[Preclinical and clinical management after mass disaster : Experiences from the train collision in Bad Aibling on 9 February 2016]. / Präklinisches und klinisches Management nach Massenunfall : Erfahrungen aus dem Zugunglück Bad Aibling am 9.2.2016.

Mass casualty incidents (MCI) in this day and age represent a special challenge, which initially require on-site coordination and logistics and then a professional distribution of victims (triage) to surrounding hospitals. Technical, logistical and even specialist errors can impair this flow of events. It therefore seems advisable to make a detailed analysis of every MCI. In this article the railway incident from 9 February 2016 is analyzed taking the preclinical and clinical cirumstances into consideration and conclusions for future management are drawn. As a special entity it could be determined that fixed table units in passenger trains represent a particularly dangerous hazard and in many instances in this analysis led to characteristic abdominal and thoracic injuries.

[Diagnosis and immediate therapeutic management of limb injuries. A systematic review of the literature]. / Diagnostik und sofortige Therapiemassnahmen bei Verletzungen der Extremitäten. Eine systematische Literaturübersicht.

OBJECTIVE: Limb injuries are often underestimated in the diagnostic procedures initiated in the resuscitation room. Missed diagnosis is therefore a frequent consequence in this issue. A systematic analysis of evidence-based procedures was therefore investigated in this paper. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Following admission of a multiple trauma patient vital functions have to be established in first priority. After stabilization a systematic clinical investigation and consecutive specific radiological procedures should rule out extremity injuries. These are the only evidence-based criteria leading to a complete detection of all limb injuries. All other aspects are only based on clinical experience or the opinion of expert committees. CONCLUSION: The quality of shock room management is mostly dependent on the experience of the " trauma team" (and especially of the trauma leader). Guidelines and specific trauma algorithms can provide a helpful instrument in this issue.

Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

[Development of a standardized instrument for quantitative and reproducible rehabilitation data assessment after polytrauma (HASPOC)]. / Entwicklung eines standardisierten Instruments zur quantitativen und reproduzierbaren Rehabilitationserfassung nach Polytrauma (HASPOC).

INTRODUCTION: Previous scoring systems for measurement of the quality of outcome are based on scores regarding injuries to individual body regions. Known scores which describe several organ regions are of no importance for trauma patients. Therefore a new rehabilitation outcome evaluation score was developed at our hospital. METHODS: Based on a prospective reinvestigation, a score system was developed that allows a quantitative appraisal of the subjective and objective outcome. A complete physical examination was performed, including ROM, neurologic examination and strength analysis. Part I (113 questions) is to be filled out by the patient; part II (191 questions) focusses on different body regions, physical examination and functional scoring. Included are the MFA, FIM, GCO and Frankel score. A final score (HASPOC) was developed to give a quantitative result of the outcome. RESULTS: The new score has a range from 5 to 411 points. One hundred and fifty patients were re-examined. The mean follow-up time was 2.2 +/- 0.1 years. The SF 12 indicated an outcome more than satisfactory in 63% of cases. The MFA demonstrated moderate or severe restrictions in 41%, in the case of injuries of the lower extremity in 52% of patients. The HASPOC indicated a mean of 44.5 points. CONCLUSION: This paper describes the development, structure, and the quantitative outcome of rehabilitation in polytrauma patients. This standardized rehabilitation instrument deals with a very heterogeneous patient population and shows the rehabilitation deficits accurately. Implemented recognized evaluations allow comparison of these results with those of other scoring systems.

[Ventilation according to the "open lung" concept of multiple trauma patients]. / Beatmung nach dem "open-lung"-Konzept bei polytraumatisierten Patienten.

OBJECTIVE: The ventilation mode clearly influences the course of patients with multiple trauma on the ICU. Ventilation according the "open lung" approach rapidly opens up atelectatic lung regions. Generation of an adequate intrinsic PEEP enables to keep the lung open. We studied the consequences of the "open lung" approach on the lung function and monitored its side effects on patients with multiple trauma. METHODS: 18 consecutive patients with multiple trauma and additional thoracic trauma were routinely ventilated according the "open lung" approach between May and November 1999. We were mainly interested in data of lung mechanics, oxygenation and ventilation. Side effects on other organ systems and consequence for the infection rate were monitored. RESULTS: Ventilation according the "open lung" approach enables early sufficient oxygenation and ventilation of patients with severe multiple trauma and accompanying thoracic trauma. The ventilation mode helps to prevent baro-, volu- and atelectrauma and thus fulfils the requirements for a present-day ventilation mode. An immediate complete healing of the lung damages was not found. Nevertheless, as a trend the length of ventilation support seems short. Even extensive osteosynthesis at multiple fractures was possible without delay. Side effects of the high opening pressure on the lung or other organs as well as sequels of the high intrinsic PEEP on liver, kidney or intestine were not found. The infection rate was low, therapeutic doses of antibiotics were necessary only in less than half of the ICU-stay. CONCLUSION: Ventilation according the "open lung" approach is a very effective and safe way to ventilate patients after severe multiple trauma with accompanying thoracic trauma.

[Extracorporeal shock wave therapy for delayed union of long bone fractures - preliminary results of a prospective cohort study]. / Die extrakorporale Stosswellentherapie (ESWT) in der Behandlung von Pseudarthrosen des Röhrenknochens. Erste Ergebnisse einer prospektivenklinischen Untersuchung.

Extracorporal shock wave therapy (ESWT) has been postulated as an additional therapeutic option in nonunion after fracture treatment. We have reexamined patients with nonunions treated at our institution to evaluate the efficacy of the method. In a prospective nonrandomized study patients were investigated with a minimum duration of nonunion of 6 months. Following 2 cycles of ESWT with 2000 impulses/18 kV, the reevaluation was performed at 1, 3 and 6 months after treatment. A total of 27 pseudarthroses was reevaluated, in 11 one or more reosteosyntheses had been performed prior to ESWT. Following ESWT we found a success rate of 41 % (n = 11). The clinical evidence of subjective, clinical improvement was found in 5 of these patients within 1 month, in all of these patients within a period of 3 months. Radiologic evidence of improvement occurred in none of these patients within 1 month, in all of these patients within 6 months. ESWT appears to represent an additional treatment option in patients with longstanding nonunion. If no improvement occurs, the maximum delay of reosteosynthesis is three months.

[Optimal duration of primary surgery with regards to a "Borderline"-situation in polytrauma patients. Arbeitsgemeinschaft "Polytrauma" der Deutschen Gesellschaft für Unfallchirurgie]. / Welche primäre Operationsdauer ist hinsichtlich eines "Borderline-Zustandes" polytraumatisierter Patienten vertretbar? Eine prospektive Evaluation anhand des Traumaregisters der DGU. Arbeitsgemeinschaft "Polytrauma" der Deutschen Gesellschaft für Unfallchirurgie.

Primary stabilization of major fractures in polytrauma patients is known to represent an important principle of treatment and has been shown to reduce the incidence of posttraumatic complications and of organ failure. However, in critically injured patients it has been discussed that extensive primary definitive treatment may also cause adverse effects due to its systemic burden by blood loss, loss of temperature etc. Patients who deteriorated unexpectedly following primary surgery have been named "borderline patients". In these patients it appears necessary to limit the amount of operative procedures, e. g. by performing temporary fixation of major fractures primarily. The threshold beyond which surgical procedures may cause more harm than good has not been well defined. This holds true especially for the duration of primary surgery. We investigated the clinical outcome in a large number of prospectively documented multiple trauma patients with respect of the duration of primary fracture stabilization. If a primary surgical procedure exceeded 6 hours in multiple trauma patients with an ISS of 25 points, patients demonstrated a significantly elevated ventilation time, an increased mortality, and a higher incidence of death from MOF in comparison with patients that were injured comparably, but were submitted to shorter primary operative procedures.

Parameters of multiple organ dysfunction fail to predict secondary amputation following limb salvage in multiply traumatized patients.

OBJECTIVE: The purpose of this retrospective analysis was to evaluate whether systemic parameters that are used to characterize multiple organ dysfunction could also be used to predict the optimal time for amputation in patients failing limb salvage surgery following severe extremity injury. METHODS: The principal criterion for the study group was a lower limb amputation following a type IIIb or IIIc open tibial shaft fracture in multiply traumatized patients. This group was then divided into one group of primary amputation (group A) and one group of secondary amputation (group B). Beside these groups a third group of total traumatic lower limb amputation was recruited (group C). Data analysis included demographics, injury severity according to the ISS, evaluation of the limb injury by three different salvage scores (HFS, MESS and NISSSA) and organ function monitoring by the Denver MOD Score over a 14-day period posttrauma or up to 7 days after secondary amputation. RESULTS: Within the period 1987-1997 a total of 15 patients were recruited for group A (primary amputation), 10 patients for group B (secondary amputation) and nine patients for group C (traumatic amputation). The MOD score was only positive for pulmonary dysfunction, also reflected by the Horovitz quotient, in those patients that died later in either group. Mortality was higher in group A (three out of 15) compared with group B (one out of 10), which may be due to a higher ISS in group A (mean ISS 28.2 vs. 21.0 of group B). Although the MOD score of all recovered patients revealed no significant difference between group A and B, secondary amputation resulted in significantly longer demand of mechanical ventilation. According to our results secondary amputation may lead to transiently decreased pulmonary function but does not necessarily end in multiple organ dysfunction. The need for amputation in failed limb salvage was not indicated by systemic parameters. CONCLUSION: The right time for secondary amputation in order to prevent subsequent pulmonary dysfunction cannot be predicted by parameters otherwise indicating organ dysfunction. As the risk of secondary amputation for developing pulmonary dysfunction apparently cannot be estimated the decision for amputation or limb salvage should be made initially after trauma and should be the definite one.

Intestinal cytokine response after gut ischemia: role of gut barrier failure.

OBJECTIVE: To investigate the effect of intestinal ischemia with and without a reperfusion injury on intestinal cytokine production and gut permeability. SUMMARY BACKGROUND DATA: In humans and in animal models, the gut has been implicated as a cytokine-producing organ after ischemia/reperfusion (I/R)-type injuries. Because of the limitations of in vivo models, it has been difficult to demonstrate directly that the gut releases cytokines after an I/R injury or whether there is a relation between the magnitude of the ischemic process and the cytokine response. METHODS: Ileal mucosal membranes from rats subjected to sham or 45 or 75 min of superior mesenteric occlusion (SMAO) or 45 minutes of SMAO and 30 minutes of reperfusion (SMAO 45/30) were mounted in the Ussing chamber system. Levels of tumor necrosis factor-alpha and interleukin-6 were serially measured in the mucosal and serosal reservoirs of the Ussing system, as was mucosal permeability as reflected by the passage of bacteria or phenol red across the ileal membrane. In a second group of experiments, Escherichia coli C25 was added to the mucosal reservoir to determine if the cytokine response would be increased. RESULTS: Mucosal and serosal levels of tumor necrosis factor-alpha were equally increased after SMAO, with the highest levels in the 75-minute SMAO group. The highest levels of interleukin-6 were found in rats subjected to 75 minutes of SMAO or SMAO 45/30; the serosal levels of interleukin-6 were four to sixfold higher than the mucosal levels. The addition of E. coli C25 resulted in a significant increase in the amount of interleukin-6 or tumor necrosis factor-alpha recovered from the mucosal reservoir. Increased ileal membrane permeability was observed only in rats subjected to 75 minutes of SMAO or SMAO 45/30. CONCLUSION: These results directly document that the levels of tumor necrosis factor-alpha and interleukin-6 released from the gut increase after an ischemic or I/R injury, such as SMAO, and that there is a relation between the magnitude of the gut ischemic or I/R insult and the cytokine response.

Long term results after multiple injuries including severe head injury.

OBJECTIVE: To describe the long term results in patients with multiple injuries including severe head injury. DESIGN: Retrospective and prospective clinical study. SETTING: Level I trauma centre, Germany. PATIENTS: Patients aged 16-60 years who had been injured more than 2 years before, whose Injury Severity Score was over 20 and whose cranial Abbreviated Injury Score (AIS) was over 3. MAIN OUTCOME MEASURES: Glasgow Outcome Scale (GOS), functional, neuropsychological, vocational and social outcomes. RESULTS: 58 patients, median age 24 (range 16-53, interquartile range (IQR) 21-32) years were investigated 5 (3-9; IQR 4-7) years after their injury. Median ISS was 34 (21-57; IQR 26-41) and GCS 6 (3-8; IQR 4-7). Duration of coma was 10 (2-51; IQR 7-22) days and neurological rehabilitation lasted 169 (10-830; IQR 80-300) days. Movements of the elbow and ankle was most impaired by injury. All psychometric tests showed deficits, particularly in speed of processing, concentration, recent memory, and learning performance. The social environment had been changed in half and vocational rehabilitation was dependent on age. 24 (42%) returned to their former profession, 18 (31%) were retrained to another profession, 16 (27%) were unemployed or retired on a pension. 31 (53%) made a good recovery with moderate disability, 19 (33%) had severe disability, and 8 (14%) remained in a persistent vegetative state assessed by the GOS. CONCLUSION: Early and concentrated rehabilitation facilitates functional, social, and neuropsychological reintegration.

Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients?

Body positioning (kinetic therapy) is known to improve oxygenation in patients with impaired pulmonary function and ARDS. We have used body positioning prophylactically in trauma patients whose injury and pattern predispose to ARDS. This retrospective study reports the effects of early prophylactic (group P) versus late (group L) axial rotation on pulmonary function and the incidence of ARDS. Both groups were comparable in age, injury severity and the degree of thoracic injury. Systemic oxygenation was significantly better and the incidence of ARDS significantly lower in group P (group P: 34.3 per cent, group T: 74.1 per cent, P < 0.05). There was a tendency towards a lower incidence of pneumonia and a better survival in group P, which did not reach statistical significance. The duration of kinetic therapy and of ventilation was comparable in both groups. In this retrospective evaluation early prophylactic kinetic therapy was associated with a significantly lower incidence of ARDS compared with that instigated later.

[Amputation or reconstruction of IIIB and IIIC open tibial fracture. Decision criteria in the acute phase and late functional outcome]. / Amputation oder Rekonstruktion bei der IIIB und IIIC Offenen Unterschenkelfraktur. Entscheidungskriterien in der Akutphase und funktionelles Spätergebnis.

In IIIB and IIIC type open tibial fractures (according to Gustilo) the primary decision that has to be made regarding therapy is wether or not the limb can be salvaged. To standardize the criteria for amputation different salvage scores have been established in recent years. In this study the Hannover Fracture Scale (HFS), the Predictive Salvage Index (PSI), the Mangled Extremity Severity Score (MESS) and the NISSSA score were evaluated regarding their clinical relevance. When ROC Analysis was performed for all these scores in our patients the HFS revealed the highest sensitivity (0.91), but low specificity (0.71). The highest specificity was noted for the MESS (0.97), which in parallel showed the lowest sensitivity (0.59). In general it seems to be essential to make the right decision initially in order to avoid secondary amputation. All the scores mentioned here appear to be helpful in decision making. Salvaged limbs in IIIB and IIIC fractures presented a comparable good outcome, whereas salvaged IIIC injuries with a high score presented an outcome which was as bad as in secondary amputations. Secondary amputated patients required not only significant longer hospitalization but also resulted in poor outcome compared with the patients having received reconstruction or primary amputation.

[Pediatric polytrauma. A retrospective comparison between pediatric, adolescent and adult polytrauma]. / Das polytraumatisierte Kind. Ein retrospektiver Vergleich zwischen polytraumatisierten Kindern, Jugendlichen und Erwachsenen.

Numerous epidemiological studies about multiple trauma patients do not include an analysis of patients under the age of 18. To study this, the data of 682 patients with multiple traumata, treated between 1981 and 1991 at Hannover Medical School, Germany, were retrospectively analyzed. The patients were divided into four age-related groups: preschool age (< 6 years), school age (< 13 years), teenagers (< 18 years) and adults (> or = 18 years). Analyzed were the cause of trauma, localization of injuries and the cause of death. Children were less often injured as passengers in cars, but more often injured as pedestrians and bicyclists than adults. However, children showed a significant higher mortality than adults, with threefold increased risk of death when they injured as passengers in car accidents. In all groups injuries to the head and the legs were most common. Children showed a lower incidence of trauma to the thorax, abdomen, hip and arms than the adult group. Nevertheless, trauma to the thorax, abdomen and head was associated with the highest risk of death in all groups. Spinal cord injuries, especially injuries to the neck, also showed a high risk of death. Children younger than 6 years had the most severe head injuries. Safety improvements for children in cars, helmet usage on bicycles and early training in traffic safety for children might decrease the lethality in this group of trauma patients.

[The intestine as the central organ in the development of multiple organ failure after severe trauma--pathophysiology and therapeutic approaches]. / Der Darm als zentrales Organ in der Entwicklung de Multiorganversagens (MOV) nach schwerem Trauma--Pathophysiologie und therapeutische Ansätze.

Multiple organ failure is with an incidence of 10-25% and a mortality of 50-70% the most severe complication after severe trauma. Intestinal ischemia and a corresponding impaired gut barrier function is thought to have a high impact on the development of multiple organ failure after severe trauma. Under normal conditions the intestinal wall is a sufficient barrier against bacteria and their products. Gut ischemia is followed by mucosal lesions, the intestinal permeability is increased. Translocating bacteria and bacterial products (endotoxin, peptidoglykan) can lead to a local and/or systemic immun-inflammatory response, which is made responsible for the development of multiple organ failure. Tonometry as a possibility of monitoring intestinal ischemia as well as a tool to estimate the prognosis of multiple trauma patients is still discussed controversially. Dopexamin, which directly influences intestinal ischemia (goal directed therapy) might be a successful treatment option, however until now no clinical study about beneficial effects of dopexamine in severely injured patients is available. Selective gut decontamination showed no clinical benefits in multiple trauma patients. Early enteral nutrition especially with immunomodulating ingredients ("immunonutrition") decreases posttraumatic complications as well as the incidence of MOF. However a reduction of mortality could not be described in severely injured patients so far.

[Intramuscular pO2 monitoring in compartment syndrome--an experimental study]. / Intramuskuläres pO2-Monitoring des Kompartmentsyndroms--Eine experimentelle Studie.

HYPOTHESIS: Measuring intracompartmental pressure is a well accepted method in evaluating a compartment syndrome, which may occur after limb ischemia followed by reperfusion. As a compartment syndrome is paralleled by a decreased microcirculation it should be possible to evaluate a compartment syndrome also by measuring intramuscular pO2. METHODS: Anesthetized rats (spontaneous breathing via tracheotomy) were subjected to infrarenal ligation of the aorta. A pressure catheter was placed subfascial in the crural muscle group of one hind limb, whereas the contralateral side was prepared with a pO2 catheter. Besides a sham operated group, three experimental groups were subjected to either 2 hrs, 4 hrs or 6 hrs of ischemia followed by 4 hrs of reperfusion. One further group was also subjected to 4 hrs of ischemia and 4 hrs of reperfusion but received a fasciotomy at the time of reperfusion. Compartment pressure and intramuscular pO2 were recorded every 15 min. For histological examination muscle specimen were obtained after each experiment. RESULTS: Two hours of ischemia followed by 4 hrs of reperfusion did not result in any morphological changes and also not in any significant change in compartment pressure during both phases, whereas pO2 significantly dropped during ischemia (from 19.0 mmHg to 3.0-5.0 mmHg) and returned to normal during reperfusion. In prolonged ischemia (4hrs) morphologically a severe interstitial edema was evident, compartment pressure increased during reperfusion (from 2.0 mmHg to 8.8 mmHg) and pO2 dropped during ischemia down to 3.0 mmHg and did not return to normal during reperfusion (10.5 mmHg versus 19.0 mmHg normal). In case of 6 hrs ischemia, partial necrosis and only little interstitial edema were found morphologically. There was no significant change in compartment pressure throughout the study; and pO2 remained significantly decreased even during reperfusion (2.0-3.0 mmHg). DISCUSSION: Normal compartment pressure could mislead to false negative interpretation of compartment syndrome, whereas pO2 clearly identifies the microcirculatory state of the muscle. Thus, intramuscular pO2 monitoring presents a valuable method in evaluating compartment syndrome, especially in case of suspect clinical signs but normal compartment pressure.

[Must the accident victim be protected from the emergency physician?]. / Muss der verunfallte Patient vor dem Notarzt geschützt werden?

Quality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance. Regarding the triage, for example, it was noted that 28% of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7% of patients two additional mistakes and in 4% of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment. Preclinical intubation and mechanical ventilation was not performed in 16.5% although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38% of patients suffering from severe thoracic trauma (AISThorax > or = 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17% of all documented patients. According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.

[Elbow para-articular pseudarthrosis. Etiology and treatment]. / Ellenbogennahe Pseudarthrosen. Ursachen und Behandlung.

Non-unions in the proximity of the elbow are very rare and in most cases caused by mistakes in initial treatment. Reconstruction after pseudarthrosis of the elbow continues to pose a challenge for any surgeon. The aim of our study was to analyze the initial mistakes and to underline the most important aspects of reconstructive surgery. In a retrospective study over a defined period of 10 years (1/1985 to 12/1994) we were able to treat altogether 27 non-unions in the proximity of the elbow. These patients were transferred to our hospital at an average of 44 weeks after initial therapy elsewhere. The main symptoms were in 17 cases pain and in all other patients functional deficit. Reconstructive surgery was performed an average 54 weeks after the primary injury. In 24 out of 27 cases a re-osteosynthesis, in 12 an arthrolysis, in 7 a neurolysis and in 2 cases an arthroplasty was needed. The patient could return to work an average 18 weeks after the operation and 53 weeks after injury. The initial complaints were reduced in 24 of 27 cases, with a significant improvement in the ROM and functional outcome according to the Mayo Elbow Performance Index.

Cytokines and adhesion molecules in elective and accidental trauma-related ischemia/reperfusion.

BACKGROUND: The major pathophysiologic role of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, and IL-6, as well as of the (soluble) adhesion molecules ICAM-1 and E-selectin, has been identified using different experimental models of ischemia/reperfusion injury. Moreover, in intensive care management, evaluation of these agents as diagnostic or prognostic tools is of great interest in ischemia/reperfusion injury caused by surgical or accidental trauma. For this reason, inflammatory mediators including those mentioned above were investigated in three different groups of surgical patients. METHODS: The first group (A, n = 13) comprised patients undergoing elective limb surgery without a tourniquet. The second group (B, n = 36) included patients subjected to limb surgery with a tourniquet. The third group (C, n = 30) was composed of accidental trauma patients who were retrospectively divided into those with and without multiple organ dysfunction (+MOD and -MOD, respectively) as defined by the Denver Score. Serial blood samples were taken during a 5-day (elective surgery) or 14-day (accidental trauma) observation period for monitoring of cytokines and soluble adhesion molecules. The clinical course and the degree of MOD were recorded daily. RESULTS: Only when a tourniquet was applied for a mean time of 105 minutes did elective limb surgery result in significantly increased serum levels of IL-6, IL,-1ra, and IL-10 but not TNF-RII. Yet, the increase in cytokine levels was not sufficient to cause an enhanced shedding of adhesion molecules, and both soluble ICAM-1 and soluble E-selectin remained unchanged in groups A and B throughout the 5-day observation period. In patients with multiple injuries (group C), all parameters increased early after trauma up to 10- to 20-fold in comparison with the elective limb surgery patients in groups A and B. When the accidental trauma patients were divided according to the Denver Score for +MOD (n = 8, mean Injury Severity Score = 33.8) and -MOD (n = 22, mean Injury Severity Score = 31.2), a clear difference became evident in serum IL-6 and IL-1ra levels within the first 4 days and in serum IL-10 levels for the first 2 days after trauma, with cytokine levels being significantly higher in the +MOD patients 3 to 4 days before the onset of MOD. Although highly elevated, TNF-RII levels did not differentiate between +MOD and -MOD at any time. The increase in serum cytokine levels was associated with a remarkable expression and shedding of ICAM-1 and E-selectin made obvious by significantly increased soluble serum ICAM-1 levels in +MOD patients compared with the -MOD group between days 3 and 5 after trauma and increased soluble serum E-selectin levels between days 2 and 4 after trauma. CONCLUSION: The release of cytokines and soluble adhesion molecules into the circulation correlates well with the degree of trauma (elective surgery vs. accidental multiple trauma), depending on the extent of the associated ischemia/reperfusion injury. Both groups of mediators are also clearly related to the development of MOD in patients with multiple injuries with generalized ischemia/reperfusion injury caused by hemorrhagic shock. They may be predictive of patients at risk for MOD when measured early in the posttraumatic period.

Internal fixation of multiple fractures in patients with polytrauma.

Within the last decade understanding of the pathogenetic consequences of trauma has been improved significantly. An additional reduction of lethality has been achieved that in part is related to increasing discrimination of complex injury patterns. Accordingly, additional staging in fracture management of these injuries has been developed. An overview of the current status of fracture management in polytrauma is given and certain regimens that are still controversially are discussed. The principles determined are based on the treatment experience of 4003 multiply injured patients within the past 23 years. The most important principles within the first hours after trauma represent adequate hemorrhage control. In fracture treatment the primary goal remains to perform primary stable osteosynthesis. In severe polytrauma with severe injuries to the extremities, the first decision is whether limb salvage can be achieved without risk of deterioration of the patient's condition. If this is the case, open fractures Grades III b and c usually can be stabilized primarily by unreamed intramedullary nailing or percutaneous plating. The priority pattern in multiple closed fractures is as follows: (1) tibia; (2) femur; (3) pelvis; (4) spine; and (5) upper extremity. Exceptions may ensue if severe head or thoracic trauma is present. Delayed treatment is performed for complex joint reconstruction, definitive treatment of maxillofacial injuries, and soft tissue reconstruction.