Detection of fractures of hand and forearm in whole-body CT for suspected polytrauma in intubated patients.

BACKGROUND: The aim of this study was to evaluate the potential of whole-body CT for diagnosis of hand and forearm fractures in intubated patients with suspected polytrauma. METHODS: We performed a retrospective analysis on data collected from two trauma centres in Germany, including demographics, ISS, clinical symptoms, depiction in whole-body CT, and time to diagnosis. RESULTS: Out of 426 patients included in the study, 66 (15.5%) suffered a hand or forearm fracture. The total number of fractures was 132, the whole-body CT report mentioned 98 (74.2%). 16 (12,1%) fractures of 12 patients were diagnosed later than 24 h after admission. Late diagnoses of fractures of the hand occurred more often if the hand was not fully included in the CT scan field. The sensitivity of whole-body CT for cases with fractures of hand and/or forearm with full inclusion of the corresponding area in the scan field was 80.2%. CONCLUSIONS: This study shows that whole-body CT is a valuable diagnostic tool for hand fractures in polytrauma patients. Hands should be evaluated regardless of clinical presentation in intubated patients after suspected polytrauma if they are included in the whole-body CT.

[Mobility of unstable fractures of the odontoid during helmet removal. A biomechanical study]. / Verhalten der instabilen Densfraktur bei Abnahme des Motorradhelms. Eine biomechanische Untersuchung.

In severe motorcyclist accidents unstable injuries of the cervical spine can usually not be excluded before an X-ray has been taken in the hospital. Despite this the helmet has to be taken off at the place of the accident in order to provide adequate treatment and airway management of the injured driver. There are no data in the current literature showing what happens to unstable lesions of the cervical spine during helmet removal. An experimental unstable lesion of the cervical spine was created by an osteotomy of the odontoid in 10 fresh frozen cadavers with intact soft tissues. All motions occurring in the segments C1-2 and C2-3 during helmet removal were recorded by fluoroscopy. The average motion in the unstable segment C1-2 was 23.7 degrees during a full range of extension-flexion movement of the cervical spine without any signs of dislocation of the segment. After application of the helmet there was one case of dislocation of C1-2 in neutral supine position already, and two further cases of dislocations during helmet removal. The average motion of C1-2 recorded during helmet removal was 19.0 degrees (2-25 degrees ), median 18.0 degrees. In order to avoid fracture dislocations and motion in the unstable upper cervical spine the helmet should better be cut in pieces at the place of the accident. There is a need for discussions with helmet producers to develop a new generation of helmets that can be removed easily without manipulating the head.

[Spinal epidural hematoma as a sequelae of knife stab injury. A diagnostic problem?]. / Spinales epidurales Hämatom als Folge einer Messerstichverletzung. Ein diagnostisches Problem?

Spinal epidural hematoma are a rare but serious complication of thoracic stab wounds. Their incidence should always be taken into consideration when first examining the patient, and it is also necessary to be able to find proof in either MRI or CT-scan. In our case the patients diffuse neurologic symptoms connected with a rather unreliable appearing personality made the diagnosis even more difficult. Initially it was possible to show the defect only in MRI.

The determination of ketone bodies: preanalytical, analytical and physiological considerations.

The arterial ketone body ratio is calculated as the ratio of arterial levels of acetoacetate/beta-hydroxybutyrate. It correlates with survival in experimental hemorrhagic shock and outcome after liver surgery and myocardial infarction. Procedures for determination of ketone bodies are often laborious and unreliable. As yet the relationship between results from arterial and venous samples is unclear. We therefore describe the determination of the ketone bodies acetoacetate and 3-hydroxybutyrate by an easy, reliable, rapid, inexpensive enzymatic assay using 3-hydroxybutyrate dehydrogenase (E.C. 1.1.1.30) in a semi-automated setting that does not require deproteinization. Preanalytical parameters, including separation from corpuscular elements within 1 h and storage on ice for less than 1 h, must be strictly observed to avoid rapid decay of acetoacetate by spontaneous decarboxylation. The assay has high sensitivity, specificity (+/-5%), and precision (CV <2.5%) with a measurable range of 5-500 micromol/l for either ketone body, and requires only 23.5 microl of plasma. At temperatures below -17 degrees C plasma may be stored for prolonged periods. Results from prospectively scheduled simultaneous sampling of arterial blood and venous blood from the right atrium in 100 consecutive patients with severe multiple trauma (mean Injury Severity Score 38+/-13) support the view that the lung has no role in ketone body metabolism. We conclude that central venous blood can safely be substituted for arterial blood for determination of the ketone body ratio.

Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases.

OBJECTIVE: To analyze the results of 45 patients after ankle arthrodesis in the presence of joint infection. METHODS: Arthrodesis was performed with two compression screws and an anterior plate in 29 patients and with two compression screws only in 16 patients. In all patients, additional stabilization with external fixation was used. In 29 patients, isolated fusion of the ankle joint was performed; in 13 patients, the ankle and subtalar joints were fused, and in 3 patients, isolated arthrodesis of the subtalar joint was performed. RESULTS: In 39 of 45 patients (86.6%), solid fusion was obtained. Nonunions occurred in 6 patients (13.4%). A below-knee amputation was necessary for one patient. Full weight-bearing was achieved after 21.6 weeks on average. Thirty-two patients returned to work after 35.5 weeks on average. Five of the six patients with failed ankle fusion needed special shoes; in one patient, a below-knee amputation was performed. A total of 33.3% of failed ankle fusions were associated with systemic disorders such as diabetes mellitus, and other concomitant diseases compromising local arterial blood supply and proprioception. CONCLUSION: Our results prove that limb salvage is possible even in complex ankle and subtalar pathology by thorough fusion by using a number of different techniques.

[Minimally invasive therapeutic concepts in fracture surgery]. / Minimal-invasive Therapiekonzepte in der Unfallchirurgie.

Recent publications show a clear tendency towards minimally invasive procedures for fracture care in trauma patients. Intramedullary stabilization has become the first choice in reconstructing axis and length of the diaphyseal fractures of the long bones. Indications for intramedullary nailing have become wider with the development of unreamed or retrograde nailing. Essential modifications of plate osteosynthesis from limited contact implants to percutaneous plating and the development of an internal fixator have made this procedure minimally-invasive as well. Techniques of closed reduction and percutaneous osteosynthesis or arthroscopically-assisted procedures have become more important in the stabilization of metaphyseal fractures. Although long term results of some of the mentioned procedures are unknown by now, minimally-invasive techniques appear to have positive influence on functional outcome in most patients. However problems of intraoperative control of axis and rotation in long-bone fractures as well as the surgeon's high exposure to radiation remain unsolved problems in minimally-invasive traumatology.

[Ankle para-articular tibial fracture. Is osteosynthesis with the unreamed intramedullary nail adequate?]. / Der sprunggelenksnahe Unterschenkelbruch. Ist die Osteosynthese mit ungebohrtem Marknagel ausreichend?

In a prospective study, 53 fractures of the distal fifth of the tibia were stabilized by unreamed nailing. Additional involvement of the ankle joint occurred in 18 patients. 50 patients returned for follow-up. In 30 patients tibia and fibula were fractured at the same (distal) level; in 20 patients the fracture of the fibula was located more proximally. In 12 patients the fractures extended into the tibial pilon. Severe soft tissue damage was seen in 24 fractures (18 open, 6 closed). Ninety percent of all fractures healed uneventfully without further surgical intervention after unreamed nailing. In two patients the unreamed nail had to be exchanged for a reamed tibial nail. Bone grafting and secondary dynamization of the nail by removal of a proximal interlocking bolt were performed in one case each. Thirty-one fractures healed in anatomical position. Valgus or varsus angulation of less than 5 degrees occurred in 18 patients. One fracture healed with rotatory angulation of 15 degrees. The highest rate of complications (22%) was seen in patients with distal fractures of the fibula without additional plating (of the fibula). There was no deep infection. Tibial fractures close to the ankle joint can be managed by unreamed nailing. Distal fractures of the fibula should be stabilized by additional plating. Because of the unreamed technique of implantation this procedure can also be used in grade II or III open fractures.