Post-traumatic thrombo-embolic complications in polytrauma patients

INTRODUCTION

Thrombo-embolic events after trauma are considered to be life-threatening complications. Our aim was to determine the incidence of arterial and venous thrombo-embolic events (TE) in severely-injured trauma patients, and its associated risk factors by using a large trauma registry.

METHODS

Patients' data from the TraumaRegister DGU® (TR-DGU) were screened for TE (DVT [symptomatic deep vein thrombosis], PE [symptomatic pulmonary embolism], MI [myocardial infarction], and stroke) through the clinical course of severely injured adult trauma patients from January 2005 to December 2012. Univariate analysis was used to compare the clinical outcomes (endpoints: mortality, ICU and hospital length of stay, ventilator days), and a multivariate regression analysis was used to assess the independent risk factors associated with each TE event.

RESULTS

From a cohort of 40,846 trauma patients, 1122 (2.8%) patients developed a TE during their post-traumatic clinical course (313, 0.8% DVT; 425, 1.0% PE; 160, 0.4% MI and 231, 0.6% stroke). ICU length of stay [LOS], total LOS, days on mechanical ventilation, and incidence of multiple organ failure (MOF) and sepsis were significantly increased in patients with TE complications. Injury severity, major pelvic injury, and one or more operations were found to be independent risk factors for the development of DVT. Age ≥ 60 years, male gender, and more than one operation were risk factors for PE development. For MI age was the only significant risk factor. The occurrence of a stroke is increased in patients with an age ≥ 60 years, major head injury (AIS head ≥ 3), and more than one operation. Finally, mortality rates were significantly higher in the TE group when compared to the non-TE cohort (21.8% vs. 12.7%; p < 0.001).

CONCLUSION

TE complications were associated with longer ICU and hospital stay as well as a higher mortality. Overall, age and repeated operations were the most important risk factors for the development of TE events.

Ten years of helicopter emergency medical services in Germany: do we still need the helicopter rescue in multiple traumatised patients?

BACKGROUND

Helicopter emergency medical service (HEMS) has been established in the preclinical treatment of multiple traumatised patients despite an ongoing controversy towards the potential benefit. Celebrating the 20th anniversary of TraumaRegister DGU(®) of the German Trauma Society (DGU) the presented study intended to provide an overview of HEMS rescue in Germany over the last 10 years analysing the potential beneficial impact of a nationwide helicopter rescue in multiple traumatised patients.

PATIENTS AND METHODS

We analysed TraumaRegister DGU(®) including multiple traumatised patients (ISS ≥ 16) between 2002 and 2012. In-hospital mortality was defined as main outcome. An adjusted, multivariate regression with 13 confounders was performed to evaluate the potential survival benefit.

RESULTS

42,788 patients were included in the present study. 14,275 (33.4%) patients were rescued by HEMS and 28,513 (66.6%) by GEMS. Overall, 66.8% (n=28,569) patients were transported to a level I trauma centre and 28.2% (n=12,052) to a level II trauma centre. Patients rescued by HEMS sustained a higher injury severity compared to GEMS (ISS HEMS: 29.5 ± 12.6 vs.

ISS GEMS

27.5 ± 11.8). Helicopter rescue teams performed more on-scene interventions, and mission times were increased in HEMS rescue (HEMS: 77.2 ± 28.7 min. vs. GEMS: 60.9 ± 26.9 min.). Linear regression analysis revealed that the frequency of HEMS rescue has decreased significantly between 2002 and 2012. In case of transportation to level I trauma centres a decrease of 1.7% per year was noted (p<0.001) while a decline of 1.6% per year (p<0.001) was measured for level II trauma centre admissions. According to multivariate logistic regression HEMS was proven a positive independent survival predictor between 2002 and 2012 (OR 0.863; 95%-CI 0.800-0.930; Nagelkerkes-R(2) 0.539) with only little differences between each year.

CONCLUSIONS

This study was able to prove an independent survival benefit of HEMS in multiple traumatised patients during the last 10 years. Despite this fact, a constant decline of HEMS rescue missions was found in multiple trauma patients due to unknown reasons. We concluded that HEMS should be used more often in case of trauma in order to guarantee the proven benefit for multiple traumatised patients.

Relevance of induced and accidental hypothermia after trauma-haemorrhage-what do we know from experimental models in pigs?

Recent experimental research has either focused on the role of accidental hypothermia as part of the lethal triad after trauma or tried to elucidate the effects of therapeutically induced hypothermia on the posttraumatic course. Induced hypothermia seems to reduce the mortality in experimental models of trauma-haemorrhage. As potential mechanisms, a decrease of cellular metabolism, beneficial effects on haemodynamic function and an attenuation of the inflammatory response have been described. However, negative side effects of hypothermia have to be considered, such as impairment of the coagulatory function and immunosuppressive effects. Furthermore, the optimal strategy for the induction of hypothermia (magnitude, duration, timing, cooling rate, etc.) and subsequent rewarming remains unclear. Nevertheless, this piece of information is essential before considering hypothermia as a treatment strategy for severely injured patients. This review aims to elaborate the differences between accidental and induced hypothermia and to summarize the current knowledge of the potential therapeutic use of induced hypothermia suggested in porcine models of trauma-haemorrhage.

Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study

OBJECTIVE

Bankart and Hill-Sachs lesions are often associated with anterior shoulder dislocation. The MRI technique is sensitive in diagnosing both injuries. The aim of this study was to investigate Bankart and Hill-Sachs lesions with MRI to determine the correlation in occurrence and defect sizes of these lesions.

METHODS

Between 2006 and 2013, 446 patients were diagnosed with an anterior shoulder dislocation and 105 of these patients were eligible for inclusion in the study. All patients were examined using MRI. Bankart lesions were classified as cartilaginous or bony lesions. Hill-Sachs lesions were graded I-III using a modified Calandra classification.

RESULTS

The co-occurrence of injuries was high [odds ratio (OR) = 11.47; 95% confidence interval (CI) = 3.60-36.52; p < 0.001]. Patients older than 29 years more often presented with a bilateral injury (OR = 16.29; 95% CI = 2.71-97.73; p = 0.002). A correlation between a Bankart lesion and the grade of a Hill-Sachs lesion was found (ρ = 0.34; 95% CI = 0.16-0.49; p < 0.001). Bankart lesions co-occurred more often with large Hill-Sachs lesions (O  = 1.24; 95% CI = 1.02-1.52; p = 0.033).

CONCLUSION

If either lesion is diagnosed, the patient is 11 times more likely to have suffered the associated injury. The size of a Hill-Sachs lesion determines the co-occurrence of cartilaginous or bony Bankart lesions. Age plays a role in determining the type of Bankart lesion as well as the co-occurrence of Bankart and Hill-Sachs lesions.

ADVANCES IN KNOWLEDGE

This study is the first to demonstrate the use of high-quality MRI in a reasonably large sample of patients, a positive correlation of Bankart and Hill-Sachs lesions in anterior shoulder dislocations and an association between the defect sizes.

Interleukin-6 as inflammatory marker referring to multiple organ dysfunction syndrome in severely injured children

Background

Despite the suggestion that the inflammatory response in traumatized children is functionally unique, prognostic markers predicting pediatric multiple organ failure are lacking. We intended to verify whether Interleukin-6 (IL-6) displays a pivotal role in pediatric trauma similar to adults.

Methods

Traumatized children less than 18 years of age with an Injury Severity Score >9 points and consecutive admission to the hospital’s pediatric intensive care unit were included. Organ function was evaluated according to the score by Marshall et al. while IL-6 levels were measured repetitively every morning.

Results

59 traumatized children were included (8.4 ± 4.4 years; 57.6% male gender). Incidence of MODS was 11.9%. No differences were found referring to age, gender, injury distribution or overall injury severity between children with and without MODS. Increased IL-6 levels during hospital admission were associated with injury severity (Spearman correlation: r = 0.522, p < 0.001), while an inconsistent association towards the development of MODS was proven at that time point (Spearman correlation: r = 0.180, p = 0.231; Pearson's correlation: r = 0.297, p = 0.045). However, increased IL-6 levels during the first two days were no longer associated with the injury severity but a significant correlation to MODS was measured.

Conclusions

The presented prospective study is the first providing evidence for a correlation of IL-6 levels with injury severity and the incidence of MODS in traumatized children.

Physical and psychological long-term outcome after traumatic brain injury in children and adult patients

Background

Several studies have indicated that younger age is associated with worse recovery after pediatric traumatic brain injury (TBI) compared to elder children. In order to verify this association between long-term outcome after moderate to severe TBI and patient’s age, direct comparison between different pediatric age groups as well as an adult population was performed.

Methods

This investigation represents a retrospective cohort study at a level I trauma center including patients with moderate to severe, isolated TBI with a minimum follow-up of 10 years. According to their age at time of injury, patients were divided in pre-school (0–7 years), school (8–17 years) and adult (18–65 years) patients. Physical examination and standardized questionnaire on physical and psychological aspects (Glasgow Outcome Scale, Barthel Index, Impact of Event Scale, Hospital Anxiety and Depression Scale, short form 12) were performed.

Results

135 traumatized patients were included. Physical and psychological long-term outcome was associated with injury severity but not with patients’ age at time of injury. Outcome recovery measured by Glasgow Outcome Scale was demonstrated with best results for pre-school aged children (p = 0.009). According to the Hospital Anxiety and Depression Scale an increased incidence of anxiety (p = 0.010) and depression (p = 0.026) was evaluated in older patients.

Conclusion

Long-term outcome perceptions after moderate to severe TBI presented in this study question current views of deteriorated recovery for the immature brain. The sustained TBI impact seemed not to reduce the child’s ability to overcome the suffered impairment measured by questionnaire based psychological, physical and health related outcome scores. These results distinguish the relevance of rehabilitation and family support in the long term.

[Prognosis of polytraumatized patients: estimates in the shock room and intensive care station]

Treatment of patients with multiple trauma is known to require validated established algorithms, experienced medical staff and intensive interdisciplinary cooperation between the medical disciplines. In order to predict the risk for potential complications and mortality, adequate assessment of patients with multiple trauma is crucial for further treatment decisions. Therefore, different scoring systems have been developed to assess injury severity and to predict the potential outcome after multiple trauma. These scores have in common that the severity of trauma is converted to a numeric value simplifying the physiological reality in general. But the anatomic as well as physiological impact after multiple trauma can hardly be represented comprehensively by a single numeric value. Consequently, the established scores can only be safely interpreted, if the individual limitations of each scoring system are known.

Radiographic changes in the operative treatment of acute acromioclavicular joint dislocation - tight rope technique vs. K-wire fixation

Background

Operative treatment of higher degree acromioclavicular joint luxation is common. A new option is made available by the tight rope technique. It claims to provide adequate outcome with the use of a minimally invasive technique. First clinical studies justified its medical use, but the equivalence to established surgical methods remains unclear. We therefore analyzed radiographic data from patients that were treated with the tight rope system (TR) and compared them to those treated with K-wires (KW) fixation.

Material/Methods

Retrospective study with inclusion criteria: surgery for acromioclavicular joint luxation between 2004 and 2011, classified as Rockwood type III, no concomitant injury, first event injury. We compared pre- and post-operative X-rays with those taken at the end of treatment. Clinical data from follow-ups and radiographic data were evaluated. The main outcome variable was the remaining distance between the acromion and clavicle (ACD), as well as the coracoid process and clavicle (CCD).

Results

27 patients (TR: n=16; KW: n=11) with comparable demographics and injury severity were included. Surgery reduced ACD (TR: p=0.002; KW: p<0.001) and CCD (TR: p=0.001; KW: p=0.003). Heterotopic ossification or postoperative osteolysis was not significantly associated with either one of the procedures. Three patients (18.75%) in the TR group showed impaired wound healing, migrating K-wires were recorded in 2 patients (18.2%) and impingement syndrome occurred in 1 patient (9.1%) with K-wires. Posttraumatic arthritis was not seen. There was a loss of reduction in 2 cases within the TR-group (12.51%) and 1 in the KW-group (9.1%). At last follow up, ACD and CCD were wider in both groups compared to the healthy side.

Conclusions

This study shows that the Tight rope system is an effective alternative in the treatment of higher degree acromioclavicular luxation and comparable to the established methods.

Subjective impact of traumatic brain injury on long-term outcome at a minimum of 10 years after trauma- first results of a survey on 368 patients from a single academic trauma center in Germany

Background

Traumatic Brain Injury (TBI) may lead to significant impairments in personal, social and professional life. However, knowledge of the influence on long-term outcome after TBI is sparse. We therefore aimed to investigate the subjective effects of TBI on long-term outcome at a minimum of 10 years after trauma in one of the largest study populations in Germany.

Methods

The current investigation represents a retrospective cohort study at a level I trauma center including physical examination or standardized questionnaires of patients with mild, moderate or severe isolated TBI with a minimum follow-up of 10 years. We investigated the subjective physical, psychological and social outcome evaluating the Glasgow Outcome Scale, short-form 12, and social as well as vocational living circumstances.

Results

368 patients aged 0 to 88 years were included. Patients with severe TBI were younger compared to patients with moderate or mild TBI (p < 0.05). Patients with severe TBI lived more often as single after the trauma impact. A significantly worse outcome was associated with higher severity of TBI resulting in an increased incidence of mental disability. A professional decline was analyzed in case of severe TBI resulting in significant loss of salary.

Conclusions

The severity of TBI significantly influenced the subjective social and living conditions. Subjective mental and physical outcome as well as professional life depended on the severity of TBI 10 years after the injury.

Surgical strategies in polytraumatized patients with femoral shaft fractures - comparing a German and an Australian level I trauma centre

BACKGROUND

Femoral shaft fractures are one of the most common injuries in multiple trauma patients. Due to their prognostic relevance, there is an ongoing controversial discussion as to the optimal treatment strategy in terms of Damage Control Orthopaedics (DCO) and Early Total Care (ETC). We aimed to describe the differences in fracture management and clinical outcome of multiple trauma patients with concomitant femoral shaft fractures treated at a German and an Australian level I trauma centre using the same inclusion criteria.

METHODS

Polytraumatized patients (ISS ≥ 16) with a femoral shaft fracture aged ≥ 16 years treated at a German and an Australian trauma centre between 2003 and 2007 were included. According to ETC and DCO management principles, we evaluated demographic parameters as well as posttraumatic complications and clinical outcome.

RESULTS

Seventy-three patients were treated at the German and 134 patients at the Australian trauma centre. DCO was performed in case of increased injury severity in both hospitals. Prolonged mechanical ventilation time, and length of ICU and hospital stay were demonstrated in DCO treatment regardless of the trauma centre. No differences concerning posttraumatic complications and survival were found between both centres. Survival of patients after DCO was similar to those managed using ETC despite a greater severity of injury and lower probability of survival. There was no difference in the incidence of ARDS. DCO was, however, associated with a greatly increased length of time on mechanical ventilation and length of stay in the ICU.

CONCLUSION

We found no differences concerning patient demographics or clinical outcomes in terms of incidence of ARDS, MODS, or mortality. As such, we propose that comparability between German and Australian trauma populations is justified. Despite a higher ISS in the DCO group, there were no differences in posttraumatic complications and survival depending on ETC or DCO treatment. Further research is required to confirm whether this is the case with other countries, too.

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

INTRODUCTION

Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive.

METHODS

Traumatized patients (Injury Severity Score; ISS≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score.

RESULTS

A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n=8,231) were transported by GEMS and 37.7% (n=4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P<0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P<0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P<0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P<0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P<0.001) resulting in an increased length of ICU treatment and in-hospital time (P<0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862).

CONCLUSIONS

Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.

Cytokine productive capacity of alveolar macrophages and Kupffer cells after femoral fracture and blunt chest trauma in a murine trauma model

INTRODUCTION

Specific cellular and inflammatory factors that contribute to the severity of pulmonary dysfunction after blunt chest trauma and osteosynthesis of femoral fractures are yet not fully understood. Therefore, we investigated alterations of the cytokine productive capacity of alveolar macrophages (AM) and Kupffer cells (KC) after femoral fracture stabilized with intramedullary pin with or without blunt chest trauma.

MATERIALS AND METHODS

In male C57BL/6N mice an intramedullary pin was implanted in an intact femur as the sham procedure. In trauma groups mice either received an isolated femoral fracture with subsequent fracture stabilization with an intramedullary pin (group Fx) or a combined trauma of blunt chest trauma and femur fracture also stabilized by an intramedullary pin (group TTFx). Animals were sacrificed 0h, 6h, 12h, 24h and 3d after trauma induction. Cytokine concentrations were measured in plasma and supernatant of cultivated AM and KC by FACS analysis. Pulmonary and hepatic infiltration of polymorphonuclear leukocytes (PMN) was determined by Ly6G-staining.

RESULTS

At 6h, isolated femoral fracture with intramedullary stabilization resulted in a significantly increased productive capacity of KC (IL-6, TNF-α, CCL2, CCL3, CCL5 and CCL7) compared to sham animals. Combined trauma additionally resulted in an increased productive capacity of AM (IL-6, TNF-α, CCL2, CCL3, CCL4, CCL5 and CCL7) at 6h and the effect was prolonged up to 3d compared to controls. Combined trauma also led to a significant higher amount of plasma CCL2 at 3d and plasma CCL7 at 6h after the insult compared to group Fx. Compared to shams, pulmonary and hepatic infiltrations of PMNs were increased in group Fx and TTFx after 6h, but in the combined trauma model the effect was prolonged up to 3d.

CONCLUSION

An intramedullary stabilized femur fracture alone results in a significant activation of the immune response. The combination of femoral fracture and blunt chest trauma however, results in an increased and prolonged activation of the inflammatory response. Transferred to the clinical setting, these results emphasize the critical role of severe chest trauma for treatment strategies of femoral fractures in multiple trauma patients.

Merits and capabilities of helicopter emergency medical service (HEMS) in traumatized patients

Since the introduction of helicopter emergency medical service (HEMS) into the civilian rescue system, there is an ongoing discussion on its potential benefits in terms of time- and cost-effectiveness as well as clinical outcome improvement. Currently, the use of HEMS seems to provide a survival benefit in traumatized patients due to several aspects compared to ground emergency medical service (GEMS). First of all, HEMS facilitate rapid transport from the scene to hospital based on increased transportation velocity. Furthermore, HEMS medical crew members are experienced in trauma management resulting in improved on-scene management and patients' triaging. However, these aspects should be considered carefully as specific circumstances referring to rescue teams, on-scene management as well as preclinical durations, triaging of trauma patients and subsequent treatment at different hospitals have to be attended. In the present review current aspects of HEMS compared to GEMS are discussed.

Effects of accidental hypothermia on posttraumatic complications and outcome in multiple trauma patients

INTRODUCTION

Accidental hypothermia seems to predispose multiple trauma patients to the development of posttraumatic complications, such as Systemic Inflammatory Response Syndrome (SIRS), sepsis, Multiple Organ Dysfunction Syndrome (MODS), and increased mortality. However, the role of accidental hypothermia as an independent prognostic factor is controversially discussed. The aim of the present study was to evaluate the incidence of accidental hypothermia in multiple trauma patients and its effects on the development of posttraumatic complications and mortality.

PATIENTS AND METHODS

Inclusion criteria for patients in this retrospective study (2005-2009) were an Injury Severity Score (ISS) ≥16, age ≥16 years, admission to our Level I trauma centre within 6h after the accident. Accidental hypothermia was defined as body temperature less than 35°C measured within 2 h after admission, but always before first surgical procedure in the operation theatre. The association between accidental hypothermia and the development of posttraumatic complications as well as mortality was investigated. Statistical analysis was performed with χ(2)-test, Student's t-test, ANOVA and logistic regression. Statistical significance was considered at p<0.05.

RESULTS

310 multiple trauma patients were enrolled in the present study. Patients' mean age was 41.9 (SD 17.5) years, the mean injury severity score was 29.7 (SD 10.2). The overall incidence of accidental hypothermia was 36.8%. The overall incidence of posttraumatic complications was 77.4% (SIRS), 42.9% (sepsis) and 7.4% (MODS), respectively. No association was shown between accidental hypothermia and the development of posttraumatic complications. Overall, 8.7% died during the posttraumatic course. Despite an increased mortality rate in hypothermic patients, hypothermia failed to be an independent risk factor for mortality in multivariate analysis.

CONCLUSIONS

Accidental hypothermia is very common in multiply injured patients. However, it could be assumed that the increase of mortality in hypothermic patients is primarily caused by the injury severity and does not reflect an independent adverse effect of hypothermia. Furthermore, hypothermia was not shown to be an independent risk factor for posttraumatic complications.

Tip apex distance, hip screw placement, and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures

PURPOSE

To describe the quality of osteosynthesis after intertrochanteric fractures evaluation of tip apex distance (TAD) and position of the hip screw have been established. Furthermore, a slightly valgus fracture reduction has been suggested to reduce the risk of cut-out failure. However, uniform recommendations for optimal screw positioning and fracture reduction are still missing. The purpose of our study was to confirm potential risk factors for cut-out of hip screws of intertrochanteric fractures and to provide recommendations for practical clinical use.

METHODS

A retrospective analysis of all patients with intertrochanteric fractures treated with a DHS or a gamma nail between January of 2007 and May of 2010 was performed at a level I trauma center.

RESULTS

Two hundred thirty-five patients with intertrochanteric fractures after intra- and extramedullary stabilization were analyzed. A TAD of more than 25 mm was demonstrated to be the most important factor for cut-out in stable and unstable fractures. Fracture reduction with a valgus NSA of 5-10° was associated with a trend towards a lower rate of screw cut-out while an anterior placement of the screw (Parker's ratio index of <40) significantly increased cut-out incidence.

CONCLUSIONS

According to our results, the TAD should not exceed 25 mm in stable (AO/OTA A1) as well as unstable (AO/OTA A2) fractures. An increased anterior hip screw placement should be avoided while fracture reduction with a slight valgus Neck Shaft seems favorable.

Knee injuries in severe trauma patients: a trauma registry study in 3.458 patients

Background

Purpose of the presented study is to answer the following questions: Are knee injuries associated with trauma mechanisms or concomitant injuries? Do injuries of the knee region aggravate treatment costs or prolong hospital stay in polytraumatized patients?

Methods

A retrospective analysis including 29.779 severely injured patients (Injury Severity Score [greater than or equal to] 16) from the Trauma Registry of the German Society for Trauma Surgery database (1993-2008) was conducted. Patients were subdivided into two groups; the "Knee" group (n=3.458, 11.6% of all patients) including all multiple trauma patients with knee injuries, and the "Non Knee" group (n=26.321) including the remaining patients. Patients with knee injuries were slightly younger, less often male gender and had a significantly increased ISS.

Results

Patients in the Knee group suffered significantly more traffic accidents compared to the Non Knee group (82% vs. 52%, p<0.001). These injuries were more often caused by car or motorbike accidents. Severe thoracic and limb injuries (AIS[greater than or equal to]3) were more frequently found in the Knee group (p<0.001) while head injury was distributed equally. The overall hospital stay, ICU stay, and treatment costs were significantly higher for the Knee group (38.1 vs. 25.5 days, 15.2 vs. 11.4 days, 40,116 vs. 25,336 Euro, respectively; all p<0.001).

Conclusions

Traffic accidents are associated with an increased incidence of knee injuries than falls or attempted suicides. Furthermore, severe injuries of the limbs and chest are more common in polytraumatized patients with knee injuries. At last, treatment of these patients is prolonged and consequently more expensive.

Are polymorphisms of molecules involved in bone healing correlated to aseptic femoral and tibial shaft non-unions?

Fracture healing is a well-organized process between several molecules and mediators. As known from other diseases, genetic polymorphisms may exhibit different expression patterns in these mediators. Concerning fracture healing, this may lead to an extended healing process or non-union. We investigated the incidence of polymorphisms in patients with aseptic non-unions after femoral and tibial shaft fractures as compared to patients with uneventful healing. Exclusion criteria were smoking, diabetes, bilateral fractures, systemic corticoid therapy, and septic non-unions. Analysis of allele frequencies and genotype distribution of various mediators were carried out following PCR. Clinical parameters such as injury severity and in-hospital were analyzed. Fifty patients following non-union (group NU) were enrolled, the control group consisted of 44 patients (group H). A significant association of a PDGF haplotype and non-unions following fracture could be observed. There was a significantly increased in-hospital time and amount of surgical procedures in group NU. Polymorphisms within the PDGF gene seem to be a genetic risk factor for the development of non-unions of the lower extremity following fracture. The early identification of high risk patients could result in an adapted therapeutical strategy and might contribute to a significant decrease of posttraumatic non-unions.

Comparison of different thoracic trauma scoring systems in regards to prediction of post-traumatic complications and outcome in blunt chest trauma

BACKGROUND

As accurate assessment of thoracic injury severity in the early phase after trauma is difficult, we compared different thoracic trauma scores regarding their predictive ability for the development of post-traumatic complications and mortality.

MATERIALS AND METHODS

Two hundred seventy-eight multiple trauma patients (ISS ≥ 16) age > 16 y with severe blunt chest trauma (AIS(chest) ≥ 3) admitted between 2000 and 2009 to Level I Trauma center were included. Exclusion criteria were severe traumatic brain injury (AIS(head) ≥ 3) and penetrating thoracic trauma. The association between AIS(chest), Pulmonary Contusion score (PCS), Wagner-score and Thoracic Trauma Severity score (TTS), and duration of ventilation, length of ICU stay, development of post-traumatic complications, and mortality was investigated. Statistical analysis was performed with χ(2)-test, ANOVA, logistic regression, and receiver operating characteristic (ROC) curve.

RESULTS

Patients' mean age was 42.7 ± 17.0 y, the mean injury severity score was 28.7 ± 9.3 points. Overall, 60 patients (21.6%) developed ARDS, 143 patients (51.4%) SIRS, 110 patients (39.6%) sepsis, and 36 patients (13.0%) MODS. Twenty-two patients (7.9%) died. Among the examined thoracic trauma scores only the TTS was an independent predictor of mortality. With the TTS showing the best prediction power, the TTS, PCS, and Wagner-score were independent predictors of ventilation time, length of ICU stay, and the development of post-traumatic ARDS and MODS.

CONCLUSIONS

Thoracic trauma scores combining anatomical and physiologic parameters like the TTS seem to be most suitable for severity assessment and prediction of outcome in multiple trauma patients with concomitant blunt chest trauma.

Androstenediol exerts salutary effects on chemokine response after trauma-hemorrhage and sepsis in mice

OBJECTIVES

The pathogenesis of multiple organ dysfunction syndrome and sepsis after polytrauma is related to the posttraumatic immune response and the associated release of inflammatory mediators. There exists a gender dimorphism in the posttraumatic host response. Sex steroids are believed to beneficially modulate the posttraumatic immune response. The specific effect of androstenediol on chemokines after trauma is unknown. We investigated whether the application of androstenediol has an effect on plasma chemokine levels and the associated remote organ damage in a two-hit mouse-model of trauma-hemorrhage, cecal ligation, and cecal puncture.

MATERIALS AND METHODS

Traumatic hemorrhage was induced followed by androstenediol application and volume resuscitation. Thereafter, androstenediol was given once daily in combination with a vehicle (Intralipid). The control group was injected with a solution containing only the vehicle at the same time points as the treatment groups' androstenediol applications. Sepsis was induced by cecal ligation and cecal puncture 48 hours afterward. Four hours after cecal ligation and cecal puncture, plasma measurements of chemokines were performed. Pulmonary infiltration by polymorphonuclear lymphocytes was measured by immunhistochemical staining and myeloperoxidase measurements were taken.

RESULTS

Application of androstenediol led to significantly decreased monocyte chemoattractant protein-1, monocyte chemoattractant protein-3, macrophage inflammatory protein-1α, and macrophage inflammatory protein-1β levels compared with the control animals after trauma-hemorrhage, cecal ligation, and cecal puncture (P < 0.05). Pulmonary infiltration and myeloperoxidase activity were significantly decreased in androstenediol-treated animals (P < 0.05).

CONCLUSION

Androstenediol modulates the immune response after trauma-hemorrhage, cecal ligation, and cecal puncture by reducing systemic chemokine levels, which are known to direct immune cells into the tissue possibly leading to organ damage. Androstenediol represents a potential therapeutic agent after major trauma in high-risk patients.

Protective effects of finasteride on the pulmonary immune response in a combined model of trauma-hemorrhage and polymicrobial sepsis in mice

Literature supports findings about a gender specific outcome following multiple trauma. Male sex hormones such as dihydrotestosterone (DHT) exert deleterious effects on the posttraumatic immune response whereas increased estradiol concentrations are correlated with improved outcome. Pretreatment with the 5α-reductase inhibitor finasteride resulted in an improved outcome following trauma-hemorrhage (TH) in mice. The present study tested the hypothesis that finasteride exerts beneficial effects on the posttraumatic immune response also in a combined setting of TH and sepsis when administered during the resuscitation process.

MATERIAL AND METHODS

Male C57BL/6N-mice were subjected to TH (blood pressure, 35 mm Hg, 60 min) followed by finasteride application and fluid resuscitation. Thereafter, finasteride was administered every 12h. 24h after TH, sepsis was induced by cecal ligation and puncture (CLP) or sham operation was performed. Plasma cytokines (MIP-1α, MIP-1β, TNF-α, MCP-1, IL-6), productive capacity by alveolar macrophages (AM) and systemic estradiol levels were determined 4 h thereafter. The expression of pro-inflammatory mediators in lung tissue was evaluated by PCR. Pulmonary infiltration of PMN was determined by immunohistochemical staining.

RESULTS

Finasteride treatment resulted in a reduced posttraumatic cytokine secretion of AM as well as in a decreased concentration of MCP-1 and MIP-1β in lung tissue. Systemic estradiol levels were increased following finasteride treatment.

CONCLUSION

Finasteride mediates salutary effects on the pulmonary immune response using a therapeutical approach following TH-CLP in mice. Thus, finasteride might represent a relevant therapeutic substance following major trauma also in the clinical setting.