[Future perspective of the TraumaRegister DGU® : Further development, additional modules and potential limits]. / Zukunftsperspektiven des TraumaRegister DGU® : Weiterentwicklung, Zusatzmodule und potenzielle Grenzen.

Since its founding in 1993 the TraumaRegister DGU® has become one of the largest registries especially in terms of data diversity. Since the introduction of the TraumaNetzwerk DGU®, the TraumaRegister DGU® has enabled a quasi-nationwide picture of the quality of care of severely injured patients in Germany. The register is subject to constant development, under the guidance of the working groups of the German Society for Trauma Surgery (DGU). The first modular expansion of special injury entities (craniocerebral trauma and complex hand injuries) is currently taking place. The future developments will involve the extension of the register to certain injury patterns. The existing registry will also be supplemented with other recorded qualities (from the supplementary serum database up to the quality of life). This makes the TraumaRegister DGU® a tool for quality assurance and science which is well prepared for the future.

[Acute compartment syndrome after a bowling game]. / Kompartmentsyndrom nach Bowlingspiel.

A 28-year-old male patient was initially conservatively treated by a general physician for muscle strain of the right calf after a bowling game. Due to increasing pain and swelling of the lower leg 5 days later, the differential diagnosis of a deep vein thrombosis was considered. Furthermore, the onset of neurological deficits and problems with raising the foot prompted inclusion of compartment syndrome in the differential diagnosis for the first time. Admission to hospital for surgical intervention was scheduled for the following day. At this point in time the laboratory results showed a negative d-dimer value and greatly increased C-reactive protein level. On day 6 a dermatofasciotomy was performed which revealed extensive muscular necrosis with complete palsy of the peroneal nerve. In the following lawsuit the patient accused the surgeon of having misdiagnosed the slow-onset compartment syndrome and thus delaying correct and mandatory treatment. The arbitration board ruled that the surgeon should have performed fasciotomy immediately on day 5 at the patient's consultation. The clinical presentation of progressive pain, swelling of the lower leg in combination with peroneal palsy must lead to the differential diagnosis of compartment syndrome resulting in adequate therapy. The delay of immediate surgery, therefore, was assessed to be faulty as this knowledge is to be expected of a surgeon.

Association between volume of severely injured patients and mortality in German trauma hospitals.

BACKGROUND: The issue of patient volume related to trauma outcomes is still under debate. This study aimed to investigate the relationship between number of severely injured patients treated and mortality in German trauma hospitals. METHODS: This was a retrospective analysis of the TraumaRegister DGU® (2009-2013). The inclusion criteria were patients in Germany with a severe trauma injury (defined as Injury Severity Score (ISS) of at least 16), and with data available for calculation of Revised Injury Severity Classification (RISC) II score. Patients transferred early were excluded. Outcome analysis (observed versus expected mortality obtained by RISC-II score) was performed by logistic regression. RESULTS: A total of 39,289 patients were included. Mean(s.d.) age was 49.9(21.8) years, 27,824 (71.3 per cent) were male, mean(s.d.) ISS was 27.2(11.6) and 10,826 (29.2 per cent) had a Glasgow Coma Scale score below 8. Of 587 hospitals, 98 were level I, 235 level II and 254 level III trauma centres. There was no significant difference between observed and expected mortality in volume subgroups with 40-59, 60-79 or 80-99 patients treated per year. In the subgroups with 1-19 and 20-39 patients per year, the observed mortality was significantly greater than the predicted mortality (P < 0.050). High-volume hospitals had an absolute difference between observed and predicted mortality, suggesting a survival benefit of about 1 per cent compared with low-volume hospitals. Adjusted logistic regression analysis (including hospital level) identified patient volume as an independent positive predictor of survival (odds ratio 1.001 per patient per year; P = 0.038). CONCLUSION: The hospital volume of severely injured patients was identified as an independent predictor of survival. A clear cut-off value for volume could not be established, but at least 40 patients per year per hospital appeared beneficial for survival.

[Conservative treatment of distal radius fracture. Consequences of an uncritical follow-up]. / Konservative Behandlung einer distalen Radiusfraktur : Folgen einer unkritischen Verlaufskontrolle.

A 74-year-old woman sustained a fracture of the distal radius with an additional fracture of the styloid process of the ulna due to a fall. After reduction under local anesthesia immobilization treatment in a forearm cast was initiated. Despite increasing secondary dislocation during radiological x-ray follow-up control, the bone was described as correctly aligned by the treating physician and non-operative treatment was continued. After a total treatment period of 9 months including 7 months of physiotherapy the patient still presented a limited range of motion and local soft tissue swelling of the right wrist. The patient filed a complaint for wrong treatment of the distal radius fracture resulting in severe pain and considerable deformity of the right wrist leading to a significant handicap during activities of daily living. The expert opinion of the arbitration board ascertained a case of medical malpractice in terms of the indications. Due to the initial presence of criteria of radiological instability, an operative treatment had already been indicated at the first presentation. In addition, secondary dislocation during radiological follow-up examination should have led to conversion of treatment in favor of surgery. The arbitration board furthermore concluded that iatrogenic malpractice led to a severe deformity of the right wrist which would result in a loss of grip strength and future arthritic deformation of the wrist. Legal aspects of the case are discussed.

Is there a benefit to a routine preoperative screening of infectivity for HIV, hepatitis B and C virus before elective orthopaedic operations?

PURPOSE: Before elective operations, particularly orthopaedic surgery, national guidelines in Germany recommend testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) to reduce the risk of transmission of the virus through a needlestick or cutting injury. Such testing is expensive. The number of new and unknown diagnoses of viral infections that can be detected by routine screening has not yet been evaluated. METHODS: The aim of our department of orthopaedic surgery is to screen every adult patient listed for an operation for HBV, HCV and HIV. We retrospectively analysed the number of operations in this single centre from 2001 to 2010, correlated this number with the total number of screens and calculated the number of newly diagnosed infections. An additional cost:benefit ratio was calculated. RESULTS: A total of 20,869 operations were performed by the department between 2001 and 2010. After exclusion of all interventions in children and all patients who had multiple operations, 15,482 patients remained. Test results were found for 10,011 of these patients during this period (screening rate 65 %). Of those screened, in only four cases (0.4 ‰) was a previously unknown infection detected. CONCLUSIONS: Two-thirds of the patients included in our study actually underwent screening; this rate was lower than expected. The incidence of newly detected infections was low, putting the benefit of a routine preoperative screening for HBV, HCV and HIV into question. From an economic point of view the low detection rate is a strong argument in favour of omitting routine preoperative screening. Screening only those patients with risk factors may be as safe as screening every patient and would help reduce costs.

[Emergency room management of severely injured patients]. / Schockraumversorgung von schwer verletzten Patienten. Analyse vermeidbarer Abweichungen vom Behandlungsalgorithmus. Analysis of avoidable deviations from the treatment algorithm.

BACKGROUND: In cases involving major trauma life-threatening situations should be immediately diagnosed and treated. Clinical algorithms can potentially decrease the rate of complications and errors. The purpose of this study was to investigate the incidence of deviations from a multislice computed tomography based trauma room algorithm. MATERIALS AND METHODS: During a primary trauma survey an independent study monitor observed the on site treatment sequence step by step. Time intervals between admission and start of each procedure were recorded. Deviations from the algorithm and delays were analyzed. RESULTS: In 57 trauma patients a total of 49 deviations were documented. Median time between admission and transfer to the adjacent MSCT room was 9 min. Of the patients 11 were bypassed to the MSCT suite without a primary survey (19.3%). In 2 cases an absence of non-invasive blood pressure monitoring was recorded (3.5%) and 3 patients with potential cervical spine trauma were not immobilized at the scene or during primary survey (5.3%). In 8 cases focused assessment with sonography for trauma (FAST) was not performed (14%). Contrary to the algorithm 10 patients received an arterial or central venous line during initial treatment (18%) resulting in a median delay of 8 min. The deviations from the algorithm resulted in no adverse effects on complications or mortality. CONCLUSION: Self-critical analysis of trauma resuscitation can increase the quality of treatment by revealing constantly recurring faults.

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis.

OBJECTIVE: Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients. METHODS: The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management. RESULTS: Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm. CONCLUSIONS: The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Duration and predictors of emergency surgical operations--basis for medical management of mass casualty incidents.

BACKGROUND: Hospitals have a critically important role in the management of mass causality incidents (MCI), yet there is little information to assist emergency planners. A significantly limiting factor of a hospital's capability to treat those affected is its surgical capacity. We therefore intended to provide data about the duration and predictors of life saving operations. METHODS: The data of 20,815 predominantly blunt trauma patients recorded in the Trauma Registry of the German-Trauma-Society was retrospectively analyzed to calculate the duration of life-saving operations as well as their predictors. Inclusion criteria were an ISS≥16 and the performance of relevant ICPM-coded procedures within 6h of admission. RESULTS: From 1,228 patients fulfilling the inclusion criteria 1,793 operations could be identified as life-saving operations. Acute injuries to the abdomen accounted for 54.1% followed by head injuries (26.3%), pelvic injuries (11.5%), thoracic injuries (5.0%) and major amputations (3.1%). The mean cut to suture time was 130min (IQR 65-165min). Logistic regression revealed 8 variables associated with an emergency operation: AIS of abdomen ≥3 (OR 4,00), ISS ≥35 (OR 2,94), hemoglobin level ≤8 mg/dL (OR 1,40), pulse rate on hospital admission <40 or >120/min (OR 1,39), blood pressure on hospital admission <90 mmHg (OR 1,35), prehospital infusion volume ≥2000 ml (OR 1,34), GCS ≤8 (OR 1,32) and anisocoria (OR 1,28) on-scene. CONCLUSIONS: The mean operation time of 130min calculated for emergency life-saving surgical operations provides a realistic guideline for the prospective treatment capacity which can be estimated and projected into an actual incident admission capacity. Knowledge of predictive factors for life-saving emergency operations helps to identify those patients that need most urgent operative treatment in case of blunt MCI.

[Estimation of surgical treatment capacity for managing mass casualty incidents based on time needed for life-saving emergency operations]. / Abschätzung von Operationskapazitäten bei einem Massenanfall von Verletzten anhand des Zeitbedarfs für lebensrettende Notfalloperationen.

The surgical treatment capacity of a hospital constitutes a significant restriction in the capability to deal with critically injured patients from multiple or mass casualty incidents (MCI). With regard to the time needed for life-saving operative interventions there are no basic reference values available in the literature, which can aid in detailed planning for management of mass casualty incidents. The data of 20,815 trauma patients, recorded in the trauma registry hosted by the German Association for Trauma Surgery DGU, were analyzed to extract the median duration of life-saving surgical interventions carried out in an operating theatre. Inclusion criteria were an ISS > or = 16 and the performance of relevant ICPM coded procedures within 6 h after trauma room admission. Orthopedic procedures as well as the placement of ICP catheters and chest tubes or performance of laparoscopies were not included. Complete data sets with the required variables were available from 9,988 trauma patients with an ISS > or = 16, and included 7,907 interventions that took place within 6 h after hospital admission. From among 1,228 patients 1,793 operations could be identified as relevant life-saving emergency operations. Acute injury to the abdomen was the major cause accounting for 54.1% of all emergency surgical procedures with a median intervention duration of 137 min followed by head injuries accounting for 26.3% with a median duration of 110 min. Interventions in the pelvis amounted to 11.5% taking an average of 136 min, 5.0% were in the thorax requiring 91 min and 3.1% major amputations with 142 min. The average cut to suture time for all emergency surgical interventions was 130 min. A prerequisite for estimating the surgical operation capacity for critically injured patients of an MCI is the number of OR teams available during and outside of the normal working hours of the hospital. The average operation time of 130 min calculated from investigation of 1,793 emergency life-saving surgical procedures provides a realistic guideline. Used in combination with the number of available OR teams the prospective treatment capacity can be estimated and projected into an actual incident admission capacity. The identification and numerical value of such significant variables are the basis for operations research and realistic planning in emergency and disaster medicine.