Quality and quantity of serious violent suicide attempts during the COVID-19 pandemic

BACKGROUND

While repeated shutdown and lockdown measures helped contain the spread of SARS-CoV-2 during the COVID-19 pandemic, social distancing and self-isolation negatively impacted global mental health in 2020 and 2021. Although suicide rates did reportedly not increase during the first months of the pandemic, long-term data, and data on the quality of serious violent suicide attempts (SVSAs) are not available to date.

MATERIALS AND METHODS

Orthopaedic trauma patient visits to the emergency department (ED), ED trauma team activations, and SVSAs were retrospectively evaluated from January 2019 until May 2021 in four Level-I Trauma Centers in Berlin, Germany. SVSAs were assessed for suicide method, injury pattern and severity, type of treatment, and length of hospital stay.

RESULTS

Significantly fewer orthopaedic trauma patients presented to EDs during the pandemic (n = 70,271) compared to the control (n = 84,864) period (p = 0.0017). ED trauma team activation numbers remained unchanged. SVSAs (corrected for seasonality) also remained unchanged during control (n = 138) and pandemic (n = 129) periods, and no differences were observed for suicide methods, injury patterns, or length of hospital stay.

CONCLUSION

Our data emphasize that a previously reported rise in psychological stress during the COVID-19 pandemic does not coincide with increased SVSA rates or changes in quality of SVSAs.

Radiologic diagnostic procedures in severely injured patients - is only whole-body multislice computed tomography the answer?

BACKGROUND

Whole-body multislice computed tomography (WB-MSCT) has become an important diagnostic tool in the early treatment phase of severely injured patients. The optimal moment of WB-MSCT's use during this treatment phase remains unclear. Many trauma centers use WB-MSCT in addition to conventional radiographs, while some trauma centers use WB-MSCT as the only radiological tool. The aim of this study was to determine the differences between these two protocols and to answer the question of whether conventional radiographs can still be used in the safe treatment of polytrauma patients.

METHODS

Patients from the TraumaRegister DGU® with an injury severity score (ISS) of ≥16 were included. Group I received conventional radiographs and focused assessment with sonography in trauma (FAST) prior to a WB-MSCT, and group II received an initial WB-MSCT and FAST. Both groups were compared concerning treatment time and outcome.

RESULTS

A total of 3,995 patients in group I were compared to 4,025 patients in group II. There were no differences in ISS (29.97 vs. 29.94), gender (male: 73.5% vs. 72.8%), age (45.47 vs. 45.12 years), or calculated mortality (21.41% vs. 21.44%). Time needed in the resuscitation room was slightly longer in group I (72 vs. 64 min); the durations until admittance to the ICU and arrival to the OR were not significantly different between the groups. There was no difference in mortality (18.2% vs. 18.4%) or the standardized mortality ratio (SMR) (0.85 vs. 0.86).

CONCLUSIONS

WB-MSCT plays an inherent role in the treatment of multiple-injured patients. However, the use of WB-MSCT as the only diagnostic method in the resuscitation room is not needed. Conventional radiographs and FAST followed by WB-MSCT can be performed in the early resuscitation phase without impairing patient outcomes. This approach enables the emergency room team to perform life-saving procedures - chest-tube insertion, laparotomy, cardiopulmonary resuscitation -immediately and simultaneous. Nevertheless, randomized multi-center trials are needed to determine the comparability and effectiveness of these algorithms.

[Atlas fracture due to aneurysmal bone cyst after minor trauma]

Aneurysmal bone cysts predominantly occur in young adults and the long bones, the lumbar spine and the pelvis are mainly affected. This article presents the case of a 22-year-old woman with the very rare localization of an aneurysmal bone cyst of the atlas and an atlas fracture after a minor trauma. The initial radiological diagnosis was a suspicted aneurysmal bone cyst which was confirmed histologically. Due to the unstable fracture it was decided to carry out surgical treatment with occipitocervical stabilization in combination with a transoral bone graft. After a period of 11 months the fracture had completely healed and the implants were removed without any complications.

Fracture of the shoulder girdle in multiply injured patients - an imperative for a high level of suspicion for associated neurovascular injuries

Background

The combination of a bony injury to the shoulder girdle and damage to the brachial plexus and the subclavian vessels is a rare finding. The cases of this combined injury pattern described in the literature are most notably reported in multiply-injured patients after high velocity trauma.

Findings

Three cases were admitted to our hospital after motorcycle accidents resulting in a combination of severe bony injuries to the shoulder girdle, to the subclavian artery and a lesion to the brachial plexus. Based on these three clinical cases the patterns of injury, as well as primary and secondary treatment approaches are presented.

Conclusion

The early detection of these injuries can be difficult in given acute, life threatening injuries addressed first in these multiply injured patients. A high level of suspicion, in conjunction with standardized ATLS based institutional protocols for secondary and tertiary survey, should increase the likelihood of a timely detection and early management of these rare but potentially devastating injuries.

Embalmed and fresh frozen human bones in orthopedic cadaveric studies: which bone is authentic and feasible?

BACKGROUND AND PURPOSE

The most frequently used bones for mechanical testing of orthopedic and trauma devices are fresh frozen cadaveric bones, embalmed cadaveric bones, and artificial composite bones. Even today, the comparability of these different bone types has not been established.

METHODS

We tested fresh frozen and embalmed cadaveric femora that were similar concerning age, sex, bone mineral density, and stiffness. Artificial composite femora were used as a reference group. Testing parameters were pullout forces of cortex and cancellous screws, maximum load until failure, and type of fracture generated.

RESULTS

Stiffness and type of fracture generated (Pauwels III) were similar for all 3 bone types (fresh frozen: 969 N/mm, 95% confidence interval (CI): 897-1,039; embalmed: 999 N/mm, CI: 875-1,121; composite: 946 N/mm, CI: 852-1,040). Furthermore, no significant differences were found between fresh frozen and embalmed femora concerning pullout forces of cancellous screws (fresh frozen: 654 N, CI: 471-836; embalmed: 595 N, CI: 365-823) and cortex screws (fresh frozen: 1,152 N, CI: 894-1,408; embalmed: 1,461 N, CI: 880-2,042), and axial load until failure (fresh frozen: 3,427 N, CI: 2,564-4290; embalmed: 3,603 N, CI: 2,898-4,306). The reference group showed statistically significantly different results for pullout forces of cancellous screws (2,344 N, CI: 2,068-2,620) and cortex screws (5,536 N, CI: 5,203-5,867) and for the axial load until failure (> 7,952 N).

INTERPRETATION

Embalmed femur bones and fresh frozen bones had similar characteristics by mechanical testing. Thus, we suggest that embalmed human cadaveric bone is a good and safe option for mechanical testing of orthopedic and trauma devices.

Multiple blunt trauma after suicidal attempt: an analysis of 4,754 multiple severely injured patients

PURPOSE

The suicidal attempt is a significant cause for multiple severe injuries in Germany. The aim of the present study was to obtain information regarding injury patterns, clinical treatment, and outcome.

METHODS

We analyzed the data of 4,754 patients of the Trauma Registry of the German Trauma Society (1993-2007) with an Injury Severity Score (ISS) ≥9 after a suicidal jump from a height (SUICIDE) and after an accidental fall from a height (ACCIDENT).

RESULTS

Comparing the data of 3,682 patients with accidental fall versus those with intentional fall/jump (n = 1,072), we found that male patients were predominant in the ACCIDENT group (84.9 vs. 52.2%). The SUICIDE group had more severe injuries (ISS: 31.8 vs. 26.4). The ACCIDENT group suffered more severe head injuries (51.1 vs. 36.6%). Mortality (21.4 vs. 14.2%), length of stay in hospital (29.5 vs. 26.5 days), and costs (€34,833 vs. €24,701) were higher in the SUICIDE group.

CONCLUSIONS

Falls from a height are a common cause of injury among severely injured patients. The resulting trauma composes a particular form of blunt trauma with severe and multiple injuries, which depends on the fact of whether the free fall from a height was caused by an accident or as a result of a suicidal attempt. Taking the injury severity into consideration, there is no difference in the prognosis of the patients.

Monoaxial versus polyaxial locking systems: a biomechanical analysis of different locking systems for the fixation of proximal humeral fractures

OBJECTIVE

The development of locking plate systems has led to polyaxial screws and new plate designs. This study compares monoaxial head locking screws (PHILOS© by Synthes) and a new generation of polyaxial locking screws (NCB-LE© by Zimmer) with respect to biomechanical stability.

METHODS

On nine pairs of randomised formalin fixed humerus specimens, standardised osteotomies and osteosyntheses with nine monoaxial (group A) und nine polyaxial (group B) plate/screw systems were performed. A material testing machine by Instron (M-10 14961-DE) was used for cyclic stress tests and crash tests until defined breakup criteria as endpoints were reached.

RESULTS

After axial cyclic stress 200 times at 90 N, plastic deformation was 1.02 mm in group A and 1.25 mm in group B. After the next cycle using 180 N the additional deformation averaged 0.23 mm in group A and 0.39 mm in group B. The deformation using 450 N was 0.72 mm in group A compared to 0.92 mm in group B. The final full power test resulted in a deformation average of 0.49 mm in group A and 0.63 mm in group B after 2,000 cycles using 450 N. When reaching the breakup criteria the plastic deformation of the NCB plate was 9.04 mm on average. The PHILOS plate was similarly deformed by 9.00 mm. As a result of the crash test, in group A the screws pulled out of the humeral head four times whereas the shaft broke one time and another time the implant was ripped out. The gap was closed four times. In group B, there were three cases of screw cut-through, four shaft fractures/screw avulsions from the shaft and two cases of gap closure.

CONCLUSION

The two systems resist the cyclic duration tests and the increasing force tests in a similar manner. The considerable clinical benefits of the polyaxial system are enhanced by equal biomechanical performance.

The benefit of wire cerclage stabilisation of the medial hinge in intramedullary nailing for the treatment of subtrochanteric femoral fractures: a biomechanical study

PURPOSE

Reduction and intramedullary fixation of subtrochanteric fractures is often challenging. Osteosynthesis frequently fails and a higher rate of non-unions is found. The aim of this study was to evaluate the benefit of an additional cerclage to anatomically reduce and support the medial hinge. The application is based on the experience of the surgeon; as yet no biomechanical data are available.

METHODS

Ten pairs of human cadaveric femora were used to determine the biomechanical and clinical advantage of an additional cerclage. All femora were tested in a materials testing system after osteotomy, osteosynthesis with the Gamma III nail and randomisation into two groups with or without additional cerclage.

RESULTS

After cyclic loading the compressive load to reach plastic deformation of 5 mm was 2,160 N on average in the group without cerclage vs 2,330 N on average in the group with cerclage. This biomechanical advantage showed no statistical significance (p = 0.2). Radiological examination when the abort criterion was reached revealed that use of the additional wire cerclage could significantly decrease the failure of osteosynthesis (100 vs 10%) after intramedullary nailing of subtrochanteric fractures (p < 0.05).

CONCLUSION

In view of the more invasive operative approach with additional soft tissue injuries, application of an additional cerclage should still be considered carefully. Nevertheless, a mini-open approach to difficult fractures could be helpful in reducing the fracture with a clamp and is sometimes essential. The damage to the soft tissue must be weighed against the benefits of the procedure. An additional cerclage in oblique subtrochanteric fractures is a good option to ensure the reposition and cortical medial support if appropriate and to decrease osteosynthesis failure and rates of non-unions.