[Mortui vivos docent : The dead teach the living]

Biomechanical Comparison of 2 Double Plating Methods in a Coronal Fracture Model of Bicondylar Tibial Plateau Fractures

OBJECTIVES

Because management of bicondylar tibial plateau fractures are complicated even for expert surgeons, with using a coronal fracture model, we aimed to compare 2 kinds of double locked plating techniques that consisted of the lateral locking plate and the medial locking plate inserted medial anteriorly (MA-ly) or medial posteriorly (MP-ly).

METHODS

Fourteen fresh-frozen tibias stabilized with the MA or MP methods were allocated into 2 groups with similar bone mineral density values. Implanted samples were tested under incremental fatigue loading conditions using a customized load applicator. An optical motion tracking system was used to assess relative displacements and rotations of fracture fragments during loading. Static and dynamic global stiffness, failure load, failure cycles, as well as movements of fracture fragments were measured.

RESULTS

There were no significant differences between the 2 fixation methods regarding global stiffness, failure load, or failure cycles (P = 0.67-0.98, depending on the parameter). The kinematic evaluations, however, revealed that different positions of the medial locking plates altered the directions of movements for the medial-anterior or medial-posterior fracture segments.

CONCLUSIONS

The mechanical stability of tibia-implant constructs fixed with the double plating methods was not remarkably affected by the location of the medial locking plate. Depending on clinical conditions and surgeons' preferences, bicondylar tibial plateau fractures can be managed with either MA or MP methods.

[On the quality of the external post-mortem examination in cases of fatal head trauma : A comparison of death certificate and forensic autopsy]

BACKGROUND

In Germany it is required by law that basically every type of physician needs to be capable of executing a correct external post-mortem examination of a corpse. In recent years, numerous investigations on external post-mortem examinations repeatedly reported systematic mistakes and erroneous procedures in various clinical and medicolegal case groups. Accordingly, the completion of death certificates is frequently performed incorrectly. As one of the typical unnatural death cases, decedents dying from fatal head trauma (FHT) represent a special autopsy case group, which is expected to be correctly recognized during the primary external post-mortem examination because the external injuries are mostly obvious.

OBJECTIVE

The present study aimed at investigating the quality of the external post-mortem examination in medicolegal FHT cases by means of comparison of death certificates and autopsy reports from a 10-year period.

MATERIAL AND METHODS

In a retrospective study design all autopsy cases from the Institute of Legal Medicine of the University Hospital Münster in the years 2006-2015 (n = 3611) were analyzed as to the presence of FHT. A total of 328 cases with FHT and the concomitant presence of a death certificate filled out before the autopsy were identified. Subsequently, the cause of death according to the death certificate was compared with the cause of death according to the autopsy. The degree of agreement was classified into six different categories from I to VI. While category I represented a complete lack of agreement, category VI was assigned to cases with full agreement.

RESULTS

In 58.5% of the cases (category VI) FHT was identified correctly during the external post-mortem examination. In 1.5% of the cases, a completely different cause of death was determined during the external post-mortem examination (category I). In 19.2% of the cases, no cause of death or the statement "unclear" was given as the cause of death in the death certificate (categories II and III). Cross-analyses and intuitive heatmap visualization were generated to identify case constellations with an increased risk for discrepancies. These analyses revealed that among all discrepant cases (categories I-V), falls were found significantly more often than in the nondiscrepant cases (p < 0.01), especially falls of women older than 57 years (median age of women) or falls considered as accidents by the examiner. In addition, traffic-associated FHT of men older than 44.5 years (median age of men) was identified more frequently in the external post-mortem examination.

CONCLUSION

Despite the fact that FHT should be a cause of death that is comparably easy to identify during external post-mortem examination, more than one third of the cases were not sufficiently recognized. Therefore, special attention must still be paid to certain case constellations during the external post-mortem examination. Typical examples of such cases are burned bodies, cases of advanced putrefaction and falls.

[Additional emergency medical measures in trauma-associated cardiac arrest]

INTRODUCTION

More than half of all traumatic deaths happen in prehospital settings. Until now, there have been no long-term studies examining the actual additive treatment during trauma-associated cardiopulmonary resuscitation (tCPR), including pleural decompression, pericardiocentesis, tourniquets and external stabilization of the pelvis. The present cohort study evaluated forensic autopsy reports of trauma deaths occurring at the scene with respect to additive actions in preclinical tCPR as well as the potentially preventable nature of the individual death cases.

MATERIAL AND METHODS

All autopsy protocols from the Institutes of Legal Medicine in Leipzig and Chemnitz, Germany within the years 2011-2017 were retrospectively examined and all trauma deaths with professional prehospital tCPR at the scene, during transport or shortly after arriving at the emergency room were analyzed. In addition to epidemiological parameters all forms of medical procedure performed by emergency physicians and the injury patterns were recorded. Thus, the questions whether any of the trauma deaths were preventable and if failures in work-flow management were evident could be retrospectively answered through a structured Delphi method.

RESULTS

Overall, 3795 autopsy protocols were listed containing 154 trauma cases (4.1%) with various preclinical tCPR attempts (male patients 70.1%; mean age 48 ± 21 years). Most of them died at the accident site (84.4%), some during transport (2.6%) or directly after admission to a hospital (13.0%). Only 23 patients (14.9%) received 25 additional interventions exceeding the normal scope (pleural decompression 80.0%, pericardiocentesis 8.0% and external stabilization of the pelvis 12.0%). A relevant number of potentially reversible causes for trauma-associated cardiac arrest was determined. There were deficits in the performance of pleural decompression in cases of tension pneumothorax. Even if isolated traumatic hemopericardium was a rare occurrence in the examined cases, the rate of pericardiocentesis was still too low. Also, more focus needs to be placed on provisional external pelvic stabilization of trauma patients which was performed too rarely even though an instable pelvic ring was apparent during the postmortem external examination. None of the cases received a rescue thoracotomy even if a few patients might have derived benefit from this and none of the cases showed injury patterns with tourniquet indications. Furthermore, no single case of death due to incorrect or missing airway management was determined. Errors in work-flow management were found in 37.0% and potentially preventable deaths occurred cumulatively in 12.3% of the cases. The potentially preventable deaths were particularly related to penetrating chest injuries caused by a sharp force.

DISCUSSION

The percentage of patients who might benefit from additive treatment implemented in tCPR efforts was shown to be equal between the local situations in Leipzig and Chemnitz compared to previous reports in Berlin. A need for optimizing the professional resuscitation process still remains as not all reversible causes were appropriately addressed. Further training and education should intensively address the mentioned deficits and continuous awareness of necessary additional medical procedures in the preclinical setting in cases of traumatic cardiac arrest is inevitable. Cooperation with forensic institutes can help to impart particular issues and treatment options of emergency medicine in cases of potentially reversible causes of traumatic cardiac arrest.