[Hollow organ injury and multiple trauma: treatment, course and outcome - an organ-specific evaluation of 1127 patients from the trauma registry of the DGU]. / Inzidenz von Hohlorganverletzungen nach Trauma: Behandlung, Verlauf und Outcome - eine organspezifische Auswertung von 1127 Patienten des Traumaregisters der DGU.

BACKGROUND: The relevance of hollow organ trauma in severely injured patients within a large collective has not been thoroughly reviewed as yet. This study aimed at assessing the prevalence of hollow organ trauma in relation to the outcome and the currently established method of treatment. PATIENTS AND METHODS: Altogether data of all patients of the Trauma Register of the German Society of Trauma Surgery (DGU) (1993 - 2009) were interpreted retrospectively. All patients with an "Injury Severity Score" (ISS) ≥ 16, direct admission to a trauma centre and an age of ≥ 16 years were included. All patients with abdominal trauma (AISabdomen ≥ 2) were compared with patients with hollow organ trauma (AIShollow organ ≥ 2). The following organs were attributed to the hollow organs: stomach, small intestine (duodenum, jejunum / ileum), colon, gall bladder and urinary bladder. RESULTS: From 9268 patients with abdominal injuries 1127 (12.2 %) additionally showed a hollow organ injury (AISabdomen ≥ 2, AIShollow organ 2 - 5) and were analysed in dependence on the classification of the "American Association for the Surgery of Trauma" (AAST) organ severity score. AAST-hollow organ: II°: 4.6 %, III°: 5.3 %, IV°: 2.1 %, V°: 0.2 %. Patients with leading hollow organ injury (grades IV and V) thereby showed a significant increase of lethality (IV°: 32.7 % and V°: 31.3 %). With an increasing grade of hollow organ injury, however, the ISS increased as well. Lethality was not increased over the expected lethality rate (RISC score) due to the additional hollow organ injury though. CONCLUSION: The results presented here show the prevalence and the outcome of hollow organ injury in a large collective within the Trauma Register of the DGU for the first time.

Sample taking during orthopedic surgery: sensitivity and specificity using the BACTEC blood culture system.

The use of blood culture systems for sterile body fluids other than blood has proven to be superior to routine culture methods. This study was conducted in order to assess the performance of the BACTEC blood culture system compared to swab/tissue sample collection for the detection of infection from intraoperative samples taken during surgical procedures. Sensitivity was determined by taking samples (BACTEC and swab/tissue samples) from patients with clinically evident infection (Infection group). Specificity was tested by taking the same sample sets from patients who had aseptic operations with no history of infection (Control group). The sensitivity was found to be much higher for the BACTEC group (50 isolates from 56 samples, sensitivity: 89%) compared to the swab/tissue samples (29 isolates out of 56 samples, sensitivity: 52%). The specificity was lower in the BACTEC group (32 isolates out of 44 samples, specificity: 27%) compared to the swab/tissue samples (1 isolate out of 44 samples, specificity: 98%). We conclude that BACTEC is useful for intraoperative sample collection in cases of low-grade infection. However, it is less specific and there is always the possibility for contamination. Therefore, it is advisable to use this technique in combination with regular tissue samples.

[Kidney injury and multiple trauma: outcome, course and treatment algorithm. An organ-specific evaluation of 835 patients from the trauma register of the DGU]. / Nierenverletzung und Polytrauma: Outcome, Verlauf und Behandlungsalgorithmus. Eine organspezifische Auswertung von 835 Patienten des TraumaRegisters der DGU.

BACKGROUND: The relevance of renal trauma in severely injured patients within a large collective has not yet been thoroughly reviewed. This study aimed at assessing the prevalence of renal trauma in relation to the outcome and the currently established method of treatment. PATIENTS AND METHODS: Altogether data of 35,664 patients of the TraumaRegister of the German Society of Trauma Surgery (DGU) (1996-2007) were interpreted retrospectively. All patients with an injury severity score (ISS) ≥16, direct admission to a trauma center and an age of ≥16 years were included. All patients with abdominal trauma (AIS(Abdomen) ≥2) were compared with patients with abdominal and renal trauma (AIS(Kidney) ≥2). RESULTS: A total of 18,416 patients fulfilled the inclusion criteria of which 6,218 (34.1%) had abdominal injuries. Of these patients with abdominal injury 835 (13.3%) additionally showed a kidney injury (AIS(Abdomen) ≥2, AIS(Kidney) 2-5) and were analyzed according to the classification of the American Association for the Surgery of Trauma (AAST) organ-severity-score. AAST kidney: II°: 45.5%, III°: 31.1%, IV°: 15.6%, V°: 7.8%. Patients with leading kidney injury (grade IV and V) thereby showed a significant increase in mortality (IV: 32.3% and V: 40.0%) and an increase in the need for surgical intervention (IV: 61.5 and V: 81.5%). With an increasing grade of renal injury, however, the ISS is also increased but mortality was not increased over the expected mortality rate (RISC score) due to the additional renal injury. Dialysis rate in the surviving patients showed an increased rate depending on the degree of the kidney injury (II: 5.5%, III: 7.6%, IV: 18.8%, V: 8.3%). CONCLUSION: The results presented here show the prevalence and the outcome of kidney injury in a large collective within the TraumaRegister of the DGU for the first time. Based on the current literature and the findings a treatment algorithm has been developed.

[Fracture of the diaphyseal radius during Cyr wheel practice - an uncommon injury of wheel gymnastics]. / Distale Radiusschaftfraktur beim Cyr Wheel-Turnen - eine ungewöhnliche Rhönradverletzung.

The cyr wheel is a modified gymnastic wheel with only one ring that can lead to extreme forces on the gymnast. We report on a distal radius shaft fracture (AO 22 A 2.1) and a fracture of the styloid process of the ulna that occurred after holding on to a slipping Cyr wheel and exposition to high pressure on the lower arm. The fracture was fixed by screws and a plate.

[Open pertrochanteric fracture of the femur and post-traumatic osteitis in a child : Interposition of a pedicled vascularized fibula to preserve the femoral head]. / Offene pertrochantäre Femurfraktur und posttraumatischer Osteitis beim Kind : Interposition einer gefäßgestielten Fibula zum Hüftkopferhalt.

The free microvascular fibula diaphysis transplant as femoral neck replacement with preservation of the patient's own femoral head due to a severe infection situation represents a rare indication in the treatment of young patients. In the current literature, such surgical methods do not exist. In the case described here, the free microvascular fibula transplant serves as femoral neck replacement with preservation of the patient's own femoral head without any postoperative mobility restrictions. The depicted course of the disease not only shows the effectiveness of this form of treatment in aseptic femoral head necrosis, but also represents a possible treatment in severe infection situations after trauma.

[The "wheel gymnast's elbow" - first description of a common overuse syndrome]. / "Der Rhönradellenbogen" - Erstbeschreibung eines häufigen Überlastungssyndroms.

BACKGROUND: Overuse syndromes of the elbow due to wheel gymnastics are unknown in medical literature. This study describes a common overuse syndrome of the elbow in wheel gymnastics. METHODS: We conducted internet research and interviewed 260 wheel gymnasts, who trained the "hip roll" element. RESULTS: 60.4 % of the gymnasts reported changes of the elbow region. The intensity of pain during training was 1.51 out of 10 points. Lacerations were reported in 33.1 %, hematomas were reported in 68.7 %, and a loss of hair at the elbow region was reported in 11.7 %. 11.5 % of the gymnasts described a bump and 5.8 % described a depression of the proximal ulnar region that was not found before wheel gymnastics. Gymnasts using protective gear reported significantly higher levels of pain compared to gymnasts without protective gear. DISCUSSION: The "wheel gymnast's elbow" is a common overuse syndrome of the proximal ulnar due to direct contact and friction of the proximal ulnar to the giant wheel bars. The "wheel gymnast's elbow" describes a combination of lacerations, hematoma, hair loss, bumps, and depression of the proximal ulnar region with only slight pain. CONCLUSION: An early preventive use of protective gear during "hip roll" training can possibly reduce the "wheel gymnast's elbow" syndrome.

[Minimally invasive dorsal stabilization of the thoracolumbar spine]. / Minimal-invasive dorsale Stabilisierung der thorakolumbalen Wirbelsäule.

Thoracolumbar spine injuries represent the vast majority of unstable spine fractures. In common, patients are instrumented from a dorsal position while primary stabilization of those fractures using a ventral approach remains exceptional. Fracture morphology and concomitant injuries of the discoligamentous complex help to determine whether combined positions or second staged ventral positioned stabilization is indicated. While segmental stabilization and proper fracture reduction are the primary goals, the latter is of specific importance due to the angular point of the vertebral column in fractures of the thoracolumbar spine. The invasive surgical approach in open reduction and stabilization from a dorsal position seems to be replaced increasingly by less invasive angular stable internal spine fixator systems. This article describes the principle, suited indications and the limitations of one of the internal spine fixators available to achieve angular stable percutaneous dorsal stabilization.

[Multisegmental and minimally invasive dorsal stabilization of thoracic and lumbar vertebral column. Operative technique]. / Multisegmentale und minimal-invasive dorsale Stabilisierung der Brust- und Lendenwirbelsäule : Operative Technik.

Dorsal stabilization of the thoracic and lumbar vertebral column is still the fundamental technique for acute treatment of unstable vertebral fractures and intervertebral ligament injuries as well as in tumor surgery and the treatment of degenerative and inflammatory diseases. The aim is to achieve the best possible anatomical and axis-correct stabilization of the physical lordosis and kyphosis. This article describes in detail the operational preparation (e.g. necessary imaging, possible positioning of the patient) and procedure (e.g. access, placement of screws and plates, wound closure and postoperative follow-up treatment) and possible complications due to misplaced pedicle screws, the rate of which can possibly be reduced by intraoperative 3D imaging.

[Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma. Influence of preclinical volume replacement - an analysis of 604 patients from the trauma registry of the DGU]. / Letalität und Outcome beim Mehrfachverletzten nach schwerem Abdominal- und Beckentrauma. Einfluss der präklinischen Volumengabe - Eine Auswertung von 604 Patienten des TraumaRegisters der DGU.

BACKGROUND: Uncontrollable hemorrhaging after blunt trauma and the resulting hemorrhagic shock is still one of the main causes of death in trauma patients. Starting volume replacement before admission to hospital is one of the main pillars of immediate treatment. The statements concerning the quantity of the preclinically administered fluid are still controversial and have a low level of evidence in the literature. Massive abdominal trauma and unstable pelvic fractures belong to the most relevant causes of hemorrhagic shock. The aim of this study was to analyze the influence of the quantity of the preclinically administered fluid on the posttraumatic course of patients with massive abdominal and pelvic injuries. PATIENTS AND METHODS: All patients of the trauma registry of the DGU (German Society for Trauma Surgery) who met the following criteria were included: injury severity score ≥16 points, primary admission to hospital, age ≥16 years, initial blood pressure <100 mmHg and transfusion of erythrocyte concentrate (EC). Out of this collective patients with an AIS abdomen ≥4 or an AIS pelvis ≥4 were analyzed. Both groups were divided into 4 subgroups subject to the preclinically infused volume (<1000 ml, 1000-2000 ml, 2001-3000 ml and >3000 ml). RESULTS: Of the 375 patients with abdominal trauma and 229 patients with pelvic trauma were consistent with the inclusion criteria. In both groups an increasing volume replacement was associated with an increased need for transfusion and a reduction of the coagulation ability (Quick 61% in the case of <1000 ml versus 49.1% in the case of >3000 ml). The rescue time had a relevant influence on the quantity of preclinically infused volume (62 min for <1000 ml versus 88 min for >3000 ml). On admission to hospital the blood pressure values were on average the same in all patients (~ 95 mmHg). With an increasing volume a slight elevation of lethality was found as well as a significant increase of the transfused erythrocyte concentrates, a significant deterioration of coagulation and an increase of patients with mass transfusions. CONCLUSION: In the case of a preclinical relevant bleeding after blunt pelvic or abdominal trauma moderate volume replacement (<1000 ml) results in an enhancement of the initial coagulation situation and in a reduction in the need for transfusion. The results of this study support the concept of a restrained volume therapy after massive trauma with and bleeding requiring transfusion.

No further incidence of sepsis after splenectomy for severe trauma: a multi-institutional experience of The trauma registry of the DGU with 1,630 patients.

OBJECTIVE: Non-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure. METHODS: 13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score >16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)). RESULTS: From 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (>10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%). CONCLUSIONS: Non-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.

[The importance of CT angiography for screening supra-aortic vascular damage in severely injured patients]. / Bedeutung der CT-Angiographie zum Screening supraaortaler Gefässverletzungen beim Schwerverletzten.

PURPOSE: Traumatic injury of supra-aortic vessels remains a challenge in the initial diagnostics of severely injured patients. The presented prospective study analyzed the impact of multislice computed tomography angiography (CTA) as the primary diagnostic method. METHODS: Patients with the following criteria were included and screened for a dissection of the supra-aortic vessels: a) admission directly from the scene, b) resuscitation room treatment indicated by the official criteria of the DGU (German Society for the Surgery of Trauma), c) suspected blunt trauma to head or trunk as well as d) age over 16 years. RESULTS: During a period of 18 months 374 patients were treated for blunt trauma in the resuscitation room. In 176 cases CTA of the supra-aortic vessels was performed and pathological findings were observed in 16 patients. In 4 cases (2%) a traumatic dissection of supra-aortal vessels was diagnosed and confirmed by magnetic resonance imaging (MRI). All patients received heparin in a PTT effective dosage for 2 weeks and after rehabilitation there were no neurologic deficits. CONCLUSION: Traumatic supra-aortic dissection was found in 2% of cases in the presented study group. The mechanisms of injury were not distinct in this group. Essentially MSCT angiography screening was demonstrated to be a safe diagnostic tool.

[Impact of hypothermia on the severely injured patient]. / Bedeutung der Hypothermie in der Traumatologie.

Accidental hypothermia is a common complication in severely injured patients. Risk factors include environmental exposure of the patient at the accident site or in the clinic, infusion of cold fluids, hemorrhagic shock and anesthetics which influence thermoregulation. In contrast to animal studies, human studies and clinical experiences have identified accidental hypothermia of the severely injured patient to be associated with increased complication and mortality rates. As a consequence, hypothermia together with acidosis and coagulopathy, have been coined the lethal triad in severely injured patients. On a cellular level hypothermia reduces cellular activity and metabolism resulting in reduced oxygen consumption, which is therapeutically used in patients following cardiac arrest. However, the activity of important enzymes, such as those of the coagulation pathway, is simultaneously down regulated. Hypothermia-induced coagulopathy, which is refractory to substitution of coagulation factors, is a major complication of hypothermia in traumatized patients. Therefore, hypothermic trauma patients with hemodynamic instability require aggressive rewarming.

[Surgical management of life-threatening injuries]. / Chirurgisches Management vital bedrohlicher Verletzungen.

Life-threatening situations after multiple trauma which then require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. Emergency surgery after trauma may be necessary for the abdomen, the pelvis, the chest as well as the head. Therefore, several disciplines may be involved. Damage control surgery is the leading surgical strategy in emergency surgery in unstable trauma patients. The main aspects of damage control surgery are outlined in this article. The goal of damage control surgery is to gain control of bleeding as soon as possible without additional surgical trauma. Packing plays a central role in damage control surgery of the abdomen and the pelvis. Surgical decision-making occurs under unfavorable circumstances and extreme time pressure. However, surgical interventions in the shock room rarely occur in the German health system. Therefore, indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms. The "Definitive Surgical Trauma Care" (DSTC)- courses may contribute to a straightforward performance in an emergency operation.

[Bite injuries of the hand]. / Bissverletzungen der Hand.

Bite injuries of the hand have a clearly increased risk for infection compared with other regions. Surgical treatment of the wound is indicated, and the debridement must be done thoroughly and with consideration of the wound closure. Antibiotic therapy may be indicated in addition to the surgery if signs of infection exist. Antibiotics alone are not a suitable treatment. Common complications in cases of deficient primary therapy are flexor tenosynovitis, purulent arthritis, and phlegmons of the dorsal hand. These are emergencies and need immediate surgical intervention.

[Volar locking compression plating versus dorsal plating for fractures of the distal radius: a prospective, randomized study]. / Volare winkelstabile vs. dorsale Plattenosteosynthese bei der distalen Radiusextensionsfraktur: Eine prospektive, randomisierte Untersuchung.

INTRODUCTION: This study investigated the radiographic and functional outcomes of two different methods for treating fractures of the distal part of the radius. PATIENTS AND METHODS: In a prospective controlled study patients with forearm fractures were randomized by age, handedness, and fracture type. RESULTS: The study included 120 patients, with a mean age of 66 years. Forty-nine percent of the fractures were extraarticular, and 51% were intraarticular. In the group treated with volar locking compression plates, six patients needed operative decompression of the median nerve and one needed reconstruction of the extensor pollicis longus (EPL) tendon. The group with dorsal plating had three complications requiring operative treatment: one deep infection, one dislocation of the plate, and one reconstruction of the EPL tendon. The radiological results for the Stewart 1 score showed 68% excellent results in volar locking compression plating compared with 57% in dorsal plating. Regarding functional outcome, 48% with volar plating showed excellent results compared with 22% with dorsal plating, as measured by the Stewart 2 score. CONCLUSION: Despite significant advantages of the volar locked compression plating, subjective satisfaction did not differ between the two groups.

[Embolization of life-threatening intercostal hemorrhaging in a severely injured patient: a rarity in trauma care]. / Embolisation einer lebensbedrohlichen Interkostalblutung bei einem Schwerstverletzten : Eine Rarität in der Traumaversorgung.

Transarterial embolization of ruptured intercostal arteries due to massive bleeding represents an infrequent indication in severely injured patients. The current literature shows isolated case descriptions but no clinical trials exist. In the case depicted here embolization is represented as a form of therapy after haemorrhagic shock caused by a ruptured intercostal artery. The embolization carried out led to an immediate cessation of bleeding. The vital signs returned to normal immediately after the procedure and surgical intervention could be avoided. The course of the disease represented in the following shows the effectiveness of this type of treatment not only for bleeding due to pelvic fractures and abdominal injuries, but also for isolated arterial bleeding in other body regions.

[Intramedullary stabilization of bilateral femur fractures with pulmonary artery embolism]. / Intramedulläre Stabilisierung beidseitiger Femurfrakturen bei Polytrauma mit primärer Lungenembolie.

This is a case report of a 31-year-old motorcyclist who was admitted to our emergency department with severe multiple injuries and an ISS score of 38 points.There were bone injuries on all 4 extremities, fractures of both proximal femurs, both radii, a great soft tissue injury of the lower limb, stable fractures of the spine and a blunt thoracic injury. A bone fragment compressed femoral vein and artery on the right side with consecutive thrombus in the inferior caval vein and thrombembolism of the central lung artery. The proximal femur fractures were treated initialy with gamma-nails after implanting a cava-filter because of the high-risk constellation for further thrombembolism. Operation was monitored with transesophageal echocardiography.The cava filter could be delivered on 2nd postoperative day without complication. The patient was ventilated for 1 day, stayed on ICU for 9 days and left hospital in a good condition after 28 days. It was the strategic and logistic great achievement of an interdisciplinary trauma center to implant cava filter and decide for intramedullar osteosythesis without delay.

[Vascularized bone transfer]. / Die vaskularisierte Knochentransplantation.

Vascularized pedicled bone grafts are known since the beginning of the last century. Microvascular bone grafts (free vascularized bone transfer) are known since the beginning of the seventies. In many experimental and clinical studies vascularized bone grafts were compared to their non-vascularized analogues. Because of their own non-interrupted blood supply and thus nearly normal vitality vascularized bone grafts show more rapid fracture healing, more pronounced adaptation to the new mechanical loadings (e. g. graft hypertrophy), higher survival and consolidation rate in poor or bad recipient bed conditions (infection, bad vascularization) and some neovascularization potential on the surrounding tissue. Because of those properties, it became possible to successfully treat a large segmental bone defect by only few operations. As the treatment of complicated combined soft tissue/bone defects led to high complication rate up to 40 to 60% the indications of this method were altered.