No trauma-related diagnosis in emergency trauma room whole-body computer tomography of patients with inconspicuous primary survey.

PURPOSE: Whole-body computer tomographic examinations (WBCT) are essential in diagnosing the severely injured. The structured clinical evaluation in the emergency trauma room, according to ATLS® and guidelines, helps to indicate the correct radiological imaging to avoid overtriage and undertriage. This retrospective, single-center study aimed to evaluate the value of WBCT in patients with an inconspicuous primary survey and whether there is any evidence for this investigation in this group of patients. METHODS: This retrospective, single-center study was conducted with patients admitted to a maximum-care hospital and supraregional trauma center in Germany and part of the TraumaNetwork DGU® in southwest Germany between January 2012 and November 2017. Hospital files were used for evaluation, and WBCT was carried out using a 32-row MSCT device from Siemens Healthineers, Volume Zoom, Erlangen, Germany. For evaluation, non-parametric procedures such as the chi-square test, U test, Fisher test, and Wilcoxon rank sum test were used to test for significance (p < 0.05). RESULTS: From 3976 patients treated with WBCT, 120 patients (3.02%) showed an inconspicuous primary survey. This examination did not reveal any trauma sequelae in any of this group. Additionally, 198 patients (4.98%) showed minor clinical symptoms in the primary survey, but no morphological trauma sequence could be diagnosed in WBCT diagnostics. Three hundred forty-two patients were not admitted as inpatients after WBCT and discharged to further outpatient treatment because there were no objectifiable reasons for inpatient treatment. Four hundred fifteen patients did not receive WBCT for, e.g., isolated extremity trauma, child, pregnancy, or death. CONCLUSION: Not one of the clinically asymptomatic patients had an imageable injury after WBCT diagnostics in this study. WBCT should only be performed in severely injured patients after clinical assessment regardless of "trauma mechanism." According to guidelines and ATLS®, the clinical examination seems to be a safe and reliable method for reasonable and responsible decision-making regarding the realization of WBCT with all well-known risk factors.

Comparison between Ultrasound-Guided and Palpatory Localization of the Dorsal Joint Space of the Shoulder Joint.

AIM OF THE STUDY: Arthroscopy ranks among the frequently performed interventions in orthopedics. The aim of this study was to compare the palpation technique with the ultrasound technique for locating the dorsal glenohumeral joint space (JS) in shoulder joint punctures. MATERIAL AND METHODS: Participants inexperienced in ultrasound examinations were included. Palpatory and ultrasound finding of the joint space by the participants was performed according to current recommendations and was initially demonstrated by an instructional video. The ideal point (IP) was marked under ultrasound visualization by an experienced ultrasound examinator and shoulder-elbow surgeon. Furthermore, a corridor for a safe puncture was defined. The palpatorily determined point (pdP) was marked by the participants and evaluated by means of a coordinate system. The evaluation of the sonographically determined point (sdP) was performed similarly to that of the palpatory procedure. RESULTS: Fifty-four participants were included in the study, and the mean length of work experience was 6.3 years. On average, participants had performed 16.5 punctures of the shoulder joint and 6.8 arthroscopies of the shoulder joint. The mean experience in performing sonographic examinations of the shoulder was 27.6 examinations. A total of 100 shoulder joints were examined (54 left, 46 right shoulders). The mean deviation from the ideal point (IP) for the palpatory approach was 17.1 mm with a maximum deviation of 59.5 mm; for the sonographic technique, the mean deviation was 10.3 mm (max. 30.2 mm). Overall, 22% of pdPs were within the defined corridor, while 42% of sdPs were within the target corridor. The average difference between palpatory and sonographic approaches was 9.0 mm in favor of the sonographic technique (max. 46.5 mm). A significantly greater deviation (p < 0.001) from the IP was observed with the palpatory approach than with the sonographic approach. CONCLUSION: Based on the results, the authors recommend ultrasound imaging of the shoulder joint as well as ultrasound-assisted punctures, especially for inexperienced users. Furthermore, training in ultrasound-assisted interventions should be implemented in future training curricula.

The Modified Ultrasound-Assisted Method: A Study of the Correlation between Magnetic Resonance Imaging and the Ultrasound-Assisted Evaluation of the Critical Shoulder Angle.

BACKGROUND: An increased or decreased critical shoulder angle (CSA) is a known risk factor for osteoarthritis, lesions, and re-ruptures in the rotator cuff. A CSA greater than 35° correlates with degenerative rotator cuff tears, while a CSA of less than 30° correlates with osteoarthritis in the glenohumeral joint. The diagnostic gold standard for its determination is X-ray or MRI. OBJECTIVES: The primary objective of this research was to assess the viability of utilizing sonography imaging as a diagnostic tool to determine the modified critical shoulder angle (mCSA). This study aimed to investigate the feasibility and effectiveness of sonographic techniques in accurately diagnosing CSA compared to MRI. STUDY DESIGN AND METHODS: A cohort study was carried out (level of evidence 3). The CSA (MRI) and the mCSA (ultrasound) were assessed retrospectively by two independent board-certified investigators in 109 patients with shoulder pain by MRI and musculoskeletal sonography. The CSA in the MRI dataset was determined using routine protocols and then compared to the values assessed using the modified sonography-assisted method (mCSA). Both results were analyzed with linear regression to determine a possible correlation. All investigations were performed by a DEGUM (German Society for Medical Ultrasound)-certified specialist in musculoskeletal sonography. RESULTS: A total of 112 patients were included in this study, namely 40 female patients and 72 male patients with a mean age of 54.7 years at the time of the investigation. The mean CSA in MRI was 31.5° ± 3.899, and the mCSA in sonography was 30.1° ± 4.753. The inter- and intraobserver reliability for the CSA was factual with values of 0.993 and 0.967. The inter- and intraobserver reliability for mCSA was factual as well, with values of 0.989 and 0.948. The ANOVA analysis did not reveal a significant difference between the CSA and the mCSA values, and linear regression determined the R2 value to be 0.358 with p < 0.05. CONCLUSIONS: Diagnosing the mCSA using sonography is a safe and valid method. No statistically significant differences between the results in MRI and sonography could be seen. Although this is a retrospective, single-center study including only Caucasian mid-Europeans, and with the known limitations of ultrasound imaging, it nevertheless shows that sonography can be used as a simple, cheap, and fast technique to assess a modified CSA, which shows very good correlation with the standard CSA without losing the diagnostic quality.

Association of Chondrolabral Lesions with Ultrasound-Guided Detection of Pathological Head-Neck Contour.

OBJECTIVE: This study aimed to investigate whether the asphericity of the neck-head junction of the femur confirmed via ultrasound is associated with further pathology due to femoro-acetabular impingement (FAI). METHODOLOGY: After a clinical examination with positive FAI tests, an ultrasound examination of the hip was performed. In the case of asphericity, a quantitative ultrasound-assisted assessment of the hip was performed, followed by contrast-enhanced arthro-MRI with the question of cartilage or labral damage. RESULTS AND CONCLUSIONS: We included 51 patients with a mean age of 35.25. According to the examination algorithm, asphericity was present in all patients via ultrasonography. The average anterior alpha angle (AAA) determined in ultrasonography was 43.49°. The average AAA on the arthro-MRI was 44.19°. The mean anterior head neck offset (AHNO) in ultrasound was 5.27 mm, and in arthro-MRI, it was 5.36 mm. Arthro-MRI confirmed a bump in 47 patients and a talization disorder in 4 patients. In 49 patients, a labral lesion was found, with one being a re-rupture. Furthermore, in one patient, labral degeneration was identified. Cartilage damage to the hip joint was found in 25 patients. Two patients had neither labral nor cartilage damage in the arthro-MRI. In our study, sonographically confirmed asphericity of the head-neck junction was found in 49 cases, which was associated with further pathology and, according to the current doctrine, was attributable to the FAI and required surgical intervention. This study shows that the detection of a pathologic head and neck contour via ultrasound in combination with positive clinical signs, as present in FAI, is associated with chondrolabral lesions detected via arthro-MRI in 96.1% of cases.

[Care of the severely injured in mass casualty incidents : What is the difference compared to emergency room management?] / Schwerstverletztenversorgung beim Massenanfall von Verletzten : Worin besteht der Unterschied zum Schockraummanagement?

The management of a severely injured patient according to the standards and principles of individualized trauma care is a well-established procedure in many hospitals. The process is structured and standardized by the content of several course formats. In contrast, a mass casualty incident (MCI, MANV) is a rare and exceptional situation. In this case the treatment priorities and approaches are changed. The main aim in this situation is to ensure the best possible chance of survival for every casualty by organizational measures to mobilize rooms, personnel and material and to temporarily abandon the standards of individualized trauma care. To be prepared for a MCl situation it is necessary to know the realistic scenarios, to update the hospital emergency plan and to adapt all treatment procedures to the transient lack of resources. This article gives an overview of this process and summarizes the current clinical concepts to cope with a MCl situation and the current principles for the care of the severely injured involving many casualties.

Traumatic pancreas, kidney, liver, spleen, gastric and diaphragma rupture with enterothorax after blunt trauma caused by falling in an adolescent: a case report.

Injury of almost all intra-abdominal organs in blunt trauma without bone and brain injury is very rare. This is the case report of a 16-year-old adolescent with severe abdominal trauma who was hit on his abdomen by a falling maytree. After admission to a Level I trauma center, emergency room treatment according to ATLS and after this emergency surgery was performed. Blood coagulation diagnostics was done using thrombo-elastography and factors and blood products have been applied according to its results keeping guidelines in mind. Damage-control surgery stopped the bleeding, and he was admitted to ICU. After second and third look surgery, the abdomen was closed. Structured diagnostics and treatment were crucial in this case. The education of trauma surgeons should include general surgery skills. These skills and knowledge of blood coagulation diagnostics and therapy saved the patient's life in this case.

Breakage of Tapered Junctions of Modular Stems in Revision Total Hip Arthroplasty-High Incidence in a Consecutive Series of a Single Institution.

BACKGROUND: Modularity in revision THA (RTHA) has become accepted during the last three decades. Nevertheless, specific risks of modularity of current revision devices such as breakage of taper junctions occur during follow-up. Data reporting failure rates are predominantly given by the manufacturers but independent data acquisition is missing so far. QUESTIONS/PURPOSES: 1. What time-related risk of breakage of taper junction between neck and body of an established modular revision device can be expected in a consecutive single institutional series and a mid-term follow-up? 2. Are there specific factors influencing breakage in this cohort? MATERIALS AND METHODS: A retrospective analysis was performed of a consecutive series of 89 cases after femoral revision using a tapered modular revision stem. Mean follow-up period was 7.1 (range: 3.0-13.7) years. Breakage of stem as failure criteria of the implant was investigated with a Kaplan-Meier analysis. RESULTS: Breakage of taper junctions occurred in four patients during follow-up showing a time-depending implant survival of 94.2 (95% CI: 88.6-100%) after 13.7 years. Implant survival of stems with lateralized necks of 87.4 (95% CI: 75.6-100%) after 13.7 years was significantly lower compared to the standard offset variant with 100% after 13.5 years (log rank test p = 0.0283). Chi square test also revealed a significantly higher risk of breakage of lateralized necks compared to standard offset pieces (p = 0.0141). Three of four patients were obese with a mean BMI of 37.9 kg/m2. Grade of obesity (grade 1 or higher) had significant influence on risk of breakage. Survival of the implant was significantly lower in obese patients with at least grade 1 obesity compared to patients with a BMI < 30 kg/m2 (82.9 (95% CI: 64.9-100%) after 11.6 years vs. 98.4 (95% CI: 95.3-100%) after 13.7 years; log-rank p = 0.0327). CONCLUSIONS: Cumulative risk for failure of taper junctions was high in this consecutive single institutional cohort and may further increase during follow-up. As independent data acquisition in registries is missing, failure rate may be higher than reported data of the manufacturers. The use of lateralized offset necks in obese patients of at least grade 1 obesity showed a significantly higher risk of breakage. The use of monobloc revision devices may be an option, but randomized control trials are currently missing to establish standardized treatment protocols considering individual risks for both monobloc and/or modular implants.

Sonography-Based Determination of Hip Joint Anterior Alpha-Angle: A Reliable and Reproducible Method.

PURPOSE: Femoroacetabular impingement (FAI) is a known risk factor for hip osteoarthritis. The gold standard for diagnostics is X-ray and MRI. The accuracy of hip joint alpha angle measurements obtained using sonography is equal to measurements in MRI for patients with cam impingement of the hip joint. MATERIALS AND METHODS: Patients with hip pain and MRI and sonography were evaluated between January 2015 and December 2019 in a single center. Musculoskeletal sonography was performed according to the DEGUM guidelines by ultrasound-certified specialists. Measurements were repeated three times by two independent investigators. RESULTS: 285 patients were screened, and 110 patients (49 females, 61 males) met the inclusion criteria. The mean age at time of investigation of 54 left and 56 right hip joints was 54.2 years. 1320 measurements were performed. The mean alpha angle was 50.7° in MRI and 50.4° in sonography with a mean difference of 0.28° (p>0.05). CONCLUSION: Determining hip alpha angle using sonography is a safe and reproducible method. No statistically significant differences between results in MRI and sonography could be seen. Although this is a retrospective, single-center study including only Caucasian mid-Europeans and with the known limitations of ultrasound imaging, it nevertheless shows that sonography can be used as a simple, cheap, and fast technique to assess the hip alpha angle without losing diagnostic quality.

Implementation of Copy Number Variations-Based Diagnostics in Morphologically Challenging EWSR1/FUS::NFATC2 Neoplasms of the Bone and Soft Tissue.

In the last decade, new tumor entities have been described, including EWSR1/FUS::NFATC2-rearranged neoplasms of different biologic behavior. To gain further insights into the behavior of these tumors, we analyzed a spectrum of EWSR1/FUS::NFATC2-rearranged neoplasms and discuss their key diagnostic and molecular features in relation to their prognosis. We report five patients with EWSR1/FUS::NFATC2-rearranged neoplasms, including one simple bone cyst (SBC), two complex cystic bone lesions lacking morphological characteristics of SBC, and two sarcomas. In three cases, fluorescence in situ hybridization (FISH) and in all cases copy number variation (CNV) profiling and fusion analyses were performed. All patients were male, three cystic lesions occurred in children (aged 10, 14, and 17 years), and two sarcomas in adults (69 and 39 years). Fusion analysis revealed two FUS::NFATC2 rearrangements in two cystic lesions and three EWSR1::NFATC2 rearrangements in one complex cystic lesion and two sarcomas. EWSR1 FISH revealed tumor cells with break-apart signal without amplification in one complex cystic lesion and EWSR1 amplification in both sarcomas was documented. CNV analysis showed simple karyotypes in all cystic lesions, while more complex karyotypes were found in NFATC2-rearranged sarcomas. Our study supports and expands previously reported molecular findings of EWSR1/FUS::NFATC2-rearranged neoplasms. The study highlights the importance of combining radiology and morphologic features with molecular aberrations. The use of additional molecular methods, such as CNV and FISH in the routine diagnostic workup, can be crucial in providing a correct diagnosis and avoiding overtreatment.

Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk.

PURPOSE: Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries. METHODS: In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed. RESULTS: In seven patients (0.26%; mean age 50.4 years, range 18-90; mean ISS 39.7, range 34-50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h-4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The "number needed to fail" was 385 (95%-CI 0.0010-0.0053). CONCLUSION: Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey. LEVEL OF EVIDENCE: Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference "gold" standard).

Pelvic antropometric measurement in 3D CT for placement of two unilateral iliosacral S1 - 7.3 mm screws.

PURPOSE: Stability of the dorsal pelvic ring is important for patient mobilisation and can be restored using several surgical procedures after fracture. Placement of percutaneous iliosacral screws is a reliable and minimal-invasive technique to achieve stabilisation of the dorsal pelvic ring by placement of two screws in the first sacral vertebra. Aim of this study was to evaluate 3D CT scans regarding the anatomical possibility to place two 7.3 mm iliosacral screws for fixation of the dorsal pelvic ring. METHODS: 3D CT datasets of 500 consecutive trauma patients with 1000 hemipelves of a mid-european level I trauma centre with or without pelvic injury were evaluated and measured bilaterally in this retrospective study. RESULTS: One thousand hemipelvic datasets of 500 patients (157 females, 343 males) with a mean age of 49.7 years (18 to 95) were included in this study. Only 16 hemipelves (1.6%, 11 in females, 5 in males) in 14 patients (2.8%, 9 females = 5.73%, 5 males = 1.5%) showed too narrow corridors so that 7.3 mm screw placement would not be possible (p = 0.001). In women, too narrow corridors occurred 3.9 times as often as in men. Only two females showed this bilaterally. CONCLUSION: The evaluation of 3D CT scans of the pelvis showed the importance of planning iliosacral screw placement, especially if two 7.3 mm screws are intended to be placed in the first sacral vertebra.

Low complication rate and better results for intramedullary nail - arthrodesis for infected knee joints compared to external fixator-a series of one hundred fifty two patients.

PURPOSE: Arthrodesis of the knee joint is still a salvage procedure after recurrent prosthetic joint infections (PJI) of total knee arthroplasties (TKA) with substantial bone loss and seems to be a good solution to avoid amputation. Until now, intramedullary arthrodesis has increasingly been performed; no study has yet been published to compare these techniques after septic removal of TKA in terms of functional assessment and quality of daily life. METHODS: In a single-centre retrospective setting, clinical and radiographic evaluation of consecutive patients after knee arthrodesis using intramedullary and external fixation for infected knee joints was performed. All patients were evaluated clinically, with x-ray and questionnaire including analysis regarding any complications at latest follow-up of a minimum 12 months postoperatively. RESULTS: We included 152 patients (75 females, 77 males) in this study. The mean age of the patients at surgery was 63.6 years (range 12 to 90 years). The minimum follow-up was 12 months (mean 3.1 years, range 12 to 49 months). Arthrodesis with external fixator (83 patients, 52.2%) showed less blood loss and less peri-operative complications (1.6%) but a high rate of post-operative, pin-track infections (35.5%); loose pins (12.7%); and pin fractures (4.8%), and therefore risk factors for instability and nonunion (30.9%). Revision rate was 22.6% for arthrodesis with external fixator, and the primary union rate was 65.6%. Intramedullary arthrodesis (69 patients, 43.4%) showed a similar re-infection rate to external fixation (16.1% and 15.9%, respectively) but a significantly lower revision rate (5.4%, p < 0.001). Eighty percent of patients with intramedullary arthrodesis showed very good patient-related outcomes regarding pain, function and daily life activities in the questionnaire. CONCLUSION: Despite similar results regarding patient satisfaction and everyday competences in questionnaires, intramedullary arthrodesis of the knee is superior to the external fixator, as it results in fewer complications, lower revision rate, and union rates/loosening.

[Safety culture in orthopedics and trauma surgery : A qualitative study of the physicians' perspective]. / Sicherheitskultur in der Orthopädie und Unfallchirurgie : Eine qualitative Untersuchung der ärztlichen Perspektive.

BACKGROUND: Hospitals in Germany operate risk management, which can support the prevention of adverse events and to systematically process them. Safety culture is one aspect of this. In German-speaking countries, however, surveying the safety culture is still limited and almost exclusively carried out using quantitative instruments. In Germany, the discipline of orthopedics and trauma surgery is characterized by a high number of confirmed treatment errors and lack of risk clarification, Therefore, this study investigated the safety culture in this discipline. OBJECTIVE: (I) How do orthopedic and trauma surgeons perceive the handling of adverse events in trauma centers and (II) what are relevant components of the safety culture from a medical perspective? MATERIAL AND METHODS: A qualitative study using 14 semi-structured one-to-one interviews was carried out with physicians in orthopedics and trauma surgery. The interviews were audiotaped, transcribed, and analyzed using the thematic analysis by Braun and Clarke and the Yorkshire contribution factors framework. The MAXQDA software was used to organize data. RESULTS: A strong influence of senior staff on the handling of adverse events in the medical team could be determined. It was expected that senior staff members have a strong model role function. They were expected to exemplify a high safety culture, because their behavior influences the team's behavior in patient safety-related situations. CONCLUSION: The involvement of senior staff in the development of interventions to improve the safety culture in orthopedics and trauma surgery should be considered due to the importance of hierarchical structures.

[Bone segment transport for defects of the tibia : Technique with unilateral fixator and plate]. / Knochensegmenttransport bei Defekten der Tibia : Technik mit unilateralem Fixateur und Platte.

BACKGROUND: Various options are available for treatment of bone defects of the tibia. Bone segment transport is carried out relatively rarely because the surgical technique is not easy and there is a learning curve. OBJECTIVE: This article gives an overview of the history, indications, planning and surgical technique of bone segment transport of the tibia. MATERIAL AND METHODS: A technique using unilateral external fixation in combination with a locking plate osteosynthesis is described. RESULTS: The technique and results are explained exemplified by a case report and in particular pitfalls during surgery and the aftercare concept are outlined. CONCLUSION: Bone segment transport of the tibia using an external fixator and a locking plate is a reliable and practicable technique for treatment of bone defects of the tibia.

[Terror awareness of 5th year medical students in the Mannheim reformed curriculum medicine plus]. / "Terror awareness" bei Humanmedizinstudierenden im 5. Jahr des Mannheimer Reformierten Curriculums Medizin plus.

BACKGROUND: The treatment of gunshot wounds and wounds caused by explosive devices as used in terrorist attacks is not currently an issue for education in most medical faculties; however, because of the increasing number of terrorist attacks in Germany and Europe this is becoming more important. The aim of this study was to evaluate the knowledge of dealing with and treatment of patients as victims of terrorist attacks of 5th year medical students at the Mannheim Medical Faculty of Heidelberg University prior to and after a specific seminar. METHODS: All students offered to participate voluntarily. Before the seminar a questionnaire with six questions about previous knowledge on terror awareness was distributed. After the seminar another almost identical questionnaire with six questions was distributed and completed by the students. RESULTS: A total of 97 medical students agreed to take part in the study of whom 53 were female. The mean age was 25.4 years (SD 2.75 years). After the seminar the students wanted to statistically significantly intensify the topic and believed that hospitals should be prepared for the treatment of victims of terrorism. CONCLUSION: With the seminar "Military Medicine", which was held as part of the Mannheim reformed curriculum of medicine (MaReCuM plus) in the 5th year, the interest of medical students could be significantly increased. This study could show for the first time that terrorist attacks and the resulting injuries have significant relevance for medical students. Consideration of this topic in all medical school curricula would be justified.