High-resolution MR imaging of the carpal tunnel and the wrist: Application of a 5-cm surface coil

Purpose: To make a comparative analysis of transversal tomograms obtained by high-resolution MR imaging with frozen cross-sections of an anatomical forearm specimen. Twenty-two healthy volunteers were also examined using the same coil system to test for a range of possible clinical applications and for the depiction of morphological and morphometrical values of normal anatomy in vivo.

Material and Methods: MR images of the carpal tunnel of 22 healthy volunteers were obtained with a 1.5-T whole-body system with a 5-cm surface coil. Measurements were recorded with a field-of-view between 50 × 50 mm2 and 60 × 60 mm2 in a 256 × 256 pixel matrix for the T1 sequence. A slice thickness of 2 mm was used. The images were acquired using a T1-weighted SE sequence (TR/TE 500/38 ms) and a T2-weighted SE sequence (TR/TE 2000/70 ms). Additionally, a formalin-fixed anatomical forearm specimen was imaged for anatomic correlation. The imaged transversal cross-section levels in the specimen were subsequently freeze-sectioned. The anatomical structures of the MR findings were identified and compared with the macroscopical sections of the specimen.

Results: Based on the good depiction of details at this coil system with a pixel size in T1 of 0.195 × 0.195 mm, high-resolution MR imaging enabled identification of the interior structures of the carpal tunnel, as well as delineation of connective tissue. The clinical value of high-resolution MR includes the diagnosis of carpal tunnel syndrome and inflammatory disorders of the wrist.

Conclusion: Our results support the feasibility of high-resolution MR imaging of the carpal tunnel and the wrist using small surface coils.

[Patients with minor injuries in a Berlin inner-city emergency room : substance misuse, residential area, and sociodemographics]

BACKGROUND

The aim of this post hoc study was to evaluate the association of substance use disorders (SUD) and residential neighborhood affiliation in a group of patients with minor injuries presenting to an inner-city emergency room (ER) in Berlin.

METHODS

A total of 2,716 patients with minor injuries presenting to the ER were evaluated concerning alcohol use disorders (AUDIT, cut-off: males 8 points, females 5 points), smoking status, and illicit drug use in the past year. Information about residential area (zip code) and sociodemographics (paper-pencil questionnaire) were also obtained.

RESULTS

With respect to residential area, significant differences concerning SUD were identified: from the perspective of the inner-city ER, living close to the ER was associated with substance misuse. Here, alcohol use disorders (AUD), smokers, and illicit drug use were found more frequently compared to patients living in the periphery of the city. In addition, patients living close to the ER were more often unemployed, had a lower income, or were students.

CONCLUSION

There are differences in SUD with respect to residential area. However, in order to be able to draw reliable conclusions, an approach collecting representative data at the city district level as well as using a multicenter approach at the city ER level is necessary.

[Development of trauma surgery in the next 20 years]

During the last century trauma surgery became established as an independent and academically accepted surgical specialty and significant progress was achieved. A high international reputation was also gained. Nowadays health care in Germany is under increased economical pressure mostly caused by a loss of resources as a sign of decreased public appreciation of excellent trauma care. Thus it becomes more and more necessary to find new structures for delivery of trauma care as well as for development of staff, especially in times of feminization in medicine. It is beyond any doubt that the demand for musculoskeletal surgery will rise during the next 20 years especially for the elder generation but it is uncertain how excellent trauma care should be delivered without massive spending and financing of health care including research and innovative forms of trauma treatment.

[Physicians in traumatology. Critically endangered? Results of an inquiry]

INTRODUCTION

The aim of this investigation was to describe the current situation and atmosphere among residents and consultants in traumatology, using the results of a questionnaire. Wishes and needs concerning training programs in traumatology were addressed.

METHODS

A questionnaire consisting of 25 items was distributed among members of the German Society of Traumatology (DGU) to document basic data concerning the state of residency and physicians' current workload. The participants were also asked about their personal interests and aims within traumatology. Finally, questions concerning educational programs, compensation, and work-life balance were addressed. The results were analysed descriptively.

RESULTS

The final analysis included 549 questionnaires. The mean age of the participants was 36 years (SD +/-7.5). Sixty percent (329) were residents, and 16% (88) served as consultants. The mean workload per week was 61 h (SD +/-10.8 h), and participants were on call seven times (SD +/-5.6) a month. The work-life balance was rated a mean of only 5 ("mediocre"). The majority of participants rejected working longer in order to reduce the duration of their educational program. On the other hand, most of the participants would also reject a reduction in working time accompanied by a reduced salary. Nevertheless, 78% (428) of the participants would, in retrospect, choose the same profession, and 85% (466) would even choose the same specialty.

DISCUSSION

The study reports on the atmosphere among residents and consultants in traumatology. Despite European regulations, the individual workload is exceptionally high. It is a clear task of hospital administrators to increase the attractiveness of hospital jobs in order to ensure qualified personnel in the future.

[Has anything changed in the quality of continuing education in orthopaedic/trauma surgery? Evaluation 1 year after implementation of a new code of practice for resident training in orthopaedic/trauma surgery in Bavaria]

OBJECTIVE

It was the aim of this study to evaluate any changes in the quality of orthopaedic/trauma training 1 year after implementation of the new code of practice for resident training in Bavarian clinics.

METHODS

A questionnaire was prepared by the Educational Committee and the Junges Forum of the German Trauma Society and sent to all 120 instructors (and their medical staff) for resident training in Bavaria for general surgery, trauma surgery as well as orthopaedic/trauma surgery on July 26 2005.

RESULTS

While 56% of the chairmen claimed to perform a structured, curricular training, only 18% of the residents could verify this. In a similar manner, the majority of chairmen were satisfied with the new code of practice for resident training, while the majority of residents and attendings were not.

CONCLUSION

One year after implementation of a new code of practice for resident training in Bavaria, surgical training structures are not well established. There is a large discrepancy in the evaluation of training quality between chairmen and residents. It is therefore imperative to develop recommendations for structuring orthopaedic/trauma training.

[Proposals for adapting a DRG system in the fields of orthopedics and trauma surgery for 2004]

The introduction of the DRG system in Germany-optional since 1 January 2003 and mandatory for all hospitals as of 1 January 2004-has resulted in great uncertainty, particularly on the part of hospitals, since apprehension prevails that the diagnostic and therapeutic measures practiced in Germany will not be appropriately represented and remunerated by a DRG system. The G-DRG version 1.0 prepared within the framework of substitutive execution is largely identical to the Australian AR-DRG version 4.1. Adjustments that do justice to the realities of German treatment modalities were at most insignificant. It is therefore essential that stock be taken for each medical specialty to determine to what extent treatment procedures commonly followed in Germany are adequately reflected in this G-DRG system or whether adjustments are necessary to make allowances for German realities. To be able to provide qualified statements on the problems involved, scientific analysis of possible problems is necessary utilizing German data. Thus, we undertook an evaluation of how the special fields of orthopedics and accident surgery are represented in the G-DRG system. The resultant data form the basis for evidence of presumable deficits in the representation of orthopedic and accident surgery cases in the G-DRG system. The German Association for Trauma Surgery and the German Association for Orthopedics and Orthopedic Surgery have undertaken a DRG evaluation project together with the Organization of Directors for Accident Surgery (chairperson: Professor Dr. Mischkowsky, Kempten), the Organization of Directors for Orthopedics (chairperson: Professor Dr. Puhl, Ulm), the DRG Working Group of the German Association for Accident Surgery, and the Joint Commission of the Professional Association of German Surgeons and the German Association for Surgery in cooperation with the DRG Research Group of the University Clinic Muenster, the German Hospital Association, and the German Medical Association with the goal of examining the medical and economic homogeneity of the case groups. A total of 12,645 orthopedic and trauma surgery cases were collected from 23 clinics-11 university hospitals and 12 non-university hospitals-and assessed. On the basis of this database and when too few cases were evaluable also based on clinical considerations, 14 adjustment proposals were formulated and submitted on schedule on 31 March 2003 to the Institute for Hospital Remuneration. The results of the DRG evaluation project illustrated the problems involved in representing the exceedingly heterogeneous and complex activities of orthopedic and trauma surgery departments in a flat rate financing system that is not attuned to the realties of German treatment procedures. Version 1.0 of the G-DRG system is not sufficiently differentiated to represent the multifaceted diagnostic and therapeutic services provided by trauma surgery and orthopedic departments in Germany.

[Suggestions for implementation of DRG in the fields of Orthopaedics and Trauma Surgery for 2004]

OBJECTIVE

The Implementation of a DRG-Variant in Germany - voluntarily since January 1 st, 2003 and obligatory from January 1 st, 2004 - has been leading to uncertainty, particularly in the hospitals, due to fears that currently practised German diagnostic and therapeutic measures will not be financed properly by a DRG-Variant. The G-DRG-Version 1.0 that was drawn up in connection with an executive order law is to a large degree identical to the Australian AR-DRG-Version 4.1. Adjustments to German requirements were made only marginally. Therefore it is necessary for every medical field to investigate by stock-taking to what extent currently practised German diagnostic and therapeutic measures are considered in the G-DRG-Version 1.0 and whether and where modifications and adaptations need to be made. In order to make qualified statements scientific evaluations of possible problems have to be made based German data. Therefore an evaluation was made of the mapping of the medical fields of orthopaedics and trauma surgery. The German Society of Trauma Surgery (DGU), the German Society of Orthopaedy and Orthopaedic Surgery (DGOOC) in cooperation with the DRG-Research-Group of the University Hospital Muenster, the German Hospital Federation (DKG) and the German Medical Association carried out a DRG evaluation project in order to investigate the medical and economical homogeneity of the case groups.

METHOD

12,645 orthopaedic and trauma surgery cases from 23 hospitals - 11 university hospitals and 12 non-university hospitals - were collected within an period of three months and were scientifically evaluated with regard to their performance homogeneity and length of stay homogeneity.

RESULTS

The data formed the basis for the proof of suspected deficiencies of mapping of orthopaedic and trauma surgery cases within the G-DRG-Variant. Based on the data and additionally on conclusions of medical experts when the number of cases were small, 14 suggestions for adaptation were proposed and submitted by the deadline of March 31 st, 2003 to the InEK.

CONCLUSION

The results of the DRG-Evaluation Project demonstrate the problems of mapping the very heterogenous and complex medical performances of orthopaedy and trauma surgery to a flat rate financing system that is not adapted properly to German conditions. The G-DRG-Variant Version 1.0 does not offer the sufficient possibilities of differentiation that are needed to map the various orthopaedical and trauma surgical measures in Germany.

MRI in decompression illness

We report a case of decompression illness in which the patient developed paraparesis during scuba diving after rapid ascent. MRI of the spine revealed a focal intramedullary lesion consistent with the symptoms. The pathophysiological and radiological aspects of spinal decompression illness are discussed.

[Cast immobilization versus vacuum stabilizing system. Early functional results after osteosynthesis of ankle joint fractures]

In a prospective randomized trial the early functional results after immobilisation in a cast were compared to those after using a vacuum stabilizing system. The vacuum stabilizing system Vacoped offers equivalent stability compared to a plaster cast. In contrast to the cast the Vacoped can be removed for body care and physical therapy. Additionally the range of motion for dorsal flexion/extention in the upper ankle joint can be adjusted. From 9/1996 to 7/1997 there were 40 patients included in the study with an operated ankle fracture as monotrauma. Six weeks postoperatively the patients with cast treatment showed significantly higher functional deficits for the upper ankle joint (20%), the lower ankle joint (40%) and muscle atrophy (2.1 cm side difference) than the group with the vacuum stabilizing system (upper ankle joint 15%, lower ankle joint 25%, 1.4 cm muscle atrophy). Five patients out of the group with the vacuum system were already at work three weeks postoperatively. Three months postoperatively the functional results for both groups were approximating. The vacuum stabilizing system Vacoped offers better early functional results than conventional cast treatment after osteosynthesis of ankle fractures. Because of the increased patient comfort and the early ability for physical therapy the vacuum stabilizing system is preferable to cast treatment.

High-resolution MR imaging of the carpal tunnel and the wrist. Application of a 5-cm surface coil

PURPOSE

To make a comparative analysis of transversal tomograms obtained by high-resolution MR imaging with frozen cross-sections of an anatomical forearm specimen. Twenty-two healthy volunteers were also examined using the same coil system to test for a range of possible clinical applications and for the depiction of morphological and morphometrical values of normal anatomy in vivo.

MATERIAL AND METHODS

MR images of the carpal tunnel of 22 healthy volunteers were obtained with a 1.5-T whole-body system with a 5-cm surface coil. Measurements were recorded with a field-of-view between 50x50 mm2 and 60x60 mm2 in a 256x256 pixel matrix for the T1 sequence. A slice thickness of 2 mm was used. The images were acquired using a T1-weighted SE sequence (TR/TE 500/38 ms) and a T2-weighted SE sequence (TR/TE 2000/70 ms). Additionally, a formalin-fixed anatomical forearm specimen was imaged for anatomic correlation. The imaged transversal cross-section levels in the specimen were subsequently freeze-sectioned. The anatomical structures of the MR findings were identified and compared with the macroscopical sections of the specimen.

RESULTS

Based on the good depiction of details at this coil system with a pixel size in T1 of 0.195x0.195 mm, high-resolution MR imaging enabled identification of the interior structures of the carpal tunnel, as well as delineation of connective tissue. The clinical value of high-resolution MR includes the diagnosis of carpal tunnel syndrome and inflammatory disorders of the wrist.

CONCLUSION

Our results support the feasibility of high-resolution MR imaging of the carpal tunnel and the wrist using small surface coils.

[Outcome of primary surgical management of liver trauma]

We evaluated retrospectively 43 patients with liver trauma undergoing laparotomy between 1/89 and 12/95. Blunt trauma (27 patients) and penetrating trauma (16 patients) to the liver had a mortality of 37% and 0%, respectively. The overall mortality was 23.3% and was significantly related to concomitant injuries (p = 0.002), whereas age, severity of the liver trauma as well as the surgical treatment had no significant influence on the outcome.

[Trauma center 2000. How many and which trauma centers does Europe need around the year 2000?]

The treatment of severely injured patients is a challenge for preclinical and clinical treatment concepts, causing financial aspects of increasing importance for the German health care system. A total of 32,500 polytraumatized patients (PTS III and IV) are managed in trauma center levels I-IV in Germany. Trauma center levels I or II are by definition capable of supporting the full range of treatment for the severely injured. With the baseline calculation of 64,000 DM per patient and 104 polytrauma treated per year in the Berlin Virchow Clinic, 6.66 million DM primary costs must be spent for treatment. The total annual costs of this center are nearly 24 million DM for emergency cases and 7 million DM fixed costs per year, for a trauma center level I. In Europe the distribution of trauma center levels I or II is sufficient and can be specified with 1 center per 1 million inhabitants. Nevertheless, the european air medical service could support more intensive use of these central trauma institutions. This was shown by comparing the number of polytrauma patients and the number of trauma centers. Less then half of these patients are treated in levels I or II trauma centers. The financial pressure on the health system and the rising quality must lead to better utilization of trauma centers. To meet this goal a annual treatment rate of 300-400 polytrauma patients should be aimed at. The claim of the American College of Surgeons that a trauma surgeon should treat 50 severely injured patients per year would then be possible.

[Arterial and venous alcohol elimination in 10 polytrauma patients]

Alcohol elimination was examined in 10 patients involved in accidents while intoxicated. The influence of trauma, particularly polytrauma resulting in haemorrhage shock and its therapeutic treatment were analysed. The blood alcohol concentrations were determined according to the usual forensic criteria (2 alcohol dehydrogenase and 2 gas chromatography measurements). Observation periods ranged from 3 hours 45 minutes to 12 hours 35 minutes, with blood being drawn at intervals ranging from 45 minutes to 185 minutes (on average 70 minutes). Results of two patients (delta 60 = 0.22/1000/h and 0.28/1000/h) who only had 3 venous drawn and results of a deceased patient from whom only four arterial samples could be obtained (beta 60 = 0.21/1000/h) were disregarded when working out the average values. The blood alcohol curve plateaued in the case of the deceased patient as well as in the case of a patient whose hepatic circulation was curtailed for approximately half an hour during surgery. The blood alcohol curves for the remaining patients for uniformly linear with beta 60 values between 0.17/1000/h and 0.21/1000/h (mean = 0.18/1000/h +/- 0.01) in arterial samples and 0.18/1000/h and 0.21/1000/h (mean = 0.18/1000/h +/- 0.01) in venous samples. Given our results and the existing literature, we feel that retrograde calculations of the BAC can be justified in patients with polytrauma, despite the small number of patients included in the study. Naturally, the usual forensic criteria have to be taken into account, as well as individual situations. Examples that can be mentioned here are liver failure or curtailment of hepatic circulation during surgery.

[The MRT of scaphoid pseudarthrosis with Gd-DTPA. Its staging and clinical correlation]

During a period of two years, 134 patients with pseudo-arthrosis of the scaphoid were examined by conventional radiography and by MRI in the course of a prospective study. The aim of the study was to define radiological staging using contrast enhanced MRI in order to improve the prognostic criteria. All MRI examinations were carried out with a 1.5 tesla scanner (SP63) using a surface coil and T1 weighted spin echo sequences in sagittal and frontal projection and frontal FLASH T2 sequences and axial spin echo T2 sequences. The T1 weighted SE sequences in frontal projection were carried out before and after iv contrast (0.1 mmol Gd-DTPA/kg KG). All sequences were compared with conventional radiographs and the operative findings. Eight patients in stage 0 showed high signal intensity of both fragments in T1 weighted SE sequences and at surgery there was good vascularisation. In 22 cases there was reduced signal intensity in at least one fragment (stage I). 45 patients with scaphoid pseudo-arthrosis showed complete signal loss but marked contrast uptake with still vital nuclei at surgery (stage II). In 22 patients, there was no increase in signal intensity after contrast and complete loss of vitality of the fragments at surgery. Staging was not possible in 37 patients because of previous operative intervention. The use of contrast enhanced MRI provides additional information compared with conventional radiography or plain MRI.

The incidence of osteitis in open fractures: an analysis of 948 open fractures (a review of the Hannover experience)

Even though treatment protocols of open fractures have been improved in the past two decades, osteitis is still a major complication in these injuries. To investigate the primary factors responsible for posttraumatic osteitis, 19 cases of osteitis out of 297 open fractures (retrospective series from 1981 to 1983) and nine cases of osteitis out of 651 open fractures (prospective series from 1984 to 1989) were analyzed. The Hannover fracture scale was used for quantitative evaluation of the injury. A high prognostic index for bone infections was found for the amount of bone loss, the fracture type, the type of bacteriologic contamination, deep soft-tissue defects, compartment syndromes, vascular injuries, and soft-tissue infections.

[Indications and incidence of spongiosa transplantation in open fractures: analysis of 470 open fractures]

From a prospective series of 651 open fractures, treated at the institution of the authors in the years 1984-1989, 124 cancellous bone grafts in 470 open long bone fractures--651 open fractures excluding amputation after Type III open fractures, excluding traumatic amputations and open fractures of the ankle joint and foot--were analyzed using approximately 155 variables per individual fracture to deduct the influencing factors for indication and frequency of bone grafts. As a result of this analysis it could be shown that bone grafting depends significantly on variables describing the bone injury as well as the type of fixation used. The frequency of bone grafts in this series was much higher than stated in the literature. The time of surgery for bone grafting depends on the type of fixation used, the concomitant soft tissue injury and the amount of primary bone loss. In contrast to the literature the analysis revealed that for good indications the use of allogeneous bone grafts in open fractures is possible.

[MEDKOM--new perspectives for accident surgery?]

MEDKOM is a new communication concept in trauma surgery, originally inaugurated as a multi-user online video communication system and now proving its benefits in medicine. The technological conditions needed and its daily usefulness are described, and examples from our clinic are given. The importance of modern technology and the possibilities it opens up, especially for medical training programmes and quality protection in trauma care, are pointed out.

[Compartment syndrome of the hand. Diagnosis, therapy, results, late sequelae]

Ischemic necrosis of the intrinsic muscles of the hand has been known about for decades, as has the resulting local ischemic contracture in the hand. As isolated compartment syndrome of the hand is a rare condition, this term has not yet become established. The etiopathology, diagnosis, therapy and results of treatment in 13 patients treated for compartment syndrome of the hand are presented. At the time of our follow-up study, 3 patients had died and 2 did not attend. In 1 patient the upper limb had meanwhile had to be amputated. Thus, late results were examined in 7 patients, but 2 of these had not recovered any hand function, as they had suffered a brachial plexus lesion on the affected side. In 5 patients the range of motion was unimpaired, but a slight loss of strength persisted in 4 patients and 1 patient complained of moderate paresthesia at the palmar scar. Despite the small number of patients, we feel that these results emphasize the need for early and adequate decompression in the case of compartment syndrome of the hand.

[Compartment syndrome of the forearm]

This paper reviews the etiology, clinical picture, treatment and follow-up in 25 patients treated for a forearm compartment syndrome at the medical school in Hanover. A volar-ulnar and, when indicated, a straight dorsal incision gave adequate decompression in all operatively treated patients. Follow-up examination revealed no damage or deficit that could be related to fasciotomy. Therefore, these results support the concept that operative treatment is widely indicated for forearm compartment syndrome.

[Surgical possibilities in managing large giant cell tumors of the wrist joint and carpal bones]

Two cases with extensive giant cell tumors of the wrist and their one-step functional preserving operative treatment are presented. Special regard is put on the reconstruction of hand function with and without the use of microsurgical techniques.

Diagnostic and therapeutic possibilities for fibreoptic bronchoscopy in inhalation injury

Inhalation injury is a relatively common complication of burn injury requiring early attention with respect to diagnosis and therapy, and frequent assessments of the tracheobronchial status. Clinical, radiological and laboratory findings often cannot fulfil these needs. Therefore the advantages of flexible fibreoptic bronchoscopy (FFB) in diagnosis and therapy of respiratory tract injury are shown by these case reports.