[Combination of ipsilateral supracondylar humeral- and forearm fractures in children]. / Ipsilaterale knöcherne Begleitverletzungen bei kindlichen suprakondylären Humerusfrakturen - Diagnostik, Therapie und Versorgungsergebnisse -

In an 11-year period, from 01. 08. 1987 to 31. 08. 1998, a total of 72 children (mean age 7.6 years, range 2-12 years) with dislocated supracondylar humeral fractures were treated surgically in the Department for Traumatology, University Hospital, Essen. The combination of supracondylar humeral fracture and ipsilateral forearm fracture occurred in 8 children (11.1 %). 4 revealed a complete forearm fracture in the distal third, 4 children a fracture of the distal physis (Salter-Harris type II). The supracondylar humeral fractures were reduced openly via a single lateral approach and stabilized by crossed K-wire fixation. The distal forearm fractures were treated by closed reduction and percutaneous pinning. Fractures of the distal physis were treated by closed reduction and application of an above elbow cast. Excellent results were achieved in all children with ipsilateral supracondylar and forearm fractures.

Intermittent prone positioning in the treatment of severe and moderate posttraumatic lung injury.

OBJECTIVE: Severe posttraumatic lung injury is characterized by impairment of gas exchange and pulmonary densities. The influence of intermittent prone positioning on pulmonary gas exchange and parenchymal densities was investigated prospectively in patients with pulmonary injury after multiple trauma with blunt chest trauma. SETTING: A six-bed trauma intensive care unit in a university hospital. DESIGN: Prospective, descriptive study. PATIENTS: Twenty-two consecutive patients with pulmonary injury after multiple trauma with blunt chest trauma and acute lung injury (n = 11) or severe acute respiratory distress syndrome (ARDS) (n = 11) according to the definitions of the consensus conference on ARDS. INTERVENTIONS: Pulmonary densities were calculated planimetrically from computed tomographic scans of the chest before the first and after the last cycle of prone positioning. Indications for prone positioning were a) mechanical ventilation with FIO2 >0.5 at positive end-expiratory pressure >10 cm H2O for >24 hrs; or b) pulmonary densities in two or more quadrants being constant or increasing within 48 hrs. Arterial blood gas analysis was performed every 2 hrs. Intrapulmonary right-to-left shunt (Qs/Qt) and alveolar-arterial PO2 difference were calculated 2 hrs after the beginning and end of every prone and supine cycle, respectively. Patients were ventilated in the prone position for 8 hrs each day. MEASUREMENTS AND MAIN RESULTS: Every single posture change from the supine to the prone position resulted in a significant average increase in the oxygenation index of 28+/-8 torr (3.7+/-1.1 kPa) (p<.0001). There was a significant improvement in oxygenation (4.3+/-0.8 torr [0.57+/-0.11 kPa]) with time between two consecutive measurements in the prone as well as the supine position (p<.0001). Alveolar-arterial PO2 difference and Qs/Qt showed a significant decrease of 25+/-7 torr (3.3+/-0.9 kPa) and 1.1+/-0.46%, respectively, for every cycle of prone positioning. Statistical analysis revealed no significant alteration of gas exchange within every prone and supine cycle. Total static lung compliance improved significantly over time (p<.001). However, ventilation of patients in the prone position demonstrated a mean decrease in compliance of 2.1+/-0.72 mL/cm H2O. The response to prone positioning was similar in patients with ARDS and acute lung injury and revealed no significant difference. In both groups, the course of the oxygenation index and Qs/Qt over time was almost parallel. Posture changes were continued for 9.0+/-1.1 days. The oxygenation index showed an overall increase of 129+/-20 torr (17.2+/-2.7 kPa) from baseline supine at the end of prone positioning (p<.0001). Pulmonary densities were reduced significantly from 31.1+/-2.5% to 3.8+/-0.81%, Qs/Qt was reduced from 24.9+/-1.5% to 11.7+/-0.32%, and FIO2 was reduced from 0.43+/-0.04 to 0.26+/-0.02 (p<.01). Gas exchange improved in all patients, and no patient died immediately as a result of respiratory failure. CONCLUSION: Repeated prone positioning recruits collapsed lung tissue and improves gas exchange in trauma patients with blunt chest trauma and severe ARDS as well as in trauma patients with acute lung injury.

[Injuries due to falls from a great height. A comparative analysis of injuries and their outcome following suicide-related and accidental falls]. / Verletzungen nach Fall aus grosser Höhe. Eine vergleichende Analyse von Verletzungsmuster und Verlauf nach suizidalem und akzidentellem Absturztrauma.

The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights > 4 m. 211 patients with an injury severity score (ISS) > 17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 +/- 1; A: 30 +/- 1), ventilation time (I: 16 +/- 2; A: 15 +/- 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27%), fractures of lumbarspine (I: 34; A: 15%), pelvis (I: 51; A: 38%), lower leg (I: 47; A: 20%), pilon (I: 15; A: 5%), and os calcis (I: 17; A: 9%). Liver lacerations occurred more often after intentional fall (I: 16; A: 6%). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A(I: 1; A: 8%). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69%) or related to brain-injuries (I: 35; A: 19%). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.

The extent of traumatic damage determines a graded depression of the endotoxin responsiveness of peripheral blood mononuclear cells from patients with blunt injuries.

OBJECTIVE: To study whether the endotoxin responsiveness of peripheral blood mononuclear cells correlates with the severity of injury in trauma patients. DESIGN: Prospective, observational study. SETTING: University trauma center. PATIENTS: Fifty-nine patients with blunt trauma (Injury Severity Score [ISS] 4 to 57 points). INTERVENTIONS: Standard emergency department care, surgical care, and postoperative intensive care unit treatment. MEASUREMENTS AND MAIN RESULTS: Whole blood and serum were obtained 94+/-89 (SD) mins post trauma (day 0) and during a 14-day period postinjury. Endotoxin-induced tumor necrosis factor-alpha (TNF-alpha) synthesis of peripheral blood mononuclear cells ex vivo was tested using a whole blood assay. Serum samples were assayed for TNF-alpha concentrations. A reduced capacity of whole blood to produce TNF-alpha ex vivo with endotoxin treatment was found to be closely correlated with the ISS. The capacity to produce TNF-alpha on endotoxin stimulation of whole blood from patients with an ISS > or =16 points was depressed immediately after trauma and did not reach normal values during the observation period. In patients with an ISS >22 points, maximum depression of the capacity of whole blood to produce TNF-alpha occurs within 100 mins post injury. In contrast, in patients with an ISS <22 points, maximal depression of whole blood TNF-alpha production occurs with a delay of 24 to 48 hrs after trauma. Based on pre- and postoperative values, primary surgical intervention caused a decrease of the endotoxin-stimulated TNF-alpha production of whole blood in the latter patient subgroup, as well as in the entire patient population (ISS 4 to 57) when secondary surgical treatment was necessary 5 to 13 days after trauma. CONCLUSIONS: The extent of traumatic tissue damage leads to a graded depression of immunocyte function and appears to be amplified by surgical treatment. The endotoxin responsiveness of peripheral blood mononuclear cells displays a functional marker of the anatomically defined severity of injury and gives insights into the regulation of immunocyte function after severe blunt trauma.

[How many severely injured multiple-trauma patients can benefit from the biomechanical advantage of early mobilization following femoral intramedullary nailing?]. / Wieviel schwermehrfachverletzte Patienten können den biomechanischen Vorteil der Frühbelastbarkeit nach Femurmarknagelung nutzen?

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.

Local and systemic reactions after lung contusion: an experimental study in the pig.

The present study was designed to investigate the consequences of isolated unilateral lung contusion on local alveolar and systemic inflammatory responses in an animal model in the pig. Isolated unilateral lung contusion was induced by bolt shot in eight mechanically ventilated animals under general anesthesia (sham: n=4). Plasma and bronchoalveolar lavage fluid were collected during a period of 8 h following lung contusion. Leukocytes, leukocyte neutral protease inhibitor (LNPI), terminal complement complex (TCC), thrombin-antithrombin-complex (TAT) as well as pulmonary microvascular permeability and surfactant function were determined. Within 30 min, lung contusion was found to cause a significant local and systemic increase in TCC and TAT concentrations and a systemic increase in LNPI concentrations. The latter was accompanied by a sequestration of leukocytes in the contused lung. Complement activation and leukocyte sequestration in the contused lung progressively increased during the investigation period. Although surfactant function decreased in the entire lung 30 min after contusion, TCC, TAT, and leukocyte sequestration was unchanged in the contralateral lung. The first indication of an involvement of the contralateral lung was obtained by an increase in leukocyte sequestration 8 h after lung contusion. Unilateral lung contusion initiates an early systemic activation of humoral and cellular defense systems. Involvement of the contralateral lung appears to be a secondary event caused by a systemic inflammatory reaction.

Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion.

BACKGROUND: The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of this retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients sustaining flail chest with and without pulmonary contusion. METHODS: The hospital records of 405 patients with multiple trauma (Injury Severity Score > 17) between 1988 and 1994 were reviewed. Forty-two patients sustained flail chest. Twenty of these underwent operative chest wall stabilization for the following indications: 1) flail chest with indication for thoracotomy due to intrathoracic injury (n = 6); 2) flail chest without pulmonary contusion (n = 9); 3) paradoxical movement of a chest wall segment in the weaning period from the respirator (n = 3); and 4) severe deformity of the chest wall (n = 2). For the purpose of analysis the patients were separated into groups: group 1: operative chest wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with pulmonary contusion (n = 10); group 3: flail chest without pulmonary contusion and without chest wall stabilization (n = 18); group 4: flail chest with pulmonary contusion and without chest wall stabilization (n = 4). Data were coded for time of operation, duration of ventilatory support, and complications. RESULTS: There were no significant differences in age, severity of injury, and extent of injury between groups 1, 2, and 3 (p < 0.42). Group 4 was excluded for statistical analysis because of the small number of patients. Patients in group 1 required a shorter ventilatory support time compared to patients in group 3 (6.5+/-7.0 versus 26.7+/-29.0 days) and group 2 (p < 0.02). In group 2 (ventilator time 30.8+/-33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturbance of gas exchange. All patients in group 1 survived; deaths in group 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure. CONCLUSIONS: In patients with flail chest and respiratory insufficiency without pulmonary contusion, operative chest wall stabilization permits early extubation. Patients with pulmonary contusion do not benefit from chest wall stabilization. Secondary operative chest wall stabilization in these patients is indicated when progressive collapse of the chest wall is evident during weaning from the ventilator.

[Effect of primary femoral plate osteosynthesis on the course of polytrauma patients with or without thoracic trauma]. / Einfluss der primären Oberschenkelplattenosteosyntheses auf den Verlauf polytraumatisierter Patienten mit oder ohne Thoraxtrauma.

Primary intramedullary nailing of femoral fractures is well known to increase the risk of pulmonary complications, especially in multiple-trauma patients with severe thoracic injuries. Aim of this study was to investigate the influence of primary plate osteosynthesis of femur fractures on major complications after trauma. This retrospective study based on the records of 325 multiple trauma patients (Injury severity score ISS > 18, no lethal brain injury, age 16-65). According to the abbreviated injury scale of the Thorax (AIS T) patients were divided in groups without (AIS T < 3, "N") or with relevant thoracic injury (AIS T > = 3, "T"). Both groups were additionally divided in subgroups without severe trauma to the extremities (AIS E < 3, "O") or primary plate-osteosynthesis of femur fractures (< 24 h, "I"). 4 groups were performed: NO (n = 39, ISS 25 +/- 1, pneumonia 10%, ARDS 5%, lethality 10%); NI (n = 55, ISS 27 +/- 1, pneumonia 4%, ARDS 5%, lethality 4%); TO(n = 137, ISS 28 +/- 1, pneumonia 21%, ARDS 15%, lethality 16%); TI (n = 94, ISS 31 +/- 1, pneumonia 21%, ARDS 17%, lethality 15%). Primary plate-osteosynthesis of femur fractures did not increase lethality or incidence of pulmonary complications in patients with or without severe thoracic injuries. Also complication rate after primary plate-osteosynthesis was less compared to published results after intramedullary nailing. For this, primary plate-osteosynthesis is recommendable in case of multiple trauma with thoracic injuries.

[Results of cement-free implanted, Robert Mathys isoelastic acetabular cup]. / Ergebnisse der zementfrei implantierten, isoelastischen Hüftpfanne nach Robert Mathys.

In 163 patients--125 (76.7%) female, 38 (23.3%) male--172 cementfree isoelastic acetabular cups were implanted. The average patient age was 72.6 years (range: 16 to 96 years). Sixty-seven (41.1%) patients with 72 (41.9%) cups could be followed-up for an average of 6.0 years (range: 2.0 to 12.2 years) after the procedure. Using the Harris-hip-score we found 49 (68.1%) "very good" to "fair" results. In 23 (31.9%) hips scoring had to be classified as "bad". The rate of cup-loosenings in the collective was low at 3.5% (6/172), probably due to the reduced physical activity of our comparatively older patients. Because after the 8th year symptomatic loosening must be routinely expected, the procedure is not indicated for younger patients. In older patients with femoral neck fractures the cementfree isoelastic acetabular cup has proven itself effective in our experience.

[Comparison of severe multiple injuries in childhood and adulthood]. / Vergleich schwerer Mehrfachverletzungen im Kindes- und Erwachsenenalter.

Multiple injuries in children are responsible for a great part of childhood mortality. Remaining handicaps after injuries have a social and economic significance. In this study, the characteristics of polytrauma in childhood are evaluated by comparison with severely injured adults. The two groups of multiple trauma patients (117 children between 3 and 15 years of age and 1159 adults between 16 and 59) were equal in the overall severity of all injuries. Children were mainly hurt as pedestrians, whereas adults had an accident more often as car passengers. The most frequently injured region were in both groups fractures of the extremities. The greatest injury severity represented head injuries in each group. Complications were seen more often in adult patients. Multiple organ failure and isolated liver failure were exclusively seen in the adult group, pneumonia and lung failure occurred significantly more often. The duration of artificial ventilation and the duration of hospital stay were prolonged in the adult group. In summary, children with multiple injuries have a lower mortality rate than adults. The main cause of death are cerebral injuries. Remaining handicaps in surviving children are most often caused by fractures of the lower extremities.

[Causation and injury pattern in in-line skating]. / Unfallursachen und Verletzungsmuster beim In-line-Skating.

Accident proceedings and injuries were investigated in a consecutive series of 70 patients (65.2% male, 34.8% female, age: 18 +/- 9 years) presented to the emergency department after in-line skate falls. 52.7% wore no protective equipment. 41.8% used knee pads, 27.3% wrist guards, 12.7% elbow pads, and 5.5% each helmets and gloves. The most common cause of fall were obstacles/irregularities (32.7%) on a dry and plain surface. The upper extremity (67.9%) and the head (12.8%) were the most commonly injured body parts. 47.8% in-line skaters sustained fractures. The distal radius (51.5%) was most commonly injured body parts. 47.8% in-line skaters sustained fractures. The distal radius (51.5%) was most commonly fractured. Injuries to novice skaters were more often severe. Advanced freestyle and jumping in-line skaters sustained even injuries of the trunk. Life-threatening injuries of the abdomen and the head may occur. The use of a complete personal protection equipment is recommended.

[Cost analysis of primary care and intensive care treatment of multiple trauma patients]. / Kostenanalyse der Primärversorgung und intensivmedizinischen Behandlung polytraumatisierter Patienten.

Treatment costs of emergency therapy, surgery and intensive care were analysed in 20 randomly chosen, representative patients with severe multiple trauma (mean ISS 32 p). For an average stay of about 22.5 days in the ICU, the total costs were DM 106,924.36 (about $70,000), which breaks down as DM 39,635.88 (= 37%) for physicians and nurses, DM 67,289.08 (= 63%) for materials, X-rays, laboratory investigations, drugs and blood components. The whole treatment caused daily costs of DM 4,752.22, or DM 3.30 per min. The first emergency diagnostic procedures and emergency therapy take a mean of 451.9 min from admission to the beginning of the ICU treatment and itself generates costs of about DM 12,325.99. In Germany a new system of compensation by diagnosis-related group was introduced in 1996. Therefore, these data indicate that treatment of severe multiple trauma is very expensive and trauma care could be economically by damaging for smaller hospitals. We conclude that treatment of multiply injured patients (ISS > 16 p) should be concentrated in selected trauma centres and compensated by payment of a special daily amount of about DM 5,000 (about $3,500).

Regulation of whole blood tumor necrosis factor production upon endotoxin stimulation after severe blunt trauma.

BACKGROUND: Trauma has been recognized to be accompanied by alterations of leukocyte functions such as cytokine release. The regulatory principles involved in these changes are still poorly defined. To further characterize leukocyte function after multiple trauma, endotoxin-stimulated tumor necrosis factor (TNF) production of trauma patients' whole blood and a possible regulatory mechanism were studied. METHODS: Endotoxin responsiveness in trauma patients (n = 18, Injury Severity Score = 24 +/- 7) was assayed ex vivo using a whole blood model. TNF release and TNFalpha mRNA levels were determined during a 14-day period. Furthermore, the influence of patients' sera on whole blood TNF production was evaluated. MAIN RESULTS: The capacity of trauma patients' whole blood to produce TNF was reduced for 2 to 6 days after trauma and was equally evident for both TNF release and TNFalpha mRNA levels. The reduction of TNF coincides with the appearance of an inhibitory activity for TNF production in trauma patients' sera. No correlation was found between the inhibitory activity and soluble TNF receptors, endotoxin-neutralizing molecules, inhibitory cytokines (interleukin 10 and transforming growth factor beta), or prostaglandins. CONCLUSIONS: Major trauma leads to the appearance of a circulating inhibitory activity for TNF synthesis that may potentially contribute to an anti-inflammatory response in patients with multiple trauma. The elucidation of its structural and functional properties may contribute to the understanding of the pathogenesis of severely injured patients.

[Acceptance of Allgöwer/Wenzl partial dynamic weight bearing orthosis. Results using a hidden step counting device]. / Akzeptanz der dynamischen Teilbelastungsvorrichtung nach Allgöwer/Wenzl. Ergebnisse der Anwendung eines verdeckten Schrittzählers.

In 30 patients (12 male and 18 female) with extensive lesions of the cartilage of the upper and lower ankle joint, controlled partial-loading of the lower extremity was established by means of the load-relieving orthosis by Allgöwer and Wenzl. In these orthoses a hidden step-counter could be integrated. Average patient age was 46 (range 20 to 74) years. The load-relieving orthosis was used on average for 68 (range 22 to 98) days with a mean of 10,756 steps (range: 261 to 30,538); respectively 158 steps per day. Neither age, sex, diagnosis nor the duration of complete postoperative immobilisation correlated with the number-of-steps-per-diem compliance (r > +0.22).

[Results of peripheral arterial vascular injury in polytraumatized patients]. / Ergebnisse peripherer arterieller Gefässverletzungen beim polytraumatisierten Patienten.

The therapeutic concept of limb salvage or immediate amputation is controversial in patients with multiple trauma. Sixty-three multiple trauma patients (injury severity score ISS > 18 patients) with blunt arterial injuries were investigated. Twenty-seven had injuries of the upper limb and 36 patients of the lower limb. In 33 cases a limb salvage procedure was performed (group I), while in 30 cases the limb was amputated (group II). Neither group showed a significant difference in age (I: 33 +/- 3, II: 30 +/- 3 years), ISS (I: 30 +/- 2, II: 29 +/- 2 patients), time of ischemia (I: 238 +/- 30, II: 203 +/- 20 min) ICU stay (I: 18 +/- 4, II: 19 +/- 4 days). Lethality and morbidity were slightly increased in group I (death: I: n = 8; II: n = 4; MOF: I: n = 5; II: n = 3; Sepsis: I: n = 11, II: n = 4). No differences were found in the incidence of local infections (I: n = 12, II: n = 10). Secondary amputations were performed in 7 patients after 12 +/- 2 days (range 3-40; median: 5 days). We conclude that limb salvage did not increase the risk for severe complications. Lethality and morbidity were related to the severity of the injury. To prevent complications, secondary amputations had to be performed early.

Nailing versus plating in thoracic trauma: an experimental study in sheep.

In this study, femoral intramedullary pressure, fat embolization, and pulmonary response were measured during reamed and unreamed nailing and plating of femoral fractures after blunt thoracic trauma. Intramedullary peak pressures of 425 mm Hg (mean 205 mm Hg) occurred in the reamed nail group (group I) during reaming with the 9-mm reamer, while in the unreamed nail group (group II) peak values were seen during nail insertion (330 mm Hg) with a mean of 203 mm Hg. Plating never led to a pressure rise over 67 mm Hg (mean 37 mm Hg). In reamed nailing, the most intense embolism was identified under ultrasound imaging with the large awl and with the 9.0-mm reamer (mean 2.2) and in the unreamed nail group during nail insertion (mean 2.8). Minimal echoes appeared during plating. The pulmonary arterial pressure did not vary significantly postoperatively between the three groups (p < 0.08). Our findings indicate that intramedullary fracture fixation causes a higher increase of intramedullary pressure and more fat and bone marrow embolization than extramedullary ones. Nevertheless, only minimal differences in the pulmonary hemodynamic response (pulmonary arterial pressure) were noted even in the presence of thoracic trauma.

[Treatment outcome of surgical thoracic wall stabilization of the unstable thorax with and without lung contusion]. / Behandlungsergebnisse der operativen Thoraxwandstabilisierung bei instabilem Thorax mit und ohne Lungenkontusion.

Between 1988 and 1994, 295 patients with blunt chest trauma were treated. Forty-two patients had flail chest, requiring mechanical ventilation. Open reduction and osteosynthesis (ASIF reconstruction plates or isoelastic rip clamps) of the chest wall were performed in 20 patients. For the purpose of analysis we separated the patients into five groups: group I (n = 10) had chest wall stabilization in flail chest without pulmonary contusion (average ISS 31.0, AIS-thorax 4.1); group II (n = 10) had chest wall stabilization in flail chest with pulmonary contusion (average ISS 37.0, AIS-thorax 4.3); group III (n = 18) had fail chest without pulmonary contusion (average ISS 36.3, AIS-thorax 4.2); group IV (n = 4) had flail chest with pulmonary contusion (average ISS 37.8, AIS-thorax 4.0); group V (n = 29) had pulmonary contusion without flail chest (average ISS 34.5. AIS-thorax 4.1). With open reduction and internal fixation of unstable chest wall segments, the duration of ventilatory support, mortality and pneumonia were significantly reduced to 6.5 (1-25) days in group I (mortality rate 0%, incidence of pneumonia 10%) compared to group III (duration of ventilatory support 26.7 days, mortality rate 39%, incidence of pneumonia 16%). Eighty percent of the patients in group I were extubated within 5 days postoperatively. In group II 4 patients underwent emergency thoracotomy for intrathoracic injuries (3 of them died between 4 h and 31 days) and 2 patients for laceration of the lung. In all these cases the chest wall was stabilized after thoracotomy. One patient was stabilized for a deformation of the chest wall and two for paradoxical movement of the chest wall during weaning from the respirator. The mean duration of ventilation in group II was 30.8 (10-112) days (mortality rate 30%, incidence of pneumonia 30%). No complications related to the osteosynthesis arose during the follow-up. In conclusion, the best indication for early operative chest wall stabilization is flail chest without pulmonary contusion, leading to a significant reduction in the duration of ventilatory support. Secondary stabilization is recommended in patients with pulmonary contusion showing paradoxical movement of the chest wall during weaning from the respirator.

[Emergency care and treatment costs of polytrauma patients]. / Erstversorgungs- und Behandlungskosten polytraumatisierter Patienten.

Treatment costs of emergency therapy, surgery and intensive care were analysed in 20 randomly chosen, representative patients with severe multiple trauma (mean ISS 32 p). For an average stay of about 22.5 days on ICU, the total costs were DM 106924.36 (about 70,000 US $). DM 39,635.88 (= 37%) were the costs for physicians and nurses; DM 67,289.08 (= 63%) were needed for materials, X-rays, laboratory investigations, drugs and blood components. The whole treatment caused daily costs of DM 4752.22 or DM 3.30/min. The first emergency diagnostic procedures and emergency therapy take a mean time of 451.9 min from admission to the beginning of the ICU treatment and by itself already generates costs of about DM 12325.99. In Germany, a new way of compensation by a diagnosis-related group was introduced in 1996. These data suggest that treatment of severe multiple trauma is very expensive and trauma care could be economically harmful for smaller hospitals. We conclude that treatment of multiply injured patients (ISS > 16 p) should be compensated for by a special daily amount of about DM 5000 (about 3500 US $) for selected trauma centres.

[Perforation of the heart wall--a rare complication after thoracic drainage treatment]. / Herzwandperforation--seltene Komplikation nach Anlegen einer Thoraxdrainage.

Complications after chest-tube treatment are rare if the correct technique is used. We describe a case of an iatrogenic perforation of the heart after bringing in a chest tube to treat a ventral pneumothorax during the postoperative intensive care treatment.