Do admission glucose levels independently predict coagulopathy in multiple trauma patients? A retrospective cohort analysis.

BACKGROUND: Coagulopathy is prevalent in multiple trauma patients and worsens bleeding complications, leading to higher morbidity and mortality rates. Hyperglycemia upon admission predicts hemorrhagic shock and mortality in severely injured patients. This study aimed to assess admission glucose levels as an independent prognostic factor for coagulopathy in multiply injured patients. METHODS: This retrospective cohort study observed multiple trauma patients treated at a level I trauma center between January 1, 2005, and December 31, 2020. Coagulopathy was defined as an international normalized ratio (INR) > 1.4 and/or activated thromboplastin time (APTT) > 40 s. Analysis of variance compared clinical and laboratory parameters of patients with and without coagulopathy. Receiver-operating-characteristic (ROC) and multivariate logistic regression analyses identified risk factors associated with coagulopathy. RESULTS: The study included 913 patients, of whom 188 (20%) had coagulopathy at admission. Coagulopathy patients had higher mortality than those without (26% vs. 5.0%, p < 0.001). Mean glucose level in coagulopathy patients was 10.09 mmol/L, significantly higher than 7.97 mmol/L in non-coagulopathy patients (p < 0.001). Admission glucose showed an area under the curve (AUC) of 0.64 (95% CI [0.59-0.69], p < 0.001) with an optimal cut-off point of 12.35 mmol/L. After adjusting for other factors, patients with high admission glucose had a 1.99-fold risk of developing coagulopathy (95% CI 1.07-3.60). Other laboratory parameters associated with coagulopathy included haemoglobin, bicarbonate (HCO3), and lactate levels. CONCLUSION: This study emphasizes the significance of admission blood glucose as an independent predictor of coagulopathy. Monitoring hyperglycemia can aid in identifying high-risk patients.

Reconstruction of an Extensive Segmental Radial Shaft Bone Defect by Vascularized 3D-Printed Graft Cage.

We report here a 46-year-old male patient with a 14 cm segmental bone defect of the radial shaft after third degree open infected fracture caused by a shrapnel injury. The patient underwent fixed-angle plate osteosynthesis and bone reconstruction of the radial shaft by a vascularized 3D-printed graft cage, including plastic coverage with a latissimus dorsi flap and an additional central vascular pedicle. Bony reconstruction of segmental defects still represents a major challenge in musculo-skeletal surgery. Thereby, 3D-printed scaffolds or graft cages display a new treatment option for bone restoration. As missing vascularization sets the limits for the treatment of large-volume bone defects by 3D-printed scaffolds, in the present case, we firstly describe the reconstruction of an extensive radial shaft bone defect by using a graft cage with additional vascularization.

Validation of direct CT measurement of malrotation in femoral neck fractures: A bone model study.

BACKGROUND: While postoperative malrotation in the subtrochanteric region is a well-known problem, malrotation after osteosynthesis in proximal femoral fractures has not been extensively studied. In this context, many methods for perioperatively assessment of femoral torsion have been described, but none of them is applicable in the basicervical region of the proximal femur. As an important difference in femoral neck fractures, the discontinuous neck fails to serve as a significant "pointer" for measurements and malfunctions to be placed in relation to the condylar plane. Considering postoperative maltorsion at any location as a substantial negative effect on patients' outcome and functional expectations, precise and patient-friendly rotation measurement standards in femoral neck fractures are desired in clinical practice. Recently, a novel computed tomography (CT) based geometric technique was described named "direct measurement" with promising results covering this diagnostic disparity, but still requires validation. Thus, we aimed to validate the previously described technique using a controlled range of displacement in a femoral neck fracture Sawbone® model. METHODS AND FINDINGS: A goniometer was designed to set retro- and anteversion of the proximal femur in a reproducible manner. Prospectively, all femurs underwent a CT scan and were measured 3D for displacement. The interclass correlation between the CT measurements and the goniometer measurements was calculated and was found to be very high (1.00, 95% confidence interval: 0.99-1.00; p < 0.001). For the mean of all measurements, the Pearson's correlation was 1.00 (p < 0.001). No significant differences in the measurements of both investigators were observed, with 20° of retroversion not significant (-1.20 ± 1.71; 95% confidence interval: -2.43-0.03; p = 0.054). CONCLUSION: This CT-based 3D measurement technique may allow for perioperative malrotation assessment in basicervical femoral neck fractures and appears to be feasible in femoral neck fractures when it comes to rare cases of osteosynthesis. Further investigations are still needed to define the thresholds of malrotation provoking functional impairment after osteosynthesis in basicervical femoral neck fractures.

[Biological reconstruction of large bone defects : Masquelet technique and new procedures]. / Biologische Rekonstruktion von großen Knochendefekten : Masquelet-Technik und neue Verfahren.

Extensive diaphyseal and metaphyseal bone defects continue to pose a major challenge for orthopedic trauma surgeons. Various treatment options have been described for the biological reconstruction of these defects. The most frequently used methods are bone segment transport, the Masquelet technique and 3D printed scaffolds. As far as the Masquelet technique is concerned, in the first stage spacers, such as polymethyl methacrylate (PMMA), calcium sulfate or polypropylene are inserted into the bone defects to induce a foreign body membrane. In the second stage the bone defect surrounded by the induced membrane is filled with autologous cancellous bone. The time interval between the first and second interventions is usually 4-8 weeks whereby the induced membranes do not lose their bioactivity even with a latency period longer than 8 weeks. Three-dimensional printed scaffolds are increasingly used but large clinical studies are lacking in order to show the exact role of this procedure in the reconstruction of bone defects.

Profit Analysis of Minimal-invasive Approaches for Surgical Treatment of A3 Spinal Burst Fractures.

BACKGROUND/AIM: Regarding the surgical treatment of incomplete burst fractures of the spine, no optimal standard procedure has been established. While previous studies have focused on radiological and surgical outcome parameters, the literature has not elucidated economic aspects of various surgical treatment options in detail yet. This study aimed to investigate whether open and minimal-invasive approaches differ in their economic profit gain. Furthermore, we examined whether a single-stage or two-stage approach of anterior-posterior fusion was more profitable. PATIENTS AND METHODS: By analyzing retrospectively data of 129 patients who underwent surgical procedure due to isolated incomplete burst fractures, we examined the economic profit and radiological parameter of open pedicle screw insertion, minimal-invasive techniques (percutaneous screws, percutaneous screws combined with SpineJack®, kyphoplasty or SpineJack®), and anterior-posterior fusion. RESULTS: Percutaneous screws in combination with SpineJack® gained significantly higher profit and higher profit per day of hospital length of stay. Profit was similar after single-stage and two-stage approach of vertebral body replacement. No significant difference in radiological outcome after 24 months was detected between the various surgical techniques. CONCLUSION: From a financial aspect, our finding suggests that application of percutaneous screws in combination with SpineJack® may generate the highest economic profit gain regarding treatment of incomplete burst fracture.

[Management of fracture-related infections]. / Management von frakturassoziierten Infektionen.

Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.

A Rare Case of Complex Pelvic Injury and Associated Intrathecal Fat Embolism due to Spinopelvic Dislocation with Sacral Burst Fracture.

INTRODUCTION: Pelvic and lumbar spine injuries are very common especially in multiple trauma patients. The usual mechanism in young patients leading to pelvic fractures is a high-energy trauma such as traffic accidents. In elderly patients, low energy traumas are causal for such injuries. Compared to the high number of patients with pelvic or lumbar spine injuries, cerebral fat embolism is a quite rare finding but it needs to be considered to not misinterpret the radiological findings. CASE: We present the case of a 41-year-old patient, who got hit and trapped in the lumbar region by a hydraulic arm in a car repair shop. The patient was primarily admitted to a level II trauma center. The radiological and clinical examinations revealed an open pelvic type C injury in terms of a spinopelvic dissociation, dislocation of the left hip joint, rupture of the mesentery of the rectum and colon sigmoideum, and a complex injury to the left ureter. Additionally, CT scan showed fluid with higher density than cerebro spinal fluid (CSF) in the lateral ventricles indicating an intracranial bleeding. After an immediate surgery to stabilize the patient, he was admitted to a level I trauma center. The reanalysis of the existing CT datasets combined with a new head CT leads to the conclusion that the high density fluid in the lateral ventricles is not a intracranial bleeding but rather fat deriving from the complex pelvic and lumbar spine fracture into the CSF system. Therefore, an immediate operation was performed to stabilize the spinopelvic dissociation and to close the injured dural sheath. Additionally, a ventricle drainage has been placed, which confirmed the diagnosis of intrathecal fat embolism. Afterwards, complex plastic surgery was necessary to restore the soft tissue damage. CONCLUSIONS: Intrathecal fat embolism in muliple trauma patients is a rare condition, which should be considered in patients with complex spine or pelvic injuries. It is important to distinguish this rare condition from intracranial bleedings, which are much more common because the consequent therapeutic strategy is quite different. In case of intrathecal fat embolism, a ventricle drainage system should be placed immediately, and the underlying spine or pelvic injuries need to be stabilized combined with closure of the dural sheath to prevent continuous fat embolism and meningeal infection.

A Rare Case of a Traumatic Posterior Hip Dislocation in a 3-Year-Old Boy: A Case Report and Review of the Literature.

We present a rare case of neglected hip dislocation in a 3-year-old boy. Hip dislocations in childhood represent less than 6% of all injuries. The boy presented to the ED with ongoing hip pain after his leg got stuck in a carousel. The physical and radiologic examination revealed a posterior right hip dislocation. The closed reduction failed, so open reduction during surgery was performed. The postoperative protocol included 3 days of immobilization with early mobilization and pain-adapted weight bearing. No signs of femoral head malperfusion occurred 2 months after the injury. The patient did not complain of any limitations such as weight bearing problems or loss of range of motion. In comparison to adults, there are several specialties such as the fact that minor trauma can lead to hip dislocations due to the laxity of the ligaments, and due to the limited direct anamnestic options, neglected hip dislocations can occur. The treatment should focus on immediate proper reduction. The main complications after traumatic hip dislocation are avascular necrosis of the femoral head, redislocation, and early osteoarthritis.

Impact of Accidental Hypothermia on Pulmonary Complications in Multiply Injured Patients With Blunt Chest Trauma - A Matched-pair Analysis.

BACKGROUND/AIM: Blunt chest trauma is one of the major injuries in multiply injured patients and is associated with an increased risk of acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia (VAP). Accidental hypothermia is a common accompaniment of multiply injured patients. The objective of this study was to analyze the influence of accidental hypothermia on pulmonary complications in multiply injured patients with blunt chest trauma. PATIENTS AND METHODS: Multiply injured patients [injury severity score (ISS) ≥16] with severe blunt chest trauma [abbreviated injury scale of the chest (AISchest) ≥3] were analyzed. Hypothermia was defined as body core temperature <35°C. The primary endpoint was the development of ARDS and VAP. Propensity score matching was performed. RESULTS: Data were analyzed for 238 patients, with a median ISS of 26 (interquartile range=12). A total of 67 patients (28%) were hypothermic on admission. Hypothermic patients were injured more severely (median ISS 34 vs. 24, p<0.001) and had a higher transfusion requirement (p<0.001). Their mortality rate was consequently increased (10% vs. 1%, p=0.002); After propensity score matching, the mortality rate was still higher (10% vs. 2%, p=0.046). However, hypothermia was not an independent predictor of mortality. Hypothermic patients had to be ventilated longer (p=0.02). However, there were no differences in occurrence of ARDS and VAP. Hypothermia was not identified as an independent predictor of ARDS and VAP. CONCLUSION: Among multiply injured patients with severe blunt chest trauma, accidental hypothermia is not an independent predictor of ARDS and VAP and is more likely to be an accompaniment of injury severity and hemorrhage.

Predictive Value of Osteoprotegerin and Neutrophil Gelatinase-associated Lipocalin on Multiple Organ Failure in Multiple Trauma.

BACKGROUND/AIM: Multiple organ dysfunction syndrome (MODS) is the leading cause of late posttraumatic mortality. This study analyzed the prognostic values of osteoprotegerin (OPG) and neutrophil gelatinase-associated lipocalin (NGAL/lipocalin 2) compared to interleukin-6 (IL-6) in multiply injured patients. PATIENTS AND METHODS: A retrospective observational cohort study on multiply injured patients with an injury severity score (ISS) of ≥16 was performed. OPG, NGAL and IL-6 blood concentrations were measured. Statistical analysis comprised receiver-operating-characteristic (ROC) analysis with the corresponding area under the curve (AUC). RESULTS: Thirty-nine patients with a mean ISS of 34±11 were included. Fourteen patients (36%) developed MODS and 8 patients (21%) died. Plasma levels of NGAL, OPG, and IL-6 were significantly elevated in the MODS+ group. Each biomarker positively correlated with MODS score and diagnosis of MODS. CONCLUSION: NGAL and OPG might be indicative of MODS and could have the potential to be biomarkers in the early detection of patients at risk of posttraumatic MODS.

Admission blood glucose as a predictor of shock and mortality in multiply injured patients.

INTRODUCTION: Reliable diagnosis of shock in multiply injured patients is still challenging in emergency care. Point-of-care tests could have the potential to improve shock diagnosis. Therefore, this study aimed to analyze the impact of admission blood glucose on predicting shock in multiply injured patients. METHODS: A retrospective cohort analysis of patients with an injury severity score (ISS) ≥ 16 who were treated in a level I trauma center from 01/2005 to 12/2014 was performed. Shock was defined by systolic blood pressure ≤ 90 mmHg and/or shock index ≥ 0.9 at admission. Laboratory shock parameters including glucose were measured simultaneously. Receiver-operating-characteristic (ROC) analysis and multivariate logistic regression analysis was performed. RESULTS: Seven hundred and seventy-two patients were analyzed of whom 93 patients (12.0%) died. Two hundred and fifty-nine patients (33.5%) were in shock at admission. Mortality was increased if shock was present at admission (18.1% vs. 9.0%, p < 0.001). Mean glucose was 9.6 ± 4.0 mmol/L if shock was present compared to 8.0 ± 3.0 mmol/L (p < 0.001). Admission glucose positively correlated with shock (Spearman rho = 0.2, p < 0.001). Glucose showed an AUC of 0.62 (95% CI [0.58-0.66], p < 0.001) with an optimal cut off value of 11.5 mmol/L. Patients with admission glucose of > 11.5 mmol/L had a 2.2-fold risk of shock (95% CI [1.4-3.4], p = 0.001). Admission blood glucose of > 11.5 mmol/L positively correlated with mortality too (Spearman rho = 0.65, p < 0.001). Patients had a 2.5-fold risk of dying (95% CI [1.3-4.8], p = 0.004). DISCUSSION: Admission blood glucose was proven as an independent indicator of shock and mortality and, therefore, might help to identify multiply injured patients at particular risk.

Limited Influence of Flail Chest in Patients With Blunt Thoracic Trauma - A Matched-pair Analysis.

BACKGROUND: Flail chest is considered as one of the most severe forms of blunt thoracic trauma. However, its actual influence on post-traumatic morbidity and mortality is debatable. MATERIALS AND METHODS: A retrospective cohort analysis was performed of multiply injured patients (injury severity score ≥16) at a level I trauma center. Flail chest was defined as segment fracture of at least three consecutive ribs on at least one side. Propensity score matching was performed. RESULTS: A total of 600 patients were included, with a mean age of 44.1±19.1 years and a mean injury severity score of 31.6±10.4. Overall, 367 patients (61.2%) had a serial rib fracture. Forty-five patients (7.5%) presented with flail chest. Patients with flail chest more often had lung contusions (70 vs. 50%, p=0.04) and pneumo-/hematothorax (93 vs. 71%, p=0.005). There were no differences in post-traumatic morbidity and mortality. CONCLUSION: Flail chest had no independent influence in addition to injury severity on post-traumatic morbidity and mortality in multiply injured patients with blunt thoracic trauma.

El traslado secundario de pacientes con traumatismo grave no influye en el pronóstico / Interhospital transfer of severely injured trauma patients does not influence outcome

Objetivo: Examinar los resultados y la mortalidad de pacientes politraumáticos admitidos de forma primaria y secundaria en un hospital de traumatología de nivel 1 en Alemania, así como analizar el motivo de traslado desde los otros hospitales. Método: Análisis retrospectivo de una base de datos que abarca de enero de 2005 a diciembre de 2014. Se construyeron dos grupos principales [de admisión primaria (AP) y de admisión secundaria (AS)] y se investigó el carácter de los hospitales de transferencia (locales vs regionales vs suprarregionales). Se incluyeron datos demográficos, características del traumatismo, aspectos relacionados con la unidad de cuidados intensivos (UCI) [como por ejemplo tiempo de ventilación, requisitos de transfusión, complicaciones postraumáticas como el síndrome de distrés respiratorio del adulto (SDRA) y el síndrome de disfunción orgánica múltiple (SDOM)] y la escala de Glasgow y mortalidad. Los motivos de transferencia analizados fueron obtenidos a través de la historia clínica y los protocolos de transferencia. Resultados: Se identificaron 999 pacientes: 863 AP y 136 AS procedentes de centros traumatológicos locales (43,3%), regionales (39,7%) y suprarregionales (16,9%). No hay efectos negativos en los resultados a corto plazo debido al transporte interhospitalario de pacientes politraumatizados. Los pacientes con AS mostraron un puntaje APACHE II aumentado en el momento de admisión, pero no presentaron heridas de mayor gravedad que los pacientes con AP. La transferencia secundaria no es un factor de riesgo independiente de mortalidad: la estancia media hospitalaria para ambos grupos es semejante y el resultado es equivalente. Los motivos y el momento de transferencia difieren según el nivel del centro traumatológico (suprarregional vs regional/local). Conclusiones: Los pacientes transferidos a un hospital de traumatología nivel 1 por lo general se encuentran más enfermos (en el momento de admisión), pero presentan resultados semejantes de mortalidad y estancia en comparación con los pacientes admitidos de forma primaria

Objectives: To examine outcomes and mortality in multiple-injury patients initially admitted or transferred to a level-I trauma center in Germany and to analyze the reasons for transfers from other level hospitals. Methods: Retrospective analysis of data recorded from January 2005 through December 2014. We compared 2 main groups: patients admitted directly to the level-I center and patients transferred from another center. We also analyzed transferred patients according to whether they came from local, regional or supraregional trauma centers. Demographic information and trauma characteristics were collected. We also recorded variables related to management in the intensive care unit (eg, duration of ventilation, transfusion requirement), complications [eg, presence of Acute Respiratory Distress Syndrome or Multiple Organ Dysfunction Syndrome], Glasgow Outcome Scale, and mortality. The reasons for transfer were extracted from the case histories and transfer protocols. Results: A total of 999 cases were identified: 863 patients were admitted directly and 136 were transferred (from local centers, 43.3%; regional centers, 39.7%; supraregional centers, 16.9%). We identified no negative effects on short-term outcomes that could be attributed to interhospital transfers. Transferred patients had higher Acute Physiology and Chronic Health Evaluation II scores on admission, but their injuries were not more severe than transferred patients’. Interhospital transfer was not independently associated with mortality, and the mean hospital stay and outcomes were similar in the 2 groups. Reasons for transfer differed according to the timing of transfer and to type of trauma center (regional or local vs supraregional center). Conclusions: Patients transferred to a level-I trauma center are generally more severely ill at the time of admission, but mortality and mean hospital stay are similar in directly admitted and transferred patients

Interhospital transfer of severely injured trauma patients does not influence outcome. / El traslado secundario de pacientes con traumatismo grave no influye en el pronóstico.

OBJECTIVES: To examine outcomes and mortality in multiple-injury patients initially admitted or transferred to a level-I trauma center in Germany and to analyze the reasons for transfers from other level hospitals. MATERIAL AND METHODS: . Retrospective analysis of data recorded from January 2005 through December 2014. We compared 2 main groups: patients admitted directly to the level-I center and patients transferred from another center. We also analyzed transferred patients according to whether they came from local, regional or supraregional trauma centers. Demographic information and trauma characteristics were collected. We also recorded variables related to management in the intensive care unit (eg, duration of ventilation, transfusion requirement), complications [eg, presence of Acute Respiratory Distress Syndrome or Multiple Organ Dysfunction Syndrome], Glasgow Outcome Scale, and mortality. The reasons for transfer were extracted from the case histories and transfer protocols. RESULTS: . A total of 999 cases were identified: 863 patients were admitted directly and 136 were transferred (from local centers, 43.3%; regional centers, 39.7%; supraregional centers, 16.9%). We identified no negative effects on short-term outcomes that could be attributed to interhospital transfers. Transferred patients had higher Acute Physiology and Chronic Health Evaluation II scores on admission, but their injuries were not more severe than transferred patients'. Interhospital transfer was not independently associated with mortality, and the mean hospital stay and outcomes were similar in the 2 groups. Reasons for transfer differed according to the timing of transfer and to type of trauma center (regional or local vs supraregional center). CONCLUSION: Patients transferred to a level-I trauma center are generally more severely ill at the time of admission, but mortality and mean hospital stay are similar in directly admitted and transferred patients.

OBJETIVO: Examinar los resultados y la mortalidad de pacientes politraumáticos admitidos de forma primaria y secundaria en un hospital de traumatología de nivel 1 en Alemania, así como analizar el motivo de traslado desde los otros hospitales. METODO: Análisis retrospectivo de una base de datos que abarca de enero de 2005 a diciembre de 2014. Se construyeron dos grupos principales [de admisión primaria (AP) y de admisión secundaria (AS)] y se investigó el carácter de los hospitales de transferencia (locales vs regionales vs suprarregionales). Se incluyeron datos demográficos, características del traumatismo, aspectos relacionados con la unidad de cuidados intensivos (UCI) [como por ejemplo tiempo de ventilación, requisitos de transfusión, complicaciones postraumáticas como el síndrome de distrés respiratorio del adulto (SDRA) y el síndrome de disfunción orgánica múltiple (SDOM)] y la escala de Glasgow y mortalidad. Los motivos de transferencia analizados fueron obtenidos a través de la historia clínica y los protocolos de transferencia. RESULTADOS: Se identificaron 999 pacientes: 863 AP y 136 AS procedentes de centros traumatológicos locales (43,3%), regionales (39,7%) y suprarregionales (16,9%). No hay efectos negativos en los resultados a corto plazo debido al transporte interhospitalario de pacientes politraumatizados. Los pacientes con AS mostraron un puntaje APACHE II aumentado en el momento de admisión, pero no presentaron heridas de mayor gravedad que los pacientes con AP. La transferencia secundaria no es un factor de riesgo independiente de mortalidad: la estancia media hospitalaria para ambos grupos es semejante y el resultado es equivalente. Los motivos y el momento de transferencia difieren según el nivel del centro traumatológico (suprarregional vs regional/local). CONCLUSIONES: Los pacientes transferidos a un hospital de traumatología nivel 1 por lo general se encuentran más enfermos (en el momento de admisión), pero presentan resultados semejantes de mortalidad y estancia en comparación con los pacientes admitidos de forma primaria.

Influence of Entrapment on Prehospital Management and the Hospital Course in Polytrauma Patients: A Retrospective Analysis in Air Rescue.

BACKGROUND: Entrapment is a challenging and crucial factor in the prehospital setting. Few studies have addressed whether entrapment has an influence on on-scene treatment or on the following hospital course. OBJECTIVES: Here we aimed to investigate the influence of entrapment on prehospital management and on the hospital course of polytrauma patients. METHODS: We performed a retrospective analysis of consecutive patients with an Injury Severity Score ≥16 and aged 16-65 years that were admitted between 2005 and 2013 to a Level I trauma center. Two groups were built: entrapped (E) and nonentrapped patients (nE). These groups were evaluated for multiple prehospital and clinical parameters, including on-scene time, prehospital interventions, and posttraumatic complications. RESULTS: There were 310 patients (n = 194 no entrapment [Group nE], n = 116 with entrapment [Group E]) enrolled. The on-scene time was significantly longer in Group E than Group nE. Moreover, this group received a significantly higher volume of colloidal solution. Regarding the Injury Severity Score and Abbreviated Injury Scale (AIS), there were no significant differences between the groups, except for the AISextremities, which was significantly increased in Group E. The overall hospital stay and the initial theater time were significantly longer in Group E than Group nE. No significant differences were present for the occurrence of systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and acute respiratory distress syndrome, nor for Acute Physiology and Chronic Health Evaluation II and estimated and final mortality. CONCLUSION: In polytraumatized patients, entrapment has a minor influence on the outcome and treatment in the prehospital and hospital setting when using physician-based air rescue. However, entrapped patients are prone to sustain more severe trauma to the extremities.

Long-term outcome in 324 polytrauma patients: what factors are associated with posttraumatic stress disorder and depressive disorder symptoms?

BACKGROUND: Physical impairment is well-known to last for many years after a severe injury, and there is a high impact on the quality of the survivor's life. The purpose of this study was to examine if this is also true for psychological impairment with symptoms of posttraumatic stress disorder or depression after polytrauma. DESIGN: Retrospective cohort outcome study. SETTING: Level I trauma centre. POPULATION: 637 polytrauma trauma patients who were treated at our Level I trauma centre between 1973 and 1990. Minimum follow-up was 10 years after the injury. METHODS: Patients were asked to fill in a questionnaire, including parts of the Posttraumatic Stress Diagnostic Scale, the Impact of Event Scale-Revised and the German Hospital Anxiety and Depression Scale, to evaluate mental health. Clinical outcome was assessed before by standardised scores. RESULTS: Three hundred and twenty-four questionnaires were evaluated. One hundred and forty-nine (45.9%) patients presented with symptoms of mental impairment. Quality of life was significantly higher in the mentally healthy group, while the impaired group achieved a lower rehabilitation status. CONCLUSIONS: Mental impairment can be found in multiple trauma victims, even after 10 years or more. Treating physicians should not only focus on early physical rehabilitation but also focus on early mental rehabilitation to prevent long-term problems in both physical and mental disability.

Improved success rates using videolaryngoscopy in unexperienced users: a randomized crossover study in airway manikins.

BACKGROUND: Videolaryngoscopy has been proven to be a safe procedure managing difficult airways in the hands of airway specialists. Information about the success rates in unexperienced users of videolaryngoscopy compared to conventional laryngoscopy is sparse. Therefore, we aimed to evaluate if there might be more success in securing an airway if the unexperienced provider is using a videolaryngoscope in simulated airways in a randomized manikin study. Differences between commonly used videolaryngoscopes were elucidated. METHODS: A standardized hands-on workshop prior to the study was performed. For direct laryngoscopy (DL) we used a Macintosh laryngoscope, whereas for videolaryngoscopy (VL) we used the cMac, the dBlade, and a King Vision videolaryngoscope. Endotracheal intubations in three simulated normal and difficult airways were performed. Main outcome parameters were time to view and time to intubation. Cormack and Lehane (C + L) classification and the percentage of glottic opening (POGO) score were evaluated. After every intubation, the participants were asked to review the airway and the device used. RESULTS: 22 participants (14.8 ± 4.0 intubations per year, mostly trauma surgeons) with limited experience in videolaryngoscopy (mean total number of videolaryngoscopy .4 ± .2) were enrolled. We found improved C + L grades with VL in contrast to DL. We saw similar data with respect to the POGO score, where the participants achieved better visibility of the glottis with VL. The hyperangulated blade geometries of videolaryngoscopes provided a better visibility in difficult airways than the standard geometry of the Macintosh-type blade. The subjective performance of the VL devices was better in more difficult airway scenarios. CONCLUSIONS: After a short introduction and hands-on training, a videolaryngoscope seems to be safe and usable by unexperienced providers. We assume a standard geometry laryngoscope is optimal for a patient with normal anatomy, whereas VL device with a hyperangulated blade is ideal for difficult airway situations with limited mouth opening or restricted neck movement.

Femoral malrotation after surgical treatment of femoral shaft fractures in children: a retrospective CT-based analysis.

BACKGROUND: Rotational malalignment is an important and not always avoidable complication after surgical treatment of femoral shaft fractures. The purpose of this study was to determine the incidence of rotational malalignment in children after surgical treatment of femoral shaft fractures and to identify potential patient- and treatment-related risk factors based on data obtained from CT scans. METHODS: We conducted a retrospective analysis of all patients aged less than 15 years with femoral shaft fractures admitted to our level 1 trauma centre between January 2004 and July 2014. Patients having obtained postoperative CT scans were included for the determination of rotational malalignment. A difference of greater than 15° in femoral torsion between both legs was considered as clinically relevant. Additionally, demographic data and clinical information such as fracture type, treatment method, fluoroscopy time and operating time were reviewed. RESULTS: A total of 24 patients were enrolled in this study. Clinically relevant femoral malrotation was identified in 10 patients (41.6%). Surgical revision was performed in 7 patients (29.2%). There was no association between the type of surgical procedure, age and the incidence and/or amount of femoral malrotation. CONCLUSIONS: The data suggest that relevant femoral malrotation is an evident problem after surgical treatment of femoral shaft fractures in children that requires critical postoperative assessment. LEVEL OF EVIDENCE: Level III, retrospective study.

Synovial Fluid Cell Count for Diagnosis of Chronic Periprosthetic Hip Infection.

BACKGROUND: There is a paucity of data regarding the threshold of synovial fluid white blood-cell (WBC) count and polymorphonuclear cell (neutrophil) percentage of the WBC count (PMN%) for the diagnosis of chronic periprosthetic joint infection (PJI) after total hip arthroplasty. Despite this, many organizations have provided guidelines for the diagnosis of PJI that include synovial fluid WBC count and PMN%. We attempted to define a threshold for synovial fluid WBC count and PMN% for the diagnosis of chronic PJI of the hip using a uniform definition of PJI and to investigate any variations in the calculated thresholds among institutions. METHODS: From 4 academic institutions, we formed a cohort of 453 patients with hip synovial fluid cell count analysis as part of the work-up for revision total hip arthroplasty. Using the definition of PJI from the Musculoskeletal Infection Society (MSIS), 374 joints were diagnosed as aseptic and 79, as septic. Intraoperative aspirations were performed as routine practice, regardless of the suspicion for infection, in 327 (72%) of the patients. Using receiver operating characteristic curves, the optimal threshold values for synovial WBC count and PMN% were identified. RESULTS: For the diagnosis of chronic PJI of the hip, the threshold for the overall cohort was 3,966 cells/µL for WBC count and 80% for PMN%. Despite the high predictive accuracy for the cohort, there was notable institutional variation in fluid WBC count and PMN%. Furthermore, the rate of PJI was 14% (4 of 28) for patients with a WBC count of 3,000 to 5,000 cells/µL compared with 91% (20 of 22) for patients with a WBC count of >50,000 cells/µL. Similarly, the rate of PJI was 29% (14 of 49) for patients with a PMN% of 75% to 85% compared with 69% (33 of 48) for patients with a PMN% of >95%. CONCLUSIONS: Using the MSIS criteria, the optimal synovial fluid WBC count and PMN% to diagnose chronic PJI in the hip is closer to thresholds for the knee than those previously reported for the hip. This study validates the diagnostic utility of synovial fluid analysis for the diagnosis of periprosthetic hip infection; however, we also identified a clinically important "gray area" around the threshold for which the presence of PJI may be unclear. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rapid exclusion of bacterial arthritis using a glucometer.

Bacterial arthritis is a medical emergency. However, prompt diagnosis and differentiation from non-infectious diseases are challenging. As bacterial metabolism leads to glucose reduction, measurement of synovial fluid glucose seems to be a promising diagnostic approach. The purpose of this study was to determine whether synovial fluid glucose levels could be accurately measured by using a glucometer and to evaluate its diagnostic accuracy in diagnosing bacterial arthritis compared to currently available markers. In a prospective diagnostic study, 102 consecutive patients with atraumatic joint effusion were included. Synovial fluid glucose concentrations were determined using both glucometer and automated analyzer respectively. Synovial fluid culture, crystal analysis, and synovial cell analysis were performed. Blood samples were taken for blood cultures, analyses of serum infection markers, and serum glucose. There was a high correlation between synovial fluid glucose measured by the glucometer and the automated analyzer (r 2 = 0.92). According to the receiver operating characteristic curve, a threshold of 1.4 mmol/l had a sensitivity of 100 % (95 % CI 78.2-100 %), a specificity of 92.0 % (95 % CI 84.1-96.7 %), a positive predictive value of 68.2 % (95 % CI 45.1-86.1 %), and a negative predictive value of 100 % (95 % CI 95.5-100 %). These results suggest that synovial fluid glucose concentrations could be reliably measured using a glucometer. Due to its simplicity, this test has the potential to be an adjunct in the diagnostic cascade of bacterial arthritis.