Stefan Rose

Double traumatic abdominal wall hernia and colon laceration due to a pelvic fracture

A traumatic abdominal wall hernia was observed in association with a colonic laceration due to a pelvic fracture. The presence of this specific combination of injuries is a rare clinical entity. CT evaluation with intravenous and bowel contrast media identified the traumatic abdominal wall hernia and the bowel entrapment.

Wertigkeit der Radiodiagnostik beim Schädel-Hirn-Trauma im Kindesalter

ZusammenfassungFragestellung. Bei eingeschränkter klinischer Beurteilbarkeit nach Schädel-Hirn-Trauma (SHT) werden Kinder oftmals einer kraniellen Computertomographie (CCT) unterzogen.In Abhängigkeit von der Verletzungsschwere (GlasgowComa Scale,GCS)wurde die Relevanz der CCT in Bezug auf die therapeutischen Konsequenzen analysiert. Methodik. Über einen 5-Jahres-Zeitraum wurde retrospektiv die klinische Ersteinschätzung und Verletzungsschwere (GCS) mit den Ergebnissen einer erweiterten radiologischen Diagnostik verglichen. Ergebnisse. Bei 408 Kindern mit leichtem SHT (GCS 15–13) zeigten sich im CCT (n=217) 2 intrakranielle Blutungen ohne klinische Folgen. Von 29 Kindern mit schwerem SHT (GCS <12) zeigten sich bei 12 Kindern im CCT (n=29) eine intrakranielle Blutung,17 Kinder litten unter einer intrakraniellen Blutung und einer Schädelfraktur. Schlussfolgerung. Kinder (GCS 15–13) mit fraglicher initialer Bewusstlosigkeit,vegetativer Begleitsymptomatik oder unklarer Vigilanz sollten stationär überwacht werden.In dieser Gruppe hat die primäre CCT keine therapeutische Konsequenz erbracht.Bei einem GCS <12,sowie bei polytraumatisierten Kindern sollte hingegen sofort eine CCT mit entsprechender stationärer Behandlung erfolgen.AbstractAim of the study. Clinical evaluation of pediatric head injury is quite difficult and often cranial CT scans are performed.We investigated the relevance of CT scans in relation to the therapeutic outcome. Methods. During a 5-year-period we retrospectively evaluated the results of x-ray and cranial CT scan in respect to primary clinical assessment and degree of head injury. Results. From 408 children classified as mild head injury (GCS 15–13) 217 received CT scans with 2 presenting pathological intracranial findings, none of these children required neurosurgical treatment.Out of 29 children suffering from severe head injury (GCS <12) 12 suffered from intracranial bleeding, and 17 had intracranial bleeding and a scull fracture. Conclusion. Children encountering mild head injury combined with primary loss of consciousness or vomiting, require hospitalisation. Initial CCT did not lead to therapeutic consequences in this group.Children classified as severe head injury or multiple traumatized children need immediate cranial CT scan and hospitalisation.

Minimally Invasive Technique for Reduction and Stabilization of Radial Head and Radial Neck Fractures in Children A Description of a Modified Technique and an Overview of the Literature

Integrity of soft tissues plays a major role in the final outcome of fractures of the proximal radius. Numerous minimally invasive operative techniques were developed to avoid additional trauma during surgical procedure. An overview over the literature is given in the present paper.We report a modified technique of Kapandji for percutaneous reduction and stabilization of displaced radial neck and radial head fractures in children. Functional results in 5 cases were good, and the children had no complaints. In one case with a luxation of the elbow and a fracture of the lateral epicondyle of humerus persitent rotation deficit was oberseved.The modified percutaneous method described here demonstrates an alternative procedure to reduce and stabilize displaced radial head and radial neck fractures. In contrast to open reduction this method avoids impairment of the anular ligament and joint capsule. Associated complex injuries of the elbow with soft tissue trauma, however, may lead to unsatisfactory functional results despite minimal operative technique and anatomic reduction.

Altered calcium regulation and function of human neutrophils during multiple trauma.

Altered intracellular Ca2+ concentration is a pivotal regulatory mechanism of leukocyte function. Since polymorphonuclear neutrophils (PMN) are involved in traumatic organ dysfunction, we prospectively investigated Ca2+ regulation and function of circulating PMN multiple trauma patients (Group A: ISS < 27; Group B: ISS > or = 27). Circulating PMN were isolated during 12 days, followed by determination of formyl-methionyl-leucyl-phenylalanine (fMLP)-induced PMN-superoxide production (PMN-SOP) by SOD-inhibitable ferricytochrome C reduction, and PMN cytosolic Ca2+ concentration ([Ca2+]i) by fluorescent fura2/AM (340/380 ratio). PMN-SOP was significantly higher in Group B (mean ISS: 39.9 +/- 2; n = 21) at day of admission than in controls and Group A (mean ISS: 18.2 +/- 1; n = 22) (P< 0.05). In Group B, the significant rise of basal [Ca2+]i between Day 2 and Day 4 was associated with significant lower PMN-SOP during that period (P < 0.05). The fMLP-induced [Ca2+]i response was supranormal in both groups. PMN-elastase concentrations were substantially higher in Group B compared with Group A until Day 4. Circulating IL-6, IL-8, and soluble TNF-receptor (55 kD) were significantly increased in Group B compared with Group A at the day of trauma (P < 0.05). Severe trauma is characterized by a biphasic pattern of neutrophil priming characterized by early increase and secondary suppression. The association of depressed neutrophil superoxide production (deactivation) and elevated basal [Ca2+]i suggests Ca2+-mediated disturbance of neutrophil NADPH-oxidase metabolism.

Circulating Inflammatory and Metabolic Parameters to Predict Organ Failure after Muliple Trauma

AbstractBackground: Patients encountering severe trauma are at high risk of sequential organ complications. We studied the value of circulating inflammatory mediators and metabolic parameters to evaluate their predictive value with respect to the development of multiple organ failure (MOF). Patients and Methods: In 77 traumatized patients with a mean Injury Severity Score (ISS) of 28.8±1.1 points, C-reactive protein (CRP), polymorphonuclear (PMN) elastase, lactate, interleukin-6 (IL-6), IL-8, and soluble tumor necrosis factor receptors 1 and 2 (TNF-R1 and TNF-R2) were determined for a period of 11 days following multiple trauma. Results: Weak and moderate correlations were found between mean plasma concentrations of all parameters and mean MOF scores calculated from the whole observation period [range: lactate (r=0.31, p < 0.01) to TNF-R1 (r=0.53, p < 0.001)]. Daily TNF-R1 and lactate concentrations of the 1st week moderately correlated with mean MOF scores of the 2nd week (p < 0.01). ISS weakly correlated with all parameters exept lactate [range: IL-8 (r=0.27, p < 0.05) and PMN elastase (r=0.46, p < 0.001)]. Prediction of MOF could not be improved by inclusion of several or all investigated mediators into multiple regression models. Conclusion: Only early plasma TNF-R1 and blood lactate concentrations showed a moderate association with the development of late posttraumatic organ failure. Thus, the predictive role of inflammatory mediators with respect to the manifestation of organ dysfunction after severe trauma seems limited.

Primäre und sekundäre freisetzung von interleukin 6 und 8 bei der gestuften polytraumaversorgung

ZusammenfassungDer polytraumatisierte Patient entwickelt wegen der unfallbedingten Kombination aus Schock, Weichteilschaden, Organverletzungen und Frakturen regelmäßig ein systemisches Entzündungssyndrom mit dem Risiko eines Multiorganversagens. Zur Minimierung der Belastung mit proinflammatorischen Mediatoren hat sich daher ein gestuftes Versorgungskonzept polytraumatisierter Patienten mit Primärstabilisierung aller relevanten Frakturen und Weichteilschäden und einer zeitlichen Aufschiebung sekundärer Rekonstruktionen oder Verfahrenswechsel durchgesetzt.Ziel dieser prospektiven klinischen Studie war die Evaluation der durch Sekundäreingriffe verursachten konsekutiven Entzündungsstimulation in Abhängigkeit vom Zeitpunkt ihrer Durchführung. Hierzu wurden die proinflammatorischen Zytokine Interleukin (IL) 8 und IL-6 am Tag vor und nach einem operativen Eingriff in der vulnerablen Phase bis Tag 5 und danach analysiert.Die Auswertung der Plasmaspiegel der Zytokine IL-8 und IL-6 zeigte, daß operative Eingriffe zwischen Tag 2 und 5 eine wesentlich ausgeprägtere proinflammatorische Antwort als Eingriffe ab dem sechsten Tag verursachen. Zwischen dem zweiten und fünften Tag boten postoperativ 14 von 26 Patienten erhöhte IL-8-Werte und neun von 27 erhöhte IL-6-Werte. Im Vergleich hierzu wurden nach dem sechsten Tag für IL-8 nur noch bei fünf von 28 Patienten (p = 0,017) und für IL-6 bei zehn von 30 Patienten erhöhte postoperative Werte festgestellt. Diejenigen Patienten, die außerhalb des gestuftes Versorgungskonzepts als Notfall großen Eingriffen zwischen Tag 2 und 5 unterzogen wurden mußten, hatten signifikant höhere Werte im Multiorganversagen-Score als Patienten mit geplanten kleineren Eingriffen im gleichen Zeitintervall (p = 0,001).Die beobachteten Veränderungen der proinflammatorischen Zytokine IL-8 und IL-6 bestätigen eindrücklich das Konzept der gestuftes Polytraumaversorgung.AbstractThe combination of shock, soft tissue damage, organ injury and fractures in patients with multiple trauma is responsible for the development of the systemic inflammatory response and multiple organ failure. To minimize the release of proinflammatory mediators a staged treatment of patients suffering from multiple trauma has been established. This includes immediate stabilization of long bone fractures and treatment of soft tissue injuries with definitive osteosynthesis or secondary reconstructive surgery following later on.The aim of this prospective study was to evaluate the influence of consecutive surgery on the stimulation of proinflammatory mediators, depending on the timepoint of operation. Therefore, interleukine (IL) 8 and IL-6 plasma levels were measured the day before and the day after surgery.We found that the proinflammatory response was increased markedly when surgery was performed between day 2 and 5 in comparison with surgery between day 6 and 28. Surgery between day 2 to 5 after trauma caused an increase in IL-8 values in 14 out of 26 patients, in contrast only 5 out of 28 showed an increase when surgery was performed after day 6. Significant changes of the IL-6 response following surgery was not observed between the 2 time periods. The patients undergoing unscheduled surgery between days 2 to 5 because of vital indications had significant higher multiple organ failure-scores than those with elective minor surgery in the respective period.In conclusion, our results stress the importance of a staged treatment of patients suffering from multiple trauma furthermore.

Neutrophil Response to Replantation of Large Human Extremities

AbstractBackground:Polymorphonuclear leukocytes (PMN) play a pivotal pathogenic role in ischemia/reperfusion injury of various tissues. The aim of the present study was to investigate the effect of replantation of large extremities on the function of circulating PMN in human patients.Patients and Methods:PMN were isolated from whole blood up to 90 min after vessel repair and reperfusion. PMN superoxide anion production was measured by a cytochrome C reduction assay. Ten patients with amputations of the leg (n = 2), lower leg (n = 5), upper arm (n = 2), forearm (n = 1), and three subtotal amputations of the lower leg with severe vessel damage were enrolled.Results:In four of six reamputated patients, total time of limb ischemia exceeded 5 h and PMN superoxide production was substantially increased at 60 min after reperfusion. With successful replantation, time of ischemia was < 5 h and PMN superoxide production did not further increase during reperfusion.Conclusion:The neutrophil response to replantation of large extremities is associated with the time of ischemia which may be involved in multiorgan dysfunction syndrome observed in some of these patients.

Spinal Body Replacement and Endoscopic Reconstruction

Fractures, tumors, and bacterial infections of the thoraco-lumbar spine often require dorsal stabilization to reconstruct the vertebral alignment or to support tension band stability. In many cases, and especially in fractures, we have learned that healing of the injured spinal segment is not in any case accomplished by dorsal procedures alone. Since the stability of the whole spinal segment mainly depends on the integrity of the ventral load-bearing column, we should consider anatomic reconstruction of the vertebral body when indicated. Since main secondary loss of correction derives also from the injured disc space [1], disc replacement is a further indication for ventral spinal stabilization. In this respect, MRI has a high diagnostic relevance and might help in decision-making using mono- or bisegmental ventral spondylodesis. Although we have gathered a lot of experience with different stabilization devices and products, neither the definite concept performing spinal stabilization, nor perfect implants, biological or artificial, are yet available. A prospective multi-center study including 682 patients comparing internal fixateurs combined with bone grafts, dorso-ventral, and isolated ventral stabilizations demonstrated in one third of the patients’ functional impairment, for all techniques a loss of reduction and especially a high donor-side morbidity of the tricortical bone graft. The study, however, concluded that the combined dorsoventral fusion brings about the best reduction over time [2]. Some questions have to be asked. How much stabilization is necessary? How to reconstruct: with bone, plate, or cages? What to do in situations like infection and severe osteoporosis? How to approach mono- and bisegmental injury patterns? What about the risks of ventral stabilization procedures? In this issue, we published a series of papers dealing with the anterior spinal body reconstruction after trauma, tumors, and infection. The papers critically evaluate surgical procedures, drawbacks, and pitfalls that will be very helpful for spine surgeons of all disciplines. In order to discuss these papers and open questions thoroughly, we want to put forward some basic considerations, which may be kept in mind during reading: