Christian Fialka

Open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: a consecutive series of 38 cases.

BACKGROUND According to the literature, the overall outcome in a patient population with chest or abdominal injury with initial cardiac arrest has to be rated as poor. In cases of penetrating injuries, open-chest cardiopulmonary resuscitation (CPR) has been recommended as a treatment option to improve the survival rate. The aim of this study was to prove equal outcome for patients with blunt chest or abdominal trauma. METHODS During a 5-year period, a consecutive patient series admitted to an urban Level I trauma center was examined. Only patients with blunt trauma and witnessed cardiac arrest, who had a documented, uninterrupted closed-chest CPR (CCCPR) of less than 20 minutes were included in this study (n=38). Exclusion criteria were age over 70 years, penetrating injuries, CCCPR of more than 20 minutes, as well as nonprofessional bystander resuscitation. RESULTS Four of 38 patients survived. In comparison with the group of nonsurvivors, both groups showed a similar age and gender ratio (mean age, 28, 32, respectively). The mean Injury Severity Scale was 54 (range, 42-66) in the survivor group and 66 (range, 29-75) in the nonsurvivor group, respectively. The time of CCCPR was on average 13 minutes (range, 11-15 minutes) for the survivors and 16 minutes (range, 1-20 minutes) for the nonsurvivors. CONCLUSION Patients with blunt trunk trauma and cardiac arrest after hemorrhagic shock may benefit from open-chest CPR with the same probability as shown for patients with penetrating injuries. This is especially true if the procedure is started as soon as possible, but at the latest within 20 minutes after initial CCCPR.

Visualization of Intraarticular Structures of the Acromioclavicular Joint in an Ex Vivo Model Using a Dedicated MRI Protocol

OBJECTIVE The purpose of this study was to develop an MRI protocol that could visualize the intraarticular structures of the acromioclavicular (AC) joint. MATERIALS AND METHODS Using six fresh specimens from cadaveric shoulders, several MRI sequences were performed on 1.0-T scanners with a superficial coil (the temporomandibular joint coil). After the radiologic examination, the specimens were prepared for histology and 300-microm-thick, toluidine blue-stained sections were prepared that corresponded to the MR images. In each series of sections, immunohistochemistry using a type II collagen antibody was performed to further characterize the intraarticular structures. RESULTS The coronal 3D T1-weighted fast-field echo water-selective sequence allowed the identification of the intraarticular disk in all cases. Determination on MRI of other intraarticular structures--adipose tissue, synovial fluid, and the borders between neighboring tissues of different types--that corresponded to the histologic sections was possible. The use of a second plane in the 1.0-T sequences did not reveal additional information. CONCLUSION The described MRI protocol allows the visualization of the intraarticular fibrocartilaginous disk and the border between articular cartilage and the disk. Future clinical studies will indicate the diagnostic value of this protocol. We assume that this MRI protocol could help us to better understand AC joint disorders, in particular those located intraarticularly, and dislocations.

Physeal injuries of the proximal humerus: long-term results in seventy two patients

PurposeThe aim of this study was to evaluate our treatment methods of proximal humeral physeal injuries retrospectively and elucidate the relationship between the trauma mechanism, the radiographic injury pattern, the consequent therapy and the functional outcome, and to further deduct and verify prognostic criteria.MethodsAt our Department of Trauma Surgery, 303 children and adolescent patients with fractures of the proximal humeral epiphysis were treated from 1992 to 2009. 72 cases were diagnosed as physeal fractures according to the Salter–Harris classification and were included in our study.Results15 physeal fractures of the proximal humerus were reconstructed anatomically by open or closed reduction and produced 93.3% excellent results. 57 physeal fractures were treated in a conservative way and produced 94.7% excellent results.ConclusionWe state that epiphyseal injuries should to be treated depending on the age of the patient. This is the only way to decrease the rate of posttraumatic epiphysiodesis with consequent problems, including limb-length discrepancy and/or angular deformities.

Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures

AIM The aim of this study was to evaluate risk factors for the development of humeral head necrosis and non-union after proximal humeral fractures-in particular, general risk factors that exist independent of fracture type. MATERIALS AND METHODS This study included patients (n=154) treated for proximal humeral fracture by means of open reduction and internal fixation (ORIF) using the Philos plate at a single level I trauma centre between January 2005 and December 2013. Follow-up monitoring included radiographic examination before hospital discharge, and again at 6 weeks, 12 weeks, and 6 months after surgery. At a minimum follow-up time of 6 months, radiographs taken in the anteroposterior and axial projection were evaluated in regard to the development of humeral head necrosis, non-union, and secondary screw cut out. RESULTS A total of 154 patients (61 males, 93 females) were available for radiological checkup. Mean age was 55.8 years (range: 19-91 years). There were statistically significant correlations between the development of avascular necrosis (AVN) and fracture type, non-union and smoking, and screw cut out - as well as overall complication rate - and age. The time to surgery did not influence the risk for AVN or non-union, independent of fracture type. In this study population, the risk of developing non-union after ORIF was 3.9-fold higher in heavy smokers (i.e., >20 cigarettes per day). The risk for screw cut out was 4.1-fold higher in patients over 60 years of age, and the overall risk for complications was 3.3-fold higher. CONCLUSION The older the patient, the more carefully one must consider the decision between conservative and operative treatments. If surgical treatment is performed, screw length should be selected depending on the patients age. Heavy smokers must be informed preoperatively of the increased risk for bony non-union after ORIF.

Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4–92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3–22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE Epidemiologic study, level IV.

The arterial supply of the tendon of the long head of the biceps brachii in the human: A combined anatomical and radiological study

PURPOSE Arthroscopic repair of superior labral anterior to posterior (SLAP) lesions is often associated with a prolonged period of pain during the rehabilitation process. This might possibly be due to hypoxia in the biceps tendon anchor caused by sutures. The purpose of the study was to investigate the arterial supply of the long head of the biceps brachii tendon (LHBT) that may be impaired by surgery in the region of the biceps tendon anchor. METHODS On 20 human formalin-fixed bodies, the anterior circumflex humeral artery (ACHA) was located and followed into the intertubercular groove until it reached the LHBT. On 10 fresh-frozen anatomic specimens of the upper extremities, contrast medium was injected into the axillary artery, a 3D scan was performed, and multiplanar reconstructed (MPR) slices were generated. A set of maximum intensity projection (MIP) reconstructions from 10 computed tomography angiographies (CTA) of the upper extremities was used to confirm the findings of the 3D scan. RESULTS All anatomical dissections and radiological investigations revealed that the proximal portion of the LHBT was consistently supplied by an ascending branch of the ACHA. No artery was found to supply the biceps tendon anchor from the proximal aspect. CONCLUSIONS As the arterial supply of the LHBT is mainly provided by the ACHA, which enters the glenohumeral joint from the distal aspect, surgery at the bony origin of the LHBT may not interfere with this specific vessel.

Neurofilament distribution in the superior labrum and the long head of the biceps tendon

BackgroundThe postoperative course after arthroscopic superior labrum anterior to posterior (SLAP) repair using suture anchors is accompanied by a prolonged period of pain, which might be caused by constriction of nerve fibres. The purpose was to histologically investigate the distribution of neurofilament in the superior labrum and the long head of the biceps tendon (LHBT), i.e. the location of type II SLAP lesions.MethodsTen LHBTs including the superior labrum were dissected from fresh human specimen and immunohistochemically stained against neurofilament (NF). All slides were scanned at high resolution and converted into tagged image file format, and regions of interest (ROIs) were defined as follows: ROI I—superior labrum anterior to the LHBT origin, ROI II—mid-portion of the superior labrum at the origin of the LHBT, ROI III—superior labrum posterior to the LHBT origin and ROI IV—the most proximal part of the LHBT before its attachment to the superior labrum. The entire images were automatically segmented according to the defined ROIs and measured using a programmed algorithm specifically created for this purpose. The NF-positive cells were counted, and their total size and the area of other tissue were measured separately for the different ROIs.ResultsDistribution of NF-positive cells in absolute numbers revealed a clear but insignificantly higher amount in favour of ROI I, representing the superior labrum anterior to the LHBT origin. Setting ROI I at 100%, a significant difference could be seen compared to ROI III, representing the superior labrum posterior to the LHBT origin (ROI I vs. ROI III with a p value < 0.05).ConclusionsSummarizing, the density of neurofilament is inhomogeneously distributed throughout the superior labrum with the highest number of neurofilament in the anterior superior labrum. Thus, suture placement in type II SLAP repair could play an important role for the postoperative pain-related outcome.

Is suprascapular neuropathy common in high-performance beach volleyball players? A retrospective analysis

SummaryBackgroundPain in the shoulder is a common problem in overhead sports and at times goes along with atrophy of the supra- and infraspinatus muscles. A neuropathy of the suprascapular nerve is one possible reason. The aim of the study was to examine the suprascapular nerve in Austrian high-performance beach volleyball players.MethodsIn this cross-sectional study, 18 high-performance beach volleyball players were included. An electrophysiological examination was performed consecutively. Nerve conduction studies of the suprascapular nerve were performed bilaterally. Needle electromyography was done for the infraspinatus muscle of the dominant arm. Additionally, pain and muscle atrophy were evaluated.ResultsNo acute or chronic neurogenic changes in the infraspinatus muscle were seen in any player, although atrophy of the suprascapularis innervated muscles was present in five players.ConclusionsA lesion of the suprascapular nerve could not be shown in any of the players. Therefore, a biomechanical cause has to be considered for the clinical symptoms in the present study population.ZusammenfassungGrundlagenSchulterbeschwerden treten häufig bei Überkopfsportlern auf und gehen oftmals mit einer Atrophie des M. supra- und infraspinatus einher. Eine mögliche Ursache für diese Beschwerden stellt eine Neuropathie des N. suprascapularis dar. Ziel dieser Studie war die Untersuchung des N. suprascapularis bei Österreichischen Elite-Beach-Volleyballspielern.MethodikIn diese Beobachtungsstudie wurden 18 Elite-Beach-Volleyballspieler eingeschlossen. Eine elektrophysiologische Untersuchung erfolgte konsekutiv. Eine Nervenleitgeschwindigkeitsmessung vom N. suprascapularis wurde beidseits mittels Oberflächenelektroden durchgeführt. Weiters erfolgte eine Untersuchung des M. infraspinatus vom dominanten Arm mittels Nadelelektromyographie. Zusätzlich wurde Schmerz und Muskelatrophie erhoben.ErgebnisseEs konnten keine akuten oder chronischen Veränderungen im M. infraspinatus gefunden werden, obwohl sich bei 5 Spielern eine Atrophie der vom N. suprascapularis innervierten Muskulatur zeigte.SchlussfolgerungenEs konnte keine Läsion des N. suprascapularis gefunden werden. Die Beschwerden in unserer Studienpopulation könnten durch biomechanische Gründe ausgelöst worden sein.

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb

Purpose and hypothesis Although sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL. Methods This study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis. Results In total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9–90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site. Conclusions The results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries.

Extremitätenerhalt unter Massentransfusion bei Grad III offener Oberschenkelfraktur mit GefäßläsionEin Fallbericht

ZusammenfassungDie Hauptprobleme bei der Versorgung offener Frakturen mit hohem Blutverlust sind Hypothermie, Azidose und Verbrauchskoagulopathie. Die Indikation zum Extremitätenerhalt trotz schwerer Weichteilschädigung wird aufgrund von verbesserter Primärversorgung und dem Einsatz von Massentransfusionssystemen, welche die genannten Komplikationen vermeiden helfen ständig erweitert. Ein Grenzfall der chirurgischen Versorgbarkeit bei Grad III offener Oberschenkelfraktur mit Läsion der Vasa femoralis unter Massentransfusionsbedingungen soll hier dargestellt und diskutiert werden. Diese Kasuistik soll zeigen, daß die Vitalfunktionen auch zu einem Zeitpunkt noch stabilisierbar sind, zudem die chirurgische Versorgung kaum noch möglich erscheint.SummaryThe major problems in the treatment of open fractures with high blood loss are hypothermia acidosis and coagulopathy. By improving the standards of polytrauma management and using massive transfusion systems, which should help to avoid those complications, the indication for primary limb salvage under hypovolemic shock conditions is greatly increased. The following case of an grade 3 open fracture of the femur with severe soft-tissue damage, including vascular lesions, with consecutive massive transfusion, should demonstrate that the cardiac-respiratory system can still be stabilized, even if a surgical solution seems impossible.