[Management of fracture-related infections]. / Management von frakturassoziierten Infektionen.

Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.

Influence of Entrapment on Prehospital Management and the Hospital Course in Polytrauma Patients: A Retrospective Analysis in Air Rescue.

BACKGROUND: Entrapment is a challenging and crucial factor in the prehospital setting. Few studies have addressed whether entrapment has an influence on on-scene treatment or on the following hospital course. OBJECTIVES: Here we aimed to investigate the influence of entrapment on prehospital management and on the hospital course of polytrauma patients. METHODS: We performed a retrospective analysis of consecutive patients with an Injury Severity Score ≥16 and aged 16-65 years that were admitted between 2005 and 2013 to a Level I trauma center. Two groups were built: entrapped (E) and nonentrapped patients (nE). These groups were evaluated for multiple prehospital and clinical parameters, including on-scene time, prehospital interventions, and posttraumatic complications. RESULTS: There were 310 patients (n = 194 no entrapment [Group nE], n = 116 with entrapment [Group E]) enrolled. The on-scene time was significantly longer in Group E than Group nE. Moreover, this group received a significantly higher volume of colloidal solution. Regarding the Injury Severity Score and Abbreviated Injury Scale (AIS), there were no significant differences between the groups, except for the AISextremities, which was significantly increased in Group E. The overall hospital stay and the initial theater time were significantly longer in Group E than Group nE. No significant differences were present for the occurrence of systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and acute respiratory distress syndrome, nor for Acute Physiology and Chronic Health Evaluation II and estimated and final mortality. CONCLUSION: In polytraumatized patients, entrapment has a minor influence on the outcome and treatment in the prehospital and hospital setting when using physician-based air rescue. However, entrapped patients are prone to sustain more severe trauma to the extremities.

Femoral malrotation after surgical treatment of femoral shaft fractures in children: a retrospective CT-based analysis.

BACKGROUND: Rotational malalignment is an important and not always avoidable complication after surgical treatment of femoral shaft fractures. The purpose of this study was to determine the incidence of rotational malalignment in children after surgical treatment of femoral shaft fractures and to identify potential patient- and treatment-related risk factors based on data obtained from CT scans. METHODS: We conducted a retrospective analysis of all patients aged less than 15 years with femoral shaft fractures admitted to our level 1 trauma centre between January 2004 and July 2014. Patients having obtained postoperative CT scans were included for the determination of rotational malalignment. A difference of greater than 15° in femoral torsion between both legs was considered as clinically relevant. Additionally, demographic data and clinical information such as fracture type, treatment method, fluoroscopy time and operating time were reviewed. RESULTS: A total of 24 patients were enrolled in this study. Clinically relevant femoral malrotation was identified in 10 patients (41.6%). Surgical revision was performed in 7 patients (29.2%). There was no association between the type of surgical procedure, age and the incidence and/or amount of femoral malrotation. CONCLUSIONS: The data suggest that relevant femoral malrotation is an evident problem after surgical treatment of femoral shaft fractures in children that requires critical postoperative assessment. LEVEL OF EVIDENCE: Level III, retrospective study.

Simulator-Based Air Medical Training Program Christoph Life: From Concept to Course.

OBJECTIVE: Christoph Life is a simulator-based air medical training program and a new and innovative educational concept. Participants pass different scenarios with a fully equipped and movable helicopter simulator. Main focuses of the program are crew resource management (CRM) elements and team training. Information about expectations end effectiveness of the training is sparse. METHODS: During a 2-day training, participants learn CRM basics and complete various emergency medical scenarios. For evaluation, we used an anonymous questionnaire either with polar questions or a 6-coded psychometric Likert scale. The Wilcoxon test was used for statistical analysis. The significance level was set at P < .05. RESULTS: Thirteen teams of emergency physicians and specially trained paramedics underwent Christoph Life. It was evaluated largely positively and considered very helpful for daily work (5.7 ± 0.5) and avoiding mistakes (5.7 ± 0.5). The quality of participants' knowledge about CRM basics (3.5 ± 1.2 vs. 5.4 ± 0.7, P < .001), self-assessment of communication skills (4.2 ± 0.7 vs. 4.8 ± 0.8, P = .02), and active reflection of communication aspects (3.9 ± 0.9 vs. 5.5 ± 0.5, P < .001) could be strikingly increased. CONCLUSIONS: There is a considerable demand for intensified training on the part of the users. We were able to show that a simulator-based air medical training program is a helpful training tool with an obvious subjective benefit for the participants' nontechnical skills.

Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model.

BACKGROUND: The deterioration of hemodynamics instantly endangers the patients' life after polytrauma. As accidental hypothermia frequently occurs in polytrauma, therapeutic hypothermia still displays an ambivalent role as the impact on the cardiopulmonary function is not yet fully understood. METHODS: We have previously established a porcine polytrauma model including blunt chest trauma, penetrating abdominal trauma, and hemorrhagic shock. Therapeutic hypothermia (34°C) was induced for 3 hours. We documented cardiovascular parameters and basic respiratory parameters. Pigs were euthanized after 15.5 hours. RESULTS: Our polytrauma porcine model displayed sufficient trauma impact. Resuscitation showed adequate restoration of hemodynamics. Induced hypothermia had neither harmful nor major positive effects on the animals' hemodynamics. Though heart rate significantly decreased and mixed venous oxygen saturation significantly increased during therapeutic hypothermia. Mean arterial blood pressure, central venous pressure, pulmonary arterial pressure, and wedge pressure showed no significant differences comparing normothermic trauma and hypothermic trauma pigs during hypothermia. CONCLUSIONS: Induced hypothermia after polytrauma is feasible. No major harmful effects on hemodynamics were observed. Therapeutic hypothermia revealed hints for tissue protective impact. But the chosen length for therapeutic hypothermia was too short. Nevertheless, therapeutic hypothermia might be a useful tool for intensive care after polytrauma. Future studies should extend therapeutic hypothermia.

Do admission glucose levels independently predict coagulopathy in multiple trauma patients? A retrospective cohort analysis.

BACKGROUND: Coagulopathy is prevalent in multiple trauma patients and worsens bleeding complications, leading to higher morbidity and mortality rates. Hyperglycemia upon admission predicts hemorrhagic shock and mortality in severely injured patients. This study aimed to assess admission glucose levels as an independent prognostic factor for coagulopathy in multiply injured patients. METHODS: This retrospective cohort study observed multiple trauma patients treated at a level I trauma center between January 1, 2005, and December 31, 2020. Coagulopathy was defined as an international normalized ratio (INR) > 1.4 and/or activated thromboplastin time (APTT) > 40 s. Analysis of variance compared clinical and laboratory parameters of patients with and without coagulopathy. Receiver-operating-characteristic (ROC) and multivariate logistic regression analyses identified risk factors associated with coagulopathy. RESULTS: The study included 913 patients, of whom 188 (20%) had coagulopathy at admission. Coagulopathy patients had higher mortality than those without (26% vs. 5.0%, p < 0.001). Mean glucose level in coagulopathy patients was 10.09 mmol/L, significantly higher than 7.97 mmol/L in non-coagulopathy patients (p < 0.001). Admission glucose showed an area under the curve (AUC) of 0.64 (95% CI [0.59-0.69], p < 0.001) with an optimal cut-off point of 12.35 mmol/L. After adjusting for other factors, patients with high admission glucose had a 1.99-fold risk of developing coagulopathy (95% CI 1.07-3.60). Other laboratory parameters associated with coagulopathy included haemoglobin, bicarbonate (HCO3), and lactate levels. CONCLUSION: This study emphasizes the significance of admission blood glucose as an independent predictor of coagulopathy. Monitoring hyperglycemia can aid in identifying high-risk patients.

Reconstruction of an Extensive Segmental Radial Shaft Bone Defect by Vascularized 3D-Printed Graft Cage.

We report here a 46-year-old male patient with a 14 cm segmental bone defect of the radial shaft after third degree open infected fracture caused by a shrapnel injury. The patient underwent fixed-angle plate osteosynthesis and bone reconstruction of the radial shaft by a vascularized 3D-printed graft cage, including plastic coverage with a latissimus dorsi flap and an additional central vascular pedicle. Bony reconstruction of segmental defects still represents a major challenge in musculo-skeletal surgery. Thereby, 3D-printed scaffolds or graft cages display a new treatment option for bone restoration. As missing vascularization sets the limits for the treatment of large-volume bone defects by 3D-printed scaffolds, in the present case, we firstly describe the reconstruction of an extensive radial shaft bone defect by using a graft cage with additional vascularization.

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients.

INTRODUCTION: Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive. METHODS: Traumatized patients (Injury Severity Score; ISS≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score. RESULTS: A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n=8,231) were transported by GEMS and 37.7% (n=4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P<0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P<0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P<0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P<0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P<0.001) resulting in an increased length of ICU treatment and in-hospital time (P<0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862). CONCLUSIONS: Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.

Impact of the body mass on complications and outcome in multiple trauma patients: what does the weight weigh?

Obesity is known as an independent risk factor for various morbidities. The influence of an increased body mass index (BMI) on morbidity and mortality in critically injured patients has been investigated with conflicting results. To verify the impact of weight disorders in multiple traumatized patients, 586 patients with an injury severity score >16 points treated at a level I trauma center between 2005 and 2011 were differentiated according to the BMI and analyzed regarding morbidity and outcome. Plasma levels of interleukin- (IL-) 6 and C-reactive protein (CRP) were measured during clinical course to evaluate the inflammatory response to the "double hit" of weight disorders and multiple trauma. In brief, obesity was the highest risk factor for development of a multiple organ dysfunction syndrome (MODS) (OR 4.209, 95%-CI 1.515-11.692) besides injury severity (OR 1.054, 95%-CI 1.020-1.089) and APACHE II score (OR 1.059, 95%-CI 1.001-1.121). In obese patients as compared to those with overweight, normal weight, and underweight, the highest levels of CRP were continuously present while increased systemic IL-6 levels were found until day 4. In conclusion, an altered posttraumatic inflammatory response in obese patients seems to determine the risk for multiple organ failure after severe trauma.

[Biological reconstruction of large bone defects : Masquelet technique and new procedures]. / Biologische Rekonstruktion von großen Knochendefekten : Masquelet-Technik und neue Verfahren.

Extensive diaphyseal and metaphyseal bone defects continue to pose a major challenge for orthopedic trauma surgeons. Various treatment options have been described for the biological reconstruction of these defects. The most frequently used methods are bone segment transport, the Masquelet technique and 3D printed scaffolds. As far as the Masquelet technique is concerned, in the first stage spacers, such as polymethyl methacrylate (PMMA), calcium sulfate or polypropylene are inserted into the bone defects to induce a foreign body membrane. In the second stage the bone defect surrounded by the induced membrane is filled with autologous cancellous bone. The time interval between the first and second interventions is usually 4-8 weeks whereby the induced membranes do not lose their bioactivity even with a latency period longer than 8 weeks. Three-dimensional printed scaffolds are increasingly used but large clinical studies are lacking in order to show the exact role of this procedure in the reconstruction of bone defects.

Validation of direct CT measurement of malrotation in femoral neck fractures: A bone model study.

BACKGROUND: While postoperative malrotation in the subtrochanteric region is a well-known problem, malrotation after osteosynthesis in proximal femoral fractures has not been extensively studied. In this context, many methods for perioperatively assessment of femoral torsion have been described, but none of them is applicable in the basicervical region of the proximal femur. As an important difference in femoral neck fractures, the discontinuous neck fails to serve as a significant "pointer" for measurements and malfunctions to be placed in relation to the condylar plane. Considering postoperative maltorsion at any location as a substantial negative effect on patients' outcome and functional expectations, precise and patient-friendly rotation measurement standards in femoral neck fractures are desired in clinical practice. Recently, a novel computed tomography (CT) based geometric technique was described named "direct measurement" with promising results covering this diagnostic disparity, but still requires validation. Thus, we aimed to validate the previously described technique using a controlled range of displacement in a femoral neck fracture Sawbone® model. METHODS AND FINDINGS: A goniometer was designed to set retro- and anteversion of the proximal femur in a reproducible manner. Prospectively, all femurs underwent a CT scan and were measured 3D for displacement. The interclass correlation between the CT measurements and the goniometer measurements was calculated and was found to be very high (1.00, 95% confidence interval: 0.99-1.00; p < 0.001). For the mean of all measurements, the Pearson's correlation was 1.00 (p < 0.001). No significant differences in the measurements of both investigators were observed, with 20° of retroversion not significant (-1.20 ± 1.71; 95% confidence interval: -2.43-0.03; p = 0.054). CONCLUSION: This CT-based 3D measurement technique may allow for perioperative malrotation assessment in basicervical femoral neck fractures and appears to be feasible in femoral neck fractures when it comes to rare cases of osteosynthesis. Further investigations are still needed to define the thresholds of malrotation provoking functional impairment after osteosynthesis in basicervical femoral neck fractures.

Comparison of different thoracic trauma scoring systems in regards to prediction of post-traumatic complications and outcome in blunt chest trauma.

BACKGROUND: As accurate assessment of thoracic injury severity in the early phase after trauma is difficult, we compared different thoracic trauma scores regarding their predictive ability for the development of post-traumatic complications and mortality. MATERIALS AND METHODS: Two hundred seventy-eight multiple trauma patients (ISS ≥ 16) age > 16 y with severe blunt chest trauma (AIS(chest) ≥ 3) admitted between 2000 and 2009 to Level I Trauma center were included. Exclusion criteria were severe traumatic brain injury (AIS(head) ≥ 3) and penetrating thoracic trauma. The association between AIS(chest), Pulmonary Contusion score (PCS), Wagner-score and Thoracic Trauma Severity score (TTS), and duration of ventilation, length of ICU stay, development of post-traumatic complications, and mortality was investigated. Statistical analysis was performed with χ(2)-test, ANOVA, logistic regression, and receiver operating characteristic (ROC) curve. RESULTS: Patients' mean age was 42.7 ± 17.0 y, the mean injury severity score was 28.7 ± 9.3 points. Overall, 60 patients (21.6%) developed ARDS, 143 patients (51.4%) SIRS, 110 patients (39.6%) sepsis, and 36 patients (13.0%) MODS. Twenty-two patients (7.9%) died. Among the examined thoracic trauma scores only the TTS was an independent predictor of mortality. With the TTS showing the best prediction power, the TTS, PCS, and Wagner-score were independent predictors of ventilation time, length of ICU stay, and the development of post-traumatic ARDS and MODS. CONCLUSIONS: Thoracic trauma scores combining anatomical and physiologic parameters like the TTS seem to be most suitable for severity assessment and prediction of outcome in multiple trauma patients with concomitant blunt chest trauma.

Facts and fiction: the impact of hypothermia on molecular mechanisms following major challenge.

Numerous multiple trauma and surgical patients suffer from accidental hypothermia. While induced hypothermia is commonly used in elective cardiac surgery due to its protective effects, accidental hypothermia is associated with increased posttraumatic complications and even mortality in severely injured patients. This paper focuses on protective molecular mechanisms of hypothermia on apoptosis and the posttraumatic immune response. Although information regarding severe trauma is limited, there is evidence that induced hypothermia may have beneficial effects on the posttraumatic immune response as well as apoptosis in animal studies and certain clinical situations. However, more profound knowledge of mechanisms is necessary before randomized clinical trials in trauma patients can be initiated.

Tip apex distance, hip screw placement, and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures.

PURPOSE: To describe the quality of osteosynthesis after intertrochanteric fractures evaluation of tip apex distance (TAD) and position of the hip screw have been established. Furthermore, a slightly valgus fracture reduction has been suggested to reduce the risk of cut-out failure. However, uniform recommendations for optimal screw positioning and fracture reduction are still missing. The purpose of our study was to confirm potential risk factors for cut-out of hip screws of intertrochanteric fractures and to provide recommendations for practical clinical use. METHODS: A retrospective analysis of all patients with intertrochanteric fractures treated with a DHS or a gamma nail between January of 2007 and May of 2010 was performed at a level I trauma center. RESULTS: Two hundred thirty-five patients with intertrochanteric fractures after intra- and extramedullary stabilization were analyzed. A TAD of more than 25 mm was demonstrated to be the most important factor for cut-out in stable and unstable fractures. Fracture reduction with a valgus NSA of 5-10° was associated with a trend towards a lower rate of screw cut-out while an anterior placement of the screw (Parker's ratio index of <40) significantly increased cut-out incidence. CONCLUSIONS: According to our results, the TAD should not exceed 25 mm in stable (AO/OTA A1) as well as unstable (AO/OTA A2) fractures. An increased anterior hip screw placement should be avoided while fracture reduction with a slight valgus Neck Shaft seems favorable.

Profit Analysis of Minimal-invasive Approaches for Surgical Treatment of A3 Spinal Burst Fractures.

BACKGROUND/AIM: Regarding the surgical treatment of incomplete burst fractures of the spine, no optimal standard procedure has been established. While previous studies have focused on radiological and surgical outcome parameters, the literature has not elucidated economic aspects of various surgical treatment options in detail yet. This study aimed to investigate whether open and minimal-invasive approaches differ in their economic profit gain. Furthermore, we examined whether a single-stage or two-stage approach of anterior-posterior fusion was more profitable. PATIENTS AND METHODS: By analyzing retrospectively data of 129 patients who underwent surgical procedure due to isolated incomplete burst fractures, we examined the economic profit and radiological parameter of open pedicle screw insertion, minimal-invasive techniques (percutaneous screws, percutaneous screws combined with SpineJack®, kyphoplasty or SpineJack®), and anterior-posterior fusion. RESULTS: Percutaneous screws in combination with SpineJack® gained significantly higher profit and higher profit per day of hospital length of stay. Profit was similar after single-stage and two-stage approach of vertebral body replacement. No significant difference in radiological outcome after 24 months was detected between the various surgical techniques. CONCLUSION: From a financial aspect, our finding suggests that application of percutaneous screws in combination with SpineJack® may generate the highest economic profit gain regarding treatment of incomplete burst fracture.

Protective effects of finasteride on the pulmonary immune response in a combined model of trauma-hemorrhage and polymicrobial sepsis in mice.

UNLABELLED: Literature supports findings about a gender specific outcome following multiple trauma. Male sex hormones such as dihydrotestosterone (DHT) exert deleterious effects on the posttraumatic immune response whereas increased estradiol concentrations are correlated with improved outcome. Pretreatment with the 5α-reductase inhibitor finasteride resulted in an improved outcome following trauma-hemorrhage (TH) in mice. The present study tested the hypothesis that finasteride exerts beneficial effects on the posttraumatic immune response also in a combined setting of TH and sepsis when administered during the resuscitation process. MATERIAL AND METHODS: Male C57BL/6N-mice were subjected to TH (blood pressure, 35 mm Hg, 60 min) followed by finasteride application and fluid resuscitation. Thereafter, finasteride was administered every 12h. 24h after TH, sepsis was induced by cecal ligation and puncture (CLP) or sham operation was performed. Plasma cytokines (MIP-1α, MIP-1ß, TNF-α, MCP-1, IL-6), productive capacity by alveolar macrophages (AM) and systemic estradiol levels were determined 4 h thereafter. The expression of pro-inflammatory mediators in lung tissue was evaluated by PCR. Pulmonary infiltration of PMN was determined by immunohistochemical staining. RESULTS: Finasteride treatment resulted in a reduced posttraumatic cytokine secretion of AM as well as in a decreased concentration of MCP-1 and MIP-1ß in lung tissue. Systemic estradiol levels were increased following finasteride treatment. CONCLUSION: Finasteride mediates salutary effects on the pulmonary immune response using a therapeutical approach following TH-CLP in mice. Thus, finasteride might represent a relevant therapeutic substance following major trauma also in the clinical setting.

Challenges of surgical trauma emergency admission.

INTRODUCTION: Trauma still remains as one of the leading causes for mortality in Western civilization. The early clinical management of severely injured patients leads to structural and organizational challenges involving different specialties. EMERGENCY DEPARTMENT: Trauma team leaders have to coordinate diagnostic and therapeutic steps in cooperation with different involved specialties. Furthermore, they have to make decisions based on contrary department-depending assessments. In addition, several special injuries commonly found in multiple traumatized patients require special attention. RECENT DEVELOPMENT: Actually, structural changes in generating trauma networks are to be mentioned. Trauma networks suggest to improve patients survival in close cooperation between hospitals with different structural and personal capabilities. Close communication networks are required to guarantee transportation to an adequate trauma center.

Head injury in polytrauma-Is there an effect on outcome more than 10 years after the injury?

INTRODUCTION: Head injuries are of great relevance for the prognosis of polytrauma patients during acute care. However, knowledge about the impact on the long-term outcome is sparse. Therefore, this study analysed the role of head injuries on the outcome of polytrauma patients more than 10 years after injury in a matched-pair analysis. PATIENTS AND METHODS: Out of 620 polytrauma patients with and without head injury, a matched-pair analysis with comparable age, injury severity and gender distribution and a minimum of 10 years follow-up was performed. The outcome and quality-of-life were measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form 12 (SF-12), Glasgow Outcome Scale (GOS) and other parameters. RESULTS: The matched-pair analysis consisted of 125 pairs (age 27.9 ± 1.2 years, ISS 20.0 ± 0.8 [head injury] vs ISS 19.8 ± 0.8 [no head injury]). A significant difference was shown for the GOS Score only (GOS head injury 4.3 ± 0.3 vs no head injury 4.9 ± 0.2, p = 0.01). The psychological outcome was similar in both groups. Both groups reported comparable subjective rehabilitation satisfaction. CONCLUSIONS: Matching pairs of equally injured polytrauma patients of same gender with and without head injury 10 years following trauma indicated significantly worse results in the GOS due to head injury.

A Rare Case of a Traumatic Posterior Hip Dislocation in a 3-Year-Old Boy: A Case Report and Review of the Literature.

We present a rare case of neglected hip dislocation in a 3-year-old boy. Hip dislocations in childhood represent less than 6% of all injuries. The boy presented to the ED with ongoing hip pain after his leg got stuck in a carousel. The physical and radiologic examination revealed a posterior right hip dislocation. The closed reduction failed, so open reduction during surgery was performed. The postoperative protocol included 3 days of immobilization with early mobilization and pain-adapted weight bearing. No signs of femoral head malperfusion occurred 2 months after the injury. The patient did not complain of any limitations such as weight bearing problems or loss of range of motion. In comparison to adults, there are several specialties such as the fact that minor trauma can lead to hip dislocations due to the laxity of the ligaments, and due to the limited direct anamnestic options, neglected hip dislocations can occur. The treatment should focus on immediate proper reduction. The main complications after traumatic hip dislocation are avascular necrosis of the femoral head, redislocation, and early osteoarthritis.

A Rare Case of Complex Pelvic Injury and Associated Intrathecal Fat Embolism due to Spinopelvic Dislocation with Sacral Burst Fracture.

INTRODUCTION: Pelvic and lumbar spine injuries are very common especially in multiple trauma patients. The usual mechanism in young patients leading to pelvic fractures is a high-energy trauma such as traffic accidents. In elderly patients, low energy traumas are causal for such injuries. Compared to the high number of patients with pelvic or lumbar spine injuries, cerebral fat embolism is a quite rare finding but it needs to be considered to not misinterpret the radiological findings. CASE: We present the case of a 41-year-old patient, who got hit and trapped in the lumbar region by a hydraulic arm in a car repair shop. The patient was primarily admitted to a level II trauma center. The radiological and clinical examinations revealed an open pelvic type C injury in terms of a spinopelvic dissociation, dislocation of the left hip joint, rupture of the mesentery of the rectum and colon sigmoideum, and a complex injury to the left ureter. Additionally, CT scan showed fluid with higher density than cerebro spinal fluid (CSF) in the lateral ventricles indicating an intracranial bleeding. After an immediate surgery to stabilize the patient, he was admitted to a level I trauma center. The reanalysis of the existing CT datasets combined with a new head CT leads to the conclusion that the high density fluid in the lateral ventricles is not a intracranial bleeding but rather fat deriving from the complex pelvic and lumbar spine fracture into the CSF system. Therefore, an immediate operation was performed to stabilize the spinopelvic dissociation and to close the injured dural sheath. Additionally, a ventricle drainage has been placed, which confirmed the diagnosis of intrathecal fat embolism. Afterwards, complex plastic surgery was necessary to restore the soft tissue damage. CONCLUSIONS: Intrathecal fat embolism in muliple trauma patients is a rare condition, which should be considered in patients with complex spine or pelvic injuries. It is important to distinguish this rare condition from intracranial bleedings, which are much more common because the consequent therapeutic strategy is quite different. In case of intrathecal fat embolism, a ventricle drainage system should be placed immediately, and the underlying spine or pelvic injuries need to be stabilized combined with closure of the dural sheath to prevent continuous fat embolism and meningeal infection.