Validation of two methods to measure posterior tilt in femoral neck fractures.

INTRODUCTION: Posterior tilt of the femoral head in femoral neck fractures (FNF) may influence stability of the fracture and may therefore affect the treatment outcome. Posterior tilt can be measured with different methods. The Lateral Garden Angle (LGA) has been used for this purpose for decades and more recently the Posterior Tilt Measurement (PTM) was introduced. Despite the fact that both methods (LGA and PTM) are used in multiple studies, they have never been compared for reliability in a direct study. The aim of this study is to analyze the intra and inter observer reliability of the LGA described by Garden and the PTM according to Palm. METHODS: Four observers measured the posterior tilt on the radiographs of 50 FNF two times with both methods. Intra and inter observer reliability were determined for the LGA and the PTM. RESULTS: The intra observer reliability for both methods is substantial with an intra class coefficient of 0.75. The inter observer reliability of the PTM is also substantial with an intra class coefficient of 0.75 compared to a moderate reliability of the LGA with an intraclass coefficient of 0.60. CONCLUSION: Based on our results we believe the LGA and the PTM are both reliable methods to measure posterior tilt. Yet the Posterior Tilt Measurement seems to have a better inter observer reliability and therefore has a slight preference over the Lateral Garden Angle.

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury.

BACKGROUND: Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment. METHODS: The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up. RESULTS: At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain. CONCLUSIONS: Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive-behavioural techniques involving reducing catastrophizing might be useful.

Influence of routine computed tomography on predicted survival from blunt thoracoabdominal trauma.

INTRODUCTION: Many scoring systems have been proposed to predict the survival of trauma patients. This study was performed to evaluate the influence of routine thoracoabdominal computed tomography (CT) on the predicted survival according to the trauma injury severity score (TRISS). PATIENTS AND METHODS: 1,047 patients who had sustained a high-energy blunt trauma over a 3-year period were prospectively included in the study. All patients underwent physical examination, conventional radiography of the chest, thoracolumbar spine and pelvis, abdominal sonography, and routine thoracoabdominal CT. From this group with routine CT, we prospectively defined a selective CT (sub)group for cases with abnormal physical examination and/or conventional radiography and/or sonography. Type and extent of injuries were recorded for both the selective and the routine CT groups. Based on the injuries found by the two different CT algorithms, we calculated the injury severity scores (ISS) and predicted survivals according to the TRISS methodology for the routine and the selective CT algorithms. RESULTS: Based on injuries detected by the selective CT algorithm, the mean ISS was 14.6, resulting in a predicted mortality of 12.5%. Because additional injuries were found by the routine CT algorithm, the mean ISS increased to 16.9, resulting in a predicted mortality of 13.7%. The actual observed mortality was 5.4%. CONCLUSION: Routine thoracoabdominal CT in high-energy blunt trauma patients reveals more injuries than a selective CT algorithm, resulting in a higher ISS. According to the TRISS, this results in higher predicted mortalities. Observed mortality, however, was significantly lower than predicted. The predicted survival according to MTOS seems to underestimate the actual survival when routine CT is used.

First aid and basic life support: a questionnaire survey of medical schools in the Netherlands.

PURPOSE: Adequate education in first aid and basic life support (BLS) should be considered as an essential aspect of the medical curriculum. The objective of this study was to investigate the current medical training in first aid and BLS at all 8 medical schools in the Netherlands. SUMMARY: An evaluation was made, by sending a questionnaire to all medical schools, regarding whether the medical training was performed in accordance with the national Dutch guidelines for medical education. The response was 100%. Seven of the eight medical schools train their students in first aid and BLS during the medical curriculum. An average of only 38% of the clinical pictures and diseases and 69% of the skills were mastered at the level-defined national Dutch guidelines. CONCLUSION: The medical education in the Netherlands does not meet the required objectives as stated in the national Dutch guidelines concerning first aid and BLS.

Exsanguination in trauma: A review of diagnostics and treatment options.

Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing 'blind' transfusion or 'damage control resuscitation', a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

Increased vagal tone accounts for the observed immune paralysis in patients with traumatic brain injury.

Traumatic brain injury (TBI) is a leading cause of death and disability, especially in the younger population. In the acute phase after TBI, patients are more vulnerable to infection, associated with a decreased immune response in vitro. The cause of this immune paralysis is poorly understood. Apart from other neurologic dysfunction, TBI also results in an increase in vagal activity. Recently, the vagus nerve has been demonstrated to exert an anti-inflammatory effect, termed the cholinergic anti-inflammatory pathway. The anti-inflammatory effects of the vagus nerve are mediated by the alpha 7 nicotinic acetylcholine receptor present on macrophages and other cytokine-producing cells. From these observations, we hypothesize that the immune paralysis observed in patients with TBI may, at least in part, result from augmented vagal activity and subsequent sustained effects of the cholinergic anti-inflammatory pathway. This pathway may counteract systemic proinflammation caused by the release of endogenous compounds termed alarmins as a result of tissue trauma. However, sustained activity of this pathway may severely impair the body's ability to combat infection. Since the cholinergic anti-inflammatory pathway can be pharmacologically modulated in humans, it could represent a novel approach to prevent infections in patients with TBI.

[Walking in the sun: heat stroke and heat exhaustion during the Four-Day March in Nijmegen, in 2006]. / Wandelen in de zon: hitteberoerte en hitte-uitputting tijdens de Nijmeegse Vierdaagse 2006.

The annual Four-Day March in Nijmegen, The Netherlands, in July 2006 was cancelled after the first day because two participants had died, men aged 65 and 57 years, and many had become unwell while walking in unusually high ambient temperatures. However, the cause of death of the two who died turned out to be cardiovascular and not heat-related. The case of two of the people that became unwell, men aged 58 and 59 years, respectively, shows that heat stroke and heat exhaustion were important causative conditions. Heat-related illnesses are relatively uncommon in the Netherlands due to its temperate climate. Heat stroke is the most severe of these and associated with a high mortality rate if not recognised and treated promptly. The primary cause is accumulation of heat due either to diminished loss or increased endogenous heat production, such as by physical exertion. Heat exhaustion is caused by salt or water depletion.

Safety of computer-assisted surgery for cannulated hip screws.

Computer-assisted orthopaedic surgery has developed considerably during the past few years. Several manufacturers produce hardware and software for use in trauma surgery. Validation of these systems before clinical application is mandatory to be sure they work accurately and safely. The accuracy of surgical performance is highly correlated with the cut-out percentages of hip screws. In a standardized operative setting, three cannulated hip screws were inserted in each of 20 sawbones. The screws were positioned either by fluoroscopic navigation technique or by conventional operative technique depending on randomization. Our primary aim was to assess whether computer-navigated screw fixation is equally safe compared with conventional screw fixation using fluoroscopy. To determine safety, we investigated number of drilling attempts, screw position, and radiation time. Secondary to these safety parameters, we also compared the operating time between the two procedures to assess the efficiency of computer navigation. Statistical analysis showed no differences regarding accuracy of screw position. Computer-assisted surgery resulted in fewer drilling attempts and less radiation time, with a similar operation time. We believe the currently used navigation system is safe and accurate.

[Navigation surgery and fracture treatment]. / Navigatiechirurgie en fractuurbehandeling.

During operative fracture treatment the surgeon depends on fluoroscopic or X-ray radiological images as well as CT scans or MRI scans. This means that the surgeon sees only images at a given moment. Continuous imaging is technically complex and is accompanied by considerable exposure to radiation. Between images the surgeon has to depend on his or her knowledge of anatomical relationships and three-dimensional orientation. This may lead to the incorrect positioning of implants with ensuing morbidity and sometimes even death. Throughout the surgical procedure, computer assisted surgery (CAS) informs the surgeon of the exact position of the instruments in relation to the affected bone. The concept can be compared to that of the global positioning system (GPS) that is used by motorists. Clinical applications of CAS have been described for the operative treatment of vertebral fractures as well as fractures of the pelvis, hip and long bones. In reconstructive surgery, CAS is used for positioning the patient for total hip and knee surgery. The potential advantages of CAS are: increased accuracy, safety and reproducibility combined with lower radiation levels. Currently CAS is not widely used. There are a number of reasons for this. The technique is expensive and complex although the newer systems are more user friendly. It is possible that in the future CAS will be in standard use in orthopaedic and trauma surgery.

[Protocols for trauma care and the missing of injuries in severely injured accident victims during the prehospital phase]. / Protocollering van traumazorg en het missen van letsels bij ernstig gewonde ongevalspatiënten in de prehospitale fase.

Standardizing trauma care according to internationally accepted life-support principles is being increasingly implemented in the prehospital as well as the intramural setting. In the primary survey it is important to distinguish between aspects of major and minor importance, without losing sight of details. In prehospital care it is of little use to be focused on the complete diagnoses and the approach should be related to signs and symptoms. First attention should be paid to the mechanism of injury, related potential vital impairment and obvious visible injuries. The goal should be effective treatment, focused on the stabilization of vital functions and triage related to the choice of facility necessary for definitive care.

[Damage control surgery in polytraumatized patients]. / 'Damage control surgery' bij polytraumapatiënten.

Care for the polytraumatized patient in the pre-hospital phase has improved rapidly in recent years. This has resulted in more patients being alive on arrival at the hospital. The treatment of polytraumatized patients requires a different approach to that of regular trauma patients because they are threatened not only by the injuries themselves but also by the metabolic disruptions that follow. Therefore, the concept of damage control surgery (DCS) has been developed with the primary aim of controlling the life-threatening situation without immediate definitive repair of the sustained injuries. DCS describes a triphasic approach for abdominal and thoracic injuries and for injuries of the pelvic and extremities. The first phase aims at surgical intervention to stop the bleeding and to prevent further contamination. The second phase consists of resuscitation on the Intensive Care Unit and the third phase aims at definitive repair of the sustained injuries. Despite the low level of evidence found in the literature, DCS seems to reduce mortality rates in polytraumatized patients. Therefore, when initiated correctly and at the right moment, it appears to be a promising technique.

Prehospital chest tube thoracostomy: effective treatment or additional trauma?

BACKGROUND: The use of prehospital chest tube thoracostomy (TT) remains controversial because of presumed increased complication risks. This study analyzed infectious complication rates for physician-performed prehospital and emergency department (ED) TT. METHODS: Over a 40-month period, all consecutive trauma patients with TT performed by the flight physician at the accident scene were compared with all patients with TT performed in the emergency department. Bacterial cultures, blood samples, and thoracic radiographs were reviewed for TT-related infections. RESULTS: Twenty-two patients received prehospital TTs and 101 patients received ED TTs. Infected hemithoraces related to TTs were found in 9% of those performed in the prehospital setting and 12% of ED-performed TTs (not significant). CONCLUSION: The prehospital chest tube thoracostomy is a safe and lifesaving intervention, providing added value to prehospital trauma care when performed by a qualified physician. The infection rate for prehospital TT does not differ from ED TT.

The role of recombinant factor VIIa in the treatment of life-threatening haemorrhage in blunt trauma.

BACKGROUND: Recombinant factor VIIa (rFVIIa) is a novel haemostatic agent originally developed to treat bleeding in haemophiliacs. Several case reports suggest effectiveness of rFVIIa in the treatment of patients without pre-existing bleeding disorders. The aim of this study is to evaluate treatment with recombinant (rFVIIa) in blunt trauma patients with uncontrolled bleeding. PATIENTS AND METHODS: This study was designed as a retrospective case review. Consecutive patients with life-threatening uncontrolled bleeding due to blunt trauma who were treated with rFVIIa were selected. Data were obtained from medical records. RESULTS: A total of eight blunt trauma patients were treated with rFVIIa for uncontrolled bleeding. After treatment the need for transfusion of red blood cells (RBC) decreased significantly from 31.3 +/- 15.8 to 6.1 +/- 6.8 units (P = 0.003), fresh frozen plasma (FFP) from 13.3 +/- 6.6 to 5 +/- 6.3 units (P = 0.02), and platelets from 3.6 +/- 1.8 to 1.5 +/- 2.3 units (P = 0.01). Three patients died of non-bleeding complications. The other five fully recovered. CONCLUSION: Treatment with rFVIIa reduced or stopped bleeding in all patients. No adverse events were registered. Prospective studies are mandatory to elucidate the role of rFVIIa in blunt trauma.

Retrospective analysis of factors influencing the operative result after percutaneous osteosynthesis of intracapsular femoral neck fractures.

A retrospective analysis of 104 patients with an intracapsular femoral neck fracture, treated with closed reduction and internal fixation showed that the Garden classification, the age of the patient and the quality of reduction and fixation are predictors for the final outcome. Fractures with a Garden classification of 1 and 2 have significantly better results than Garden 3 and 4 (P < 0.01). An unsuccessful reduction of the fracture and a poor surgical fixation technique had significant effect on the outcome (P = 0.01 and 0.02, respectively). If internal fixation is considered, the reduction and the technique of fixation should be perfect.

Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures.

OBJECTIVE: To determine the stiffness and strength of various sacroiliac screw fixations to compare different sacroiliac screw techniques. DESIGN: Randomized comparative study on embalmed human pelvises. MATERIALS AND METHODS: In 12 specimens, we created a symphysiolysis and sacral fractures on both sides. Each of these 24 sacral fractures was fixed with 1 of the following methods: 1 sacroiliac screw in the vertebral body of S1, 2 screws convergingly in S1, or 1 screw in S1 and 1 in S2. On the left and right side of a pelvis, different techniques were used. The pubic symphysis was not stabilized. We measured the translation and rotation stiffness of the fixations and the load to failure using a 3-dimensional video system. RESULTS: The stiffness of the intact posterior pelvic ring was superior to any screw technique. Significant differences were found for the load to failure and rotation stiffness between the techniques with 2 screws and a single screw in S1. The techniques utilizing 2 screws showed no differences. CONCLUSIONS: Based on the results of this study, we can conclude that a second sacroiliac screw in completely unstable pelvic fractures increases rotation stiffness and improves the load to failure.

Beneficial effect of helicopter emergency medical services on survival of severely injured patients.

BACKGROUND: In Rotterdam, the Netherlands, a helicopter-transported medical team (HMT), staffed with a trauma physician, provides additional therapeutic options at the scene of injury. This study evaluated the influence of the HMT on the chance of survival of severely injured trauma victims. METHODS: This was a 2-year prospective observational study of consecutive adults who suffered multiple trauma (Injury Severity Score (ISS) 16 or more) and presented to the Erasmus Medical Centre emergency ward. The effect of the HMT was quantified by an odds ratio (OR), adjusted for confounding variables in logistic regression models. RESULTS: Complete data for a total of 346 patients were available for analysis. Two hundred and thirty-nine patients were treated by ambulance personnel alone and 107 received additional HMT assistance. Patients in the HMT group had significantly lower Glasgow Coma Scale scores (mean 8.9 versus 10.6; P = 0.001) and a higher ISS (mean 30.9 versus 25.3; P < 0.001). The unadjusted OR for death was 1.7 in favour of the group treated by ambulance staff only (OR for survival 0.61 (95 per cent confidence interval (c.i.) 0.37 to 1.0, P = 0.048)). After adjustment, however, patients in the HMT group had an approximately twofold better chance of survival (all injuries: OR 2.2 (95 per cent c.i. 0.92 to 5.9), P = 0.076; blunt injuries: OR 2.8 (95 per cent c.i. 1.07 to 7.52), P = 0.036). CONCLUSION: The presence of the HMT may increase chances of survival for patients suffering multiple trauma, especially for those with blunt trauma.