[Decision making and and priorities for surgical treatment during and after shock trauma room treatment]

[Fracture management in polytrauma]

The management of polytrauma patients is a complex multidisciplinary and dynamic task. The early and comprehensive assessment of the clinical condition is of great importance with respect to the timing and the individual decision-making on surgical fracture treatment. Stable patients benefit from early definitive fracture treatment, whereas for unstable patients, the concept of multistage fracture treatment with temporary minimally invasive stabilization has gained wide acceptance. These concepts, known as early total care (ETC) and damage control orthopedics (DCO), have been extended in recent decades by dynamic and injury-adapted treatment protocols, such as early appropriate care (EAC) or safe definitive orthopedic surgery (SDS): Therefore, patients in an initially unclear condition (borderline patients) can now also be treated with an individually adapted care concept as soon as possible.

Electromagnetic Real Time Navigation in the Region of the Posterior Pelvic Ring: An Experimental In-Vitro Feasibility Study and Comparison of Image Guided Techniques

Background

Electromagnetic tracking is a relatively new technique that allows real time navigation in the absence of radiation. The aim of this study was to prove the feasibility of this technique for the treatment of posterior pelvic ring fractures and to compare the results with established image guided procedures.

Methods

Tests were performed in pelvic specimens (Sawbones^®) with standardized sacral fractures (Type Denis I or II). A gel matrix simulated the operative approach and a cover was used to disable visual control. The electromagnetic setup was performed by using a custom made carbon reference plate and a prototype stainless steel K-wire with an integrated sensor coil. Four different test series were performed: Group OCT: Optical navigation using preoperative CT-scans; group O3D: Optical navigation using intraoperative 3-D-fluoroscopy; group Fluoro: Conventional 2-D-fluoroscopy; group EMT: Electromagnetic navigation combined with a preoperative Dyna-CT. Accuracy of screw placement was analyzed by standardized postoperative CT-scan for each specimen. Operation time and intraoperative radiation exposure for the surgeon was documented. All data was analyzed using SPSS (Version 20, 76 Chicago, IL, USA). Statistical significance was defined as p< 0.05.

Results

160 iliosacral screws were placed (40 per group). EMT resulted in a significantly higher incidence of optimal screw placement (EMT: 36/40) compared to the groups Fluoro (30/40; p< 0.05) and OCT (31/40; p< 0.05). Results between EMT and O3D were comparable (O3D: 37/40; n.s.). Also, the operation time was comparable between groups EMT and O3D (EMT 7.62 min vs. O3D 7.98 min; n.s.), while the surgical time was significantly shorter compared to the Fluoro group (10.69 min; p< 0.001) and the OCT group (13.3 min; p< 0.001).

Conclusion

Electromagnetic guided iliosacral screw placement is a feasible procedure. In our experimental setup, this method was associated with improved accuracy of screw placement and shorter operation time when compared with the conventional fluoroscopy guided technique and compared to the optical navigation using preoperative CT-scans. Further studies are necessary to rule out drawbacks of this technique regarding ferromagnetic objects.

Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma

Introduction

The usefulness of thoracic damage control (DC) for trauma requiring a thoracotomy is not established. The aim of this study was to clarify the usefulness of thoracic packing as DC surgery.

Methods

This was a retrospective case series study of 12 patients with thoracic trauma suffering uncontrollable intrathoracic haemorrhage and shock who underwent intrathoracic packing. Our thoracic DC technique consisted of ligation and packing over the bleeding point or filling gauze in the bleeding spaces as well as packing for the thoracotomy wound. The success rates of intrathoracic haemostasis, changes in the circulation and the volume of discharge from the thoracic tubes were evaluated.

Results

Packing was undertaken for the thoracic wall in five patients, for the lung in four patients, for the vertebrae in two patients and for the descending thoracic aorta in one patient. Haemostasis was achieved successfully in seven cases. Of these, the volume of discharge from the thoracic tube exceeded 400ml/hr within three hours after packing in three patients, decreased to less than 200ml/hr within seven hours in six patients and decreased to 100ml/hr within eight hours in six patients. Systolic pressure could be maintained over 70mmHg by seven hours after packing.

Conclusions

Intrathoracic packing is useful for some patients, particularly in the space around the vertebrae, at the lung apex, and between the diaphragm and the thoracic wall. After packing, it is advisable to wait for three hours to see whether vital signs can be maintained and then to wait further to see if the discharge from the thoracic tube decreases to less than 200ml/hr within five hours.

Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma

Introduction

The usefulness of thoracic damage control (DC) for trauma requiring a thoracotomy is not established. The aim of this study was to clarify the usefulness of thoracic packing as DC surgery.

Methods

This was a retrospective case series study of 12 patients with thoracic trauma suffering uncontrollable intrathoracic haemorrhage and shock who underwent intrathoracic packing. Our thoracic DC technique consisted of ligation and packing over the bleeding point or filling gauze in the bleeding spaces as well as packing for the thoracotomy wound. The success rates of intrathoracic haemostasis, changes in the circulation and the volume of discharge from the thoracic tubes were evaluated.

Results

Packing was undertaken for the thoracic wall in five patients, for the lung in four patients, for the vertebrae in two patients and for the descending thoracic aorta in one patient. Haemostasis was achieved successfully in seven cases. Of these, the volume of discharge from the thoracic tube exceeded 400ml/hr within three hours after packing in three patients, decreased to less than 200ml/hr within seven hours in six patients and decreased to 100ml/hr within eight hours in six patients. Systolic pressure could be maintained over 70mmHg by seven hours after packing.

Conclusions

Intrathoracic packing is useful for some patients, particularly in the space around the vertebrae, at the lung apex, and between the diaphragm and the thoracic wall. After packing, it is advisable to wait for three hours to see whether vital signs can be maintained and then to wait further to see if the discharge from the thoracic tube decreases to less than 200ml/hr within five hours.

Muscle regeneration is undisturbed by repeated polytraumatic injury

INTRODUCTION

Clinical observations suggest that repeated injury within a week after a traumatic event impairs the regeneration of tissues. Our aim was to investigate the effect of repeated trauma on the proliferation of satellite cells in skeletal muscle tissue.

MATERIALS AND METHODS

Cold lesion injury was performed in the soleus muscle and in the motor cortex of anesthetized male Wistar rats 0, 1, or 2 times with 7 day intervals between the interventions. Following the last operation, 5-bromo-2'-deoxyuridine was injected i.p. for 6 or 12 days to label dividing cells. Gut epithelium was used as positive control. Immunohistochemistry was performed 1 and 5 weeks after the last injury and the sections were analyzed with confocal microscopy.

RESULTS

In the case of repeated trauma, the percentage of proliferating cells remained the same compared to single hit animals after 1 week (28.0 ± 2.5% and 29.6 ± 3.0%) as well as after 5 weeks (13.9 ± 1.8% and 14.5 ± 2.2%).

CONCLUSION

The second hit phenomenon is probably due to systemic factors rather than to a diminished regenerating potential of injured soft tissues.

Polytrauma management - a single centre experience

The management of polytraumatised patients remains challenging in spite of advances and improvements in trauma care in recent decades. Trauma systems require enormous staff resources as well as technical equipment. Internal and external quality management processes are necessary to identify weak points and improve treatment quality. Continuous training of all professionals involved in trauma care is necessary to assure high quality, up-to-date therapy in patients with multiple injuries. Standard operating procedures such as prehospital trauma algorithms and clinical management protocols (ie, ATLS) can help to standardise and compare treatment of patients suffering from major trauma. In this overview, we describe the development and current state of our trauma department. Differences in our cohort of polytraumatised patients compared to other facilities and current strategies for initial treatment of these patients are also discussed.

[Polytrauma management in a period of change: time analysis of new strategies for emergency room treatment]

BACKGROUND

Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment.

METHODS

The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III).

RESULTS

The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p<0.001). The times for phase B were 70 min (IQR 56-85 min) for group I, 23 min (IQR 17-33 min) for group II and 17 min (IQR 13-21 min; p<0.001) for group III. For phase C the times were 82 min (IQR 66-110 min) for group I, 47 min (IQR 37-59 min) for group II and 42 min (IQR 34-52 min; p<0.05) for group III.

CONCLUSION

Quality management and the early implementation of whole-body MSCT can accelerate the treatment work flow. A rapid initial diagnosis represents an important component in the high quality of treatment of polytrauma patients.

[Fast track in casualty surgery]

The concept of "fast track" has not yet been established in orthopaedic trauma surgery. Principles such as those used in the "fast track" procedure for abdominal surgery have been employed in orthopaedic surgery for a long time. The best results can be achieved by early operative treatment, stable osteosynthesis and, if the soft tissues allow, an early initiation of mobilization under optimal pain management. Based on new techniques in osteosynthesis, in particular locked-screw techniques, "fast track" is also applicable for fragility fractures (osteoporosis), complex shattered bone and bone defect situations.

ATLS(R) and damage control in spine trauma

Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS(R) polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS(R) protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.

[The vacuum-assisted closure (V.A.C.) and instillation dressing: limb salvage after 3 degrees open fracture with massive bone and soft tissue defect and superinfection]

We report the case of a 17-year-old boy who was hit by a high velocity train. The polytraumatized patient suffered a 3 degrees open femur defect fracture with a substantial loss of the lateral femoral muscles and significant disruption of the soft tissue of the lower leg. The enormous wound areas on the thigh and the lower leg were infected by Pseudomonas aeruginosa, Enterobacter cloacae, and Stenotrophomonas maltophilia. The enormous tissue defects and the superinfection did not leave any hope for saving the limb from amputation. After rapid aggressive debridement and pulsatile lavage, we covered the wounds as a last resort with a new technique of vacuum-assisted closure (V.A.C) and instillation (V.A.C. Instill(R)) dressings. In sequences of 1 min we instilled Lavasept, kept it for 20 min on the wound surface, and exhausted the liquid. We repeated this for 6 consecutive days and then changed the dressing. In the follow-up examinations the number of germs was significantly reduced. During follow-up care we used the V.A.C. treatment without instillation and finally we transplanted skin onto the clean wound surface and were able to save the leg of this young patient. We discharged him with a good function of his lower leg. This technique of V.A.C. Instill seems to offer great possibilities in critically infected wound situations.

Polytrauma--pathophysiology and management principles

BACKGROUND

Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic "danger response", the surgical treatment has to be modified.

OBJECTIVES

This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management.

RESULTS

First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of "day-one-surgery" damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the "vulnerable phase" when the patient's defense is rather uncontrolled, only "second look" debridement to minimize a "second hit" is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, "reconstructive surgery" can be applied.

CONCLUSION

Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management.

[Developments in polytrauma management. Priority-based strategy]

The acute and early phase of polytrauma management is decisive for determining and implementing priority-based operative strategy. The patient's general condition and pattern of injury have to be considered. The highest priorities in the acute phase of operative treatment are control of mass bleeding and the release of body cavities (life-saving surgery). In the primary phase of surgical management (day 1 surgery), selected injuries are treated in the order of their urgency. Conceptual damage control surgery is distinguished from early total care. Damage control surgery should be performed only in patients meeting certain instability and risk criteria to avoid additionally burdening their condition.

The risk of local infective complications after damage control procedures for femoral shaft fracture

OBJECTIVES

To determine infection rates after damage control orthopaedics (DCO) and primary intramedullary nailing (1' IMN) in multiply injured patients with femoral shaft fracture.

DESIGN

Retrospective case analysis.

SETTING

Level I trauma center.

PATIENTS

All patients with New Injury Severity Score (NISS) >20 and femoral shaft fracture (AO 32-) treated in our unit between 1996 and 2002.

INTERVENTION

Damage control orthopaedics, defined as primary external fixation of the femoral shaft fracture and subsequent conversion to an intramedullary nail, or primary IMN.

MAIN OUTCOME MEASUREMENTS

Rates of infection classified as contamination (positive swabs with no clinical change), superficial, deep (requiring surgery), and removal of hardware (those requiring removal of femoral instrumentation or amputation).

RESULTS

A total of 173 patients with 192 fractures were included; 111 fractures were treated by DCO and 81 by primary IMN. Mean follow-up was 19.1 months [median, 16.7, range, 1 (patient died)-67 months]. DCO patients had a significantly higher NISS and more grade III open fractures (P<0.001). IMN procedures took a median of 150 minutes compared with 85 minutes for DCO (P<0.0001). Although wound contamination (including contaminated pin sites) was more common in the DCO group (P<0.05), the risk of infectious complications was equivalent (P=0.86). Contamination was significantly more likely when conversion to IMN occurred after more than 14 days (P<0.05); however, this did not lead to more clinically relevant infections. Logistic regression analysis showed that although a DCO approach was not associated with infection, delay before conversion in the DCO group might be [P=0.002 for contamination and removal of hardware, P=0.065 for serious infection (deep or worse), not significant for other infection outcomes]. Grade III open injury also was significantly associated with serious infection in all patients (P<0.05).

CONCLUSIONS

Infection rates after DCO for femoral fractures are comparable to those after primary IMN. We see no contraindication to the implementation of a damage control approach for severely injured patients with femoral shaft fracture where appropriate. Pin-site contamination was more common where the fixator was in place for more than 2 weeks. For patients treated by using a DCO approach, conversion to definitive fixation should be performed in a timely fashion.

Die Beckenringzerreißung beim polytraumatisierten Patienten

Pelvic injuries represent a thorny and stubborn therapeutic challenge. Because major forces are required to fracture the pelvis, pelvic ring disruption, more than any other fracture, can lead to life-threatening associated injuries such as massive bleeding, organ injuries, and open fractures including hemipelvectomy. The rapid diagnosis and effective treatment ("damage control") of those injuries play the key role in the patient's survival, inasmuch as the mortality of multiply injured patients with pelvic ring disruption remains high with 20-35%. Exsanguinating hemorrhage represents the most dreaded acute complication of pelvic injuries. Therefore, diagnostic and therapeutic procedures have to be primarily adapted to the hemodynamics of the patient, secondarily to injuries of the brain and the torso. The time point and the techniques of definitive pelvic ring stabilization may be different in the patient with multiple injuries compared to isolated pelvic ring injuries.