Which pre-hospital triage parameters indicate a need for immediate evaluation and treatment of severely injured patients in the resuscitation area?

PURPOSE: To find ways to reduce the rate of over-triage without drastically increasing the rate of under-triage, we applied a current guideline and identified relevant pre-hospital triage predictors that indicate the need for immediate evaluation and treatment of severely injured patients in the resuscitation area. METHODS: Data for adult trauma patients admitted to our level-1 trauma centre in a one year period were collected. Outpatients were excluded. Correct triage for trauma team activation was identified for patients with an ISS or NISS ≥ 16 or the need for ICU treatment due to trauma sequelae. In this retrospective analysis, patients were assigned to trauma team activation according to the S3 guideline of the German Trauma Society. This assignment was compared to the actual need for activation as defined above. 13 potential predictors were retained. The relevance of the predictors was assessed and 14 models of interest were considered. The performance of these potential triage models to predict the need for trauma team activation was evaluated with leave-one-out cross-validated Brier and logarithmic scores. RESULTS: A total of 1934 inpatients ≥ 16 years were admitted to our trauma department (mean age 48 ± 22 years, 38% female). Sixty-nine per cent (n = 1341) were allocated to the emergency department and 31% (n = 593) were treated in the resuscitation room. The median ISS was 4 (IQR 7) points and the median NISS 4 (IQR 6) points. The mortality rate was 3.5% (n = 67) corresponding to a standardized mortality ratio of 0.73. Under-triage occurred in 1.3% (26/1934) and over-triage in 18% (349/1934). A model with eight predictors was finally selected with under-triage rate of 3.3% (63/1934) and over-triage rate of 10.8% (204/1934). CONCLUSION: The trauma team activation criteria could be reduced to eight predictors without losing its predictive performance. Non-relevant parameters such as EMS provider judgement, endotracheal intubation, suspected paralysis, the presence of burned body surface of > 20% and suspected fractures of two proximal long bones could be excluded for full trauma team activation. The fact that the emergency physicians did a better job in reducing under-triage compared to our final triage model suggests that other variables not present in the S3 guideline may be relevant for prediction.

Fragility fractures of the pelvis: should they be fixed?

Due to the aging population, there is an increasing number of fragility fractures of the pelvis (FFP). They are the result of low energy trauma. The bone breaks but the ligaments remain intact. Immobilizing pain at the pubic region or at the sacrum is the main symptom. Conventional radiographs reveal pubic rami fractures, but lesions of the dorsal pelvis are hardly visible and easily overlooked. CT of the pelvis with multiplanar reconstructions show the real extension of the lesion. Most patients have a history of osteoporosis or other fragility fractures. The new classification distinguishes between four categories of different and increasing instability. FFP Type I are anterior lesions only, FFP Type II are non-displaced posterior lesions, FFP Type III are displaced unilateral posterior lesions and FFP Type IV are displaced bilateral posterior lesions. Subgroups discriminate between the localization of the dorsal instability. FFP Type I lesions are treated non-operatively. FFP Type II lesions are fixed in a percutaneous procedure when a trial of conservative treatment was not successful. FFP Type III lesions are treated with open reduction and internal fixation (ORIF). FFP Type IV lesions are treated with bilateral ORIF or with a bridging osteosynthesis. Iliosacral screw osteosynthesis is widely used, but has an elevated risk of screw loosening due to diminished bine mineral density. Transsacral bar osteosynthesis enable interfragmentary compression and does not have this danger of loosening. Bridging plate osteosynthesis is used as an additional fixation to iliosacral screw osteosynthesis. Lumbopelvic fixation is restricted to highly unstable lumbopelvic dissociations. More studies are needed to find the optimal treatment for each type of instability. Key words: pelvis, fragility fracture, diagnosis, classification, treatment.

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient's comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient's mobility.

Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits.

PURPOSE AND METHODS: External fixation is a safe option for stabilisation of extremity lesions in the polytraumatised patient as well as in fractures with severe soft tissue damage. Nevertheless, long-term-complications are to be expected when external fixation is chosen as a definitive treatment. The purpose of this review article is twofold: primarily, to define the rationale of a procedural change from an external fixator to an intramedullary nail; secondarily, to assess the possible advantages and pitfalls of a single- or two-staged procedure. RESULTS AND CONCLUSIONS: External fixation of the femur is recommended in multiply injured patients who are critically ill to avoid an additional inflammatory response caused by the surgical trauma of primary nailing. The conversion towards nailing must be done as soon as the clinical condition of the patient has been stabilised. Stable polytraumatised patients do not benefit from initial stabilisation with an external fixator and should immediately be treated with a definitive osteosynthesis. In tibial fractures, external fixation followed by intramedullary nailing is recommendable in fractures with severe soft tissue injuries. Conversion should be done as soon as the soft tissues allow before pin-tract infections occur and performed in a one-staged procedure.

[Selection of access and positioning for operative treatment of pelvic injuries. Decision-making strategies]. / Zugangs- und Lagerungswahl bei operativer Behandlung von Beckenverletzungen. Entscheidungsstrategien.

Surgical treatment of pelvic ring injuries requires in-depth knowledge of the topographic anatomy of the pelvic bones, joints and soft tissue structures. A wide range of stabilizing techniques is available including bridging plate osteosynthesis, iliosacral compression screw osteosynthesis and transpubic positioning screws. In this article the different treatment strategies with the respective surgical approaches and patient positioning for pelvic ring fractures and combined lesions of the pelvic ring and acetabulum are presented. Pelvic ring lesions with rotational instability are approached from the anterior and occasionally from both the anterior and posterior based on the amount and localization of the instability. In vertically unstable lesions the most unstable part must be addressed first by reduction and fixation of the dislocated part to the axial skeleton. In combined fractures of the pelvis and acetabulum dorsal stabilization is carried out first.

Intercalary segmental reconstruction after bone tumor resection.

BACKGROUND/AIMS: Intercalary resection can be used for primary as well as metastatic tumors. Reconstruction options include vascularized fibula graft, interposition of an allograft, combination of vascularized fibula and allograft, segmental prosthesis, insertion of an extracorporally irradiated autograft, segmental transportation, either with external fixation or by using an intramedullary rod, intercalary scaffolds augmented with growth factors, and technical refinements for the resection of tumors located close to the growth plate. The purpose of this review is to discuss the indications, limitations and pitfalls of each of these techniques. METHODS: The PubMed database was searched for articles on intercalary reconstruction after bone tumor resection and for the different reconstruction options presented in this review. Additionally, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcomes and complications of the reconstruction options. RESULTS: With the advance of imaging techniques and the use of chemotherapy for malignant bone tumors, surgical techniques can be refined. There are many techniques for the reconstruction of large intercalary defects of long bones, with which the orthopedic oncologist needs to be familiar. General oncologic principles of achieving a wide margin still need to be respected. CONCLUSION: The techniques presented in this review will allow a better functional outcome of patients. It will continue to be important to carefully analyze each patient's situation and to adapt and individualize the method of reconstruction used.

Classification of graft hypertrophy after autologous chondrocyte implantation of full-thickness chondral defects in the knee.

OBJECTIVE: Graft hypertrophy is a major complication seen in autologous chondrocyte implantation (ACI) with a periosteal flap. We present the first magnetic resonance imaging (MRI) classification for periosteal hypertrophy including a grading of clinical symptoms and the surgical consequences. METHODS: One hundred and two patients with isolated chondral defects underwent an ACI covered with periosteum and were evaluated preoperatively, 6, 18 and 36 months after surgery. Exclusion criteria were meniscal pathologies, axial malpositioning and ligament instabilities. Baseline clinical scores were compared with follow-up data by paired Wilcoxon-tests for the modified Cincinnati knee, the ICRS (International Cartilage Repair Society) and a new MRI score including the parameters defect filling, subchondral edema, effusion, cartilage signal and graft hypertrophy. Hypertrophic changes were graded from 1 (minimal) to 4 (severe). RESULTS: All scores showed significant improvement (P<0.001) over the entire study period. Patients with femoral lesions had significantly better results than patients with patella lesions after 18 and 36 months postoperative (P<0.03). Periosteal hypertrophy occurred in 28% of all patients. Fifty percent of all patella implants developed hypertrophic changes. No patient with grade 1, and all patients with grade 4 hypertrophy had to undergo revision surgery. The Pearson correlation between graft hypertrophy and ICRS score was 0.78 after 6 months, and 0.69 after 36 months (P<0.01). Inclusion of graft hypertrophy in the MRI score improves the correlation to clinical scores from 0.6 to 0.69. CONCLUSIONS: Grading graft hypertrophy helps to identify patients needing an early shaving of the graft. Its integration into an MRI score improves correlation with clinical scores. Re-operation depends on the grade of hypertrophy and clinical symptoms.