Ljubljana Marshes Hot Air Balloon Crash: A Multiple Casualty Incident

On August 23rd, 2012 at 7:54 am a hot air balloon crashed in Ljubljana Marshes, leaving 32 injured on site. This case report analyses the biggest multiple casualty incident attended by University Medical Centre Ljubljana in recent history. Analysis of all segments regarding the incident was conducted: mobilisation, arrivals, triage, work-up, identification, public relations and outcome. Issues such as mobilisation, diagnostics, communication, documentation and intensive care unit space are discussed. Twenty-one patients arrived over 63 minutes, 8 of those were immediate resuscitation cases and 10 of those suffered burns. The average Injury Severity Score was 15.7 (ranging 3 to 50), 28.1 for admitted patients. 90% of patients had x-ray, 23% CT and 38% ultrasound diagnostic procedures. 33% of patients required urgent surgery and 60% of admitted cases required intensive care units. A relatives and media territory was established. CT location, loss of communication, inadequate documentation and intensive care bed space were most problematic. At 7-year follow up, we had a roughly 5% hospital fatality rate, 74% of patients gained full recovery and 21% good recovery. Even though the event occurred on a weekday during regular hours, it still exposed many weaknesses. A new radio frequency system for intra-hospital communication has been implemented, the multiple casualty incident protocol has been revised, and regular drills are now performed. Our emergency department is currently undergoing renovation to include CT diagnostics on the same floor. Plans have been made to ease documentation with dictation modules, whereas bed space remains unchanged.

Causes for Delay to Surgery in Hip Fractures and How It Impacts on Mortality: a Single Level 1 Trauma Center Experience

PURPOSE OF THE STUDY The increasing number of hip fractures puts enormous demand on our level 1 trauma centre. Because we have to synchronize hip fracture treatment with all other injuries delays to surgery can occur. In this study, we analysed the reasons for delay to surgery and how it impacts on mortality of hip fracture patients in our institution. MATERIAL AND METHODS We retrospectively studied 641 patients operated for hip fractures in one year period. Investigated characteristics were: age, gender, American Society of Anaesthesiologists score (ASA), time of hospital admission, time of surgery, type of surgery, anticoagulant therapy (ACT) and non-routine pre-operative tests (NRPT). Trochanteric (TF) and femoral neck fractures (FNF) were analysed separately. The surgery in first 48 hours was considered early. The time of death was obtained from the federal database. Univariate and multivariable analysis were performed. P-values <0.05 were considered statistically significant. RESULTS All tested characteristics were significantly different in both time groups. Delay to surgery was significantly influenced by the type of surgery - arthroplasty, odds ratio (OR) 17.2, ACT (OR 6.9) and NRPT (OR 4.0) in FNF group of patients and by ACT (OR 31.1) and ASA (OR 2.2) in TF. 30-day mortality rate was 5.1% and 1-year mortality was 18.4%. ASA (OR 1.9), preinjury residence (OR 1.4) and age (OR 1.1) had statistical influence on survival, but not delay to surgery. CONCLUSIONS The majority of delays are due to unavailability of operative capacities, after patient optimization. We see solution in dedicated operation rooms and teams for hip fracture treatment. Mortality is influenced by the patients' characteristics, but not by delay to surgery. A multidisciplinary approach and skilled surgical teams are, besides early operation, the most important assurance of a good outcome. Key words: trochanteric fracture, femoral neck fracture, timing, mortality.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Microstructural analysis of implant-bone interface of hydroxyapatite-coated and uncoated Schanz screws

The aim of the study was to compare the pin-bone interface microstructural characteristics of hydroxyapatite-coated (HAC) and stainless steel Schanz screws after 2, 4 and 6 months of implantation in a sheep model. The microstructure and composition of the hydroxyapatite coating were analyzed using scanning electron microscopy (SEM) and X-ray diffraction (XRD) analysis. Twelve coated and 12 uncoated screws were implanted into both femora of three sheep, each sheep receiving eight screws. Specimens of polished bone with screws were examined with SEM and light microscope for morphometric analyses. The HAC was approx. 40 microm thick, the grain size ranged from 5 to 40 microm, with pores less than 20 microm. The atomic ratio of Ca/P was 1.62. SEM showed that the bone-implant contact was better with HAC than with uncoated implants. The ingrowth of the bone in the HAC was clearly seen. Morphometric analysis showed good bone-implant contact in 65.1 (+/-24.6)% in the HAC and 32.0 (+/-23.3)% in the uncoated group (p<0.001). Although the percentage of good contact increased with time for both groups, it was significantly higher for HAC screws. Our investigation demonstrated a time dependent improvement of implant-bone contact of the HAC compared to standard stainless steel implants in the chosen experimental conditions.

Physiological differences for distinct somatic sensory modalities and sweating among the donor sites of cutaneous and fasciocutaneous free flaps

Differences of sensation and sweating among the typical sites of cutaneous and fasciocutaneous flaps (scapular, lateral arm, radial forearm, groin and dorsalis pedis) were assessed in 30 healthy volunteers (20 males and 10 females) aged 17-62 years (mean 38.2 years). Standard clinical methods were used: Semmes-Weinstein monofilaments for testing light touch threshold, discriminator and blunt caliper for evaluation of static and dynamic two-point discrimination and the Marstock quantitative method for assessing the normative values of warm-cold difference limen and heat and cold pain thresholds. Spontaneous sweat secretion was observed and documented by the ninhydrin test. We established various physiological differences for distinct somatic sensory modalities and sweating among the body regions (donor sites of cutaneous and fasciocutaneous free flaps).