Gerrit Matthes

Blunt Liver Injuries in Polytrauma: Results from a Cohort Study with the Regular Use of Whole-body Helical Computed Tomography

The estimated prevalence of liver injury in patients with blunt multiple trauma ranges from 1% to 8%. The objective of this study was to investigate the profile of accompanying liver injury in a cohort of polytraumatized patients who had regularly undergone contrast-enhanced, whole-body helical computed tomography (CT). We enrolled consecutive patients admitted between September 1997 and January 2001 to a level I trauma center. Clinical baseline data were compiled as part of a nationwide trauma registry. Morphologic features were evaluated descriptively, whereas prognostic variables were assessed by logistic regression analysis. We identified 218 patients [149 men, mean age 35 ± 18 years, mean injury severity score (ISS) 35 ± 10], 55 of whom had sustained blunt liver trauma [25.2%, 95% confidence interval (CI) 19.6–31.5%]. The prevalence of Moore III to V lesions was 10.1%. There were 99 parenchymal contusions, 15 capsular tears, and 2 liver fractures. Surgery was required in 15 patients and was best predicted by the classification of the American Association for the Surgery of Trauma [odds ratio (OR) 3.91, 95% CI 1.59–9.61]. The mortality rate was 0.0035/person/day. Patients requiring surgical repair had fourfold increased relative odds of case fatality (OR 4.50, 95% CI 1.01–19.96). Sevenfold increased relative odds were observed if liver laceration was considered the leading injury (OR 7.17, 95% CI 1.17–43.97). The prevalence of liver lacerations among multiple-trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT. High-grade hepatic injuries and the need for surgical repair are associated with poorer survival prognosis.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

Background: Contrast-enhanced whole-body computed tomography (also called “pan-scanning”) is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. Methods: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. Results: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7–490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%–8.0%). Interpretation: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Retrograde fixation of distal femoral fractures: results using a new nail system.

Objectives To investigate the management and outcome of distal femur fractures treated with retrograde nailing. Design Prospective. Setting Unfallkrankenhaus Berlin, level I trauma center. Patients A consecutive series of 47 patients with 48 fractures of the distal femur (37 fractures AO type A and 11 fractures type C) operated on between May 1999 and June 2000. Outcome Measures Outcome was assessed by using standard radiographic criteria of time to union, incidence of infection, malunion, and knee function (Leung score). Results After an average time of 33 months (range 12–37 months), 44 patients were reexamined. Three patients were lost to follow-up. The average age was 44 years (range 17–92 years). Of patients, 19 sustained polytrauma, and 10 had associated soft tissue damage. A total of 34 patients underwent primary definitive osteosynthesis within 12 hours after trauma. All fractures healed after an average of 12.6 weeks (range 9–17 weeks). Seven complications were noted—three related to severity of injury (one deep venous thrombosis, two leg length shortenings of 1.5 cm and 2.5 cm) and four related to the operation (insufficient counterboring of the nail in two patients, one malreduction, one iatrogenic fracture of femur shaft). There was no relevant difference between type A and type C fractures in functional, clinical, or radiographic outcomes. Conclusions Retrograde nailing is recommended as an alternative method to plate osteosynthesis in stabilizing distal femoral fractures, particularly in type C fractures.

Role of magnetic resonance imaging in the diagnosis of distal tibia fractures in adolescents.

This prospective study was performed to assess the benefits of magnetic resonance imaging (MRI) compared with plain radiographs in the diagnosis and analysis of transitional fractures in terms of fracture type, anatomy, and dislocation. During a 24-month period, 22 adolescents with a fracture of the distal tibial epiphysis were treated. In addition to plain film radiographs, MR images of the distal tibia were also obtained. Plain film radiographs and MR images were randomized and diagnosed by two surgeons and two radiologists. Fifteen transitional fractures were diagnosed using plain radiographs, while 17 transitional fractures could be found with MRI. Fracture type was misclassified, fracture displacement was underestimated in general, and rotational displacements were not visualized on plain film radiographs. MRI was found to provide anatomic detail and information superior to plain film radiographs.

Operative Therapie abdomineller Verletzungen

ZusammenfassungZielBegleitende Verletzungen des Abdomens sind beim Polytrauma typisch und stellen eine der häufigsten Todesursachen dar. Ziel der vorliegenden Arbeit war eine Literaturanalyse mit Darstellung wesentlicher Aspekte der initialen operativen Versorgung abdomineller Verletzungsfolgen.MethodeDie Literaturrecherche erfolgte in PubMed Medline, dem Cochrane Central Register of Controlled Clinical Trials und den Datenbanken der DIMDI. Die Graduierung der Beweiskraft der zugrundeliegenden Studien erfolgte nach den Vorschlägen des Centre for Evidence-based Medicine.ErgebnisseBei der Versorgung abdomineller Verletzungen sollte die Medianlaparatomie bevorzugt werden. Insbesondere beim instabilen Patienten ist eine Versorgung nach Damage-Control-Prinzipien anzustreben. Bei Verletzungen des Kolons sollte, wenn es der Gesamtzustand des Patienten zulässt, eine primäre Anastomose realisiert werden. Hier ist die Handnaht am besten geeignet. Bei Milzverletzungen ist ein Organerhalt vorzusehen. Eine angiographische Embolisation blutender Läsionen von Leber und Milz sollte frühzeitig erwogen werden.DiskussionDie konservative Therapie stumpfer Abdominalverletzungen tritt zunehmend in den Vordergrund. Ist eine operative Intervention unumgänglich, sollte gerade beim instabilen Patienten zugunsten der Damage-Control-Prinzipien entschieden werden.AbstractPurposeAccompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.MethodsLiterature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.ResultsVertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of “damage control surgery” should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.DiscussionNon-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

Resorbable screws versus pins for optimal transplant fixation (SPOT) in anterior cruciate ligament replacement with autologous hamstring grafts: rationale and design of a randomized, controlled, patient and investigator blinded trial [ISRCTN17384369]

BackgroundRuptures of the anterior cruciate ligament (ACL) are common injuries to the knee joint. Arthroscopic ACL replacement by autologous tendon grafts has established itself as a standard of care.Data from both experimental and observational studies suggest that surgical reconstruction does not fully restore knee stability. Persisting anterior laxity may lead to recurrent episodes of giving-way and cartilage damage. This might at least in part depend on the method of graft fixation in the bony tunnels. Whereas resorbable screws are easy to handle, pins may better preserve graft tension. The objective of this study is to determine whether pinning of ACL grafts reduces residual anterior laxity six months after surgery as compared to screw fixation.Design/ MethodsSPOT is a randomised, controlled, patient and investigator blinded trial conducted at a single academic institution. Eligible patients are scheduled to arthroscopic ACL repair with triple-stranded hamstring grafts, conducted by a single, experienced surgeon. Intraoperatively, subjects willing to engage in this study will be randomised to transplant tethering with either resorbable screws or resorbable pins. No other changes apply to locally established treatment protocols. Patients and clinical investigators will remain blinded to the assigned fixation method until the six-month follow-up examination.The primary outcome is the side-to-side (repaired to healthy knee) difference in anterior translation as measured by the KT-1000 arthrometer at a defined load (89 N) six months after surgery. A sample size of 54 patients will yield a power of 80% to detect a difference of 1.0 mm ± standard deviation 1.2 mm at a two-sided alpha of 5% with a t-test for independent samples.Secondary outcomes (generic and disease-specific measures of quality of life, magnetic resonance imaging morphology of transplants and devices) will be handled in an exploratory fashion.ConclusionSPOT aims at showing a reduction in anterior knee laxity after fixing ACL grafts by pins compared to screws.

Surgical management of abdominal injury

ZusammenfassungZielBegleitende Verletzungen des Abdomens sind beim Polytrauma typisch und stellen eine der häufigsten Todesursachen dar. Ziel der vorliegenden Arbeit war eine Literaturanalyse mit Darstellung wesentlicher Aspekte der initialen operativen Versorgung abdomineller Verletzungsfolgen.MethodeDie Literaturrecherche erfolgte in PubMed Medline, dem Cochrane Central Register of Controlled Clinical Trials und den Datenbanken der DIMDI. Die Graduierung der Beweiskraft der zugrundeliegenden Studien erfolgte nach den Vorschlägen des Centre for Evidence-based Medicine.ErgebnisseBei der Versorgung abdomineller Verletzungen sollte die Medianlaparatomie bevorzugt werden. Insbesondere beim instabilen Patienten ist eine Versorgung nach Damage-Control-Prinzipien anzustreben. Bei Verletzungen des Kolons sollte, wenn es der Gesamtzustand des Patienten zulässt, eine primäre Anastomose realisiert werden. Hier ist die Handnaht am besten geeignet. Bei Milzverletzungen ist ein Organerhalt vorzusehen. Eine angiographische Embolisation blutender Läsionen von Leber und Milz sollte frühzeitig erwogen werden.DiskussionDie konservative Therapie stumpfer Abdominalverletzungen tritt zunehmend in den Vordergrund. Ist eine operative Intervention unumgänglich, sollte gerade beim instabilen Patienten zugunsten der Damage-Control-Prinzipien entschieden werden.AbstractPurposeAccompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.MethodsLiterature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.ResultsVertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of “damage control surgery” should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.DiscussionNon-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

Sechs Jahre Advanced Trauma Life Support (ATLS) in Deutschland

With over 1 million certified physicians in more than 50 countries worldwide, the Advanced Trauma Life Support (ATLS) concept is one of the most successful international education programs. The concept is simple, priority-orientated (ABCDE scheme) and assesses the situation of the trauma patient on the basis of vital signs to treat the life-threatening injuries immediately. With over 100 ATLS provider courses and 10 instruction courses accomplished in less than 6 years, no other land in the world has successfully established this concept in such a short time as Germany. Meanwhile nearly 1,600 colleagues have been trained and certified. Evaluation of the first 100 ATLS courses in Germany supports this concept. The total evaluation of all courses is 1.36 (1.06-1.8, n=100). The individual parts of the course were marked as followed: presentations 1.6 (1.0-2.81, n=100), practical skills stations 1.46 (1.0-2.4, n=100) and surgical skills stations 1.38 (1.0-2.38, n=100). In 2009 a total of 47 ATLS courses were accomplished which will clearly increase in 2010. Other ATLS formats, such as ATCN (Advanced Trauma Care for Nurses) and refresher courses are planned for the beginning of 2010.

Predictive factors of liver injury in blunt multiple trauma

IntroductionThis study was conducted to clarify whether injuries that are likely to be revealed by initial clinical and conventional radiological examination at the trauma bay (e.g., right-side rib fractures) meaningfully contribute to the prior probability of accompanying hepatic lesions in multiple injured patients.Material and methodsFifty-five subjects (sampled from a cohort of 218 patients) with liver injury fulfilling the definition of polytrauma were compared with 55 polytrauma patients without liver injury. Controls were individually matched for age, gender, and Injury Severity Scores. Whole-body, helical, contrast-enhanced computed tomography was applied to all participants. We modeled independent predictors of liver involvement by conditional logistic and random-effects regression analysis.ResultsIn the present sample, the prevalence of hepatic injury was 25.2%. Neither the injury mechanism (car crash, pedestrian accident, fall from height) nor certain accompanying injuries (right-side serial rib fractures, lumbar spine fractures) predicted the presence of hepatic injury. Liver injury was particularly unlikely in bikers [odds ratio (OR) 0.78, 95% confidence interval (CI) 0.59–1.03] and patients with left-side rib fractures (OR 0.80, 95% CI 0.66–0.98).DiscussionThere are no index injuries that will reliably indicate the presence of liver involvement in multiple trauma cases. Also, the absence of these injuries cannot rule out liver damage.

Der benigne tenosynoviale Riesenzelltumor im Bereich des oberen Sprunggelenks Seltene Differentialdiagnose eines Weichteiltumors am Fuß

ZusammenfassungBei dem tenosynovialen Riesenzelltumor handelt es sich um eine benigne Neoplasie, die klassischerweise im Bereich der Finger zu finden ist. Dort geht sie in der Regel von Sehnenscheiden aus, seltener aus der Synovialis hervor. Gerade bei den seltenen und atypischen Lokalisationen kann die differentialdiagnostische Abgrenzung gegenüber Lipomen, Ganglien oder malignen Weichteiltumoren schwierig sein. Es wird über einen 21jährigen Patienten mit einem Riesenzellsynovialom im Bereich des linken Innenknöchels berichtet. Die klinischen, radiologischen und pathologisch-anatomischen Befunde werden dokumentiert. Der Tumor wurde in toto reseziert, andere Herde konnten nicht gefunden werden. Die Problematik der richtigen diagnostischen Einordnung wird dargestellt.SummaryThe giant cell synovialoma is a benign neoplasia classically located in the fingers. It mostly rises from tendon sheaths, sometimes from the synovia. Other locations than the fingers are rare. Making a differential diagnosis to lipomas, gangliomas or even malignant soft tissue tumors can be very difficult especially in rare locations. We report the case of a 21 years old man suffering from a giant cell synovialoma in the area of the right ankle joint. The clinical, radiological and patho-morphological findings are documented. The tumor was excised totally, other foci were not found. The problems of making the right diagnosis are described.