J.P.M. Frolke

Exsanguination in trauma: A review of diagnostics and treatment options.

Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations permissive hypotension may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing blind transfusion or damage control resuscitation, a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

Definition and classification of fracture non-unions

Classifications in general provide relevant information for clinical purposes to compose a suitable treatment strategy and for research purposes to be able to define comparable study groups. Two distinct types of non-unions are described in the established literature. In the first type the ends of the fragments are hypervascutar or hypertrophic and are capable of biologic reaction. In the second type the ends of the fragments are avascular or atrophic and are inert and incapable of biologic reaction. Hypervascular as well as avascular non-unions may be complicated by the presence of infection, poor soft-tissue quality, short peri-articular fragments or significant deformity, demanding mu[ti-stage treatment strategies with concomitant worsened prognosis and subsequent increased frequency of amputation.

Walking Ability and Quality of Life in Subjects With Transfemoral Amputation: A Comparison of Osseointegration With Socket Prostheses

OBJECTIVEnTo investigate walking ability and quality of life of osseointegrated leg prostheses compared with socket prostheses.nnnDESIGNnProspective case-control study.nnnSETTINGnUniversity medical center.nnnPARTICIPANTSnSubjects (N=22) with transfemoral amputation (1 bilateral) referred to our center because of socket-related skin and residual limb problems resulting in limited prosthesis use. Their mean age was 46.5 years (range, 23-67y) and mean time since amputation was 16.4 years (range, 2-45y). Causes of amputation were trauma (n=20) and tumor (n=2).nnnINTERVENTIONnImplantation of an osseointegration prosthesis (OIP).nnnMAIN OUTCOME MEASURESnGlobal score of the Questionnaire for Persons With a Transfemoral Amputation (Q-TFA), prosthesis use, 6-minute walk test (6MWT), Timed Up & Go (TUG) test, and oxygen consumption during treadmill walking.nnnRESULTSnWith the socket prosthesis, the mean ± SD Q-TFA global score, prosthesis use, 6MWT, TUG, and oxygen consumption were 39±4.7 points, 56±7.9h/wk, 321±28m, 15.1±2.1 seconds, and 1330±310mL/min, respectively, and significantly improved with OIP to 63±5.3 points, 101±2.4h/wk, 423±21m, 8.1±0.7 seconds, and 1093±361mL/min, respectively.nnnCONCLUSIONSnOsseointegration is a suitable intervention for persons whose prosthesis use is reduced because of socket-related problems. Subjects with OIP significantly increased their walking ability and prosthesis-related quality of life.

Safety of "pain exposure" physical therapy in patients with complex regional pain syndrome type 1.

&NA; “Pain exposure” physical therapy (PEPT) is a new treatment for patients with complex regional pain syndrome type 1 (CRPS‐1) that consists of a progressive‐loading exercise program and management of pain‐avoidance behavior without the use of specific CRPS‐1 medication or analgesics. The aim of this study was to investigate primarily whether PEPT could be applied safely in patients with CRPS‐1. Twenty patients with CRPS‐1 were consecutively enrolled in the study after giving informed consent. The diagnosis of CRPS‐1 was defined using the Bruehl and Harden/IASP diagnostic criteria. CRPS‐1 was diagnosed between 3 and 18 months after the inciting event (trauma). According to a multiple single‐case design (baseline [A1], treatment [B], follow‐up [A2]), multiple baseline and follow‐up measurements were performed to evaluate changes in CRPS signs and symptoms and to assess functional parameters. When comparing the baseline with the follow‐up phase, patients improved significantly with respect to pain on the visual analogue scale (57%), pain intensity (48%), muscle strength (52%), arm/shoulder/hand disability (36%), 10‐meter walking speed (29%), pain disability index (60%), kinesiophobia (18%), and the domains of perceived health change in the SF‐36 survey (269%). Three patients initially showed increased vegetative signs but improved in all other CRPS parameters and showed good functional recovery at follow‐up. We conclude that PEPT is a safe and effective treatment for patients with CRPS‐1. A progressive‐loading exercise program and management of pain‐avoidance behavior without the use of specific medication (“pain exposure” physical therapy) is safe and effective for patients with complex regional pain syndrome.

Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation.

BACKGROUNDnSurgical treatment of displaced intra-articular fractures of the calcaneus is a standard procedure in many institutions. To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques.nnnMETHODSnAll patients who underwent percutaneous screw fixation according to the method of Forgon and Zadravecz between 1998 and 2006 were selected. Postoperative infections were recorded. During follow-up, pain, functional outcome, range of motion, and change in footwear were evaluated with the use of the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients also completed a general health status form (Short Form-36 [SF-36]) and a visual analog scale (VAS) for patient satisfaction. Subsequent subtalar arthrodesis and the removal of irritating screws were performed when indicated.nnnRESULTSnWe reviewed the cases of thirty-seven patients who had a combined total of thirty-nine displaced intra-articular calcaneal fractures and a follow-up period of at least twenty-four months. Five wound infections occurred, two of which were superficial and three of which were deep. At a mean follow-up time of sixty-six months, the mean AOFAS and MFS scores were 84 and 86 points, respectively, of 100 possible points. The mean score on the SF-36 was 76 points, and the mean score on the visual analog scale for patient satisfaction was 7.9 points of 10 possible points. Twenty-nine patients (78%) were able to wear normal shoes. At the time of follow-up, subtalar arthrodesis had been performed in two patients and seventeen patients (46%) had undergone an uncomplicated removal of painful screws. No substantial correlation was found between the severity of the fracture (Sanders classification) or the quality of the reduction when correlated with functional outcome parameters.nnnCONCLUSIONSnWe consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.

Is Radiation Superior to Indomethacin to Prevent Heterotopic Ossification in Acetabular Fractures?: A Systematic Review

Heterotopic ossification is a well-known complication after fixation of an acetabular fracture. Indomethacin and radiation therapy are used as prophylaxis to prevent heterotopic ossification. It is unclear, however, whether either is superior, although this may relate to lack of power in individual studies. To compare the effectiveness of indomethacin with the effectiveness of radiation therapy, we conducted a systematic review in which all published prospective studies were evaluated. We performed a literature search in PubMed®, MEDLINE®, EMBASE™, and the Cochrane Controlled Trial Register. The retrieved studies were analyzed and categorized according to the quality and validity score of Jadad et al. We found five appropriate prospective studies, describing 384 patients. Although the quality of the available studies made a proper meta-analysis inappropriate, the incidence of heterotopic ossification was significantly lower in patients treated with radiation than in patients receiving indomethacin (five of 160 versus 20 of 224, respectively). Until further information is available, we believe the evidence supports radiation therapy as the preferred method for preventing heterotopic ossification after operative treatment of acetabular fractures.Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Warm and cold complex regional pain syndromes Differences beyond skin temperature

PAIN SYNDROMES: DIFFERENCES BEYOND SKIN TEMPERATURE? To the Editor: Eberle et al.1 investigated the difference between patients with primarily warm and cold complex regional pain syndrome (CRPS). In this study, 25% of the patients were excluded due to inconsistent findings at CRPS onset. To further validate this classification, a reassessment of 80% of the 50 patients was done 6 weeks later and warm and cold switch was not observed. We prospectively investigated 26 patients (19 women, 7 men) with acute CRPS—according to Bruehl/IASP criteria—3–12 months after the trigger event. Patients confirmed that their affected limb felt warmer, colder, or indistinct compared to the unaffected limb. Measurements of skin temperature were routinely measured with an infrared thermometer (GENIUSTM Covidien, Mansfield, MA) according to an established method.2 During a 12-week follow-up, patients’ skin temperatures were measured using an advanced infrared thermometer (DermaTempTM Exergen, Newton, MA). Each patient visited 6 times with at least 1 week between visits. In our measurement protocol, there were 13 different measurement sites distally on each limb, resulting in 26 sites per patient. On each site, the temperature was measured twice, averaged, and then the 13 averages were averaged again. The 2 temperature averages between affected and unaffected side were then compared during each visit. Of 26 patients included in our study, 15 (58%) presented with unclear or inconsistent signs and symptoms of warm or cold CRPS. The remaining 11 patients included 7 patients presenting with cold CRPS who had a mean temperature of 1.8°C (SD 1.34) and 4 patients with warm CRPS with a mean temperature of 1.4°C (SD 0.90) compared to the unaffected extremity. During follow-up, 2 patients out of 11 who had experienced either warm or cold CRPS switched from warm to cold CRPS or vice versa. The other 9 did not switch during the follow-up period. In contrast with the results of Eberle et al., we suggest that primarily warm or cold CRPS only exist in a minority of patients (30% instead of 75%). Small subgroups can be identified using any diagnostic tool from the criteria of Bruehl et al.3 It is unlikely that warm or cold CRPS imply different pathophysiology. We consider any objective difference in skin temperature as vasomotor instability in the diagnostic assessment of patients suspected of CRPS. Therefore, temperature measurements are an important tool. Almar W.A. Bruggeman, Margreet H. Oerlemans, Jan Paul M. Frölke, Nijmegen, the Netherlands

Femoral neck shortening after internal fixation of a femoral neck fracture.

This study assesses femoral neck shortening and its effect on gait pattern and muscle strength in patients with femoral neck fractures treated with internal fixation. Seventy-six patients from a multicenter randomized controlled trial participated. Patient characteristics and Short Form 12 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected. Femoral neck shortening, gait parameters, and maximum isometric forces of the hip muscles were measured and differences between the fractured and contralateral leg were calculated. Variables of patients with little or no shortening, moderate shortening, and severe shortening were compared using univariate and multivariate analyses. Median femoral neck shortening was 1.1 cm. Subtle changes in gait pattern, reduced gait velocity, and reduced abductor muscle strength were observed. Age, weight, and Pauwels classification were risk factors for femoral neck shortening. Femoral neck shortening decreased gait velocity and seemed to impair gait symmetry and physical functioning. In conclusion, internal fixation of femoral neck fractures results in permanent physical limitations. The relatively young and healthy patients in our study seem capable of compensating. Attention should be paid to femoral neck shortening and proper correction with a heel lift, as inadequate correction may cause physical complaints and influence outcome.

Safety of Osseointegrated Implants for Transfemoral Amputees: A Two-Center Prospective Cohort Study

BACKGROUNDnOsseointegrated implants are an alternative for prosthetic attachment for individuals unable to wear a socket following an amputation. The concept of an integrated metal implant communicating with the external environment raises substantial concern about the risk of ascending infection. We report on the safety of press-fit osseointegrated implants currently used in Australia and the Netherlands.nnnMETHODSnWe prospectively recorded all adverse events in all patients with transfemoral amputation who were managed with an osseointegration implant system between 2009 and 2013 at two centers. The procedure was performed in two stages. A customized porous-coated implant was placed in the first stage, and a stoma was created in the second. Adverse events were categorized according to type (infection or other) and severity. Infections were classified according to four grades of severity based on clinical and radiographic findings: (1) low-grade soft-tissue infection, (2) high-grade soft-tissue infection, (3) bone infection, and (4) septic implant failure.nnnRESULTSnEighty-six patients (ninety-one implants), twenty-five to eighty-one years of age, were included in the study and followed for a median of thirty-four months (range, twenty-four to seventy-one months). Thirty-one patients had an uneventful course with no complications; twenty-nine developed infection (all grade 1 or 2); and twenty-six did not develop infection but had one or more other complications requiring intervention, including stoma hypergranulation (seventeen patients), soft-tissue redundancy (fourteen), proximal femoral fracture (three), inadequate osseointegration leading to implant replacement (one), implant breakage (two), and breakage of the pin used as a fail-safe mechanism (twenty-five).nnnCONCLUSIONSnMild infection and irritation of the soft tissue in the skin-penetration area are common in transfemoral amputees who have an osseointegrated implant. These complications were successfully managed with simple measures. Severe infections resulting in septic implant loosening are rare.nnnLEVEL OF EVIDENCEnTherapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Displaced midshaft fractures of the clavicle: non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial

BackgroundThe traditional view that the vast majority of midshaft clavicular fractures heal with good functional outcomes following non-operative treatment may be no longer valid for all midshaft clavicular fractures. Recent studies have presented a relatively high incidence of non-union and identified speciic limitations of the shoulder function in subgroups of patients with these injuries.AimA prospective, multicentre randomised controlled trial (RCT) will be conducted in 21 hospitals in the Netherlands, comparing fracture consolidation and shoulder function after either non-operative treatment with a sling or a plate fixation.Methods/designA total of 350 patients will be included, between 18 and 60 years of age, with a dislocated midshaft clavicular fracture. The primary outcome is the incidence of non-union, which will be determined with standardised X-rays (Antero-Posterior and 30 degrees caudocephalad view). Secondary outcome will be the functional outcome, measured using the Constant Score. Strength of the shoulder muscles will be measured with a handheld dynamometer (MicroFET2). Furthermore, the health-related Quality of Life score (ShortForm-36) and the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure will be monitored as subjective parameters. Data on complications, bone union, cosmetic aspects and use of painkillers will be collected with follow-up questionnaires. The follow-up time will be two years. All patients will be monitored at regular intervals over the subsequent twelve months (two and six weeks, three months and one year). After two years an interview by telephone and a written survey will be performed to evaluate the two-year functional and mechanical outcomes. All data will be analysed on an intention-to-treat basis, using univariate and multivariate analyses.DiscussionThis trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. The gathered data may support the development of a clinical guideline for treatment of clavicular fractures.Trial registrationNetherlands National Trial Register NTR2399