Non-invasive assessment of muscle compartment elasticity by pressure-related ultrasound in pediatric trauma: a prospective clinical study in 25 cases of forearm shaft fractures.

BACKGROUND: Soft-tissue swelling after limb fractures in pediatric patients is well known to be a risk factor for developing acute compartment syndrome (ACS). Clinical assessment alone is uncertain in specific cases. Recently, we proposed a non-invasive ultrasound-based method to objectify muscle compartment elasticity for monitoring. We hypothesize a strong correlation between the soft-tissue swelling after stabilization of upper limb fractures and the compartment elasticity objectified with a novel ultrasound-based approach in pediatric trauma. PATIENTS AND METHODS: In a prospective clinical study, children suffering forearm fractures but not developing an ACS were included. The muscle compartment elasticity of the m. flexor carpi ulnaris was assessed after surgical intervention by a non-invasive, ultrasound-based method resulting in a relative elasticity (RE in %) in both the control (healthy limb) and study group (fractured limb). Soft-tissue swelling was categorized in four different levels (0-3) and correlated with the resulting RE (%). RESULTS: The RE in the study group (15.67%, SD ± 3.06) showed a significantly decreased level (p < 0.001) compared with the control (22.77%, SD ± 5.4). The categorized grade of soft-tissue swelling resulted in a moderate correlation with the RE (rs = 0.474). CONCLUSIONS: The presented study appears to represent a novel approach to assess the posttraumatic pressure changes in a muscle compartment after fracture stabilization non-invasively. In this first clinical study in pediatric cases, our measurement method represents a low-cost, easy, and secure approach that has the potential to substitute invasive measurement of suspected ACS in muscle compartment conditions. Further investigations in lager cohorts are required to prove its daily clinical practicability and to confirm the expected reliability.

Non-invasive and reliable assessment of compartment elasticity by pressure related ultrasound: An in-vitro study.

PURPOSE: The development of acute compartment syndrome is a serious threat to trauma patients. The clinical assessment alone is not reliable enough to determine the need for fasciotomy in many cases. The Physician´s assessment of the elasticity of the muscle compartment might be particularly important to objectively evaluate the pressure in this enclosed space. The purpose of this study was to determine the observer´s reproducibility, of compartment elasticity measurements by a novel ultrasonic approach. METHODS: Increasing intra-compartmental pressures (ICP) were simulated in a water filled in-vitro model. Pressure related ultrasound was used to determine the relative elasticity (RE) of soft tissue compartments. A pressure transducing probe head was combined with the ultrasonic probe to obtain cross section views of the simulated compartment and to detect the amount of applied pressure by the observer. In this model, the compartment depth without compression (P0) was set to be 100%. Changes of the compartment depth due to a probe pressure of 80 mmHg (P80) were correlated to P0 and an elasticity quotient as a value for RE (%) was calculated. Twelve blinded observers performed measurements for RE determination (%) under three pressure conditions. Reproducibility was calculated using intraclass correlation coefficient (ICC). RESULTS: Measurements (n = 432) revealed that the RE (%) in the control group was 17,06% (SD+/-2,13), whereas the RE of the group ICP30 significantly decreased to 12,66% (SD+/- 1,19) (p<0,001). The ICP50 group revealed a further significant decrease to 8,43% (SD+/- 0,67) (p<0,001). Repeated measurement of RE and ICP showed a high level of correlation (spearman correlation coefficient: roh=0,922). A RE <14% resulted in a sensitivity of 96% and a specificity of 90,3% for diagnosis of an ICP >30 mmHg. ICCinter was 0,986; 95%, CI: 0,977-0,992 (p<0,001). DISCUSSION: The presented ultrasound-based approach reliably assesses the elasticity in a simulated compartment model. In this pioneer study investigating the inter- and intra-observer reproducibility, this method of measurement appears to be of low cost in addition to being an easy and secure approach that may have the potential to substitute invasive measurement. Further investigations are required to improve its feasibility and to confirm the reliability under clinical conditions.

Major trauma in winter sports: an international trauma database analysis.

PURPOSE: The aim of this study was to compare the demographics, injury patterns, and outcomes following major trauma between Alpine skiing, snowboarding, and sledding winter sports. METHODS: An international population-based prospective trauma database (TraumaRegister DGU®) was analyzed for demographic data, types and severity of injuries [body regions, Injury Severity Score (ISS)], early physiology [Glasgow Coma Scale (GCS), blood pressure, body temperature], rescue modality, surgical care, length of stay, and major complications (shock, multiple organ failure mortality). Participating countries included Germany, Austria, Switzerland, Finland, Slovenia, Belgium, Luxembourg, and The Netherlands. RESULTS: A total of 243 winter sport athletes with major trauma were identified (1993-2012), and subjects were divided into Alpine skiers (n = 174), snowboarders (n = 29), and sledders (n = 40). Athletes were predominantly male and presented hypothermic at emergency room arrival, despite a large proportion of air rescue (77 %). Alpine skiing was associated with higher injury severity (ISS 20.8 ± 14.0, p = 0.010) when compared with snowboarding (ISS 18.7 ± 14.0) and sledding (ISS 13.8 ± 9.5). Snowboarding was associated with the highest pre-hospital intubation rate (40.9 %, p = 0.007), despite comparable GCS values and prevalence of loss of consciousness at scene. The injury patterns were different between the three groups. Skiing was associated with head (47.1 %), chest (40.2 %, p = 0.047), and spinal injuries (40.9 %, p = 0.022). Snowboarding was associated with the highest percentage of upper extremity trauma. Sledders had the highest prevalence of facial and lower extremity trauma. CONCLUSIONS: Alpine skiing, snowboarding, and sledding result in different injury patterns and affect various age groups. Our data suggest an increased risk for chest and spinal injuries in Alpine skiers. Due to high-energy injury mechanisms, all three winter sports involve a risk of severe multiple trauma. While all athlete groups required a high rate of emergency surgery procedures, the observed in-hospital mortality from winter sports remains low.

[Cost-benefit analysis of cranial computed tomography in mild traumatic brain injury--appropriate depiction within the G-DRG system?]. / Kosten-Nutzen-Analyse der Schnittbildgebung beim leichten Schädel-Hirn-Trauma--Wie sachgerecht ist die Abbildung im G-DRG-System?

BACKGROUND: The treatment of patients with mild head injury is related to a continuous lack of finances. The current investigation summarises radiological costs of patients from a level I trauma centre and discusses the indication for CT scanning within the G-DRG system. MATERIAL AND METHODS: The study includes all patients who underwent a CCT scan in 2011. Diagnosis, length of stay and cost data were recorded for every patient. Finally, frequent diagnosis groups were summarised to clusters (Basis-DRG/MDC 21A). RESULTS: A total of 380 patients was treated. Within the largest group (G-DRG B80Z) the costs for a CCT already took up one quarter of the total proceedings. In combination with the high cost for monitoring patients with mild head injuries this causes an ongoing lack of finances. CONCLUSION: In spite of the often necessary CCT investigation in mild head injuries, the earnings do not cover the costs of the patients. To improve the situation clear guidelines for CCT scanning should be provided and the reimbursement in particular in the diagnosis group of the G-DRG B80Z has to be improved.

Contrast enhanced ultrasound (CEUS) reliably detects critical perfusion changes in compartmental muscle: a model in healthy volunteers.

PURPOSE: The purpose of this study was to assess the utility of contrast enhanced ultrasound (CEUS) in the differentiation between physiological and simulated pathophysiological lower limb muscle perfusion pressures in healthy volunteers. METHODS: The lower limb muscle perfusion pressures in eight healthy volunteers were assessed in the supine position (as a control) and then subsequently in an elevated position with a thigh tourniquet applied to induce venous stasis. An intravenous bolus injection of 2.5 ml contrast agent was given to create a perfusion signal, which was measured with a multiple-frequency probe. Semiquantitative analysis was performed using specific software to create a perfusion curve which allowed measurement of six parameters: the time to arrival (TTA) starting from bolus application (s); peak of signal intensity (%); time to peak (TTP) maximum (seconds); regional blood volume (RBV), regional blood flow (RBF), and mean transit time (MTT) in seconds. Statistical analysis was performed using the Mann-Whitney U test as a non-parametric test (IBM SPSS statistics, version 21, USA). RESULTS: The group of simulated hypoperfusion showed significant higher values for TTA (39.8 ± 5.1 s) (p = 0.028), TTP (43.8 ± 13.6 s) (p = 0.003), RBV (8,424 ± 5,405) (p = 0.028), and MTT (262 ± 90.6 s) (p = 0.005). In contrast, the parameter of regional blood flow (32.1 ± 10.9) was significantly lower (p = 0.038). The peak signal intensity (25.8 ± 8.2 %) was lower, but this was not significant (p = 0.083). CONCLUSIONS: CEUS provides a reliable non-invasive imaging modality for the assessment of lower limb muscle perfusion pressures. This may be of clinical use in the assessment of a developing compartment syndrome. Further clinical studies are required to further define its accuracy and reproducibility.