[Treatment of severe tibial fractures with extensive soft tissue damage and/or contamination. Quality of life after use of the Ilizarov external fixator]. / Behandlung schwerster Tibiafrakturen mit gefährdetem Weichteilmantel und/oder Kontamination. Lebensqualität nach Einsatz des Ilizarov-Fixateur externe.

BACKGROUND: The Ilizarov external fixator (IF) is an immediate and definitive treatment option for severe tibial fractures compromised by extensive soft tissue damage. The aim of this study was to assess the general performance of the IF and especially the impact on patient quality of life. METHOD: A postal questionnaire including an SF-12 health survey and questions about various other aspects of quality of life was sent to all patients who received an IF for primary fracture treatment at a level 1 trauma centre between January 2000 and June 2009. RESULTS: A total of 48 completed questionnaires were received from patients treated with IF for severe tibial fractures. The median time to removal of the IF was 154 days (range 70-614 days). The mean SF-12 mental component score (MCS) was 52 (SD±12) and the mean physical component score (PCS) was 38 (SD±11). Of the patients 100 % answered that they were either satisfied or very satisfied with the treatment and 91 % would choose the same method of treatment under similar circumstances. CONCLUSIONS: This study demonstrates a high performance of IF in the treatment of severe tibial fractures with compromised soft tissue where more standard forms of treatment are contraindicated.

[Who is responsible for the removal of inferior vena cava filters?]. / Wer ist verantwortlich für die Entfernung von V.-cava-Filtern.

The fact that many inferior vena cava filters (IVCF) in trauma patients are not being removed has been described numerous times in the literature, but nobody really gives a reason why. This case presents a young patient who prophylactically received an optional IVCF after sustaining severe multitrauma. He had a failed retrieval 8 weeks post insertion and consequently was lost to follow-up before a second removal attempt was performed. Institutions inserting IVCF should establish guidelines for following up patients receiving prophylactic IVCF.

[Vena cava filters in trauma patients]. / Vena-cava-Filter bei unfallchirurgischen Patienten.

BACKGROUND: The introduction of removable inferior vena cava filters (IVCF) has created new options for the prevention of pulmonary embolisms in surgical trauma patients. We have observed increasing use in trauma patients. PATIENTS AND METHODS: A retrospective analysis was carried out of 49 trauma patients out of 85 who received IVCFs at our level 1 trauma centre in 2008. RESULTS: The indications for IVCF placement were multiple trauma in 33 patients, severe head injury in 13 and spinal injury in 3 patients. Of the patients 34 underwent successful removal, 11 (22%) patients had had no retrieval attempt by December 2009 and attempts at removal were unsuccessful in 3 patients. The mean age of the patients was 33.3 years. CONCLUSION: In 2008 the vast majority of IVCFs were inserted for prophylaxis in trauma patients. To increase the number of retrieved IVCFs, responsibility for the removal should be clarified in every hospital. The indications, advantages, safety and also the design of IVCFs are still under debate. A randomized controlled trial is needed to determine the appropriate use and indications for this potentially useful device in trauma patients.

Apoptosis induction and reduced proliferation in human osteoblasts by rhBMP-2, -4 and -7.

BACKGROUND: The role of bone morphogenetic proteins (BMPs) in bone healing has been demonstrated in numerous in vivo animal models. BMP-2, -4 and -7 have also been shown to stimulate the differentiation of human and animal stem cells into osteoblasts in vitro. There are, however, contradictory reports of BMPs causing apoptosis and inhibition of proliferation of osteoblastic cells. Therefore, a more complete understanding of the effects of BMP-2, -4 and -7 on human osteoblasts is required. METHODS: Cells of the immortalised human fetal osteoblastic line hFOB 1.19 were exposed to recombinant human (rh) BMP-2, -4 and -7. In addition, primary human osteoblasts were exposed to rhBMP-7. Cell proliferation was measured using a colorimetric assay. Apoptotic cells were detected using the TUNEL assay. RESULTS: The hFOB cells exposed in a dose-dependent manner to rhBMP-2, -4 and -7 had significantly lower rates of proliferation than non-treated cells, (p<0.01 for rhBMP-2, -4 and -7). The proliferation results for rhBMP-7 were replicated using primary human osteoblasts. Additionally, rhBMP-2, -4 and -7 induced a significantly higher rate of apoptosis in the hFOB cells, with a temporal and dose-dependent pattern (p<0.05), irrespective of the presence of serum growth factors. CONCLUSIONS: Despite interest in the potential clinical application of BMPs to improve bone healing, further studies are necessary to determine their full biological function before they can be used confidently in humans.

Trauma-hemorrhage causes prolonged depression in cellular immunity.

A number of clinical studies have shown that multiple and severe trauma causes immunosuppression and increases the susceptibility to sepsis. However, because there is a close temporal relationship between trauma and hemorrhage in humans, it is difficult to dissociate the effects of tissue trauma versus hemorrhage on immunity in the clinical setting. Studies in mice have shown that simple hemorrhage per se as well as laparotomy alone produces a marked depression in cellular immunity and no difference was seen in the extent of depression at 2 h if these two insults were combined. Nonetheless, it remains unknown whether the combined model of trauma-hemorrhage produces a more protracted depression in immune function. To study this, 5 days after either sham operation, laparotomy (i.e. trauma), hemorrhage alone (35 mmHg for 1 h, followed by resuscitation), or the combination of laparotomy and hemorrhage, mice (C3H/HeN) were sacrificed, after which splenocyte and peritoneal macrophage cultures were established. The proliferative capacity of the splenocytes, as well as their ability to release IL-2 and IL-3, was markedly decreased in the trauma-hemorrhage animals but was normal in the other groups. Furthermore, the release of IL-6 by peritoneal macrophages from animals that underwent trauma-hemorrhage was also significantly depressed. These results support the concept that traumatic injury in the form of a midline laparotomy combined with hemorrhage produces a more protracted impairment in cell-mediated immunity than laparotomy or hemorrhage alone.

Immune function is more compromised after closed bone fracture and hemorrhagic shock than hemorrhage alone.

OBJECTIVE: To determine whether closed bone fracture in conjunction with hemorrhagic shock compromises immune functions more severely than hemorrhagic shock alone. DESIGN: In a randomized, controlled trial, closed bone fracture of the right lower leg and/or hemorrhagic shock (mean +/- SEM arterial blood pressure, 35 +/- 5 mm Hg for 90 minutes) were induced in male C3H/HeN mice (weight, 25 g). Animals subjected to hemorrhage were resuscitated with the shed blood and lactated Ringer solution. At 72 hours after the experiment, all animals were killed to obtain whole blood, splenocytes, and splenic and peritoneal macrophages. Macrophage interleukin-1 and splenocyte interleukin-2 and interleukin-3 release were determined by bioassay, and splenocyte proliferation was measured by tritiated thymidine incorporation. RESULTS: Closed bone fracture alone did not affect immune functions 72 hours after the trauma. Hemorrhagic shock, however, induced a significant depression of splenocyte and macrophage functions. Bone fracture followed by hemorrhagic shock further depressed splenocyte proliferation and splenocyte interleukin-2 and interleukin-3 release as well as interleukin-1 release. CONCLUSION: Since bone injury coupled with hemorrhagic shock produces more severe depression of immune functions than hemorrhage alone, bone injury appears to play a contributory role in further depressing immune functions in trauma patients who experience major blood loss.

Mechanism of immunosuppression in males following trauma-hemorrhage. Critical role of testosterone.

OBJECTIVE: To determine whether male sex steroids contribute to the depression in cell-mediated immunity following trauma-hemorrhage and resuscitation. DESIGN: Two weeks before the induction of soft-tissue trauma (2.5-cm midline laparotomy) and hemorrhagic shock (mean [+/-SEM] blood pressure, 35 +/- 5 mm Hg), male C3H/HeN mice were castrated or sham castrated. Following trauma-hemorrhage, the mice were resuscitated and killed 24 hours thereafter to obtain whole blood and the spleen. RESULTS: Splenocyte proliferation and splenocyte interleukin-2 and interleukin-3 release were significantly depressed in sham-castrated animals after trauma-hemorrhage. In contrast, these variables in castrated mice after trauma-hemorrhage were similar to those in sham-operated animals. Corticosterone plasma levels were significantly elevated in both trauma-hemorrhage groups compared with those in sham-operated mice. Plasma testosterone levels were undetectable in castrated animals and detectable in sham-castrated mice. CONCLUSIONS: Castration before soft-tissue trauma and hemorrhagic shock maintains normal immune function in male mice, but sham-castrated male mice show significant immunodepression. The maintenance of immune function by androgen deficiency does not seem to be related to changes in the release of corticosterone. We conclude that male sex steroids are involved in the immunodepression observed after trauma-hemorrhage. Thus, the use of testosterone-blocking agents following trauma-hemorrhage should prevent the depression of immune functions and decrease the susceptibility to sepsis under those conditions.

Half pipe snowboarding: an (un)forgettable experience or an increasing risk for head injury?

The case is presented of a professional half pipe snowboarder with a large post-traumatic subdural haematoma, which allowed close to normal functioning and socialisation. It is an example of a potentially life threatening sports injury in an increasingly commercialised and popular winter sport. It highlights that a knowledge of injury patterns and a high level of suspicion should be maintained in the treatment of snowboarding injuries.

A soccer player with a sore toe: recognizing subungual osteochondromas.

In contrast to usual osteochondromas, subungual osteochondromas may arise following trauma rather than from aberrations in bone development. The rarity of subungual osteochondromas frequently leads to misdiagnosis and undertreatment, especially as a sports injury. When patients have nail-bed bruising, x-rays can rule out or confirm bone involvement, as in our case of a 20-year-old soccer player who had increasing pain in his left great toe. Treatment consists of radical, anatomic resection of symptomatic osteochondromas with periosteal realignment to prevent recurrence. Functional outcome after resection is excellent.

[Heterotopic ossification - from the aetiology to the current management]. / Heterotope Ossifikation : Von der Atiologie zur aktuellen Therapie.

Heterotopic ossifications (HO) are defined as the abnormal formation of bone in soft tissues. It can be classified into acquired and congenital forms. The acquired form, of which the pathogenesis is not fully understood, is often diagnosed in patients with traumatic brain injury, spinal cord injury, musculo-skeletal trauma or injuries associated with burns. HO presents itself mostly asymptomatically, the symptoms of the initial stadium are often unspecific; however, severe forms can lead to severe disability. Imaging techniques, foremost bone szintigraphy, are mostly used for verification of the diagnosis. Local radiotherapy and nonsteroidal anti-inflammatory drugs are the classical therapeutic and prophylactic options. In advanced stages, surgical resection may be required.

[Diagnosis and management of patients with mild traumatic brain injury--an update with recommendations and future perspectives]. / Diagnostisches und therapeuti- sches Vorgehen bei Patienten mit leichtem Schädelhirntrauma.

Mild traumatic brain injury (TBI) is a reversible brain damage, without structural changes, which is caused by an external force. By definition, patients with mild TBI have a GCS of 13-15. It is an established risk factor for both morbidity and mortality. Prognosis is dependent on the primary damage incurred as well as secondary damage, for example, posttraumatic bleeding and oedema. Initial management should focus on the identification of patients at risk for serious intracranial pathologies. Investigations should be directed towards the severity of the injuries. Notably, the conventional X-ray is inadequate for the assessment of TBI. The following article discusses practical algorithms for the management of mild TBI and the indications for early use of CT.

Complete medulla/cervical spinal cord transection after atlanto-occipital dislocation: an extraordinary case.

STUDY DESIGN: Case report. SUMMARY OF BACKGROUND DATA: Traumatic atlanto-occipital dislocation (AOD) with a complete medulla/spinal cord transection is rare and believed to be fatal owing to the high level of the spinal cord injury. Clinical outcome is poor. Consequently, relatively few case reports of adult patients surviving this injury appear in the literature. OBJECTIVES AND RESULT: We present the case of a 20-year-old male, who sustained an AOD with a complete medulla/spinal cord transection in a motorcycle accident to discuss the possibility of long-term survival with this condition. The patient underwent occipito-cervical stabilization. With an Injury Severity Score of 75, by definition unsurvivable, the patient is 16 months after the injury, ventilated and fully dependent for all care. CONCLUSION: Long-term survival following AOD with a complete medulla/spinal cord transection is possible if immediate resuscitation at the scene is available. Nevertheless, it remains questionable whether or not a patient with such a devastating injury and without any prospect of functional recovery should be kept alive under all circumstances.

[Whiplash injury--an update]. / HWS-Distorsionstrauma (sog. Schleudertrauma)--Ein Update.

Whiplash injuries of the cervical spine are of paramount clinical and socioeconomic importance. To date, many problems in regard to diagnosis, classification, treatment and assessment have not been sufficiently solved. Diagnosis is often made subjectively and the ideal mode of treatment is still the subject of controversy. Scientific progress has lead to the development of a prognostic classification system, objective diagnostic tests, different treatment modalities and, perhaps most importantly, the production of more secure automobiles. Current scientific evidence of the assessment and treatment of whiplash injuries is only partially integrated into clinical routine, although modern strategies of combining medicamentous therapy with early physiotherapy has shown good results. Clear dignostic criteria and treatment guidelines would conquer the cost explosion associated with whiplash injuries largely evident in the Swiss-German population.

Selective non-operative management of liver gunshot injuries.

BACKGROUND: In contrast to non-surgical treatment of blunt liver trauma, non-operative management (NOM) of liver gunshot injuries (LGSIs) is not widely accepted. This prospective study evaluated an experience of NOM of gunshot wounds to the liver. METHODS: All patients presenting with LGSIs who were haemodynamically stable with no evidence of peritonism underwent a protocol of NOM. RESULTS: Thirty-three patients (mean age 25 (range 13-50) years) were enrolled over a 36-month period. Fourteen had grade III injuries according to the American Association for the Surgery of Trauma (AAST) classification, whereas 11 and eight patients sustained major (AAST IV/V) and minor (AAST I/II) injuries respectively. NOM was successful in 31 of 33 patients. Two patients required delayed laparotomy for indications unrelated to the hepatic trauma. One patient died from necrotizing fasciitis, which appeared unrelated to the liver injury. CONCLUSION: This study demonstrated that, regardless of the grade of liver trauma, NOM is safe and effective in appropriately selected patients with LGSI treated in centres with suitable facilities.

Richter's hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview.

OBJECTIVE: To describe the clinical recognition, pathology, and management of Richter's hernia and to review the relevant literature of the past 400 years. SUMMARY BACKGROUND DATA: The earliest known reported case of Richter's hernia occurred in 1598 and was described by Fabricius Hildanus. The first scientific description of this particular hernia was given by August Gottlob Richter in 1778, who presented it as "the small rupture." In 1887, Sir Frederick Treves gave an excellent overview on the topic and proposed the title "Richter's hernia." To his work-a cornerstone to modern understanding-hardly any new aspects can be added today. Since then, only occasional case reports or small series of retrospectively collected Richter's hernias have been published. METHODS: The authors draw on their experience with 18 prospectively collected cases treated in the ICRC Lopiding Hospital for War Surgery in northern Kenya between February and December 1998 and review the relevant literature of the past 400 years. RESULTS: The classic features of Richter's hernia were confirmed in all case studies of patients: only part of the circumference of the bowel is entrapped and strangulated in the hernial orifice. The involved segment may rapidly pass into gangrene, yet signs of intestinal obstruction are often absent. The death rate in the authors' collective was 17%. CONCLUSION: Richter's hernia is a deceptive entity whose high death rate can be reduced by accurate diagnosis and early surgery. Considering the increasing incidence at laparoscope insertion sites, awareness of this special type of hernia with its misleading clinical appearance is important and of general interest.

[Cost analysis of acute therapy of polytrauma patients]. / Kostenanalyse der Akuttherapie von polytraumatisierten Patienten.

The rising costs of the Swiss health care system are currently a source of discussion. Precise facts about the treatment costs in Switzerland are not available. The aim of this paper is to assess the price of the acute therapy of multiple trauma patients at the University Hospital of Zurich. We analysed the exact treatment costs of 16 patients with an average Injury Severity Score (ISS) of 33.9. All these cases had a private or a supplementary insurance coverage, were foreigners or were otherwise invoiced according to the so-called hospital tariff (Spitalleistungskatalog/SLK). We developed a concept to measure the expenditure not covered by the insurance of those with a basic insurance, who entail the largest percent of all hospitalized patients. The average amount invoiced was 128,135 Swiss Francs (31,266-310,358 CHF). After subtracting the profit, gained on cases charged according to the SLK, the remaining deficit per ordinary insured was 42-65% or 33,703-138,829 CHF The range of this amount depends on the insurance status of the afflicted person. If hospitals are required to work with a balanced budget, then these losses can no longer be neglected. New forms of invoicing multiply trauma patients must be found in Switzerland.

The role of bacterial translocation on Kupffer cell immune function following hemorrhage.

Studies have shown that Kupffer cell and splenic macrophage, as well as peritoneal macrophage antigen presentation function, was significantly depressed following hemorrhage and remained so for at least 96 hours after resuscitation. Although macrophage antigen presentation was depressed, in all the cell populations studied, it was only the Kupffer cells which were upregulated to produce increased inflammatory cytokines. Furthermore, Kupffer cells from hemorrhaged animals exhibited enhanced, as opposed to reduced toxicity by peritoneal and splenic macrophages. This correlated well with increased cell-associated TNF on Kupffer cells. as well as increased capacity of Kupffer cells to release inflammatory cytokines after hemorrhage. It, therefore, could be postulated that while the enhanced Kupffer cell cytotoxicity may be beneficial in the destruction of pathogens seen in the liver due to bacterial translocation, this same activity may also contribute directly or indirectly to hepatocellular dysfunction and injury which is seen following hemorrhagic shock. Nonetheless, the depression in various immune functions after hemorrhage and resuscitation was comparable in both endotoxin-tolerant and -intolerant mice. Thus, it is debatable whether the alterations in immune function seen after hemorrhage are primarily due to the release of endotoxin into the blood stream during and/or following the hemorrhagic insult. Although translocation and/or endotoxemia occurs following severe hemorrhage, endotoxin may not be the sole or primary agent responsible for the induction of immunodepression after hemorrhage. The depressed Kupffer cell functions and increased inflammatory cytokine release by these cells can be significantly improved by post-treatment of animals with chloroquine, ibuprofen, diltiazem or ATP-MgCl2. Thus, these agents offer new therapeutic modalities in restoring the depressed Kupffer cell immune functions and in the treatment of generalized immunosuppression, as well as for decreasing the susceptibility to sepsis which is observed following severe blood loss.

Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique, results.

BACKGROUND: The surgical treatment of complex unstable proximal femur fractures from the trochanteric region to the middle shaft area is difficult and often highly invasive, especially in older patients with osteoporotic bones. METHODS: In 1993, we began to treat all unstable proximal femur fractures from the trochanteric region to the middle third of the shaft with the long gamma nail (LGN) and allowed the patients immediate full weightbearing after surgery. Perioperative, postoperative, and follow-up data were analyzed. RESULTS: During a 3-year period, we treated 37 patients with unstable proximal femur fractures with the LGN. Five of the patients had sustained pathological fractures, and four patients had sustained multiple trauma. The 37 operations were performed by 22 different surgeons with varying degrees of experience. The LGN implantations through maximal 40-mm skin incisions were performed in a mean skin-to-skin operation time of 125 minutes (range, 65-200 minutes) without any further complications. Thirty-one of the 37 patients were allowed immediate full weightbearing after the second postoperative day. The six patients who were not allowed full weightbearing were the ones who had multiple trauma (4) and those who were unable to walk before surgery (2). Three postoperative complications were as follows: one deep infection 4 months after surgery, one superficial infection 3 weeks after surgery, and one deep vein thrombosis 2 weeks after discharge. All three complications occurred in the group of patients who had sustained only one trauma. All traumatic fractures (n = 32) healed without any bone grafting, which means a union rate of 100%. Although immediate full weightbearing was allowed, there were no implant dislocations, implant failures, or other problems. The 30-day mortality was 0%. The follow-up examinations after a mean time of 6 months were very satisfying. All traumatic fractures were healed. The patients had symmetrical functional findings to the opposite side or before surgery, respectively, except for two patients with a leg shortening of 2 cm, two patients with an external malrotation of 10 degrees, and one patient with a hip extension deficit of 10 degrees after a pathological fracture. CONCLUSION: The LGN is, after appropriate introduction and training, a safe and easy implant for the treatment of complex proximal femur fractures from the trochanteric region to the middle shaft area. The minimal invasive technique with low risks and minimal complications and the possibility of immediate full weightbearing sets a new standard, especially for older patients with osteoporotic bones.

Diagnostic laparoscopy and diverting sigmoid loop colostomy in the management of civilian extraperitoneal rectal gunshot injuries.

BACKGROUND: This prospective study reviews the management of isolated civilian extraperitoneal rectal gunshot injuries using a protocol of diagnostic laparoscopy and abdominal wall trephine diverting loop colostomy, without laparotomy, distal rectal washout and presacral drainage. METHODS: Patients admitted to the trauma unit at Groote Schuur Hospital between January 2000 and December 2002 with a rectal injury were evaluated. A rectal injury was confirmed by digital rectal examination and proctosigmoidoscopy. Missile peritoneal violation was excluded by diagnostic laparoscopy. Normal laparoscopy was followed by creation of a diverting sigmoid loop colostomy through an abdominal wall trephine, without a laparotomy. No distal rectal washout or presacral drainage was performed. RESULTS: Of the 104 patients admitted with 106 rectal injuries, 20 (19.2 per cent) qualified for inclusion in the study. All had sustained low-velocity gunshot injuries of which 18 exhibited a transpelvic trajectory. Diagnostic laparoscopy was normal and a trephine diverting loop sigmoid colostomy was performed in all 20 patients. No pelvic sepsis occurred. Two patients developed rectocutaneous fistulas, both of which resolved without surgical treatment. Nineteen stomas have since been closed. CONCLUSION: Low-velocity gunshot injuries isolated to the extraperitoneal rectum can be managed safely by laparoscopic exclusion of intraperitoneal missile penetration and diverting sigmoid loop colostomy, without laparotomy, distal rectal washout or presacral drainage