[Emergency treatment of dislocation of large joints]. / Notfallbehandlung von Luxationen großer Gelenke.

Joint dislocations are always accompanied by rupture of the joint capsule. Depending on the forces exerted on the joint as well as individual bone quality, fractures (dislocation fractures) and injuries to ligaments occur. As blood vessels and nerves can also be damaged, reduction is an urgent measure. Only impaired peripheral perfusion, loss of motor function or sensation justify reduction without radiological documentation. As reduction can be a painful procedure, analgosedation is nearly always necessary. Evidence for superiority of individual maneuvers is weak. Reduction is followed by immobilization and documented by another control X­ray. Follow-up treatment depends on concomitant injuries, age and individual demands on joint function. Even with correct follow-up treatment, deficits often persist. This article deals with the diagnostics and treatment of dislocations of the shoulder, elbow, hip, patella and knee.

[Parameters influencing the preclinical application of cervical collars]. / Einflussfaktoren auf die präklinische Anlage einer Zervikalstütze.

BACKGROUND: The application of cervical collars is a standard procedure in emergency care of trauma patients. It is often observed that the application of cervical collars is performed incorrectly, which may lead to reduced immobilization of the cervical spine. OBJECTIVES: The objective of this study was to analyze the practical skills of professional emergency care providers concerning the application of cervical collars. MATERIALS AND METHODS: Emergency care professionals (n = 104) were asked to apply a cervical collar to a training doll. Each performance step was assessed separately. Furthermore, personal and occupational data of all study participants were collected using a questionnaire. RESULTS: The study participants included professional rescue personnel and emergency physicians. The average occupational experience of all study participants in out-of-hospital emergency care was 11.1 ± 8.9 years. Most participants had already received training on trauma care (61 %) and felt "very confident" in handling a cervical collar (84 %). The application of the cervical collar was performed correctly in 11 % of the performances. The most common error was incorrect size adjustment of the cervical collar (66 %). No association was found between the correct application of the cervical collar and possible parameters of influence, such as working experience in emergency care or participation in trauma courses. CONCLUSIONS: Despite pronounced subjective confidence regarding the application of cervical collars, this study shows that there are general deficits in the practical skills of applying cervical collars. Therefore, a critical assessment of the current training contents on the subject of trauma care must be demanded.

[Standardisation of the Initial Treatment of Severely Burned Patients: The Necessary Transfer of Concepts from Trauma Care]. / Standardisierung der Initialbehandlung von Schwerbrandverletzten: Die notwendige Übertragung von Konzepten aus der Schwerverletztenversorgung.

The initial treatment of severely burned patients remains a huge challenge for first responders in emergency services as well as emergency doctors who do not work in a centre for severe burn injuries. The reason for this is the low number of cases in developed countries and a lack of training concepts for the specific aspects of the initial treatment of severe burn injuries. Because of guidelines with limited evidence (S1, S2k) and a lack of structured treatment approaches, uncertainties with respect to initial treatment are still visible. Even within the professional societies and on international comparison, controversial aspects remain. In contrast, optimised and standardised procedures are available for the treatment of severely injured (trauma) patients, based on PHTLS® (Pre Hospital Trauma Life Support) for preclinical and ATLS® (Advanced Trauma Life Support) for in-hospital first aid. This article takes stock of the current structure of care and the relevant evidence for the initial treatment of severe burns. Also it discusses a possible transfer and further development of concepts for primary trauma care by all disciplines involved. Nine essential steps in the primary care of burned patients are identified and evaluated. The need for the introduction of a uniform treatment algorithm is illustrated. The treatment algorithm presented in this article addresses all first responders who are faced with initial treatment in the first 24 hours outside of burn centres. As an essential, new aspect, it offers a transfer and adaptation of concepts from trauma care to standardise the care of severely burned patients.

[Essential measures for prehospital treatment of severely injured patients: The trauma care bundle]. / Wesentliche Maßnahmen zur prähospitalen Versorgung schwerverletzter Patienten: Das Trauma Care Bundle.

BACKGROUND: In order to ensure adequate treatment and to avoid complications, care bundles are increasingly being implemented. These are comprehensive and evidence-based procedures for the treatment of individual diseases or injuries which should be carried out for every patient. The aim of this study was to define a care bundle for the prehospital treatment of severely injured patients. MATERIAL AND METHODS: The scientific contents of the bundle were gathered from the interdisciplinary evidence-based S3 guidelines for the treatment of severely injured patients by the German Trauma Society. The ABCDE scheme suggested by the prehospital trauma life support (PHTLS®) and the advanced trauma life support (ATLS®) functioned as a matrix for the individual elements in the bundles. The identified elements were finalized by a consensus process. RESULTS AND DISCUSSION: A bundle of six elements was suggested and a comprehensive summary of key items during prehospital management of severely injured patients was identified. In a next step the effectiveness of the care bundle should be evaluated in a clinical trial.

[Postoperative implant-associated osteomyelitis of the shoulder: Hardware-retaining revision concept using temporary drainage]. / Postoperative implantatassoziierte Osteitis am Schultergürtel: Materialerhaltendes Revisionskonzept mit Einlage einer Dauerdrainage.

BACKGROUND: Posttraumatic and postoperative osteomyelitis (PPO) is a subgroup of bone infections with increasing importance. However, to date no standardized reoperation concept exists particularly for patients with PPO of the shoulder region. Therefore the purpose of this study was to evaluate a revision concept including débridement, irrigation, and insertion of temporary drainage with hardware retention until healing. PATIENTS AND METHODS: A total of 31 patients with PPO were included with a proximal humerus fracture (n = 14), clavicle fracture (n = 10), or AC-joint separation (n = 7). In all, 27 of these patients could be followed for > 1 year. RESULTS: Hardware retention until fracture or ligament healing could be achieved in > 83%. Six patients required follow-up débridement due to recurrent infections, but then were unremarkable. Clinical outcome showed excellent Constant scores (91.6 ± 2.8). CONCLUSION: A cost-efficient, simple, and successful revision concept for patients with PPO of the shoulder region is described.

[New aspects of polytrauma treatment - current facts and developments: report of the first annual conference of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS)]. / Neuigkeiten aus der Polytraumaversorgung: aktuelle Fakten und Entwicklungen: Bericht vom 1. Jahreskongress der Sektion Notfall-, Intensivmedizin und Schwerverletztenversorgung (Sektion NIS).

Taking care of severely injured patients is a complex and ambitious mission. The committee on emergency medicine, intensive care and trauma management of the German Society of Trauma Surgery (Sektion NIS) has accepted this challenge. On the occasion of the release of the annual report of the TraumaRegistry DGU®, the committee held its first annual congress in order to provide members and an intrigued audience with current trends and results from the latest research in national trauma care ranging from the animal facility to the S3 guidelines. Topics of focus were new realizations based on data from the TraumaRegistry DGU® and means of quality assurance in trauma care. This article gives a report on the meeting and summarizes the major results of the presented studies and the latest deployments in this field of trauma research.

[Digital X-ray: interhospital data transfer by CD-ROM. Prospective data evaluation during the import process]. / Digitales Röntgen: interhospitaler Datentransfer auf CD-ROM. Prospektive Datenevaluation während des Arbeitsprozesses.

BACKGROUND: Increasing numbers of radiological imaging diagnostics are archived in digital form. In addition to the results of diagnostics performed in hospital a growing number of patients present with digital results of outpatient radiological investigations. These digitized images represent a challenge for the internal hospital work flow. The aim of the study was to determine the expenditure for the hospital when dealing with digital outpatient diagnostic results. METHOD: Several parameters were observed and analyzed within the import process of nearly 400 CD-ROMs over a time period of 5 months. Only a negligible number of data on CD-ROMs could not be transferred into the hospital archive (1.5%). The duration of the process depended on the amount of data and the time period. RESULTS: During regular hours the import process took on average 13 min per CD and 19 min per patient while the time increased significantly during on-call duties. This study demonstrates the significance of the import of digital outpatient radiological diagnostic results into the hospital archive which can in particular influence patient treatment.

[The Ludwigshafen Osteoporosis Screening Questionnaire (LOS Questionnaire): result of the evaluation of anamnestic risk factors in osteoporosis diagnostics]. / Ludwigshafener Osteoporosescreeningbogen (LOS-Bogen) : Resultat aus der Evaluation anamnestischer Risikofaktoren in der Osteoporosediagnostik.

BACKGROUND: Osteoporosis is a major health problem worldwide and is included in the WHO list of the top ten major diseases. However, it is often undiagnosed until the first fracture occurs, due to inadequate patient education and lack of insurance coverage for screening tests. METHODS AND MATERIAL: In our study of 78 patients with metaphyseal long bone fractures, we searched for a correlation between anamnestic risk factors, bone-specific laboratory values, and the bone morphogenic density (BMD). Each indicator was examined as a possible diagnostic instrument for osteoporosis. The secondary aim of this study was to demonstrate the high prevalence of osteoporosis in patients with metaphyseal fractures. RESULTS: Of our fracture patients 76.9% had decreased bone density and 43.6% showed manifest osteoporosis in DXA (densitometry) measurements. Our modified LOS Questionnaire, identifying anamnestic risk factors, correlated highly significantly (p=0.01) with reduced BMD, whereas seven bone-specific laboratory values (p=0.046) correlated significantly. CONCLUSION: Anamnestic risk factors correlate with pathological BMD more than bone-specific laboratory values. The LOS Questionnaire used in this study would therefore function as a cost-effective primary diagnostic instrument for identification of osteoporosis patients.

Validation of a novel testing machine for the investigation of the biomechanical properties of lumbar vertebrae in an osteoporotic rat model.

BACKGROUND: For the investigation of the biomechanical properties of bone, various testing devices have been described. However, only a limited number have been developed to test the vertebral body of small animals. The aim of this study was to develop and validate a new bone testing device, which investigates the different biomechanical properties in small-animal vertebrae as a whole, three-dimensional unit, respecting its anatomical structure. METHODS: Thirty-five twelve-week-old female Sprague Dawley rats were utilized. Group 1 was composed of 17 rats with a normal bone metabolism without osteoporosis, while Group 2 consisted of 18 rats with manifest osteoporosis, 8 weeks after ovariectomy. The 5th lumbar vertebra of each animal was tested using the new bone testing device. This device has the ability to be adjusted to the slanted nature of each individual vertebral body and fix the vertebra in a natural position to allow for a non-dislocating axial force application. The device is designed to respect the anatomical three-dimensional shape of the vertebral body, thus avoiding the application of non-anatomic, non-physiological forces and thus preventing a distortion of the biomechanical testing results. The parameters investigated were stiffness, yield load, maximum load and failure load, and the results were compared to current literature values. RESULTS: The conduction of the biomechanical bone testing of the vertebral bodies with the new device was conductible without any instances of dislocation of the vertebrae or machine malfunctions. Significant differences were found for stiffness, maximum load and failure load between groups, with a lower value in the osteoporotic rats in each parameter tested. The yield load was also lower in the osteoporotic group, however not significantly. The values achieved correlate with those in current literature. CONCLUSIONS: This study demonstrates that the newly developed testing machine is easy to handle and produces valid data sets for testing biomechanical bone parameters of whole vertebral bodies in an established small animal model. Therefore, it can be utilized, also as reference data, to test different structural properties and changes in vertebral bone, for example, in different metabolic settings or under the influence of different pharmaceutical entities in further studies.

[Results of nonunion treatment with bone morphogenetic protein 7 (BMP-7)]. / Ergebnisse der Pseudarthrosenbehandlung mit "bone morphogenetic protein 7" (BMP-7).

BACKGROUND: Complex patterns of impaired bone healing can result in a severe economic and social burden for the patient. Herein we describe the local application of recombinant human bone morphogenetic protein 7 (BMP-7). The goal of this prospective study is to review the indications, application and validation of this therapy. MATERIAL AND METHOD: From June 2002 to June 2008, we applied 101 BMP-7 treatments in 101 nonunions of 98 patients. The average age of the patients was 50 years (18-88 years). The gender composition was 29 women (30%) and 69 men (70%). Before BMP-7 application, patients had already underwent surgical treatement an average of 3.3 times (median 3, 1- to 13-times). We used BMP-7 "off-label" in all long bones. RESULTS: In 93 cases (92%), we observed proper bone healing. The average healing time was 4.8 months (range 1.5-11 months). The average time from injury to BMP-7 application was 18.4 months (3-84 months). In 65 cases, BMP-7 application was combined with re-osteosynthesis and autologous bone grafting. Serious side effects were not observed. CONCLUSIONS: BMP-7 should not be used as general treatment of nonunion in all patients, but appears to be effective for the treatment of complex cases. In clinical practice, the decision to proceed with off-label use of BMP-7 should be made on a case-by-case basis.

[Six years of Advanced Trauma Life Support (ATLS) in Germany: the 100th provider course in Hamburg]. / Sechs Jahre Advanced Trauma Life Support (ATLS) in Deutschland: 100. Providerkurs in Hamburg.

With over 1 million certified physicians in more than 50 countries worldwide, the Advanced Trauma Life Support (ATLS) concept is one of the most successful international education programs. The concept is simple, priority-orientated (ABCDE scheme) and assesses the situation of the trauma patient on the basis of vital signs to treat the life-threatening injuries immediately. With over 100 ATLS provider courses and 10 instruction courses accomplished in less than 6 years, no other land in the world has successfully established this concept in such a short time as Germany. Meanwhile nearly 1,600 colleagues have been trained and certified. Evaluation of the first 100 ATLS courses in Germany supports this concept. The total evaluation of all courses is 1.36 (1.06-1.8, n=100). The individual parts of the course were marked as followed: presentations 1.6 (1.0-2.81, n=100), practical skills stations 1.46 (1.0-2.4, n=100) and surgical skills stations 1.38 (1.0-2.38, n=100). In 2009 a total of 47 ATLS courses were accomplished which will clearly increase in 2010. Other ATLS formats, such as ATCN (Advanced Trauma Care for Nurses) and refresher courses are planned for the beginning of 2010.

[How to become a trauma surgeon: analysis of the current situation and concepts for career development in the new common field of orthopaedics and trauma surgery--part I]. / Der Weg zum Unfallchirurgen : Situationsanalyse und Konzepte zur Nachwuchsförderung in der Unfallchirurgie im Umfeld des neuen gemeinsamen Fachs Orthopädie/Unfallchirurgie - Teil I.

The lack of clinical residents especially in the surgical domains, including orthopaedics and trauma surgery, is not only omnipresent but also a topic of lively discussions. This lack originates from sociopolitical and healthcare policy issues as well as from a loss of attractiveness of all surgical disciplines. The loss is caused by the high workload and disadvantageous working hours especially in those disciplines with a high rate of emergencies, e.g. trauma surgery. Moreover, it is caused by the poorly structured and unpredictable period of residency. In order to anticipate the bottleneck in supply due to the lack of trainees, a number of structural and contextual measures have to be taken to improve both undergraduate und postgraduate surgical training. Due to the numerous facets of the topic the first part of this analysis refers to the period until the trainee decides on the field of training.A basic insight into the field of orthopaedics and trauma surgery can already be offered far before the period of medical studies itself. During undergraduate medical education the existing structures should be modified, the characteristics of the discipline should be emphasized and the charm of combining theory and practical skills should be highlighted in order to enhance student's perception of the discipline. This might begin during preclinical training and should be continued throughout clinical training and elective courses (basic wound care, TEAM approach, AO course for students and seminars for M.D. candidates). Contextual and structural improvements of the practical year are indispensable to arouse students' interest in our discipline. These options conjoined with the actual offers for students provided by our scientific society, such as guided tours during the annual congress, travelling grants and the recently inaugurated summer school, might provide the basis for clearly structured information and offer a distinct stimulus to apply for residency in our field.

[How to become a trauma surgeon: analysis of the current situation and concepts for career development in the new common field of orthopaedics and trauma surgery--part II]. / Der Weg zum Unfallchirurgen: Situationsanalyse und Konzepte zur Nachwuchsförderung in der Unfallchirurgie im Umfeld des neuen gemeinsamen Faches Orthopädie/Unfallchirurgie--Teil II.

An increasing lack of young fellowship trainees in operative medicine, particularly in orthopaedics and traumatology and the various options to counteract this problem during the phases until the individual decision for residency and the fellowship program is made, were the focus of part I. The present part concentrates on residency and the fellowship phase including the individual perspectives after successful training. With respect to an attractive and highly qualified training in orthopaedics and traumatology, three essential points are to be made: a timely general framework, the establishment of a clinic-specific management of training and a general evaluation of training in the sense of a benchmarking system. A flexible work schedule including structural entities, such as an in-hospital day care facility for children, a structured and reliable curriculum of training according to a model curriculum to be adapted to the corresponding training unit including options of rotation to other facilities of training and the integration of nationwide education and mentoring programs represent further elements of an attractive training program. Thus the quality of training will become a decisive criterion of selection. The fellowship program for specialized traumatology inevitably leads to limitations of the whole spectrum of the field with an increasing specialization. In the future the contents of fellowship training will need a well-considered adaptation to the clinical needs and realities in the light of the emerging national trauma network program. A wide field of activity will open up to specialists in orthopaedics and traumatology with a focus on special traumatology considering the rapid changing field of hospital and outpatient care. Thus a systematic and creative reorganization of the residency and fellowship phases will overcome any problem of attractiveness.

[Standardised primary care of multiple trauma patients. Prehospital Trauma Life Support und Advanced Trauma Life Support]. / Standardisierte Primärtherapie des polytraumatisierten Patienten. Prehospital Trauma Life Support und Advanced Trauma Life Support.

INTRODUCTION: Standardised management improves treatment results in seriously injured patients. For conditions like stroke or acute coronary syndrome (ACS) there are set treatment pathways which have been established for prehospital and primary hospital care. The treatment of critical trauma patients, however, follows varying procedures in both the prehospital and primary hospital phases. From an analysis of the trauma register of the German Society for Trauma Surgery (DGU), we know that a seriously injured patient remains on the road for 70 min on average before transferral to hospital. This requires improvement. With the 2003 introduction of the ATLS programme in Germany, the initial clinical phase could be improved upon simply by means of standardised training. PHTLS und ATLS complement one another. RESULTS: PHTLS und ATLS represent training concepts which teach standardised, priority-based prehospital and hospital trauma management. The aim is to make an initial rapid and accurate assessment of the patient's condition, thereby identifying the"critical" patient. The concepts also make priority-based treatment possible and facilitate decision-making as to whether patients can receive further on-the-spot treatment or whether immediate transport is necessary. The procedure is identical in the shock room. The primary consideration is to prevent secondary damage, not to lose track of time and to ensure consistent quality of care. The courses teach systematic knowledge, techniques, skills and conduct in diagnosis and therapy. The courses are oriented to all medical specialities associated with trauma care. With the support of the German Society for Trauma Surgery (DGU) and the German Society for Anesthesiology and Intensive Medicine (DGAI), the German Professional Organisation of Rescue Services (DBRD) has adopted the PHTLS course system on licence from the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and has been offering it in Germany since late 2007. ATLS was established by the DGU in 2003 and represents successful and similarly structured shock-room management. CONCLUSION: PHTLS und ATLS are established and standardised concepts, which are constantly reviewed and updated according to the latest medical knowledge. They provide the opportunity to standardise prehospital and primary clinical trauma management for all specialties and hospitals, while incorporating own knowledge.

[Medical care reality in trauma surgical clinics in Germany. A survey of the professional committee of the German Society for Trauma Surgery]. / Zur Versorgungsrealität unfallchirurgischer Kliniken in Deutschland. Eine Umfrage des Berufsständischen Ausschusses der Deutschen Gesellschaft für Unfallchirurgie.

Due to revised conditions of medical care in Germany, in particular the introduction of the newly designated specialist for orthopaedics and trauma surgery, the working conditions in trauma surgical clinics in Germany has changed. In May 2008 the professional committee of the German Trauma Society conducted a survey at the 729 trauma surgical clinics and departments in order to establish the true level of care at these particular sites. The results of the 90,000 variables presented in the following article, reflect the changes in trauma care as well as in the medical care structures and emphasize the increased work load. In particular the lack of qualified candidates underlines the main explanation for vacant posts and is also evaluated in this article.

[Physicians in traumatology. Critically endangered? Results of an inquiry]. / Arzte in der Unfallchirurgie. Unglücklich und vom Aussterben bedroht? Ergebnisse einer Umfrage.

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.