Necessity of Immediate MRI Imaging in the Acute Care of Severely Injured Patients.

Background and Objectives: The standard diagnostic procedure for a patient with a suspected polytrauma injury is computed tomography (CT). In individual cases, however, extended acute imaging using magnetic resonance imaging (MRI) can provide valuable and therapy-relevant information. The aim of our cohort study was to find such cases and to describe their characteristics in order to be able to give possible recommendations for MRI application in acute trauma situations. Materials and Methods: In the study period from 2015-2019, an evaluation of the imaging performed on polytrauma patients was carried out. The specific diagnostic and therapeutic criteria of the MRI group were further defined. Results: In total, 580 patients with an ISS ≥16 (injury severity score) were included in the study. Of these 580 patients, 568 patients received a CT scan and 12 patients an MRI scan as part of the initial diagnostic. Altogether, 66.67% of the MRIs took place outside of regular service hours. The main findings for MRI indications were neurological abnormalities with a focus on myelon injuries. Further MRI examinations were performed to rule out vascular injuries. All in all, 58.3% of the MRIs performed resulted in modified therapeutic strategies afterward. Conclusions: MRI in the context of acute diagnostic of a severely injured patient will likely remain reserved for special indications in the future. However, maximum care hospitals with a high flow of severely injured patients should provide 24/7 MR imaging to ensure the best possible care, especially in neurological and blunt vascular injuries.

Comprehensive treatment algorithm for atlanto-axial rotatory fixation (AARF) in children.

BACKGROUND: Atlanto-axial rotatory fixation (AARF) is an uncommon condition in children presenting with torticollis. Many studies have elaborated on the diagnostic sequence of AARF. However, there is no consensus for the algorithm of management of AARF. METHODS: This study proposes to provide a comprehensive step-by-step guideline which aims to achieve and retain anatomic reduction of the atlanto-axial joint (AAJ). We recommend a 'therapeutic crescendo': closed reduction and immobilization in a rigid cervical collar (step I). In cases of re-dislocation, a second attempt of closed reduction and immobilization in a Halo-jacket (step II). Cases of recurrent dislocations due to persistent instability require open reduction and internal fixation. We present a new surgical technique of transverse suture transfixation (TSF) of C1/C2 (step III). Alternatively, a dorsal stabilization of C1/C2 is indicated after open reduction (step IV). 13 patients with radiologically confirmed AARF were included in this study. These patients were treated as per the above mentioned algorithm. All these patients were serially evaluated with a minimum follow-up of 1 year. RESULTS: Clinical data of 10/13 patients were available for follow-up evaluation at mean 4.6 years after the onset of symptoms. Two patients were managed surgically. We recorded good clinical results in all patients treated according to the algorithm. CONCLUSIONS: AARF is a subacute pediatric emergency. Reduction and maintenance of joint congruency of the AAJ are the treatment goals. The comprehensive therapeutic algorithm presented in this study is applicable in patients with AARF to achieve excellent long-term results. LEVEL OF EVIDENCE: IV, Retrospective cohort study. TRIAL REGISTRATION NUMBER: Clinical Trial Registry University of RegensburgZ-2014-0453-4. Registered 01 December 2014.

[Violence and aggression in hospitals-what if the personnel need help?] / Gewalt und Aggression im Krankenhaus ­ Was, wenn das Personal Hilfe braucht?

In view of the increasing violence and aggression against medical personnel in healthcare facilities, there are considerations by the legislature to punish violent offenders in hospitals more severely. Hospital and emergency room staff are increasingly confronted by physically and psychologically violent patients or their relatives. Sometimes medical treatment in a hospital or emergency room is an exceptional physical or mental situation for many patients and their relatives. In addition, the consumption of alcohol and drugs, long waiting times, psychiatric illnesses and dissatisfaction with medical care or communication problems are considered to be the cause of violence against medical personnel in healthcare facilities. In addition to the physical consequences for the affected employees, the psychological consequences, such as job dissatisfaction, fear of work and posttraumatic stress disorder also pose major challenges for the employer. In order to fulfil the obligation of care towards employees, the latter should provide concepts for protection against violence as part of the company health management. Structural, organizational and personal measures as well as concepts for dealing with aggressive patients are the cornerstones of employee protection. Professional training courses on de-escalation, self-protection and self-defense can also contribute to the protection of employees and are gladly accepted by the staff. Even in the extreme case of a rampage situation, hospital deployment and alarm plans have to be developed and established.

A guideline for placement of an infra-acetabular screw based on anatomic landmarks via an intra-pelvic approach.

BACKGROUND: Due to demographic changes, more and more fracture patterns involving anterior acetabular structures occur. The infra-acetabular screw is seen a useful tool to increase stability in fixation of the acetabular cup. However, the exact position of this screw in relation to anatomic landmarks which are intra-operatively palpable via an intra-pelvic approach has not yet been determined. METHODS: This biomorphometric experimental study references the ideal screw position of an infra-acetabular screw to anatomic landmarks palpable via an intra-pelvic approach. Therefore, we created a computer tomography-based 3D-model of 40 patients (20 women, 20 men) who received a computer tomography (CT) scan of the pelvis for any other reason than an acetabular fracture. RESULTS: The entry point of an ideal infra-acetabular was of high constancy. At mean, this point was 10.2 mm caudal and 10.4 mm medial of the ilio-pubic/ilio-pectineal eminence. This reference is independent of age, gender, or physical dimensions. However, we found gender-dependent differences for the angulation and the length of the screw. CONCLUSIONS: This study provides a comprehensive guideline to determine the ideal entry point for an infra-acetabular screw via an intra-pelvic approach. The entry point is located 10.2 mm caudal and 10.4 mm medial of the ilio-pubic/ilio-pectineal eminence. TRIAL REGISTRATION: Clinical Trial Registry University of Regensburg Z-2017-0930-1 . Registered 04. Dec 2017.

Joint awareness in posttraumatic osteoarthritis of the knee: validation of the forgotten joint score in long term condition after tibial plateau fracture.

BACKGROUND: Evaluating patient-reported outcomes (PRO) in early osteoarthritis (OA) of the knee is difficult. Established measurement tools are focused on one of the two major patient groups in knee surgery: young, highly active patients, or older patients with advanced degenerative OA of the knee. Joint awareness in everyday life is a crucial criterion in measuring PRO. The purpose of this study was to validate a German version of the "Forgotten Joint Score" (FJS) in patients after surgical treatment of tibial plateau fractures. METHODS: In this prospective cohort study, clinical and radiological outcomes data were collected from patients after surgical treatment of tibial plateau fractures following a skiing accident. Functional outcome questionnaires were administered including the FJS, the Lysholm-Score, the Tegner-Activity Scale (TAS), the EuroQol-5D (EQ 5-D), and a subjective rating of change. The validation study was carried out according to the COSMIN checklist protocol. The KLS was used to measure the presence and severity of OA on knee radiographs, and correlation with the FJS was measured. RESULTS: Cronbach's alpha was .96 (95%-CI .92, .99) confirming good internal consistency. Test-retest reliability of the FJS was high with an ICC(67) = .91 (95%-CI .85,.95). Furthermore, no relevant floor or ceiling effects were observed. FJS significantly differed in patients with different OA degrees (p = .041). Symptomatic patients had significant lower FJS than asymptomatic patients (p < .001). CONCLUSIONS: This is the first study validating a disease-specific PRO, the FJS, in long-term outcomes after joint fracture. We demonstrated good psychometric properties and a significant correlation between the FJS and the radiologic degree of OA in patients with a history of tibial plateau fracture. TRIAL REGISTRATION: Clinical Trial Registry University of Regensburg Z-2015-0872-2 . Registered 01. October 2015.