft fractures. The Leuven experience.

For many years, plating has proved to be a reliable method for the fixation of fractures of the humeral shaft. In the early nineties however, intramedullary devices became increasingly popular for fractures of the humeral shaft. This was based on a global tendency towards minimally invasive surgery, and the attractiveness of the relatively simple procedure and potentially lower complication rate of intramedullary nailing, which had proved to be successful in osteosynthesis of the lower limb, However, until now there is no consensus in the literature as to which device is preferable for different indications. We reviewed 161 patients, operatively treated for a fracture of the humeral shaft in our department between 1986 and 1999. Our experience shows in most indications a higher union rate, better functional results and a lower reoperation rate after plate and screw fixation. In addition, even though plating requires a more technically demanding procedure, in experienced hands, it gave rise to fewer iatrogenic fractures, and fewer persisting pain problems. We recommend the use of plate and screws as primary treatment in all operative indications, except for pathological fractures, very obese patients, and open fractures.

Dermatotraction: an effective technique for the closure of fasciotomy wounds: a preliminary report of fifteen patients.

Dermatotraction was evaluated as an alternative technique for the closure of dermatofasciotomy wounds, with a review of literature and of our clinical experience. The dermatotraction technique provides closure of fasciotomy wounds and avoids the use of skin grafting. Patients treated with dermatofasciotomy for an acute compartment syndrome of the limbs, without obvious tissue necrosis and without shock or urgent life saving surgery, had their fasciotomy wound closed with dermatotraction with vessel loops, the skin approximation system, or the prepositioned intracutaneous suture. In our experience, the mean time to wound closure was nine days. Dermatotraction techniques that cause local skin compression should be avoided because skin necrosis might occur (skin approximation system). Dermatotraction with vessel loops or the prepositioned intracutaneous suture provides good skin apposition without the necessity for skin grafting.

Fractures of the distal radius. Current concepts for treatment.

The authors review the treatment of fractures of the distal radius, based on their experience and from data in the literature. The choice of a treatment for any given fracture must take into account first of all the stability of the fracture. The best results are achieved in stable fractures. Only minimally displaced distal radius fractures can be treated functionally. However, a plaster cast for one week is indicated for the comfort of the patient. In displaced but stable fractures both closed reduction and percutaneous fixation are indicated. In case of closed reduction, the plaster cast should be applied for 5 to 6 weeks with an above-elbow cast for 3 weeks. Percutaneous fixation gives the best results in extraarticular fractures in younger patients. Because of its simplicity however, it should not be ignored in the elderly osteoporotic patients. In the authors' experience, both techniques were only used for extraarticular fractures. Good and excellent results were found in the closed reduction and plaster cast group in 74% of the patients; the Kapandji technique gave 75% good and excellent results. These results are in line with other findings which show that, for simple fracture types, the Kapandji technique and closed reduction seem to give similar results. External fixation is widely used for intra-articular comminuted fractures. Dynamic external fixation does not show any advantage over static devices. Additional K-wires or bone grafting may be necessary. External fixation gives superior results to plate and screw fixation. Internal fixation should be reserved for fractures with ventral comminution or severe displacement with unacceptable reduction by closed or minimally invasive techniques.

A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients.

OBJECTIVES: To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients. DESIGN: Longitudinal prospective before/after design (sequential design). SETTING: The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium. PARTICIPANTS: 60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12). INTERVENTION: (1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol. MEASUREMENTS: All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively. RESULTS: Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive. CONCLUSIONS: This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.