[Trauma surgery in Pacific Small Island Developing States (SIDS)]. / Unfallchirurgie in den kleinen Inselnationen des Pazifiks.

BACKGROUND: The small developing countries in the Pacific are grouped together as Small Island Development States (SIDS) because they face similar problems which they cannot cope with nationally. They are developing countries, so-called low and lower middle income countries (LMIC), are economically weak and the islands of the different nations are widely scattered. Approximately 80% of the 10 million inhabitants live in rural regions. EPIDEMIOLOGY AND SURGICAL CAPACITY: Over 40% of patients in the surgical departments of hospitals are hospitalized for injuries, and this tendency is increasing. Fractures of the upper extremities are relatively more frequent in the Pacific than in the countries of the North. Long distances, lack of possibilities for treatment and lack of transport often cause complications, such as infected open fractures, pseudarthrosis and posttraumatic malformations. There are too few hospitals with sufficiently competent surgeons, anesthetists and obstetricians (SAO) and appropriate equipment. PACIFIC ISLANDS ORTHOPEDIC ASSOCIATION (PIOA): The PIOA was founded in Honiara, Solomon Islands, and offers surgeons of the Pacific SIDS a comprehensive, structured trauma and orthopedic surgery training in their own countries. It lasts 4 years and leads to an M­Med (orthopaedic surgery) diploma and to a Fellowship of the International College of Surgeons (FICS), which are both recognized by the participating hospitals. It is free for participants. THE AO ALLIANCE FOUNDATION (AOAF): The AOAF is an independent organization with the only aim to enhance trauma surgery capacity in LMICs. The AOAF supports the PIOA program together with the Wyss Medical Foundation. Currently, 18 trainees from 8 Pacific SIDS are participating in the PIOA training program.

Telepathology on the Solomon Islands--two years' experience with a hybrid Web- and email-based telepathology system.

The National Referral Hospital in Honiara, Solomon Islands, has used an Internet-based system in Switzerland for telepathology consultations since September 2001. Due to the limited bandwidth of Internet connections on the Solomon Islands, an email interface was developed that allows users in Honiara to submit cases and receive reports by email. At the other end, consultants can use a more sophisticated Web-based interface that allows discussion of cases among an expert panel. The result is a hybrid email- and Web-based telepathology system. Over two years, 333 consultations were performed, in which 94% of cases could be diagnosed by a remote pathologist. A computer-assisted 'virtual institute' of pathologists was established. This form of organization helped to reduce the median time from submission of the request to a report from 28 h to 8.5 h for a preliminary diagnosis and 13 h for a final report. A final report was possible in 77% of all submitted cases.

[The future of telepathology. An Internet "distributed system" with "open standards"]. / Die Zukunft der Telepathologie. Ein im Internet "verteiltes System" mit "offenen Standards".

With the availability of Internet, the interest in the possibilities of telepathology has increased considerably. In the foreground is thereby the need of the non-expert to bring in the opinions of experts on morphological findings by means of a fast and simple procedure. The new telepathology system iPath is in compliance with these needs. The system is based on small, but when possible independently working modules. This concept allows a simple adaptation of the system to the individual environment of the user (e.g. for different cameras, frame-grabbers, microscope steering tables etc.) and for individual needs. iPath has been in use for 6 months with various working groups. In telepathology a distinction is made between "passive" and "active" consultations but for both forms a non-expert brings in the opinion of an expert. In an active consultation both are in direct connection with each other (orally or via a chat-function), this is however not the case with a passive consultation. An active consultation can include the interactive discussion of the expert with the non-expert on images in an image database or the direct interpretation of images from a microscope by the expert. Four software modules are available for a free and as fast as possible application: (1) the module "Microscope control", (2) the module "Connector" (insertion of images directly from the microscope without a motorized microscope), (3) the module "Client-application" via the web-browser and (4) the module "Server" with a database. The server is placed in the internet and not behind a firewall. The server permanently receives information from the periphery and returns the information to the periphery on request. The only thing which the expert, the non-expert and the microscope have to know is how contact can made with the server.

Coconut palm-related injuries in the Pacific Islands.

INTRODUCTION: Coconut palms are an integral part of life in the Solomon Islands, given the widespread dependence of subsistence agriculture. Injuries related to the coconut palm are thus inevitable. Hospital records from the Central Referral Hospital were reviewed to identify (i) how commonly the coconut palm is implicated in injuries referred to the surgery department; (ii) which patients are being injured; and (iii) the type of injuries sustained. METHODS: The present study reviews all patients referred to the Department of Surgery and Orthopaedics between January 1994 and December 1999 who had a coconut palm-related injury. This was possible due to the trauma epidemiology form, which records the patient details, cause of injury, fracture details and other injury information. RESULTS: A total of 3.4% of all injuries presenting to the surgical department was related to the coconut palm. Eighty-five patients fell from the coconut palm, 16 patients had a coconut fruit fall on them, three patients had a coconut palm fall on them and one patient kicked a coconut palm. The majority of patients who were injured by falling from a coconut palm were young (aged 6-25 years). Eleven of the 16 patients struck by falling fruit were under 25 years of age. The majority of injuries sustained were fractures. Patients falling from coconut palms sustained mainly upper limb fractures (60.1% of all fractures) or spinal fractures (16.3%). Patients injured by falling fruit sustained skull or upper limb fractures. All skull fractures occurred in patients under the age of 10 years. CONCLUSION: This is the largest review of coconut palm-related injuries. It highlights some epidemiological facts that raise considerations for preventative health measures in the Solomon Islands. Parents and young children must be warned of the dangers of playing beneath coconut trees. Boy and girls should be warned of the dangers of collecting fruit. With an increasing amount of schooling becoming available the Solomon Islands is an ideal place to direct an education programme about the dangers of coconut palms as well as many other primary health issues. Because subsistence farming plays a crucial role in the life of most Solomon Islanders, injuries that result in loss of function are crippling both to the patient and the village. Any preventative measure to reduce the rates of injury will be important.

An audit to assess the impact of a strategy to reduce inappropriate red cell transfusions at Honiara Hospital.

A blood transfusion committee was established at Honiara Central Hospital (HCH), a national referral hospital for the Solomon Islands to promote a rational, safe and cost-effective blood transfusion service and to audit the use of blood particularly in the perioperative context. Following the education strategy, a 29.7% reduction in the number of units of blood crossmatched as a proportion of total admissions was achieved as well as a 30.1% reduction in the number of units transfused per 100 operations. The failure of the education strategy to increase the proportion of 'group and hold' requests confirms the need for an integrated approach between the different hospital departments involved to ensure a fully satisfactory result.

[External fixator: surgical technique, pinless fixator, change in procedure]. / Fixateur externe: Operationstechnik, pinless fixator, Verfahrenswechsel.

External Fixation-Technique: The advantages of external over internal fixation are as follows: a) endosteal and periosteal blood supply is undisturbed, b) "low-tech" equipment may be used, c) secondary adjustments are possible and d) easy implant removal. These benefits however are outweighed by the main disadvantages of long term external fixation i.e. pin complications and delayed union of fractures. Better understanding of postoperative management and careful application of screws of improved design will lead to better results. Today's standard applications of external fixation for tibial fractures is a unilateral fixator, using Schanz screws. The pin-bone interface is the most critical site of all external fixation. By avoiding heat necrosis (low temperature drilling) and preventing micro motion at the pin-bone interface (by applying bending- or more recently radial-preload), pin complications such as infection and loosening can be reduced. Two Schanz screws are inserted into each main fragment and are connected with one short tube per fragment. The fracture is then reduced by using these tubes as handles. After reduction a third tube connects the first two by means of two tube-to-tube clamps. This type of fixation will easily allow for three dimensional secondary corrections of alignment. Approximately three weeks following the injury some motion at the fracture site will stimulate callus formation. This can be achieved by destabilisation, dynamisation or "active stimulation" of the fracture site [2]. Pinless fixator: The pinless external fixator holds the fragments firmly with pointed clamps that penetrate about one millimeter into cortical bone without entering and contaminating the medullary canal.(ABSTRACT TRUNCATED AT 250 WORDS)

[The open femoral fracture in war--173 external fixators applied to the femur (Afghanistan war)]. / Die offene Femurfraktur im Krieg--173 Fixateur-externe-Applikationen am Femur (Afghanistankrieg).

During the three years 1988 through 1990, more than 700 external skeletal fixations (AO/ASIF Tubular System) were utilized at the ICRC Hospital for Afghan War Wounded in Peshawar, Pakistan, 173 of which were for femoral fractures. 13% of the fractures were open grade II, and 71% open grade III, mostly due to high velocity gunshot or shrapnel injuries. Usually, the external fixator was left in place until consolidation of the fracture. The average time of external fixation was 128 days. Three major groups of complications have been observed: fracture complications, implant complications, and residual loss of function of the knee joint, probably the most significant permanent complication to the patient. In order to improve the functional results in treating open fractures of the femur, three measures are recommended: unilateral frame with posterolateral insertion of Schanz screws, postoperative positioning of the patient with 90 degrees of flexion of hip and knee joints and mobilization of the patient as soon as possible (on the first or second postoperative day).