O. Ackermann

Sonographische Diagnostik von metaphysären Wulstbrüchen

BACKGROUND Metaphyseal forearm fractures are a common pathology in any emergency department. The standard diagnostic procedure involves X-rays of the forearm and wrist. As former studies have shown that these fractures can be visualized using ultrasound, we compared the accuracy of sonographic and X-ray diagnostics. METHODS From January 2007 to May 2008, a total of 93 patients aged between 0 and 12 years with forearm trauma were initially examined using a 7.5-Mhz linear transducer. After diagnosis, axis deviation and treatment were fixed and standard X-rays were taken. The results of the two diagnostic procedures were compared. The examiners were doctors in training or consultants and underwent no specific training. RESULTS We found 77 fractures in 64 patients (50 radius, 1 ulna, 13 radius and ulna). The sensitivity of ultrasound diagnostics was 94% and the specificity 99% compared with X-ray diagnosis. Mean axis deviation differences were 1.8 degrees (radius) and 0.7 degrees (ulna). CONCLUSION Ultrasound seems to be a valuable and safe alternative to X-ray diagnosis. Patients with inconclusive findings should undergo X-ray diagnosis.

Sonographic diagnosis of metaphyseal forearm fractures in children: a safe and applicable alternative to standard x-rays.

Objective Metaphyseal forearm fractures are very common in childhood. Radiography of the wrist is the standard diagnostic procedure. The aim of our study was to evaluate and confirm the safety and applicability of the ultrasound diagnostic procedure in comparison to x-ray diagnosis. Methods We investigated 76 patients aged between 1 and 14 years. After clinical assessment, patients with suspected forearm fractures first underwent ultrasound examination of the metaphyseal forearm followed by standard 2-view radiographs of the wrist. Ultrasound and radiographic findings were then compared, and sensitivity and specificity for ultrasound were calculated. Results Of 76 patients, we found 42 patients with 52 metaphyseal forearm fractures by x-rays. By ultrasound, we also diagnosed 52 fractures. All patients with no fractures were correctly diagnosed as well. Referring to x-ray, we calculated for ultrasound a sensitivity of 96.1% and a specificity of 97%. Comparing axis deviation of displaced fractures, we found a mean difference of 2.1 degrees between sonographic and x-ray values. Conclusions We confirm that ultrasound is an applicable and safe alternative tool to x-rays in nondisplaced or excluded metaphyseal forearm fractures in children.

Patient care at the 2010 Love Parade in Duisburg, Germany: clinical experiences.

BACKGROUND The mass panic at the Love Parade 2010 attracted a great deal of public attention in Germany and abroad. The goals of this paper are to summarize the available data on the injured persons and their treatment, and to assess the preparations that should be made for such an eventuality and the acute measures that should be taken if it occurs. METHODS Patient data from the Duisburg hospitals were subjected to a structured statistical analysis, and all of the measures taken were assessed by qualified evaluators on the basis of questionnaires, a consensus conference, and individual interviews of the clinical coordinators. RESULTS A total of 250,000 persons took part in the Love Parade; 5600 patient contacts occurred at first-aid posts and 473 patients (mean age, 25.5 years; male:female ratio, 1.4:1) were treated in 12 hospital emergency rooms, 41.7% were admitted to the hospital. Among the admitted patients, 73% stayed in the hospital for less than 24 hours, and 41% signed out against medical advice; 62.2% had a surgical diagnosis, 40.6% a medical one, and 8.0% a psychiatric one (some patients had more than one diagnosis). 47.6% of the surviving patients were classified as mildly injured, 47.8% as moderately injured, and 4.0% as severely injured. Most medical activity was concentrated in three areas: the treatment of drug abuse, the care of many mild and moderate injuries, and Shock Room diagnostic assessment of patients potentially harboring serious injuries. Hospitals were subject to the highest strain 2 to 3 hours after the mass panic, at which time they received up to 20 new patients per hour. CONCLUSION These data permit a detailed view of the medical care that was provided. In situations of this kind, the main problems can be dealt with through targeted and structured preparation and optimized emergency plans which consider both foreseeable and unforeseeable events. Priority must be given to rapid diagnostic assessment and clinical decision-making; the prerequisites for these are transparent institutional structures and clear assignments of responsibility.

Die Sonografie als sichere Alternative zur konventionellen Röntgendiagnostik bei distalen Unterarmfrakturen im Kindesalter

AIM Distal forearm fractures are very common in childhood. Radiography of the wrist is the standard diagnostic procedure. But because of higher sensitivity of growing bones to ionising radiation the diagnostic use of X-rays should be minimised as much as possible. Recent studies have shown that distal forearm fractures in children can be safely and reliably diagnosed using only ultrasound. The aim of our study was to evaluate and confirm the safety and applicability of the ultrasound diagnostic procedure in comparison to X-ray diagnosis under routine conditions of our paediatric emergency department. PATIENTS AND METHODS We investigated 115 patients aged 2-14 years. After clinical assessment patients with suspected forearm fractures first underwent ultrasound examination of the metaphyseal forearm followed by standard two view radiographs of the wrist. Ultrasound and radiographic findings were then compared and sensitivity and specificity for ultrasound were calculated. In 9 patients with suspected displacements, sonographic and radiographic axis measurement were done and also compared. RESULTS Radiologically we found 62 patients with 78 distal forearm fractures. By ultrasound we also diagnosed 52 fractures. All patients with no fractures were correctly diagnosed as well. Referring to X-rays we calculated for ultrasound a sensitivity of 94.9 %, a specificity of 98 %, a negative predictive value of 97.4 % and a positive predictive value of 96.1 %. The mean difference of the deformities of the radius in the sagittal section measured sonographically and radiologically were 1.7° (SD 1.6°). CONCLUSION We confirm ultrasound is an applicable, rapid and safe alternative to X-rays in diagnosing metaphyseal forearm fractures in children. Even sonographic axis measurement seems to be a viable method. Thereby ultrasound potentially reduces the X-ray burden in children and additionally accelerates the diagnostic procedure.

Effektives Training der chirurgischen Röntgenbefundung durch E-Learning

BACKGROUND The effectiveness of e-learning for reporting of x-ray-findings in a prospective, randomized trial was tested. MATERIAL AND METHODS Twenty advanced medical students were randomized into two groups. The test group practiced 4-6 hours with the newly developed software, the control group used conventional learning material. Afterwards, a test was carried out including 30 pathologic x-ray films that were randomly spread through 200 non-pathologic images. The required time, the number of correctly appraised images and the frequency of falsely suspected pathologies were recorded. In addition, we asked for an assessment of the own capabilities in evaluating x-ray films and of passing the radiology training. RESULTS The test group showed a markedly improved efficiency in comparison to the control group in all parameters. The required time was 57.4% shorter than in the control group (p < 0.05), 18.3% more cases were evaluated correctly (p < 0.05). The frequency of falsely suspected pathologies decreased by 61% (p < 0.05). There was no significant correlation of the objective abilities of a student with his/her self-assessment or of passing the radiology course. CONCLUSION This study shows that an effective standardized training of practical skills by means of e-learning is feasible and reasonable.

[Ultrasound diagnosis of forearm fractures in children: a prospective multicenter study].

BACKGROUND Metaphyseal forearm fractures are a common pathology in any emergency department. The standard diagnostic procedure involves X-rays of the forearm and wrist. As former studies have shown that these fractures can be visualized using ultrasound, we compared the accuracy of sonographic and X-ray diagnostics. METHODS From January 2007 to May 2008, a total of 93 patients aged between 0 and 12 years with forearm trauma were initially examined using a 7.5-Mhz linear transducer. After diagnosis, axis deviation and treatment were fixed and standard X-rays were taken. The results of the two diagnostic procedures were compared. The examiners were doctors in training or consultants and underwent no specific training. RESULTS We found 77 fractures in 64 patients (50 radius, 1 ulna, 13 radius and ulna). The sensitivity of ultrasound diagnostics was 94% and the specificity 99% compared with X-ray diagnosis. Mean axis deviation differences were 1.8 degrees (radius) and 0.7 degrees (ulna). CONCLUSION Ultrasound seems to be a valuable and safe alternative to X-ray diagnosis. Patients with inconclusive findings should undergo X-ray diagnosis.

Loveparade 2010 Duisburg – klinische Erfahrungen in Vorbereitung und Versorgung

ZusammenfassungHintergrundDer tragische Verlauf der Loveparade 2010 hat starke öffentliche Aufmerksamkeit erregt. Bei steigender Frequenz ähnlicher Großveranstaltungen werden zunehmend Kliniken und Praxen mit der Vorbereitung und Reaktion auf unvorhergesehene Ereignisse konfrontiert. Verbindliche ärztliche Leitlinien bestehen nicht, so dass bei jeder Veranstaltung erneut Grundsätzliches diskutiert wird. Ziel dieses Beitrags ist es, die Erfahrungen der an der Loveparade beteiligten Kliniken und Ambulanzen strukturiert auszuwerten, um daraus sinnvolle, für Kliniken und Praxen anwendbare Maßnahmen abzuleiten.MethodeDie strukturierte Analyse der Daten zur Vorbereitung der Patientenströme und der Patientenstatistik aller beteiligten Kliniken ergab ein Profil, aus dem die Notwendigkeit zur Vorhaltung von Personal, Räumlichkeiten und Material resultiert. Zusätzlich erfolgten eine Konsensuskonferenz nach der Veranstaltung und Einzelinterviews mit den Klinikkoordinatoren, um Vorbereitungen und Maßnahmen zu bewerten und sinnvolle von nicht sinnvollen Maßnahmen zu trennen.ErgebnisseEs werden personelle, logistische und räumliche Maßnahmen aus der konkreten Anwendung beschrieben. Sinnvolle Maßnahmen zu Vorbereitung und Bewältigung der aufgetretenen Massenpanik werden analysiert und detailliert dargelegt, sowie konkrete Probleme benannt und Lösungsmöglichkeiten besprochen. Es resultiert ein qualitativer Katalog, der Planung und Vorbereitung zukünftiger Veranstaltungen unterstützen kann.SchlussfolgerungMit konkreten Erfahrungen aus der Loveparade 2010 lassen sich Vorbereitungen zu Großveranstaltungen optimieren und Notfallpläne überprüfen. Eine koordinierte Zusammenarbeit aller Beteiligten ist notwendig.AbstractBackgroundTragic incidents at the 2010 Love Parade attracted significant public attention. As the frequency of similar events increases, more hospitals and practitioners will face the necessities of planning and response to unforeseeable occurrences. Obligatory guidelines for physicians do not exist, so that essential aspects are repeatedly discussed for each new event. This paper summarizes the experience of hospitals and emergency departments and draws conclusions, allowing recommendations for reasonable proposals for hospitals and practitioners.Methods and materialA structured analysis of data concerning planning, patient flow and injury statistics led to a profile determining personnel, rooms and material which have to be provided by the hospitals. In a consensus conference afterwards and personal interviews with clinical coordinators the preparation of hospitals was evaluated to separate reasonable from needless efforts.ResultsWe describe various measures concerning staff, logistics and rooms from the viewpoint of actual application. Reasonable measures for preparation and management of mass panic are analysed and described in detail. Problems are explained and solutions discussed. The result is a qualitative catalogue, which supports the organization of future events.ConclusionKnowledge and reflection on the experience of the 2010 Love Parade optimizes local emergency guidelines and planning for similar events. A coordinated cooperation of all involved is essential.BACKGROUND Tragic incidents at the 2010 Love Parade attracted significant public attention. As the frequency of similar events increases, more hospitals and practitioners will face the necessities of planning and response to unforeseeable occurrences. Obligatory guidelines for physicians do not exist, so that essential aspects are repeatedly discussed for each new event. This paper summarizes the experience of hospitals and emergency departments and draws conclusions, allowing recommendations for reasonable proposals for hospitals and practitioners. METHODS AND MATERIAL A structured analysis of data concerning planning, patient flow and injury statistics led to a profile determining personnel, rooms and material which have to be provided by the hospitals. In a consensus conference afterwards and personal interviews with clinical coordinators the preparation of hospitals was evaluated to separate reasonable from needless efforts. RESULTS We describe various measures concerning staff, logistics and rooms from the viewpoint of actual application. Reasonable measures for preparation and management of mass panic are analysed and described in detail. Problems are explained and solutions discussed. The result is a qualitative catalogue, which supports the organization of future events. CONCLUSION Knowledge and reflection on the experience of the 2010 Love Parade optimizes local emergency guidelines and planning for similar events. A coordinated cooperation of all involved is essential.

Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)

BACKGROUND In the clinical evaluation of femoroacetabular impingement (FAI), there is a lack of quantitative, reliable and informative assessment methods for the overall functional capability of an individual. OBJECTIVE We compared clinical and radiological measurements of the hip joint with a new methodology based on the concept of 3-dimensional reachable workspace using Microsoft Kinect. METHODS We assessed the correlation between the alpha angle of Nötzli on full-length radiographs and the clinical internal rotation. We evaluated the accuracy of joint positions and angles of the hip between the Kinect system and clinical examination including range of motion (ROM). RESULTS The results of our clinical trial with 24 study participants showed a significant difference between normal internal rotation (> 21°) and reduced internal rotation (⩽ 21°) in comparison to the radiological alpha angle of Nötzli (P=0.026). The acquired reachable Kinect data demonstrated a moderate agreement between the Kinect and clinical examination (correlation coefficients between 0.230 and 0.375). CONCLUSIONS The findings suggest that a higher grade alpha angle of Nötzli accompanies reduced clinical internal rotation. The Kinect system provides reliable results of hip ROM. However, further test series must be performed for the application of Kinect in the clinical evaluation of FAI.

Qualität der Röntgenbefundung im traumatologischen Bereitschaftsdienst

BACKGROUND The aim of the study was to ascertain the state of the art in x-ray assessment in an emergency surgical department. METHODS From August 2008 to February 2009 a total of 1,588 plain x-rays of 658 patients from the emergency department were included in this study. The images were assessed by 3 experienced orthopedic surgeons and 1 experienced radiologist. The incidence of missed traumatic lesions and suspected lesions and the treatment of these patients were noted. RESULTS A total of 136 pathological cases with 238 pathological x-ray findings were found. The mean rate of missed lesions was 13% of the assessed cases. Despite the fact that the rate of missed lesions varied from 9-25% depending on the level of experience, all patients were treated adequately. The quality of x-ray assessment improved with the level of training of the individual doctors. CONCLUSION The present situation is in need of improvement but it is not critical. Junior medical staff should undergo a special training in x-ray assessment.

Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation.

Objectives Metaphyseal forearm fractures are a common occurrence in childhood accounting up to 20% of all pediatric fractures. The standard diagnostic procedure is an x-ray scan. Sonographic examinations could be an alternative that avoids exposition to ionizing radiation and possibly reduces pain, time, and costs. This is a systematic review of clinical studies evaluating ultrasound as a possible alternative to radiographs in diagnosing metaphyseal forearm fractures in children. Methods A systematic literature research for diagnostic studies and reviews was conducted in EMBASE, MEDLINE, and the Cochrane Library in May 2013 and updated in May 2014. In addition, reference lists of publications included were scanned. Outcome parameters were diagnostic accuracy, costs, examination time, and the assessment of pain. The study population is defined as children, because forearm fractures are very common in this age group and the impact of radiation on younger patients is greater than that on adults. Methodological quality of the studies has been assessed with Quality Assessment of Diagnostic Accuracy Studies-2. In addition, we carried out a cost center accounting. Results Eight diagnostic studies and 2 reviews were included in the analysis. The risk of bias of 4 studies was low; and of the other 4 ones, it was moderate. Critical aspects were missing or inaccurate blinding and insufficient descriptions of the study protocol, especially the order of examinations. Twenty-six to 115 patients within the age of 0 to 21 years were included in the studies. Sensitivity ranged from 64% to 100% and specificity did between 73% and 100%. Sensitivity was in six studies and specificity was in seven studies higher than 90%. Chaar-Alvarez et al reported an average time reduction of 25 minutes by using sonography instead of x-ray and a reduction of pain from 1.7 to 1.2 points on a visual analog scale (0-5 points). In 2 other studies, all patients reported pain-free sonographic examinations. The results of the cost center accounting, not being representative, were costs of &OV0556;20.54 per examination with ultrasound and &OV0556;26.60 per radiography-based one, which is a potential saving of 22.79% by replacing radiographic examinations by ultrasound. Conclusions Sensitivity and specificity of ultrasound examinations are high. Single study results show that sonographic examinations can be faster and less painful. In addition, the calculation model shows a tendency towards less-expensive ultrasound examinations. Further studies are needed with an adequate sample size calculation for assessing equivalence or non-inferiority of ultrasound and x-ray and to collect data on pain, examination time, and costs. The age of the older participants may be problematic because of the fact that epiphyseal plates close within the age from 15 to 22 years, which may influence the diagnostic accuracy of sonographic examinations. Therefore, future studies should contain age-stratified analyses. In addition, the calculation model for costs should be tested on a wider data base.