Settlement Is at the End-Common Trauma Scores Require a Critical Reassessment Due to the Possible Dynamics of Traumatic Brain Injuries in Patients' Clinical Course.

Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIShead (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis.

The Impact of Defect Size on Bone Healing in Critical-Size Bone Defects Investigated on a Rat Femur Defect Model Comparing Two Treatment Methods.

Critical-size bone defects up to 25 cm can be treated successfully using the induced membrane technique established by Masquelet. To shorten this procedure, human acellular dermis (HAD) has had success in replacing this membrane in rat models. The aim of this study was to compare bone healing for smaller and larger defects using an induced membrane and HAD in a rat model. Using our established femoral defect model in rats, the animals were placed into four groups and defects of 5 mm or 10 mm size were set, either filling them with autologous spongiosa and surrounding the defect with HAD or waiting for the induced membrane to form around a cement spacer and filling this cavity in a second operation with a cancellous bone graft. Healing was assessed eight weeks after the operation using µ-CT, histological staining, and an assessment of the progress of bone formation using an established bone healing score. The α-smooth muscle actin used as a signal of blood vessel formation was stained and counted. The 5 mm defects showed significantly better bone union and a higher bone healing score than the 10 mm defects. HAD being used for the smaller defects resulted in a significantly higher bone healing score even than for the induced membrane and significantly higher blood vessel formation, corroborating the good results achieved by using HAD in previous studies. In comparison, same-sized groups showed significant differences in bone healing as well as blood vessel formation, suggesting that 5 mm defects are large enough to show different results in healing depending on treatment; therefore, 5 mm is a viable size for further studies on bone healing.

Cell-Based Therapy by Autologous Bone Marrow-Derived Mononuclear Cells for Bone Augmentation of Plate-Stabilized Proximal Humeral Fractures: A Multicentric, Randomized, Open Phase IIa study.

Proximal humerus fractures are common in an aging population. The standard operative treatment is open reduction internal fixation (ORIF) using an angular stable plate. However, this procedure has complications such as a relatively high rate of secondary dislocation, humeral head necrosis or nonunion caused by delayed bony consolidation. Autologous bone marrow mononuclear cells (BMC) combined with a ß-TCP scaffold could support bone healing and is considered clinically safe. This multicentric, randomized, open phase IIa clinical trial (Clinical Trials. Gov Identifier: NCT02803177, Eudra CT No: 2015-001820-51) evaluated whether autologous BMC with ß-TCP in addition to ORIF reduces the incidence of secondary dislocations in patients with proximal humerus fracture. Ninty-four patients equally divided between verum group (BMC+ß-TCP) and control group (ß-TCP only) were targeted and calculated. At the time of planned interim evaluation, ie, enrolment of 56 patients, no statistical difference in secondary dislocations or complications was demonstrated in either group after an observation period of 12 weeks. Radiographic bone healing and DASH score to determine shoulder function were comparable between both groups. Bone marrow harvest and BMC transplantation did not result in any severe adverse events. Therefore, the study was terminated after the interim analysis, as no other result could be expected. From the study results, it can be concluded that the application of autologous BMC is well tolerated, and bone healing can be achieved. Augmentation of bone defects with ß-TCP could be shown to be feasible and might be considered in other clinical situations.

Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider.

Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.

Measuring Bone Healing: Parameters and Scores in Comparison.

(1) Background: Bone healing is a complex process that can not be replicated in its entirety in vitro. Research on bone healing still requires the animal model. The critical size femur defect (CSFD) in rats is a well-established model for fractures in humans that exceed the self-healing potential. New therapeutic approaches can be tested here in vivo. Histological, biomechanical, and radiological parameters are usually collected and interpreted. However, it is not yet clear to what extent they correlate with each other and how necessary it is to record all parameters. (2) Methods: The basis for this study was data from three animal model studies evaluating bone healing. The µCT and histological (Movat pentachrome, osteocalcin) datasets/images were reevaluated and correlation analyses were then performed. Two image processing procedures were compared in the analysis of the image data. (3) Results: There was a significant correlation between the histologically determined bone fraction (Movat pentachrome staining) and bending stiffness. Bone fraction determined by osteocalcin showed no prognostic value. (4) Conclusions: The evaluation of the image datasets using ImageJ is sufficient and simpler than the combination of both programs. Determination of the bone fraction using Movat pentachrome staining allows conclusions to be drawn about the biomechanics of the bone. A standardized procedure with the ImageJ software is recommended for determining the bone proportion.

EVALUATION OF CYFRA 21-1, ANGIOPOETIN-2, PENTRAXIN-3, SRAGE, IL-6, AND IL-10 IN POLYTRAUMATIZED PATIENTS WITH CONCOMITANT THORACIC TRAUMA-HELPFUL MARKERS TO PREDICT PNEUMONIA?

ABSTRACT: Background: Pneumonia is a frequent complication after polytrauma. This study aims to evaluate the ability of different serum markers to identify patients at risk of developing pneumonia after polytrauma. Methods: A retrospective analysis of prospectively collected data in polytraumatized patients with concomitant thoracic trauma (Injury Severity Score ≥16, Abbreviated Injury Scale Thorax ≥ 3) was performed. The study cohort was divided into patients with and without pneumonia during the clinical course. Serum levels of lung epithelial (CYFRA 21-1), endothelial (Ang-2), and inflammatory (PTX-3, sRAGE, IL-6, IL-10) markers were measured upon arrival in the trauma room and on days 2 and 5. Results: A total of 73 patients and 16 healthy controls were included in this study. Of these, 20 patients (27.4%) developed pneumonia. Polytraumatized patients showed significantly increased CYFRA 21-1 levels with a distinct peak after admission compared with healthy controls. Serum PTX-3 significantly increased on day 2 in polytraumatized patients compared with healthy controls. Injury Severity Score and demographic parameters were comparable between both groups (pneumonia vs. no pneumonia). No statistically significant difference could be observed for serum levels of CYFRA 21-1, Ang-2, PTX-3, sRAGE, IL-6, and IL-10 between the groups (pneumonia vs. no pneumonia) on all days. Logistic regression revealed a combination of IL-6, IL-10, sRAGE, and PTX-3 to be eventually helpful to identify patients at risk of developing pneumonia and our newly developed score was significantly higher on day 0 in patients developing pneumonia ( P < 0.05). Conclusion: The investigated serum markers alone are not helpful to identify polytraumatized patients at risk of developing pneumonia, while a combination of IL-6, IL-10, PTX-3, and sRAGE might be.

Local Gentamicin Fixation with Sprayed Fibrin-An In Vivo Animal Study Reveals New Options to Treat Soft Tissue Infections.

For acute and chronic soft tissue infections, radical surgical debridement is required and is considered the gold standard, along with its immediate systemic antibiotic therapy. Treatment with local antibiotics and/or antibiotic-containing materials is commonly used as an additional tool in clinical practice. Spraying with fibrin and antibiotics is a newer technique that has been studied for some antibiotics. However, for gentamicin, data are not yet available on absorption, optimal application, antibiotic fate at the site and transfer of antibiotic into the blood. In an animal study involving 29 Sprague Dawley rats, 116 back wounds were sprayed with gentamicin using either gentamicin alone or one of two possible spray combinations of gentamicin and fibrin. Simultaneous application of gentamicin and fibrin via a spray system to soft tissue wounds resulted in significant antibiotic concentration over a long period of time. The technique is easy and cost-effective. The systemic crossover was significantly minimized in our study, which may have led to fewer side effects in patients. These results could lead to an improvement in local antibiotic therapy.

One Stage Masquelets Technique: Evaluation of Different Forms of Membrane Filling with and without Bone Marrow Mononuclear Cells (BMC) in Large Femoral Bone Defects in Rats.

The classic two-stage masquelet technique is an effective procedure for the treatment of large bone defects. Our group recently showed that one surgery could be saved by using a decellularized dermis membrane (DCD, Epiflex, DIZG). In addition, studies with bone substitute materials for defect filling show that it also appears possible to dispense with the removal of syngeneic cancellous bone (SCB), which is fraught with complications. The focus of this work was to clarify whether the SCB can be replaced by the granular demineralized bone matrix (g-DBM) or fibrous demineralized bone matrix (f-DBM) demineralized bone matrix and whether the colonization of the DCD and/or the DBM defect filling with bone marrow mononuclear cells (BMC) can lead to improved bone healing. In 100 Sprague Dawley rats, a critical femoral bone defect 5 mm in length was stabilized with a plate and then encased in DCD. Subsequently, the defect was filled with SCB (control), g-DBM, or f-DBM, with or without BMC. After 8 weeks, the femurs were harvested and subjected to histological, radiological, and biomechanical analysis. The analyses showed the incipient bony bridging of the defect zone in both groups for g-DBM and f-DBM. Stability and bone formation were not affected compared to the control group. The addition of BMCs showed no further improvement in bone healing. In conclusion, DBM offers a new perspective on defect filling; however, the addition of BMC did not lead to better results.

Saturday Night Fever: Interpersonal Violence as a Reason for Presentation in a University Emergency Department.

(1) Presentations to a trauma emergency department following a violent confrontation account for a relevant proportion of the overall population. To date, violence (against women) in the domestic setting has been studied in particular. However, representative demographic and preclinical/clinical data outside of this specific subgroup on interpersonal violence are limited; (2) Patient admission records were searched for the occurrence of violent acts between 1 January and 31 December 2019. A total of 290 patients out of over 9000 patients were retrospectively included in the "violence group" (VG). A "typical" traumatologic cohort (presentation due to, among other things, sport-related trauma, falls, or traffic accidents) who had presented during the same period served as comparison group. Then, differences in the type of presentation (pedestrian, ambulance, or trauma room), time of presentation (day of week, time of day), diagnostic (imaging) and therapeutic (wound care, surgery, inpatient admission) measures performed, and discharge diagnosis were examined; (3) A large proportion of the VG were male, and half of the patients were under the influence of alcohol. Significantly more patients in the VG presented via the ambulance service or trauma room and during the weekend and the night. Computed tomography was performed significantly more often in the VG. Surgical wound care in the VG was required significantly more often, with injuries to the head being the most common; (4) The VG represents a relevant cost factor for the healthcare system. Because of the frequent head injuries with concomitant alcohol intoxication, all mental status abnormalities should be attributed to brain injury rather than alcohol intoxication until proven otherwise, to ensure the best possible clinical outcome.

Cranial CT is a mandatory tool to exclude asymptomatic cerebral hemorrhage in elderly patients on anticoagulation.

Background: Traumatic brain injury (TBI) after falls causes death and disability with immense socioeconomic impact through medical and rehabilitation costs in geriatric patients. Diagnosing TBI can be challenging due to the absence of initial clinical symptoms. Misdiagnosis is particularly dangerous in patients on permanent anticoagulation because minimal trauma might result in severe intracranial hemorrhage. The aim of this study is to evaluate the diagnostic necessity of cranial computed tomography (cCT) to rule out intracranial hemorrhage, particularly in the absence of neurologic symptoms in elderly patients on permanent anticoagulation in their premedication. Patients and methods: Retrospective cohort analysis of elderly trauma patients (≥ 65 years) admitted to the emergency department (ED) of the level-1-trauma center of the University Hospital Frankfurt from 01/2017 to 12/2019. The study included patients who suffered a ground-level fall with suspected TBI and subsequently underwent CT because of preexisting anticoagulation. Results: A total of 227 patients met the inclusion criteria. In 17 of these patients, cCT showed intracranial hemorrhage, of which 14 were subdural hematomas (SDH). In 8 of the patients with bleeding showed no clinical symptoms, representing 5% (n = 160) of all symptom-free patients. Men and women were equally to suffer a post-traumatic hemorrhage. Patients with intracranial bleeding were hospitalized for 14.5 (±10.4) days. Acetylsalicylic acid (ASA) was the most prescribed anticoagulant in both patient cohorts-with or without intracerebral bleeding (70.6 vs. 77.1%, p = 0.539). Similarly, patients taking new oral anticoagulant (NOAC) (p = 0.748), coumarins, or other platelet inhibitors (p > 0.1) did not show an increased bleeding incidence. Conclusion: Acetylsalicylic acid and NOAC use are not associated with increased bleeding risk in geriatric trauma patients (≥ 65 years) after fall-related TBI. Even in asymptomatic elderly patients on anticoagulation, intracranial hemorrhage occurs in a relevant proportion after minor trauma to the head. Therefore, cCT is an obligatory tool to rule out cerebral hemorrhage in elderly patients under anticoagulation.

[Costs-revenue deficit of outpatient treatment of minor injuries in the emergency department]. / Kosten-Erlös-Defizit der ambulanten Versorgung von Bagatellverletzungen in der Notaufnahme.

BACKGROUND: Many patients with minor injuries hastily present in the emergency department and tie up resources and personnel there. OBJECTIVE: To establish the cost-revenue relationship of outpatient care of minor injuries in the traumatology emergency department. MATERIAL AND METHODS: The calculation was based on the uniformly billed emergency flat rates of the uniform assessment standard (EBM). Using the current collective bargaining agreements for physicians and nurses, per minute costs were calculated. The time required for treatment was determined on the basis of 100 reference patients with minor injuries. The case cost calculation with the respective resources was carried out with the operational controlling of the University Hospital Frankfurt. RESULTS: A total of 4088 patients with minor injuries who presented in 2019 were included. Most common reasons for presentation were contusions of the lower (31.9%; n = 1303) and upper extremities (16.6%; n = 677). A time expenditure of 166.7 min per day for the medical staff and 213.8 min per day for nursing staff was calculated. A total revenue of 29,384.31 € and total costs of 69,591.22 € were calculated. Thus, a revenue deficit of -40,206.91 € can be calculated for the year 2019. This corresponds to a monetary deficit of 9.84 € per patient. CONCLUSION: There is a shortage of the medical resource "personnel" to satisfactorily and economically manage the nowadays high volume of self-presenting pedestrian patients with minor injuries. The current remuneration of the treatment of minor injuries by the uniform assessment scale is insufficient for the hospital sector.

Early start of thromboprophylaxis does not increase risk of intracranial hematoma progression in multiply injured patients with traumatic brain injury.

BACKGROUND: Venous thromboembolism (VTE) in severely injured patients with severe traumatic brain injury (TBI) is a risk during the clinical course. Data on the safety of an early initiation of pharmacological VTE prophylaxis in severely injured patients with concomitant severe TBI is sparse. METHODS: Admissions to our level-1-trauma center between January 2015 and December 2018 were screened. Patients suffering from severe TBI (Abbreviated Injury Scale (AIS) of the head ≥3) and at least one further AIS ≥ 3 in any other body region were included. Demographic data, thromboembolic events, and progression of the intracranial hemorrhage were extracted from the patient's charts. According to the first application of pharmacological thromboprophylaxis (VTEp), patients were categorized either to the early, the late (later than 24 h) or the no therapy group. RESULTS: In 79 patients (early: n = 35, late: n = 29, no therapy: n = 15) the Injury Severity Score (ISS) was 36.7 ± 12.7 points (AIShead 4.1 ± 0.8). No differences were found regarding the progression of the intracranial hemorrhage after initiation of the VTE prophylaxis (adj. p = 0.8). The VTE rate was low (n = 1, 1.6%). CONCLUSION: In severely injured patients with severe TBI, the early administration of pharmacological thromboprophylaxis did not result in a higher rate of intracranial hematoma progression.

Health Economic Challenge: Geriatric Trauma-An Age-Based Observational Analysis of Treatment Costs and Reimbursement Issues.

Demographic change is having a major impact on the economic and structural development of the healthcare system. People stay active longer and the number of mild traumatic brain injury [mTBI] in patients ≥ 65 years of age consequently increases. The aim of this comparative analysis is to illustrate the impact of demographic change and the increasing treatment of geriatric trauma patients on the cost structure of the health care system using mTBI as an example diagnosis. Patients and Methods: The 12-month retrospective analysis included 220 in-patients treated with mTBI and remunerated under the German Diagnosis Related Group [G-DRG] B80Z. For comparative analysis, the patient population was divided into two study groups according to age [U65 18−64 years, G65 ≥ 65 years]. For the cost and proceeds calculation, itemized cost reports (personnel, supply, material, and equipment costs, etc.) were created. Results: 163 patients U65 and 57 patients G65 were included. In the G65 group, the most frequent accident mechanism was a fall from a short distance (84.1 vs. U65 36.7%; p = 0.007). For the inpatient admission of G65, the use of anticoagulants (p < 0.001) and comorbidity (p = 0.002) played a primary role, while for younger patients it was more neurological symptoms (p < 0.001) and alcohol (p < 0.001) that led to inpatient monitoring. The mean length of hospitalization of G65 patients was significantly longer than that of younger patients (G65 2.4 ± 1.9 days > U65 1.7 ± 0.8 days; p = 0.007) and radiological examinations (G65 94.7% > U65 23.3%; p = 0.013) were performed more frequently. Comparing analysis of the cost and proceeds of U65 vs. G65 results in a proceeds difference of €51,753.91 per year for the G-DRG B80Z compared to U65. Conclusions: It has been shown that there is a difference in costs and proceeds when comparing younger and older patients, resulting in a reimbursement deficit. In view of the demographic development in Europe, flat-rate remuneration will lead to a considerable discrepancy between DRG reimbursement and the coverage of hospitals' running costs. Providing health care to an increasingly aging society represents one of the major personnel and financial challenges for the public health system in the coming decades. Further adaptation of the DRG system to the growing costs caused by older patients is imperative.

Local Fixation of Colistin With Fibrin Spray: An in vivo Animal Study for the Therapy of Skin and Soft Tissue Infections.

Objective: Skin and soft tissue infections (SSTI) are a commonly known entity of diseases associated with difficult treatment procedures. The current gold standard when there is a rapidly progressing infection of soft tissues with a risk of sepsis is radical surgical debridement accompanied by systemic antibiotic therapy. In clinical settings, local antibiotics alone or formulated within carrier material are commonly used alongside this therapy regimen. One possibility of local antibiotic application is the fixation of colistin with fibrin glue spray. It is not yet sufficiently researched how the local antibiotic concentrations remain as high as possible over time. Methods: We conducted an animal study including 29 male Wistar rats inducing sterile back sores reaching the muscle fascia. We sprayed only colistin, simultaneously or consecutively, with fibrin glue in different groups in order to measure the tissue concentration of the antibiotic applied locally. Results: After liquid chromatography and quadrupole mass spectrometry analysis, it could be demonstrated that in comparison to the colistin group, tissue concentrations of colistin stayed significantly higher in the wound tissue when it was fixed with fibrin glue. This was observed in both groups, the simultaneous as well as in the consecutively fibrin glue sprayed groups after colistin application. Conclusion: The fixation of colistin with the fibrin-glue-spray technique as a carrier for local antibiotic therapy is an easy and inexpensive method and shows promising potential for the treatment of SSTI.

Primary or revision arthroplasty with an integrated acetabular cup-MUTARS® RS cup system.

INTRODUCTION: The aim of this article is to show a new concept of indication and application of the MUTARS® RS Cup System in primary and revision hip arthroplasty. This integrated system is applicable for different acetabular cup replacements in patients with acetabular fractures or instable defects, as well as periprosthetic acetabular fractures. The MUTARS® RS Cup System is a cementless revision cup for insertion into the acetabulum with an integrated polyethylene cup, which fits to a regular or bipolar head. This system replaces the conventional approach for acetabular revision with a Burch-Schneider ring, in which a normal polyethylene cup is cemented. This interface with its complications is avoided with this system of a titanium revision cup with integrated polyethylene cup. Steps of preoperative planning and the intraoperative implementation will be highlighted in this article. MATERIAL AND METHODS: This system was applied in 49 patients with 52 MUTARS® RS Cup Implantations in 30 males, 22 females, with an average age of 76,1 years (36,9-94,4 years). RESULTS AND DISCUSSION: The system shows a good operative feasibility, as well as a reliable handling and safe method for stable treatment of non-reconstructable acetabular fractures or acetabular incongruencies and instabilities.

The Induced Membrane Technique-The Filling Matters: Evaluation of Different Forms of Membrane Filling with and without Bone Marrow Mononuclear Cells (BMC) in Large Femoral Bone Defects in Rats.

The Masquelet technique is used to treat large bone defects; it is a two-stage procedure based on an induced membrane. To improve the induced membrane process, demineralized bone matrix in granular (GDBM) and fibrous form (f-DBM) was tested with and without bone marrow mononuclear cells (BMC) as filling of the membrane against the gold standard filling with syngeneic cancellous bone (SCB). A total of 65 male Sprague-Dawley rats obtained a 5 mm femoral defect. These defects were treated with the induced membrane technique and filled with SCB, GDBM, or f-DBM, with or without BMC. After a healing period of eight weeks, the femurs were harvested and submitted for histological, radiological, and biomechanical analyses. The fracture load in the defect zone was lower compared to SCB in all groups. However, histological analysis showed comparable new bone formation, bone mineral density, and cartilage proportions and vascularization. The results suggest that f-DBM in combination with BMC and the induced membrane technique cannot reproduce the very good results of this material in large, non-membrane coated bone defects, nevertheless it supports the maturation of new bone tissue locally. It can be concluded that BMC should be applied in lower doses and inflammatory cells should be removed from the cell preparation before implantation.

Injury Patterns after Falling down Stairs-High Ratio of Traumatic Brain Injury under Alcohol Influence.

Falling down a staircase is a common mechanism of injury in patients with severe trauma, but the effect of varying fall height according to the number of steps on injury patterns in these patients has been little studied. In this retrospective study, prospectively collected data from a Level 1 Trauma Center in Germany were analyzed regarding the injury patterns of patients admitted through the trauma room with suspicion of multiple injuries following a fall down a flight of stairs between January 2016 and December 2019. In total 118 patients were examined which where consecutively included in this study. More than 80% of patients suffered a traumatic brain injury, which increased as a function of the number of stairs fallen. Therefore, the likelihood of intracranial hemorrhage increased with higher numbers of fallen stairs. Fall-associated bony injuries were predominantly to the face, skull and the spine. In addition, there was a high coincidence of staircase falls and alcohol intake. Due to a frequent coincidence of staircase falls and alcohol, the (pre-)clinical neurological assessment is complicated. As the height of the fall increases, severe traumatic brain injury should be anticipated and diagnostics to exclude intracranial hemorrhage and spinal injuries should be performed promptly to ensure the best possible patient outcome.

Manikins versus simulated patients in emergency medicine training: a comparative analysis.

PURPOSE: Every physician must be able to sufficiently master medical emergencies, especially in medical areas where emergencies occur frequently such as in the emergency room or emergency surgery. This contrasts with the observation that medical students and young residents often feel insufficiently prepared to handle medical emergencies. It is therefore necessary to train them in the treatment of emergency patients. The aim of this study is to analyze the influence of the assignment of manikin versus simulated patients during a training for undergraduate medical students on learning outcomes and the perceived realism. METHODS: The study had a prospective cross-over design and took place in a 3-day emergency medicine training for undergraduate medical students. Students completed three teaching units ('chest pain', 'impaired consciousness', 'dyspnea'), either with manikin or simulated patient. Using a questionnaire after each unit, overall impression, didactics, content, the quality of practical exercises, and the learning success were evaluated. The gained competences were measured in a 6-station objective structured clinical examination (OSCE) at the end of training. RESULTS: 126 students participated. Students rated simulated patients as significantly more realistic than manikins regarding the possibility to carry out examination techniques and taking medical history. 54.92% of the students would prefer to train with simulated patients in the future. Regarding the gained competences for 'chest pain' and 'impaired consciousness', students who trained with a manikin scored less in the OSCE station than the simulated patients-group. CONCLUSION: Simulated patients are rated more realistic than manikins and seem to be superior to manikins regarding gained competence.

Combined trauma in craniomaxillofacial and orthopedic-traumatological patients: the need for proper interdisciplinary care in trauma units.

AIM: The primary aim of this study was to analyze frequency and characteristics of combined facial and peripheral trauma with consecutive hospitalization and treatment. MATERIALS AND METHODS: The study included all patients with concomitant orthopedic-traumatolgical (OT) and craniomaxillofacial (CMF) injuries admitted to our level I trauma center in 2018. The data were collected by analysis of the institution's database and radiological reviews and included age, sex, injury type, weekday and time of presentation. All patients were examined and treated by a team of surgeons specialized in OT and CMF directly after presentation. RESULTS: A total number of 1040 combined OT and CMF patients were identified. Mean age was 33.0 ± 26.2 years. 67.3% (n = 700) were male patients. Primary presentation happened most frequently on Sundays (n = 199) and between 7 and 8 pm (n = 74). 193 OT fractures were documented, where cervical spine injuries were most frequent (n = 30). 365 facial and skull fractures were recorded. 10.8% of the 204 patients with fractures of the viscerocranium presented with at least one fracture of the extremity, 7.8% (16/204) with cervical spine fractures, 33.3% (68/204) with signs of closed brain trauma and 9.8% (20/204) with intracranial hemorrhage. DISCUSSION: The study shows a high frequency of combined facial with OT-injuries and brain damage in a predominantly young and male cohort. Attendance by interdisciplinary teams of both CMF and OT surgeons specialized in cervical spine trauma surgery is highly advisable for adequate treatment. CONCLUSION: Diagnostics and treatment should be performed by a highly specialized OT and CMF team, with a consulting neurosurgeon in a level-1 trauma center to avoid missed diagnoses and keep mortality low.

Orbital floor fractures: epidemiology and outcomes of 1594 reconstructions.

OBJECTIVE: The aim of this study was to retrospectively review the midface and orbital floor fractures treated at our institution with regard to epidemiological aspects, surgical treatment options and postoperative complications and discuss this data with the current literature. STUDY DESIGN: One thousand five hundred and ninety-four patients with midface and orbital fractures treated at the Department of Oral, Cranio-Maxillofacial and Facial Plastic Surgery of the Goethe University Hospital in Frankfurt (Germany) between 2007 and 2017 were retrospectively reviewed. The patients were evaluated by age, gender, etiology, fracture pattern, defect size, surgical treatment and complications. RESULTS: The average patient age was 46.2 (± 20.8). Most fractures (37.5%) occurred in the age between 16 and 35. Seventy-two percent of patients were male while 28% were female. The most common cause of injury was physical assault (32.0%) followed by falls (30.8%) and traffic accidents (17.0%). The average orbital wall defect size was 297.9 mm2 (± 190.8 mm2). For orbital floor reconstruction polydioxanone sheets (0.15 mm 38.3%, 0.25 mm 36.2%, 0.5 mm 2.8%) were mainly used, followed by titanium meshes (11.5%). Reconstructions with the 0.15 mm polydioxanone sheets showed the least complications (p < 0.01, r = 0.15). Eighteen percent of patients who showed persistent symptoms and post-operative complications: 12.9% suffered from persistent hypoesthesia, 4.4% suffered from post-operative diplopia and 3.9% showed intra-orbital hematoma. CONCLUSION: Results of the clinical outcome in our patients show that 0.15 mm resorbable polydioxanone sheets leads to significantly less post-operative complications for orbital floor defects even for defects beyond the recommended 200 mm2.