European Journal of Trauma and Emergency Surgery Supplement II Vol

European Journal of Trauma and Emergency Surgery Supplement II Vol. 33 · 2007 Official Publication of the European Trauma Society

st Aims and Scope Abstracts 1 Joint Congress, European Association for Trauma and Emergency Surgery–EATES and European Trauma Society–ETS Trauma causes individual patterns of May 23–26, 2007, Graz, Austria injury and involves shock, fractures, Congress President: Prof. Dr. Selman Uranues, Graz, Austria soft tissue and organ injuries. Treat- Congress Co-President: Prof. Dr. Otmar Trentz, Zurich, Switzerland ment therefore requires the joint effort of emergency medicine, orthopedic and trauma surgery, critical care Contents medicine and rehabilitation. Both scientific progress and the in-depth 3 Preface experimental and clinical research Presentations within individual disciplines contribute to the ongoing continuous 4 Best Free Paper Prize Session improvement of trauma care. Abstracts 1-9 The EUROPEAN JOURNAL OF TRAUMA AND EMERGENCY SURGERY aims to open an 6 Video Presentations interdisciplinary forum that allows Abstracts 10-19 for the scientific exchange between

basic and clinical science related to Free Paper Sessions – Oral and Poster Presentations pathophysiology, diagnostics and 9 Research in Trauma treatment of traumatized patients. Abstracts 20-39 The journal covers all aspects of clini- 15 cal management, operative treatment Trauma Education and Training Abstracts 40-49 and related research of traumatic injuries. 17 Preclinical Trauma Care and the First 24 hrs in Polytrauma Clinical and experimental papers on Abstracts 50-74 issues relevant for the improvement 25 of trauma care are published. Reviews, Trauma Imaging original articles, short communi- Abstracts 75-91 cations and letters allow the appropri- 29 Head and Spinal Trauma Management ate presentation of major and minor Abstracts 92-122 topics. The papers published are allocated to one of the following sections 37 Skeletal Trauma of the journal: Abstracts 123-208 Biomaterials, Experimental Research, Foot and Ancle Trauma, Hand Trauma, 60 Trauma to the Chest and Abdomen Intensive Care, Neurotrauma, Pediatric Abstracts 209-246 Trauma, Pelvic Trauma, Polytrauma, Reconstructive Surgery, Spine Trauma, 71 Abdominal Emergencies Sports Injuries, Thoracic and Abdominal Abstracts 247-271 Trauma, Upper and Lower Extremity. 78 Vascular Trauma, Mangled Extremity and DVT The EUROPEAN JOURNAL OF TRAUMA AND Abstracts 272-283 EMERGENCY SURGERY invites articles not only from Europe but also from 81 Soft tissue Injuries and Infections of Prosthetic Materials the United States, Japan, and other Abstracts 284-291 countries. The journal is peer-reviewed according to international standards 83 Antibiotics and Topical Sealants and each paper submitted will be Abstracts 292-296 scrutinized by two or three referees 85 and a biostatistical consultant. For ar- Challenges in Disasters ticles describing Abstracts 297-305 important new findings, accelerated 87 Miscellaneous peer-review and fast track publication Abstracts 306-315 are made available. 91 Authors’ Index Cited in: EMBASE/Excerpta Medica . CINAHL®

Eur J Trauma Emerg Surg 2007; 33(Suppl II): 1 –92 DOI 10.1007/s00068-007-1002-x

Eur J Trauma Emerg Surg 2007 . Supplement II © URBAN & VOGEL 1 www.europeantrauma.net Supplementary Electronic Material

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2 Eur J Trauma Emerg Surg 2007 . Supplement II © URBAN & VOGEL European Journal of Trauma and Emergency Surgery Preface

Dear Colleagues,

This edition of the European Journal of Trauma and Emergency Surgery contains the selected abstracts for the first joint congress of the two largest European societies of trauma and emergency surgery. The anonymized abstracts were reviewed with regard to scientific methodology and content by three independent specialists in the respective fields. The number of high quality submissions was far greater than we had expected and a number of abstracts had to be rejected due to space limitations. I should like to take this opportunity to encourage the authors of abstracts that were not accepted to continue their good work and submit their newest findings for the congress next year in Budapest.

As the contents of this abstract book show, the scientific program is first rate, not only in the plenary but in the free-paper sessions as well; in both, exciting findings as the result of well-planned studies will be presented convincingly. I am very pleased that we are able to publish these works in the official organ of these two European societies. As of 2007, the European Journal of Trauma has expanded not only its content spectrum but also its name, as mentioned above, and now is the one and only European journal on the subject of traumatology and emergency surgery. This broadened topical coverage should not be seen as an arbitrary merger but as a future-oriented rapprochement of the specialized fields of traumatology and emergency surgery. At a time when healthcare systems are plagued with economic and financial concerns, the current international trend to subsume all acute indications under one roof certainly makes sense, whereby the ultimate goal is still “the best outcome result with the best cost effectiveness.”

First steps have been taken in this direction in the USA and distinguished trauma surgeons have analyzed these developments on the basis of scientific and clinical criteria (Moore EE et al. Acute care surgery. Eraritjaritjaka. JACS 2006;202:698) and summarize their findings as follows: “As representatives of the generation of trauma surgeons who were fortunate to have experienced the golden age, we submit that the key ingredient to salvage our discipline is the return to performing complex surgical procedures. We have Eraritjaritjaka”. [Eraritjaritjaka is an archaic poetic expression from the Australian Aboriginal language Aranda and describes a desire for something that has been lost. It is the title of a music-theater work by Heiner Goebbels based on texts by Elias Canetti]. Moore et al. further write, “The European model … is an enticing proposal, and has been an enduring field in Austria and Switzerland... Perhaps it is time to reconsider the European model in the United States.”

I hope that this meeting with its scientific and social focus will be an unforgettable experience on the path to new developments in our special field and will contribute to ever better clinical care of the very sick people entrusted to our care.

Selman Uranues President of the 1st Joint Congress of EATES and ETS

Cover picture: Mur Island by Vito Acconci (www.graztourismus.at)

Eur J Trauma Emerg Surg 2007 . Supplement II © URBAN & VOGEL 3 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Best Free Paper Prize Session Experimental part: In 11 mongrel dogs in general anesthesia with Thiopental laparotomy was performed under sterile conditions. The splenic artery was identified. Than the spleen was 10–15mm deep incised on the diaphtagmatic surface in different directions. 1 A non-absorbable thread loop was tightened around the artery until Multicentre Randomized, Double-Blind, Controlled bleeding stopped. Arterial occlusion was not complete. After 12 Trial of Laparoscopic Versus Open Surgery week relaparotomy was done and the spleen inspected. In all animals the spleen healed with scars. for Suspected Appendicitis in Adults Clinical study: In 4 patients splenic artery occlusion was performed (The Leonardo Study): Preliminary results as an additional haemostatic measure to splenic package into a L. Ansaloni, F. Catena, F. Coccolini, F. Gazzotti, A. Pinna resorbable mesh in AAST Grade III (3 pat.) and IV (1 pat.) St. Orsola-Malpighi University Hospital splenic lesions. In two pat. Doppler sonography was performed to establish splenic circulation and blood flow in the occluded Introduction: In the literature a recent extensive systematic review artery. Additionally immunologic and haematologic follow-ups comparing laparoscopic vs. open appendectomy (OA) in adults were done. concluded that in those clinical settings where surgical expertise Results: Postoperative course was in 3 pat. uneventful. One pat. died and equipment are available and affordable laparoscopic appen- because of additional brain injury. Of the 3 survivors 2 could be dectomy (LA) seems to have advantage over OA, recommending examined 9 and 14 months postoperatively. Doppler sonography it in patients with suspected appendicitis unless laparoscopy itself showed normal blood flow in the splenic artery and good splenic is contraindicated. But the reviewers even pointed out that their blood supply. The spleen was normally shaped without structural systematic review was based on studies of mediocre quality, with changes. The haematologic and immune statuses showed normal very similar flaws, like unclear randomization method, lack of values. blindness, non intention-to-treat analysis and finally absence of the Conclusion: Occlusion of the splenic artery seems to be a safe and description of numbers of patients eligible and refusing trial par- effective method of bleeding control in splenic trauma without long- ticipation. In order to compare the therapeutic effects of LA and term sequelae. OA in the treatment of suspected acute appendicitis, we designed a randomised controlled trial, taking particular attention to answer to the following methodological issues: concealed randomiza- 3 tion, double blinding, intention-to-treat analysis and finally the Haemostasis After Liver and Spleen Injuries. clear report of numbers of eligible, excluded and refusing patients. An Experimental Study Comparing Autologous, Methods: The LEONARDO (Laparoscopic Excision vs OpeN Heterologous and Semi-synthetic Sealants Appendectomy multicentre Randomized, DOuble blind controlled T. Auer1, N. Toprak1,2, D. Nagele-Moser1, S. Uranu¨s1 trial) study is a multicentre prospective, randomised, double-blinded 1Department of Surgery, medical University of Graz, Graz, Austria comparison of LA versus OA with a sample size of 420 patients. 2Cerrahpasa University, Medical Faculty, Istanbul, Turkey Results: The results of the planned outcomes (postoperative pain; wound infections; intraabdominal abscesses; duration of operation; Methods: Nineteen sheep were laparotomized and subjected to length of hospital stay; return to normal activity; return of bowel standardized defects of the liver and spleen. Three types of sealants function and cosmesis) relative of the first 42 patients (10% of sample were used: Vivostat: homologous fibrin Tissucol: heterologous fibrin size) are reported. Flo Seal: lyophilised thrombin of bovine origin The sheep were Discussion: The LEONARDO study in its preliminary results seems randomized to treatment. Severity of bleeding was scored on a scale effective to reach the aim planned. of 0 to 3. Bleeding was assessed after 30sec,then every minute for 20 min. Results: Liver: After 30sec, bleeding had stopped in 30% after application of FloSeal; the others were still bleeding weakly. With 2 application of Vivistat and Tissucol, there was no significant dif- Splenic Artery Occlusion: An Additional Measure ference to the ‘‘no treatment’’ control group. After 5minutes: All bleeding had ceased in the FloSeal group, in 70% of the Tissucol in Splenic Preservation. Experimental and Clinical group and in 25% of the Vivostat group. Spleen: After 30sec, Study bleeding had stopped in 10% of the FloSeal group; 50% were T. Braunsteiner1, P. Simko2, S. Vajczik3, S. Mikuska2,V.Većsei1 bleeding weakly and the remainder was bleeding moderately or 1Vienna Medical University, Dept. of Trauma Surgery, Vienna, severely. Bleeding was not stopped in the Tissucol and Vivostat Austria groups. After 5min, bleeding has ceased in 80% of the FloSeal 2Department of Trauma Surgery, Derer Univ. Hospital, Bratislava, group while the remaining 20% showed slight bleeding. In the Slovakia Tissucol group, bleeding was stopped in 30% and was weak in 30%, 3Department of Orthopaedics and Trauma Surgery, Petrzalka while the remainder still bled moderately to strongly. In the Hospital, Bratislava, Slovakia Vivostat group, 15% had stopped bleeding and 45% were bleeding slightly. Introduction: Splenic preservation is an important therapeutic Conclusion: Spleen lesions bled more severely than liver lesions. objective in splenic trauma. Splenic artery ligation is one of the de- FloSeal was seen as a highly efficient sealant for liver and spleen scribed preservation techniques. Methods. We describe a method of injuries. Tissucol was 70% as efficient as FloSeal. Vivostat showed splenic haemostasis by occlusion of the splenic artery. poor results both for liver and spleen injuries.

4 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

4 trans-articular technique. Ilizarov external fixator with hinges was Injection of bone components in Injured Soft used to allow early joint mobility Minimal open reduction was used after failure of percutaneous reduction in 8 patients with closed Tissue Induces Systemic Inflammation with fractures.Weight bearing was allowed from the second day after the Remote Organ Dysfunction operation for all 20 patients had a bridged trans-articular external P. Kobbe1,D.2, K. Mollen2, T. Billiar2, H. Pape1 fixation. All patients were followed for at least 12 months. Clinical 1Department of Orthopaedic Surgery, University of Pittsburgh evaluation of joints mobility, time to healing, presence or absence of 2Department of Surgery, University of Pittsburgh, USA pain and radiological evaluation after the operation and at the time of the follow up were done for all patients. Final outcome will be Purpose: The local mechanisms inducing systemic inflammation fol- presented lowing long bone fractures are not well understood. Osteoclasts, osteoblasts as well as bone marrow cells possess immunologic properties, which may play an important role in the induction of systemic 6 inflammation following long bone fractures. In this study the systemic inflammatory response and its effects on the lung after injection of Local Application of Basic Fibroblast Growth bone components in injured thigh muscle are investigated. Factor Increases the Risk of Local Infection Material and Methods: Induction of soft tissue injury (STI): Both After Trauma. An In-vitro and In-vivo Study thigh muscles were bruised with a hemostat Groups: Sham-group T. Ka¨licke, T. Frangen, M. Ko¨ller, S. Arens, G. Muhr (STI + injection NaCl); BMC-group (STI + injection of bone mar- BG Kliniken Bergmannsheil, Germany row cells); BMF-group (STI + injection of soluble bone marrow components) and Bone-group (STI + injection of dissolved bone) Introduction: Local application of growth factors to stimulate wound Parameter: Serum IL-6, IL-10 and TNF-a´ levels were determined. and fracture healing attracts increasing interest. Pulmonal neutrophil accumulation and lung permeability were as- Methods: The in-vitro investigations were performed by isolation of sessed using a MPO assay and bronchoalveolar lavage respectively. human leukocyte fractions, cytokine analysis, phagocytosis assay, Results: The serum IL-6 levels were significantly increased in all flow cytometry and LDH assay. In-vivo investigation: A paired groups as compared to the Sham-group and in the Bone-group as comparison of infection rates was carried out on Sprague-Dawley compared to the BMC- and BMF-group. Serum TNF-alpha levels rats after standardized, closed soft tissue trauma and local, percuta- were significantly increased in all groups compared with the Sham- neous bacterial inoculation of different concentrations of Staphylo- group. There was no significant difference in serum IL-10 levels. The coccus aureus, whereby the lower leg was treated with 1, 10 and bronchoalveolar-lavage-protein concentration as well as the pul- 100ng bFGF. monal neutrophil accumulation was significantly increased in all Results: Cytotoxic reactions due to the used concentrations of bFGF groups as compared with the Sham-group. could be excluded in-vitro. A significant increase in cytokine release Conclusion: The injection of bone components in injured soft tissue was observed after coincubation of PBMC with 100 or 200ng of the induces systemic inflammation with remote organ dysfunction. This same bFGF which was used for the animal experiments. The capacity emphasizes the importance of immunogenic cellular and non-cellular of phagocytes within whole blood to phagocyte bacteria was sup- components of the bone in the development of systemic inflamma- pressed in the presence of 100ng exogenously added bFGF. We tion following long bone fractures. found continuously reduced granulocytic phagocytosis in FGF-supplemented blood compared to non-supplemented blood. In the in- vivo investigation the infection rate for the group without bFGF was 5 0.25. In the groups with 1, 10 and 100ng bFGF, the infection rates were 0.5, 0.7 and 0.8. The difference in the infection rates for the Management of Joints Closed and Open Fractures groups with 10 and 100ng bFGF were applied was significant com- Using Trans Articular or Extra-articular External pared with the group without bFGF. Fixation with or without Minimal Internal Summary: If these initial results are confirmed for other angiogenic potent growth factors, then the local application of growth factors to Fixation stimulate wound and bone healing will need to be reconsidered and Y. Elbatrawy preceded by a strict evaluation of the risks and benefits. Elzahra’a University Hospital, Cairo, Egypt

36 intra-articular fractures of lower and upper limbs in 35 patients were treated using external fixation. The medium age of the patients 7 was 41.6 years. 9 patients are female while 26 are males. Among The New Product Guiding Star for Fractures them, 6 were intra-condylar femoral fractures, 12 tibial plateau, 6 tibial plafond and 12 distal radius. X- rays and 3-D CT scan were Treatement with Cannulated Nails Using The used for evaluation in all patients. 8 of them all were open fractures. Nonivasive Technique for Distal Interlocking Minimal internal fixation were used for fixation in 27 fractures in A. Kristan1, M. Cimerman1, P. Brandoli2, T. Fius2, D. Kreuh2 addition to the external fixation. In the other 9 fractures, just 1UMC Ljubljana, Department of Traumatology external fixation pins were enough to fix. 2 techniques were used to 2Ekliptik ltd, Slovenia apply the external fixation. First is trans-articular and second is extra-articular or joint preservative. Trans-articular technique was ap- The need for a non-invasive, fast and precise distal interlocking plied for 20 fractures. Extra articular non bridging external fixation technique with intramedulary nails has persisted in the long bones was applied for 16 fractures. Sixteen of the 20 fractures used the surgery for many years. GUIDING STAR resolves the problems of

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 5 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

interlocking time, and most importantly, altogether sets aside the use 9 of X-rays. The LIDIS (less invasive distal interlocking system) In Vivo Expression of Vegf-R2 During module resolves the problem of a ‘‘free hand’’ interlocking technique and presents a novel product that can be used with any cannulated Early Hindlimb Ischemia-Reperfusion intramedulary nail assembly. When using the new LIDIS module it is Injury possible to place distal interlocking screws exactly on the proper M. Hofmann, R. Mittermayr, T. Morton, H. Redl, position without any exposure to x-rays. The internal guide with M. van Griensven navigation sensor is placed into the channel of the intramedular nail. Ludwig Boltzmann Institute For Experimental And Clinical Trau- With the help of the external guide with second navigation sensor, matology, Vienna, Austria the surgeon finds the appropriate position for drilling the hole. The special transmitter of the navigational system, placed above the pa- This study investigates the in vivo expression of VEGF-R2 dur- cient table, enables the position and orientation of both tracers to be ing early hindlimb ischemia/reperfusion and its alteration via displayed on the PC monitor. The new procedure, enabled by the VEGF165 released from a fibrin biomatrix. Transgenic FVB/N- GUIDING STAR and its module LIDIS, sinificantely shorten the Tg(Vegfr2-luc)Xen mice were used for non-invasive, real-time distal interlocking. The proximal interlocking is performed by stan- assessment of the VEGF-R2(Flk-1/KDR) expression. Ischemia was dard guides and conventional technique. The system also enables the induced by a tension controlled tourniquet to the hindlimb and producers to design a completely new generation of cannulated nails was verified by laser Doppler imaging technique. Ischemia was with almost limitless possibilities of interlocking. This new generation maintained for 2h with subsequent reperfusion for 24h. Control of devices can broaden the indications of intrameddular fixation animals received no treatment whereas the animals of the FS/ and make the operation more »user friendly« to thepatient and the VEGF group received 20ng VEGF/final FS clot in their hindlimb surgeon as well. subcutaneously, 15min prior to reperfusion. The vehicle group (FS) was subjected to the same procedure. At different time points LDI, to show hindlimb perfusion, as well as bioluminescence detection to observe VEGF-R2 expression, were done. Applying 8 the tourniquet resulted in ischemia as verified by LDI. Restoration Less Invasive Stabilization System for the of blood flow was seen to 83%-112% of baseline in all groups after 24h of reperfusion. VEGF-R2 expression was similar to the Treatment of Distal Femoral and Proximal baseline data in the control group after 24h of reperfusion in the Tibial Fractures; Results of 52 Cases ischemic hindlimb. With VEGF in the fibrin biomatrix a significant M. Wijffels1, S. de Haseth1, P. Ott2, S. Meylaerts1, S. Rhemrev1 increase in receptor expression was observed at 24h, compared to 1Department of Surgery, Medical Center Haaglanden, The Hague, baseline as well as to the control group while after 4h no recep- The Netherlands tor alterations were seen. This ischemia/reperfusion model in 2Department of Radiology, Medical Center Haaglanden, The Hague, transgenic mice enables in vivo observation of the VEGF-R2 The Netherlands expression, a key receptor in angiogenesis. VEGF-R2 is not up- regulated in the reperfusion period after severe ischemic condi- Background: The Less Invasive Stabilization System with its special tions. However following the concept of therapeutic angiogenesis, features such as, angular stability and its minimal invasive charac- VEGF application causes an increase in VEGF receptor expres- teristics might be a promising implant for the surgical treatment of sion at 24h. distal femoral and proximal tibial fractures. These fractures are acknowledged to be a challenging reconstructive task. Complicating factors are many such as, osteoporosis in the elderly, loss of bone volume and risk of infection. Video Presentations Objective: To test the Less Invasive Stabilization System for treatment of the distal femoral fractures and proximal tibial fractures. Setting: Therapeutic study, level I trauma Centrum. Subjects and participants: 26 patients were treated for a fracture of 10 the distal femur and 26 patients for a fracture of the proximal tibia using LISS between January 2000 and November 2006. Laparoscopic Procedures At An Acute Outcome Measurements: Results of treatment were evaluated by Intestinal Obstruction radiographic follow-up until healing and by functional assessment L. Oleg E.1, G. Eduard A.2, S. Alexey A.3, using the scoring system of the Oxford Knee Score. Mean follow-up S. Maxim D.4 was 17 months (1–39). Results: 4 people died with cause in no rela- 1Moscow State Medical And Dental University, Russia tionship to fracture-stabilization. Operation-related complications were 1 venous thrombosis, 2 wound infections, 1 deep infection. 1 Laparoscopic adhesiolis at an acute adherent intestinal obstruction it wound haematoma had to be evacuated. Mean Oxford Knee Score is successfully executed 68 patients from 75. In 7 cases conversion is was 33 (12–54). Reduction and LISS alignment were preserved in all undertaken. The first trocar was placed in view of the most probable patients during follow-up. localization of the adhesions by the open method under visual or Conclusions: The LISS system with its angular stability and its min- manual control. At scheduled laparoscopic operations at earlier imal invasive characteristics is safe to use in distal femur and proxi- operated patients, trocars settled down atypically. The preferred size mal tibial fractures. These characteristics provide adequate stability of trocars 10 mm, for more mobile using a telescope from the different for good functional and radiological results in these demanding sides. Feature Laparoscopic adhesiolis consists in an opportunity use fractures. of a traction and cutting by scissors and to a lesser degree coagulations

6 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

in a kind of danger of development of relapse of adherent process and the right flank with open technique. Other two trocars was employed coagulative complications to reduce the entire small bowel but terminal ileum. No signs of bowel strangulation occurred. Mesenteric defect was closed with in- tracorporeal knotted absorbable stitches. Postoperative course and 11 follow-up were uneventful. Conclusions: Only five cases of laparoscopic repair of a left paradu- Laparoscopic Procedures in Urgent Surgery odenal was previously reported in literature. CT increase the rate of 1 1 1 1 L. Oleg E. , G. Eduard A. , S. Alexey A. , S. Maxim D. preoperative diagnosis of congenital and postoperative internal her- 1 Moscow State Medical And Dental University, Russia nias. Laparoscopy confirmed its role in diagnosing and treating small bowel obstruction of unclear origin and should be considered of The laparoscopic procedures at 314 patients with suspicion on acute choice approaching diagnosed mesenteric defect. Preoperative diag- abdominal surgical diseases are executed. At 204 patients the nosis allowed us a preoperative planning of trocar positioning and an destructive appendicitis is established. From them, at 28 patients easy repair of the mesenteric defect. was gangrenous or perforative appendicitis, in 17 cases it is complicated by a peritonitis, in 11 cases periappendicular infiltrate and in 16 cases – periappendicular abscess. To all patients appendec- 13 tomy is laparoscopicaly executed, laparoscopic sanation and a drainage of an abdominal cavity was made under indications. In 26 Destructive Appendicite Laparoscopic cases of not changed process it has been taped: 10 apoplexies of an Treatment ovary, at 5 patients a terminal ileitis, at 1 - Meckel diverticulitis, 8 - L. Oleg E.1, G. Eduard A.1, S. Alexey A.1, S. Maxim D.1 mesadenitis. 42 patients with clinical a peritonitis are operated: 32 – Moscow State Medical And Dental University, Russia an acute adhesive desease of a peritoneum, 16 - a ruptured ulcer of a stomach and a duodenum, 12 - inflammatory process in a small Laparoscopic procedures are executed at 132 patients with suspicion basin, 6 – a pancreatonecrosis. At 62 patients various early and late on an acute appendicitis in the age of from 15 till 86 years. The postoperative complications are taped: 12 - intraabdominal bleed- destructive appendicitis is diagnosed for 98 patients. (22 - was gan- ings, 3-bile-leaking. 45 - a postoperative peritonitis (including at 11 grenous or perforative appendicitis, 10 – with a local or diffusive patients – after the open interventions). At 19 patients abscesses of purulent peritonitis, 6 – with periappendicular infiltrate, 5 – periap- an abdominal cavity are taped, the laparoscopy, opening, an aspi- pendicular abscess). All sick acute appendicitis executes laparoscopic ration of contents and a drainage of an abscess is executed. Being appendectomy with coveration of appendix stump by intracororpal based on own experience, any operation at the patient with an suture. At presence of a peritonitis sanation and a drainage of an acute abdomen should begin with a diagnostic laparoscopy. Local- abdominal cavity was carried out laparoscopically. At the phenomena ization of the center and prevalence of pathological process, an of a typhlitis the stump plunged noose sutures. The intact appendix has expression of a destruction of tissues, presence of a peritonitis, are been found out in 12 cases. Duration of operations has averaged 40 not contraindication to carrying out adequate completely laparo- minutes. No postoperative complications and lethal outcomes. Being scopic procedures. based on own experience, we consider, that any operative measure at suspicion on an acute appendicitis should begin with a diagnostic laparoscopy which at acknowledgement of the diagnosis should pass in medical. Variants of localization of a process, an expression of a 12 destruction, presence of a peritonitis and accompanying diseases at Laparoscopic Repair of a Left Paraduodenal well equipped and qualified surgical service of medical establishment, Hernia are not contraindication to laparoscopic appendectomies. M. Zago, M.G. Turconi, H. Kurihara, D. Mariani, A. Casamassima Dept of General and Minimally Invasive Surgery, Emergency and 14 Trauma Surgery Unit - Istituto Clinico Humanitas – IRCCS, Rozz- ano (Milano), Italy Large Intrathoracic Knife Removed Under Vats Background: Paraduodenal hernia is a rare cause of bowel A. Garcıá-Marıń, I. Arjona, N. Moreno-Mata, D. Serralta, obstruction. It is seldom diagnosed preoperatively because of F. Ture´gano-Fuentes unfamiliarity with this type of internal hernia. Left paraduodenal University Hospital Gregorio Maran˜ o´ n hernia is more common than the right one. Morbidity and mortality are quite high (as to 50%), due to misdiagnosis and delay. We Aim: To present a case of a patient with a thoracic stab wound and a describe a case of left paraduodenal hernia, successfully treated by large knife stuck into the lung, which was removed under Video laparoscopy. Assisted Thoracic Surgery (VATS). Patient and Methods: A 46 years-old female was admitted to the ED Clinical Case: A 32 years old male patient was brought into the complaining nausea, vomiting and colicky abdominal and back pain, Emergency Department with a large knife stuck into the left hemi- with a previous history of nephrolithiasis, diverticular disease and no thorax. On the primary survey he was hemodynamically normal, with abdominal surgery. Plain abdominal film revealed an abnormal bo- normal breath sounds. Secondary survey was unremarkable. His past wel gas pattern. CT showed absence of nephrolithiasis and suggested medical history included a diagnosis of paranoid schizophrenia not small bowel obstruction from internal left paraduodenal hernia. The treated at the moment. A decision was made to remove the knife patient underwent urgent laparoscopy. Taking into account the under VATS and the knife was found to be stuck into the lingula. suggested preoperative diagnosis, the first trocar was inserted in There was little bleeding upon its removal and a small resection with

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 7 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

endo-stapler was performed. Postoperative recovery was uneventful, according to the Rowe score. There were 2 redislocations in this his thoracic drain was removed on the 3rd day and he was transferred group, both in patients with borderline bone defects. We conclude to the psychiatry ward. that arthroscopic stabilization is asafe and reliable to prevent re- Discussion: In patients who are either hemodynamically normal or dislocation after ﬁrst time shoulder dislocation. stable, foreign bodies stuck into the lung parenchyma can be assessed under VATS and an attempt made at its removal, avoiding a formal 17 thoracotomy. Intramedullar Locked Nailing of A3 Distal Radius Fractures S. Nijs, A. Sermon, P. Broos 15 UZ Gasthuisberg KULeuven

Dynamic External Fixation of Comminuted A3 fractures of the distal radius are among the most frequent Intra-Articular Fractures of the Distal Tibia fractures we treat. Whereas closed reduction and Kapandji pinning (Type C Pilon Fractures do result often in a rather disappointing anatomic and functional M. Mitkovic, Z. Golubovic, D. Mladenovic, I. Micic, results in the osteoporotic but still active patient, open reduction S. Milenkovic and internal fixation using angular stable plates remains rather Orthopaedic And Traumatology Clinic invasive. We demonstrate an angular stable locked intramedullar technique that can performed with minimal soft tissue disturbance Dynamic external fixation of comminuted intra-articular fractures of using the dorsal nail plate (Hand Innovations). We demonstrate the the distal tibia (type C pilon fractures) We report 37 patients with 28 technique in an illustrative video. Special attention is paid to tips type C3, distal intraarticular tibial (pilon) fractures treated by dy- and tricks to avoid intra-operative problems. The results in our 15 namic external fixation. Follow-up was at least two years, and the first patients are reported. We saw uniformly good and excellent results (subjective and objective) were classified according to the anatomical and functional outcomes according to the Mayo wrist Ovadia system. The mean to fracture union was 14 weeks (range: 12 score. to 20 weeks). There were three cases with angulation deformity (from 7 degrees to 20 degrees). There were no cases with nonunion or deep infection. Based on these results, this treatment with closed 18 reduction and dynamic external fixation allowing early motion ap- Intra-Operative Use of Color-Power-Doplpler (CPD) pears as a suitable method for treatment of comminuted intraarticular tibial pilon fractures. for Perforator-Based Fasciocutaneous Rotation Flap P. Prasad, S. Singh, S. Narayan, K. Graham, D. Nayagam Royal Liverpool University Hospital 16 Purpose: To report our experience and show a video demonstration Results of Arthroscopic Fixation After First Time of using colour power doppler intra-operatively for perforator based Shoulder Dislocation fasciocutaneous flaps for lower leg reconstruction. S. Nijs, P. Broos Introduction: Sonosite 180 is a portable and easy to use ultrasound UZ Gasthuisberg KULeuven system with Colour Power Doppler (CPD) which allows for quick detection of blood flow in vessels. We have been using Sonosite The shoulder joint is the joint most often dislocated. In the young 180 for central venous cannulation for a long time. This mode is a and active patient, the risk of recurrence is unacceptably high, very sensitive and is less angle-dependent than velocity based especially in those active in sports. To prevent recurrence an colour flow. The probe required for this mode is same as one used arthroscopic stabilization can be performed. This technique is get- for central venous access (L38 Linear vascular and small parts (5– ting well accepted in recurrent dislocators. The indication in first 10MHz). Our plastic surgeons were using continuous wave time dislocators remains less well defined. After confirming the Doppler to detect the perforators which is inaccurate in locating traumatic origin of the dislocation we perform an arthro –CT scan perforators and does not give any guide to the depth/location and to confirm the diagnosis of Bankart lesion and to exclude major the size of the vessels. CPD allows for accurately locating the bony defect. After confirmation the patients get information on perforators, it also gives the idea about the adequacy of the size their relative redislocation risk, and those who opt for stabilization and flow. are included in this study. A full arthroscopic repair is performed Material & methods: Perforator-based fasciocutaneous rotation flaps using two or three portals. In first time dislocators neither a cap- are used at our institute for the tissue defects in patients having sular shift nor an interval closure is performed. Patients start active Ilizarov frames. All the flaps were perforator based and the perfo- rehabilitation with full range of motion the day after surgery. Most rators were localised intra-operatively using CPD. The flaps are patients are treated on an outpatient basis. Most patients regain full elevated with preservation of one to three perforators. Rotation of range of motion 6 weeks after surgery. Sports are allowed 3 months the flaps is possible without dissection of the vessels deep to the after surgery, high impact contact sports are best avoided for 6 muscle. The donor site is then closed primarily. months. We did include 50 patients in the study, and report the Results: All flaps completely survived and there were no periopera- results of their surgery. Average loss of motion is less than 5 in all tive complications. There was no functional disability of the donor directions. We saw almost uniformly good and excellent results area and the results were aesthetically pleasing.

8 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

19 Results: 94 patients were included. No significant differences in injury Laparoscopic Approach to Blunt Hepatic and distribution, injury severity and demographic data were observed between group + ARDS and group –ARDS. Group + ARDS dem- Splenic Trauma onstrated significantly higher IL-8 plasma concentrations from day 3 O.Gorletti, G.Basili, L. Lorenzetti, C.Angrisano, G. Biondi until the end of the observation period compared to group -ARDS. Health Unit 5 Pisa - Pontedera Hospital - General Surgery Unit, Italy In addition, duration of mechanical ventilation and length of stay in the ICU were significantly longer in this group. Furthermore, a sig- Management of blunt hepatic and splenic injuries has evolved over nificant association between the IL-8–251A allele and IL-8 produc- the past two decades with a trend towards nonoperative treatment in tion (day 4-8) was observed. Genotype A/A showed a significantly hemodinamically stable patients. The introduction of minimally longer duration of mechanical ventilation compared to genotype T/T. invasive surgery has revolutionized many surgical diagnostic proto- A trend towards an association between the IL-8–251A allele and an cols and nowadays laparoscopic approach could be placed between increased incidence of posttraumatic ARDS was observed (p = 0.08) conservative method and traditional surgery. Laparoscopy has been Conclusion: This data reaffirms a central role of IL-8 in the patho- applied safely and effectively as a screening tool in stable patients genesis of ARDS. Furthermore, it points towards a genetic predis- with acute trauma and the major advantage was the obviation of position for posttraumatic IL-8 synthesis which might also be unnecessary laparotomy in approximately 60% of cases. associated with the development of posttraumatic ARDS. We represent two cases of blunt abdominal trauma with a II degree laceration of hepatic and splenic parenchyma respectively. Both patients were hemodynamically stable and diagnostic laparoscopy is performed with low pressure, under general anaesthesia. Three 5-mm 21 ports and a 30-degree laparoscope were used for exploration. All Radiofrequency Assisted Haemostasis patients underwent complete exploration of the abdominal cavity. in Experimental Trauma Model. A New Device Therapeutic procedures consisted of cauterizing an actively bleeding D. Zacharoulis, A. Poultsidis, G. Tzovaras, F. Fafoulakis, E. Sioka, from the IV hepatic segment and the upper pole of the spleen. Both E. Katasogridakis, C. Hatzitheofiloui patients experienced an uncomplicated recovery. There were no Larissa, Greece missed injuries. The optimum roles for laparoscopy in trauma have yet to be estab- Introduction: The liver and the spleen are the most frequently in- lished. The presented technique enables a systematic laparoscopic jured organs during abdominal trauma. Hemorrhage control along exploration of the abdomen, which follows the same principles as open with tissue preservation is the ultimate goal during an emergency exploration. Bleeding from minor injuries to the liver and the spleen, as trauma laparotomy. We experimentally investigate a new technique in the cases observed, can be easelycontrolled through the laparoscope. for haemostasis and control of biliary leak after liver and splenic The role of minimally invasive procedures in the treatment of a trauma using a bipolar radiofrequency (RF) energy device. stable trauma patient is increasing as more surgeons acquire ad- Method: Under general anaesthesia multiple stab wounds close to the vanced laparoscopic skills. liver hilum and to the hepatic veins along with a grade IV spleen trauma was produced in 5 white male Landrace pigs. The RF bipolar Free Paper Sessions - Oral and Poster device (Rita Medical Systems Inc., USA) consists of two pairs of opposing electrodes with an active end. The device is connected to a Presentations 500 kHz RF generator (Model 1500x Rita Medical Systems Inc., Research in Trauma USA). Results: After multiple applications all bleeding sites were controlled intraoperatively with no additional means. Postoperatively, all animals appeared clinically healthy, and one month later when the 20 animals were sacrificed, no blood, pus, or hematoma was identified. Association of IL-8–251A/T Polymorphism Conclusion: We believe that radiofrequency energy may be used in with Incidence of Acute Respiratory Distress liver and splenic injury for haemostasis and tissue preservation avoiding unnecessary major surgery. The bipolar mode may help to Syndrome (ARDS) and IL-8 Synthesis After avoid uncontrolled spread of energy, tissue charring and subsequent Multiple Trauma short and long term septic complications. Further clinical studies are F. Hildebrand1, A. Gaensslen2, M. Frink3, C. Haasper4, C. Krettek5 required to validate our results. Trauma Department, Hannover Medical School, Germany

Introduction: IL-8 is regarded as the most important mediators in the 22 pathogenesis of ARDS. However, knowledge regarding the influence of genetic variations within the IL-8 gene either on the development The Safety of Suturless Methods in Experimental of ARDS or on IL-8 production after trauma is sparse. Gastric Ulcer Perforations Repair Patients and methods: In this prospective study, patients were in- M. Nuri, V. Celik, B. Ekci, H. Uzun cluded if the following criteria were fulfilled: ISS >16, age 18–60 Cerrahpasa Medical School, Istanbul, Turkey years, survival > 48 hours after injury. IL-8 plasma-concentrations and the polymorphisms (IL-8–251A/T) were determined. Patients Aim: The effectiveness of suturless methods of repairing ulcer per- were separated according to the ARDS-development (group + - forations by compairing the fibrin glue, oxidised regenerated cellu- ARDS vs. group –ARDS) and the genotypes of the IL-8–251A/T lose and omental patch methods with each other and with the sutural polymorphism (genotypes A/A, A/T and T/T). method.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 9 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Materials and methods: Wistar - Albino type fifty female rats sepa- desirable. Wetting with an antibiotic solution in this closed system rated into five groups. Group 1: repair by polypropyline su- would be ideal. ture(n = 10) Group 2: repair by fibrin glue(n = 10) Group 3: repair Material and Methods: A new construction after first experiences with by oxidised regenerated cellulose (surgicel) + fibrin glue(n = 10) the conventional vacuum system had been designed. Options for Group 4: repair by omental patch + fibrin glue (n = 10) Group 5: alternating suction and instillation is programmable now. An irrigation control, no repair is done to the perforation site (n = 10). On the 4th tube and a documentation system had been added. Four patients with post operative day the rats were sacrified. At the repaired perforation widespread infection of soft tissue an joint had been treated with the site bursting pressure and hyroxyproline levels were measured. Be- new system. The aim had been to find options for technical innovation. sides, the repaired areas sent for the histopathological evaluation. Results: A few options for improvement had been found. The dosage Results: The repair with sutural materials is the safest method, but for the amount of antibiotic so¨ lution, the pressure ti instill and the tube surgicel + fibirin glue method repair is also a safe method and is safer system should be corrected for a better handling and treatement. than omental patch + fibrin glue. Fibrin glue alone method is unsafe Discussion: All together the new vacuum system is a simple and easy and should not be used alone in the repair of an ulcer perforation. handling method for wound infection. The old system had shown its advantages in management of wounds already. Innovation to the old system is the permanent wetting with antibiotic solution beside the 23 covering and evacuation of secretions. The Economic Implications of Syndesmotic Screw Fixation 25 T. Thangarajah, P. Prasad, B. Narayan The Royal Liverpool University Hospital, UK Clinical Results of Compartment Syndrome of the Lower Limb in Polytraumatized Patients Background: Traditionally, the syndesmotic component of ankle M. Frink1, A. Klaus1, F. Hildebrand1, C. Krettek1, H. Pape2 fracture fixation is removed 6–8 weeks after surgery to permit weight 1Trauma Department, Hannover Medical School, Germany bearing. This requires another operative procedure, with its associ- 2Division of Traumatology, University of Pittsburgh Medical Center, ated cost implications. USA Aim: To assess the economic impact of syndesmotic screw removal, and to devise a cost-efficient method for this procedure. Acute compartment syndrome represents a severe complication after Method: Retrospective analysis of 25 consecutive syndesmotic screw trauma of lower extremities. To date, there is limited knowledge removals. about the outcome of compartment syndrome of the lower limb in Setting: University Teaching Hospital with a dedicated trauma sub- patients with multiple injuries. We hypothesized that multiple injuries unit. worsen the long term results of compartment syndrome of the lower Results: Timing for syndesmotic screw removal varied from 5 to 15 leg. Patients who underwent fasciotomy for established compartment postoperative weeks. Preoperative stay ranged from 0 to 5 nights syndrome of the lower leg from 1999 to 2004 in our trauma centre (median 1). Postoperative stay ranged from 0 to 2 nights (median 0). were included. Demographic data, additional injuries (Injury Severity Investigations were ordered in 60% patients. All patients were seen in Score) and method of treatment were analyzed. Outcome assessments clinic once for suture removal. The average cost of screw removal per included clinical examination and isokinetic strength testing of plantar patient was £1363. Discussion: In spite of its predictability, screw re- flexion and dorsal extension at two different angular velocities (60/ moval was not planned well, contributing to variable periods of non- sec; 120/sec). The mean age was 38.0 ± 4.4 years at the time of injury; weight bearing. Patients were admitted for screw removal on dedicated males were affected twice as often as females. Mean ISS of patients trauma lists – this led to delays. Despite having undergone surgery just with multiple injuries was 20.2 ± 2.3 points. Time between admission 2–3 months ago, investigations were unnecessarily repeated. Follow-up and surgical treatment of compartment syndrome was extended in just for suture removal meant an additional, avoidable trip to hospital. polytraumatized patients (38.6 ± 13.8 vs. 13.2 ± 3.8 hours; p = 0.04). Conclusions: 1. Patients undergoing syndesmosis fixation are identi- At follow-up, 15.4% of all patients complained of pain at rest and fied prior to discharge, so that they can be listed for surgery later. 2. 26.9% reported pain on exertion. A significant reduction of torque Screw removal is done in a day-case unit, minimising preoperative and work was found in the dorsal extensors on the injured side and postoperative stay. 3. Preoperative investigations are not re- (p < 0.05). Polytraumatized patients did not show extended weakness peated. 4. Attendance at clinic for suture removal alone is unneces- as compared to those with isolated injuries. No difference was seen sary. 5. There is a potential for the use of biodegradable screws, between both groups regarding pain and function. Polytraumatized which do not need removal. patients did not suffer from worse long term effects regarding sensory or motor deficits. Associated injuries did not seem to influence outcome of the compartment syndrome. 24 VAC-Instill, a System Variation for Vacuum 26 Sealing with Irrigation H. Clement, W. Grechenig, W. Hartwagner, R. Mauschitz, Special Aspects Concerning Acute Trauma K. Tanzer Management in Geriatric Polytrauma Universita¨tsklinik Fu¨ r Unfallchirurgie Graz, Austria O. Gonschorek, A. Woltmann, S. Wurm, V. Bu¨hren Trauma Center, Germany Introduction: An established system in management of wounds is vacuum sealing. In the case of wound infection, small part defekt with Aim of the study: Reduced general condition and health problems incomplete recovery and cavity not only removal of secretion is of elderly polytraumatized patients lead to a worse outcome in this

10 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

patients group. Special aspects result concerning the acute man- about stem cells taken from especially bone marrow, cord blood in agement of elderly polytraumatized patients. Aim of this pro- human. spective study was to show the cut-off for death depending on age. Special clinical aspects of the geriatric polytrauma are presented. Methods: All polytraumatized patients which fulfilled the criteria of the ‘‘AG Polytrauma der DGU’’ entering the trauma center 28 were recorded prospectively. Patients were divided into three Differentiated Complication Pattern and a groups depending on their age: A (<61 years), B (61–74 years), C Decrease of Complications Since the (>74 years). Statistical analysis of AIS, ISS, gender and letality was Introduction of the Registration performed (SPSS 11.0, ‚2-test, level of significance p < 0.05). M. de Kruijf, M. Bemelman, L. Leenen Results: 961 polytraumatized patients (A657,B199,C105)were re- Department of Surgery, University Medical Centre Utrecht, corded prospectively bet-ween 2003 and 2006. There was no sig- The Netherlands nificant difference concerning the injury seve-rity (ISS: A27.4,B23.4,C 23.4). There was a higher percentage of women in Within the framework of quality improvement much is invested in the elder-ly patients (A21%,B24%,C49%). This group presented a the development of complication registration systems. Since 2001 significant higher letality (A12.8%,B15.7%,C43.9%) and more an electronically medical file (EMF) Trail is used in our clinic. head injuries (A61%,B55%,C74%). Injuries of other regions are It is a self developed system in accordance with the requirements less represented in this group. Patients of group C recover worse stipulated by the medical order. Based on the 10th revision of the from head injury (bad recover from head injury: International Classification of Diseases and Related Health Prob- A31%,B37%,C64%). lems (ICD-10) policlinic and clinical complications are registered Conclusions: Letality after polytrauma correlates significantly with and stored in a database. Microsoft Access and SPSS are age of the patients. There are more women in the elderly group, they applied to perform analysis on the registered data. In the period suffer more frequently from head injuries and recover worse. This is 2001–2005 a total amount of 16270 admitted patients and 12149 becoming a focus in our society with growing social and finan-cial complications have been registered. In 2001 the system was implementation. The early treatment of these patients have to rec- introduced and was characterised by under registration during ognize the spe-cial aspects of the geriatric polytrauma. 2001. (1564 vs. 3203). From 2002 a realistic number of registered patients and complications are obtained. Because of the learning curve 2001 is left out of consideration. Trauma Surgery is 27 responsible for 24% of the complications. The top 3 of compli- Bone Fracture Healing with Cord Blood Stem Cells: cations in trauma is: 1 pulmonal complications, 2 infections and 3 miscellaneous. It is striking that every sub-specialism has a sig- A Controlled Animal Study nificantly different top 3 of complications. Figure 1 shows the O. Polat1, G. Polat1, S. Karahu¨seyinoðlu1, N. Kutlay2, E. Erdemli1 1 registered complications of Trauma Surgery. Ankara University Facu¨ lty Of Medicine Emergency Department, Conclusions: Sub-specialisms have a different complication pattern, Turkey 2 which requires an individual preventive strategy. Infections, pul- Ankara University Facu¨ lty Of Medicine Genetics Department, monal and miscellaneous are major contributors for complications in Turkey trauma. Detailed analysis of the complications enables a custom made prevention policy. Since the introduction of the registering Introduction: Mezenchimal stem cells induced to differentiate into system (Trail ), a significant fall in the number of complications has bone and they have potential to differentiate into osteoblasts. Our been observed. aim is to understand if the stem cells is given directly to the bone fracture side induces the healing or not with histopathologically and mechanically. Material and Methods: Getting the stem cells with the cesarian 29 maternal cord blood from albin female rabbits, umbilical-plasental nucleated cells from the female babies are decomposed. 15 Males are The Influence of Caffeic Phenethyl Ester grown for 4 weeks and the same type close fracture is formed to the in Sepsis Induced Liver and Kidney Dysfunction rabbits left and right tibias. Rights are given umbilical-plesental H. Fidan1, H. Dilek1, Y. Ela2, A. Kilbas1, D. Sahin1 nucleated cells, lefts are control. Bone tissues are stained by HE, 1Ayonkarahisar Kocatepe University, Afyonkarahisar, Turkey Safranin O or Mallory-Azan dyes. In order to expose to hold out the 2Suleyman Demirel University, Isparta, Turkey stem cells in the fracture area sections are prepared for fluorescence cross-sex FISH method. Mechanical strength data are collected via Background: NF?B activation is supposed to be one of the targets in Lloyd Software Dapmat. the treatment of sepsis and ensuing mortality. We studied the Result: In the first week of the healing period, there is no difference effectiveness of CAPE in CLP induced liver and kidney dysfunction. histopathologically between two groups that are given stem cell or Methods: 40 rats are randomized to 5 groups. All rats were operated not so as the second week In the third week, the stem cell injected to induce sepsis with CLP except control and CAPE groups. CAPE group is prior to control group bone remodeling with osteoid tissue is (50 lmole/kg) was administered to rats intramuscularly at the time of started but the control is not. With mechanical test, in stem cell operation in CAPE and CS(0) groups. CAPE was administered to injected side, more energy absorption capacity, high maximum load rats in CS(12) group 12 hours after CLP. All rats from each group capacity are detected. were sacrificed 24 hours after CLP; blood was taken for AST, ALT, Conclusion: Cord blood stem cells are induces and quickens the BUN and Creatinin study. Apoptosis, iNOS and HSP70 were fracture healing but it must be developed with the researches examined with immunohistochemistry. Malonlydialdehyde (MDA),

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 11 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

catalase, superoxide dismutase (SOD) and glutathione peroxidase aim of the study was to evaluate the effect of a substitution therapy (GSH-Px) were studied for oxidative stress evaluation. with prothrombin complex concentrate (PCC, Beriplex P/N) and Results and Discussion: Liver: All studied parameters in liver were fibrinogen (Haemocomplettan P) in a porcine model of dilutional significantly increased in sepsis group. CAPE was effective in coagulopathy and bone injury. reducing immunohistochemical parameters. AST and ALT levels Methods: A dilutional coagulopathy was induced in 21 pigs by were significantly increased in sepsis, CS(0) and CS(12) groups. sequential withdrawal of blood, erythrocyte retransfusion, and vol- Kidney: Although iNOS scores and BUN, Cre levels were not sig- ume replacement. Pigs were randomized to the following i.v. treat- nificantly different among control and sepsis groups, apoptosis and ment groups: 1. Placebo (n = 7), 2. PCC 35 U/kg (n = 7), 3. HSP70 scores were significantly increased in sepsis group. These PCC + fibrinogen 125 mg/kg (n = 7). A traumatic injury was created scores were best reduced in CS(12) group. MDA, SOD, GSH-Px and in the femoral neck by a 3 mm drill. Blood loss and time to hemo- catalase levels of liver and kidney showed that the significant change, stasis were determined. Blood samples were analyzed for thrombo- seen in sepsis group, was reduced in CS(0) and CS(12) groups and elastography (TEG) and coagulation factors. results of CS(12) group were superior. Results: The coagulopathy led to a decrease in circulating coagu- Conclusion: CAPE reduced biochemical parameters and histopatho- lation factors and fibrinogen and an abnormal TEG. Time to he- logical changes best when it was administered after sepsis formation. mostasis was 95.4 ± 21.1 min. in the placebo group and decreased significantly after substitution with PCC to 32.7 ± 23.9 min. (p < 0.001). The combination of PCC and fibrinogen further de- 30 creased time to hemostasis to 13.6 ± 8.0 min. (p < 0.0001). Blood loss was reduced concomitantly from 640.1 ± 123.4 ml (placebo) The Value of Bioabsorbable Materials in Anterior to 164.9 ± 145.5 ml (PCC, p < 0.0001) or 42.1 ± 31.6 ml (PCC + Cruciate Ligament Reconstruction fibrinogen, p < 0.0001). TEGs and coagulation factor levels were C. Patru, G. Popescu, O. Lupescu, Nagea, A. Dobre normalized. Emergency Hospital Bucharest, Romania Conclusions: It was concluded that the substitution with PCC could correct a coagulopathy and provided hemostasis in a bone trauma The aim of the present study is to demonstrate the effectiveness and injury. The combination with fibrinogen further improved the clinical low morbidity of ACL reconstruction using the bone- patelar tendon- outcome. bone and hamstring graft fixed at femoral side with absorbable cross pins or absorbable screw. Materials and Methods: A number of 137 patients with chronic ACL tear were arthroscopically operated using three different techniques: 32 -Group 1 (51 patients): BTB graft fixed whit interference screw at Ischemic-Reperfusion Injury Following both side -Group 2 (57 patients): BTB graft fixed using absorbable cross pins at the femoral side and interference screw at the tibial Hemorrhagic Shock on Liver and Kidney tunnel -Group 3 (29 patients): double loop semitendinosis and Tissues in Rats gracilis fixed whit absorbable cross pins proximally Patients were Y. Ela, H. Fidan, F. Kir Sahin, D. Sahin, S. Buyukbas evaluated objectively (Lachman test, pivot shift, KT-1000), subjec- 1Departments of Anaesthesia, Obstetric and Gynecology and tively (IKDC) and functionally (Tegner scale) before 12 and 24 Surgery, Faculty of Medicine, Ayonkarahisar Kocatepe University, month. The IKDC score was used to evaluate the result. Differences Afyonkarahisar, Turkey between groups were statistically evaluated using the Student T test. 2Departments of Biochemistry, Faculty of Medicine, Selcuk Meram Results: We did not recorded any significant difference in terms of University, Konya, Turkey effectiveness and morbidity among 3 groups. Conclusions: Based on our data the new technique of fixation at the Objective: To determine, the time-dependent effects of ischemia- femoral tunnel with absorbable cross-pin seems to be reliable and reperfusion (I/R) injury in rat liver and kidneys. assure comparable results to those obtained with interference screw. Methods: I/R model was applied to 35 male Spraque-Dawley adult This technique provide a secure fixation with satisfactory early clin- rats in 5 groups. Femoral venous blood was taken until arterial blood ical results. The results of the present study confirm that this pro- pressure was < 35 ± 5mmHg. Blood was retransfused after 20 min- cedure could represent an useful alternative option for the ACL utes in four groups other than sham-operated group. Group A; sham- reconstruction. operated control, sacrificed 1 hour post-anaesthesia. Group B, C, D, E; sacrificed 1 hour, 3 hours, 6 hours and 24 hours after I/R, respectively. The kidneys and livers were removed for analysis, wa- shed twice with cold saline solution, placed into plastic tubes, labeled 31 and stored -80C for biochemical analyses. Excessive Bleeding After Bone Trauma in Pigs Results: Liver: MDA and XO levels were significantly increased Undergoing A Dilutional Coagulopathy: and SOD levels were significantly decreased in D and E groups Substitution Therapy with Prothrombin Complex when compared to group A, B and C. Kidney: MDA and XO levels were significantly increased and SOD levels were significantly de- Concentrate and Fibrinogen creased in (Y´ /R) groups B, C, D and E when compared to Group G. Dickneite A. No significant difference was not found between B, C, D, E CSL Behring GmbH groups. Conclusions: I/R injury increases in the liver after 6 hours, but does Introduction: Bone fractures lead to severe, often fatal venous not change in time in the kidney. Monitorization and treatment of I/ bleedings, especially if associated with a dilutional coagulopathy. The R induced liver and kidney dysfunction may be modified.

12 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

33 MDA and XO levels were significantly lower and SOD levels were Effects of aprotinin on kidney tissue in significantly higher than groups B and C. Conclusion: Tacrolimus was effective in reducing I/R injury in liver Ischemic-reperfusion Injury Following and kidney in a hemorrhagic-shock model. Hemorrhagic Shock in Rats F. Kir Sahin, G. Koken, D. Sahin, H. Fidan, S. Buyukbas 35 1Departments of Obstetric and Gynecology, Surgery and Anaesthe- siology, Faculty of Medicine, Afyonkarahisar Kocatepe University, Microcirculatory Resuscitation in Multiple Afyonkarahisar, Turkey Trauma - fluid Therapy Monitoring and Outcome 2Department of Biochemistry, Faculty of Medicine, Selcuk Meram T. Dedek, E. Havel, T. Holecek, J. Koci, J. Trlica University, Konya, Turkey Faculty Hospital Hradec Kralove, Czech Republic

Objective: To assess the protective effect of aprotinin, which is a Aims: The evaluation of algorithmus of microcirculatory fluid protease inhibitor, in a rat renal ischemia–reperfusion (I/R) model. resuscitation in multiple trauma. Methods: Twenty eight, adult male Spraque-Dawley rats were en- Material: 29 trauma patients (22 male; age avg .42, 6y) prime referred rolled to four groups. I/R model: Femoral vein blood was taken until (pre-hospital time avg .49, 3´) to Level I traumacenter with ISS arterial blood pressure decreased < 35 ± 5mmHg and was retrans- avg.32(66–16;SD11). fused after 20 minutes in three groups (Group B, C, D). Hemorrhagic Methods: Prospective cohort study. Inclusion: age >15; ISS >15; shock was not performed in operated sham control group (Group A). indication for central venous catheter (CVC). Exclusion: isolated One group received 0.7 ml of saline 5 minutes before reperfusion brain injury. (Group C) and another received 30.000 KIU/kg of aprotinin in 0.7ml Outcomes: Period of artificial ventilation (AV); respiratory impair- saline 5 minutes before reperfusion (Group D). After reperfusion, ment (SOFAscore); survival. Follow up: hospital discharge. Results: rats were sacrificed by taking blood with intracardiac puncture, and 5 patients (3male;age avg. 45, 9y; ISS avg .49) deceased during the kidneys were removed for analysis. Tissue MDA and GSH levels, reanimation. 24 patients survived-12 patients with avg .2, 13 days and XO activity were determined. (4–1; SD 2, 12) of AV (SAVgroup) and 12 patients with avg.10, 17 Results: MDA and XO levels were significantly increased and SOD days (27-5; SD 6, 5) of AV (LAVgroup). We found no differences in levels were significantly decreased in group B and C. However, MDA sex; age; pre-hospital time; initial arterial base deficit (BDa) and and XO levels of group D were significantly lower than group B and lactate level (LCTa); time to urine output 1, 0–1, 4ml/kg/h; time to C, and SOD levels were significantly higher than groups B and C. ScvO 2 > 70% from blood gases and CVC between the SAV and Conclusion: Our results revealed that aprotinin was effective in LAVgroups. There were differences comparing SAV vs. LAVgroups reducing I/R injury in kidneys in hemorrhagic-shock model. in: highest observed LCTa avg .4, 4 vs. 6, 5 mmol/L; < 48h administered PRBCs units avg .6, 3 vs. 11, 7; ISS avg .25, 8 vs. 32, 2; time to urine output >1, 5 ml/kg/h avg .8, 3 vs. 11, 96h; time to BDa <2, 0 mmol/L avg .13 vs. 16, 8h and to LCTa <2, 5 mmol/L avg .15, 4 vs. 24, 34 2h; fluid retention avg .11, 7 vs. 25, 5L < avg .1, 3 vs. 3, 7 days after Effects of Tacrolimus on Liver and Kidney Tissues injury and in lung SOFA score avg .1, 7 vs. 2, 6. Conclusions: The amount of fluids and time to microcirculatory in Ischemic-Reperfusion Injury Following resuscitation correlates with blood loss amount and ISS. Monitoring Hemorrhagic Shock in Rats of standard hemodynamic parameters and laboratory indicators of D. Sahin, F. Kir Sahin, S. Buyukbas, S. Erturk, S. Yuceyar metabolism remains essential for optimalization of early fluid supply. Department of Surgery, Obstetric and GynecologyAfyonkarahisar The continuous ScvO2 monitoring can support the other marks of the Kocatepe University, Afyonkarahisar, Turkey trends to shock compensation or to repeted worsening. The prime 2Department of Biochemistry, Faculty of Medicine, Selcuk Meram impact on respiratory impairment and on time of artificial ventilation University, Konya, Turkey is done by injury. 3Department of Surgery, Cerrahpasa Medical Faculty, Istanbul Study supported by research project MZO-00179906. University, Istanbul, Turkey

Background: In this study, the effect of tacrolimus, an immunsu- 36 presant, was assessed in a rat liver and renal I/R model. Prognostic Relevance of Procalcitonin (PCT) and Methods: Twenty eight, male Spraque-Dawley (250–300 g weight) Interleukin-6 (IL-6) Serum Levels in Polytrauma adult rats were enrolled to four groups with randomization. I/R model: Femoral vein blood was taken until arterial blood pressure decreased Patients to Predict Multi Organ Dysfunction <35 ± 5 mmHg and was retransfused after 20 minutes in three groups Syndrome (Mods) and Sepsis (Group B, C, D). Hemorrhagic shock was not performed in sham- C. Haasper, M. Kalmbach, M. Frink, C. Krettek, F. Hildebrand operated control group (Group A). One group received 0.7 ml saline 5 Trauma Department, Medizinische Hochschule Hannover (MHH), minutes before reperfusion (Group C) and another received 1mg/kg Germany tacrolimus in 0.7ml saline 5 minutes before reperfusion (Group D). After reperfusion, rats were sacrificed by taking blood with intracar- Introduction: Despite recent advances in treatment of severe injured diac puncture, and the kidneys were removed for analysis. Tissue patients, e.g. due to damage control orthopaedics, multi organ dys- MDA and GSH levels, and XO activity were determined. function syndrome (MODS) and sepsis are major complications in Results: MDA and XO levels were significantly increased and SOD daily practice. We examined whether procalcitonin (PCT) or inter- levels were significantly decreased in group B and C. In group D, leukin-6 (IL-6) are useful in predicting sepsis or multiple organ failure.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 13 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Method: During one year (December 2005-December 2006) 94 pa- 38 tients were prospectively collected. Inclusion criteria: ISS >16, age Recombinant Activated Factor VII – Safes the 18–60 y, primary admission to our level-1 trauma center, survival >48 hours after trauma. For at least 14 days serum levels of IL-6 and PCT Life or Corrects the Surgeon? were determined. The development of MODS (Marshall score) and J. Koci, T. Dedek, E. Havel, J. Trlica, J. Folvarsky sepsis (ACCP/SMMC criteria) were observed. Regarding develop- Department of Surgery, University Hospital Hradec Kralove, ment of sepsis and MODS different groups were formed: + MODS Czech Republic vs. –MODS and + sepsis vs. –sepsis. Hemorrhagic shock is the second most frequent cause of death in Results: Demographic data, injury severity and distribution revealed trauma patients. Recently recombinant activated factor VII has been no significant differences between the subgroups (-MODS vs. + proposed as an adjuvant therapy for hemorrhage control in trauma. MODS, -Sepsis vs. + Sepsis). Comparing groups + MODS (1843,5 ± The aim of our study was to search reason for administration 435,1pg/ml) and –MODS (348,7 ± 95,1pg/ml) significant differences NovoSeven (NVII) in patients of our Traumacenter. (p < 0,05) on admission day were observed, when PCT showed first Materials and Methods: There was a retrospective case report study on day 2 after trauma differences (-PCT: 1,7 ± 0,4 lg/l, + PCT: on the patients with administration of NVII 1.12.2005 to 1.9.2006. All 25,9 ± 5,4 lg/l, p < 0,05). Regarding the development of sepsis PCT cases were reviewed by methodology preventable death. was advantageous to IL-6 showing significant higher plasma levels in Results: There was n = 7 patients (aver. age 38 y.) with administra- group + sepsis from the first day after trauma (-PCT: 3,7 ± 0,9 lg/ tion of NVII, aver. ISS 30 (16–43). We divided the administration of l, + PCT:11,1 ± 2,4 lg/l, p < 0,05). NVII to two groups. In the group I, there was administrated NVII to Conclusions: Serum levels of IL-6 and PCT could be useful in early obtain time to damage control surgery. It was administrated to two identification of high risk patients to develop posttraumatic MODS. patients in ER to correct massive bleeding of crushed chest. Both of In order to identify sepsis PCT is the better prognostic factor as patients died. In the group II, there was administrated NVII as significant higher serum levels were observed 3 days in advance of the adjuvant therapy of damage control surgery or orthopedics. There diagnosis sepsis. were two patients with liver rupture grade V, two patients with pelvic fracture with rupture of urinary bladder and rectum, and one patient with bilateral open femoral fracture and open basis skull fracture. In the group II, the administration of NVII leads to dramatic decreasing 37 of red blood cell and fresh frozen plasma transfusions. Predictive Value of The Determination of Conclusion: NovoSeven administration in our retrospective study On-Scene Cytokine IL-6 Release in Trauma don’t safe the live, but is ‘‘very good guy’’ to trauma surgeon during the damage control surgery. Correct performance of ATLS protocol Patients and damage control surgery sustain the cornerstone in management 1 1 2 1 1 C. Mu¨ller , M. Sattler , M. van Griensven , C. Krettek , T. Gerich of bleeding after trauma. 1Medizinische Hochschule Hannover, Unfallchirurgische Klinik, Germany 2Ludwig Boltzmann Institute fu¨ r experimentelle and klinische 39 Traumatologie, Wien, Austria ECMO in a Near Drowned Adult M. Schweiger1, A. Wasler1, G. Prenner1, W. Toller2, Purpose: Interleukin 6 has been identified as a feasible marker which K. Tscheliessnigg1 reflects an early response to injury or trauma. In this study, we aimed 1Department of Surgery, Medical University of Graz, Graz, Austria to test for IL-6 release during the first minutes after trauma and 2Department of Anesthesiology, Medical University of Graz, Graz, Austria correlation to traumascores. Methods: In a prospective study 58 patients undergoing accidents were Extracorporeal membrane oxygenation (ECMO) is a technique for enrolled. Blood samples were collected at the scene within at most 30 providing life support, in case the natural lungs are failing and for minutes after trauma. All patients were treated by one team of a mechanical circulatory support. We report the case of a 38-year old helicopter rescue service and were transferred to one Level I trauma man who nearly drowned in cold water. He was found with cardiac center. Blood samples were taken again at admission to the surgical arrest and after he was rescued within 15 minutes basic life support was emergency room and daily from there on. Serum levels of interleukin 6 begun. Heart action was detected after 10 minutes of advanced life were determined. In addition ISS, PTS, systemic inflammatory re- support. Afterwards he was transferred to the nearest hospital. There sponse syndrome (SIRS), multiple organ disfunction syndrome he developed severe adult respiratory distress syndrome (ARDS) and (MODS), survival were collected and correlated to IL-6 levels. was admitted to our ICU. He presented with a body core temperature Results: IL-6 levels at the scene were significantly elevated. There of 34.0 degree centigrade, under continuous inotropic support (Nor- was a positive correlation with trauma scores ISS and PTS. Furter- adrenalin 0,1 lg/ml/h), pulmonary artery pressure (PAP) 26/22 more IL-6 at the scene correlated with IL-6 at admission and with mmHg, pulmonary capillary wedge pressure (PCWP) 15mmHg, laktat subsequent developement of MODS. of 10.1 mmol/liter and artery blood gases showed: ph 7.02, pCO2 68.9 Conclusion and Significance: Elevated levels of interleukin 6 can be mmHg, pO2 24.5 mmHg with a fiO2 1.0.. We instituted extracorporeal detected in the very first minutes after trauma, indicating an imme- membrane oxygenation (ECMO) for sufficient oxygenation and for diate systemic inflammatory response. These elevated levels corre- rewarming the patient. Improvement of the arterial blood gases (ph late to injury severity as measured by ISS or PTS. On the other hand 7,415, pO2 95,2mmHg, pCO2 40,1 mmHg) were noticed shortly after the correlation between IL-6 at admission and traumascores as well and the patient showed haemodynamic stability without inotropic as with MODS was higher. Thus, there is no advantage in the very support (heart frequency 80 bts/min, blood pressure 120/70, PAP 33/ early determination of IL-6 while this might be different with other 25). Three days later ECMO was weaned and assisted ventilation was cytokines. stopped after 9 days. No neurological deficits were observed.

14 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Trauma Education and Training equipment, integrated into a common organizational structure designed to improve emergency response operations of all types and complexities.’’ Decisions at the break even-point, where the demand of 40 the mass casualty exceeds usable resources of the ‘‘helping team’’, have Impact of Team-Training (Trauma Evaluation to be trained. Disaster training includes simulations of realistic envi- ronments in which active learning, enhanced by repetition and feed- and Management), A Simplified ATLS-Concept, back can take place. Especially tactical triage in hostile environment is on Students Performance in Complex Trauma highly recommended to be trained. General directions and recom- Scenario OSCE Stations mendations have to be supported and to be implemented in appro- M. Ru¨sseler, M. Weinlich, M. Stier, F. Walcher, I. Marzi priate algorithms. This should be reflected in disaster training. Department Of Trauma Surgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany 42 Background: The ATLS concept is used worldwide for medical Stress Influence On Specialist Performance During treatment of traumatized patients. In 2002, the workshop emergency Operation on a Laparoscopic VR-Simulator – medicine of the DGU (German society for trauma surgery) trans- lated the TEAM-concept (trauma evaluation and management) in Impact on Training and Education order to have a standardized programme in the education of emer- J. Beardi, E. Gercek, F. Hartmann, P. Rommens gency medicine. As part of the undergraduate education, the TEAM Universityhospital Mainz, Germany programme covers not only training of algorithms (ABCD’s), but Purpose: In simulation medicine score systems and expert levels are also practical and social skills. This work seeks to determine weather developed and used for evaluation of surgical skills. We performed TEAM-training has an impact on student’s performance of trauma this study to examine the influence of stress on the outcome of patients’ therapy and management by using the objective structured experienced surgeons. clinical examination (OSCE). Methods: At the congress of the german society of surgery we enclosed Methods: As part of their training, all medical students in Frankfurt 10 experienced laparoscopic surgeons with a minimum of 10 years participate in a two day ACLS-training. A modified training inte- practice in laparoscopic surgery. Subjects performed testing tasks on a grates the TEAM-training into this course. 22 students with modified laparoscopic virtual reality simulator (Immersion Corporation, San training and 22 students with standard training participated on a Jose, California, USA).The setting was build up in a surgical labora- voluntary basis in a 10-station OSCE, including a trauma scenario. tory. Stress was induced through a noisy environment and a minimum Correct adherence to the algorithm was assessed via checklist. Psy- of ten adjacent observers. Three different tasks were chosen and sub- chomotor skills were evaluated via global rating. ject were randomised to one task. Each task was performed with 10 Results: In the checklist rating, students with standard training iterations. The performance was evaluated through defined expert reached 12,1 points + 3,1 SD out of a maximum of 25 points. Stu- levels. dents with TEAM-training achieved 20,0 + 3,0. In the global rating Results: Under induced stress none of the subjects reached the cut- on a 5-point Lickert scale (1=very good, 5=unsatisfactory) students off level of overall performance. Overall performance ranged from with TEAM-training obtained 1,9 + 0,7, whereas students without 20% to 80%. In some sub measurements the cut-off level was TEAM gained 3,6 + 0,9. reached, but we saw no significant results. Regarding the individual Conclusion: In conclusion, TEAM training does not only result in learning curves of every individual subject after ten iterations, no better adherence of algorithms, but also in accretion of competence steady learning curve was recorded in comparison to normal learning in practical and social skills in treatment and management of trau- curves, which were detected without stress induction. matized patients. Conclusion: Stress induction leads to reduced performance levels. Although all subjects had high experience in clinical laparoscopy, 41 none of the subjects reached the expert levels. Special stress sce- Didactic Aspects of Disaster Training the Achilles’ narios and score systems are necessary developments for surgical Heel in Disaster Education education and training, even if subject had high experiences in clinic. P. Kemetzhofer, H. Edelbauer, M. Mousavi SMZ Ost Unfallchirurgie, Vienna, Austria 43 To train on ‘‘disaster care’’ means to forecast an unpredictable situa- Emergency Medicine in The Undergraduate tion. Therefore we use indirect approaches in didactic training, such as Medical Education: Curriculum and Assessment rules of human behaviour and identification of sources of error. The M. Ru¨sseler, M. Weinlich, F. Walcher, I. Marzi training concentrates on leadership and management. Group dynam- Department of Trauma Surgery, Johann Wolfgang Goethe-Univer- ics of both ‘‘wounded and knight’’ must be taken into account. Risky sity, Frankfurt am Main, Germany shifts, where the group holds a more extreme view than the individual, do influence decision, which is taken on the field and the trauma leader Background: In 2003 emergency medicine became an autonomous has to be prepared for it. The three base errors are lack of appropriate cross section speciality in undergraduate medical education. Thereby, skill, rule and knowledge. The repeating of training and learning of the obligation of students’ performance records for all undergraduate emergency and the complete trauma surgery, infection control and subjects was enacted. This works presents the first results with the other aspects (e.g. burns, sepsis, paediatrics and geriatrics) improves new curriculum, moreover a study of practicability of a 10-station- on-scene work flow. A possible description of Incident Command OSCE (objective structured clinical examination) as assessment tool System (ICS) is ‘‘a set of personnel, policies, procedures, facilities and in emergency medicine.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 15 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Work done: The students attend a longitudinal structured education established by the Trauma Group at the Faculty of Medicine at UAE program starting with theoretical and practical sessions of medical University at May 2004 aiming to introduce doctors who have limited first aid, followed by interdisciplinary lectures covering all fields of knowledge of ultrasound to the basics of FAST. This presentation aims emergency medicine. After passing a written examination, they ob- to summarize the performance of the Trauma Group in this area and tain an basic life support as well as an extended advanced cardiadic modifications of the course. Five courses have been run since the life support course. Besides, they participate in three shifts on establishment of this course. 106 doctors have had hands on training on ambulance vehicles supervised by emergency physicians and teaching the use of FAST. A median range of 20 (18–29) participants were paramedics. 45 voluntary students participated in the Pilot-OSCE. trained in each course. The majority were from Al-Ain city (56) fol- They had to solve 6 complete emergency cases, as well as four skill lowed by Abu Dhabi (26) and Dubai (12). The participants were senior stations. Students were evaluated via checklist and global rating. registrars (78), residents (22) and consultants (6). The majority were Results: 70% of 481the participating students rated the overall pro- emergency physicians (64) followed by surgeons (22). The practical gram as excellent, 30% as good. 97% judged the program as expe- sessions were increased from 3 to five stations to accommodate the dient preparation for their future medical occupation. The OSCE was recent advances in the literature. This included teaching the 6 Points rated as excellent by 76% and as good by 24%. All students judged FAST and use of ultrasound in disaster and prehospital settings. the OSCE to test relevant aspects of medical practice. Gained experience have made this course more focussed and smooth Conclusion: The implementation of the longitudinal structured edu- reaching its objectives, increased the harmony and interdisciplinary cation program for the cross section speciality emergency medicine collaboration in the clinical setting, and gave the candidates a better resulted in very positive evaluations. The OSCE offers an adequate chance of practical skills. We have noticed the increasing support and option to assess practical skills acquired in the cross section speciality popularity for using FAST in the clinical practice in our setting. The emergency medicine, although it is time and manpower consuming. course has recently received international recognition as it was run as part of the 7th European Congress of Trauma and Emergency Surgery. 44 Development of a Training Program Including 46 Periodical Laparoscopic Training on a Virtual Riskmanagement and Emergency Room Procedures Reality Simulator D. Bo¨ckmann, P. Kemetzhofer, H. Zaoral, M. Mousavi J. Beardi, E. Gercek, F. Hartmann, P. Rommens SMZ Ost Unfallchirurgie, Vienna, Austria Universityhospital Mainz, Germany Patient safety and the quality of care are becoming an important issue Purpose: Novices in laparoscopic surgery often suffer of a lack of in the past years. Medical errors are common with more than 70 per- training and experience in operating and even assisting laparoscopic cent being preventable.. Historically medical staff tend to play down operations. We developed a training programm on a virtual reality the effects of stress and fatigue, substantial pressure exists to cover up laparoscopic Simulator (Immersion Corporation, San Jose, Califor- mistakes. Error is difficult to discuss in medicine and not all staff accept nia, USA) to determine if surgical novices canbe brought up rapidly personal susceptility to error. The traditional approach has been to to a level of a third year intern by periodical simulator training. emphasize personal responsibility, autonomy and accountability. This Methods: A group of 30 medical students after finishing their rotation approach is reinforced by human nature which seeks someone to in surgery was trained on a VR-Simulator starting in four basic lap- blame or someone to pay. There is no need for a culture of blame. A aroscopic tasks, four advanced laparoscopic tasks and finally the fundamental different approach derived from extensive experience in clipping and dissection procedure of the cyst duct and the cystic high risk industries (aviation, nuclear power plants, space programs, artery during cholecystectomy have to be done in three increasing military)is discussed, e.g. High Reliability Organisations (HRO). Ev- levels of difficulty. A second group of 12 experienced interns was ery system is designed to produce exactly the results it gets. Change the build and their performance of the same tasks was recorded. system, not change the people! It is important to create a culture that Results: After a period of 6 weeks training none of the subjects in the deals effectively with errors. The approach is to deal with errors non- student group reached the results of the intern group in overall punitively. Errors always occur and reported errors are an opportunity performance. After the end of 4 months of periodical training 10 of to learn. Research in HRO´ s proved the benefit of a systemic approach. 12 followed up subjects in the student group reached the results of Individuals can be trained to recognise stress as an error inducer by the intern group in all performed tasks. crew resource management training. There is a clear relationship be- Conclusion: A periodically performed training programm including tween perception of teamwork and status in the team. Teaching superb standard resident and staff directed instructions can bring up surgical clinical skills to individuals does not guaranty effective team perfor- novices to a level of third year interns with a minimum duration of 4 mance in critical medical situations. A ‘‘new’’ approach to error with months. systematic solutions and fact finding will be presented.

45 47 A Practical Fast Course Research Facilities on Field Operational Medicine F. Abu-Zidan1, J. Czechowski2, P. Corr1, E. Kazzam1 1Trauma Group, Faculty of Medicine and Health Sciences, in The French Armed Forces Health Service UAE University L. Bourdon, J. Risso, T. Fusai, A. Bry, D. Lagarde, J. Menu 2Department of Radiolgy, Al-Ain Hospital, Saudi Arabia I.M.N.S.S.A., Toulon Arme´es, France

Focused Assessment Sonography for Trauma (FAST) is useful for In France, the military forces Health Service (MFHS) is common screening multiple trauma patients. A full day FAST Course was to the four military forces ; it comprises ﬁve components : i) unit’s

16 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

medical service, ii) military hospitals, iii) medical supply, iv) 49 medical academy and school for formation of medical officers and Emergency Department Triage and Trauma Team nurses and v) research. The four MFHS research institutes are devoted to missions of both formation and research; they share Activation strong relationships in a federation in order to emphasize ex- M. Kalemoglu changes among the scientists and optimize utilization of big GATA Haydarpasa Teaching Hospital,Istanbul, Turkey equipments. Research projects carried out in the research institutes are annually studied and proposed to the MFHS staff in 8 major Objective: Criteria for trauma team activation are continually being fields (operational research program, ORP). ORP1 ‘field opera- evaluated to ensure proper use of resources. The purpose was to tional medicine’ comprises the research activities of telemedicine study the effects of supertriage on injury severity and disposition by and field and en-route critical care medicine. However, no facility patients managed with and without team activation. are specifically devoted to this last domain. It was recently decided Methods: After a retrospective review of medical records and trauma to create such a structure which will be a component of the re- registry, a study on Trauma Level I trauma center was performed. search institute located in Toulon, close to the Military hospital Observational study of consecutive patients transported for alert ‘Ste-Anne’ and the Military Nurse School. An initial 3 Me budget consideration undergoing supertriage by a trauma nurse. Chart re- has already been announced for it which would open in 2009. It view was performed for disposition and Injury Severity Score. Con- will be equipped to provide full facility for studying brain-medulla tingency table or t test with pU+00AlU¨ 0.05 was used for data analysis. traumatic injury, hemorrhagic shock and ballistic injuries (rear Results: Resuscitation time was short. Analysis by mechanism of effects of bullet-proof garments, etc). Aside its research mission, injury demonstrates that this was true for blunt trauma (28 U+00AlA´ this structure will be used for practical formation in critical care 11 minutes) and for penetrating trauma (23 U+00AlA´ 15 minutes). medicine and operational active telemedicine for medical officers Three hundred eighty patients were screened; 72% of the 53 with and nurses. International cooperation will be encouraged in order positive supertriage and team activation needed the operating room to share in real time the teaching from recent conflicts with in 24 hours or the intensive care unit versus 45% of cases with neg- medical community. ative supertriage managed in the ED and admitted (p = 0.02). Of the 70 admitted ED patients, 20 required the operating room and twelve required the intensive care unit. Conclusions: The presence of a trauma surgeon on the trauma team 48 reduced resuscitation time and reduced time to incision for emergent operations Supertriage identified a majority requiring team activa- Advanced Trauma Life Support Courses tion; however, resources must be available for the seriously injured in The United Arab Emirates not meeting field or hospital triage criteria. Attending trauma sur- F. Abu-Zidan1, F. Branicki1, F. Torab1, F. Albarracin2, geon presence on the trauma team improves in-hospital trauma S. Gautam2 system function without affecting patient outcome. 1Trauma Group, Faculty Of Medicine, UAE University 2ATLS UAE Chapter, Saudi Arabia Preclinical Trauma Care and the First 24 Hours

It was important to train UAE doctors using ATLS principles to in Polytrauma improve the management of trauma patients. Inaugural back to back Provider and Instructor ATLS courses were held in Al-Ain in April 2004. This stemmed from joint efforts of the American 50 College of Surgeons, The Trauma Committee of the Surgical Dispatch Criteria for Helicopter Mobile Medical Advisory Committee of UAE and the Faculty of Medicine and Teams – An Overview of Literature Health Sciences, UAE University. 312 doctors have taken the A. Ringburg, G. De Ronde, E. Van Lieshout, P. Patka, Provider Course of whom 145 were surgeons. A median range of I. Schipper 20 (12–24) participants were trained in each course. 10/312 (3.2%) Erasmus MC, Department of Surgery-Traumatology, Rotterdam, were required to retake the whole course because they could not The Netherlands pass the Initial Assessment and Management station. This was attributed to lack of prior preparation, neglecting basic ATLS te- Introduction: The application of a dispatch protocol for pre-hospital nets, and relying on one’s own practice rather than ATLS princi- assistance by Helicopter Emergency Medical Services (HEMS) is not ples. Another 51 needed to resit the MCQ paper. Reasons for established in all European countries. Dispatch criteria may be un- failing the MCQ included inadequate study of the manual prior to clear, impractical, or lack sensitivity or speciﬁcity. This study aimed the course, difﬁculties with English language medical terminology to generate an overview of dispatch criteria used worldwide, and to as well as lack of experience of some junior doctors. The overall assess their degree of validation. success rate of the ATLS Provider course was 251/312 (80.5%). 27 Methods: Seven literature databases were searched using the key- successful candidates have already successfully completed an words: ‘‘air ambulance’’, ‘‘air medical’’, ‘‘aeromedical’’, ‘‘criteria’’, Instructor course. This course in now been taught in three centres. ‘‘dispatch’’, ‘‘emergency medical services’’, ‘‘helicopter’’, ‘‘stan- In total 21 instructors taught a total of 17 provider courses to date. dards’’, ‘‘triage’’, and ‘‘utilization’’. Only papers describing validity of We have been encouraged by increasing support and popularity of HEMS dispatch criteria, written in English and published in peer- ATLS in the UAE. A great awareness of the value of ATLS reviewed journals were considered eligible. enhancement of the early management of severe trauma is more Results: Thirty-seven publications were used; all were level III or IV evident in our setting. studies. Fifty-one HEMS dispatch criteria were mentioned. Most of

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 17 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

these are identical to or deviated from the criteria for field triage to a care. The only mandatory training is a short course in emergency level one trauma center (American College of Surgeons). Sensitivity medicine of about 60–80 hours. Most of the required diagnostic and of individual criteria has hardly been studied. Groupwise, dispatch therapeutic techniques must be part of the physicians´ training during criteria related to mechanism of injury are sensitive but lack speci- internship or residency and are not taught in the course. The aim of this ficity, which may result in unnecessary HEMS dispatch. The group of retrospective study was to detect differences in the prehospital treat- criteria related to type of injury is fairly sensitive, but connected to ment of emergency patients according to the physicians´ disciplines. unknown specificity. Dispatch criteria related to vital signs and Methods: We evaluated the frequency of prehospital interventions neurology are specific, but lack sensitivity. This leads to under triage, (Endotracheal intubation, ECG-monitoring, pulse oxymetry, cap- refraining 50% of severely injured patients from HEMS assistance. nometry, chest tube, central venous access, laboratory tests (blood Conclusion: Optimal use of HEMS is largely influenced by sensitivity gas analysis, haematocrit, electrolytes, lactate), arterial line and the and specificity of dispatch criteria. Worldwide, similar criteria with prehospital treatment time) and compared it to the discipline of the low levels of evidence are in use. Validation of individual criteria is attending emergency physician. mostly lacking. Only groups of criteria have been investigated. Results: During the observation period of 9 years data from 5 920 patients (39,6% female and 60,4% male) were obtained. Anaesthe- siologists most frequently used the diagnostic or therapeutic proce- 51 dures listed above, followed by surgeons. Internists applied distinctly Correlation of External Factors with Incidence and fewer of the interventions, whereas specific techniques from intensive Outcome of Severe Trauma care (central venous access, arterial line, laboratory testings) now R. Lefering1, G. Pietzner2, D. Rixen3, E. Neugebauer1 available on-the-scene were nearly exclusively performed by anaes- 1IFOM, University Witten/Herdecke, Cologne, Germany thesiologists. Due to the small number of cases, there was no dif- 2Faculty of Management & Economics, University Witten/Herdecke, ference in application of a chest tube (n = 10). Witten, Germany Conclusions: In our study prehospital emergency care seems to 3Department of Traumatology, University Hospital Cologne-Mer- depend on the physician´ s discipline. Physicians with a more specific heim, Germany education and higher experience in trauma care act more invasively at the scene too. Incidence and outcome of polytrauma depends on multiple factors. However, external factors like time, day, season, moon, or weather are seldom investigated. The present study evaluates these correla- 53 tions using the DGU Trauma Registry. Methods: 10,737 patients from the Registry fulfilled the criteria: First Experiences and Future Aims with a New primary admission, German hospital, 1995–2004, ISS > = 9, and Electronic Emergency Medical Care Documentation sufficient data for the RISC score. Subgroups were formed according System in Graz to the external factors, and observed hospital mortality was com- G. Wildner, J. Kainz, G. Gemes, G. Prause pared with RISC prognosis using SMRs with confidence intervals. Department Of Anesthesiology And Intensive Care Medicine, Mean age was 40.4 years; 73% were males; ISS was 26.1, and Results: Medical University Graz, Austria hospital mortality rate 17.6%. During the day, highest admission rates were observed at 6–7 PM which was 5.3 times higher than at night. but From November 2006 to January 2007, a new documentation system SMRs were similar (0.98 – 1.00). Saturdays showed slightly increased called ‘‘MEDEA’’, developed by Carinthian company ‘‘Ilogs’’ to- admission rates but SMRs for days of week did not differ significantly. gether with the Carinthian technical college, has been tested by the Admission rates in June and July was about twice as high as in emergency physician system based at the Graz University hospital. December, mainly due to motor bike riders. Again, SMR did not differ We present our first experiences with the system and future aims. due to season (range 0.98 – 1.00). Incidence of severe trauma was not ‘‘MEDEA’’ is a laptop-based documentation system connected to a increased during full moon periods, neither did SMR show a differ- central server via GPRS. Employment Data by the rescue dispatch ence. Cases admitted on days with low average temperature showed center is received automatically, patients data and documentation higher mortality rates (21.5% versus 17.4%), although ISS was similar. can be entered using a integrated e-card reader and a touch screen or However, the prognoses show similar values (21.1% versus 17.6%). keyboard. The program was adapted to fit the currently used emer- Conclusion: Some external factors like time of day or month of year gency documentation in Styria. The documentation sheet can be have substantial influence on trauma incidence. However, adjusted printed with a Bluetooth printer or every printer connected to a local for severity on admission, none of these factors demonstrated a network, also ahead of arrival. The ‘‘MEDEA’’ system was well remarkable influence on outcome. accepted by the majority of physicians. The small laptop is easy to use and highly robust. With some practice, documentation does not 52 take any longer than with usual means. Printing layouts were adapted Differences in Prehospital Emergency Treatment of several times and are concise. Improvements should concern GPRS connection, operating time of the rechargeable battery and some Trauma Patients– Comparing Anaesthesiologists, smaller items. Company support was very good. In future the system Internists and Surgeons will allow sending information to emergency departments in advance G. Prause, G. Gemes, G. Wildner, J. Kaniz to patient’s arrival; using appropriate interfaces, monitor data can be Department of Anaesthesiology and Intensive Care, Medical Uni- implemented automatically and also processed for telemetry; statis- versity of Graz, Graz, Austria tical usability for scientific purposes as well as for quality control will increase significantly. With further efforts by developers and users, Objective: In Austria, anaesthesiologists, internists, surgeons and ‘‘MEDEA’’ could become quite a milestone in pre-hospital emer- general practitioners work as emergency physicians in prehospital gency care documentation.

18 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

54 different European trauma centers. The data of included patients Prehospital Interventions: Time Wasted were evaluated regarding time to hospital and influence of transportation service on lethality of polytraumatized patients. 7534 or Time saved? An Observational Cohort Study patients (HEMS: 3870, ground ambulance (NEF): 3664) were in- of Management in Initial Trauma Care cluded. There were 74.9% male patients in the HEMS group, and A. Ringburg1, M. Van der Velden1, E. Steyerberg2, P. Patka1, 71.3% male patients in the NEF group. The mean ISS was higher I. Schipper1 in the HEMS group (HEMS: 31.4, NEF: 30.7; p < 0.01); patients 1Erasmus Mc, Dept. of Surgery-Traumatology, Rotterdam, transported by NEF were older (HEMS: 39.2 vs. NEF: 41.3; The Netherlands p < 0.01). The ground ambulance arrived earlier on scene (NEF: 2Erasmus MC, Dept. of Public Health, Rotterdam, The Netherlands 14:33, HEMS: 18:18 min; p < 0.01) while the HEMS remained longer on scene (HEMS: 26:26 min; NEF: 22:29 min; p < 0.01). Objective: Preclinical actions in the primary assessment of trauma Evaluation of the TRISS prediction of survival showed benefit in victims may prolong the time to definitive clinical care. This study patients transported with HEMS. In a multivariate analysis intu- aimed to analyze interventions and timing within the initial trauma bated patients with ISS>16 had a lower lethality rate if transported care. It also investigated effects of on-scene time (OST) and per- with HEMS (NEF: 40.1%; HEMS 34.9%; p < 0.01). The aim of this formed prehospital interventions on hospital resuscitation time and study was to evaluate the influence of transportation mode on in-hospital interventions. survival in polytraumatized patients using the German Trauma Methods: 147 high-energy blunt trauma patients were studied pro- Registry. According to our analysis of the German Trauma spectively. Prehospital time intervals and interventions were docu- Registry, patients with multiple injuries benefit from HEMS mented and compared with hospital data, collected from continuous transportation. video registration. Analyses were performed with correction for injury severity and type of prehospital medical assistance (Emergency Medical Services (EMS) versus physician staffed Helicopter EMS (HEMS)). 56 Results: Clinical primary survey and treatment were completed The Frequency of Acute Post-Traumatic within 1h after arrival of the first EMS at the accident scene. Eighty-three percent of this ‘golden hour’ elapsed out-of-hospital. Coagulopathy: A Retrospective Analysis Eighty-one percent (n = 224) of all interventions were performed on 8.724 Patients from the German Trauma prehospitally. Increased numbers of prehospital interventions were Registry associated with increased OSTs (p < 0.001). Subanalyses showed no M. Maegele1, R. Lefering2, E. Neugebauer2, B. Bouillon1 such association in the HEMS-group. The HEMS-assisted group 1Cologne-Merheim Medical Center (CMMC) showed a longer mean OST (p < 0.001) and a shorter in-hospital 2Institute for Research in Operative Medicine (IFOM), Cologne, primary survey. Prehospital intubation (p = 0.05), chest tube place- Germany ment (p = 0.005) and second intravenous line insertion (p = 0.001) were associated with significantly increased OSTs. Overall OST and prehospital intervention numbers showed no relation with in-hospital There is increasing evidence for acute post-traumatic coagulopathy primary survey time and numbers of intervention. to occur prior to emergency room (ER) admission but detailed Conclusion: Prehospital treatment consumes 83% of the golden hour. information is lacking. The objective of the present study was to HEMS involvement will enhance the number of prehospital inter- evaluate the frequency of acute post-traumatic coagulopathy upon ventions, but is not associated with increased OST. Although the ER admission in patients with multiple injury. A retrospective number of subsequently in-hospital performed interventions may be analysis using the German Trauma Registry database including lower, in-hospital time gain is not expected. 17.200 multiple injured patients was conducted to determine to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated with impaired outcome and mortality. 8.724 patients with 55 complete data sets were screened. Coagulopathy upon ER admis- Influence of Transportation Mode on Lethality sion was present in 2.989 (34.2%) of all patients. Males were more affected than females (72.5% vs. 27.5%) and in 96% the trauma in Polytraumatized Patients – an Analysis Based mechanism was blunt. The mean ISS score in the coagulopathy on the German Trauma Registry group was 30 ± 15, while trauma patients without coagulopathy M. Frink1, C. Probst1, F. Hildebrand1, C. Krettek1, H. Pape2 upon ER admission generally presented with lower ISS scores 1Trauma Department, Hannover Medical School, Germany (mean ISS 21 ± 12; p < 0.001). 29% of patients with coagulopathy 2Division of Traumatology, University of Pittsburgh Medical Center, developed multi organ failure (p < 0.001). Early in-hospital mor- USA tality (< 24 hrs) was 13% in patients with coagulopathy (p < 0.001) and overall in-hospital mortality totalled 28% (p < 0.001). There is Thirty years after its introduction the benefit of the helicopter a high frequency of established coagulopathy in multiply injury emergency medical service (HEMS) still remains unclear. The aim upon ER admission. The presence of early traumatic coagulopathy of this study was to evaluate the influence of the helicopter was associated with injury severity and impaired outcome. Sup- transport on rescue time and lethality based on the data of the ported by the a.) the AG Polytrauma of the German Trauma German Trauma Registry. Data of patients with multiple injuries Society (DGU) and b.) the Merheim Coagulation Study Group (ISS>16) were documented prospectively between 1993 and 2003 in (MCSG).

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 19 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

57 countries already use uniform national report forms while in other Missed Fractures in the Multi Trauma Patient countries each region (province, federal state, or canton) uses its own form. This process should lead to a new paper-based report B. Punt1, K. Brown2, E. Caldwell2,S.DA´ mours2, M. Sugrue2 form as well as a software-based emergency report system to in- 1Albert Schweitzer Ziekenhuis crease the quality of care of the patient to the highest possible level. 2Liverpool Hospital Sydney, Australia Keywords - Emergency Response Information Systems, Emergency Patient Care Report Form, medical documentation, emergency Introduction: In trauma the timely detection of all patient injuries is physicians, standardization challenging. Missed fractures may result in significant adverse outcomes for patients and doctors. Aim: The aim of this study is to identify the patient prone to having a missed fracture. Methods: Patients admitted with fractures between 1995 and 2005 59 were retrospectively compared to the patients admitted in the same The Effects of Helicopter Emergency Medical period who had missed fractures. A missed fracture was defined as Services on Survival – an Overview of one diagnosed > 24 hours after admission. Data prospectively col- Two Decades of Literature lected included patient demographics, injury severity score (ISS), 1 2 1 1 glascow coma scale (GCS), mechanism of injury (MOI), trauma team A. Ringburg , E. Steyerberg , D. Den Hartog , P. Patka , I. Schipper1 activation (TTA), type of admission (ICU/Operating Theatre or 1 ward) and intoxication. Erasmus MC, Department of Surgery-Traumatology, Rotterdam, The Netherlands Results: In the 11 years, of the 10065 admitted patients, 6920 had a 2 fracture (68.8%), and 236 (3.4%) were diagnosed after 24 hours. Erasmus MC, Department of Public Health, Rotterdam, The There was no difference in GCS or ISS between patients with or Netherlands without missed fractures (13.6 vs 14.0, p = 0.06; 13.2 vs 12.2, p = 0.12 respectively). Patients with a missed fracture were more Objective: The effectiveness of Helicopter Emergency Medical Ser- often admitted to the ICU or Operating Theatre (OT) than patients vices (HEMS) is a frequently debated subject. This study provides an without a missed fracture (41.5% vs 29.7%, p = 0.0001). There were overview of literature about the effect of Helicopter Mobile Medical more trauma team activations in the missed fracture population Teams on survival, using international data as well as national and compared to the no missed fracture population (76.7% vs 64.7%, regional data from the Netherlands. p = 0.0001). Methods: A Pubmed-Medline search for international and national Conclusion: This study identified that missed # occurred in 3.4 % of literature between 1985 and 2004 was performed. Manuscripts had to our population. Patients following TTA and ICU/OT admission are be written in English, and had to describe effects of HEMS on survival. significantly more prone to have a delay in the diagnosis of a fracture. Both physician staffed and non-physician staffed HEMS organizations This calls for a refinement of the tertiary survey in these patients. were included. Moreover, analysis regarding increased chances of survival had to be performed using adequate adjustment for differences between the compared groups. In addition to the literature 58 search, the effect of HEMS on the reduction of mortality in polytraumatized patients between October 2000 and 2002 was analyzed for A Proposal for the Establishment of a Standardised the South-West Netherlands. The number of lifes saved upon HEMS European Emergency Report form assistance was calculated using logistic regression analysis. F. Waldher1, K. Pessenbacher2, J. Thierry3, C. Hafner3, S. Grasser3 Results: National and international literature indicated that HEMS 1ILogs Mobile Software GmbH, Klagenfurt, Austria assistance increased the chance of survival compared with when a 2Amt Der Steierma¨rkischen Landesregierung, Austria similarly injured patient was treated by EMS alone. Between 1.1 and 3Carinthia University Of Applied Sciences, Klagenfurt, Austria 12.1 additional survivors were recorded for every 100 HEMS dis- patches. Logistic regression analysis of data from South West Neth- The improvement of quality assurance in medical emergency sys- erlands revealed 8.4 additional survivors for every 100 (physician tems is an important goal of public health care institutions. A major staffed) HEMS treated patients. Overall, a potential total reduction step to achieve this goal is the complete documentation of emer- of mortality of 25 percent was estimated. gency situations. Because of the increasing amount of documenta- Conclusion: International and national literature suggest a clear tion data, the use of electronic systems and software-based report positive effect on survival associated with HEMS assistance. This forms is inevitable. Furthermore, the homogenisation of the docu- is in accordance with data from the South West area of the mentation data is also a very important factor to reach a certain Netherlands. level of standardisation across Europe. This presentation deals with European patient report forms used by emergency physicians and paramedics to document their responses to emergencies. Approxi- 60 mately 50 patient reports were collected from emergency services, regional and supra-regional federations and ministries from 23 Mobile Medical Emergency Documentation – countries from all over Europe. The collected patient report forms Overview and First Experiences were evaluated, compared to one another and centralised in a re- J. Thierry2, G. Prause1, C. Hafner2, S. Grasser2 port form database. Graphical elements such as charts and dia- 1Medical University Graz, Austria grams, representation of injuries and accident mechanics were 2Caritnhia University Applied Sciences, Klagenfurt, Austria evaluated separately from the rest of the form. A standardization of the symbols used in the forms is proposed and there are ongoing Emergency response documentation systems in Austria - as pre- endeavours to establish a European report form standard. Some sumably in most parts of the world - are still largely paper based

20 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

(Emergency Patient Care Report Form - EPCRF). The information 62 collected within these forms is reported back to the dispatching Factors Affecting Mortality in Motor Vehicle hospital, where it is received together with the patients at the emergency department. Obviously, immediate electronic transmis- Collisions in AL-AIN City 1 1 1 1 1 sion of patient data and diagnoses would place the receiving insti- F. Abu-Zidan , H. Eid , S. Adam , F. Torab , K. Lunsjo 1 tution into a more favorable position, since admission of the expected Trauma Group, Faculty of Medicine, UAE University, patients could be much better prepared in advance. The research Saudi Arabia project CANIS (Carinthian Notarzt3 Information System) reflects this problem as it aims to develop an electronic EPCRF and to Objectives: To define factors that affect the outcome of hospitalized establish and optimize a wireless and bi-directional information trauma patients following motor vehicle collisions. stream between the emergency physician at the accident site and the Methods: Data of the Trauma Registry of Al-Ain Hospital were receiving hospital. The remote clients employed within the project collected prospectively over 3 years (2003–2006). Patients who were comprise of rugged Tablet PCs as well as smaller, handier Personal injured by motor vehicle collisions were studied. Demography of Digital Assistants (PDAs), and possibly even a combination of both patients, mechanism of injury, systolic blood pressure on admission, in order to optimally support the user in any potential medical Glasgow Coma Scale (GCS), Injury Severity Scores (ISS), and emergency scenario. In addition to the standard touch screen, both mortality as outcome were analysed. device categories can be equipped with either voice recognition Results: There were 1070 patients (956 males and 114 females). Mean software - in order to enable the emergency physician to perform (range) age was 31.1 (3 months-80 years). 26% were UAE nationals. medical treatments and data entry simultaneously - or with a digital 143 (13%) patients needed ICU admission, of them 17 (12%) died. pen for manual form-based data input. CANIS has been successfully Mean (range) ICU stay was 4.4 (1–35) days. Overall mortality was introduced in a real testing environment in Graz (Austria), and the 4.1%. A direct logistic regression model showed that the significant first results show a high user acceptance due to its user-friendly factors that affected mortality were GCS (P < 0.001), ISS (P < 0.01) handling and reliable performance. and low systolic blood pressure on admission (P < 0.03). Conclusions: Head injury is a major factor that affects outcome followed by anatomical injury severity and hypotension. 61 The Epidemiology of Trauma Deaths: 63 The Australian Contex Z. Balogh, J. Evans, K. King, D. McDougall Shockroom Management Including MSCT Trauma Service, John Hunter Hospital, University Of Newcastle, in Polytraumatized Patients Australia H. Neugebauer, G. Frohnhoefer Trauma Hospital Graz West, Austria Background: In view of the aging populations and the potential changes in injury mechanism, the purpose of this study was to pro- Objectives Management of polytrauma patients in the resuscitating spectively re-evaluate the epidemiology of trauma deaths with area is still challenging. The aims of this study is to reveal a significant comparing high-energy (HE) and low-energy (LE) deaths. shortage of patient’s shock room stay by including MSCT into pri- Methods: All pre and in-hospital trauma deaths occurred in a trauma mary survey. Furthermore aquired data can be used for CT recon- system during 2005 had autopsy. Deaths were categorized based on struction. mechanism, timeframes (Prehospital, < 48hrs, 2–7 days and >7 days) Methods: From 09/2002 until 12/2006 a number of 166 polytrauma- and causes [central nervous system (CNS), exsanguination, tized patients (ISS 20 and more)underwent MSCT. During the pri- CNS + exsanguination, airway, multiple organ failure (MOF)]. Data mary phase(ALPHA) rapid traumatological eval was performed are presented as % or Mean + /–SEM. according ATLS. The second phase (BRAVO) included FAST, x-ray Results: 175 deaths were evaluated. The 103 HE fatalities’ of the thorax (exclusion of a tensiontorax) and MSCT but only in (Age = 43+/–2, ISS = 49+/–2, Male 63%) mechanisms were MVA- hemodynamically stable patients. Finally during further phases related (72%), falls (4%), gunshots (8%), stabs (6%) and burns additional X-rays were performed. (5%). Sixty-six % died during the prehospital phase, 27% <48hours Results: All above mentioned patients were identified from a trauma in hospital, 5% between 3–7 days and 2% >7 days. CNS (33%) and registry of a Level II trauma center and data were reviewed for exsanguination (33%) were the most common causes of deaths fol- demographics, type of injury, and outcome. The medium stay in lowed by CNS + exsanguination (17%), airway compromise 8%, phase A and B was 8 minutes and MSCT scanning time including the MOF was only 3%. All LE deaths (n = 72, age = 83+/–1, change of arms was 50 seconds. During transfer of the patients to ISS = 14+/–1, Male 45%) had low-falls. All LE patients died in ICU or OR all required data were collected and secondary calcula- hospital (20% <48hours, 32% between 3–7 days and 48% after 7 tions including multiplanar reconstruction followed. Finally all data days) caused by head injury (26%) and complications of skeletal were transposed to all PACS stations. injuries (74%). Conclusion: The first step of shockroom management in polytrau- Conclusion: Compared to the seminal reports the HE injury matized patients is maintaining vital functions and performing x-ray mechanisms, timeframes and causes are different. The classic tri- of the thorax and ultrasound of the torso. in hemostable patients modal death distribution is more skewed to early deaths. Exsan- MSCT follows as a clearly structured and standardized investigation guinations became as frequent as lethal head injuries, the leading to a significant shortage of exam time. Secondary CT incidence of fatal MOF is lower than earlier. LE trauma is reconstructions can be obtained at any time. The presentation will responsible for 41% of the postinjury mortality with distinct illustrate our stepwise procedure including technical features of epidemiology. MSCT.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 21 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

64 patients had difference between clinical and autopsy ISS value. Risk Taking and Driving Attidude – a Questionnaire Dominant injured was head in 10 (47.6%), thorax in 7 (33.3%), abdomen in 3 (14.3%) and extremities in 1 (4.8%) patient. Eight Study Amongst Young Drivers in Vietnam patients (38.1%) have 2, ten (47.6%) have 3 and three patients 1 1 2 3 1 U. Schmucker , D. Stengel , L. Hien , L. Bogar , G. Matthes (14.3%) had 4 organ systems injured. 1 Ernst-Moritz-Arndt-University, Department Trauma and Orthope- Conclusions: Analyze of mortality is one of the most important dic Surgery, Greifswald, Germany methods for collecting epidemiology data and recognition the 2 Thai Binh Medical University, Trauma and Orthopedic Surgery, weaknesses in system of trauma care. Severity and mechanism of Thai Binh, Vietnam injury, age, gender, number of missed injuries, localization and 3 University of Pecs, Department Anesthesia and Intensive Care, combinations of injuries, are important outcome factors. Pecs, Hungary

Introduction: In Vietnam, growing motorization leads to a dramatic 66 increase of traffic accident victims. Nevertheless data on road traffic One Year of Severe Polytrauma: Where We Stand? accidents and drivers behaviour is not available. Therefore we gen- F. Iordache, M. Beuran, B. Martian, O. Rosu, D. Surdeanu erated a basic data set. Bucharest Emergency Hospital, Romania Methods: A questionnaire was distributed to 1000 students in Thai Binh, Vietnam (appr.100000 inhabitants). We analyzed demographic Background: Polytrauma patients represent an important category of factors, use of different vehicles, risk behaviour in road traffic. Fur- Bucharest Emergency Hospital activity. The most severe cases of thermore, attidude toward risky situations was investigated. This trauma are referred to our center. Still, the outcome of our patients study is part of a European Union co-financed cooperation project of can be improved. European and Vietnamese Universities (SAVE). Aims: To evaluate the experience of a large trauma center regarding Results: Depending on specific items, 767 – 1000 questionnaires were the most severe polytrauma patients. analyzed. Mean age of study population: 22.1 yrs. [SD 3.4], 55% female. Methods: The charts of the most severe cases of polytrauma patients Distribution of regularly used vehicles: 62% bicycles, 41% motorcy- admitted in 2006 in Bucharest Emergency Hospital were reviewed. cles, 2% passenger cars. A mean of 61.9 km/h was regarded ‘‘High The inclusion criterion was the severity of trauma (ISS over 15). The driving speed’’. Answers given to questions regarding acceptance of admittance situations were evaluated in terms of time, referral from official traffic regulations and laws: traffic rules necessary [‘‘yes’’ 99%], other units. The charts were reviewed for admittance diagnosis, drink and drive [‘‘no’’ 87%], respect traffic signs [‘‘always’’ 93%], use investigations performed, treatment options (surgical, nonsurgical) mobile phone while driving [‘‘never’’ 81%], use motorcycle helmet and results in term of perioperative deaths and complication. [‘‘always’’ 47%]. The following were named important sources of Results: The average age was 39.1 years for the 81 patients in study. information for traffic safety purposes: 73% TV, 46% school. The Injury Severity Score (ISS) was 27 on average. Death rate was Conclusions: Development of prevention strategies necessitates 33% (27 patients) and is correlated with the severity of trauma. reliable data which could be raised in a representative study popu- Conservative treatment for parenchimatous organs injuries was lation. Demographic process requires addressing of countermeasures rarely used in these patients (only 4 cases). The most frequent region to very young and female drivers. Restrictive measures alone seem to involved was the head (37 cases) being the most frequent cause of be not efficient. Here implementation of preventive measures may be death. Also, death correlates very clearly with ISS. a sufficient way to reduce numbers of traffic accident and injury Conclusions: With a mortality surpassing 1/3 of our cases, polytrauma severity. Especially mass media may be used for promotion of pre- poses a continuous defiance for the emergency surgeon. ISS accu- vention strategies. rately predicts death still other factors have to be included. A better prehospital management would have had an important impact in our cases. Conservative treatment can rarely be employed in these severe 65 cases. First 24 h in Polytrauma: an Analyze of Mortality Z. Korac, N. Simic - Korac, M. Mlinac - Lucijanic, V. Stitic General Hospital Karlovac 67 Introduction: Trauma deaths follow a trimodal distribution: imme- 365 Days in an Emergency Service diate, early and late. Patients who die early sometimes have a cor- P. Yazici1, U. Aydin1, A. Uguz1, I. Solak2, A. Moral2 rectable injury. An analyze of various factors influencing on fatal 1Ege University School of Medicine, Department of General Surgery outcome can improve results and treatment. 2Ege University School of Medicine, Emergency Service Depart- Aim: A retrospective analyze of polytrauma fatalities in first 24 h ment, Izmir, Turkey after injury according the medical documentation, including autopsy findings. Patients and methods: We analyzed data for patients who Efficacy depends on well-qualified triage in an emergency depart- died after trauma in thirty months period (January 1st, 2004 – June ment, especially in the populous Centers. We aimed to analyze the all 30th, 2006) in General Hospital Karlovac, Croatia. patients, who were admitted to the emergency in one year period, to Results: We analyzed 21 trauma fatalities, there were 14 (66.6%) check our knowledge about what we are required to do to ensure male and 7 (33.3%) female with a median age of 48.7 years. Most qualified service. Between April 2005 and April 2006, all patients frequent mechanisms of injury were traffic accidents and fall from the who were admitted to the Emergency Service were reviewed. 8540/ height. At addmition median Glasgow Comma Scale was 8.3 (range 65350 cases were admitted due to various types of trauma. 41.2% 3–15). The median ISS in clinical diagnosis was 34.4 (range 17–57) female, 58.8% male were detected with a mean age of 29.1. and in autopsy diagnosis was 42.4 (range 20–57). Twelve (57.1%) Attending time was found between 01:00–08:00 o’clock in 21.3% of

22 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

the patients, between 08:00-16:00 o’clock in 33.2% and between cases that were treated initially as minor injuries and high index of 16:00-24:00 o’clock in %51.2. The etiologies of the trauma were suspicion led to identify serious fractures of cervical spine that re- followed as; minimal injury to different parts of the body 57.2%, quired stabilisation. traffic accident 21.6%, blunt trauma 12.5%, penetrating injury 3.2%, Methods: Two young patients presented to us with vague neck and the others 6.5%. The most of the trauma patients admitted to the pain following minor road traffic accidents. Both patients were emergency in the third part of the day. 84.3% of all cases treated with assessed on site of the accident by paramedics and later treated in out-patient procedure, whereas 10.9% were transferred to associated our minor injuries department as walk-in. Clinical examination clinical department. However, 8.9% observed in the emergency for revealed no neurological deficit but radiologically one patient had several days. The mortality rate in the emergency department was C4/C5 unifacetal dislocation and the other had fracture disloca- 0.27% and 82% was occurred in the third part of the day. The tion of C5/C6 vertebra. Both the cases were then treated by majority of the admitting factors are consisted of minimal injuries stabilisation. which mostly present in the first and second part of the day. Nev- Discussion: We recommend that even in low velocity injuries pre- ertheless, appropriate triage of the acutely traumatized patient hospital cervical spine immobilisation is necessary especially when mostly admitting in the third interval of the day should be the aim or injured patients are complaining of vague symptoms until clinical and policy of the emergency services. radiological evaluation is completed.

68 70 How much Do I Cost Doc? Who Operated on me? Do Patients Really Know E. Prempeh, F. Peart their Doctor? Selly Oak Hospital E. Prempeh, C. Mauffrey University Hospitals Coventry and Warwickshire Introduction: The effect of clinical governance is to continuously improve the quality of health services and safeguard high standards Introduction: EWTD means that doctors have had to reduce the of care. This requires the use of time, facilities and expertise. Regular number of hours they work per week. The reduction of work hours updates show that there is a continuous increase in debt by the NHS. has been resolved by doctors working shift patterns, the implemen- The expense any one patient can incur upon the NHS can be great tation of the ‘hospital at night’ plan and increasing the number of but sometimes unwarranted. doctors working. The detriment of such a situation is the lack of Case: A 49 year old right hand dominant unemployed patient was continuity of care, a reduction of hands on training time, production regularly admitted to a central hospital for similar and repeated of complex shift rotas and a decline in the frequency of consent being injuries to the upper limbs. Other significant history included treated obtained by the surgeon or someone able to perform operation. We depression. Over a three year period this patient had 94, 42 and 71 decided to see whether, and how affected are our patients by this appearances to A&E, outpatient department and plaster room situation. respectively. There were also 48 bed days, 37 radiographs, 7 courses Method: Prospective consecutive series of 100 trauma patients (two of antibiotics and six operations. During this time the patient was days post operative) questioned on the management of their cared for by eleven consultants (a combination of plastic and pathology (including consent, operation and expectations), their orthopaedic surgeons). The patient was then referred to the psychi- knowledge of who the responsible consultant is and who operated on atrist. the patient. Discussion: The total cost of the above as calculated by the accounts Results: This study showed that although patients knew what oper- department totalled approximately twenty two thousand pounds. ation was performed they were unable to recall the name of the After this total was released the patient was referred to the psychi- surgeon who operated (97%) and had difficulty remembering the atrist after which the number of admissions had decreased and hence consultant responsible for their care (80%). The latter occurred de- the expenditure of the NHS. spite having the consultants name written below the generic infor- Conclusion: The surgical specialties should always be aware of the mation posted above the patients’ bed. Patients tended to recall the multidisciplinary management required by patients who may seem a benefits more than the risks of their respective operations. bit ‘difficult’. This would help both to reduce the cost to the NHS and Conclusion: Despite the reduced working hours and change to shift increase the time, facilities and expertise for other patients. patterned rotas, we do believe that the informed consent is being carried out appropriately, however time should be taken to allow patients to get to know their doctor. 69 Should We Immobilise all Patients in Pre Hospital Setting for Cervical Spine Injuries in Low Velocity 71 Accidents? a Report of 2 Cases A Case of Tracheal Rupture Managed by N. Venkatram, M. Bhattacharyya, S. Sakka Prehospital Fiberoptic Intubation Department of orthopaedics, University Hospital Lewisham, G. Gemes, J. Heydar-Fadai, G. Wildner, G. Prause London, U.K. Department Of Anaesthesiology, Medical University of Graz, Graz, Austria Introduction: Cervical spine fractures and dislocations are usually associated with high velocity trauma. Soft tissue injuries /whiplash We present the case of a patient with a severe multiple trauma fol- injuries are more common in low velocity trauma. We report two lowing a traffic accident. After prehospital rapid sequence induction,

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 23 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

tracheal intubation was attempted. Although a clear view of the 73 larynx could be obtained by direct laryngoscopy, the tube could not Improvement of Rescue, Transportation and be advanced even with force. Fiberoptic bronchoscopy performed on the scene revealed a complete rupture and dislocation of the trachea. Medical Care of Polytrauma Patients in a Big The distal stump was identified and the tracheal tube was advanced Trauma Center in Hungary over the bronchoscope. Next, a chest tube was installed, after that B. Ka´da´r, Z. Szabo´, F. Kazacsay adequate ventilation was achieved without a problem. The patient B.A.Z. County Teaching Hospital, Traumatology Center, Miskolc, was transported to a level one trauma center, but died in the emer- Hungary gency room from severe haemorrhagic shock due to intrathoracic and intraabdominal bleeding. Complete traumatic tracheal transsection is Background: BAZ County Teaching University Hospital is one of the rarely encountered in emergency trauma care. Airway management biggest trauma centers in Hungary. It covers an area of 7248 km2 in that case appears to be extremely difficult; available data are with approximately 750.000 inhabitants. In this county there are limited to case descriptions. Fiberoptic intubation is a standard 73km motorways and 362 km highroads. We have 10 hospitals, 20 procedure for the management of the expected difficult airway, its ambulance stations and several medical units. use in emergency care has been described, however controlled trials Aim: During the last 10 years a large series of technical, organisa- to prove its efficacy are lacking. Relevant literature is discussed in the torical and infrastructural modifications happened in the rescue, paper. In summary, there are situations in emergency care where a transportation and primary medical care of the serious injured pa- fiberoptic bronchoscope seems to be only way to establish a secure tients. Our retrospective study has the aim to demonstrate if these airway. In the hands of an experienced operator, it is a powerful tool changes had lead to a significant improvement of the results in the whose widespread use in emergency care would deserve further treatment of these patients. investigation. Material and Methods: We analysed the number of polytrauma patients transported in our trauma department and the number of death in the first 24 hours after the accident in 1996 and in 2006. Results: In 1996 a total of 25 polytrauma patients arrived in our 72 departament. In the first 24 hours 4 patients died.(16%) In 2006 a Secondary Prevention of Fragility Fractures, total of 55 polytrauna patients reached our emergency unit and only a number of 6 patients (10.9%) died in the first 24 hours. A Study of our Practice and Knowledge Discussion: Improving the technical background of the rescue, in a Trauma Centre transportation and primary medical care in the hospital we achieved E. Prempeh, J. Clarkson, T. Lewis, C. Mauffrey a significant improvement of the results. We present the changes, University Hospital Coventry and Warwick which have lead to our better results.

Introduction: The prevalence of hip fractures is expected to triple 74 from 1990 to 2020 in the United States because of an ageing population and suboptimal treatment of fragility fractures. In our study we Monitoring System of the Golden Hour in focused on assessing clinical practice and the knowledge of ortho- Polytrauma Patient in the Emergency Room paedic surgeons on current guidelines. G. Merenyi, I. Zagh, A. Bozsik Method: The study was conducted retrospectively and prospectively Karolyi Sandor Hospital, Budapest, Hungary where we quantified the number of orthopaedic patients discharged on bisphosphonates or referred for a DEXA scan over an eight Introduction: The first hour of the management of a polytrauma month period. Questionnaires were used to check the surgeons’ basic patient (‘‘the golden hour’’) is crucial for survival and for prevention knowledge of secondary prevention of fragility fracture and assessed of severe and long-term disabilities. Aims: Continuous recording the their agreement with starting treatment for osteoporosis and their life parameters of the patient and the therapeutic interventions of the awareness of the NICE guidelines. staff by a multimedia computer system in the emergency room. Results: Over eight months of activity in a busy level 1 trauma Analysing the management, detecting the mistakes and optimizing centre, no patients were started on Biphosphonates or referred the treatment algorithm. for DEXA scans. 56% prescribed Biphosphonates < 1 year ago, Materials and Methods: A computer system records the physiological 31% were aware of guidelines, 9% felt confident to treat osteo- parameters of the patient from monitors in the emergency room. An porosis, 42% thought it right but not have confidence and 49% authorised person detects all emergency procedures (e.g. intubation, referred. insertion of IV lines, thoracocentesis, fluid resuscitation) on line. The Discussion: Women who have suffered a previous fragility fracture patient’s all images of x-ray, CT and ultrasound (PACS) and labo- are at increased risk of further fractures, independent of BMD. Men ratory data are transferred to the system as well. These are filed by an and women aged 65 years or older with a vertebral fracture have a event-orientated framework. Meanwhile if it is necessary treatment five year risk of femur or hip fracture of 6.7% and 13.3% respec- guidelines and protocols can be recalled from databases. tively. NICE concluded that: Bisphosphonates are recommended as Results: The collected data of the first management of the patient can treatment options for the secondary prevention of osteoporotic fra- be analysed according to the occurrence. The emergency staff eval- gility fractures. uates the evens regularly. Conclusion We believe that with persistent education and constant Conclusions: Applying this multimedia computer system in the first reminders and multidisciplinary treatment we could increase the management of polytrauma patient enables us to optimize the treatment of osteoporotic patients who have experience fragility treatment algorithm. After collecting data from other level I trauma fractures. centres it allows to generate a national trauma register.

24 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Trauma Imaging at 25min. ± 0,02). The strict protocol included 4x1mm kallination (50sec.) for head and cervical spine and 16x0,75mm for facial cranium. For thorax, abdomen and pelvis 4x2,5mm kallination (25sec.) and 16x1,5mm (15sec.) was used. After 45 ± 0,02 min. the diagnostic 75 procedure and decision making was completely fulfilled. The stan- Multislice CT in the Multiple Injured Patient-New dardized protocol (Traumawatch) allowed external benchmarking Algorithm with Surprising Results and revealed the encouraging data concerning the time schedule and outcome of our patients. The results not only support the importance P. Weninger, W. Mauritz, H. Hertz of a standardized clinical examination and documentation but also Trauma Hospital Lorenz Boehler, Vienna, Austria the necessity for an algorithm for trauma imaging after severe injury. Introduction: Early management of patients with blunt major trauma represents a challenge for trauma teams. Conventional radiography 77 (CR), diagnostic peritoneal lavage (DPL), focused assessment with sonography for trauma (FAST) and even computed tomography Evaluation of a New Technique for X-Ray dose (CT) have its limitations and, as reported recently, seem to be infe- Reduction in Trauma Surgery –Measurement of rior to multislice computed tomography (MSCT) protocols. Objective and Subjective Parameters Material: Retrospective study comparing 2 cohorts of blunt major A. Paech1, A. Schulz2, L. Simon2, J. Kiene1, M. Wenzl1 trauma patients. The ‘‘CT-scan first’’ cohort (n = 185) had a MSCT 1University Hospital Lu¨ beck, Department of Trauma, Germany prior to resuscitation; the ‘‘resuscitation first’’ cohort (n = 185) had 2BG Trauma Hospital Hamburg, Germany diagnostic procedures (CR, FAST, CT) after resuscitation. All patients had an ISS 3 17 and at least one life threatening injury. TRISS Aim: of this study is to assess objective and subjective changes in analysis was performed, SAPS II was calculated, emergency room image quality of optically re-exposed, radiation-reduced x-ray images (ER) stay, surgery, intensive care unit (ICU) stay, total in-hospital in comparison to a normal reference image and if optical re-exposure stay and survival were evaluated. compensates the loss of information caused by underexposure. Results: The mean (ISS) of the study population (n = 370) was Material + Methods: Anterior shoulders of lambs were used as the 27.1 ± 10.9. Demographic data were comparable in both cohorts. The animal model. After taking a normal exposed reference image, dose- full extent of injuries was definitively diagnosed after 12 ± 9 minutes in reduced, underexposed images were prepared by reducing the mAs 92.4% of the ‘‘CT-scan first’’ patients while definitive diagnosis was product. These underexposed x-rays were then re-exposed for a de- possible after 41 ± 27 minutes in only 76.2% of ‘‘resuscitation first’’ fined period of time. Four different osseous structures were defined patients. Total ER time (, surgical procedures, ICU stay and total in- as regions of interest (ROI) for evaluation of the objective changes in hospital stay were significantly shorter in ‘CT-scan first’’ patients. image quality. The contrast transfer factors as the function of local Discussion: Immediate MSCT in patient with blunt major trauma frequency were determined from this, which served as the basis for leads to more accurate and faster diagnosis. The ‘‘CT-scan first’’ calculating the modulation transfer factor. Subjective changes in algorithm seems to be safe and effective. If followed by adequate image quality in the four ROI were recorded using evaluation sheets fluid resuscitation the administration of contrast medium to patients filled out by 10 experienced traumatologists. in traumatic shock has no negative effects on renal function. Results: In comparison of the different re-exposure times, the technically optimal time was found to be 60 seconds, the objective quality was even better than that of the film in conventional exposure 76 technique. Evaluation of the subjective picture quality as assessed by Algorithm for Trauma Imaging in the Emergency the group of trauma surgeons showed the best picture quality Room (p < 0,05) with a re-exposure time of 60s. M. Maier1, S. Wutzler1, M. Mack2, F. Walcher1, I. Marzi1 Conclusion: Film sensitization provides a technically simple and 1Department of Trauma Surgery inexpensive procedure, which is easily integrated into previous film 2Department of Radiology, Frankfurt am Main, Germany development processes and considerably reduces the patient radiation exposure as well as clearly improving the image quality and thus Severe trauma requires a thorough clinical and apparative exami- detail recognition in trauma radiography. nation of the patient within a short time. The treatment of life threatening injuries has to start immediately while the diagnostic pathway has to be adequately fulfilled to detect all relevant injuries. 78 Advanced trauma life support (ATLS) describes clinical algorithms The Swimmer’s View – does it Really Improve and skills the trauma surgeon needs for a standardized examination in the emergency room. However, the apparative diagnostic tools and Visualisation of the Cervical Spine After an their use have rarely been described in a standardized manner in Inadequate Lateral Cervical Spine Radiograph? multiple trauma patients. 1214 patients with multiple trauma have U. Rethnam, R. Yesupalan, B. Ramesh, T. Muthukumar, been admitted to our clinic via the emergency room from September S. Bastawrous 2002 until August 2005. A standardized protocol (Traumawatch) Glan Clwyd Hospital accompanied the diagnostic procedures. After 3 min. ± 0,003 abdominal ultrasound excluded severe intraabdominal bleeding and Background: One of the basic principles in the primary survey of a the x-ray documented severe disorders of the thorax (after trauma patient is immobilisation of the cervical spine till cleared of 7 min. ± 0,005) and pelvis (9 min. ± 0,004). If initial cardiopulmo- any injury. Lateral cervical spine radiograph is the gold stan- nary and ventilatory stabilization was successful the CT scan started dard initial radiographic assessment. More than often additional

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 25 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

radiographs like the Swimmer’s view are necessary for adequate vi- 80 sualisation of the cervical spine. How good is the Swimmer’s view in Total – body Digital X-ray (LODOX/ Statscan) in the visualisation of the cervical spine after an inadequate lateral cervical spine radiograph? Emergency Room. an Experience Report on the First Materials & Methods: 100 Swimmer’s view radiographs randomly Operational LODOX Scanner in Europe selected over a 2 year period in trauma patients were included for the M. Hilty, A. Mu¨ller, L. Martinolli, H. Zimmermann, study. All the patients had inadequate lateral cervical spine radio- A. Exadaktylos graphs. The radiographs were assessed with regards to their adequacy Emergency Department, University Hospital of Berne, Switzerland by a single observer. The criteria for adequacy were adequate visualisation of the C7 body, C7/T1 junction and the soft tissue shadow. Background: Trauma patients require x-ray series which can be time Results: Only 55% of the radiographs were adequate. None of the consuming and radiation intensive. In comparison the total-body inadequate radiographs provided adequate visualisation of the C7 digital radiology device LODOX/Statscan obtains a.p./lat. whole- body and the C7/T1 junction. In 19% radiographs the soft tissue body exams in 3–5min, requiring only about 1/3 of the radiation shadow was unclear. Poor exposure accounted for 53% of the inad- compared to conventional radiography. Indications in patients pre- equacies while overlapping bones accounted for the rest. senting with non trauma related surgical emergencies include chest Conclusion: Clearing the cervical spine prior to removing triple im- and/or abdominal x-rays, foreign bodies search, visualization of mobilisation is essential in a trauma patient. This needs adequate ventriculo-peritoneal shunts in their entirety, etc. visualisation from C1 to C7/T1 junction. In our study Swimmer’s Methods: Experience report on the use of a new imaging technique views did not satisfactorily provide adequate visualisation of the which originally was introduced for trauma use only. We report on cervical spine in trauma patients. We recommend screening the the implementation of a modified ATLS algorithm, where x-ray of cervical spine by a CT scan when the cervical spine lateral radio- C-spine, chest and pelvis have been replaced by single–total a.p./lat. graphs and Swimmer’s views are inadequate. body radiographs. In non-traumatized patients we use LODOX/ Statscan for a.p./lat. thoraco-abdominal radiographs in favour of multiple conventional x-ray series. 79 Results: Oct. 2006 to Jan. 2007, n = 160 patients, 143 trauma, 17 non-trauma. Findings in trauma patients: Mean ISS 15+/–14 (3–75), Endoscopic Retrograde Cholangiopancreatography total-body scanning time: 3.5min (3–6min), total ER time: 28.7min (13– Cases of our Emergency Service 58min). In 116/143 patients additional CT scans, in 43/143 additional x- H. Yanar, C. Ertekin, H. Alis, O. Pesluk, R. Guloglu rays were performed. Findings in non-trauma patients: intraabdominal Istanbul University, Istanbul Faculty Of Medicine, Departement of pathologies and chest infection (n = 10); foreign bodies in GI tract (n = General Surgery, Trauma And Emergency Surgery Service, Capa, 3); VP shunt dysfunction (n = 3); lumbar segment degeneration (n = 1). Turkey Conclusion: Our experience shows that the implementation of LO- DOX allows a total-body exam without significant increase in time Objective: In the emergency services, ERCP is used at the diagnosis taken for resuscitation. LODOX allows a reduction in radiation and treatment of acute obstructive lesions and biliary pancreatitis. exposure and an ‘‘all-in-one’’ visualization of skeletal, chest and The aims of this study evaluate the results of ERCP in our emergency abdominal pathologies. We are confident that in future time we can service. show this new technique to be useful for further indications. Material - Method: Four hundred and ninety seven ERCP was performed by the same surgeon from March 2001 to August 2005. Indications, premedication, diagnosis, therapeutic procedure and 81 complications were evaluated. Results: Most common indications for ERCP was biliary obstructive Evaluation of Novel Digital Enhancement disorder (n = 272), acute pancreatitis (n = 127), cholangitis (n = 57), Techniques Ultrasound Imaging and biliary fistula (n = 18) followed by other indications in 23 pa- A. Paech1, A. Schulz1,2, S. Maegerlein2, C. Queitsch2,C.Ju¨rgens1,2 tients. In 94.2% of patients choledochus could be canulated. Canu- 1University Hospital Lu¨ beck, Dept. Trauma Surgery, Germany lation of choledochus was performed with a precut in 78 patients 2BG Trauma Hospital Hamburg, Dept. Trauma Surgery, Germany (16.7%). During ERCP, sphincterotomy was performed to 98.1% of patients (n = 459). In 349 cases (74.6%) Wirsung, and in 162 cases Digital radiography offers various possibilities to process and edit to (34.6%) gallbladder was imagined. In 91 cases cholelithiasis was enhance picture quality. Digital image data is also available in detected. In the serie, choledocholithiasis (n = 136), gallbladder sonography, nevertheless only contrast optimization is usually used for stone (n = 42), cholecystocholedocholithiasis (n = 39), papillary tu- improvement of picture quality. This study analyzes the possibility of mor (n = 28), stricture in distal choledochus (n = 22), periampullary different digital imaging techniques on standard shoulder sonography tumor (n = 11), right ductus hepaticus injury, choledochus injury, images. Standard sonographic shoulder images were gathered on biliary fistula, klatskin tumor, hydatic cyst, intrahepatic lithiasis, shoulders of healthy test persons as the standard value. These were coagulum, colanjiocarsinoma, cyst of choledochus, mirizzi syndrome, then analyzed by computer with various image editing algorithms. perforation of gallbladder, leakage from systic duct, and obstruction Following methods were used: Contrast optimization, Contrast filters in stent was established. Stone extraction was successfull in 94.3% (window technique, distancing of grey scales pixel by pixel, line by (n = 165) of 175 patient. Biliary stend was placed in 46 patients line), ‘‘Look up table operations’’ (Via change between the type of (tumor, enclave stone, biliary tree injury). In 1 patient basket cath- density, contrast can be globally optimized linear, sigmoidal, loga- etary was broken and in two cases hemorrhage occurred. rithmical or inverse). The resulting edited sonographic images were Conclusion In emergency service ERCP is minimal invasive and investigated and judged in a ROC-Analysis by 5 independent and helpful technique with low complication. experienced examiners. Points were given for image while considering

26 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

different questions/indications (e.g. judging the border layers or Methods: In a prospective study, we analysed 50 consecutive patients structural homogeneity) in comparison to the original sonographic with signs of a scaphoid fracture at physical examination but no images. Using the standard method of contrast optimization whilst evidence of a scaphoid fracture on scaphoid radiographs. All patients comparing the edited images with the original images, no distinct had a protocolised follow up at fixed intervals. The clinical outcome image quality improvement could be achieved. There was statistical was defined according to a standardized algorithm. significant improvement with different digital enhancement tech- Results: Bone scintigraphy revealed 32% (16/50) occult scaphoid niques. The techniques and the relevant structures are discussed in fractures and 40% (20/50) occult other fractures. Clinical outcome detail. In Conclusion, digital editing of sonographic images is a novel proved that bone scintigraphy was false positive in five patients and way to enhance image quality and diagnostic reliability. A further in one case false negative for a scaphoid fracture. evaluation of the determined indicational filters in traumatic and Conclusion: Bone scintigraphy in combination with protocolised posttraumatic shoulder pathology is a task for future studies. physical examination is the gold standard for patients with signs of a scaphoid fracture that cannot be proven on scaphoid radiographs. 82 Blunt Abdominal Trauma: Remains a Diagnostic 84 Challenge The Sonographic Diagnosis of Retroperitoneal J. Keulen van, M. Bemelman, J. Tolenaar, R. Verhage, L. Leenen Intestinal Rupture- a Case Report Department of Surgery, University Medical Center Utrecht, P. Gregorie`, D. Braeìka Vidmar, M. Tonin The Netherlands Clinical Centre Ljubljana, Slovenia

The majority of traumas in the Netherlands are blunt. During the Background: The diagnosis of bowel injury is difficult due to delay of assessment in our clinic, the trauma surgeon decides whether an morphological signs. A reliable sign of bowel perforation is extralu- ultrasound or a CT is performed. We compared the radiographic re- minal air. In cases of pneumoperitoneum the accuracy of US diagnosis sults with the emergency laparotomy results. We analysed the data is comparable to that of CT, but sonographic determination of ret- from our prospective digital database (Trail). Period 2001–2004. roperitoneal air is difficult and the accuracy much worse than for CT. Demographic, trauma and physical characteristics, trauma scores (ISS, Patient and Method: A 59 year old female was presented to the RTS, TRISS), imaging, resusative and operative data we collected. emergency room following a car accident. She had a safety belt mark Analysis was done with SPSS (Chi2 en Kruskal Wallis test). 889 pain the left lower abdominal quadrant, but no abdominal pain. US was tients were analysed. Mean age was 35 yrs, with a male / female dis- performed in the emergency room. tribution 72/28%. Mean EMV score was 12, abdominal AIS 0.72, ISS Results: US showed about 50 ml of free fluid in the right lower 15, RTS 7 and a TRISS survival 91%. Ultrasound was performed in quadrant, and subtle signs of irritation of the hepatic flexure. Due to 98% and CT 10%. 87(9,8%) patients underwent a laparotomy. In the the typical mechanism of injury and the presence of free fluid but no laparotomy group the mean EMV was 12, RTS 6.8, ISS 27, abdominal signs of injury to parenchimal organs we performed a plain radio- AIS 3.2 and TRISS 88%. Ultrasound was performed in 95% and CT graph which had failed to show extraluminal air. An US follow up 37%. Operation results were: spleen rupture 34%, liver rupture 28%, after six hours showed more fluid and an air collection in the right intestinal injury 17% and retroperitoneal damage 14%. 10% had a anterior pararenal space. This indicated perforation of the retro- negative laparotomy. Compared to a positive laparotomy the sens/spec peritoneal part of the bowel. CT was performed just to confirm this of ultrasound are respectively 0,79/0,21. Sens/spec of CT are 0,91/1,00. finding. Urgent laparotomy revealed rupture of the duodenum. Organ specific diagnosis with ultrasound is 52% false and CT 14%. Conclusion: The finding of a retroperitoneal air collection following Majority of mist injuries were intestinal. Conclusion Sensitivity and blunt abdominal trauma proves perforation of the retroperitoneal specificity of ultrasound is lower than CT. In case of a hemodynamic part of the bowel. It is difficult, but possible to detect retroperitoneal unstable patient the ultrasound is first choice to detect intra-peritoneal air by US. If detected by US, CT isnt’ needed. fluid. Organ specific analysis for lesions is unreliable with ultrasound and should be reserved for CT and thus with stable patients. 85 83 Severe and Complete Abdominal Wall Transection A Prospective Comparison for Suspected Scaphoid by Seat-Belt L. Bachiller, A. Garcıá-Marıń, D. Serralta, J. Martıń, Fractures: Bone Scintigraphy Versus Clinical F. Ture´gano-Fuentes Outcome University Hospital Gregorio Maran˜ o´ n F. Beeres1, M. Hogervorst2, P. den Hollander1, S. Meylaerts1, S. Rhemrev1 Introduction: General use of safety-belts has changed the injury 1Medisch Centrum Haaglanden patterns in victims of motor vehicle accidents (MVA), reducing 2Gelre Ziekenhuizen global mortality and head injuries severity, but increasing the frequency of other injuries such as intestinal perforations. A special type Background: Early diagnosis and treatment of scaphoid fractures limits of injury associated to seat-belts is traumatic hernia of the abdominal the number of delayed and non-unions. Bone scintigraphy proved to be wall. Classified by Ganchi and Orgill in class I (focal) and class II a sensitive diagnostic tool for the detection of occult scaphoid fractures. (diffuse), they are almost always linked to the seat-belt sign and, in However, the results have to be interpreted with care. the 66% of cases, to intra-abdominal injuries. Objective: To prospectively correlate the results of bone scintigraphy Case: study A 22-year-old obese male was involved in a high-speed with clinical outcome. MVA. After the crash, the patient walked out of the car, and was

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 27 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

taken to our Emergency Department. Primary and secondary surveys Case and Result: We report a case of lateral compression injury with were normal except for a mild, diffuse abdominal pain without significant pain over the sacrum. Initial plain radiographs and computer peritoneal irritation, and a very impressive neck and infraumbilical tomography (CT) failed to demonstrate any abnormality. In particular, seat-belt signs. A CT scan was performed, showing a complete and there was no anterior pelvic ring injury. However, a magnetic reso- severe anterior abdominal wall transection, with no other findings. nance imaging (MRI) confirms the diagnosis of a stable impacted The patient was operated on, and a 4 cm. length of serosal damage to trabecular fracture of the sacral alar with extensive bone bruising. the 3rd duodenal portion, and a 15 cm. length of devascularized The patient was mobilised and recovered over the following six weeks. descending colon were found. A segmental colonic resection with Conclusion: We believe that lateral compression injuries to the pelvis terminal colostomy, and a primary abdominal wall repair were car- are under-diagnosed. This may be due to the relative insensitivity of ried out, with delayed reestablishment of colonic transit at 4 months. plain radiographs to detect subtle cortical changes or of CT to visu- The patient remains asymptomatic at 18 months. alise marrow oedema. MRI is likely to provide the diagnosis in such Discussion: This case reveals the importance of maintaining a high cases. We advocate the use of MRI in patients with undiagnosed index of suspicion in patients with the seat-belt sign, irrespective of pelvic ring pain after a lateral compression injury, who may have the findings of imaging techniques (CT scan and ultrasound). what we have called an LC 0 fracture.

88 86 Correlation the Results of Ultrasonography with The Importance of 3 D Reconstruction After CT Computed Tomography of Traumatized Patients Scan in Assesment and Management of Articular P. Yazici1, U. Aydin1, A. Uguz1, S. Tamsel2, I. Solak3 Fractures 1Ege University School of Medicine, Department of General Surgery C. Patru, G. Popescu 2Ege University School of Medicine, Radiology Department Emergency Hospital, Bucharest, Romania 3Ege University School of Medicine, Emergency Department, Izmir, Turkey Purpose: Articular fractures need proper management in order to minimise their late arthritic complications with significant functional Currently, physical examination is usually followed by abdominal impairment.This study evaluates the influence of computerised ultrasonograhy. The ultrasonographic examination focused on tomography followed by 3D reconstruction upon pre-operative detection of free fluid but included evaluation of parenchymal organs planning and operative treatment of articular fractures. for injury. Computed tomography is used for the patients who have Material:The authors studied 136 displaced articular fractures treated free fluid or solid organ pathology to determine the grade of the injury. between 1.06.2001–1.06.2002: -44- humeral head ( group A) -32- In one year period, the patients, who were admitted to the Emergency distal tibia (group B) -56-tibial plateau (group C) The initial pre- Department with acute abdominal trauma, included in this study. operative planning was established ( including the type of the incision Hospital records were retrospectively reviewed and demographic and the necessary material ) after routine X rays at admission. After variables, the etiology of trauma, sonographic findings and the result that, 3D reconstructions after CT scan were used for a complete of the computed tomography were evaluated. The ultrasonographic evaluation of the fracture and a final pre-operative planning was examination focused on detection of free fluid but included evaluation made. The authors study the differences between the initial and the of parenchymal organs for injury. Of 4102 traumatized patients, 306 final pre-op planning in all the three groups. (7.4 %) required abdominal ultrasonography. There were 211 male Results:The initial and final plannings were similar only in : 22% and 95 female with a mean age of 25.6 and etiologies were followed as: (group A), 26% ( group B) and 24 % ( group C).The rest of the cases traffic accident 66.9 %, blunt trauma 26.6%, penetrating injury 6.1%. showed significant difference between Xray evaluation and 3D Abdominal ultrasonography was revealed free fluid in 25, 8% patients. reconstruction. The differences concerned: type of incision (group A- Of these, 19 were evaluated with abdominal tomography while 12%, group C-5%) , additional screws(group A-31%, group B-38%, remainder were performed both abdominal and thoracic tomography. group C-44 %) , type of the plate (group A-26%, group B-11 %, ) In comparing ultrasonography to computed tomography, diagnostic and bony stabilisation (group A-21%, group B-25%,group C-17 %). peritoneal lavage, or operative findings, we obtained 21 true positive, Conclusions: Complete assessment of articular fractures is not always 273 true negative, 4 false positive, 8 false negative results. Sensitivity of possible using only X rays. Pre-operative planning and final treat- US in detecting free fluid in abdomen was 72%, specifity was 97%, and ment are often influenced by 3D reconstructions after computerised accuracy was 84%. Although, ultrasonography may be used for the tomography. first diagnostic study in the emergency service, in case of clinical suspicion, CT should be the second method for further investigation.

87 89 The Occult Lateral Compression Pelvic Ring The Use of Lateral X-Ray View for the Diagnosis Fracture – Proposed Classification LC 0 and Management Plan of Fractured Neck of Femurs 2 2 E. Prempeh, K. Ho, M. Blakemore E. Prempeh, C. Mauffrey, M. Morgan , S. Bryan University Hospital Coventry and Warwickshire, UK University Hospitals Coventry and Warwickshire 2Birmingham Heartlands Hospital, UK Introduction: The Young and Burgess classification of pelvic fracture incorporates anatomic mechanism and fracture configuration, and Background: Fractured neck of femur is a condition where classifi- includes three grades of lateral compression fracture (LC I – LC III); cations, diagnosis and treatments are frequently debatable. Lateral diagnosis is normally made from plain radiographs. X-Ray are routinely requested but their quality is often suboptimal

28 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

and they are not always clinically useful for the management plan. lateral cervical spine radiograph is the single most valuable projec- We assess the role of the lateral view in the management plan of tion. Visualising the cervical spine from C1 to C7/T1 junction is of fractured neck of femur. utmost importance to avoid neurological deficit due to missed cer- Method: Eight Orthopaedic surgeons reviewed 24 AP views of frac- vical spine injuries. How adequate are lateral cervical spine radio- tured neck of femur. The classification of the fracture and the proposed graphs in a trauma situation were the patient is triply immobilised on management plan was noted. A few days later, the Lateral view of the a spinal board? same patients was added to the AP view and the classification/ man- Materials & methods: 51 consecutive trauma patients were included agement plan were noted. Both series of results (AP only VS AP and in the study. Initial lateral cervical spine radiographs of all these Lat) were compared for treatment plan and classification of fracture. patients were evaluated by a single observer. The criteria for ade- Results: Lateral view does not change significantly the classification quacy were visualisation of the entire cervical spine from C1 to C7/T1 of the fracture (p = 0.0001) or the treatment plan (p = 0.007). junction and the soft tissue shadow. Additional views were taken Conclusion: We recommend that lateral projection X-Rays are re- when the lateral cervical spine views were inadequate. quested only in cases where it is felt that the AP view is not providing Results: The lateral cervical spine views were adequate in only 23%. enough information for the diagnosis and management plan of the 77% radiographs were inadequate. C1 to C7/T1 was not visualised in fracture. 79.9%. Poor exposure accounted for 23%. All patients with inadequate radiographs had a Swimmer’s view. 23% of patients with inadequate lateral cervical spine & Swimmer’s view had CT evalu- 90 ation of the cervical spine. X-Ray Screening in Spinal Surgical Practice Conclusion: Visualisation of the entire cervical spine (C1 – C7/T1 in the United Kingdom junction) is critical in the trauma patient. Our study shows that the lateral cervical spine radiograph alone is inadequate. We recommend M. Shaw1, M. Pearce2, A. Fogg1, M. Foy1 assessing all trauma patients with the standard lateral cervical 1Royal National Orthopaedic Hospital spine radiograph an additional Swimmer’s view. A CT evaluation 2Great Western Hospital, Swindon, UK of the cervical spine would be recommended if both these views are inadequate. Null Hypothesis:- All spinal surgeons in the United Kingdom will routinely use X-ray screening in their practice when performing lumbar spinal surgery. Background: Surgery at the wrong level fortunately occurs uncom- Head and Spinal Trauma Management monly in spinal surgical practice. When it occurs it is a potential source of morbidity for the patient and may result in litigation for the surgeon. The authors analysed the intra-operative x-ray practice of UK spinal surgeons at the time of discectomy, decompression and 92 instrumented fusion. The authors assess their views on surgery at the Traumatic Brain Injury Increases Mortality and incorrect level and x-ray facilities available in their centres. Method: 130 members of BASS ( British Association of Spinal Sur- Morbidity in Patients with Hemorrhagic Shock geons) were sent an anonymous postal questionnaire concerning T. Lustenberger, L. Mica, M. Turina, O. Trentz, M. Keel their practice and views on x-ray use at the time of surgery. University Hospital of Zu¨ rich, Switzerland Results: 91(70%) questionnaires were returned. There was a large variation in practice between surgeons. 54 percent of surgeons always In polytraumatized patients the outcome is influenced by the occur- used x-ray screening for decompression/discectomy procedures whilst rence of traumatic brain injury (TBI). The aim of this study was to 12 percent only used imaging intermittently. The timing of x-ray investigate the influence of TBI in patients with different severities of screening in relation to opening of the ligamentum flavum was also hemorrhagic shock and the rule of the lethal triad (coagulation, subject to considerable variation. A small number of surgeons never lactate, hemoglobin) at admission as prognostic values in these pa- used x-ray screening for pedicle screw insertion and some only used it tients. In this retrospective study a total of 955 patients with an ISS ´ occasionally. There was a spectrum of opinion on whether wrong score U+00AlY 17 and survival of more than 3 days were included. level surgery was substandard practice. Coagulation, lactate, hemoglobin and the body temperature were Conclusion: The Null Hypothesis has been disproved. There is a wide recorded at admission. Patients were subdivided according to their ´ spectrum of practice and opinion on intra-operative x-ray practice AIS head score (U+00AlY 3 vs. < 3 points) and according to their among UK spinal surgeons. Some comments, suggestions and rec- hemorrhagic shock. Outcome measures were overall mortality and ´ ommendations are made by the authors. development of SIRS, or sepsis. Data are given as mean U+00AlA SD, significance level was set at p < 0.05, Anova. In the group with severe hemorrhagic shock and AIS head score U+00AlY´ 3 the 91 mortality was 33% compared to 8% in patients with AIS head score < 3. The incidence of severe SIRS and sepsis in patients with Lateral Cervical Spine Radiographs in Trauma severe hemorrhagic shock was significantly increased in patients with Patients. Is There Any Use? a AIS head score U+00AlY´ 3 compared to AIS head score <3 (severe U. Rethnam, R. Yesupalan, B. Ramesh, T. Muthukumar, SIRS: 45% versus 38%; sepsis: 48% versus 40%). The parameters of S. Bastawrous the lethal triad were different, however not significant between the Glan Clwyd Hospital two AIS head score groups. The mortality and morbidity of polytraumatized patients with hemorrhagic shock are significantly influ- Background: Lateral cervical spine radiograph is the gold standard enced by additional head injuries. The documented values of the initial radiographic assessment in the trauma patient. An adequate lethal triad represent the severity of hemorrhage at admission.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 29 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

93 95 Nice Guidelines: CT Scan for Head Injury: Focal Monitoring (Microdialysis and Faesability at a District General Hospital Setting Brain Tissue Oxygen) in the Management R. Kakwani, A. Sinha, K. Wahab of Severe Head-Injured Patients Good Hope Hospital NHS Trust E. Carre1, L. Bourdon1, D. Lagarde1, J. Menu1, J. Risso1, B. Palmier2 Aim: To assess the implications of implementation of the NICE 1I.M.N.S.S.A., Toulon Armeés France Guidelines for indication for CT scan in head injury patients. 2Intensive Care Unit, Toulon Armeés France Methods and Materials: A retrospective audit of the patients attending our district general hospital with head injuries over a After severe head injuries, the management of patients is usually period of one year from October 2004 till Sept 2005. A total of 3150 focalized on the prevention against secondary brain insults such as patients attending the A & E during the study period were diagnosed ischemia, hypoxia and intracranial hypertension. Global monitoring - to have head injuries. The study involved review of the case notes including intracranial pressure (ICP), jugular venous oxygen satura- and radiology results of the 135 patients requiring inpatient treat- tion (SjvO2) and cerebral perfusion pressure (CPP) - may usually ment for head injury. detect deleterious pathological events only when these are manifest. Results: Rigid compliance with the NICE Guidelines during the Thus global monitoring is often not sufficient to prevent secondary study tenure would have entailed an additional workload of 36 pa- brain lesions. In our Intensive Care Unit, some head-injured patients tients requiring a CT scan, of which 28 patients justified the scan have profited by a focal monitoring, including microdialysis and brain during ‘out of hours’ period. One elderly patient with a fatal intra- tissue oxygen, performed in the penumbra of the cerebral injured cerebral bleed was found to have justified an early CT scan on the cortex. Microdialysis offers the opportunity to explore focal brain criteria of more than one vomiting episode and a history of un- neurochemistry, especially the energetic metabolism (glucose, lac- consiousness. tate, pyruvate), commonly altered after traumatic brain injury. Brain Discussion: The implementation of NICE Guidelines was found to be tissue oxygen monitoring (PtiO2) allows the follow-up of cerebral implemented in most cases admitted during ‘working’ hours. A oxygenation in order to detect focal ischemia and/or hypoxia. This reluctance to perform CT scan was encountered during ‘out of hours’. concomitant focal monitoring is henceforth a tool for the manage- A strict compliance with the guidelines would entail on an average ment of severe head-injured patients, since this monitoring is directly one additional CT scan every fortnight during the ‘out of hours’ focalized on the injured area where the lesions are the most sus- period. Implementation of NICE Guidelines was found to tighten the ceptible to be badly exacerbated. net (and justify a CT scan) in order not to miss subtle early signs of potentially fatal head injuries. 96 94 Does Euroncap Protocols Cover Pedestrians Analyzing Risk Factors for the Outcomes Head Impact in Car Collisions ? U. Schmucker1, M. Beirau2, M. Frank1, A. Ekkernkamp1, of Patients with Extradural Haematomas: J. Seifert1 A Retrospective Clinical Investigation 1Ernst-Moritz-Arndt-University Greifswald, Germany U. Ozkan, S. Kemaloglu, M. Ozates, E. Cakmak 2Unfallkrankenhaus Berlin, Germany Dicle University, Turkey Introduction: Pedestrian accidents must be regarded as multi-impact Objective: In this study, of 4256 cases admitted with cranial trauma collisions. Previous investigators described typical body impact areas. between 1992 and 2006. The 195 cases that were diagnosed as ex- As most literature and background data are based on estimations tradural haematoma (EDH) were analyzed to investigate whether from dummy models or simulation this investigation aims to improve the outcome of extradural hematoma can be improved by CT future models by providing detailed pedestrian accident data of real examination. collisions. Methods: Each patient was evaluated retrospectively in terms of age, Methods: The IMPAIR–study (In Depth Medical Pedestrian Acci- sex, and models of injury, localization of the haematoma, origins of dent Investigation and Reconstruction) was designed as prospective bleeding, neurological findings and diagnostic investigations. The real accident data collection. Within a 4 years period all consecutive outcomes for each patient were retrieved and analyzed, and the chi– pedestrian accidents matching our specific inclusion criteria were square test was used in the statistical analyses. recorded. Documentation focused on specific impact parameters and Results: Of all the patients in this group, 136(69,7%) were male and 59 injury pattern. Interdisciplinary evaluation of each case allowed for (30,3%) were female, Of the patients, 70% were between 10–40 years reconstruction of accident biomechanics. Results are presented as old. The outcomes showed a significant correlation with Glasgow descriptives and risk variables. Coma Scale score, pupillary sizes, and pyramidal signs (p < 0.05).The Results: Our study population consisted of 37 (19 male/18 female; radiologic findings of the the size hematoma, the degree of the brain mean age 37.1yrs.) pedestrians: mean injury severity score ISS = 33.8; shift, significantly correlated with outcome (p < 0.05). 9 pedestrians died;17 pedestrians with ISS>15. The vast majority Conclusion: Factors such as coma, pupil alterations, volume of occurred on city roads (average collision speed 49.5km/h). A clear haematoma, presence of pyramidal signs, midline shift, and lucid risk correlation of injury severity and collision speed could be dem- interval the existence of local motor findings are risk factors for the onstrated. Relevant head and lower limb injuries were recorded in outcome in patients with EDH. nearly all victims. Primary head impact on windshield was more Key Words: Extradural haematoma, Outcome, Risk factors, Trauma. frequent (rate 51.4%) and resulted in higher injury severity than

30 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

impact on bonnet (rate 27.0%). A correlation of car design and injury Aim: A study was designed to assess a selective transfer policy, severity could be demonstrated. avoiding unnecessary transfers. Conclusions: Multiple injuries must be expected in every pedestrian Methods and Results: During a 24 month’s period (Aug. 2003 - Jul. accident. Countermeasures should focus on avoiding ‘‘crossing-track- 2005) 126 patients were transferred, while 83 patients were hospi- situations’’. With respect to own results EuroNCAP does cover one talized at the HYMC. The selection was made by consulting the level third of real pedestrian accidents only. Implementation of wind- 1 center neurosurgeon, who examined the CT through a tele-radi- shield and A-pillar-collision in safety test protocols is strongly ology system and considered the clinical status, as described by recommended. telephone. Most non-transferred patients recovered uneventfully. Two exceptions will be described in the presentation. Conclusions: Carefully selected head trauma patients can be safely 97 managed in a regional trauma center, as long as strict criteria for selection are met, patients are closely observed by a highly com- Outcomes and Costs of Acute Treatment of mitted trauma team and a reliable tele-radiology system is available Traumatic Brain Injury in the United Kingdom 24 hours a day for neurosurgical consultation. We encourage addi- M. Cronquist Christensen1, S. Ridley, F. Lecky2, V. Munro1, tional data collection and recommend adding radiological criteria to S. Morris3 the ATLS indications for transferring head injured patients to a 1Novo Nordisk neurosurgical facility. 2University of Manchester 3Brunel University 99 Background: Traumatic brain injury (TBI) is an important public health problem in the United Kingdom, yet its epidemiology and Head Trauma – Management and Pitfalls 1 1 2 1 treatment costs have not been documented in great detail. K. Svoboda , P. Kemetzhofer , N. Vahdani , M. Mousavi , 2 Methods: The Trauma Audit Research Network was used to identify M. Mu¨hlbauer 1 patients aged 18 or older hospitalized for TBI between 1 January, Donauspital / SMZ-Ost Unfallchirurgie, Vienna, Austria 2 2000, and 31 December, 2004. Patients were stratified by the Donauspital / SMZ-Ost Neurochirurgie, Vienna, Austria Abbreviated Injury Scale (AIS); AIS 3 = serious, AIS 4 = severe, AIS 5 = critical, and AIS 6 = virtually unsurvivable injury. Patient Introduction: Traumatic brain injury is the leading cause of death for characteristics, acute treatment, outcomes and costs were examined. children and young adults (age < 45a). In Austria approximately 300 Results: 8,263 study subjects were identified; 22.2% with AIS 3, per 100.000 inhabitants experience a traumatic head injury, 10–15% 39.3% AIS 4, 38.4% AIS 5, and 0.2% AIS 6. Motor vehicle accidents in severe form (GCS 3–8). Primary traumatic brain damage results were the most common cause of injury (41.7%), followed by falls from concussion, contusion and shear injury and is inaccessible to (37.8%), blows to the head (12.4%), gunshot wounds (2.0%), and therapy, whereas secondary brain damage evolves over time and can other types of injury (6.1%). Length of stay among survivors ranged be reduced or even reversed by correct therapy in adequate time. from 22.6 days for AIS 3 to 29.8 days for AIS 5. A total 23.0% died Mechanism of secondary brain damage include high intracranial before discharge; ranging 13.5% for AIS 3 to 94.1% for AIS 6. pressure (hematoma and edema), hypoperfusion, hypoxia, hyper- Hospitalization costs averaged £10,997 for AIS 3, £10,750 AIS 4, kapnia, free radical formation, electrolyte and acid-base changes. £11,469 AIS 5, and £1,291 AIS 6. Costs also varied by mechanism of Material and Methods: From 2001 to 2006 135 patients (ranging from injury; £13,210 for motor vehicle accidents to £3,288 for gunshot 1 month to 86 years of age : 4 infants, 26 children, 14 teenagers, 66 wounds. Hospitalization costs in hospitals with neurosurgical unit adults, 25 seniors) with traumatic brain injuries have been surgically were £13,264 compared to £8,840 in non-neurosurgical hospitals. treated in our hospital. An intracranial haematoma was evacuated in Conclusion: The burden of TBI in the United Kingdom is substantial. 81 times, an ICP measurement taken without further intervention in Acute treatment outcomes and costs vary considerably by injury 41 times, and other operations performed in 13 times. With the help severity, mechanism of injury, and hospital specialization. of exemplary case reports the management guidelines according to Rosner principles (mean MAP 70–85mm Hg to ensure optimal CPP) are being demonstrated. These rules include initial treatment guidelines, surgical intervention and critical care support, with 98 emphasis on problems to encounter and pitfalls to avoid. Guidelines for Transfer of Head Injury Victims Results: The results in relation to age, emergency room management, to Neuro-Surgery Revisited time to treatment and accompanying injuries are presented. J. Haspel, I. Ashkenazy, R. Alfici, K. Boris, T. Khashan Hillel Yaffe Medical Center, Israel 100 Background: Transfer of head injured patients from a regional hospital to a center providing neurosurgical services follows the ATLS Missed Cervical Spine Injuries and Polytrauma: guidelines and instructions of the Israeli Ministry of Health. These How Can We Avoid Them? dictate the transfer of every patient who is not defined as ‘mild head G. Vegh, D. Tihanyi, J. Dozsa injury’. Retrospective evaluation revealed that half of the 116 patients transferred during 2002 from the Hillel Yaffe Medical Center It is well-known, that the correct diagnostic of a suspected cervical (HYMC) to a level 1 trauma center did not need care beyond what spine injury can be difficult and time-consuming. However, missed or they would have received locally. Only 15% of these underwent delayed diagnosis of a cervical spine injury can have serious long- neurosurgical procedures. term and judicial problems as well. We report five cases of our spine

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 31 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

injury-data between 2000–2006, including 2 missed or delayed diag- been an increased use of cervical spine radiography. The Canadian nosis of a cervical spine fracture. Both missed cases were without Cervical Spine rule was proposed to reduce the unnecessary use of neurological and judicial consequences. Based on our report we cervical spine radiography in alert and stable patients. Our aim was would like to present our spinal clearence protocol, and to emphasize to see whether applying the Canadian Cervical Spine rule reduced the importance of correct immobilisation and diagnostic of the cer- the need for cervical spine radiography without missing significant vical spine. We want to highlight the diagnostic importance of the cervical spine injuries. upper cervical region. Using a clear and appropriate cervical spine Methods: This was a retrospective study conducted in 2 hospitals. 114 diagnostic guideline we can avoid the uncomfortable questions of the alert and stable patients who had cervical spine radiographs done for Court... suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results: 14 patients were included in the high risk category 101 according to the Canadian Cervical Spine rule. 100 patients were Decompression and Lumbopelvic Fixation for assessed according to the low risk category. If the Canadian Cer- Sacral Fracture-Dislocations with Spino-Pelvic vical Spine rule was applied, there was a significant reduction in Dissociation cervical spine radiographs (p < 0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radio- T. Schildhauer1, C. Bellabarba2, J. Chapman2, M. Routt2, G. Muhr1 graph. 2/100 patients who had significant cervical spine injuries 1BG-Universita¨tskliniken ‘Bergmannsheil’, Chirurgische Klinik would have been identified when the Canadian Cervical Spine rule U. Poliklinik was applied. 2Department of Orthopaedics, Harborview Medical Center, Uni- Conclusion: Applying the Canadian Cervical Spine rule for neck versity of Washington, Seattle, USA injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. Purpose of our study was to report the results of sacral decompres- This relates to reduction in radiation exposure to patients and cost sion and lumbopelvic fixation in neurologically impaired patients benefits. with highly displaced, comminuted sacral fracture-dislocations resulting in spino-pelvic dissociation. We identified nineteen patients over a six-year period with irreducible Roy-Camille type 2–4 sacral fractures with spino-pelvic instability patterns and cauda equina 103 deficits. All patients were treated with open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical Correlation of S100B with CT Findings and results were evaluated emphasizing alignment, hardware position and Intracranial Pressure in Patients with Isolated decompression. Neurologic outcome was measured by Gibbons’ Severe Traumatic Brain Injury-A Prospective criteria. Sacral fractures healed in all patients without loss of reduction. Average sacral kyphosis improved from 43 to 21 degrees. Study 1 1 1 1 2 Fifteen patients (83%) had full or partial recovery of bowel and P. Weninger , L. Pelinka , W. Mauritz , H. Hertz , H. Redl 1 bladder deficits, although only 10 patients (56%) had improved Trauma Hospital Lorenz Boehler, Vienna, Austria 2 Gibbons scores. Average Gibbons score improved from 4 to 2.8 at 31- Ludwig Boltzmann Institute for Traumatology, Vienna, Austria month average follow-up. Wound infection (16%) was the most common complication. Complete recovery of cauda equina function Objective: S100B has been described to be a reliable marker of brain was more likely in patients with continuity of all sacral roots (86% vs. damage. To date, however, neither a correlation between serum S 0%. p = 0.00037) and incomplete deficits (100% vs. 20%, p = 0.024). 100B and radiological findings using volumetry instruments to Although not significantly significant, recovery of bowel and bladder quantify intracranial hematomas or contusion areas, nor a correlation function specifically was more closely associated with absence of any between serum S 100B and intracranial pressure (ICP) in TBI have sacral root discontinuity (86% vs 36%, p = 0.066) than on com- been investigated. pleteness of the injury (100% vs 47%, p = 0.21). In conclusion, Material and Methods: We prospectively investigated 118 patients lumbopelvic fixation provided reliable fracture stability and allowed after severe isolated TBI. Continuous ICP monitoring was performed consistent fracture union without loss of alignment. Neurologic out- and patients had CT scans of the brain routinely on arrival and during come was, in part, influenced by completeness of injury and presence ICU stay. Intracranial hematomas and contusions were measured of sacral root disruption. using a digital volumetry program. Levels of S100B were obtained on admission and daily during ICU stay. Levels of S100B were then correlated with ICP values and CT scans. Data: We found a significant correlation between S100B and 102 dimensions of intracranial lesions (r = 0.634; p = 0.004). Further- Does Applying the Canadian Cervical Spine Rule more, we found a significant correlation between S 100B and ICP (r = 0.754; p < 0.001), midline shift (r = 0.846; p < 0.001) and ven- Reduce Cervical Spine Radiography in Alert and tricular compression (r = 0.712; p < 0.001). We did not find a corre- Stable Patients? lation between S100B and morphology (p = 0.142) or localization U. Rethnam, S. Yesupalan, T. Muthukumar (p = 0.094) of intracranial lesions. Glan Clwyd Hospital Discussion: Our data show a significant correlation between S100B and CT findings on the one hand and with ICP on the other. As a Background: A cautious outlook towards neck injuries has been the consequence, measuring S100B in patients with isolated severe TBI norm to avoid missing cervical spine injuries. Consequently there has could be used additionally to monitor these patients.

32 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

104 106 Anterior Screw Fixation of Odontoid Fractures Pediatric Spinal Tauma: A Review of 95 Hospital Comparing Younger and Elderly Patients Admissions P. Platzer, G. Thalhammer, V. Vecsei, C. Gaebler M. Vesel, I. Straus, M. Jug, M. Dobravec, S. Medical University of Vienna, Department for Trauma Surgery, Department of Traumatology,University Clinical Centre Ljubljana, Austria Ljubljana, Slovenia

Objectives: To determine functional and radiographic results after Pediatric spinal injuries are rare (1–2% of all pediatric fractures). anterior screw fixation of type II odontoid fractures, with the particular Experiences with pediatric spinal trauma are usually based on small interest to compare the outcome between younger and elderly patients. numbers of patients. A 10-year (1997–2006) retrospective study was Material/Methods: We reviewed clinical and radiographic records of undertaken of all 95 patients less than 14 years of age admitted for 110 patients with an average age of 54 years at the time of surgery spinal trauma at our department. In 57 children spinal fractures were after anterior screw fixation of their odontoid fractures between 1990 confirmed, with multilevel involvement in 75% of cases. Spinal cord and 2004. To compare functional and radiographic results between injury (1 incomplete and 2 complete lesions) was found in 5% of non-geriatric and geriatric patients, they were divided by age into two cases with spinal fractures. In 3 patients there was an incomplete groups: Group A included patients aged 65 years or less, group B spinal cord injury (SCI) without radiographic abnormality (SCIW- contained patients older than 65. ORA) and in 37% of all admissions imaging reevaluation showed no Results: 95 patients had returned to their pre-injury activity level and spinal fracture or ligamentous instability. In 23% of patients with were satisfied with their treatment. The Smiley-Webster scale showed spinal fractures emergency room imaging was misinterpreted. an overall outcome score of 1.42. In both groups patients showed an Additional fractures were found in 12 patients and there were 2 true excellent to good outcome with an average score of 1.34 in younger ‘missed’ fractures. 87% of all fractures were treated conservatively.. individuals and an average score of 1.50 in geriatric patients. Bony Seven children with spinal fractures/dislocations with neurologic le- fusion was achieved in 102 patients, failures of reduction or fixation sions or unstable fractures were operated. Conventional implants occurred in twelve patients. Comparing between the two groups, we could be used in older children, whereas younger patients needed had a non-union rate of 4% in younger individuals and a significantly modified implants. Vertebral compression fractures of type A1, even higher rate of 12% (n = 5) in geriatric patients. in multilevel involvement, healed with conservative treatment with- Conclusion: We had encouraging results using anterior screw fixation out developing a significant kyphotic deformity. Burst fractures were for surgical treatment of odontoid fractures and favour this method treated with spinal fusion and instrumentation to prevent late as preferred management for stabilization of these fractures. Com- deformity development. Type B and C fractures were highly unstable paring between age groups, we had similar results on cervical spine and needed surgical stabilisation. All incomplete SCI improved. function. With regards to fracture healing as well as morbidity and Conventional film techniques are often misinterpreted due to unfa- mortality, younger patients had a superior outcome. miliarity with pediatric spine trauma and need experienced evaluation. Additional imaging for detection of fractures and/or instability is often essential. 105 The Combined Spinal and Abdominal Trauma A. Woltmann, R. Beisse, V. Bu¨hren BG-Trauma Center Murnau, Germany 107 Respiratory Failure in Thoracic Spine Injuries – Introduction and Methods: Most challenging for trauma surgery is Has Timing of Dorsal Stabilization any the combined spinal (ST) and abdominal (AT) trauma. We studied frequency, severity of trauma, and mortality of this combination in Effect on Clinical Course in Multiple Injured multiple trauma (MT) patients admitted in our Trauma Center 2002– Patients? 2004, in order to put our surgical strategy for this pattern of injury to T. Frangen, C. Schinkel, G. Muhr proof. BG-Kliniken Bergmannsheil, Department of Surgery, Germany Results: Out of 731 MT patients 287 (39%) suffered from ST and 100 (14%) from AT. 35 (5%) patients had ST and AT in combination. 29 Background: Proper timing of stabilization for spine injuries is dis- of these had surgery: 23 abdominal, 18 spine, and 14 combined cussed controversial. Whereas early repair of long bone fractures is abdominal and spine surgery. Splenectomies (11) and small bowel known to reduce complications few studies exists investigating this repair (6) were the most frequent procedures in AT. In ST 15 pos- issue in acute spine trauma. In particular, the importance of coexis- terior stabili-zations and 6 anterior reconstructions were performed. ting lung injuries has to be determined, as it might influence clinical MT patients with AT + ST were younger (37 vs. 47 years), had a course and outcome. higher ISS (38 vs. 26, p < 0.05), and a lower mortality (7 vs. 14 %) Patients and Methods: We investigated retrospectively 30 servere than MT patients without AT/ST. injured patients that were stabilized dorsally on fractures of the Conclusion: In the surgical strategy AT with exsanguination control thoracic and upper lumbar spine. The mean Injury Serverity Score and decontamination comes first. After that associated spine instability (ISS) was 41 points. Patients were divided into 2 groups: group I: should be treated by cervical anterior and tho-racolumbar posterior acute trauma / stabilization < 72 hours; group II: acute trauma / internal fixation. Reconstructions (intestinal anastomosis, ante-rior stabilization > 72 hours. All patients in group I and group II pre- thoracolumbar spine stabilization) should be performed in the sec- sented radiological or clinical signs of lung contusion. ondary phase. Considering these surgical principles mortality can be Results: Average duration of the procedures was in group I 199min low even in combined AT + ST with high injury severity scores. (115–312min), in group II 139min (98–269min). Intraoperative blood

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 33 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

loss and PaO2/FiO2-ratio did not differ significantly between the 2 110 groups. The overall in-ICU and hospital stay was significantly shorter As a Developments’ Parameter:Pediatric Head in group I: 16d (1–78d) versus 24d (7–86d) in the late group II. Postoperative respirator therapy was necessary in group I for 15d (0– Trauma Characteristics in South-Eastern Anatolia, 79d), in group II for 19d (4–31d). Mortality rate was 10 % in this Turkey: a Comparative Aproach for 12 Years series. Results Conclusion: Our data provide further evidence that early stabiliza- S. Kemaloglu, E. Cakmak, O. Derin, A. Ceviz tion of spine injuries is safe in servere injured patients, it does not Dicle University, Turkey impair perioperative lung function and results in a reduced overall ICU and hospital stay. Further prospective randomized investiga- Pupose of this study was to determine the demographic and epide- tions are warranted to proof those results. miological characteristics pediatric head trauma. Hospital records of the 305 patients with pediatric head injury admitted to our hospital for each years in 1993 and 2006 were reviewed retrospectively. Each patient was evaluated retrospectively in terms of age, sex, and models 108 of injury, triage time and models. The outcomes for each patient Analysis of 147 Civilian Craniocerebral Gunshot were retrieved and analyzed, and the chi–square test was used in the Wounds statistical analyses. The pediatric head injuried patients were inves- U. Ozkan, S. Kemaloglu, O. Derin tigated for two periods; The first period covered patients covered Dicle University, Turkey patients admitted 1993 during which time an influx of people from rural to urban areas occured. In the second period influx of peo- In this study, we present a retrospective analysis of 147 cases due to plediclined and social instability was reduced. The most causes of civilian craniocerebral gunshot wounds that were treated by the injuries were road traffic accidents, followed by falls and bullet medical faculty of Dicle University during a period of 12 years wounds. While the leading cause of head injury for the two time (January 1993 to January 2006). Meanage was 33.1 years (69 male, 27 periods was road traffic accidents, firearm injuries for the first period female) for homocide and 28.7 (14 male, 7 female) for suicide. and falls for the second period were second most frequences causes Accidental group had 30 patients. Thirtyfour patients died at the of injury. We believed that pediatric health characteristics are hospital, and the deaths were determined to result from direct effects development parameters of the populations. We suggest that of brain damage. The patients admission coma scale scores were the demographic and epidemiologic factors may affect the characteristics best prognostic guideline. Diffuse brain damage and ventricular in- of pediatric head injury in a region based paopulation even in a short jury, particularly infections, were associated with poor outcome. period of time. Keywords Craniocerebral injury, Gunshot wound, Prognosis, Risk Keywords: Head injury, child, etiology, turkey. factors. 111 Injuries of The Thoracic and Lumbar Spine in Road 109 Traffic Accidents – an Analysis of 18353 Traffic Clinical Analysis of Head Trauma in Pediatric age Accidents Between 1985 and 2004 Group C. Mu¨ller1, C. Haasper1,T.Hu¨fner1, D. Otte2, C. Krettek1 O. Derin, S. Kemaloglu, E. Cakmak 1Medizinische Hochschule Hannover, Unfallchirurgische Klinik, Dicle University, Turkey Germany 2Medizinische Hochschule Hannover, Unfallforschung, Germany Summary: Retrospective analysis of 135 pediatric patients with head injury was performed. Patient age, Glasgow Coma Scale (GCS) Purpose: Injuries to the thoracic and lumbar spine contribute to score, pupillary abnormalities, presence of subarachnoid haemor- significant morbidity and mortality of traffic accidents. Great effort rhage, and multiplicity of parenchymal lesions on computerised has been spent to improve safety of car drivers and passengers. This tomography (CT) were examined. All the pediatric patients (up to survey aims to show, how injury patterns changed in respect to the age of 15) presenting to our emergency department due to head injuries to the thoracic and lumbar spine. trauma have been noted. This series included 135 unselected children Methods: Between 1985 and 2004 data from 18353 traffic accidents who were studied head injury. History was taken from both the pa- was collected. This data was searched for front passengers with sus- tient, when possible, and the parents. Mechanism of injury, post- picion of spine fracture and analyzed for age, impact, usage of safety traumatic seizure, 29 parameters were questioned. Both a general belt, injury severity (MAIS) and localization of the suspected injury. and a neurological examination were performed. All the patients In addition we compared data from accidents 1985–89 and 2000-04. underwent both plain radiography of the skull and a CT scan of the Results: Out of 413 front seat car passengers a safety belt was used in cranium. Intracranial injury is the major source of fall-related death 84%. There was a diagnosis of injury to the cervical spine in 65%, to the in children. The first cause of mortality from falls was intracranial thoracic in 19% and to the lumbar in 23%. The mean MAIS was 3,1. injury. Trauma triage criteria must account for in the pediatric There was significant correlation between usage of a restraining system population. These results showed that the insidance of fall from and MAIS and to injury to the lumbar and thoracic spine. The com- height was increased than the traficcal accident of pediatric age parison between 1985–89 and 2000–04 did not reveal significant dif- group. ferences in terms of injury severity (MAIS) although delta-v was lower Key words: Pediatric, head trauma, clinic analysis, retrospektive. in the 2000–04 group and the rate of safety-belt usage was higher, too.

34 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Conclusion: This analysis confirms the necessity of wearing a safety- a three-view C-spine series did not show the extent of the injury. In belt in order to prevent injuries to the thoracic and lumbar spine. four cases discoligamentous injuries were missed due to missing Interestingly, according to this data, although the number of fatal functional flexion/extension views. accidents decreased dramatically between 1985–89 and 2000–04, Conclusion: For assessment of the cervical spine in polytrauma pa- there were no advances in terms of MAIS. tients we recommend a three-view trauma series as minimum to clear the cervical spine and the more liberal use of CT-scan as standard diagnostic tool in patients with clinically suspected cervical spine 112 injuries and significant trauma history. In those patients also func- Outcome of Early and Late Surgery of Thoraco – tional flexion/extension views should be considered as obligate in Lumbar Unstable Burst Fractures later stages of diagnostic algorithm. E. Ghayem Hassankhani, A. Hotkani Mashad University of Medical Scienses 114

Background: The literature regarding the time of surgery and its Clinical Value of Kyphoplasty without Significant effect on outcome of thoraco-lumbar unstable burst fractures is Restoration of Vertebral Body Height in sparse. The aim of this study is to evaluate the efficacy of early and Pathological Vertebral Fractures late surgery on the outcome of these fractures. M. Bhattacharyya, T. Bishop, N. Venkatram, S. Sakka Materials and methods: Forthy Patients with unstable burst thoru- Department of Orthopedic colunbar fractures were included in this prospective review of patients treated with indirect reduction and short _ segment pedicle Object: In this prospective study the authors report on their experience screw fixation between 2000–2004. during their learning curve with the management of VCFs with kyp- Results: The mean time of surgery was 11 days after injury (form 2 to hoplasty for immediate pain relief, and restoration of the premorbid 33 days). 35 patients underwent early surgery (2–15 days after injury) level of daily activities. and patient’s perception with the outcome. (Group A) and 15 patients had late surgery (15–33 days ) (Group B). Methods: A cohort consisted of 7 males and 4 females with a 65yrs In group A the anterior vertebral height ( A.V.H ) was improved (±4.3yrs). Of these patients 6 had osteoporotic fractures, 4 had from a median preoperative of 20.5 mm to 39.5 mm (37% fractures secondary to multiple myeloma and 1 secondary to breast correction), and sagittal alignment ( S.A ) was improved from a mean malignnancy. The interval between onset of symptoms and surgical preoperative kyphosis of 20.4 degrees to 1/5 degrees. In group B the intervention ranged from 4 to 9 weeks. Immediate and early post- anterior vertebral height (A.V.H) was improved from a mean preoperative (6weeks follow-up visit) visual analog scale (VAS) pain operative of 20.3mm to 28/2 mm ( 24.5 % correction ) and sagittal scores, activity levels, and restoration of vertebral body (VB) height alignment ( S.A ) was improved from a mean preoperative Kyphosis were assessed. The mean preoperative VAS score was 8 + /– 1, of 20.5 degrees to 8.4 degrees. At final follow –up observation a mean whereas the immediate and early postoperative scores were 2 + /– 1. kyphosis of 4 degrees was increased in group B. These findings reflected a resolution of 90 to 100% of preoperative Conclusion: Early indirect reduction and posterior stabilization (with pain. All patients resumed routine activities within hours of the short _ segment pedicle screw) of unstable burst thoraco – lumbar procedure, although improvement in VB height was not accom- fractures allows a satisfactory reduction and correction of deformity. plished in this cohort. No major complications were encountered in this clinical series except one had cement leakage in the vein. Conclusions: The patient with cement leakage presents no new 113 symptom followed by percutaneous kyphoplasty, and the majority of Clearing the Cervical Spine in Polytrauma Patients them had the same therapeutic effect on one day after surgery VCFs. – Current Standards in Diagnostic Algorithm Failure to restore VB height does not seem to interfere with the excellent pain management. Reduced analgesic requirement and P. Platzer, G. Thalhammer, V. Vecsei, C. Gaebler patient satisfaction following kyphoplasty are likely to produce sig- Medical University of Vienna, Department for Trauma Surgery, nificant savings for health care providers. Austria

Objectives: To assess the safety and efficacy of the diagnostic algo- 115 rithm at our level I trauma centre and to propose a possible consensus of the optimal method for clearing the C-spine in polytrauma patients. Osteoplastic vs. Osteoclastic Surgery for Subdural Material/Methods: We analysed the clinical records of all polytrauma Hematoma patients with C-spine injuries (n = 118) who were admitted to our J. Leitgeb1, K. Erb2, W. Mauritz3 trauma centre between 1980 and 2004. All patients were assessed 1Department Of Traumatology University Of Vienna;Research Fel- following the trauma algorithm of our unit. Standard radiological low, INRO (International Neurotrauma Research Organisa- evaluation of the C-spine consisted of a single lateral view or a three- tion);Vienna, Austria view C-spine series. Further radiological examinations (flexion/ 2Research Fellow, INRO (International Neurotrauma Research extension views, CT-scan, MRI) were performed by clinical suspicion Organisation);Vienna, Austria of an injury or when indicated by the standard radiographs. 3Study Director; Chairman, Dept. of Anaesthesia and Critical Care Results: Correct diagnosis was made in 107 patients (91%) during Medicine, Trauma Hospital ‘‘Lorenz Boehler’’,Vienna,Austria; primary trauma evaluation, whereas in eleven patients (9%) we Chairman, INRO Medical Advisor Board failed to detect significant cervical spine injuries: In six cases skeletal injuries were missed because only a lateral view of the C-spine was Objectives: The aim of this analysis is to describe the surgical man- performed during primary trauma evaluation and in one case because agement of patients with subdural hematoma (SDH) in Austria.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 35 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Patients & Methods: Data sets from an Austrian multicenter study • when in doubt, CT scan is performed immediately or after 12 hour which enrolled 492 patients with severe traumatic brain injury were observation period available. A subgroup of 121 patients with SDH (isolated or com- • introduction of Protein S100b diagnostic bined) who required surgery was analyzed. The analysis focused on • in case of need for medical treatment, patients are admitted It’s surgical management and outcome. hoped these measures will reduce burden of unnecessarily admit- Results: Are presented in the table: ting large numbers of patients without compromising good medical SDH PatientsOsteoplastic surgeryOsteoclastic surgery Patients practice. (n)8635 Patients (%)71,128,9Males/females66 / 2024 / 9Age mean (CI)6,2 (52,0;60,3)58,4 (52,9;65,0)ISS mean (CI)21,2 (19,4;22,9)26,1 (21,3;30,6)TRISS mean (%)69,9 (64,4;75,4)59,8 (49,9;70,8)GCS (first) mean6,0 (5,3;6,7)5,9 (4,8;6,7)Dead at ICU (%)36,621,1Dead at 90 days(%)40739,5O/E ratio1,40,98 Most patients were treated by 118 osteoclastic surgery. Despite higher injury severity score (ISS) and The Effect of Weather on Patterns of Severe lower TRISS ( = expected hospital survival) ICU mortality was sig- Paediatric Head Injury nificantly (p < 0,05) lower in the patients who had had osteoclastic J. Roe surgery. 90-day mortality was similar, but the ratio of observed vs. Salford Hope Hospital, TARN or Trauma Audit Research Network, expected deaths (O/E ratio) was lower in the osteoclastic group. UK Conclusions: Based on these findings we conclude that osteoclastic surgery is the method of choice for treatment of patients with SDH. Head injury is common in children. Approximately 160 per 100000 children are admitted to British hospitals with traumatic brain injury annually. If we can identify temporal or other causative 116 factors we may be able to prevent injuries from occurring. Airbag and Oral Anticoagulation: A Deadly Anecdote holds that sunny weather, weekends or school holidays Combination in a Low Velocity Car Accident? are more likely to be associated with increased frequency of W. Pichler, R. Gumpert, W. Hartwagner, F. Seibert, W. Grechenig paediatric trauma. Recently authors have found that patterns of Department of Traumatology, Medical University of Graz, Graz, injury are correlated with calendar events such as increased as- Austria saults occurring on New Years day or at the same time as Rugby Internationals, or being higher on certain days of the week. But Airbags significantly reduce the risk of severe injury or death during they did not find a correlation with varying weather. This lack of a car accident. Nevertheless airbags are also known to produce correlation with weather was also found in a study of Paediatric injuries. This case report documents a fatal combination, airbag and Emergency Department visits comparing times of favourable or oral anticoagulation in low speed car collisions. The deploying airbag unfavourable weather. Yet others have found that there is a strong injured a 65 year old front seat passenger who was taking mainte- positive correlation between Paediatric fractures and mean nance anticoagulation, due to chronic atrial fibrillation. The blunt monthly sunshine hours, and a weak negative correlation with trauma resulted in a fatal cerebral hemorrhage. Keeping appropriate precipitation. Atherton et al also found that trauma was related to distance to the airbag or deactivating the system manually in urban weather, especially paediatric trauma and maximum mean monthly traffic may reduce the hazard of severe head injuries for patients temperature which is supported by a similar study by Macgregor. discharged on oral anticoagulation. To the best of our knowledge there have been no prior analyses on weather and its effect on patterns of severe paediatric head injury. We wish to explore this by looking at rates of presentation in a large urban conurbation (the Greater Manchester Region) 117 and by using a trauma registry (Trauma Audit and Research Managing the Minor Head Trauma Network or TARN) and weather data (Ringway Meteorological S. Herman Office). Department of Traumatology, University Clinical Centre Ljubljana, Slovenia 119 Minor head injuries represented a considerable 6,88% (5524 cases) of Craniocelebral-Gunshot Injuries -Problems all examined patients at our emergency department in 2005. More in Management important, 18,84% (1458) of admitted patients were hospitalized for N. Syrmos, V. Valadakis, K. Grigoriou, K. Spiridakis, observation due to head injury. There were 118 heavy head injuries D. Arvanitakis of which 40 required neurosurgical operation. In order to reduce Neurosurgical Department-Venizeleio General Hospital, Heraklion, unneccessary admittances due to minor head injuries, management Crete, Greece developed following plan: • every patient is thoroughly examined. If without any neurological Penetrating craniocellebral gunshot injuries have an enormous deficit and when accompanied by reliable attendant patient can be medical interest. Each year fatalities in the world increase as a discharged home with comprehensive guidlines result of gunshot wounds. This is the main reason that are one of • if under influence of drugs or alcohol patient is admitted for the most devastating causes of morbidity and mortality in civilian observation in Emergency Dpt. where special room was dedicated population The majority of the victims will not survive and for a for 12 hour period of observing patients either by relatives and/or great number of survivors life becomes an uphill battle with per- by medical staff. manent deficits and complications The purpose of this study is to

36 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

provide our experience of the current clinical and laboratory ad- Material and Method: Our objectives are to review the literature and vances in understating and treating gunshot injuries to the brain our own datas concerning the length of instrumentation,the kind of and to the face during the last years in our department (2003– approach and spondylodesis in spinal trauma. 2006) Conclusion: Advanced ankylosing spine is a rare condition and reported series are small.It is a very challenging group of patients both in diagnosis and management. 120 Spinal Fractures in Patients with Ankylosing 122 Spondylitis (Bekhterew’s Disease) – A Consequences of Vertebral Bone Bruising Retrospective Analysis of 45 Patients Following Spinal Trauma: a Case Report S. Smajic, G. Muhr, C. Schinkel M. Shaw, M. Jameson-Evans, B. Taylor, A. Saifuddin Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Royal National Orthopaedic Hospital Ruhr-Universitat Bochum, Germany. Introduction: Vertebral bone bruising is a relatively common phe- Introduction: In patients with ankylosing spondylitis(AS) fractures of nomenon associated with spinal trauma. Little has been written with the spine are considered to be very instable.Due to difficult radio- regards its significance. The authors present a case report with logic imaging the rate of initially unrecognized fractures remains sequential MRI scans over a 12 year follow-up period. high.Surgical treatment of instable fractures is demanding.Comor- Method: We report the case of a 27 yr old motorcyclist involved in a bidities result in a reported mortality of 35–57%.To achieve more road traffic accident. CT confirmed an L1 burst fracture. MRI dem- information about demography,clinical course,surgical management onstrated high signal in an otherwise normal L5 vertebral body, and outcome we retrospectively investigated patients at our trauma indicative of a bone bruise. Subsequent investigation with MRI, center. demonstrated T12/L1 degeneration and progressive isolated degen- Results: 45 patients with spinal fractures and the diagnosis of AS eration of the L4/5 disc adjacent to the level of previous bone were admitted between 2000–2005. 70 fractured vertebrae (cervical bruising. 12 years following his initial injury the patient presented 30,thoracal 31,lumbal 9) were involved.Multi level fractures oc- with an episode of debilitating lower back and leg pain. On MRI this curred in 9%.Preferably the lower cervical spine and the lower correlated with a now severely degenerate L4/5 disc. thoracic spine including the thoracolumbar transition were in- Results: Bone bruising was first described in 1987. There is some volved.Almost 60% of the patients presented neurologic deficits on consensus that it represents blunt injury to articular cartilage. Long- admission.Only about 65% of all fractures were diagnosed at the term significance of vertebral bone bruising (VBB) in relation to first radiologic examination.80% out of the initially unrecognized adjacent articular surface degeneration has not been considered up to fractures were diagnosed after appearance of neurologic dysfunc- now. In this case it is possible that bruising may represent a com- tion.Stabilization of cervical spine was performed in 52% from parable breech of an acceptable threshold of blunt injury to the posterior,in 29% from anterior-posterior and in 19% from ante- vertebral body endplate or annulus, as has been postulated in knee rior.Thoracolumbar spine fractures were treated in 66% from pos- injury. Delay in presentation of symptoms resulting from such an terior and 34% from anterior-posterior. Reoperation due to injury may have confounded any potential association between VBB pseudoarthrosis or early implant failure was necesessary in and degenerative disc disease (DDD) in the past. 16%.Overall mortality was 18%.Bony fusion was achieved in all Discussion: Bone bruising may initiate or accelerate DDD and may patients survived. be a predictor of long term morbidity for the patient. Discussion: Our study confirms that treatment of spinal fractures in patients with AS remains demanding: Difficult initial radiologic imaging,high rate of neurological lesions and comorbidities,combi- Skeletal Trauma nation of highly instable fractures and poor bone stock need a differentiated surgical approach.Multi level stabilization combined with anterior-posterior fixation if indicated and specific intensive care and 123 rehabilitation management result in stable fracture healing and re- The Complex Fracture of The Proximal Humerus: duced mortality. Locking Plate Osteosynthesis Versus Hemiarthroplasty M. Dietrich1, C. Meier2, T. Lattmann1, U. Zingg1, A. Platz1 121 1City Hospital Triemli, Zurich, Switzerland Spinal Trauma in Ankylosing Spondylitis 2University Hospital, Zurich, Switzerland, Italy M. Reischl, A. Kro¨pfl UKH Linz/ AUVA, Austria Background: The purpose of the present study was a direct comparison between fixed-angle plate fixation (FAPF) and shoulder Introduction: Spinal trauma in patients with ankylosing spondylitis is hemiarthroplasty (SHA) for complex fractures of the proximal hu- unique in many ways. Fractures can occur with trivial trauma. The merus in the elderly. traumatic ankylosing spine resemples a diaphyseal injury in long Patients and methods: A single-institution case series of 52 consec- bones and the attendant osteoporosis limits the quality of surgical utive geriatric patients (median age 82 years (71–92)) treated with fixation. FAPF (PHILOS) for 3- and 4-part fractures of the proximal hu- Aim: Presentation of our surgical management of spinal fractures in merus between 2003 and 2005 was analysed 1 year after surgery. The ankylosing spondylitis. analysis included the Constant score (CS), the Oxford shoulder score

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 37 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

(OSS), radiological evaluation and an assessment of social implica- bility and results in fixating proximal humeral fractures with the tions of the two different surgical procedures. Outcome was com- T2 PHN. pared with a similar historic group of patients (n = 59, median age 80 Methods: From 06/2003 until 06/2004 we’ve treated 40 patients with years (70–92)) which received SHA in an earlier period (1995–1997). proximal humeral fractures using the T2 PHN. All patients have been Results: Both patient groups showed no differences in age, gender and evaluated prospectively and 34 were seen in a clinical and radiolog- fracture type. Median CS was better for FAPF (71(31–92) vs. 41 (17– ical follow up examination one year later. 77), p < 0.001). Evaluating the subgroups of the CS, range of motion Results: 20 of the 34 patients had a 3-, 14 a 4-part fracture. The mean showed marked favourable result for FAPF compared with SHA (30 age was 65 years. 28 patients were female, 6 male. The mean oper- (10–40) vs. 10 (2–28), p < 0.001). Pain assessment demonstrated no ation time was 58 minutes. The mean Constant score was 73,7, age differences between the two groups in the OSS. Incidence of humeral and gender adapted 101,6% and side adapted 85,8%. Partial avas- head necrosis was 20% in the FAPF-group. Revision surgery was cular necrosis was seen in 5 cases, in another 4 cases we saw sec- performed more often in the FAPF-group (25% vs. 2%, p < 0.001). ondary dislocations due to missing tension band wiring or Conclusion: Functional outcome was superior for FAPF compared to misunderstanding of the fracture. Impingement due to prominent SHA. However, this was associated with an increased rate of revision proximal screws was the reason for implant removal in 6 patients, an surgery. Most patients were still able to live independently in their prominent proximal end of the nail in 3 patients. original environment unrelated to the type of surgery. Discussion: 3- and 4-part fractures of the proximal humerus may be treated with the T2 PHN in a stable and secure manner with minimal invasiveness. This enables early physiotherapy and good functional 124 results. Important is an operative strategy that provides a recon- Tuberosity Fixation in Fracture Shoulder struction and secure fixation of soft tissue, such as the rotator cuff, Arthroplasty: Cable or Suture after reduction and fixation of the fragments. S. Nijs UZ Gasthuisberg KULeuven, Belgium 126 Treatment of Proximal Humeral Fractures with the Arthroplasty for proximal humerus fractures results in an acceptable function. The results are directly related to age, gender and tubercle Locking Proximal Humerus Plate healing. We did prospectively document the healing of tubercle fix- C. Stevens, M. Jagt, H. ten Duis, K. Wendt ation on a shoulder fracture prosthesis after tubercle fixation using a University Medical Centre Groningen 2,0 mm steel cable. 23 consecutive patients treated between 12–2004 Proximal humeral fractures are frequently seen by low energy trauma and 07–2005 have been included in the study. Median age was 76 and osteoporoses in the elderly. In young persons is high energy years. 5 patients were lost for follow-up Tubercle healing has been trauma mostly the cause. Early pain free mobilisation is the main goal radiographically evaluated at 6 months. The control group consist of of treatment. The aim of an osteosynthesis is to obtain an anatomic an equally large group of age and sex matched patient treated before position of the greater and lesser tubercle to improve function and 12–2004. In the control group tubercle fixation was achieved using forcome a painful shoulder. Primary objective of this study was the interfragmentary and encircling suture fixation. Sound tubercle functional outcome after LPHP osteosynthesis for proximal humeral healing was achieved in 15/18 patients, i.e. 83%. In three patients no fractures and secondary dislocation. Secondary objective was the healing of the tubercles occurred (17%). In the control group only in complication rate: delayed-union, pseudoarthrosis, infection and 6/18 patients (ie 33%) sound tubercle healing could be documented. impingement. Methods From 2002 till 2005 46 fractures, in 45 patients, In 12 patients of the control group no healing could be documented. were treated with open reposition and internal fixation. To examine Sound tubercle healing is a conditio sine qua non for good functional the functional result the Constant score and DASH score were used. outcome after fracture arthroplasty for proximal humerus fractures. Results The mean Constant score was 48 (n = 23) and the mean Dash Factors as age and gender seem to be related to either functional score was 26.7 (n = 29) We did not observe pulling out of the screws outcome as to tubercle healing. However we believe that a stable out of the head. The mean time to consolidation was 30.4 weeks (6–100, fixation of a poorly vascularised fracture is of utmost importance to median 25.2 weeks) Impingement was seen in 5 patients, avascular achieve healing. To obtain this stable fixation prosthetic features, necrosis of the head in four and pseudoarthrosis in four patients as well. such as a voluminous metaphyseal part, irregular surface, height and We saw two broken plates, 2 deep infections, 1 superficial infection and version adaptability are important. But compression of the tuberos- 3 penetrations of the screws through the head. The mean follow-up was ities upon the metaphyseal part is also an important factor. 1.73 year (0.5–3.8 years, median 1.47) Conclusion The LPHP prevents secondary dislocation however the function is moderate. 125 Treatment of 3- and 4-Part Fractures of the 127 Proximal Humerus with the Proximal Humerusnail Results of the Treatment of Proximal Humeral (T2-PHN) Fractures Using tlhe Proximal Humerus Locking O. Trapp, R. Beickert, V. Bu¨hren Compression Plate BG Traumacenter Murnau, Germany F. Chiodini1, M. Berlusconi1, L. Di Mento1, I. Scarabello1, M. Zago2 1Istituto Clinico Humanitas - IRCCS - 2nd Dept of Traumatology The treatment of 3- and 4-part fractures of the proximal 2 Question: (2) Emergency and Trauma Surgery Section, Italy humerus is still a challenge for the surgeon. New implants for intramedullary and angle stable fixation of the fragments provide Introduction: The ideal treatment for fractures of proximal humerus new treatment concepts. Aim of our study was to explore feasi- is still debated. Close reduction and fixation with K wires has not

38 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

shown better results than conservative treatment. Shoulder hem- 129 iarthroplasty provides only moderate functional recovery. Open Treatment of Diaphyseal Fractures of the Humerus: reduction and internal fixation proved good results in terms of pain control and function, but it is demanding and results less predict- Operative or Conservative able in the osteoporotic bone. Fixed angle plates such as PHLCP M. Van Der Jagt, K. Wendt have shown to achieve a strong grip even on the osteoporotic bone Department of Traumatology, UMC Groningen, The Netherlands while preserving bone vascularisation. Material and Methods: Between May 2005 and May 2006, 30 pa- Objective: Diaphyseal fractures of the humerus used to be the do- tients were consecutively treated by open reduction and internal maine allocated to conservative therapy. To perform operative fixation with PHLCP for proximal humeral fractures. Endpoints of treatment specific indications were needed. The choice for operative the study were considered fracture consolidation or failure of the treatment is made easier nowadays. The question is if this benefits implant. At follow-up patients were evaluated by the DASH score the treatments’s goal; painfree mobilisation. The primarily aim is to and 2P-Xrays. evaluate the level of functional recovery. Secondarily we look at Results: Two fractures failed for aseptic loosening and one for consolidation and complications. deep infection; all required further surgery. The remaining 27 Design: Retrospective follow-up match study Patients: 302 patients healed in a mean time of 8 weeks. At a mean FU of 8.9 months have been treated for a humerusshaftfracture. After applying ex- the patients showed a mean DASH score of 15.7. One patient with clusioncriteria (pathological fracture, epiphysial plate) 222 patients radiographic signs of partial avascular necrosis of the humeral remained of which 142 patients were treated conservative and 80 head had a DASH score of 15, one patient required removal of patients were treated operatively with large demographic differences the plate for limited abduction. No other complications were in both groups. After matching the groups on gender and age, 40 detected. couples remained. Conclusions: Treatment of proximal humeral fractures with PHLCP Results: The unmatched population showed a mean DASH score for is technically demanding especially in articular and multifragmentary the operative therapy of 16, this was 1,5 for the conservative therapy fractures, but gives good results, in terms of function and patient’s which was a significant difference. After matching, the mean of the satisfaction, with a low rate of major complications. DASH score is 8,15 for the conservative treatment and 14,43 for the operative treatment, this is also a significant difference (P < 0,05). Pseudo-arthrosis was seen in 3,5% of the patients with conservative treatment, 3,7% by patients treated operatively. Nerve injury was 128 seen in 7,8% of the conservative treated patients versus 6,2% of the operative treated patients Outcome After Orif for Transolecranon Fracture Conclusion: Also after matching the outcome of functional recovery Dislocation and Posterior Monteggia Fracture of (DASHscore) is better for conservative treatment then for operative the Elbow treatment. C. Twerenbold, R. Babst2, D. Rikli3 Kantonsspital Luzern / Switzerland 130 Introduction: Transolecranon fracture dislocations (TFD) and pos- Our First Experiences with Delta-III Reverse terior Monteggia lesions (PML) are rare injuries of the elbow. There are only few reports in the literature on these specific injuries. The Shoulder Prosthesis in Proximal Humeral Fractures purpose of our retrospective study was to analyze the outcome fol- and RCA lowing operative treatment. F. Stefanic, V. Senekovic, V. Kovacic Material & Methods: 8 patients ( 61y,range 30–88y) after ORIF of a University Clinical Center Ljubljana, Slovenia TFD or a PML were retrospectively analysed at an average of 66 months postoperatively. All had ORIF of the ulna fracture and either Between December 2004 and September 2006 fifteen procedures ORIF or prosthetic replacement of the radial fracture, and ligament with Delta-III prosthesis were performed by two surgents in repair. All had early functional after treatment. We made a clinical Clinical department for traumatology in Clinical center Ljubljana. examination (Broberg and Morrey score), a functional evaluation There were nine women and six men. Average age at the time of (DASH score) and a radiograph analysis. surgery was 64 years (range 47–81). Average follow up was 12 Results: There were 5 female and 3 male patients. In 5 cases the months (range 4–21). Indicatios for surgery were devided in two injury was on the left side. In 4 patients the dominant extremity was groups. 1. In eight cases there was arthritis with massive rotator involved. There were 6 TFD and 2 PML. All fractures healed. cuff tear. Two patients had previous open rotator cuff revision There were no heterotopic ossifications. The median DASH-score procedure. 2. Other indicatios: -six cases of three or four part was 15 (range 0–38.3). Based on the Broberg and Morrey score the proximal humeral fracture, twice as primary procedure, twice after results were excellent in 5 patients, good in 1 patient, fair in 1 failed ORIF and twice after failed hemiarthroplasty (one unstable patient and poor in 1 patient; the median score was 88 (range 42.5– prosthesis and one stem loosening). -one case of persistent frosen 99). There were 2 revision operation due to failed primary fixation shoulder sindrom after open rotator cuff repair and two unsuc- (one plate, one tension band). The implants were removed in 6 cessful artroscopic capsulotomies. Constant score, ROM and pain patients. reliefe were significantly better in RCA group. Complications: one Conclusion: TDF and PML are difficult injuries. Satisfactory re- prosthesis was removed due to severe deep infection and loosening sults can be achieved with ORIF of skeletal injury and ligament of glenoid component in patient with L-dopa resistent parkinson- repair. Stable fixation of the Ulna fracture with a plate seems to ism. In three cases radiographic control showed scapular notching be crucial. without loosening of the metaglene within one to two years

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 39 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

postoperative. Deltopectoral approach was used in all cases with stable fixation using AO screws (in 3 cases the fractures were fixe by no prosthesis dislocation so far. In our paper question of indica- K-wires). The elbow after operation was immobilized by plaster of tions, surgical approach and short/long term results will be Paris for 10,5 days (5–19). discussed. Results: The consolidation was controlled by X-ray in 3 and 8 weeks after procedure. In 26 patients radiological consolidation was obtained in 8 weeks after procedure and in 2 cases (patients 15–16 years 131 old) in 12 weeks. After ablation of the plaster of Paris all patients have physical rehabilitation. The full range of motion of the elbow Minimal Invasive Plate Osteosynthesis (MIPO) was obtained after 12,5 weeks (5–17). In 3 patients was observed of Proximal Humeral Fractures Using a Proximal flexion contracture of the elbow 27 degrees (20–35). AO screws and Humerus Interlocking Plate System(Philos) K-wires were removed about 26 weeks (10–52) after the first procedure. After the second surgical procedure the elbow’s contracture C. Sommer, Y. Acklin, M. Walliser, R. Jenni was disappeared in 5 weeks (1,5–8). Departement Chirurgie, Unfallchirurgie, Kantonsspital Graubu¨ nden, Conclusion: The surgical treatment of the humeral fractures of the Switzerland medial epicondyle in children and adolescents is a save method with the good functional results. Introduction: The delto-pectoral approach is the standard approach for plate fixation of proximal humeral fractures, but it can impair the vascular supply and might increase the risk for avascular necrosis. The goal of this study was to evaluate the feasability and results of a 133 minimal invasive approach (MIPO). An Experience Based Approach to the Pulse-less Method: All PHILOS-plate osteosynthesis between 01/2003 and 06/2006 were evaluated prospectively. MIPO by an anterolateral Hand in Children’s Supracondylar Humeral delta-split approach was performed in all 2- to 4-part, not dislo- Fractures. (Alder Hey Experience.) cated fractures with minor to moderate displacement. All locally A. Dawoodi, C. Bruce resident patients have been asked for clinical and radiological Trauma & Orthopaedic Surgery follow-up. Results: 147 patients were treated with a PHILOS-plate of which Supracondylar fractures of the humerus in children associated with 70 qualified for a MIPO. In three patient conversion to an open vascular injury is reported in up to 11% with serious complications. approach was necessary. Of these 67 patients, 39 were locally res- The approach to a pulseless well perfused hand following reduction ident. Nine painfree patients with subjectively unrestricted function and pinning of supracondylar fractures is debatable. All children refused a follow-up, two patients were in constant-care and two referred to the orthopaedic department at Alder Hey Hospital patients died. 26 patients (median age 64 y) could be documented (2002–2006) with a displaced extension type supracondylar fracture after in average 11.7 months. The median operation time was 73 were reviewed retrospectively.There were 188 patients included in minutes with a fluoroscopic time of 160 seconds. The median the study. The patients’ medical records and X-rays were examined Constant-Score was 76.5. All fractures healed in adequate time. 1 for demographics information, mechanism of injury, type fracture, patient showed a partial lesion of the axillary nerve. No avascular hand perfusion, management, operative findings and the ultimate necrosis was observed. outcome. Of the 188 patients 17 had an absent radial pulse at pre- Discussion: The minimal invasive PHILOS plate osteosynthesis sentation. Average age (6.5) years (range 3–10). Fourteen were proved to be an elegant procedure for selected fractures of the males. All were extension type III fractures. Three patients had proximal humerus with a low morbidity and good functional out- abnormal perfusion with a prolonged capillary refilling prior to come. The absence of avascular necrosis is probable due to the definitive treatment. In 4 patients the radial pulse returned. Five treated fracture selection with only moderate displacement and not patients remained pulseless but the radial pulse was detected by to the operation technique. Doppler and the hand was well perfused. All had a favorable outcome. In seven patients the pulse did not return and the fracture site was explored. The artery was kinked or tethered in 5 patients, in spasm in 2 patients. One case of Volkmann’s ischaemic contracture 132 reported. Outcome of displaced supracondylar fracture following Fractures of Medial Epicondyle of Humeral Bone reduction and K-wire fixation in a pulseless but well perfused hand is favourable. Adequate circulation is restored if the radial pulse is in Children - Surgical Treatment detectable by Doppler. Post reperfusion compartment syndrome R. Tomaszewski, J. Kler, K. Pethe remains a risk. Prophylactic compartment decompression should be Uppersilesian Centre of Child and Mother’s Health, Katowice, considered when the warm ischemic time may have been prolonged. Poland

Aims: The treatment of the humeral fractures of medial epicondyle with displacement in children and adolescents is in most cases sur- 134 gical. Angular Stable Fixaton of Distal Humerus Fractures Material and Methods: From 1 jan 2001 to 30 jun 2006 in Upper- S. Nijs, P. Broos silesian Centre of Child and Mother’s Health in Katowice (Poland) UZ Gasthuisberg KULeuven, Belgium were treated 36 patients with fractures of the humeral medial epicondyle. The mean age of the patients was 13,5 (5–16). During the Distal humerus fractures do become more frequent as the popula- surgical procedure the fractures were treated by open reposition and tion ages and is more active at advanced age. The treatment of

40 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

distal humerus fractures is a surgical challenge even in the young 136 patient. In the osteoporotic aged patient the treatment becomes Is there Consensus in the Management of Distal even more difficult as fracture complexity increases and loosening of osteosynthesis and secondary displacement are more frequent. Radial Fractures ? Theoretically angular stable fixation offers better stabilisation and R. Mansingh, L. Sanz, M. Waseem, K. Barnes less risk of secondary displacement. Between February 2003 and Macclesfield DGH, UK April 2005 we did treat and document prospectively 36 patients because of a distal humerus fracture. Mean age was 55. There were Displaced distal radius fractures are very common injuries and 18 male and 18 female patients. 19 fractures did result out of a high present regularly to all orthopaedic surgeons.However, the literature energy trauma and 17 fractures were the result of a low energy suggests that there is still no consensus as to the best treatment of trauma in the geriatric, osteoporotic patient. There were 8 A-type these injuries. We set out to find what the current consensus is fractures, 1 B-type fractures and 21 C-type fractures. In 6 patients a amongst orthopaedic surgeons in England with respect to treatment delayed or malunion has been treated by secondary osteosynthesis of displaced distal radius fractures. A questionnaire was sent out to or osteotomy. Mean flexion averaged 125,5, there was an average 244 consultant orthopaedic surgeons. Antero-posterior and lateral loss of extension of 16,7. The mean pro-supination arc was 174.In radiographic images of two cases of displaced distal radius fractures 3 patients an arthrolysis did become necessary. Radiographycally all (one extraarticular and the other intraarticular) were provided along fractures did united without any compromise. Anatomical recon- with a short history. A list of the common modalities of treatment struction of distal humerus fractures remains the cornerstone of a was given. A completed form was received from 166 (69%) of sur- good functional result. Previously implant loosening and secondary geons. The results again indicated a wide variety of opinion as to the displacement often did complicate the osteosynthesis of the distal best way to manage these two cases. The most popular methods of humerus. Using angular stable implants better primary and sec- treatment were MUA + K-wiring, volar plating and application of an ondary stability can be achieved. In our series we did see no im- external fixator. In the extraarticular fracture, 82 (49%) surgeons plant related complications and better functional outcome than favoured MUA + K-wiring, 47 (28%) favoured volar plating and 14 historically reported. (8%) an external fixator. In the intraarticular case, 28 (17%) surgeons favoured MUA + K-wiring, 53 (32%) advocated volar plating and 33 (20%) an external fixator. Upper limb surgeons were more likely to treat with volar plating (63% in each case) than non upper 135 limb surgeons (18% and 23% for each case). A randomised clinical On Table Reconstruction of Complex Fractures trial would help elucidate the best mode of management for these of The Radial Head common injuries. C. Sommer, A. Businger Departement Chirurgie, Unfallchirurgie, Kantonsspital Graubu¨ nden, Switzerland 137

Introduction: Standard treatment for multifragmentary and unre- Intramedullary Stabilisation of Periarticular constructable fractures are either complete removal or prosthetic Fractures in Small Bones replacement of the radial head depending on the ulnar stability. We R. Mansingh, L. Sanz, M. Waseem, K. Barnes used an alternative protocol with ex situ on table reconstruction, Macclesfield DGH, UK reimplantation and stable plate fixation. The purpose of this study was to determine the complication rate and the functional outcome Background: Periarticular fractures of small long bones can be dif- following this treatment. ficult to stabilise if the size or shape of the articular fragment does not Methods: The records of all patient with on table reconstruction of allow for conventional means of fixation. Certain fracture configu- the radial head at our hospital between 1996–2005 were reviewed. rations or associated soft tissue injuries can make the use of wires or Standard radiographic fracture parameters were measured and plate and screws complicated. clinical assessment included active range of motion (ARM) of the Aims: We have addressed this difficulty by using headless differ- elbow, pain according to a visual analogue scale (VAS) and ential pitch screw (Herbert) in a novel way, as an intramedullary working abilitiy. device which allows for length and angular control of fracture Results: Seven patients (mean age 46y) had been treated with a fragments. 2.0 T-plate. 100% follow-up after in average 55 months. Six frac- Methods: We report a series of 7 acute cases treated in this manner. tures healed without signs of radial head necrosis with excellent There were three metacarpal head fractures and two metatarsal function. One head resection was performed due to partial head fractures. All patients where males with an age range of 18–39 years necrosis after 16 weeks. Elbow motion averaged for E/F 0-0-146, (mean age of 25 years). The mean follow up is 14 months with a for P/S 78-0-80. The overall pain was 1.4 and the lack of range of 3- 25 months. work 11 weeks on average. No plate failure or significant loss Results: No cases of non-union, loss of reduction, infection or other of reduction. In all cases the plate was removed after an average complications were recorded. All patients regained functional range 35 weeks. of movement. At the time of the stated follow up, no clinical or Conclusions: On table reconstruction of comminuted radial head radiographic signs of avascular necrosis were detected. There were fractures can obviously provide enough stability for fracture healing no functional deficits and the implants were left in situ. and secondary revascularisation of radial head. This technique may Conclusion: Headless screws used in an intramedullary fashion are a be an alternative to radial head removal and prosthetic replacement safe and reliable way of stabilising Periarticular fractures of small in cases, where the radial head fragments are avascular but still long bones in which more conventional means of fixation is precluded reconstructable on the operation table. by the fracture configuration or associated soft tissue injury.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 41 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

138 81+/–1 years, ISS 6+/–1, 5% mortality, 2% PRF-related mortality) Observer Variation of MR Imaging for Suspected and 18 pre-H died patients with PRF(47% male, 41+/–6 years, ISS 61+/–4, 100% mortality, 33% PRF-related mortality). PRF-related Scaphoid Fractures mortality was always due to bleeding. 1 2 1 1 F. Beeres , M. Hogervorst , S. Rhemrev , S. Meylaerts , Conclusions: The majority of PRF-related mortality occurs pre-H. 1 P. Den Hollander Half of the multiple-injured high-energy PRF patients still die be- 1 Medisch Centrum Haaglanden cause of the pelvic bleeding. Further preventive measures and opti- 2 Gelre Ziekenhuizen mization of the care of PRF patients is required. Trauma centre admission of 2/3 of the low-energy PRF is a significant load and Purpose: To prospectively evaluate the observer variation for Mag- should be further investigated in an inclusive trauma system. netic Resonance (MR) imaging in the detection of occult scaphoid fractures. Materials and Methods: One hundred MR scans were included to calculate the inter-observer variation. This group consisted of 79 140 consecutive patients (suspected of a scaphoid fracture but no fracture Hemodynamic Instability due to Pelvic Fracture: on radiographs) and 21 a-symptomatic volunteers (without a history Reduction or Embolization? of trauma nor any complaints). Thirty-eight MR scans (of the 79 E. Ritchie, T. van den Bosch, L. Leenen patients) were used to calculate the intra-observer variation. University Medical Center Utrecht, The Netherlands Observers blinded scored three items: 1) scaphoid fracture; 2) localisation of a scaphoid fracture; 3) free evaluation. For the first item Introduction: Pelvic fracture in combination with hemodynamic the simple kappa statistic and for the second and third item the instability is a complex problem. Differentiation between arterial or weighted kappa statistic was calculated. venous injury due to pelvic fracture is difficult. In this study we Results: The inter-observer variation for a scaphoid fracture had on evaluated different behaviors of hemodynamic instability resulting average a kappa of 0.69. Concerning the localisation of a scaphoid pelvic fractures. fracture and free evaluation, the kappa was on average 0.60 and 0.64 Patients and Material Hemodynamic unstable patients with pelvic respectively. The intra-observer variation for a scaphoid fracture had fracture between January 1994 and December 2005 were evaluated. on average a kappa of 0.90. Concerning the localisation of a scaphoid The patients’ charts and angiographies were evaluated retrospec- fracture and free evaluation, the kappa was on average 0.85 and 0.71 tively. Indications for angiography were unstable patients who re- respectively. In the volunteers four fractures and 10 bone bruises quired packed red blood cell after initial volume replacement, or were scored. clinical signs of ongoing shock. Conclusion: The kappa statistic for observer variation of MR imaging Results: 26 patients were included with a pelvic fracture. All were for occult scaphoid fractures showed a good agreement. But, the high energy traumas with multiple injuries. Ten pelvic fractures were influence of expertise in a sub group of a-symptomatic volunteers raises reduced with external fixation or C clamp, however three patients questions about the specificity and therefore requires further study. remained hemodynamic unstable after fixation. 15 patients required pelvic angiography. 13 of the remaining 15 required embolization of a pelvic artery. Whereas two patients had no arterial injury; one patient 139 remained hemodynamic unstable due to a liver rupture and died. Time from arrival at the emergency department to the angiography The Epidemiology of Pelvic Ring Fractures: suite ranged from 90 minutes till 93 hours. Patients received an The Whole Picture average of 15 RBC before embolization (range 3–51), after emboli- Z. Balogh, P. Mackay, S. Mackenzie zation transfusion requirements showed significant reduction. No Trauma Service, John Hunter Hospital, University Of Newcastle, complications were registered after embolization. Australia Conclusion: There seems to be different pattern of hemodynamic instability caused by arterial or venous hemorrhage. Venous hem- Purpose: The comprehensive describtion of the epidemiology of orrhage, non responders on initial resuscitation, is stabilized bij pelvic ring fractures (PRF) including high-energy PRF, low-energy reducing and fixating the fracture. Patients with persistent instability PRF and those who die during the prehospital phase (pre-H). or recurrent instability, transient responders, can have an injury to Methods: 12-month prospective population based study was per- the artery. An angiogram can be therapeutically. formed in a trauma system with one Level-1 trauma centre and seven referring hospitals (population: 0.6 million). Data were collected on all PRF from the trauma system including high-energy, low energy 141 fractures and pre-H deaths with PRF. Patient demographics, injury severity score (ISS), mortality (%) and PRF-related mortality were Lower Urinary Tract Injuries Associated with recorded prospectively. All high-energy deaths had autopsy at the Pelvic Fractures same department. Data presented as percentages (%) or J. Sproviero, P. Mazoud, M. Rıós, E. Aiquipa Jimeńez, mean + /–SEM. G. Carqueijeda Results: During the 12-month period 138 patients suffered PRF (45% Hospital General de Agudos Francisco Santojanni male, 59+/–2 years, ISS 20+/–2, 21% mortality and 8% PRF-related mortality). Sixty-four % of the low-energy and 92% of the high- Background: High energy forces can fracture the pelvic ring and energy patients were transferred directly to the trauma center. There damage surrounding structures, like the lower urinary tract (LUT). were 57 high-energy (71% male, 41+/–3 years, ISS 23+/–3, 14% Different centers reported this association just in 20% of the mortality, 7% PRF-related mortality) 63 low-energy (20% male, cases.

42 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Aims: To evaluate traumatic characteristics among patients with 143 LUT injuries and pelvic fractures. The Role of Early Angiography in the Management Methods: Patients with pelvic fractures and LUT injuries (bladder, urethra) were retrospectively analyzed upon clinical features, trauma of Severe Pelvic Fractures 1 1 1 1 causes, diagnostic methods, scoring, treatment and outcome. I. Jeroukhimov , V. Gazianz , B. Kessel , V. Nesterenko , 1 Results: Between 01/01/99 – 31/12/04, 1.136 trauma patients were A. Halevy 1 hospitalized, 64/1.136 presented pelvic fractures (5.6%) and 8/64 Assaf Harofei Medical Center 2 developed LUT injuries (12.5%). Seven men and one woman, Hillel Yafo Medical Center average 36.3 years old, were assisted. Blunt trauma was the main cause among these patients (5/8). Clinical signs and ultrasound were Pelvic fractures constitute about 3% of all skeletal fractures. He- used as initial assesment to diagnose LUT injuries, which were modynamic compromise in unstable pelvic fractures is associated confirmed by retrograde urethrography and CT. Each organ was with arterial hemorrhage in less than 20% of patients. Angiography is affected in 4/8 cases. Mean TSR and ISS was 10.7 and 23.3 an important tool in the management of severe pelvic injury, but respectively. Ultrasound guided percutaneous cystostomy and su- indications and timing for its performance remain controversial. ture of the bladder were the procedures performed. Two patients Methods: All patients with major pelvic fractures (Pelvic Abbreviated died (2/8). Injury Score (AIS) U+00AlY´ 3) admitted to the two high volume Conclusion: In our institution, LUT injuries were observed in Trauma Centers during 5 years period were identified and divided into 12.5% among patients with pelvic fractures, representing a lower two groups: Group I patients did not undergo angiography, Group II incidence comparing reports of other trauma centers. Physical and patients underwent angiography with/without embolization and were sonographic examinations were helpful diagnostic tools when LUT subdivided into early ( < 2 hours from admission) and late (>2 hours injuries were suspected in combination with pelvic fractures, after admission) groups. Demographics, hemodynamic status on principally in hemodynamically unstable patients. Simple surgical admission, concomitant injuries, Glasgow Coma Scale (GCS), Injury and minimally invasive procedures were effective to restore ana- Severity Score (ISS), AIS, blood requirement before and after angi- tomic integrity of the LUT and to overcome acute urinary reten- ography, arterial blood gases, length of hospital and intensive care unit tion. The complexity and high mortality rate associated with pelvic stay, and mortality were evaluated. Patient with additional sources of fractures, made an interdisciplinary approach for this patients bleeding apart from the pelvis were excluded. mandatory. Results: One hundred and four patients entered the study. Patients who underwent angiography had significantly higher ISS and AIS. Group II patients had a lower Base Excess level and received more 142 Pack Cells (PC) before angiography. A trend of decreased blood transfusion requirement was shown in the early angiography group Ultrasound in Polytraumatised Patients with but was not of statistical significance. Pelvic Ring Fractures- is it sill Needed Conclusions High ISS, Pelvic AIS, and amount of blood transfusions in Times of CT Scan? as well as decreased BE level should be considered as an indication for angiography. Early angiography has no statistically significant S. Karpik, H. Resch, R. Bogner influence on blood transfusion requirement. Abteilung Fu¨ r Unfallchirurgie Und Sporttraumatologie, St Johanns Spital, PMU Salzburg, Austria

Introduction: In our department the evaluation of polytraumatised 144 patients is done in the emergency room. After doing a first staging the patient is either undergoing a CT scan of the whole body or is Pelvic Fracture Related Haemorrhage. Should They evaluated with conventional x-ray and abdominal ultrasound. We be Immediately Definitively Fixed? evaluated if an ultrasound scan done before a CT scan is sensitive E. Varga enough to detect abdominal injury. Department of Trauma Surgery, University Of Szeged, Hungary Patients and Methods: From 2002 until 2004 135 Patients were registered in the Traumaregister, including 39% with a pelvic fracture. During the last eleven years, 156 patients with Tile C pelvic injury Those were divided by the AO- Classification. were stabilized with 10-mm diameter -specially designed - cannulated Results: 53 Patients had a pelvic fracture, with 32% Typ A fractures, iliosacral screws percutaneously posteriorly and different - mostly 45% Typ B fractures and 11% Typ C fractures. In 98% of the pa- percutaneous methods - anteriorly. Forty-eighths patients in hae- tients a CT Scan was done, in 51% an ultrasound was done addi- modinamically unstable condition were stabilized in the first two tionally. In 44% the Ultrasound and CT Scan both showed the same: hours with iliosacral screw fixation. No patient had metal failures. either no fluid was detected or a lot of free fluid. In 30% the ultra- The average OP time of the posterior stabilization was 19 minutes. sound could not detect any free fluid or organ lesions, but in the CT The average time of using of fluoroscopy was 43 seconds. The scan either free fluid or other pathologies were found. Pathological immediate posterior pelvic stabilization together with appropriate or findings were detected in 26% of the cases but CT Scan and Ultra- temporary anterior stabilization was able to control the posterior sound found very different lesions. bleeding. The stabilization of the Hgb level via the surgery was Conclusion: In only 44% there was an exact agreement between the monitored. The data from this prospective clinical study showed that findings in ultrasound and the CT Scan. But in 74% greater the percutaneous pelvic ring stabilization with 10-mm cannulated amounts of free fluid could be excluded. We can state that in case screws was enough in strengths among bothersome cases as well. The of a negative case history the negative ultrasound scan is satisfac- emergency pelvic clamp would be helpful in these cases as well, but tory. If the patient history is suggesting an abdominal trauma a CT these clamps could increase the risk of definitive posterior stabil- scan is inevitable ization procedures later, and takes only a little less time to apply

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 43 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

them. The percutaneous iliosacral stabilization can be performed the plications (Intra-op, Post-op and Deaths), duration of hospital stay easiest in the first couple of hours following the pelvic injury given a and the discharge destinations were studied from the clinical notes and definitive treatment of the patients. Unless the stabilization is per- Hospital information system. Statistical analysis was carried out using formed within this period, the air accumulation in the bowel inter- SPSS for all the available data. Statistically, the DHS has a lesser feres with the optimal fluoroscopy image during the surgery. duration of surgery, lower fluoroscopic exposure and lesser duration of hospital stay. However, clinically it appears that the IMHS is fraught with more complications. 145 Acetabular Loading in Active Abduction 147 A. Kristan1, M. Cimerman1, B. Mavcic2, V. Kralj - Iglic2, Management of Traumatic Dislocation of the Hip M. Daniel3 1 with Fracture of the Femoral Head or Neck, or Both, UMC Ljubljana, Dpt. Of Traumatology, Slovenia 2Laboratory of Physics, Faculty of Electrical Engineering, University or Fracture Acetabulum: A Prospective Study of Ljubljana, Slovenia A. Rafee1, M. Gajewar2, A. Jalgaonkar2, M. Kassim2, 3Technical University Kosice, Slovakia M. Elzubdeh,2 1Manchester University Background: Operative fixation of fragments in acetabular fracture 2Newham University Hospital treatment is not strong enough to allow weight bearing before the bone is healed. In some patients even passive or active non-weight-bearing Traumatic fracture-dislocation of the hip with or with out acetabular exercises could lead to dislocation of fragments and posttraumatic fracture is an absolute orthopaedic emergency. Early recognition and osteoarthritis. Therefore, early rehabilitation should avoid loading the prompt, stable reduction is the essence of successful management. The acetabulum in the regions of fracture lines. The aim of the paper is to purpose of this study is to identify prognostic factors that predict long- estimate acetabular loading in different body positions. term outcome. 17 patients with traumatic dislocation of the hips with Methods: Three-dimensional mathematical models of the hip joint fracture of the femoral head or fracture acetabulum were treated. reaction force and the contact hip stress were used to simulate active There were 8 posterior dislocations and 9 with central fracture dislo- exercises in different body positions. cations. All patients had both plan x ray and CT scan. Posterior frac- Results: The absolute values of the hip joint reaction force and the ture-dislocations and femoral head fractures were classified according peak contact hip stress are the highest in unsupported supine to Epstein’s (type I - V) and Pipkin’s classification respectively. The abduction (1.3 MPa) and in side-lying abduction (1.2 MPa), lower in functional evaluation system, Merle d’Aubigne was used. 8 patients upright abduction (0.5 MPa) and the lowest in supported supine (posterior dislocation) were initially treated within 6 hours with closed abduction (0.2 MPa). In all body positions the hip joint reaction force reduction ( 45.13%), and 5 patients had internal fixation. In central and the peak contact hip stress are the highest in the superior fracture dislocation out of total 9 cases, only 2 cases were operated on. quadrant of acetabulum, followed by anterior quadrant, posterior Full weight-bearing was resumed between 6 and 10 weeks. Out of 9 quadrant and finally inferior quadrant. patients treated conservative 6 had good to medium result (66.3%) and Discussion: Spatial distribution of the average acetabular loading 3 bad results (33.3%). Out of total 8 cases treated operatively, excel- shows that early rehabilitation should be planned according to lent results obtained in 2 cases and good results obtained in 6 cases ( location of the fracture lines. With fracture lines over posterior or 100%). 5 patients (29.41%) developed osteoarthritis of the hip, and 5 inferior acetabular quadrant no restriction of active abduction is patients (29.41%) developed hetrotropic ossification and one case needed. In case of fracture lines across superior and anterior ace- developed AVN of the head of femur. Conclusion: We believe that tabular quadrants, active abduction should be limited to supported good results were obtained in patients with early, stable, and accurate supine abduction throughout the whole range of motion and to up- reductions by either closed or open methods. right exercise with maximum 20 degrees of abduction. 148 146 White Cell Count in Patients with Femoral Neck Comparative Analysis of the Intra-operative and Fractures Peri-operative Outcomes of DHS vs Imhs for Hip S. Thiagarajah, S. Samad, P. Maguire, P. Dukow Fractures We performed a retrospective review of the white cell counts (WCC) in R. Mansingh, PIZON, FUCHS a 100 patients (60 female) with femoral neck fractures, both pre and South Tyneside DGH post operatively. All patients admitted with fractures of the neck of femur who had surgical intervention to deal with the fracture were Hip fractures are a major challenge and impose high demand on included. The incidence of pre-operative increased WCC was 34 %, orthopaedic services. DHS has been proved to be a gold standard and the incidence post operatively was 26 %. Patients with raised WCC method of treatment in uncomplicated extracapsular fractures. The and associated infections were noted (pre and post operatively). It was introduction of Intramedullary devices has provided us with a wider noted that for patients in whom the WCC was raised both pre and post- choice of construct. Since there was conflicting literature evidence operatively, was associated with a greater risk of complications comparing the outcomes of DHS and IMHS, we set out to analyse the (including death) and longer hospital stay. The difference was highly same in our practice. Forty patients in each group operated in the year significant (P < 0.005). It is suggested that the WCC is valuable as 2000, comparable in fracture pattern, age and sex distribution were easily estimated prognostic index to identify the subgroup of patients studied. The operating time, fluoroscopic exposure, blood loss, com- who are at increased risk of complication

44 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

149 Conclusion: If placed properly migration of the blade seems to be The Use of the Proximal Femoral Nail Antirotation minimal. Postoperative mobilization with full weight bearing seems to be possible and without a higher amount of complications. (Pfna) in the Treatment of Intertrochanteric Hip Fractures A. Sermon, P. Broos 151 Department of Traumatology, University Hospitals Gasthuisberg, Leuven, BELGIUM Intramedullary Fixation of Displaced Inter Trochanteric Femoral Fractures: Is Technique or Purpose of the study: The treatment of intertrochanteric fractures Device to Blame for Screw Cut Out still remains a challenge to the surgeon. In this retrospective study, T. Hussan, E. Mallick, R. Pratt the preliminary results of the use of the PFNa are studied. North Tyneside General Hospital Materials and Methods: Between January 1, 2004 and June 30, 2005, all patients treated with a PFNa in our department, were studied Introduction: Fracture reduction, implant used and Implant position retrospectively. Of the 112 patients included in the study, 11 died is surgeon dependent variables in determining stability of fracture within the first six months and 49 were lost for follow-up. So only 52 implant construct in displaced Intertrochanteric femur fracture. Our patients could be included in the study. aim was to determine the role of the three variables in screw cut Results: All of the patients were clinically and radiologically re- out. viewed at one, three and six months. In two patients, there was Material and Method: 106 patients in our unit with displaced IT cutting out and in one patient, there was backing out of the helical femur fracture (Kyles type II-IV) were stabilised using four different blade, leading to secondary fracture displacement. In four patients, intramedullary devices from July 2004 to June 2006. Only patients the distal end of the helical blade lead to irritation of the fascia lata. with postoperative x-ray and with clinical and radiological follow up Radiologically, 33 fractures were healed within six months. Clinically, at 3 months were included in the study. Adequacy of fixation was 28 patients could achieve their preoperative walking ability and 40 assessed by measuring reduction, implant screw position and Tip patients could return to their preoperative status of living. Apex Index. Each of the fixation assessment parameter fell into Conclusion: Despite the small study population, only few technical good, acceptable or bad. complications were encountered in this retrospective study. We think Result: 74 patients were included in our study. 7 patients (9%) had the PFNa is an improvement in the treatment of intertrochanteric hip failure of fixation by way of screw cutting out of femoral head and all fractures: it consists of a technically simple procedure which provides had bad or acceptable initial fracture reduction. However it required good stabilisation of the fracture fragments. at least one more assessment parameter falling in acceptable or bad category for the screw to cut out. IM DeviceTotal Pts Included in study Screw cut out IMHS 47 30 2 GAMMA 3 Nail 36 26 2 VARI- 150 WALL Nail 20 15 3 FIXION 03 03 0 Placement Of The Haed-Neckfragment Of The PFNA Discussion: There was no significant difference of screw cut out be- In The Treatment Of Unstabel Pertrochanteric tween the four different implants. Screw cut outs are avoidable, as all cut outs were consequent to initial inadequate surgical technique Femur Fractures especially reduction. The implant does not significantly influence W. Hartwagner, H. Clement, S. Schmidlechner, F. Seibert, complications incidence if the technique is good. W. Seggl Department of Traumatology, Medical University of Graz, Graz, Austria 152 Introduction: The new AO PFN-A was introduced in our institution Emergency Open Reduction and Screw Fixation of 04/03 and over 250 patients were prospectively monitored. According to Levy, screw support in the head-neck fragment should be in the Comminuted Femoral Head Fracture (Long Term posterior inferior part of the head to have enough hold. We tried to Result of a Case Presentation) analyse if – first - we reach this position with our implant and – second – J. Simonka, A. Horva´th if we could correlate the outcome with the placement of our device. Department Of Traumatology, University Of Szeged, Hungary Patients and Methods: Until now nearby 300 patients had their unstable trochanteric femoral fracture stabilized by a PFN-A. The Background: Femoral head fracture is a rare injury. age of the female patients was 70–93 the male were 19–90 years. All Case report: 30 years old male during motorcycle accident suffered a patients had been mobilized under full weight bearing. Preoperative, right posterior dislocation. X-ray and CT examination showed a intra-/postoperative and the last available x-rays were analysed comminuted (double) fracture of the femoral head. Urgent open concerning the Tip-Apex-Distance and the Inferior-Superior- and the reduction and fixation of the femoral head fragments with four tita- Posterior-Anterior-Ratio. nium screws was performed. Early CPM was started, weightbearing Results: Special attention is drawn to implant migration in consid- was gradually allowed after 6 months. eration to Implant placement. Our hypothesis is the following: The Results: Femoral head was survived and revascularized. It was con- PFN-A blade should be placed as inferior as possible in AP and as trolled by radiographs and MRI every 6 months. Full range of central as possible in the axial view. The Tip-Apex-Distance should painfree motion of the hip was achieved and detected at the last be under 1 cm. Reduction in both planes in mandatory but the axial clinical evaluation after six years of surgery. alignement in crucial. Nevertheless the PFN-A with its antirotationl Discussion: The femoral head fractures associated with posterior blade is more forgiving than thought. dislocation are classified by Pipkin. Our case was an ‘‘unclassifi-

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 45 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

able’’ fracture combination of Pipkin type I. and II/B. We propose Patients were graded as stable or borderline (increased risk of to classify this fracture as Pipkin type V. The literature provides systemic complications). Outcomes: Incidence of pulmonary (acute very few guidelines for the treatment of patients with Pipkin lung injury, ALI) and systemic complications. Results 10 European fractures. Open reduction and internal fixation with screws is Centers, 165 patients, mean age 32.7U+00AlA´ 6.7 years. Group indicated when anatomical reduction of the fracture cannot be IU+00Ala˜IMN, n = 94; group IU+00Ala˜ExFix, n = 71. Preopera- obtained as in our case. This was the only procedure to achieve tively, 121 patients were stable and 44 patients were in borderline revascularization of the femoral head and to prevent early post- condition. In the borderline subgroups, the NISS was comparable. traumatic arthritis of the hip joint. Conclusions: We propose Borderline IU+00Ala˜IMN patients (b-IMN) had significantly higher modification of Pipkin’s classification based on presented combined incidences of ALI {b-IU+00Ala˜IMN (43.5%); b-IU+00Ala˜Ex- femoral head fracture case. We recommend emergency open Fix (14.3%); p = 0.013}, and an eightfold increased odds ratio for reduction and screw fixation of the fragments of the femoral head ALI. to achieve a better function. Conclusion: Intramedullary stabilization of the femur fracture in borderline patients is associated with a higher incidence of lung dysfunction following primary nailing when compared with external 153 fixation. Therefore, the preoperative condition should determine the Strategies for Damage Control in Severe Open type of initial fixation for femoral fractures in patients with blunt multiple injuries. Pelvic Trauma T. Schildhauer, G. Muhr BG-Universita¨tskliniken ‘Bergmannsheil’, Chirurgische Klinik U. 155 Poliklinik, Germany Open Versus Closed Fractures in Polytrauma We report on our experience in treatment of severe open pelvic Patients trauma over the last ten years. Emergent treatment of severe pelvic J. Waddell, E. Schemitsch2, M. McKee3, A. McConnell4, S. James5 trauma is built on three mainstays. Initially, treatment of hemor- St. Michael’s Hospital, Canada rhagic shock and emergent bony stabilization are in the foreground. Transfusion, fracture stabilization using circumferential pelvic anti- Purpose: To compare the results in polytrauma patients with open shock sheeting, external fixation or pelvic clamping, as well as versus closed femur fractures to determine if open femur fractures operative or angiographic hemorrhage control are first line measures. correlate with higher injury severity scores, increased length of stay Prophylaxis of sepsis is the second mainstay, including radical wound and higher mortality rates. debridement, early internal fixation, fecal diversion or suture of Conclusion: While the presence of an open femur fracture does not intraperitoneal bladder rupture. Finally, peripelvic associated injuries correlate with an increase in injury severity score or increase in ICU need to be addressed. In the emergent situation, measures such as length of stay it does act as a marker for a more serious prognosis in suprapubic cystostomy, reconstruction of the pelvic floor, suture of polytrauma patients. an extraperitoneal bladder rupture, wound debridement or fecal Significance: Open femur fractures act as a marker for poor prognosis diversion need to be considered. in polytrauma patients. Materials & Methods: A retrospective review of a prospectively gathered trauma database at a Level 1 Trauma Centre was carried 154 out to identify polytrauma patients with femur fractures over a 36 Increased Risk of Acute Lung Injury Associated month period. There were 33 patients with open femur fractures and 80 patients with closed femur fractures. The data was collected on with Initial Intramedullary Femoral Nailing in demographics, precipitating events, length of ICU stay, ISS, AIS, Polytrauma Patients at Risk for Complications - number of femoral surgeries and patient disposition. A Prospective Randomized Controlled Trial Results: Patients in the open femur fracture group had the same length of stay, number of associated injuries, and injury severity H. Pape1, D. Rixen2, E. Ellingson3, C. Krettek4, P. Giannoudis2 score as those in the closed femur fracture group. However, their 1University Of Pittsburgh Medical Center, USA mortality rate was 30% whereas in the closed group the mortality 2University of Witten Herdecke, Germany was 12%. A Chi-squared analysis of disposition indicated that pa- 3University of Oslo, Norway tients with open femur fractures are more likely to die of their injuries (p-value 0.02) Background: The timing of definitive fixation for major fractures in polytrauma patients is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an 156 external fixateur and documented the postoperative clinical condi- Comparative Study of PFN and PFN-A Implants in tion. Methods: Multiply injured patients with femoral shaft fractures the Treatment of the PER and Subtrochanteric were randomized to either initial (<24 hours) intramedullary fem- Femoral Fractures oral nailing (group IU+00Ala˜IMN) or external fixation and later Z. Szabo, F. Kazacsay, L. Skoran, R. Hoti, S. Szabo conversion to an intramedullary nail (group IU+00Ala˜ExFix). BAZ County UniversityTeaching Hospital Inclusion: New Injury Severity Score (NISS) > 16 points, or 3 fractures and Abbreviated Injury Scale (AIS) U+00AlY´ 2 points Comparative study of PFN and PFN-A implants in the treatment of and another injury (AIS U+00AlY´ 2 points), and age 18–65 years. the per and subtrochanteric femoral fractures Introduction Our

46 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

department is one of the greatest trauma care units in Hungary. One 158 year ago we introduced the treatment of these fractures with PFN-A. Investigation to the Rotational Stability of the PFN Formerly these fractures were treated with PFN , our aim was to verify if this new device has some advantages or disadvantages in the a and the Gamma 3 Nail 1 2 2 3 1 treatment of the pertrochanteric fractures. A. Lenich , J. Fierlbeck , J. Hammer , M. Nerlich , E. Mayr 1 Material and Methods: Our retrospective randomized study com- Klinikum Augsburg, Germany 2 pared the first 100 patients operated with PFN-A with 100 patients University for applied science 3 operated in previous years with PFN. Age, sex, fracture type, time University of Regensburg, Germany from accident, time from admission to operation was considered. Presence of other injuries, and diseases, the experience of the oper- Thera are many publications about the different complications after ating surgeon, type of positioning, time of operation, intraoperative intertrochanteric fractures of the femur. The clinical documentation complications were compared. Radiografic and clinical early and late of the mechanical failure is difficult. Reproducable biomechanical results were analised too. tests are hardly published. Biomechanical tests with the helical blade Results: Considering two almost identic groups of 100 patients the of the PFN A and the screw of the Gamma3 nail in femural heads results of our comparison demonstrated the superiority of the new showed a better rotational stability for the helical blade. This pre- method by significantly reducing the operation time, the hospitali- sentation gives evidence about a possible failure mechanism after sation period the postoperative complications and the number of osteosynthesis with the PFN A and the Gamma3 nail. A testing reoperations. On the other side the new method increased the machine has been build to simulate a walking cycle with femur under number of malpositioned devices with a relative excessive length of physiologic loading. We used sawbones and 8 pairs of human cadaver the neck screw. This is probably due to the fact that once this screw femura. The bone density was measured by a CT scan. All bones introduced it is very difficult it’s replacement. were prepared with a A2.3 fractur. For the documentation of the Conclusion: Considering our first 100 operations we can conclude implant position we took a.p. and lateral X-ray pictures. The probs that this new device has a series of advantages but needs higher were loaded with 2.5 times of the bodyweight for 20.000 cycles with attention during operation for a good result 1Hz. We documented the load, ways, cycles and angles. For the data workup labview was used. All Probes showed a rotation of the femural head fragment around the implant. After the first 500 cycles for the PFN A 4.6 and the Gamma3 6.2 has been seen. After 20.000 157 cycles the probes with the PFN A presented a rotation of 5.9, the Gamma3 probes showed 9.0. The experiment showes after cyclic Locking Compression Plate System in physiologic loading with the testingmachine a rotation of the head Periprosthetic Femoral Fractures neck fragment around the implant. The PFN A showes a better M. Berlusconi1, F. Chiodini1, I. Scarabello1, D. Marchettini1, rotational stability. These results are equal with our own clinical M. Zago2 findings. 1Istituto Clinico Humanitas - IRCCS - 2nd Dept of Traumatology 2(2)Emergency and Trauma Surgery Section 3 6-Dr. Lorenzo Di Mento (1) 7-Dr. Alessandtro Casiraghi (1) 159 Surgical Reconstruction of Old Patellar Non-Union

A prospective study in the treatment of periprosthetic hip fractures (with Gap more than 5 cm ) with Semitendinosus (Vancouver type-B1 fractures, with a stable femoral stem) was Bridging Graft accomplished. Thirty-two patients were enrolled, with a mean S. Rajagopalan follow-up of 17.8 months. The mean Harris hip score was over 90 Barnet Hospital in all cases, with a mean healing time of the fracture of six months. Issues in using the LCP system (locking compression Non union of patella is very rare.Various investigators have reported plate) were analyzed. This is the first reported study evaluating non-union with an overall incidence ranging from 4.4 -12.5 %.There many configuration of the LCP system to achieve the best stability is little information regarding treatment recommendations or data in this field. This system guarantees early mobilisation, and a specifically addressing the outcome of patellar nonunions Five cases possible healing of the lesion with two types of configuration. of non union patella operated in between 2002 and 2004 were in- When the fracture lies in the proximal or mid portion of the stem, cluded in our study.Age distribution varied between 20–60 years with we performed an ORIF with a plate not so much longer than the mean age of 41.5 years.All patients were males.Four patients had stem (10 holes), using green self-blocking screws in four holes right sided non-union and one left.Average duration of post trauma proximal and distal to the fracture (four cortex proximal and was 14 months.All patients were observed prospectively. The semi- distal). When the fracture lies in the distal part of the stem we tendinosus free tendon graft was used to bridge the gap between needed longer plates (at least 14 holes), using four cortex in the patellar non union fragments. Patients were non weight bearing for 6 proximal side of the femur (even using cancellous bone screws in weeks post op. After 6 weeks post op in cylinder cast , cast was the greater throcanter) and at least eight cortex in the distal side, removed and knee mobilisation started.Patients were followed up using green self-locking screws. In two cases there was non-union and reviwed at regular intervals ( 6 weeks, 3 months, 6 months , 1 of the fracture, with rupture of the plate. These cases were fixed year). At final follwup average extensor lag was 16.66 degrees , with two plates on different planes with bone graft and healed average ROM was 0–110 degrees and residual average gap between after 4 months. LCP system has to be considered the golden fracture fragments post op was 4.75cm.Av quadriceps power was standard in the ostheosynthesis of Vancouver type-B1 peripros- 3 + .As per Knee functional score good results were seen in 4 pa- thetic fractures. tients and fair result in 1 patient.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 47 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

160 patient showed a complete condylar loss due to osteomyelitis. In two The Floating Knee – Outcome Following Surgical cases persistent soft-tissue defects were covered with flaps. Injury to the popliteal artery was one complication which was accomplished by an Management allograft bypass. Thirteen patients underwent follow-up examination. 1 2 2 1 U. Rethnam , S. Yesupalan , B. Ramesh , R. Nair The evaluated midterm results are good to excellent with no 1 St John’s Medical College Hospital mechanical failures. There are no persistent soft-tissue defects. 2 Glan Clwyd Hospital Metaphyseal-filling implants and hinged prosthesis enable us to counteract large metaphyseal defects and ligament instability. Background: Floating Knee injuries are complex injuries. The type of fractures, soft tissue and associated injuries make this a challenging problem to manage. We present the outcome of these injuries after 162 surgical management. Materials and methods: 29 patients with floating knee injuries were Anaesthetic vs Operative Time in Patients managed over a 3 year period. This was a prospective study were Undergoing Femoral Neck Fracture Fixation both fractures were surgically fixed using different modalities. The S. Thiagarajah, S. Samad, P. Maguire, P. Dukow associated injuries were managed appropriately. Assessment of the end result was done by the Karlstrom criteria after bony union. We performed, using the computerised ORMIS system, a retro- Results: The mechanism of injury was road traffic accident in 27/29 spective review of a 100 patients undergoing femoral neck fixation patients. There were 34 associated injuries. 20/29 patients had in- (50 DHS / 50 Hemiarthroplasty). ORMIS, the operating room tramedullary nailing for both fractures. The complications were knee management system collects information on the time individual stiffness, foot drop, delayed union of tibia and superficial infection. physicians take to complete specific procedures and thus pin-point The mean bony union time ranged from 15 – 22.5 weeks for femur potential inefficiencies. In particular we recorded the start and end fractures and 17 – 28 weeks for the tibia. According to the Karlstrom times of anaesthesia administration and operative treatment respec- criteria the end results were Excellent – 15, Good – 11, Acceptable – tively. In addition, the type of anaesthestic and grade of physician 1 and Poor – 3. performing the procedure were noted. The review revealed a mean Conclusion: The associated injuries and the type of fracture (open, anaesthetic time 16.5 mins, compared to mean operative times of 54.8 intra-articular, comminution) are prognostic indicators in the Float- mins and 53.4 mins for DHS and hemiarthroplasty respectively. ing knee. Appropriate management of the associated injuries and Intermediate grade surgeons on average took 23 mins less time intra-medullary nailing of both the fractures and post operative performing hemiarthroplasties. In summary, the study revealed sur- rehabilitation are necessary for good final outcome. prisingly and at times unrealistically short anaesthetic times (ranging from as short a 0 mins!), showing potential inefficiencies of the system and in particular data input from theatre staff. 161 Hinged Total Knee Arthroplasty for Salvage of 163 Substantial Femoral/Tibial Bone Loss and Deficient Short Trochanteric Antegrade Nail (T.A.N.) – a new Ligament Stability M. Frank1, S. David2, A. Ekkernkamp1,2 Solution for Displaced Subcapital Fractures of the 1Department Of Orthopedic And Trauma Surgery, University of Femur Greifswald, Germany B. Kish, Y. Brin, M. Nyska 2Department Of Orthopedic And Trauma Surgery, Unfallkranken- Meir Medical Center, Kfar Saba haus Berlin, Germany Patients sustaining intracapsular displaced hip fracture who con- Background: Management of substantial bone loss of the distal fe- sidered to be ‘young’ (active patients less then 70 years old) are mur/proximal tibia is a challenge in revision knee arthroplasty, per- generally treated by anatomical reduction and internal fixation. sistent non-union of (supra)condylar femur fractures and osteolysis Older patients are usually treated by hemiarthroplasty. We treated due to osteomyelitis of the condylar region. Metaphyseal-filling im- our active patients with displaced intracapsular hip fracture plants and hinged revision knee arthroplasty systems may offer a regardless of age by close reduction and internal fixation with Short treatment option in cases of bone loss and deficient ligament stability. Trochanteric Antegrade intramedullary Nail (T.A.N.). 19 patients, It is our objective to review our cases in which modular rotating 20 cases, mean age 72.5 (range 26–93), sustained a subcapital hinged knee arthroplastie was performed as a limb salvage option fracture of the femur, garden III and IV, and were treated by close when other surgical options were unfeasible. reduction and internal fixation with the T.A.N. (Smith & Nephew). Method: We reviewed our limb salvage procedures of patients suf- The patients were not allowed to bear weight on the operated leg fering from severe tibial/femoral bone loss or complex ligament for 4 weeks, followed with partial weight bearing for another 4 instability following trauma, osteomyelitis or revision arthroplasty. weeks. Full weight bearing was initiated 8–10 weeks following the Results, Conclusion: From March 2005 until January 2007 we per- operation. Patients were evaluated in our clinic 1,2,6 &12 months formed 14 (10 fem./4 male, age 63.9 ) modular rotating hinged knee after the operation. Two of the patients died with-in two months arthroplasties in cases of severe deficiencies of bone or ligament sta- after the operation. All the patients returned to walk on their feet. bility. Seven patients underwent this procedure because of septic/ The patients were scored by modified lower extremity question- aseptic pseudarthrosis after distal femur fractures, in 4 patients massive naire with mean results 4.36 (scale of 1 to 5, 1 poor and 5 excel- bone loss occurs from revision arthroplasty in septic/aseptic loosening. lent). There were no cases of implant failure. No cases of infections. Two patients showed a complex ligament instability after luxation. One One patient had a cut-out of the implant 2 months after the sur-

48 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

gery, treated by conversion to T.H.R. In our 6–12 months follow-up Patients and Methods: A stabilisation with a long PFN-A ( 340 mm and there were no cases of avascular necrosis. Closed reduction and longer )had been carried of subtrochanteric femoral fracture out at 12 internal ﬁxation with Trochanteric Antegrade Nail is a good patients from march 2005 till may 2006 at our clinic. The distributions alternative for hemiarthroplasty in the older active patient with of fracture type according to the AO-classiﬁcation were 32-A, B and C. displaced subcapital hip fracture. All patients with A and B fractures had been mobilized under pain dependent full weight bearing. The follow up assessments had been attended after 6. 12 and 24 weeks including an x-ray control. Results: All fractures healed within 3–6 month.We saw no migration 164 or cutout of the blade. The Biomechanics of Periprosthetic Femoral Conclusion: The PFNA shows some advantages comparing to the Fractures Following Tha: an Assessment of Locked DHS, DCS used for subtrochanteric femoral fractures at our clinic Plates, Non-Locked Plates, and Allograft Struts before. The lengs of the skin to skin time was shorter. There is no migration of the neck blade. J. Waddell1, R. Zadero1, R. Walker1, E. Schemitsch1 St. Michael’s Hospital, Canada

Introduction: Periprosthetic fractures of the femur pose a difficult 166 treatment problem. Recently locked plates have been suggested as a Complication Management of Long Bone Fracture stand-alone treatment for such fractures. We have performed a study in Klippel-Trenaunay-Weber Syndrome comparing locked plates, standard plates and standard plates with M. Coulibaly1, C. Gekle1, T. Weiss2, G. Muhr1, M. Wick1 strut allograft. 1Departemnt of Traumatology, Universityhospital Bergmannsheil, Methods: Four fracture fixation constructs were assessed. Construct Bochum, Germany A – Synthes locked plate plus locked screws; Construct B – Synthes 2Department of Anaestesiology and Intensive Care Medicine, Uni- locked plate plus wires and locked screws; Construct C – Zimmer versityhospital Bergmannsheil, Bochum, Germany non-locked cable plate plus wires and non-locked screws; and Con- struct D – Zimmer non-locked cable plate with allograft plus wires Klippel-Trenaunay-Weber syndrome (KTWS) is a rare phakomatosis and standard screws. A simulated mid-shaft femoral fracture with characterized by hemangioma, varicose veins and hypertrophy of bone comminution was constructed in 20 synthetic saw bone femurs. After and soft tissue. There is actually no data in the literature about fracture fixation with the various constructs there were tested in axial com- management of a syndrome affected extremity. We report about a 31- pression, lateral bending and torsion. year old man with KTWS and a displaced femoral shaft fracture on the Results: Construct D demonstrated either equivalent or superior affected site. The diagnosis of KTWS was made by dermatological stiffness in all testing modes compared to all other constructs in the findings. Laboratory findings showed a coagulopathy state with de- presence of both mid-shaft fractures and bone gaps. Constructs A, B, creased %-Quick and fibrinogen as well as elevated prothrombin time. and C demonstrated equivalent stiffness between themselves in all Among different surgical procedures closed reduction and intrame- test modes for both mid-shaft fractures and bone gaps. dullary nailing was chosen. The operation was complicated by a severe Discussion & Conclusions: We conclude that a combination of non- bleeding disorder via the distal surgical approach including a decrease locked plate and allograft strut remains an optimal configuration in of hemoglobin levels from 12.9 to 8.4 g/dl in between minutes. Long the treatment of periprosthetic fractures around stable femoral bone fracture is a rare complication in Klippel-Trenaunay-Weber components. It is recommended that a locked plate be used with syndrome. Surgical treatment by intramedullary nailing proved to be caution as a stand-alone treatment. an effective therapy but decisive factors are extensive preoperative planning including supply of stored blood and interdisciplinary work between intensive care medicine, anesthesiologist and trauma surgeon. 165 First Experiences of the Treatment of Subtrochanteric Femoral Fractures with the Long 167 PFN-A Intramedullary Nails in the Treatment of Femoral W. Hartwagner, H. Clement, K. Tanzer, F. Seibert, W. Seggl and Tibial Fractures in Politrauma Department of Traumatology, Medical University of Graz, Graz, M. Popescu1, D. Poenaru2, B. Tunescu1, E. Urban3, J. Poigenfurst1 Austria 1Politraumatology Casa Austria Timisoara 2IInd Department of Orthopedy and Traumatology Timi-oara Introduction: For the surgical treatment of unstable subtrochanteric 3Emergency Surgery Bruck/Mur femoral fractures (AO-classification 32-A1–3.1, B1-3.1 or 32-C1-3.1) essentially three different implant systems had been used at our Aim: To present our results of the treatment with rigid unreamed nails clinic. Either two extramedullary systems DHS and DCS or an in- in politrauma patients with tibial (TF) and femoral (FF) fractures. tramedullary the AFN had been the devices. Extramedullary osteo- Material and Method: We studied the patients admitted between synthesis is not suitable for direct postoperative full weightbearing 01.08.03-01.11.06 at Politraumatology Department-Casa Austria with where as intramedullary fixation knows a higher amount of implant TF and FF. We evaluated the following parameters: associated lesions, related complications indicating that intramedullary systems are less the interval between admission and surgery, type and localization of forgiving. Therefore at our clinic we assessed a new intramedullary the fractures, soft tissue lesions, type of osteosynthesis, complications. system consisting of only one single femoral neck element with an- Results: Our group consisted of 91 patients (p)-68 male (75%), 23 tirotational properties called PFNA. female (25%), with an average age of 36+/–15 years, with 104 frac-

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 49 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

tures. ISS: 7p with ISS 1–8, 24p with ISS 9–15, 22p with ISS 16–24, adults. In 1995 we started to use an unreamed technique with a 31p with ISS 25–40 and 7p with ISS>40. 58p had surgery in the first 24 titanium unreamed femurnail (UFN). Primary objective of this study hours, 24p in the first 10 days and 9p after 3 weeks. The patiens that was the incidence of pseudarthrosis following unreamed intrame- had surgery in the first 24 hours and those with small ISS needed the dullary stabilization of femoral fractures. Secondary objectives were smallest hospitalisation period, 19 and 7 days respectively. AO intra- en postoperative complications, femoral malrotation (>15 de- classification: the TF were: 47 diaphyseal, 5 distal and 2 with asso- greed ), leg length discrepancy (>2 cm) and implant failure. ciation 42C2 + 43C2; the FF were: 42 diaphyseal and 8 with multiple Methods: Between March 1995 and June 2005, 138 patients with 142 sites. We had 30 open TF and 9 open FF. femoral fractures were treated with the unreamed femoral nail. Pa- Complications: Infections (5%), deep venous thrombosis (3%), tients with a pathologic fracture and patients who had a reoperation pseudarthrosis (2%), breakage of the implant (3%), 3 deaths. with an unreamed femoral nail were excluded from this retrospective Conclusions: The severity of associated lesions and the moment of study. According to the AO classification, there were 74 type A, 50 surgery are 2 important factors that influence the evolution of the type B, and 18 type C fractures. patient. Unreamed intramedullary nailing is a safe method providing Results: Pseudarthrosis occurred in 4 patients (3.2%). Intraoperative stable fixation and fewer complications in TF and FF in politrau- complications were seen in 5 patients (3.6%), including one patient matized patients. who developed severe pulmonary insufficiency and died. Postoper- ative in-hospital complications occurred in 35 patients (26%), including one death caused by severe head injury. Ten patients were 168 treated for post-traumatic femoral malrotation and/or leg length The Use of Retrograde Intramedullary Nailing in discrepancy. Nailbreakage was seen in 2 patients (2.4%), one with the Management of Distal Femoral Supracondylar and the other without new trauma. Conclusion: The incidence of pseudarthrosis in this retrospective Fractures single centre is low (3.2 %). Unreamed nailing can be used safely in K. Papagiannakos, P. Kouloumentas, N. Dedoukos, the treatment of femoral shaft fractures. S. Tzevelekos, Z. Stavrou 2nd Orthopaedic Department 170 Aim: The aim of this study is to evaluate the results of the use of New Trends in Treatment of Pilon Fractures: retrograde nailing in the management of distal femoral supracondy- The Place of MIPO lar fractures. F. Castelli, R. Spagnolo, D. Capitani Material and Methods: Between 2000 and 2006, 27 patients with distal femoral fracture were treated with retrograde intramedullary Nguarda Ca’ Granda nailing. The average age was 55,1(18–97) years old. The reduction in Introduction: Modern treatment of tibial pilon fractures devolops, most cases was closed but in 8 cases had to be done openly. improves in implant’s design and in surgical approaches Parameters that were studied for the evaluation of the final outcome Materials and methods: We studied in clincal advantage of new sur- were related to the surgical procedure (such as the blood loss and gical approaches and new implants with angolar stability. We use peri-operative complications), the time to fracture union, the patient antero-lateral approach with isolation of saphenal nerve alone or satisfaction. In 8 cases the reduction had to be open. Partial weight associated to a minimal invasive plating osteosintesis trought a medial bearing started 2–3 weeks post operatively. approach. Anterolateral way is prefered because of anterolateral Results: Follow up ranged from 6 months to 7 years. All fractures comminution of the fracture evaluated on the axial CT scan views. To healed at an average time of 3,5 months. Two patients were lost at plan an osteosynthesis with plate, treated with minimal invasive way, the follow up. All cases regained full range of knee joint motion on tibial pilon fractures we need: - simple articolar fracture - reduc- except one in which the nail was protruding in the knee joint and ible articular fragments throug indirect tecnique - Intregrity and interfering with the patellar movement. The blood loss was minimal reducible medial and posterior malleolus - Any soft tissue damage in all closed cases. In one patient a distal screw had to be removed Results: We present 26 pilon fractures treated with minimal invasive because of pain during walking. There was no case of infection. techinque from from January 2004 to September 2006 with an Conclusions: Retrograde nailing in the management of distal femoral average follow-up of 14 months. We treat 6 fractures Type A with supracondylar fractures appears to be an acceptable and safe method fibualr plating and nailing and 6 fractures with minimally invasive of treatment, which gives the necessary stability and provides quick plating osteosintesis with good and excellent result; 4 fractures Type mobilization and bone healing for the patient. The method can be B1 and 5 type B2 with with good and excellent results, 5 fractures used for comminute and osteoporotic fractures. type C1 with 3 excellent and 2 good results, 3 fracture type C2 with 2 excellent and 1 good results and 2 fracture type C3 with good results. 169 The Incidence of Pseudarthrosis Following 171 Unreamed Intramedullary Nailing of Femoral Tibia Shaft Fractures - Classic and Extended Fractures Indications, Technique and Clinical Results of ETN M. El Moumni1, P. Leenhouts2, H. Ten Duis1, K. Wendt1 J. Trlica1, T. Dedek1, I. Zvak1,2, J. Folvarsky1,K.Sˇmejkal1,2 1Universitair Medisch Centrum Groningen 1University Hospital Of Hradec Kralove 2St.-Annaziekenhuis Geldrop 2University of Defence, Faculty of Military Health Sciences

Introduction: Stabilization of fractures with an intramedullary nail is Aim: Presentation of our technical experience with ETN(Expert a wide-spread technique in the treatment of femoral shaft fractures in Tibial Nail) and clinical results.

50 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Material and Method: Sept.2005-Dec.2006 ETN was used in 28 pa- Fixion IM nail system for stabilising of tibial, femoral and humeral tients with 28 tibia shaft fractures (TSF). All patients have been shaft fractures. prospectively followed. Injury severity (Tscherne-Oestern; AO clas- Method: 20 patients with tibial, 4 with femoral and 16 with humeral sification), risk factors, early and late complications and time to diaphyseal fractures were treated in our institution over a 32-month weight bearing were recorded. period. Results: Injury severity score (ISS) ranged 4–25(avg.5.9); isolated/ Results: Lower Limb Fractures: A satisfactory (stable) reduction was multiple injuries - 23/5. AO type of TSF 42 n 20 (pure shaft); 41/42 n achieved in all cases and no intra operative problems were reported. 2 (bifocal); 42/43 n 6(shaft extended to distal metaphysis (MF)). Union occurred in 100% of cases. Mean time to union was 19 weeks There were 21 close (0.-8; I.-10; II.-3) and 7 open(I.-2; II.-3; III.-2) (range 12–52 weeks). Complications included 1 compartment syn- TSF. Time to surgery ranged 1h50’ - 25h12’ (median 8h52’). Duration drome, 1 implant failure and 1 case of delayed union. There were no of operation ranged 50’-170’ (avg.87’). There was no infection; no cases of infection. 4 patients underwent planned nail removed after loss of reduction; two insufficient prime reduction requiring re- union. HUMERUS Fracture: 19 Fixion humeral nailings were per- operation through the same hospitalization. Full weight bearing formed in 16 patients; a stable fracture reduction was achieved in 15 (painless) ranged 10–24(avg.18) weeks. operations. Operations were performed for primary fracture fixation Discussion: Diameter of the nail in relation to medullary cavity can (13) and fracture non-unions (6). At follow-up, 2 patients died sec- be adjusted during operation without loss of reduction (guide wire; ondary to metastatic disease. 3 patients had non union and 2 cases of un-/reamed technique). In spite of shorter straight distal part of the delayed union. There was one instance of intraoperative device nail (compared to UTN) its very steep position through insertion to failure. the short proximal MF block remains necessary. Blunt distal end of Conclusion: We view our results for Fixion nailing of tibial and femur ETN produces distraction during deep insertion to the short distal shaft fractures as encouraging, providing satisfactory axial and rota- MF block if used without reaming. Conclusion: ETN enables proper tional stability at the fracture site until union in all cases. However, stability of TSF including extended ones to the metaphyseal parts. the implant did not show corresponding characteristics in the treat- The poller screws may be usefull in some cases. The proper reduction ment of humerus shaft fractures; with maintenance of stable fracture (especially of MF blocks) before insertion of the nail remains reduction seen in 11 of 16 patients. essential.

172 174 Importance of Early Operative Stabilization of Minimal Invasive Plate Osteosynthesis of the Lower Extremity Long Bone Fractures in Severe Distal Fibula with the Locking Compression Plate: Polytrauma First Experience of 20 Cases A. Pamerneckas, A. Macas, A. Blazgys, V. Toliusˇis C. Sommer, F. Hess Kaunas University Hospital Departement Chirurgie, Unfallchirurgie, Kantonsspital Graubu¨ nden, CH-7000 Chur, Switzerland Objectives: Early operative long bone fracture stabilization is recommended in severe multiple trauma patients. Background: Minimal invasive plate osteosynthesis (MIPO) is a new Background: Forty-eight severe blunt polytrauma patients (ISS>16) method for plate fixation of long bone fractures of the upper and were analyzed retrospectively to assess in-hospital outcome. Twenty- lower extremity. We use this technique since several years also for four patients received early (<24 hour) operative lower extremity the distal fibula in selected cases. Aim of this study is to evaluate the long bone fracture stabilization and twenty-four homogeneous (age, clinical feasability and the possible complications of the new tech- ISS, RTS, TRISS) patients with similar fractures received conserva- nique. tive treatment. Methods: Retrospective analysis from march 2001 to april 2006. From Results: Mortality in early operative fracture stabilization group a consecutive series of 701 tibia and ankle fractures with 255 plate (37,5%) was significantly lower in comparison with conservative fixations of the fibula in total, 20 were performed in the MIPO fracture treatment group (75%, p < 0.01). technique using a LCP metaphyseal plate 3.5 in bridging function. Conclusions: Early operative long bone fracture stabiliation in severe Indications were mainly multifragmentary fractures of the fibula with polytrauma patients is reasonable. severe soft tissue injury. The stabilisation was mostly performed as a two-staged procedure according to the principles of pilon/complex ankle management. Follow-up of all 20 patients after six weeks, three months and one year. 173 Results: 17 fractures healed uneventfully. Three aseptic non unions The Innovative Fixion Nailing System For were recorded: one in a pilon, one in a distal lower leg and one in an ankle fracture dislocation with delayed treatment and inadequate Stabilisation Of Tibial, Femoral And Humeral Shaft reduction of the simple fibula fracture. No infection or fixation failure Fractures – Follow Up In 40 Patients occured. E. Mallick, S. Hazarika, S. Asaad, M. Scott Conclusion: This small series of MIPO for distal fibula fracture North Tyneside General Hospital suggests that this technique can also be used for this bone with favorable results and a low complication rate. Using a proper Introduction: Reported benefits of self locking nails compared to technique, MIPO is a safe and effective treatment for few selected conventional locking nails include reduced operative time and less complex fractures of the distal fibula with critical soft tissue radiation exposure. Aim: We report our clinical experiences with the conditions.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 51 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

175 177 The Incidence of Pseudarthrosis Following Open Reduction and Internal Fixation of Displaced Unreamed Intramedullary Fixation of Intraarticular Fractures of the Calcaneus Lower Leg Fractures M. Andoljsek R. den Boer, M. Dam, K. Wendt, H. ten Duis General Hospital Jesenice University Medical Centre, Groningen In prospective study the author asked, what are the results of ORIF Background: Since the introduction of the locking nail, intramedul- in displaced intraarticular fractures of the calcaneus, and whether lary stabilisation of lower leg fractures has been used widely. type of fracture and/or congruity in the subtalar joint influence these According to literature closed fractures can now be treated with the results. Forty-three displaced intraarticular fractures of the calcaneus unreamed tibia nail (UTN). The purpose of this retrospective survey (30 Type II, 10 Type III and 3 Type IV; Sanders) were operated is to determine the incidence of pseudarthrosis following treatment through extensile lateral approach. After reduction of the subtalar with UTN and to establish risk factors for pseudarthrosis. joint and restoration of the calcaneus shape, the fracture was fixed Methods: From June 1991 until December 2004 most diaphysial with a plate. Mostly, surgery was delayed (median day 7). Motion was lower leg fractures eligible for surgery were treated with the UTN encouraged immediately, partial weight-bearing after 5–6 weeks, and and retrospective analysed. full weight-bearing after 3–4 months. Following surgery subtalar joint Results: 340 lower leg fractures of 337 patients were treated with an was congruent in 33 and non-congruent (within 2mm) in ten frac- unreamed tibia nail. 227 patients had isolated injuries and 113 pa- tures. Thirty-six fractures were evaluated 12 to 61 months postinjury. tients suffered from multiple injuries. (AO: type A: n = 191, type B: Functional results were satisfactory in 31 fractures (86%) and not n = 84, type C: n = 65, 215 closed fractures, 122 open fractures). satisfactory in five. All fractures with unsatisfactory results were After one year 321 fractures had consolidated. Pseudoarthrosis was comminutive. Four fractures with congruent subtalar joint had established in eleven patients. unsatisfactory, whereas eight of nine fractures with uncongruent joint Conclusion: The number of cases of pseudarthrosis in this survey was had satisfactory result. Statistically, functional results of the commi- small (11/340). Therefore no predisposing factors for the occurrence nuted fractures were significantly worse. However, functional results of pseudarthrosis could be identified. Treatment with UTN can be a of fractures with non-congruent joint were comparable to the results safe method for stabilising most types of tibia fracture of fractures with congruent joint and analysis of variance showed that interaction of these two factors was not important. ORIF enables satisfactory results in majority of displaced intraarticular fractures of the calcaneus. Comminution in the subtalar joint is a negative 176 prognostic factor; furthermore, comminution is a negative prognostic Complications Following Internal Fixation of factor irrespectless of the postreduction congruity in the subtalar Ankle Fractures joint, if step-off is less than 2mm. T. Thangarajah, P. Prasad, B. Narayan The Royal Liverpool University Hospital 178 Background: The incidence of postoperative complications pertain- ing specifically to ankle fracture fixation, as opposed to all internal Bohler’s Angle and Gissane’s Angles: Correlation fixation procedures, is scarcely documented. with Outcome in Intra-articular Calcaneal Fractures Aim: To determine adverse postoperative events following fixation of A. Rafee1, G. Prassad2, A. Chougle2, S. Khan2, G. McLauchlan2 closed, low-energy ankle fractures, and to identify key variables. 1Manchester University Methods: Retrospective analysis of data of 50 such patients retrieved 2Royal Preston Hospital from an operating theatre database. Setting: University Teaching Hospital with a dedicated trauma subunit. Aim: to evaluate the correlation between Bohler’s and Gessiane’s Results: Problems with wound healing were seen in 18%, and deep angles and functional outcom. A prospective study, Twenty nine infection in 6%. The Fisher’s test was tested with age, gender, type of fractures in twenty eight patients were analysed for clinical outcome fracture, number of comorbidities, delay to surgery, smoking, and as measured by Ankle and Hindfoot Score (AHS), Bristol score seniority of surgeon. Smoking was the only variable that correlated (Calcaneal Fracture Score System, CFSS) and SF-12 Health Survey strongly with wound problems (p = 0.025), with others showing scores and return to work or if there was any change in their occu- p > 0.05. Two fixations were found inadequate and admitted from pation. Radiographic results were measurements of Bohler’s and clinic for redo surgery. Gissane’s angles on plain x-rays (day of injury, 6 weeks, 6 months, 1 Discussion: In our reasonably sized sample, we found that smoking was year and 2 years). Angles were measured twice by two observers the only strong correlation with wound problems, rather than ‘tradi- working independently. Results: Initial treatment of the 13 calcaneal tional’ poor markers such as advanced age, comorbidities such as fractures in our study was nonoperative and operative (open reduc- diabetes, surgical inexperience, and complex fracture patterns. In tion and internal fixation) 16 (1 patient had bilateral fractures). In addition, two patients had been discharged home on the basis of operative group Preoperative Bohler’s and Gissane’s angles averaged ‘adequate’ perioperative image intensification films. These were found 12degrees and 141 degrees ; postoperative angles averaged 34 de- to be an inadequate judge of restoration of stability of the ankle mortice. grees and 123 degrees, respectively. The average difference between Conclusion: 1. As part of their consent, all smokers undergoing postoperative Bohler’s and Gissane’s angles compared with the internal fixation of ankle fractures should be counselled about a normal contralateral side was 3 degrees each. This prospective study potentially high risk of problems with wound healing. 2. All inter- indicates that patients initially presenting with a severely depressed nally fixed ankles undergo a plain radiograph prior to discharge. Bohler’s and Gissane’s angle have a poor two-year outcome

52 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

regardless of treatment. As well, fractures of lesser initial displace- plate angle and volar radius angle may additionally lead to an ment, as measured by Bohler’s angle, had higher functional scores on incorrect plate position. both AHF and SF-12 scoring scales. Bohler’s and Gissanes angles has significant prognostic value in terms of predicting morbidity. Frac- tures with a markedly diminished Bohler’s angle demonstrated a 181 much poorer two-year outcome. Immobilization after Primary Shoulder Dislocation in External Rotation 179 D. Seybold, C. Gekle, J. Krajewski, G. Muhr, T. Ka¨licke Berufsgenossenschaftliches Universita¨tsklinikum Bergmannsheil, The Fixion Nailing System for Stabilising Bochum, Germany Diaphyseal Fractures of the Humerus - 2 Year Clinical Experience of a District General Hospital Introduction: The recurrence rate after primary shoulder dislocation E. Mallick, H. Sharif, M. Scott in the young patient is high (up to 90%). A new method of immo- North Tyneside General Hospital bilization with the arm in external rotation improves the position of the displaced labrum. With the use of MRI the repositioning and the The self locking Humerus Fixion nail has shown good results previ- healing of the labrum is evaluated after immobilization in external ously for rapid stabilisation of long bone fractures with reduced rotation. operative time and radiation exposure. We report our experiences Methods: 20 Patients (mean age 31 years) with a primary anterior with the Interlocking humeral Fixion nailing, which was introduced dislocation of the shoulder without a hyperlaxity of the contralateral in place of the self locking nail. 19 IL Fixion nailings were per- side and isolated Bankart lesion were immobilized in 15 of external formed in 16 patients over a 2 year period, with 11 females and 5 rotation for 3 weeks. MRI was taken in internal and external rotation males of mean age 60 years (25–84 years). All fractures were dia- of the shoulder after trauma and after 6 weeks. physeal and closed. 8 primary fracture stabilisations were performed Results: Dislocation and separation of the labrum were both signif- with a mean operative time of 116.9 mins (65–150 mins). 5 fractures icantly less with the arm in external rotation due to the tension of the united within 24 weeks and 1 fracture at 27 weeks post-op. We re- anterior capsule and the tendon of the subscapularis muscle in corded 2 non-unions in this group, both associated with rotational external rotation. In the MRI 6 weeks post trauma all Bankart lesions instability at the fracture. 6 nailings were performed in 4 patients for stayed in reposition. The one-year follow up showed a Rowe score of fracture non-union + /– additional procedures, with a mean operative 92.9 and a Constant score of 94.1 Points. Two patients had a recur- time of 127.5 mins (75–255 mins). 1 case did not unite despite 3 rent dislocation after 8 and 6 months. separate Fixion nailing procedures and 1 delayed union at 56 Conclusion: Immobilization of the arm in 15 of external rotation weeks. 5 operations were performed for a pathological fracture, with seems to allow healing of the Bankart lesion in a better position than mean operative time of 79 mins (55–120 mins). Union occurred in 3 with the arm in internal rotation. To evaluate the recurrence rate cases within 14 weeks following a stable reduction. 2 patients died at after immobilization in external rotation after primary dislocation of 4 weeks post-op secondary to metastatic disease. Difficulties we the shoulder long- term results are necessary. Therefore a prospec- encountered with using this implant included achieving and main- tive study with a large number of patients is under way. taining a stable fracture reduction until union. The operative time was not reduced. Further research is warranted to ascertain whether this implant has any definite advantages over other methods of 182 humeral fracture fixation. Two Stage Operation for Severely Comminuted Distal Radius Fracture (AO 23-C3) 180 K. Ogawa, T. Doi, M. Ishiro, K. Munetomo Various Shapes of the Distal Volar Radius and its Fukuyama City Hospital Emergency Medical Center Importance for Volar Plate Osteosynthesis Background: It is challenging to perform open reduction and internal W. Pichler1, H. Clement1, L. Hausleitner2, K. Tanzer1, W. Grechenig1 fixation (ORIF) of distal radius fractures with severe comminutions 1Department of Traumatology, Medical University of Graz, Graz, (AO23-C3). AS it is difficult to evaluate very small fragments only by Austria X rays, the key to success of the treatment is the detailed preoper- 2Institute of Anatomy, Medical University of Graz, Graz, Austria ative planning with appropriate computed tomography (CT) images. Patients and Methods: Nine patients who had C3 fracture between Volar plate fixation of distal radius fractures has become a standard 2004 and 2006 were treated by two-stage operation. There were 4 procedure. Anyway descriptions of the diverse morphology of the men and 5 women with averaged age of 49.9 years. Four were open distal volar radius are rare in literature. Purpose of this anatomical fractures, which were 1 case of Gustilo II and 3 of Gustilo IIIa. study was to explore the different variations of the distal volar radius Averaged follow up period was 11.0 months. The protocol was as and the implication on volar radius osteosynthesis. Following the follows; 1)apply external fixator (EF) with closed reduction to get dissection of one hundred cadaveric forearms, the profile of the volar approximate alignment on the day of injury, 2) using 64-slice multi- distal radius has been measured by using a common profile gauge. detector-row CT scanner with a slice thickness of 0.5 mm, 3DCT, The measurements demonstrate clearly differing volar circular arc axial, sagittal and coronal views were reconstructed for preoperative radiuses between the radial and ulnar side in a total of 55 percent. planning, 3) after decreasing the swelling, volar plating using locking This characteristic may lead to a false rotation position of the distal plate with EF is performed. Postoperative evaluations were carried fracture fragment. Suboptimal fitting due to discrepancy between out clinically and radiographically.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 53 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Results: In this series, all cases were decided to perform ORIF with displacement without bony contact after immobilization, displace- locking plate. In radiographic assessment, loss of reduction was not ment threatening the integrity of the skin, concomitant neurovas- observed except one case at the final follow-up. According to Mayo cular injury, open fractures, bilateral midshaft fractures, floating Modified Wrist Score, Good were recorded in 7, Poor in 2. shoulder and multiple injured patients. Non-union was defined as Conclusion: Two-stage operation for C3 fracture is valuable proce- absence of union 24 weeks after injury. Data are presented as dure because reduction and the preservation of soft tissue can be mean ± standard deviation. obtained and minimally invasive ORIF can be performed by using Results: 910(0,5%) of total 180.878 trauma patients presented with EF. MCF. 108(11,8%) were lost for follow-up. 48(5,9%) were primarily treated with ORIF, 37(77,0%) were male, average age was 36 ± 13 years. 754(94,0%) were treated conservatively, average age was 183 42 ± 20 years, 552(73,2%) were male. 7(0,9%) primarily conservatively treated patients developed non-union, average age was Acute Volar Compartment Syndrome of the Forearm 36,2 ± 4,4 years, 3(42,8%) were male. After a Salter I Fracture of the Distal Radius Conclusion: Indications for primary ORIF in MCF are not well H. Baecker, D. Seybold, C. Gekle, G. Muhr supported. Majority are treated conservatively with reported rate of Department of Traumatology, University Hospital Bergmannsheil, non-union from 5,9–15.1%. Low non-union rate in our study could be Bochum, Germany influenced by optimal indications for primary ORIF. However, there is a need to obtain EBM-level 1 evidence on indications for primary Objective: The acute compartment syndrome of the forearm devel- operative treatment observing union rate and functional outcome. oping as a complication of a not displaced fracture of the distal radius epiphysis are uncommon injuries in children. To avoid neurovascular damage early treatment is indicated. 185 Material: This is a case of a 15 year old boy who fell on his outs- treched left hand and presented with early signs of acute compart- Elbow Fractures in Chidren: A Prospective ment syndrome at the emergency room. In the radiological Evaluation of 300 Emergency Admissions examination of the left forearm a fracture could not be seen. Because M. Hosseinpour, M. Javdan of constantly present clinical symptoms of an acute compartment Alzahra Hospital syndrome the tissue pressure has been validated and extensive decompression was performed. After volar decompressive fascioto- Background: Diagnosis and treatment of pediatric elbow fractures my a not displaced but instable fracture type I according to the require knowledge of the specific pathophysiology of children. In this Salter-Harris classification could be seen intraoperativ. The fracture study we evaluate children with elbow fractures. was treated with closed reduction and stabilization with a Kirschner Methods: Over a period of two years, all emergency admissions were wire. evaluated prospectively. Children with elbow fractures were selected Results: The early surgical decompressive fasciotomy reduced the for analysis. In each patient, type of fractures, sex, side of fractures risk of disastrous complications and led to a full functional recovery and age were collected. without residual symptoms in the follow- up examination eight weeks Results: In this survey, 300 children sustained elbow fractures. Su- after the injury pracondylar fractures represent the most common fractures Conclusion: Clinical signs of a beginning compartment syndrome (58%).Most of fractures were seen in boys((72.3%).Left elbow was should be taken serious. Especially children should be monitored fractured in 58.7% of patients. The most common age group for closely. There are a lot more reasons for elevated intracompart- elbow fractures was 4–8 years. There was a significant relationship mental pressure than displaced fractures. Clinical signs of a com- between radius head fractures and sex (P = 0.01). partment syndrome should be supplemented by pressure Conclusion: Elbow fractures are more common in boys, left arm, and measurement. Surgical decompressive fasciotomy is the state of the in age ranging 4–8 years. art treatment that reduces the risk of late complications.

186 184 Isolated Radial Head Dislocation - A Rare and Non-Union Rate of Primary Conservative Treatment Easily Missed Injury in the Presence of Major of Midshaft Clavicular Fractures in Adults Distracting Injuries R. Kosir, M. Vinder, D. Ekart, A. Cretnik, A. Frank U. Rethnam, S. Yesupalan, B. Ramesh, S. Bastawrous Department Of Traumatology, Teaching Hospital Maribor, Slovenia Glan Clwyd Hospital

Introduction: The treatment of midshaft clavicular fractures (MCF) Background: High velocity accidents can lead to major injuries – long is primarily conservative. Indications for primary ORIF are not well bone fractures, abdominal trauma, pelvic fractures and chest injuries. deﬁned. These injuries can act as distracting factors during the initial assess- Aim: Our goal was to identify the rate of non-union in primarily ment of a polytrauma patient and innocuous but signiﬁcant smaller conservatively treated MCF. injuries can be missed. Material and Methods: Our study included all trauma patients (>15 Report: A 44-year old man presented with a high velocity motorbike years old) with MCF from 1.1.2000 until 31.12.2005 at our institu- accident after a head-on collision with a truck. Examination revealed tion. Patient number, name, age, sex, method of treatment, and extensive bruising of the pelvic region, scrotal swelling and bilateral union rate were recorded. Indications for primary ORIF were knee effusions. Initial radiographs showed an open book type pelvic

54 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

fracture.12 hours later, the patient complained of pain in the right Results: Only around 24% of the hospitals ran a local hip fracture elbow. On examination, there was minimal swelling over the elbow registry. 79% felt that running a local hip fracture registry was and tenderness over the radial head. Forearm pronation and supi- advisable and a similar number (80%) were in favour of a National nation were restricted and painful. Radiographs showed an antero- Hip Fracture Registry in the lines of the one existing in Scotland. lateral dislocation of the radial head with no associated fractures of Among the hospitals not currently running a hip fracture registry, the the radius, ulna or disruption of the distal radioulnar joint. main reason for this seemed to be lack of funding or staff (72%). Conclusion: Isolated dislocation of the radial head without concom- Discussion: Plans are afoot to establish a National Hip Fracture itant ulnar fracture or humeroulnar subluxation is a rare injury with Registry for UK. To our knowledge, this is the first such survey of few reports in literature. In the presence of major distracting injuries Orthopaedic departments within the country providing valuable like long bone fractures, pelvic fractures, chest and abdominal inju- information on consensus regarding the implementation of a national ries, an isolated radial head dislocation can be easily missed. This registry. We consider setting up a National Hip registry advisable as report has been prepared to stress the importance of a thorough it provides evidence for the best management of the most common secondary survey in patients with polytrauma after high impact motor fracture in our practise. Also it leads to targeted training of junior vehicle accidents. A proper secondary survey in patients with major doctors in managing these patients. distracting injuries can prevent important injuries being missed. 189 187 Hip Fracture Fixation Surgery in the Below-Knee Predictive Value of the Hiss-Scoring System for Amputee – A Surgical Dilemma U. Rethnam1,2, K. Ratnam1, A. Shoaib3 Estimation of Trauma Severity and the Time off 1 Glan Clwyd Hospital Work After Hand Injuries 2Wrexham Maelor Hospital N. Wachter, J. Gu¨lke, M. Mentzel 3Robert Jones Agnes Orthopaedic Hospital Dep. Trauma Surgery, Hand- Plastic And Reconstructive Surgery, University Of Ulm, Germany Background: Intertrochanteric fractures and positioning for their surgical treatment pose a difficult problem when encountered in the Background: The estimation of the time off work depending on the below knee amputee. Absence of the foot and part of the leg in the injury pattern and severity is of major interest in the treatment of below-knee amputee makes positioning on the fracture table chal- hand injuries. The predictive value of the HISS – Score (Hand Injury lenging. Severity Scoring System) was evaluated. Discussion: Various techniques can be used to overcome the difficulty Material and Methods: According to this score 274 work-related associated with positioning of a below-knee amputee for hip surgery. injuries (1999 – 2003) were analyzed prospectively, excluding injuries These include placement of the limb on a radiolucent leg suppoort, of both hands. The median age was 39,6 years (18 – 66 y.), 10% of the using the patients prosthesis attached to the stump, inverting the boot patients were female. of the traction table to accomodate the knee and skeletal traction. Results: A significant correlation was established between the HISS- Conclusion: We highlight the difficulties encountered in a bilateral Score and the time off work (p < 0,0001, r = 0,52). The score also below knee amputee undergoing fixation of an intertrochanteric correlated with the degree of work incapacity (p < 0,0001). fracture. The various techniques available to overcome this problem Conclusion: Our data confirm the predictive value of the HISS–Score make it easier for the operating surgeon. for the early estimation of the time off work resulting from hand injuries. However, the estimation is limited to injuries distal to the wrist. 190 Management of Closed Internal Degloving Injuries ‘‘The Morel-Lavallee Lesion’’ Associated with Pelvic 188 and Acetabular Fractures Setting up a National Hip Fracture Registry: Is C. Steiner, O. Trentz, L. Labler There Consensus of its Usefullness? Division Of Trauma Surgery, Department Of Surgery, University E. Mallick, R. Bhattacharya, D. Kramer, M. Scott Hospital Zu¨ rich, Ra¨mistrasse 100, CH-8091 Zu¨ rich, Switzerland North Tyneside General Hospital Objective: Management of Morel-Lavallee soft tissue lesion (MLL) Introduction: Hip fractures are the commonest reason for emergency in patients with associated pelvic and acetabular fractures is still admission in orthopaedics in the UK. Unlike other European coun- under discussion. Especially, sequence of treatment of MLL soft tries, no central registry exists for these fractures in England although tissue management and osteosynthesis of pelvic and acetabular injury some Trusts run similar registries locally. The aim of our survey was remains controversial. to find out about the existence of such local registries and also the Methods: We report all consecutive MLL patients associated with consensus among orthopaedic surgeons in the UK regarding a na- pelvic ring and/or acetabular fractures during an eight-year period at tional registry. our hospital. Surgical access and techniques were analysed concern- Methods: A questionnaire survey was conducted amongst all the ing complications and outcome. hospitals in England that dealt with acute orthopaedic admissions. Results: Altogether, 20 patients were included in the report. One Out of a total of 179 hospitals, 110 valid responses were available for patient was treated conservatively and MLL healed without com- analysis. plications. 19 patients had an operative treatment of MLL. In 15

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 55 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

patients debridement was performed within one day after injury and Conclusion: This novel, experimental ovine trauma model leads to in four patients with delay of 5 days at least. Ten patients had surgery severe soft tissue damage and a reproducible fracture pattern. It is for an associated pelvic ring or acetabular fracture. In six of them currently being applied in a study where the influence of the surgical MLL was operated before, in four patients simultaneously to os- approach on fracture healing is evaluated. teosynthesis. In three patients, the same surgical approach for osteosynthesis and debridement of MLL was used; none of them showed postoperative complications. Altogether, eleven operated patients showed healing of MLL without any complications. Seven 193 operated patients showed prolonged wound healing, however, during Emergency Open Reduction and Stabilization of long term follow-up, all patients showed a complete healing of the Comminuted Femoral Head Fracture. (Long Term MLL. One patient died postoperatively. Result of a Case Report.) Conclusions: We recommend open debridement for early and delayed treatment of MLL. Osteosynthesis during first debridement J. Simonka may be performed without adverse outcome, identical surgical access Department of Traumatology, University of Szeged, Hungary for both procedures can be used. Background: Femoral head fracture is a rare injury. Case Report: 30 years old male during motorcycle accident suffered a right posterior dislocation. X-ray and CT examination showed a 191 comminuted (double) fracture of the femoral head. Urgent open Total Hip Proshesis After War Injury, Minimal reduction and fixation of the femoral head fragments with four tita- Invasive Approch nium screws was performed. Early CPM was started, weightbearing was gradually allowed after 6 months. I. Gavrankapetanovic, S. Becirbegovic, H. Tanovic Results: Femoral head was survived and revascularized. It was con- University Clinical Center Sarajevo, Bosnia & Herzegovina trolled by radiographs and MRI every 6 months. Full range of painfree motion of the hip was achieved and detected at the last In the latest war in Bosnia and Herzegovina we were facing conse- clinical evaluation after six years of surgery. quences of high energy projectal trauma. A lot fo young persons with Discussion: The femoral head fractures associated with posterior such kind of injury needs THP for treating sequelle.Data in literature dislocation are classified by Pipkin. Our case was an ‘‘unclassifiable’’ are obscur. We present our experiance of 19 patient with THR after fracture combination of Pipkin type I. and II/B. We propose to classify war injury with average follow up of 2 years this fracture as Pipkin type V. The literature provides very few guidelines for the treatment of patients with Pipkin fractures. Open reduction and internal fixation with screws is indicated when ana- 192 tomical reduction of the fracture cannot be obtained as in our case. A Novel Sheep Model for the Experimental Study of This was the only procedure to achieve revascularization of the femoral head and to prevent early posttraumatic arthritis of the hip joint. Severe Trauma to the Distal Femur Conclusions: We propose modification of Pipkin’s classification based 1 1 2 3 1 M. Wullschleger , R. Steck , R. Matthys , K. Ito , M. Schuetz on presented combined femoral head fracture case. We recommend 1 Queensland University of Technology, Institute of Health and emergency open reduction and screw fixation of the fragments of the Biomedical Innovation, Brisbane, Australia femoral head to achieve a better function. 2AO Development Institute, Davos, Switzerland 3AO Research Institute, Davos, Switzerland

Introduction: Realistic animal models are essential for studying the 194 influence of surgical methods and implants on fracture healing out- Treatment of Complicated Periprosthetic Fracture come. While there are established small animal models, no large animal model has thus far been reported. Therefore, the aim of this study of the Distal Femur Using Stable Osteosynthesis was to develop a standardised trauma model with severe soft tissue and Synthetic Hydroxyapatite damage (Tscherne III) and a multifragmentary fracture (AO C-type). M. Reska, P. Divis, J. Ciernik Methods: To create the soft tissue trauma, a pendulum impactor was I. Department of Surgery designed, which delivers a reproducible blow to the lateral thigh of the sheep. Next, a butterfly fracture is created at the distal femoral The authors have presented the treatment applied in a female-patient shaft by a combination of partial osteotomies (1/4 bone cross section) with a complicated fracture of the distal femur above the total knee and drill holes, with final fracture initiation with a small chisel, arthroplasty. The patient was treated primarily in another centre with everything performed through a small surgical approach (25 mm). adaptation osteosynthesis and plaster fixation, moreover, with a bi- Results: The soft tissue trauma was first tested on cadaver legs and, malleolar fracture in the same extremity resolved conservatively. She eventually, on 5 sheep under general anaesthesia. Every trial resulted was brought immobile for therapy to the 1st Clinic of Surgery as late in a closed soft tissue damage, assessed by macroscopical dissection. as one month after the injury. An X-ray examination revealed poor Skin and muscle bruises and haematomas were observed, and even position of the distal femur fragments even in the region of the ankle partial muscle disruptions, when additional weights were added. joint, osteoporosis and no signs of the bone healing. The following These results were confirmed by post-mortem CT-scans. The fracture interventions were performed: stable reosteosynthesis of the distal model was tested on 20 cadaver bones, cadaver legs and on 9 live femur using a distal femoral nail (DFN), stimulation of osteogenic sheep, which all resulted in reproducible C-type fractures with frac- activity with help of hydroxyapatite Cem-Ostetic made by Berkeley, ture length of 35+/–2.4(SD)mm. and osteosynthesis of the bimalleolar fracture. Then early rehabili-

56 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

tation was initiated and as early as one month after surgery evident the autopsy findings. In our case, the fracture line initiated well below signs of healing could be seen in an X-ray picture. Nowadays, the the pin trajectory and approximately 6cm from the superior border of patient is completely self-reliant and fully loading her limb. the prosthesis. This case suggests that placing a rigid body for computer-assisted navigation does not modify the risk of peri-prosthetic fractures of the femur in this population with known higher risk 195 A New Hinge System in the Treatment of Limb 197 Deformities and Fractures G. Salameh, M. Schmidt Does the Operative Treatment of Impacted Femoral Abbassen Hospital Neck Fractures Give Better Long-term Results then Conservative Treatment Amongst Patients Younger For the treatment of limb deformities, fractures, lengthening and then 65 ? correction of axial deviations a special external hinge distraction G. Makovec, M. Tonin, D. Smrke system has been developed, which allows the combined Treatment of congenital and acquired complex deformities of the leg. Since 1995 to Hip fractures present serious health problem and are often crucial 2005 this new system was used in 280 patients with deferent indica- point in physical, psychological and social aspect of life. Using an tions in the lower limbs they presented with leg length discrepancies appropriate form of treatment could present a crucial factor for the and axial deviations and fractures. The External Fixation Hinge patient. Choose the most optimal form of treatment for young patients System /Salamehfix /; is an arch hinged system consists of arches with and return them in preliminary health state as soon as possible. In the a various diameters and perimeters, to assemble the deferent sizes of retrospective study 365 patients with impacted femoral neck fractures the leg in the upper and distal part with connecting special hinges , that had been treated for the period of 14 years (1988–2002) at the deferent sizes of the arcs to choose a special size for each patient with department of Traumatology in Ljubljana were analyzed. After 6m keeping an excellent technical functions; multiplanar multidirectional follow-up and according to age limit of 65, there where 36 patients left. corrections; makes the fixator more suitable to each patient in size Patients were divided in to two groups. Selection criteria was the same and allows the patient to move his joints freely, the insertion of the for both. The first group consisted of the patients who were primarily wires and screws in nearly right angels which make a rigid fixation , treated conservatively and the other of primarily operatively treated the insertion of wires and half pens in a minor painful regions makes patients. Fracture healing in both groups was compared and analyzed the tolerance to the fixator is more acceptable. X- Ray control is easy. after 6 months. For 31/36 patients (86%) the choice of therapy was Complications where mostly superficial pin infections, No nerve or conservative treatment. In 25/31 (80%) cases the fracture was com- vascular injuries The new developed hinges are easy to use and allow pletely healed up and there was no need for operative intervention. 5/ the treatment of fractures and complex deformities with lengthening. 36 (14%) of the patients primarily received operative treatment. In all cases (100%) the fracture healed and there was no need for secondary operative treatment (the difference was not statistically significant). 196 Average hospitalization period of conservatively treated patients was Autopsy Findings with Pathoanatomy of a Peri- 23 days and of operatively treated patient 17 days. According to Prosthetic Fracture of the Femur Following radiological and clinical outcome of treatment and period of hospitalization our results support the primarily operative treatment of Navigated Total Knee Replacement impacted femoral neck fractures amongst young patients. M. Bhattacharyya, I. Rodrigues, N. Venkatram, B. Gerber Department Of Orthopaedics, University Hospital Lewisham, London, UK 198 The Treatment of Multiple Fractures with In computer assisted joint surgery, the rigid body fixation site may be regarded as a potential stress riser, which could result in peri-pros- Dislocation within the Limits of One Limb in thetic fractures. We describe a case report using the autopsy result of Children the patient to understand the pathoanatomy of the femoral suprac- R. Tomaszewski, J. Kler, K. Pethe ondylar peri-prosthetic fracture after navigated TKR. An 89 year-old Uppersilesian Centre of Child and Mother’s Health, Katowice, female with multiple medical co-morbidities underwent left TKR for Poland osteoarthritis. Post-operative recovery was complicated by mild cellulitis of the operated leg, resolved with intravenous antibiotics. Post- From 1 jan 2001 to 30 jun 2006 in Uppersilesian Centre of Child and operative x-ray showed correct alignment and patient was mobilising, Mother’s Health in Katowice (Poland) were treated 12 patients with fully weight bearing and discharged home. Following a mechanical multiple fractures within the limits of one limb, 9 patients had frac- fall, she developed a peri-prosthetic spiral femoral fracture 26 days tures in upper limb and 3 in lower limb. The mean age of the patients after the index operation. Post injury she developed pneumonia, was 12,2 (8–16). All the patients were treated by surgical procedures. hospital acquired infection and pulmonary oedema, and died 8 days 2 patients had fracture of proximal metaphysis of the humeral bone after sustaining the fracture, before surgery was possible. We per- and 7 patients had supracondylar fracture of the humeral bone. It was formed an autopsy and found the fracture originating just above the accompanied by fracture of distal metaphysis of the forearm bones or anterior notch and clearly not from the rigid body fixation site in the shafts of forearm bones. Fractures of the lower limb were located in femur. Although we would expect the rigid body fixation tract in shafts of femoral bone and the tibial and fibular bones. Fractures femoral navigation to be at risk of initiation peri-prosthetic fractures within the limits of the upper limb were treated using the K-wires or in the early postoperative period, we did not find that correlation in Metaizeau nails. After the surgical procedure the upper limb was

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 57 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

immobilized. Fractures of the lower limb were treated by Ender resources. How do we judge the success or failure of the interven- nails(2 patients) or Metaizeau nails( 1 patient). The mean time of tions? How do we assess the cost-utility of the interventions? hospitalisation of the patients was 8 days (5–14). The surgical treat- Methods: 100 consecutive patients with a fractured neck of femur were ment of both fractures within the limits of one limb permitted fast assessed for their pre-fracture, pre-operative, and post-operative removal of immobilization from the upper limb and fast physical quality of life. Three months post admission a repeat Euroqol ques- rehabilitation in lower limb. In all the patients obtained good con- tionnaire was sent either to the patient or named carer on a randomly solidation of fractures. The surgical treatment of multiple fractures selected basis in order to assess the effect upon response rate. within the limits of one limb shortens the time of therapy and facil- Results: All of the patients had surgical treatment for their injury. itates nursing and change of dressings and later on rehabilitation. Mean age was 82years. The male to female ratio was 1:5. Mortality at three months was 25%. There is a highly signiﬁcant difference between the pre-injury and post-injury EQ-5D scores (p < 0.0001, 95% 199 CI 0.69 to 0.79). There is also a highly signiﬁcant difference between the pre-injury and 3 month scores (p < 0.0001, 95% CI 0.15 to 0.29). Damage Control Orthopaedic Surgery- Current There was a 63% and 47% response rate for follow up questionnaires Choice for Femoral Fractures in Polytrauma sent to patients and relatives respectively. Patients Discussion and Conclusion: EQol can easily detect changes in function associated with NOF#. EQol is an important tool in detecting O. Lupescu1, M. Nagea2, G. Popescu2, C. Patru2 pre- to post-injury changes in health status but the important next 1Emergency Hospital, University Of Medicine And Pharmacy step is to determine if EQol can detect differences produced by Bucharest, Romania different interventions. 2Emergency Hospital, Bucharest, Romania

Introduction: : Femoral shaft fractures in polytrauma patients rep- 201 resent of the most controversial subjects of modern traumatology, since both the fracture and its’ treatment have a huge influence upon External Fixation in the Complex Knee Injury these patients. Many aproaches for femoral fractures in polytrauma J. Demel, L. Pleva, R. Madeja have been described, with differences concerning time and type of Traumacentre Of The Ostrava City surgery. Depending on the traumatic status of the patient (traumatic Introduction: Life salvage is the main priority in serious complex knee scores), most of the polytrauma patients have significant benefit after trauma associated with polytrauma. Reasonable function of the limb is immediate stabilization of the femoral fracture. The type of stabil- the aim of treatment. Aim: Verification of the own group Material: 26 ization has changed during the last years, since reamed nails were patients were treated in the Traumacentre Ostrava from 1998 to 2005. replaced by unreamed nails, and these by the concept (Krettek, Pape) Method: The external fixation was used in all 26 cases to stabilize the of Damage Control Orthopaedic Surgery ( DCOS)- initially stabil- knee position. In 19 cases ring Ilizarov type, unilateral in 7 cases. By- ization of the femoral fracture by external fixation in polytrauma pass of the popliteal artery was used in the 4 cases, nerve substitution patients at risk of organ failure, followed by intramedullary nailing. was used in 2 cases. Because of the general infection with sepsis there Material and Method: This retrospective study evaluates 60 poly- were necessary to amputate the limb in 3 cases. trauma patients with femoral fractures, treated between 1.01.2000- Results: Patiens were evaluated according to possibility of weight 1.01.2003, 38 by intramedullary nailing (IMN), 22 by DCOS, con- bearing of the injured limb. Full weight bearing without crutches are cerning: hospital stay, rate of MSOF, of ARDS and local complica- able 15 paitients, 6 patients needs the crutches to move. 3 patients tions (pin track infections, wound infections, osteomielitis, implant uses the prosthesis. Paraplegic are 2 patients. failure, non-unions). Conclusion: External fixation is the method of choice in this kind of Results: Hospital stay was not significantly influenced by the type of trauma. It is very quick and matches the requirments of the damage osteosynthesis, while the rate of MSOF and ARDS was less for the control in limb traumatology. Elimination of the posterior dislocation DCOS group than the IMN group. External fixation followed by or subluxation, the posterior drawer sign, and maintanance of the intramedullary nailing was not associated with higher rate of local blood circulation with management of the local and general schock is complications than primary IMN. the key to the next function of the limb. It is the definitive treatment Conclusion: DCOS represents a valuable alternative for femoral in most cases. fractures in polytrauma patients in order to reduce the impact of both the fracture and its’ treatment upon patients’ survival and outcome. 202 200 Intramedullary Nailing In Treatment Of Open II Assessing Quality of Life After Fracture of the Neck Tibial Fractures M. Popescu1, D. Poenaru2 of Femur 1Politraumatology Casa Austria Timisoar 1 1 1 2 1 E. Prempeh , J. Young ,K.Ho, J. Clarkson , M. Costa 22nd Clinic of Orthopedy and Traumatology Timisoara 1University Hospitals Coventry and Warwickshire 2Warwick Medical School Introduction: Tibial open III fractures are severe lesions, difficult to treat, with multiple complications. Introduction: Fractured neck of femur is a common condition Aim: To present our experience in intramedullary osteosyntesis in amongst elderly people causing considerable morbidity and mortal- treatment of these lesions. ity. The initial treatment and subsequent rehabilitation of this group Material and Method: We studied the patients with type III open of patients uses an increasingly high proportion of acute hospital fractures of the tibia admitted in 2nd Clinic of Orthopedy-Trauma-

58 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

tology and Politraumatology-Casa Austria between 01.12.1999– Methods: 11 patients suffered from bilateral tibial plateau fractures 01.12.2005. We evaluated: cause of trauma, associated lesions, type Shatzker 5 and 6, were operated 1–17 days following admission. The and localization of the fracture, type of treatment and complications. patients were operated using lateral approach. After achieving reduc- Results: Our group consisted of 48 patients, 37 male (77%) and 11 tion, one or two lags screws parallel and adjacent to the plateau were female (23%), with an average age of 36+/–12 years, who presented inserted. A pre-contoured locked plate with 3–4 locked screws parallel 51 type III open fractures. The most frequent causes were car acci- to the plateau was inserted. 3–4 more diaphyseal-metaphyseal locked dents (87.50%). By using the AO classification we had: 44 diaphyseal screws were inserted. The patients were placed in a range of motion fractures (18-A, 20-B, 6-C), 5 distal (2-A and 3-C) and 2 proximal (2- splint for 3 months with out bearing weight on the operated extremity. A). We had 29 fractures type IIIA, 14-IIIB, 8-IIIC. We used plates in Results: All fractures were healed. There were no cases of infections. 3 cases (5.88%), unreamed nails in 37 cases (72.54%), external fix- 5 patients had excellent results 5 had good results and 1 patient with ateur in 10 cases (19.6%) and amputation in 4 cases (7.84%). In 14 poor result. cases (27.45%) we used autologus cancelous bone graft. We had Discussion: The angular stability of the locked plate makes it possible complications in 13.79% of the cases with type IIIA fractures, in to fix bilateral plateau fractures with lateral approach and only one 21.42%-IIIB, 50%-IIIC. In 3 cases we had to change the primary lateral plate with locking screws reaching and holding the medial osteosyntesis material. condyle. Compared to the bilateral approach there is less exposure Conclusions: Male patients and car accidents were predominant in and less damage to the contused soft tissue and the blood supply to our study group. The first indication for osteosyntesis in type IIIA the bone is preserved. All these factors are contributing to avoid and type IIIB open fractures is the unreamed nails, and for the type infections and achieving union. The two incisions with double plating IIIC the external fixateur. We had a direct correlation between the were known as the ‘dead bone sandwich’ with high rate of infections complications and the severity of tissue damage. and nonunion. With our one incision and a locked plate we achieved 100% union with no infections. The fixation was stable and we got no cases of loss of reduction. 203 Less Invasive Stabilization System for Fracture of The Proximal Tibia: Results and Complications 205 F. Castelli, R. Spagnolo, D. Capitani Simultaneous Bilateral Tibial Fractures without Nguarda Ca’ Granda Adequate Trauma in a Patient with Chronic Polyarthritis Introduction: Proximal tibial fractures continue to be problematic for orthopaedic surgeons. Continued problems in their managment in- H. Baecker, D. Seybold, C. Schinkel, G. Muhr ¨ clude infection, soft tissue problems, failure of fixation and joint stiff- Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil ness. Combining the concept of ‘‘biological plating’’ and locked internal fixators, the LISS has been developed. LISS is an extrame- We present the case of a 48-year-old man with polyarthritis who dullary internal fixator that proposes the advantage of indirect reduc- developed bilateral tibial fractures without a history of excessive tion indicated for fractures of the complex proximal tibial fracture activity, steroid medication or metabolic bone disease. His onset of Results: We review 33 fratures treated from October 2002 to October symptoms could not be associated with a specific trauma. His bone 2005 with an average follow up of 19.7 months. The fractures treated density and biochemistry were all normal. The radiographic exami- were 15 AO 41C or B and 18 AO 41 A. 13 fractures. Two of these nation confirmed the diagnosis of bilateral tibial fractures type IV fractures presented with open soft tissue damage. The average age of according to the Schatzker classification. After open reduction the patients was 43 years. (min24 – max81) There were 9 cases of simultaneous internal fixation and spongiosa plastic was performed. polytraumatized and 18 patients a with multiple fractures. The mean In the follow-up examination after 12 weeks the fractures healed range of motion was 2 degree (R = 0–13) to 110 degree (R = 80–150). uneventfully. Such fractures are particularly rare. That for a high The mean time to full weight-bearing was 16.2 weeks (R = 9–24). degree of awareness is required for early diagnosis. We discuss the There where two non-union healed with reoperation after falure of the need of further investigations to rule out other possibilities like LISS. In two case, there was a valgus malunion of about 5 degree, in 3 secondary fracture reasons. casea valgus malunion of less of5 degreeand anyoneof moreof5 degree. Conclusion: In conclusion with the new methods of percutaneus plate 206 osteosyntesis we see decreased soft tissue complication and ttime of healing. The LISS in our opinion is the goal standard for multiseg- Mini-Invasive Surgical Repair Of Traumatic Rupture mentary or comminnuted fractures of the proximal tibia with distal Of Achilles Tendon As A Day Case Procedure With long extensions in patients with politrauma. Early Full Weight Bearing M. Bhattacharyya, B. Gerber 204 Department of Orthopedic Treatment of Bilateral Tibial Plateau Fractures with We performed a non-randomised, prospective study in order to assess the Use of Locked Plate by a Lateral Approach Only the potential of minimally invasive tendo achillis repair with early B. Kish, Y. Brin, M. Nyska weight-bearing mobilisation after rupture of the tendo Achillis as a Orthopaedic Department, Meir Medical Center short-stay surgical procedure. The first group of 25 patients who were operatively-treated in open technique showed an improved functional Purpose: Describe our experience with 11 cases of bilateral tibial outcome and mobilised fully weight-bearing after 8 weeks of surgical plateau fractures (Schatzker 5,6) treated only by lateral approach and repair. The average hospitalisation in this group is 3.3 days. The second locked plate. group of 19, on minimally invasive technique provided no evidence of

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 59 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

wound problem and a functional benefit from early weight-bearing angle, the length and the subtalar joint. Qustion was how the impact mobilisation and same day discharge. As regards to the requirement of of intraoperative 3D fluoroscopy would be. analgesia, number of days analgesia required postoperatively was Material/Methods: In the period of 10/2002 until 10/2004 we operated higher in the open technique [mean 7 days vs 2 days]. Opiates or opiate 59 patients with intraarticular fractures of the calcaneus by means of based analgesic were used by the patients in the open technique, where anatomical reduction and locked plate under control of 3D-fluoros- as paracetamol or ibuprofen were used by other group. As regards to copy. According to Sanders, 18 fractures were type II, 33 type III and the post operative morbidity, 2 cases of wound dehiscence requiring 9 type IV. A 3D-fluoroscopy was performed after reduction and repeated debridement surgery and 5 delayed wound healing in the temporary fixation of the fracture. The implant was a locked plate in open repair group suggested that careful patient selection is required all cases as patients need to follow a structured wound management. This study Results: Median theatre time was 72 minutes including 3-D-fluoros- showed that the mini-invasive surgical repair of Achilles tendon as a copy. In 22 cases the 3D-fluoroscopy uncovered remaining incongruity day case procedure with Achillon instrument and early weight-bearing which was corrected. The Boehler angle could be raised on average by mobilisation in an orthosis for the accelerated rehabilitation might be 18 (11 to 22), shortening of the hindfoot could be improved on adopted for of all patients with traumatic rupture of the tendo Achillis. average by 13 picture millimetres (9 to 17mm). Bone graft was not required. At 18 months follow up, all patients had returned to work. 25 Patients were pain free at follow-up. In all cases the achieved reduction 207 could be fixed by the implant until full weight bearing was reached. Conclusion: The use of 3D Fluoroscopy had a real impact in the Immediate Versus Postponed Operative Treatment treatment of calcaneal fractures. It is a valuable assistance for the of Malleolar Fractures accurate reconstruction of the anatomical structures. Remaining A. Van Blanken, L. Poelhekke, K. Bartlema incongruities can be recognized and corrected intraoperatively. If this Department of Traumatology, Leiden University Medical Center, short term advantage influences the long term result has to be shown The Netherlands in further follow up.

Closed malleolar fractures requiring ORIF are mostly treated immediately. This however, is not always possible due to limited operating Trauma to the Chest and Abdomen room capacity, co-morbidity or poor soft-tissue conditions. Effects of postponed surgery are unclear. It might have a negative impact on length of hospitalization, fracture healing and revalidation period. It 209 could increase the chance of infection and worsen functional outcome. This current study investigated whether there is a significant negative Post-injury Abdominal Compartment Syndrome: influence of postponed surgery. This study includes all patients aged 16 is it Still a Problem? years with closed epiphyses, being operated on closed uni-, bi-, or tri- Z. Balogh, P. Mackay, K. van Wessem malleolar ankle fractures between January 1st 2000 and January 1st Trauma Service, John Hunter Hospital, University Of Newcastle, 2005. Patients are divided in immediate and postponed ORIF. Post- Australia poned means operated U+00AlY´ 24 hours after presentation. Peri- operative information was collected through medical records and re- Introduction: Post-injury abdominal compartment syndrome (ACS) evaluation of all X-rays. Functional outcome was measured by aid of a can be predicted within 6 hours of admission. The independent questionnaire, containing the SF-36 and the AOFAS, sent to all pa- predictors of postinjury ACS have never been validated. tients. The total population counts 208 patients of which 5 are excluded. Purpose: Prospective validation of recently established independent 94 patients had postponed surgery. The groups are demographically predictors for post-injury ACS. comparable. Also type of injury, provided peri-operative care and post- Methods: All trauma patients who met inclusion criteria (ICU operative mobilization programme are comparable. At time of sub- admission, no head injury, ISS>15, Base Deficit (BD) >5, or resus- mitting the abstract 45% of the follow- up has been recorded. There are citation with >5L crystalloids) were prospectively monitored. no statistic significant differences in treatment outcome between Demographics, ISS, resuscitation fluids, physiological parameters, immediate or postponed surgery, even though the group with delayed intra-abdominal pressure (IAP) and the independent predictors in surgery has a selection-bias of patients with unfavorable pre-operative two time windows ‘‘ED discharge’’ (SBP, crystalloids, Time to OR, characteristics. Postponing surgery also diminishes the level of dis- transfusions) and ‘‘ICU admission’’ [crystalloids, urine output, Hb, utility for our specialism. Therefore postponing surgery should be Temperature, BD] were collected. Data are presented as considered on all patients with closed malleolar fractures. mean + /–SEM, p < 0.05 considered significant. Results: Twenty-two blunt trauma patients were monitored (Age 39+/–5 years, 77% males, ISS 32+/–2, SBP 107+/–5 mmHg, BD 208 7+/–1). No patients developed ACS. Seven patients developed intraabdominal-hypertension (IAH, IAP>20 mmHg). IAH and non-IAH Improvement of Reduction of Calcaneal Fractures patients had the same age (41+/–7 vs 37+/–5yrs) and admission BD by the Intraoperative Use of 3D-Fluoroscopy (7.5+/–1.3 vs 6.3+/–1.2). IAH patients had higher ISS than non-IAH A. Schulz1,2, A. Unger2, A. Paech2, L. Simon1,C.Ju¨rgens1,2 patients (39+/–3 vs 30+/–2).. Outcomes (IAH vs non-IAH): ICU LOS 1BG Trauma Hospital Hamburg, Germany (39+/–3 vs 30+/–2), Mortality (0% vs 7%), MOF (29% vs 0%). ‘‘ED- 2University Hospital Lu¨ beck, Germany discharge predictors’’: Non of the previously identified predictors were different between IAH and non-IAH. ‘‘ICU-admission pre- Aim: of the surgical therapy of intraarticular fractures of the calca- dictors’’: IAH group had lower Hb (99+/–5 vs 111+/–3 g/dl). The neus is an accurate reduction with reconstruction of the Boehler other predictors are not different.

60 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Conclusions: The incidence of ACS decreased from 14% to 0% in a filled with water to baseline level. IAP was increased in steps up to comparable population. The predictors for ACS did not predict IAH. 40mmHg by adding volume. VRC with corresponding IAP were After the elimination of the lethal ACS, the clinical importance of analyzed and compared for the different TAC techniques. postinjury IAH has to be defined. Results: VRC was the highest after BSC at all pressure levels studied (p < 0.001). VAC and ZS resulted in significantly lower VRC compared to BSC and reference (p < 0.001). The magnitude of negative 210 pressure on the VAC did not significantly influence the VRC. Conclusion: In the present in vitro model, BSC demonstrated the Temporary Abdominal Closure with Bogota Bag in highest VRC of all evaluated TAC techniques. Different levels of The Abdominal Wall Dehiscence subatmospheric pressures applied to the VAC did not affect VRC. H. Yanar, K. Taviloglu, R. Guloglu, C. Ertekin, N. Aksakal The results for ZS and VAC indicate that these TAC techniques may Istanbul University, Faculty Of Medicine, Trauma And Emergency increase the risk for recurrent IAH and should therefore not be used Service Capa, Turkey in high-risk patients during the initial phase after abdominal decompression. Introduction: Closure of abdominal wall under tension and peritonitis cause significant morbidity and mortality. The aim of this study was to evaluate the results of our experience with the usage of ‘Bo- 212 gota Bag’ for temporary closure of the abdominal wall in surgical and trauma patients. Operative and Nonoperative Treatment of Methods: This is a retrospective study and included all patients who Abdominal Injury in Patients Suffering from applied Bogota Bag. During a 4- year period (January 1999- January Multiple Trauma 2003) the charts of 98 have been reviewed. Demographics, compli- S. Wutzler1, M. Maier1, G. Woeste2, F. Walcher1, I. Marzi1 cations, clinical outcome, and abdominal closure types were investi- 1Departement of Trauma-, Hand- and Reconstructive Surgery, gated. Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Results: There were 60 male and 38 female, with a mean age of 51 Germany years (4–86 years). Two hundred ninety eight Bogota bag performed 2Departement of General and Vascular Surgery, Johann Wolfgang in 98 patients. Intra-abdominal pressure was found increased in 36 Goethe University Hospital, Frankfurt/Main, Germany patients. The indications for ‘Bogota Bag’ were serious intraabdominal sepsis in 62 patients, severe pancreatitis or mesentery Treatment procedure of blunt abdominal trauma has changed in fa- ischemia requiring multiple celoitomies in 21 patients. Seventy-eight vour of nonoperative therapy. We investigated if conservative (80 %) patients died due to primary illnesses. ‘Bogota Bag’ was re- treatment is a safe and reliable therapeutic option in patients with moved at 24 days (3–78) after the operations in 20 survivors, blunt abdominal trauma. From september 2002 until august 2005 abdominal wall were closed with skin graft in 7 patients, with PTFE 1214 patients admitted to our hospital via emergency room were in 8 patients and primarily in 5 patients. documented throughout their medical attendance. Collection of data Conclusion: ‘Bogota Bag’ could be easily applied, repeatable, rela- was prospectively performed using a PC-supported online docu- tively cheap, and safe method with acceptable morbidity. mentation program (Traumawatch). The average ISS of all patients was 15. 12,4 % (151) of all patients had a relevant abdominal injury (AISabdomen >3) with an average ISS of 33. The injuries could be subdivided as followed: 60 liver injuries (39,7 %), 50 splenic injuries 211 (33,1 %), 28 injuries of the abdominal wall (18,5 %), 19 injuries of In Vitro Comparison of Intra-Abdominal mesenterium or gut (12,6 %) and 15 injuries of kidney or urinary Hypertension Development After Different tract (9,9 %). In 77 cases (51 %) primary conservative treatment was performed, 74 (49 %) patients were primarily operated. In only 2 Temporary Abdominal Closure Techniques patients (1,3 %) a change of therapy to operative treatment was 1 1 1 2 1 E. Benninger , L. Labler , O. Trentz , M. Menger , C. Meier necessary. Patients with liver injury could be treated conservatively 1 Division of Trauma Surgery, Department of Surgery, University in 65 % of all cases as opposed to 50 % of all cases in patients with Hospital Zurich, Switzerland splenic injury. 4 patients (all with AISabdomen ≥4)died in the 2 Institute for Clinical & Experimental Surgery, University of Saar- emergency room before any operative intervention was possible. land, Homburg/Saar, Germany Nonoperative therapy in multiple traumatized patients with abdominal injury is possible in haemodynamic stable patients. Introduction: Decompressive laparotomy for abdominal compart- Especially in patients with liver injury grade Moore V or lesser ment syndrome (ACS) results in a significant decrease of intra- conservative treatment seems to be a secure therapeutic option. abdominal pressure (IAP) and reverses some of the deleterious effects of intra-abdominal hypertension (IAH). Recurrent IAH following decompression is frequently. There is no data available which elucidated the effect of different temporary abdominal closure 213 (TAC) techniques on the development of IAH. Emergency Surgery and Delayed Abdominal Closure Material and Method: A model of the abdomen was designed. C. Mesquita, A. Milheiro, F. Castro-Sousa Abdominal wall was simulated with polychloroprene. A defect was Surgery Department, Coimbra University Hospital, Portugal cut into the abdominal wall. TAC performed by zipper system (ZS), bag silo closure (BSC) or vacuum assisted closure (VAC) with sub- Delayed abdominal closure (DAC), in emergency surgery, must be atmospheric pressures ranging from 0- to 200mmHg. The model was as economical as possible, fast to execute and easy to maintain,

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 61 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

allowing second look and definitive closure a few hours or days 215 later, with minimal prejudices to the abdominal wall. As an alter- Management of Acute Small Bowel Obstruction, native to the so called vacuum closure systems, the AA have been utilising the Rotondo and Schwab technique, popularized by the About 138 Patients IATSIC’s DSTC Course, that consists in the interposition of a A. Cenedese, O. Monneuse, X. Barth, L. Gruner, E. Tissot plastic towel between the abdominal contents and the wall. Until Department Of General And Emergency Surgery now (2005 – 2006) DAC has been utilised in eight patients (4M, 4F), with a median age of 43 (32 – 67). In four, after abdomino- Aim: Find criteria for choosing between a surgical versus non oper- pelvic packing for hypovolemic shock conditions. In another four, ative small bowel obstruction management. after peritoneal decontamination procedures and lavage for septic Patients and Methods: We performed a retrospective cohort study, situations with actual or potential compartment syndrome: two from on prospective collected data of patients admitted for small bowel acute necrotizing pancreatitis, one from dehiscent duodenal suture obstruction between June 2001 and December 2003. Past medical and another one from incisional strangulated hernia, with cellulitis history, clinical exam, CT results, and treatment applied (operative and necrotizing fasceitis. Two patients died in the open abdomen versus non operative) were reviewed. situation, from pancreatitis and dehiscent duodenal suture. Primary Results: 138 patients, (61 male, 77 female, mean age 64 years) were abdominal closure has been possible in five patients: in the four identified. 113 patients (81%) had a past medical history of abdom- cases of packing and one of the cases of sepsis. In one case of inal surgery and 30 (22%) had a previous small bowel obstruction. A pancreatitis it has been possible to apply a net while waiting for a CT scan was done for 132 patients (95%). A small bowel close loop secondary closure. DAC is seen more and more like a safe proce- was identified on CT in 14 cases (10,6%). 64 patients (46%) were dure, in damage control and compartment syndrome conditions, operated on in emergency. Among the 74 patients (53%) treated which contributes to ameliorate the results of surgery in life conservatively, 53 (72%) settled without surgery and 18 (22%) nee- threatening situations. ded a complementary surgery. 3 patients died (4,3%), all in the non operative group. The following factors were significantly related to surgical management: abdominal tenderness (p < 0,0004) and vascular congestion (p = 0,027), peritoneal free fluid (p < 0,0001), 214 identification of the transitional area (p = 0,0009), or small bowel Adrenal Gland Haematomas Following closed loop diagnosis (p = 0,007) on CT. Conclusion: No obvious severity factors were found in order to Blunt Abdominal Trauma: Analysis of choose definitively between an operative and a conservative man- 10 Consecutive Patients in a Single agement. Nevertheless, some clinical and CT signs seem to be helpful Institution to choose the way the patient is managed. A complementary prospective study should be conducted to identify factors leading to a H. Kurihara, M. Zago, M. Turconi, D. Mariani, definitive safe conservative management. A. Casamassima Istituto Clinico Humanitas - IRCCS - Dept. General and Minimally Invasive Surgery, Emergency and Trauma Surgery Section 216 Background: Adrenal hemorrhage (AH) is an uncommon but Six Years of Splenic Trauma-Lessons Learned potentially lethal finding in blunt trauma patients. The adverse M. Venter, R. Marian, M. Beuran, I. Lica prognostic factor is caused by the subsequent acute adrenocortical Clinical Emergency Hospital Bucharest, Romania insufficiency (AAI). Four main mechanisms of injury are suggested: crush of the gland, acute compression of inferior vena cava (IVC), Backgrond: The spleen is the most common injured organ in IVC thrombosis, shearing of small adrenal vessels after deceleration. abdominal trauma. There has been a paradigm shift in the treatment Incidence of adrenal haematoma after abdominal trauma varies from of blunt splenic injuries since the 1980’s.The lifelong risk of over- 0.03 to 2%. AAI occurs in case of bilateral adrenal hemorrhage whelming postsplenectomy infection has been the major impetus for (BAH), it is considered to be irreversible necessitating life-long preservation of the spleen. Splenorraphy was initially used to corticosteroids therapy. accomplish this. Actually, the nonoperative management (NOM) is Materials and Methods: We report a series of 10 patients with blunt widely accepted as a safe and effective treatment modality for he- trauma related AH, observed from November 2003 to November modynamically stable patients with splenic injuries. 2006. Median Injury Severity Score (ISS) was 27.7 (range: 13–45). In Methods: All patients with splenic injury admitted to the Department 9 cases a single haematoma was detected, while one patient devel- of Surgery (Emergency Clinical Hospital Bucharest)between January oped a BAH with subsequent AAI which required corticosteroid 2000 and December 2005 were reviewed and evaluated retrospec- administration. In this patient, in which a non operative management tively. Methods of treatment were determined and the success or for a spleen injury attempt was ongoing, BAH was detected by CT failure of conservative management noted. scan 8 days after the traumatic event, simultaneously with AAI re- Results: Over the period of the study 435 patients were admitted with lated symptoms. splenic injuries as a result of trauma. These cases included isolated Conclusions: The high incidence of right adrenal injury after trauma splenic injuries as well as multitrauma patients.292 patients (67.12%) appears to confirm that AH is in the vast majority of cases strictly underwent total splenectomy (TS), 43 (9,88% ) conservative surgery linked with an acute compression of IVC. In our series the incidence and 100(23%) nonoperative management (NOM). Of the non- of BAH in case of adrenal haematoma was 10%. It is interesting to operative group 7 patients failed this management.Overall mortality note that BAH can develop several days after traumatic event. In our was 20.0%. In all the cases the causes of death were independent series AAI was not observed in case of single AH, but only in the from splenic bleeding. No severe complications in the NOM group single case of BAH. regarding splenic preservation were found.

62 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Conclusions: The most important decision remaining in the man- Patients and Methods: Data on all patients with liver injuries management of splenic injuries is who requires an operation. NOM of aged in our institution in the past 6 years was evaluated. Liver trauma splenic injuries in hemodynamically stable patients in the absence of was classified using Moore’s trauma score. other abdominal lesions requiring laparotomy is now the standard of Results: From 2001 to 2006 a total of 57 patients with liver trauma care. Multitrauma patients raise difficult decisions and generate high - mostly motor vehicle accidents (44)- were admitted to our mortality rates. trauma unit (median age of 37.5 years). Grade III traumas (36.8%) were the most common injuries, followed by Grade IV (28.1%). The laparotomy rate varied from 28.6% in Grade I injuries to 60% 217 in Grade V injuries, resulting in an overall laparotomy rate of 38.6%. Two patients required second look laparotomy for removal The Contribution of Interventional Radiology in of liver packing. The most common associated concomitant injuries the Management of Trauma Patients: Report from were right or bilateral rib fractures (27), pelvic fractures (22), long a Single Center bone fractures (22), laceration of the spleen, spine injuries (19), and head injuries (18). In Grade IV injuries we observed the C. Spyropoulos1, C. Vagianos1, D. Karnabatidis2, G. Mpakellas1, highest mortality rate (25%), overall mortality rate was 12% (7). D. Siablis2 All patients with Grade V or Grade VI traumas survived (6). 1Department of Surgery, School of Medicine, University Hospital of If laparotomy was required because of hemodynamic instability Patras, Greece or concomitant abdominal injury the mortality rate increased to 2Department of Interventional Radiology, School of Medicine, 27%. University Hospital of Patras, Greece Conclusion: The clinical pathway of management of hepatic trauma in our patients showed favourable results. Apart from the grade of Background: Interventional radiology is used with increasing fre- liver injury the overall laparatomy rates and mortality rates largely quency as an adjunct to non-operative treatment of traumatic intra- depend on concomitant injuries. peritoneal and/or retroperitoneal bleeding, or for treating ongoing bleeding despite surgical intervention. The characteristics and outcome of 14 patients with abdominal, pelvic and thoracic trauma who underwent either percutaneous angiographic embolization or vascu- 219 lar stent placement are described. Patients and Methods: During a 6-year period (2001–2006), 102 in- Gunshot Wounds to the Extrahepatic Biliary Tract terventional angiographic treatments were performed at the J. Sproviero, P. Mazoud, M. Rıós, E. Aiquipa Jimeńez, Department of Interventional Radiology of our Hospital, for treating G. Carqueijeda intraperitoneal or retroperitoneal bleeding of various etiologies. Among them were 14 bleeding trauma patients with abdominal organ Background: Injuries to the extrahepatic biliary tract (EBT) are injuries or major pelvic fractures. Source of active bleeding was the uncommon among patients with abdominal trauma and are related internal iliac artery in six patients, the lumbar artery in two and with penetrating wounds, multiorganic affection and high morbidity severe liver lacerations requiring surgical intervention with gauze rate. Aims To evaluate traumatic characteristics among patients with packing in three. Additionally, three patients presented with trau- EBT injuries. matic aortic rupture without active bleeding and transcutaneous Methods: Patients with abdominal gunshot wounds and surgical stenting was performed. Post-interventional bleeding control was confirmation of EBT injuries (extrahepatic and common hepatic documented radiographically and clinically. ducts, gallbladder and common bile duct) were retrospectively ana- Results: Embolization was successful in all patients (100%) with no lyzed upon clinical features, scoring, organ injuries, treatment and procedural complications. Aortic stenting was also successful and no outcome. further surgical intervention was necessary. Three patients died due Results: Between 01/01/98 – 31/12/04, 1.330 trauma patients to multiple organ failure related to late septic complications after a (excluding orthopedic trauma) were hospitalized, 414/1.330 pre- prolonged hospital stay. Total survival rate was 78.6%. sented abdominal trauma (31.1%), 279/414 showed gunshot wounds Conclusion: Interventional radiology is highly effective in controlling and 9/279 developed EBT injuries (3.2%). Eight men and one bleeding caused by traumatic injuries. Either as an alternative to woman, average 24.2 years old, mean TSR, ISS and NISS 11.2, 20.5 surgical haemostasis, or even after surgical intervention, it represents and 44.5 respectively, were operated on. Gallbladder and common a useful tool in the management of severe trauma patients in centers bile duct wounds were diagnosed in 7/9 and 2/9 cases respectively provided with the appropriate facilities and properly trained per- and an average of 3.1 associated injuries for each patient was ob- sonnel. served. Cholecystectomy, external biliary drainage and hepaticyey- unostomy were the surgical procedures performed. One patient died (11.1%). Conclusion: As observed by other authors, EBT injuries were a rare 218 clinical entity in our center. It was seen exclusively after penetrating A 6 Year Experience of Hepatic Trauma abdominal trauma, affecting 3.2% of the patients with gunshot B. Hofler1, M. Tadler1, G. Kopeinigg2, H. Cerwenka1, H. Mischinger1 wounds to this area. The gallbladder was the organ of the EBT 1Division Of General Surgery, Medical University Graz, Austria more frequently damaged and associated injuries were the rule. The 2Department Of Radiology, Medical University Graz, Austria most simple procedure which allowed bile leak control (cholecystectomy, external biliary drainage) was performed, delaying defini- Background: In 2000 a pathway regarding the management of liver tive bilioenteric procedures for hemodynamic stable patients. The trauma was established in our hospital. The aim of the study was to mortality was similar to other series and correlated well with assess the outcome after implementation of the guidelines. trauma scores.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 63 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

220 values. After removing blood clot, necrotic tissues by hepatic resec- Comparing the Outcomes of Isolated and tion and all swabs from the abdomen, homeostasis was managed. Inotropic support wasn’t required after postoperative hours 3, 5 and Concomitant Liver Injuries 6. All patients’ recovery was uneventful. U. Aydin, P. Yazici, M. Zeytunlu, M. Kilic, A. Coker Conclusion: The management of postreperfusion syndrome due to Ege University School of Medicine, Department of General Surgery hepatic trauma can be achieved by cooperation of the surgeon and anesthesiologist. This study was undertaken to examine the both isolated and concomitant liver injuries after abdominal trauma and analyze the management and outcomes. This retrospective study was a review of all abdominal trauma patients, either blunt or penetrating, admitted 222 with a diagnosis of liver with/without concomitant injury over a 5-year Pancreatico-Duodenal Injury due to Abdominal period. Presentation, injury grade, management, and outcomes were Trauma: A Single Center Experience analyzed. Patients with isolated hepatic injury were compared with O. Firat, P. Yazici, B. Gurcu, M. Zeytunlu, A. Coker patients having concomitant hepatic injury (liver and spleen, small Ege University School of Medicine, Department of General Surgery bowel). There were detected 80/368 (21%) patients with liver injury. Of these, the etiology was followed as: 52 (65%) blunt injury, The pancreatico-duodenal injury (PDI) is one of the most bothering 19(23%) penetrating injury, and 8 (10%) gun shot trauma. 13 patients types of abdominal trauma. The retroperitoneum, surgically difficult had also another serious type of injuries; 8 thoracic, 3 open long bone area to approach, cause a significant problem for surgeon. The fracture, 1 intra-cardiac, 1 intracranial. All patients with thoracic surgical management of these organs’s injury is still controversial trauma required tube thoracostomy. 6 patients with injury to large requiring much specialty. During 142-month period, we retrospec- abdominal vessels were observed. 3 patients who had injury to large tively reviewed the patients with PDI due to abdominal trauma. abdominal vessels died preoperatively. 11 patients (13%) with iso- Data from the case records included demographic features, etiology lated hepatic injury could be managed nonoperatively and none failed of trauma, injury severity score (ISS), diagnostic methods, operation this form of therapy.. Mortality, intensive care unit and hospital observation, surgical treatment and outcome. All injuries were length of stay, and transfusion requirements were significantly higher graded according to the AAST- OIS. 51 patients (7.2%), 43 male/8 in the patients with additive injury to the other body cavities. female, with a mean age of 35.5 (18–51) were detected. The etiol- Abdominal trauma patients with concomitant injury to the other body ogies included 36 penetrating (70%) and 15 blunt (29%) injuries. 32 cavities have higher Injury Severity Score, mortality, lengths of stay, had pancreatic injury and 19 had duodenal injury. 9, 17% were and transfusion requirements. Although isolated liver injury results in isolated PDI and remainder patients had concomitant injuries. The good outcome with nonoperative management, injury to either large most frequent organ was liver (17) and followed by colon (16) and abdominal vessels or thoracic cavity has a higher failure rate. stomach (15). The most pancreatic injury was grade 4 and grade 2 for duodenal injury. Mean ISS was 38(11–75). 22(43%) underwent primary suture and drainage, 16(29%) was performed distal pan- 221 createctomy. 9 were submitted to pancreaticoduodenectomy and 4 partial duodenectomy were performed. 11 infectious complication Management of the Resistance Cardiac Depression and 7 pancreatic fistula were the mostly detected complications. 5 After Hepatic Trauma patients required reoperation. 5 were succumbed to death preop- U. Aydin1, P. Yazici1, I. Alper2, S. Ulukaya2, M. Kilic1 eratively due to hemorrhagic shock. 6 died in the postoperative 1Ege University School of Medicine, Department of General Surgery period. The surgical intervention for PDI varies from simple 2Ege University School of Medicine, Department of Anesthesiology drainage to complicated resection procedures. The appropriate procedure for this mostly fatal and quite morbid injury is still Objective: There are many causative factors result in serious hypo- controversial. tension after hepatic trauma. Hemorrhage due to severe injury is one of the well-known reasons. In addition, air emboli, pneumothorax due to trauma, cardiac tamponade, and anaphylactic reactions due to blood 223 transfusion or drug administration may lead to this clinical feature, too. We present the patients underwent packing procedure due to severe A Novel Mechanism and a New Sign in Thoracic hepatic trauma and management of the persistent cardiac decom- Trauma pression deciding for surgical intervention in the early period. M. Rashid1 Patients and Results: 3 patients with isolated hepatic trauma were 1Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden detected. Two of them undergone perihepatic packing were transferred from district hospitals and one patient required repacking The author recently experienced two unique cases with chest trauma regarding severe hemorrhage. All patients had grade IV injury due to which are the basis of this presentation. The first case was a patient with blunt (2) and penetrating injury (1). Pringle maneuver for 45 minutes lesion that has never been reported in another discipline in medicine was performed for all patients. In intensive care unite, central venous other than neurosurgery. This lesion is a contre-coup lung injury. The pressure (8, 12, 13 mmHg), hematocrit (26, 27, 29%), blood pressure nomenclature, classification, pathophysiology, management and the (40/60, 50/70, 45/75mmHg) were in about normal ranges except blood clinical significance will be presented. Understanding the biophysical pressure despite of inotropic support with dopamine, dobutamine principles of chest trauma and any new mechanism is extremely and adrenaline. 3 patients underwent unpacking procedure 8, 10, 14 important if advances are to be made in the prevention or mitigation of hours later, respectively. In the operating room, the patients injuries. Definitely, such a new mechanism can contribute to the design reevaluated with anesthesiologist for fluid resuscitation, blood gas of protective vests thereby decreasing the mortality of chest trauma

64 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

‘‘the new plague of the young’’. The second is a patient with traumatic Conclusion: Our data reflect the Swedish experience of heart trauma: extrapleural hematoma (TEH). A new sign pathognomonic for TEH is there are few cases, alcohol and drug misuse is the principal risk revealed by CT scan of the chest and shown as two fluid collections factor, and there were no gunshot wounds. separated by a lower-density stripe (fat-parietal pleura layer). Video- assisted thoracic surgery (VATS) is invalid to approach TEH which should be considered as a major contraindication to VATS. This is of 226 great importance to save time and money and to treat patients with The Combination of Ribs Fractures Accompanying TEH (if ever diagnosed) in the most cost-effective manner. with Intra Abdominal Organs Damages Especially to the Blunt Abdominal Trauma 224 A. Dogjani Eates, Iatsic, Iss/sic Contrlateral Thoracic Injuries 1 M. Rashid Background: In the framework of blunt abdomen trauma (BAT), 1 The Institute of Surgical Sciences, Sahlgrenska University Hospital damage solid organs itself takes common place. The aim of this study (O¨ stra), Gothenburg University, Gothenburg, and Jacobsga˚rdarna is to Evidencing of correlation in between the ribs fractures and intra Health Center at Borla¨nge, Sweden abdominal organs damages too. Material and Method: The study has a retrospective character and it Background: Contralateral thoracic lesions have been rarely reported has been realized within a period of time June 2004 till April 2005. in the context of multitrauma or patients with isolated chest trauma. This study consists of 54 cases all patients admitting and treating in Such lesions contribute to diagnostic challenges and in the hurried National Trauma Center which belongs to University Central Mili- situation of trauma patients can be easily treated wrongly. tary Hospital. The Analysis of data The dates have been presented in Methods and Results: Two unique cases with chest trauma are absolute value and percentage too. In order to see links in between experienced and constitute the basis of this presentation. The first two variables the correlation coefficient Kendal staub was used. In case was well oriented 85-year-old man with a fall trauma to his left order to analyze linking of the depending variable to the other ones side. He developed a right-sided multiple rib fractures and significant being undependable a regression linear method has been also used. pneumohemothorax. The second patient was a witnessed fall trauma The distribution of thoracic traumas based on the age are as fol- in a 15-year-old girl who developed a sternal fracture when she fell lowing Till 14 years old 7 cases or 13%, from 14 to 40 years old 21 completely on her well stretched backbone during gymnastic train- cases or 39% Over 40 years old 26 cases or 48%. ing. The definition, mechanism, management and the clinical signif- Conclusion: The incidence of the intra abdominal damaged organs is icance of such an entity will be presented. highly found to our study. The ratio male/female is in favor of male 8/ Conclusion: Awareness about such uncommon lesions is extremely 2. The age mostly affected is over 40 years old or 48% From 14 to 40 important particularly when the diagnostic wok-up is in contradic- years old 38% and finally till 14 years old 14%. Regarding with tion with the history and mechanism of trauma. Such a contradic- trauma mechanism at the top list stands car accidents or 76%, falling tion can certainly lead to misleading in the diagnosis and from highness 18.5%, hitting with strong things 5.5%. consequently in the treatment specially in the urgent trauma and critically-ill patients. 227 Is Tube Thoracostomy Necessary for all Traumatic 225 Diaphragm Rupture? Heart Trauma: A Ten-Year Experience P. Yazici, U. Aydin, A. Uguz, C. Caliskan, H. Kaplan M. Rashid, T. Wikstro¨m, P. O¨ rtenwall Ege University School of Medicine, Department of General Surgery, From the Division of Vascular and Trauma Surgery, Department of Izmir, Turkey Surgery, Sahlgrenska University Hospital/O¨ stra, Gothenburg Uni- versity, Gothenburg, Sweden Diaphragm rupture is not uncommon injury due to either blunt or penetrating trauma. Diaphragm rupture due to blunt trauma is usually Objective: To present our experience of cardiac injuries treated at occurred secondary to abdominal trauma and management includes one Swedish emergency department in the 10 years 1988–97. tube thoracostomy. The aim of this study is that whether tube tho- Design: Retrospective study racostomy is necessary, even after surgical repair of diaphragm, or Setting: Teaching hospital not. Between 2001 and 2006, we retrospectively reviewed the trauma Subjects: 11 patients (9 men and 2 women, mean age 33 years, range patients with diaphragm rupture. Data collection included demo- 19–54); in 7 they were penetrating injuries and in 4 blunt. graphic variables, etiology of trauma, diagnostic method, concomitant Main Outcome Measures: Morbidity and mortality. injury, surgical repair, chest tube insertion process. Diaphragm rup- Results: The mechanisms of injury were stab wound (n = 7), and car ture was observed in 57 patients (12%), 53 male/4 female, with a mean crash, fall, boat crash, and abuse (n = 1 each); drug or alcohol misuse age of 34 (20–78). The etiology of traumas included penetrating injury played a part in all those with penetrating injuries. The penetrating (38, 66%) and blunt trauma (19, 44%). Mean injury severity score was wounds involved the left ventricle (n = 3), the right ventricle (n = 2), 42 (9–75). Diagnostic methods were plain chest x-ray (42, 73%) and and the pericardium (n = 2). All 5 patients with ventricular wounds computed tomography (7, 12%), intraoperative observation (8, 14%). presented with cardiac tamponade, in 1 of whom it was fatal (he bled The most frequent concomitant injury was liver injury (28%). 21 to death during emergency thoracotomy). The main complications patients were preoperatively performed chest tube insertion that six were anoxic brain damage and postpericardiotomy syndrome (1 were submitted to combination of hemothorax and pneumothorax. each). There was no case of myocardial concussion. Remainder patients underwent intraoperative chest drainage using

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 65 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

nelaton catheter through the rupture site and subsequently 13 had sition and osteosyntesis is very difficult with standard osteosynthetic permanent tube thoracostomy. 23(40%) didn’t required tube inser- materials and ideal treatment method still does not exist. Author tion either intraoperative or postoperatively. In this study, penetrat- describes original treatment method using ex tempore made polym- ing injury was mostly found a cause for diaphragm rupture. Almost ethylmethacrylate (PMMA) plates reinforced with non-alkaline glass half of the patients with diaphragm rupture could be managed only fibers. The method was established in cadaver experiment during with intraoperative chest drainage and primary suture of the rupture. autopsy of deceased in thoracic trauma. In vivo experiment was Diaphragm rupture without lung injury may be treated with only performed on 10 dogs, average weight 25–30kg. First group of 4 cases primary suture avoiding unnecessary tube thoracostomy. was treated as acute experiment to establish the definitive surgical procedure. Surgical procedures were performed in total endotracheal anesthesia. Two surgical fractures were made on ribs V, VI and VII to create experimental flail chest. Biological compatibility of material 228 and its osteosynthetic efficiency were tested in chronic experiment on Pseudoarthrosis of the Ribs Treated With LCP, 6 dogs. Full biochemical analysis was performed before and after the two Cases experiment, during procedures all vital signs and parameters were monitored. Chest X-rays were taken at experiment start, immediately M. Bemelman1, T. Gardenbroek1, F. Boekhoudt2, G. van Olden3, after the surgical procedure and after the acrylate plates were re- L. Leenen1 moved. Lung function was excellent. Pathohistological analysis of all 1UMC Utrecht, The Netherlands relevant tissue samples was performed. Canine experiment showed 2Mesos Medical Centre Utrecht, The Netherlands absolute biological compatibility of polymethylmethacrylate plates 3Meander Medical Centre Amersfoort, The Netherlands reinforced with non-alkaline glass fibers. PMMA is an excellent osteosynthetic material for rib and flail chest reconstruction, the sur- Pseudarthrosis after rib fractures is a rare phenomenon, seven cases gical method is simple and can be efficiently applied for different are described in the English literature. We present two patients types of flail chest. with respectively one and three pseudoarthrosis of the ribs. Both patients were initially treated with conservative therapy; unfortu- nately they developed symptomatic pseudoarthrosis of the ribs. After additional conventional x-rays and CT-scan, both patients 230 were treated with small fragment LCP osteosynthesis. One of our Evaluation of Damage Solid Organ in Patient with patients developed a pneumothorax postoperative, short term drainage was necessary. With a follow-up of six months the patients Blunt Abdomen Trauma (Bat) 1 2 2 2 are completely pain free. In case of persisting pain after a rib A. Dogjani , S. Osmanaj , A. Lila , G. Zikaj 1 fracture, pseudoarthrosis should be considered. With conventional Eates;Iatsic:Iss/sic 2 x-ray’s the diagnosis can be made however CT-scan is more effec- Second Departement Of General Surgery, University Central Mil- tive and accurate to diagnose the pseudoarthrosis. Treatment con- itary Hospital, National Trauma Center, Tirana, Albania sists of osteosynthesis in which we recommend the usage of a LCP. The unicortical LCP osteosynthesis is sufficiently rigid for an ade- Introduction: Blunt abdominal trauma is a leading cause of morbidity quate osteosynthesis of the fragile bone. Our presumption that the and mortality among all age groups. Trauma is one of todays most shortest self-drilling locking head screws would not penetrate the serious and expensive health care problems, and it is the most second cortex proved otherwise, one of our patients developed a common cause of mortality in young population.Blunt trauma pro- pneumothorax as a consequence of one or more self-drilling screws. duces a spectrum of injury from minor, single-system injury to dev- Due to this complication we developed a different technique in astating,multi-system trauma. which we use the LCP drilling guide with integrated drill with Problem: Blunt trauma caused by traffic accidents, falls, and limited penetration. After drilling controlled unicortical we insert a physical assaults can cause severe abdominal injuries such as solid non self drilling unicortical screw. In conclusion we postulate that organ or vascular trauma, which can cause hypovolemic shock and the first choice of treatment of pseudoarthrosis of the ribs should be death. osteosynthesis. Unicortical osteosynthesis with a LCP provides Aims: To evidence:The causes,incidence (ages, sex, etc),Damages sufficient rigid fixation, the developed technique reduces the risk for ration of solid organ, The way of treatment conservative or surgical pneumothorax. one of blunt abdomen trauma (BAT). Material and Methods:.We retrospectively reviewed 63 patients (49 males, 14 females); mean age was a) till 14years old 11cases, b)14–40 years old 25cases, c)over 40 years old 27 cases; meanThe type of trauma; a) there were car 229 accidents 37 cases, b)falling from height 15 cases, Surgical Treatment of Flail Chest and Rib Results: Mean way of treatment there were operator 43 cases ,conservative 20 cases.We were identified and divided into four groups Osteosinthesis by Reinforced Acrylate Plates: according to the probability ofIntra abdominal damaged solid organs, Canine Experiment patients in Group 1 (n = 18) liver injured, Group 2(n = 23) lien in- B. Donfrid jured, Group 3(n = 12) kiddnies injured, Group 4(n = 10) more than University Clinical Center Zvezdara 2 organs injured. Conclusion: Injury to intra-abdominal viscera must be excluded in all Many contemporary authors state that early rib fixation and reduc- victims of BAT. Physical examination remains the initial step in tion of mechanical respiration period are essential elements for diagnosis but has limited utility under select circumstances. Thus, successful treatment of multiple rib fractures. The main problem is various diagnostic modalities have evolved to assist the trauma sur- that due to shape and size diversity of human ribs anatomical repo- geon in the identification of abdominal injuries.

66 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

231 pubis and labium majus revealed localized purpuric plaques with a Post-Traumatic Retroperitoneal Haematoma – broad rim of erythema, tenderness, and crepitus along the sides. Based on the clinical features, Fournier’s gangrene associated with acute Diagnosis and Therapeutic Issues abdomen was diagnosed. Laparotomy revealed edematous, dilated C. Murgu, G. Jinescu, I. Lica, R. Anghel, M. Beuran and discolored small intestine. Extended cutaneous, subcutaneous and Emergency Hospital Of Bucharest, Romania fascia necrosis was evident. Aggressive surgical debridement and Bo- gota bag were performed. Patient was discharged after 3 months. Introduction: Positive diagnosis of post-traumatic retroperitoneal Conclusion: Mortality rate ranges from 8 to 67%. Early diagnosis, haematoma (RPH) is difficult to provide in a trauma patient, because early aggressive surgical debridement and beginning of broad-spec- of the overlapping associated injuries encountered in these cases. trum antibiotics are vital. Method: 118 cases of RPH have been registered at the Clinic of Surgery of the Emergency Hospital of Bucharest in a three years period (2001–2003). Out of 118 cases 104 (88%) were due to trauma. 233 Results: 52% (54) of the registered post-traumatic RPHs were motor Laparoscopic Operations at Traumas of a Spleen vehicle accidents; 21 (20%) were due to falls, 12% (12) stabbing A. Voynovskiy, A. Koltovich2, S. Kurdo3, E. Ashkhotov4 wounds, 5,5% (6) gunshot wounds and 10% (11) were due to animal Chief military clinic hospital of international armies of the Russia inflicted injuries and occupational hazards. 38% (40) of patients had Internal Ministry troops renal injuries and almost half of them required nephrectomies (16, 40%), 9% were caused by vascular damage necessitating immediate The aim of the research is to reveal laparoscopic operations oppor- vascular repair and 2% of patients had pancreatic injuries requiring tunities in case of blunt abdominal trauma including spleen injury. pancreatectomy. Splenic lacerations were 28% of all associated vis- Since 1998 there were 22 diagnostic laparoscopy performed for in- ceral injuries and all of them entailed splenectomy; hepatic injuries jured with spleen traumas and intra-abdominal hemorrhage diag- were encountered in 26% of cases and in 80% was performed he- nosed. While laparoscopy proce-dure 5 patients revealed suppressed patoraphy. 70% of patients had non-surgical complications (pulmo- hemorrhage including 2 surface ruptures of a spleen capsule and 3 nary embolism, indwelling catheter-related infections, bed sores). sub-capsule hematomas. There were 11 hemostasiss achieved while Surgical complications included wound infection (16%), eviscera- laparoscopy performance herein 2 cases of fibrinous glue Tissukol tions (5%), etc. Out of 104 patients 6 (5,7%) died shortly after application, 5 cases of electrocoagulation and 4 argon plasmatic admission and 22 (21%) deaths have been accounted following brain coagulations. There were 6 con-versions performed including tradi- injuries and non-surgical complications. tional splenectomy. Hereto laparoscopy revealed 4 cases of numer- Conclusions: Management of retroperitoneal haematomas remains ous fractures of a capsule and parenchymatous diagnosed and 2 cases confusing for surgeons. Because the underlying injuries and their of major sub-capsule hemorrhage spreading onto the spleen portal. treatment may differ considerably, the nonoperative or operative Thus there were 16 (out of 22 injured) laparoscopic operations per- approach is based on mechanism of injury coupled with hemody- formed which insured laparotomy avoidance and organ salvage namic status of the patient and extent of associated injuries. interventions. Indications for laparoscopy application were capsule’s fractures without paren-chymatous tissues injury; linear surface parenchymatous tissue fractures hereto the spleen portal was not 232 injured; stable hemodynamics. Indications for laparotomy were A Successful Treatment of Fournier’s Gangrene branching fractures, spreading onto the spleen portal; crushing, Associated with Abdominal Compartment spleen separation from the vascular pedicle, unstable hemostasis. Syndrome D. Sahin1, R. Kusaslan1, F. Kir Sahin2, Y. Ela3, O. Dilek1 234 1Department of Surgery, Afyonkarahisar Kocatepe University, Role of Endoscopic Retrograde Afyonkarahisar, Turkey 2Department of Obstetric and Gynecology, Afyonkarahisar Koca- Cholangiopancreatography in Major Trauma tepe University, Afyonkarahisar, Turkey Patients 3Department of Anaesthesiology, Afyonkarahisar Kocatepe Uni- I. Jeroukhimov versity, Afyonkarahisar, Turkey Assaf Harofei Medical Center

Background: Fournier’s gangrene is a rapidly progressive necrotic Severe hepatobiliary-pancreatic injury may pose difficult manage- disease of the genital region that may be potentially lethal. We report ment problems. Endoscopic retrograde cholangiopancreatography successful treatment of a patient of Fournier’s gangrene after (ERCP) is an important tool in patients with biliary tree and pan- abdominal compartment syndrome. creatic problems. However its role in the management of patients with Case Report: A 51-year-old female presented with a 2-day history of major trauma seems to be underestimated. Methods The charts of abdominal pain and swelling abdomen. Myomectomy was performed patients admitted to Assaf Harofeh Medical Center during a 5-year five days and laparotomy due to ileus was performed one day before period with bilio-pancreatic trauma who underwent ERCP were ret- admittance. However, gastrointestinal tract was patent during lapa- rospectively reviewed. Patient’s demographics, mechanism of injury, rotomy. She was referred to our hospital because she became lethargic Injury Severity Score, timing and type of ERCP (diagnostic, thera- and hypotensive. Physical examination revealed midline incision scar peutic) performed and ERCP-related complications were studied. above and below the umbilicus and a Pfannenstiel incision. Sepsis Results Fourteen patients underwent ERCP. Four patients with bile symptoms were evident. Abdomen was distended and bowel sounds leak following major liver injury underwent billiary stenting resulting were not heard. Examination of incision scars, bilateral groins, mons in fistula resolution. Ten procedures were performed in patients with

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 67 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

pancreatic trauma. Three patients with CT-proven pancreatic injury patients the surgeons primary aim is stopping of intraabdominally had no leak from the pancreatic duct on ERCP and were managed bleeding. Nonoperative management of patients with liver injuries expectantly. ERCP confirmed main pancreatic duct leak in two pa- becomes possible in case of hemodynamically stable patients. tients with CT-suspected pancreatic injury. Distal pancreatectomy Several complications may occure after solving intraabdominal was performed in both cases. Two patients underwent ERCP for bleeding. suspected pancreatic injury after ‘damage control’ surgery. One major Aims: The autors analyze their own seven-year experience with the pancreatic duct injury was diagnosed followed by distal pancreatec- treatment of complications after the liver injuries. tomy. Two patients initially undergoing distal pancreatectomy Materials and Methods: The management of 20 patients with com- developed a pancreatic fistula and were managed by papillotomy and plications from all 112 patients with liver trauma (mean age 37,1 pancreatic duct stenting. One patient with posttraumatic symptomatic years) range 18–72/ presenting from January 1999 to December 2006 pancreatic pseudocyst underwent ERCP and stenting followed by is retrospectively reviewed. There were 92 cases of blunt trauma endoscopic cystogastrostomy. The pseudocyst had completely re- (82,l%/ and 20 cases of penetrating trauma (17,9%). 68 cases were solved on follow up CT. No ERCP-related complications were ob- classified as simple (gr. I and II) and 46 cases as complex liver injuries served. Conclusions ERCP has an important role in the management (gr. III-V/ AAST). The most frequent complications were postop- of bilio-pancreatic trauma patients avoiding unnecessary surgical erative bleeding and biliary leak. interventions and in some cases downgrading pancreatic injuries. Results: The postoperative complications rate was 17,9% (20 patients). Number of all complications was 29. Majority of complications was cured with minimally invasive techniques a/ endoscopy- ERCP, PTC, temporary biliary stent, papilosphincterotomy b/ 235 ultrasonography / biloma evacuation under ultrasonography control Liver Trauma: Expirience in the Managment of 476 c/laparoscopy d/selective liver artery embolisation Relaparotomy due Cases to postoperative bleeding was used only twice. G. Vukovic, B. Stefanovic, Z. Lausevic Conclusions: Interdiciplinary cooperation with miniinvasive tech- University Clinical Center Of Serbia, Department Of Emergency niques has been enlarged also in the treatment of complications after Surgery, Serbia liver trauma.

Background: Non-operative treatment is standard strategy for management of blunt liver injuries in hemodynamically stable patients in 237 last decade. Methods: Retrospective study included patients with liver trauma, Is it More Dangerous to Perform Inadequate admitted in the period december 1995 - december 2005, in total 476 Packing? patients. For assessment of injury severity ISS was used. P. Yazici, U. Aydin, M. Zeytunlu, M. Kilic, A. Coker Results: Three hundred ninety-two (82.4%) of 476 patients present- Ege University School of Medicine, Department of General ing with liver trauma had blunt and only 84 (17.6%) had penetrating Surgery injury. Isolated liver injury was identified in 27.5% and 72.5% had associated injuries. Average ISS value was 24.06 (SD = 14.26). Most Peri-hepatic packing procedure which is the basic damage control of patients, 22.9%, had ISS equal to 27. Of all patients, 76.1% had technique for control of hepatic haemorrhage is one of the cor- ISS less than 29. Only 5.3% of patients underwent nonoperative nerstones of the surgical strategy. Between 2001 and 2006, we treatment. During the operation liver injury in patients was classified retrospectively analyzed the trauma patients with liver injury. The according to Moor. In 10% we found liver injury grade I, in 31% patients underwent adequate packing was assessed in Group A, grade II, in 30% grade III, in 20% grade IV, in 8% grade V and 1% and inappropriate packing in Group B. Over a five-year period, 80 grade VI. In 2% critical patients, due to hemodynamic unstability we patients (M/F: 69/11) with a mean age of 34.3 (17–75). The most performed ‘‘damage control surgery’’. Out of 476 patients 87.0% frequent type of injury was found due to blunt trauma (66.2%) were successfully managed, 6.1% died as ‘‘mors in tabula’’ or during and followed by penetrating injury (23.7%) and gun shot wounds first 24 hours and 6.9% died during hospitalization. Neither mortality (10%). The most concomitant injury was observed in spleen or complications were registered in patients with nonoperative (27%). 48 patients (60%) had isolated liver injury. 17, 21.2% treatment. patients underwent perihepatic packing that 14 of them were Conclusion: Small proportion of nonoperatively treated patients transferred from around hospitals. Of these, 8 with inappropriate could be explained by fear of surgeons that some serious conditions packing procedure were evaluated in Group B and remainders could be overlooked as well as insufficient diagnostics. Higher pro- with adequate packing were assessed in group A. Mean 3 unites portion of nonoperatively treated is among patients with ISS less of blood were transfused in Group A and unpacking procedure than 10 (25.2%) and those with injuries grade I and II (31.0%). was performed approximately 24 hours later. Only 3 (33%) patients required segment resection with homeostasis and no mortality was found. In Group B, 4 patients required repacking in 6 hours. Mean 9 unites of blood transfused until unpacking proce- 236 dure. 3 patients required hepatic resection with homeostasis. 1 Treatment of Complications After Liver Injury patient died from hypovolemic shock during transfer and 2 pa- I. Milan, J. Chmelova, D. Czerny, P. Klavana tients succumbed to death postoperatively. Prognosis of these University Hospital Ostrava, Centre Of Traumatology patients depends on the both efficiency of the packing procedure and presence of concomitant injuries. Therefore, this study Introduction: The traffic accidents are the most frequent cause of emphasize that inadequate packing may easily result in poor liver injuries in our region.In case of hemodynamically unstable outcome.

68 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

238 the disrupted segment 6 were ligated. Then cholecystectomy was Management of Liver Injuries in Politrauma performed and cytic stump was used for ingection of the metyhlene blue to determine whether a bile duct injury occurred or not and bile R. Gheorghe, duct of the segment 6 was also repaired with suturing. He recovered Department of Surgery ‘‘N.Anestiadi’’, Medical University without any complication was and discharged from the hospital on ‘‘N.Testemitsanu’’, the postoperative day 7. Combination of intraoperative Doppler ultrasonography for vascular evaluation with methylene blue ingec- Key words: Politrauma, liver, diagnosis, surgery tion for bile duct contributed to the operative success, maintaining Aim: To establish an optimal diagnostic and treatment tactics in liver short time and minimalized traumatization during operation. injury, depending upon hemodinamic stability, injury severity in politrauma pts. Material and Methods: We present the treatment results of 170 politrauma pts with liver injuries, treated in Emergency Hospital 240 during 1998–2006. M/F ratio was 4,86:1 with the mean age 36,56 ± 1,1 Sequential Treatment for Severe Liver Trauma years. Blunt trauma – 113(66,5%), penetrating trauma – 57(33,5%). B. Martian, D. Ene, B. Diaconescu, I. Dogaru, F. Iordache 141(82,9%) pts were admitted with signs of shock, 34(20%) had Surgical Department cerebral coma and 41,2% - alcohol intoxication. In 126(74,1%) pts liver injuries were associated with thoracic trauma, in 105(61,8%) – Material: We report a trauma case by falling from 6 m,. The patient is head trauma, in 64(37,6%) with limb trauma. During surgery right transported to a regional hospital, operated for massive haemoperi- liver lobe injury were diagnosed in 108(65,45%), left lobe – in toneum due to liver laceration: liver packing and helicopter transport 40(24,24%), both – 17(10,3%). Gr.I-II liver injury was diagnosed in to our hospital. The patient was brought with trauma score 2, 61, gr.III-V in 104 pts (AAST). ISS – 37,45 ± 0,97, RTS – 6,88 ± 0,12. HR = 130bpm, BP = 40/20 mmHg, on positive inotrope support, on Results: Investigation consequence depended upon the hemodinamic mechanical ventilation and was transferred directly in the operation stability and was performed simultaneously with resuscitation mea- room. Simultaneously with the initially evaluation the patient was sures in a multidisciplinary facility. Emergency surgery was per- stabilized, sent to CT that pointed out: vast lesion of the right liver formed in 157 pts. Postoperative complications occurred in lobe with active bleeding, hemoperitoneum, renal contusion without 67(39,4%) pts, postoperative mortality - 24,2%. intracranial lesions. Relaparotomy: massive laceration of the right Conclusions: The incidence of liver injury in politrauma pts was 25%. liver lobe, SVC and right hepatic vein lacerations (lesion level 5). We The diagnostic algorithm of liver injury in politrauma pts depends on performed an atypical hepatectomy (segments VI, VII, VIII and the hemodinamic stability. USG, peritoneal lavage and laparoscopy partially V and IV b), suture-ligature of the right hepatic vein and are the methods of choice to diagnose liver injury in politrauma pts. suture of the SVC lacerations. Liver packing was necessary at the Surgical tactics depends on the injury severity, includes organ-pre- end. Autotransfusion, massive blood transfusions and recombined serving approach, the main aim being hemostasis. In severe liver factor VII were also used. Planned relaparotomy 36 hours after sur- injury (gr.III-V) and associated with duodenal and pancreatic injury gery was performed for packing removal and haemostasis check up. external biliary drainage is indicated. Results: The evolution was favourable, with initial haematic drainage which stabilised within 4 days. In day 10 the drainage turned biliar and a biliar stent was placed with the stop of the bile leak within 7 days. A fungus sepsis appeared day 14 with favourable evolution 239 under Caspofungin treatment with sterile blood cultures. Combination of Intraoperatif Doppler Conclusion: The sequential surgical treatment and the intensive care Ultrasonography with Methylene Blue for the may guarantee the survival of patients with severe hepatic trauma. Management of Liver Injury due to Gun Shot U. Aydin, P. Yazici, M. Ozsoy, C. Caliskan, M. Kilic 241 Ege University School of Medicine, Department of General Surgery, Izmir, Turkey Management of Pancreatic Lesions on Trauma Patients Liver injury is regarded 10% of whole abdominal injuries and 25.8% B. Gaspar, S. Paun, R. Ganescu, M. Beuran, G. Ionescu occur due to gun shot. These are associated to large hemoperitoneum Bucharest Clinical Emergency Hospital, Romania and generally required exploratory laparotomy. This report emphasized the efficiancy of different combination of diagnostic methods in The management of pancreatic trauma provides trauma surgeons the management of high grade liver injuries. A 55-year-old man with with diagnostic and therapeutic challenges. The preoperative and a gun shot injury was brought to the emergency service. Two hours intraoperative assessment and treatment of pancreatic injury may be passed when he arrived to the hospital. He had a heart rate of of 110 difficult, especially when concurrent severe injuries are present. An beats/minute (sinus tachycardia), with a blood pressure of 90/50 initial computed tomography scan of the abdomen often fails to mmHg. An entrance wound on the sternoxiphoid junction and an demonstrate the extent or the severity of a pancreatic injury, and exit wound on the right 12th rib in the midclavicular line were ob- determinations of pancreatic enzyme levels are unreliable. served by the physical examination. After plain chest x-ray and Method: Retrospective analysis of 1534 patients admitted after mul- ultrasonography revealing pneumothorax and free fluid, respectively, tiple trauma from January 1, 1996, until December 31, 2005 within the he promptly underwent exploratory laparotomy. The bullet passing Clinic of Surgery of Emergency Hospital of Bucharest Romania. through the segment 3, 4b, 5 and 6 was determined. Intraoperative Results: The analysis contents 94 cases of pancreatic injury, 52 Doppler ultrasonography was performed to detect vascular pattern. (55,31%) of them were diagnosed during laparotomy. The pancreatic After pringle maneuver, the portal vein, hepatic artery and vein of injuries have been evaluated according to Moore’s lesions scale. The

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 69 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

treatment was from hemostasis, pancreatoraphy, peripancreatic incidental to other abdominal surgery. There were 11 women and 8 drainage to pancreatic necrectomy, necrosectomies or partial pan- men with a mean age of 63, 9 (42–88). Incidental splenectomy was the createctomy. most frequently associated upper gastrointestinal procedures, Conclusions: Pancreatic injury is not a frequent complication in se- accounting for 63% of the spleens. The most frequently employed vere trauma. Preoperative diagnosis for pancreatic trauma is rather incision was the midline (14, 72%), either upper or long, and 9(64 %) challenging. When diagnosed timely and treated according to were used in emergent operations. The traction on the splenic liga- severity of pancreatic injuries have an acceptable morbidity, but ments in the course of facilitating the exposure was encountered as the usually a high mortality. Thanks to the improved performance of mostly found reason (52%) for iatrogenic splenic injury. Postopera- spiral CT scanning and magnetic resonance pancreatography, now is tive complications included left pleural effusion, left subphrenic ab- possible to make an early diagnosis of pancreatic contusion, to cess and wound infection. Only one patient died of pneumonia caused localize the site of the injury, and (most importantly) to identify by bacteria (klebsiella pneumonia). Splenectomy may result with injury to the main pancreatic duct which has major implications for hazardous complications not only in the postoperative period but also the management of the case. in the long term. Because iatrogenic splenectomy contributes significant morbidity and mortality of the primary procedure, the first rule should be avoiding the injury. If it occurs, organ preserving procedures 242 including different homeostasis procedures make the first step. Prospective Study on Conservative Treatment of Splenic Injuries. Preliminary Results 244 P. Kornprat1, S. Uranu¨s1,2 Management fo Splenic Trauma of a Patien with 1Department of Surgery, Medical University of Graz, Graz, Austria Splenomegaly due to Portal Hipertention 2Section for Surgical Research, Medical University of Graz, Graz, A. Aren, S. Aksoy, F. Basak Austria Istanbul Education And Research Hospital, Turkey Background: After it was recognized that splenectomy puts patients Aim: In this report, we present a blunt abdominal trauma case having at lifelong risk of septic complications, splenic conservation or con- a history of portal hypertension and splenomegaly. And discussed to servative treatment after blunt abdominal trauma became routine. problems we faced to. The aim of our prospective, multicenter study is to evaluate which Case:30 years-old female was admitted to emergency department patients with splenic injury can handled conservatively. with a complaint of blunt abdominal trauma. Physical examination Methods: Patients were recruited from 4 surgical centers in Austria was revealed right and left upper abdominal quadrant tenderness. from 2003 onward. Inclusion criteria were age of at least 16 years, Noncirrhotic portal hypertension, splenomegaly and hypersplenism stable hemodynamic parameters after blunt abdominal trauma with were diagnosed during last three years. Blood analysis was showed splenic injury, and conservative treatment. To date, 40 patients with a that Htc level 26%, Hb 8.2 g/dl and Plt 52.000/mm3. Abdominal median age of 38 years have entered the study (13 female, 27 male). ultrasonography was showed abdominal fluid and computerized The most common cause of trauma was motor-vehicle accident. The tomography was showed grade 3 splenic injury. Patient was taken to patients were classified according to the severity of the splenic lesion intensive care unit for close monitorization. After five hours of and treated conservatively according to a standardized regime. resuscitation even with massive transfusion of blood products, he- Results: Conservative management was possible in 34 patients while modynamic stability could not achieved.(Plt 40.000/mm3). Splenec- six required surgery. Failure of conservative treatment was due to tomy, was performed. Postoperative period was uneventful heparin therapy in three patients, while one patient with grade IVb Conclusion: In grade 3 and even grade 4 splenic injuries nonoperative injury required splenectomy 36 hours after the trauma. In 2 further treatment is recommended in current literature. Management of patients splenorrhaphy was performed. splenic trauma with a patient with history of splenomegaly and portal Conclusions: Preliminary results suggest that nonoperative manage- hypertension is insufficiently discussed in literature. In presented case, ment is a safe and effective treatment method. hypersplenism and portal hypertension were burden on hemostasis. Even with massive resuscitation, thrombocyte level decreased to 40.000/mm3 after five hours. But, insistence on nonoperative treat- 243 ment in this situation could be fatal with deepening thrombocytopenia A Different Type of Splenic Trauma P. Yazici, U. Aydin, C. Caliskan, S. Ersin, H. Kaplan 245 Ege University School of Medicine, Department of General Surgery Non-Operative Management of Four consecutive Surgical reports are usually lack of necessary details about performing Cases with Acute Splenic Infarction splenectomy, particularly during unconcerned operative procedures, C. Ibis, A. Sezer, R. Koksal, A. Hatipoglu, I. Coskun due to serious legal threat or inaccurate recording of the indication for Trakya University Faculty Of Medicine Department of General splenectomy. The aim of this retrospective study is determining the Surgery incidence and common causes for iatrogenic splenectomy and the optimal approach to this kind of splenic injury. Between January 1995 Splenic infarction is a rare condition. It is associated with a hetero- and July 2005, 322 consecutive splenectomies were retrospectively geneous group of diseases. The infarction may be segmental or glo- reviewed. The demographic features, incision types, primary opera- bal. The clinical picture vary from asymptomatic infarction to an tion procedures, the mechanism of the injury, and the postoperative obvious acute abdomen with or without septic features. In 2006 we course were analyzed. 19 patients (5%) were performed splenectomy treated four consecutive cases with acute splenic infarction in our

70 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

department. All of four patients were admitted to the emergency the risk of hernia formation, strangulation, and high morbidity and room with classical symptoms of acute abdomen with no trauma mortality. The purpose of this study was to determine the role of DL history. Radiologic evaluation studies revealed splenic infarction. in patients with left sided asymptomatic thorocoabdominal stab The possible complications of splenic infarction such as hemorrhage, wound. rupture, abscess, or pseudocyst were not detected. All of four cases Methods: From January 2002 to January 2007, 128 patients who were managed conservatively. Even the patient with an infarction sustained penetrating injuries to the left lower chest were prospec- area more than 90% of the spleen could be treated non-operatively. tively evaluated. Diagnostic laparoscopy performed to determine the Six months follow-up showed no late death, readmission or any presence of an injury to the diaphragm. Patients with hemodynami- complaints associated with splenic infarction. Splenic infarction is cally instability and peritonitis on admission underwent laparotomy one of the rare causes of acute abdomen and in selected cases suc- and excluded from this study. cessful conservative managment is possible. Results: One hundred and twenty-eight patients with penetrating thoracoabdominal injures was enrolled. The overall incidence of occult diaphragmatic injuries was 43 (34%). For anterior, lateral, and 246 posterior injuries rate of diaphragmatic injuries was (26pts) 60%, (13 Splenic Infarction in Blunt Abdominal Trauma: pts) 30%, and (4 pts) 10% respectively (p = 0.075). Diaphragmatic injuries was found higher incidence in patient with hemo/pneumo- Case Report thoraces (12/18, 66.7% vs 26/72, 36.1% p = 0.019). In the 26 (60.4%) L. Trenti1, V. Ranieri1, M. Amorico2, M. Malagoli2, A. Rossi1 1 patients the diaphragmatic injuries repaired with laparoscopic tech- Chirurgia D’Urgenza, Azienda Ospedaliero-Universitaria Policli- niques. In 18 (20%) patients laparoscopy revealed concomitant nico Di Modena, Italy 2 injuries. Servizio di Radilogia, Azienda Ospedaliero-Universitaria Policli- Conclusion: Laparoscopy allows adequate visualization of the dia- nico di Modena, Italy phragm and useful for repairing diaphragm injuries. It also helps to detect the concomitant intrabdominal injuries and should be con- The spleen is the most commonly injured intraperitoneal organ in sidered left sided penetrating injuries blunt trauma. Splenic infarction has been described in several medical conditions but it is rarely observed in blunt splenic injury. We report the case of a 17 year-old man admitted to our A&E after a bicycle crush. The patient was alert and hemodynamically stable. Clinical examination revealed tenderness on the left upper quadrant 248 involving the lower rib cage. Laboratory blood tests ranged within Experience with 114 Emergency Thoracotomies normal limits. The chest x-ray showed a simple fracture of the the 9th L. Labler, C. Meier, M. Keel, O. Trentz rib and an urgent abdominal US documented a small amount of Department of Surgery, Division of Trauma Surgery, University perisplenic and pelvic liquid effusion and a diffusely heterogeneous Hospital Zurich, Switzerland splenic parenchima. On contrast enhanced CT (CECT) the spleen contained multiple small contusions together with at least three ischemic lesions amounting to 36% of the splenic volume. Nonop- Objective: Emergency thoracotomy is an integral part of resuscita- erative management was chosen and the patient was admitted to ICU tion in the emergency department (EDT) or OR after severe thoracic for 48 hours. Eleven days later a control CECT revealed a reduction injury or haemorrhagic shock (ET). Only a few reports exist in in volume of the infarcted areas (18%). After an uneventful recovery, Europe. on day 12 post- admission, the patient was discharged. On follow up, 3 Methods: Identiﬁcation of EDT /ET during 10 years. Demographic months later, we performed a contrast enhanced US (CEUS) showing data, ISS, RTS, diagnostic procedures, surgical techniques, survival a reduction in size and number of affected regions. Management of rates (SR), signs of life (SOL), shock class and closed cardiopulmo- spleen infarction secondary to blunt trauma is feasible without clin- nary resuscitation (CPR) were recorded. ical sequelae. CECT scanning is essential for diagnosis but CEUS can Results: EDT/ET underwent 114 patients. Fifty-six patients (49.1%) be performed for spleen monitoring, especially in young patients died, 47(83.9%) the arrival day. Annual incidence was low (3 to 17). allowing a reduction in radiation exposure. Splenic abscess or delayed Blunt mechanism occurred in 68% for EDT/ET. Male/female ratio rupture can uncommonly be seen as complications. was 3 to 1. Average age was 40 years (range 14 to 84). EDT/ET ratio was 45(39.5) to 69(60.5%). No diagnostics in 24 patients (21.1%), thoracic x-ray (69.3%) or FAST (78.1%) were mostly used. EDT ISS of 43.9 ± 1.6 (range 25 to 66) was higher (ET: Abdominal Emergencies 36.4 ± 1.6, range 10 to 66). RTS of EDT 3.548 ± 0.336 was lower (ET: 5.382 ± 0.260). Surgical accesses during EDT were 51.1% thoracotomies, 44.4% sternotomies and 4.4% clamshell (ET: 78.3%, 247 10.1%, 2.9% and 8.7% for other techniques). Before EDT 29(64.4%) patients and during ET 65(94.2%) had SOL. Shock class Prospective Evaluation of Left Thoracoabdominal III or IV were noticed in 93.3%(EDT) and 60.8% (ET). EDT Penetrating Injuries with Laparoscopy lactate level of 7.8 ± 0.6 was higher (ET: 4.8 ± 0.4). CPR before H. Yanar, C. Ertekin, K. Taviloglu, R. Guloglu, S. Destek surgery occurred in 26.7%(EDT) and 8.7%(ET). SR after EDT was Instanbul University, Medical Schooll, Department of Surgery, 5.4%(blunt) and 75%(penetrating). ET mortality rate was Trauma And Surgical Emergency Service, Capa, Turkey 39%(blunt) and 10.7%(penetrating). Conclusions: EDT/ET are rare interventions in extremis. EDT/ET Introduction: Diaphragmatic injury after penetrating thoracoab- procedures show encouraging results for patients with blunt trauma. dominal trauma is common and delayed diagnosis is associated with EDT is still indicated. Training is mandatory for success.

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249 251 Traumatic Atrial Injuries: A Diagnostic Challenge Intestinal Perforations due to Blunt Abdominal M. Rashid, J. Lund Trauma in Children Department of Cardiothoracic Surgery, Copenhagen University J. Bauer, J. Schno¨ll, G. Schimpl Hospital (Rigshospitalet), Copenhagen, Denmark Department Of Paediatric Surgery, Salzburg, Austria

Atrial injuries due to trauma or taking place during another cardiac Introduction: Intestinal perforations (IP) account for only 3% of all interventional procedure is very rare. We evaluated traumatic atrial abdominal injuries in children. ´ injuries treated at Denmarks busiest medical center (Rigshospitalet) Patients and Methods: 53 patients, aged 5 to 14 years were treated for during a six-year-period. We found 5 patients with traumatic right 2 gastric, 16 duodenal, 18 jejunal, 9 ileal and 8 colonic perforations. atrial injuries, of whom 3 were iatrogenic due to pacemaker inser- Cuases of injuries were in 22 patients a bicycle accident, in 12 falls, in tion, and 2 were caused by car crashes. Patients with iatrogenic 11 traffic accidents and in 8 collisions. For diagnosis repeated clinical trauma were presented with a diffused clinical picture of tamponade investigations, serological parameters, x-ray, US, CT scan and la- that was masked by the critical myocardial ischemia and abnormal parocopy were used. Additional injuries were present in 31 patients, rythms. The other 2 patients were presented in shock and under- 18 contusions of the pancreas, 4 head injuries, 9 bone fractures and went urgent surgery: sternotomy in one and posterolateral thora- one complexe liver-duodenal-pancreatic injury. cotomy in the other. One patient died due to massive cerebral Results: Diagnosis of IP was achieved immediately in 42 patients and lesions 4 days postoperatively. The injury severity score was high in delayed up to 48 hours in 11 patients. X-ray was conclusiv for diag- the patient who died. Conclusions: We conclude that atrial inuries nosis in 12%, US in 61%, and CT scan in 89% and laparoscopy in all are extremely difficult to dignose preoperatively. Right atrial inju- 5 patients. All patients were operated and in 49 patients the lesion ries per se seem benign in nature and the associated injuries was oversuture and in 2 patients resected and anastomosed. In 2 determines the outcome as clearly seen in this discrete Scandinavian patients complexe injuries were treated by B II and Whipple pro- experience. cedures. Complications were seen in 5 patients, 2 pancreatic pseudocysts, 2 bowel obstructions and one sever peritonitis after delayed diagnosis requiring repeated peritoneal lavages. Conclusion: IP due to blunt trauma is a rare condition and delayed 250 diagnosis and treatment is common.Abdominal US ans CT scans are Pulmonary Injuries the most conclusiv tools for accurate diagnosis. An immediate M. Rashid, T. Wikstro¨m, P. O¨ rtenwall oversuturing of the lesions is sufficient with low morbitity, and From the Division of Vascular and Trauma Surgery, Department of complications are related to delayed diagnosis and treatment. Surgery, Sahlgrenska University Hospital/O¨ stra, Gothenburg Uni- versity, Gothenburg, Sweden 252 Objective: To find out whether we could manage critical pulmonary hemorrhages in penetrating injuries, and to report our experience Colon Injuries C the Experience of 116 Cases with blunt trauma of the lung. in a Level I Trauma Centre Design: Retrospective study Subjects: 81 patients who presented G. Jinescu with pulmonary injuries during the period January 1988-December Emergency Hospital Of Bucharest, Romania 1997; 6 were penetrating and 75 blunt. Results: Four patients in the penetrating group were shocked and Background: This study sought to evaluate current trends in surgical required urgent operations; emergency room thoracotomy (n = 1), management of colon injuries in a level I urban trauma centre, in the urgent thoracotomy (n = 2), and urgent thoracoabdominal explora- light of our increasing confidence in primary repair. tion (n = 1) were done successfully. We correlated grade of lung Methods: All patients with colon injuries operated on at the injury [American Association for the Surgery of Trauma-Abbrevi- Bucharest Clinical Emergency Hospital between january 1994 and ated Injury Scale (AIS) ] with mortality. All patients with penetrating december 2005 were identified. Data were collected by a retrospec- injuries survived without serious consequences. There were a mean tive chart review. (SD) 0f 6 (2) injuries/patient in those with extrathoracic injuries Results: We analyzed 116 patients with posttraumatic colon injuries. compared with 3 (1) injuries/patient in the group with thoracic lesions Blunt injuries were more common than penetrating injuries (65% vs (p < 0.001). The corresponding hospital mortality was 6/42 (19%) 31%). Significant other injuries occurred in 85 (73%) patients. Pri- mainly as a result of the central nervous system lesions (4/6) com- mary repair was performed in 95 patients (82%). Fecal diversion was pared with 0/32. The mean (SD) Injury Severity Score (ISS) was 9.3 used in 21 patients (18%). Patients chosen for colostomy presented (4.8) in patients with thoracic lesions compared with 24.1 (14.7) in shock more frequently, had more associated injuries, and higher patients with extrathoracic lesions (p < 0.0001), and 14.9 (9.5) in scores on the Abdominal Trauma Index (ATI) and Colon Injury all survivors compared with 49.9 (13.6) among those who died Scale (CIS) and were more likely to have gross contamination. Colon (p < 0.0001). related intra-abdominal complications occured in 7% of patients in Conclusions: An excellent outcome can be achieved managing pe- whom the colon injury was closed primarily and in 14% of patients in netrating injuries of the lung by an aggressive approach and urgent whom a stoma was created, ATI having a predictive role in their surgical intervention even when emergency room thoracotomy is occurence. Stratification of patients based on ATI and CIS revealed essential. Pulmonary contusion is considered to be a relatively benign that is better to perform colostomy rather than primary repair for lesion that does not add to the morbidity or mortality in patients with patients with ATI U+00AlY´ 30 and a CIS U+00AlY´ 4. The overall blunt chest trauma. mortality rate was 19%.

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Conclusions: Primary repair of colon injuries, either by primary su- term outcome were evaluated in all patients. Hospital and 1-year ture or resection and anastomosis, is a safe method in the manage- mortality was assessed. ment of the majority of colonic injuries. Surgical judgement remains Results: Hospital mortality was 19% and 1-year mortality 23%. the ﬁnal arbiter in decision making. APACHE II, previous functional status and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the intensive care unit, ad- 253 vanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best Duodenal Perforation Post-Ercp: Diagnostic discriminative ability for poor outcome (AuROC 0.78). and Therapeutic Management Conclusion: Degree of organ dysfunction measured using SOFA L. Fattori, L. Nespoli, A. Ardito, A. Germini, A. Nespoli score was the best predictor of hospital and long term mortality in Ospedale San Gerardo Dei Tintori patients suffering from secondary peritonitis.

Objective: Endoscopic Retrograde Cholangiopancreotography (ERCP) is widely used in the treatment of common bile duct dis- 255 eases. Cited complications rate approaches 10% and mortality 1–1,5 Laparoscopic Two-Stage Left Colonic Resection for %; ERCP-related perforations carries a death rate of 16–18%. Tra- Patients with Peritonitis Caused by Acute ditionally duodenal perforation after ERCP has been managed sur- Diverticulitis gically; however in last decade management has been shifted to a more selective approach, but some authors promotes non surgical A. Fingerhut, E. Chouillard, T. Ata, J. Etienne, E. Ghiles routine management : the reported death rate of medical treatment is Digestive Surgery Unit Centre Hospitalier Intercommunal, St. Ger- as high as 50%. Author’s experience with periduodenal perforation main, Paris, France after ERCP and their systematic approach is presented. Methods: A retrospective analysis of 6 (from March 2004 to May Purpose: Purulent or fecal peritonitis is one of the most serious com- 2005) duodenal perforations related to ERCP has been performed. plications of acute diverticulitis. Up to one fourth of patients hospi- Parameters evaluated were: type of perforations, clinical presenta- talized for acute diverticulitis require an emergent operation for a tion, diagnostic methods, time to diagnosis, management, surgical complication including abscess, peritonitis, or stenosis. Open Hart- procedures, length of stay, mortality and morbidity. Imaging with CT mann’s procedure has been the operation of choice for these patients. scan was also used for in-hospital follow up. The advantages of laparoscopy could be combined with those of the Results: The diagnosis of duodenal perforation has never been per- primary resection in selected patients with peritonitis complicating formed during ERCP examination. The hypothesis of perforation acute diverticulitis. However, due to technical difficulties and to the was clinical and confirmed by CT scan. In our experience an theoretical risk of poorly-controlled sepsis, laparoscopic Hartmann’s aggressive diagnostically and therapeutically management may re- procedure has seldom been reported for such patients. duce mortality. Four of our six patients underwent to aggressive Methods: Data were prospectively collected from 2003 through 2006 in medical observation and subsequently treated surgically: mortality a single referral center specialized in abdominal emergencies. Lapa- was 0% even if a high morbidity was recorded. roscopic Hartmann’s procedure (stage 1) was performed in selected Conclusion: The decision to manage perforations related to ERCP patients with peritonitis complicating acute diverticulitis. Secondarily, procedure without surgery is a dynamic one and should undergo Hartmann’s reversal (stage 2) was also performed laparoscopically. frequent reevaluation whenever the clinical circumstances demon- Results: Thirty one patients were studied. The median Mannheim strate even the slightest untoward development A selective man- Peritonitis score was 21 (12–32). The conversion rate was 19 % and agement scheme and an aggressive but selective surgical approach 11 % for stage 1 and stage 2, respectively. The was no perioperative may influence overall mortality. uncontrolled sepsis. Overall operative 30-day mortality and morbidity rates were 3 % and 23 % for stage 1, and 0 % and 15 % for stage 2, respectively. Stoma reversal was possible in 90 % of patients. Conclusion: OUr results demonstrated that the indications of lapa- 254 roscopy in acute diverticulitis could be extrapolated to selected pa- Organ Dysfunction and Long Term Outcome tients with peritonitis. The technical feasibility and safety of in Secondary Peritonitis laparoscopic Hartmann’s procedure seem acceptable in selected patients. M. Hynninen1, J. Wennervirta1, A. Leppa¨niemi2, V. Pettila¨1 1Department of Anesthesiology and Intensive Care Medicine, 256 University of Helsinki, Finland 2Department of Surgery, University of Helsinki, Finland Prospective Blind Comparison vs. CT Staging of Acute Diverticulitis Background and Aims: Secondary peritonitis is still associated with M. Zago1, D. Mariani1, A. Pestalozza2, M. Turconi1, H. Kurihara1 high mortality, especially when multiorgan dysfunction complicates 1Dept of General and Minimally Invasive Surgery, Emergency and the disease. Good prognostic tools to predict long term outcome in Trauma Surgery Unit - Istituto Clinico Humanitas - IRCCS individual patients are lacking and therefore requires further study. 2(2) Radiology Dept Patients and Methods: 163 consecutive patients with secondary 3 6 - Dr. Andrea Casamassima (1) 7 - Dr. Giorgio Brambilla (2) 8- peritonitis were included, except those with postoperative or trau- Prof. Riccardo Rosati (1) matic peritonitis. In 60 patients treated in the intensive care unit, organ dysfunction was quantified using Sequential Organ Failure Background: Staging of acute colonic diverticulitis according to Assessment (SOFA) score the first 4 days. Predictive factors on long Hinchey (H) score remains essential for treatment. CT is considered

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the standard technique. Objective: To compare CT and US for 258 Hinchey staging of acute colonic diverticulitis. Cytokines and Severe Acute Pancreatitis: Patients and Methods: Fifty-four patients (pts) admitted to the ED between January 2004 and December 2006 with a suspicion of acute The Role of Surgery and CVVDH diverticulitis were prospectively enrolled. US was performed first, M. Cardi, M. Benedetti, G. Prezioso, G. Fanello, P. Chirletti diagnosis confirmed and staging reported. An enhanced CT was University of Rome - General Surgery N, Italy blindly performed in 42 cases; only these pts were evaluated. The radiologist knew the clinical suspicion but was unaware of US find- Aim: The evaluation of role of laparotomy with continous abdominal ings. Comparison was first made on the basis of definitive record; a lavage and CVVDH (Continous Veno Venous Dia Hemofiltration)in retrospective blind review of images by one radiologist was also severe acute necrotic pancreatitis. obtained. Material and Methods: 15 patients with necrotic-hemorragic acute Results: Thirty-seven out of 42 pts had a confirmed diagnosis of pancreatitis (Atlanta 1992), APACHE II > 19 and Ranson > 7, after acute diverticulitis on US and CT reports. In 2 cases (one US and an initial (12–36 hrs from admission) non-operative management one CT) diagnosis was not confirmed by one of the two techniques. (standard medical treatment and gabesate-mesylate), underwent US classified 27 H1, 8 H2a, 1 H2b, 1 H3. CT reports classified 26 surgery when signs of MODS began (pO2 < 60 mmHg, plts 50.000, H1, 9 H2a, 1 H2b, 1 H3. One case was classified by US H1 and by PA 100 mmHg, PT > 25%, oligo-anuria). All patients underwent in CT H2a. Similar results were obtained after the blind retrospective the postoperative period CVVDH in ICU. Samples for the deter- review of images. Twenty-two were discharged after observation mination of cytokines levels were collected at operation in serum and and antibiotic therapy. At discharge, 72.7% had mild rebound in peritoneal fluid, in the postoperative period in serum, in abdominal tenderness and/or leucocytosis. Seventeen H1 pts (40.5%) were lavage and in the hemodiafiltration fluid. hospitalized. Results: All patients survived. At laparotomy in serum and in peri- Conclusions: US staging of diverticulitis has a high correspondence toneal fluid high values of IL-1, IL-6 and TNF were demonstrated with CT findings for H1. US allows to safely discharge a large (peritoneal levels 0.8 higher than serum levels). After laparotomy, number of pts for follow-up with clinical/laboratory findings for abdominal lavage and CVVDH levels lowered to normal values admission. between 7 and 12 days. High concentrations of TNF were found in hemodiafiltration fluid between the 1st and the 4th post-operative day while IL-1 and IL-6 lowered within the 2nd post-operative day. Conclusions: CVVDH, associated with surgical treatment plays an 257 important role in the reduction of serum and peritoneal levels of IL Outpatient Treatment of Acute Colonic and TNF. This terapeutic approach can be considered a valid treat- Diverticulitis with Oral Antibiotics ment in patients with acute pancreatitis associated with necrosis or hemorragic necrosis with signs of MODS. D. Serralta, J. Carlıń, C. Rey, D. Pe´rez-Dıáz, F. Ture´gano-Fuentes University Hospital Gregorio Maran˜ o´ n

Introduction: The treatment of acute colonic diverticulitis (ACD) 259 is currently being reviewed, and there is a tendency towards reducing the number of emergency colonic resections and pro- Analysis of Preoperative Mortality Risk Factors moting conservative treatment with antibiotics and percutaneous After Relaparotomy for Abdominal Surgery drainage of abscesses. In 2000 we started a protocol of outpatient I. Martínez Casas, J. Sancho Insenser, M. Pons Fraguero, treatment for selected cases of ACD, who otherwise would have E. Nve Obiang, L. Grande Posa been admitted to our center for i.v. antibiotics according to our Hospital Del Mar previous routine. Aim: To assess whether outpatient treatment of selected cases of Objective: To analyze preoperative mortality risk factors after rela- ACD is safe and effective parotomy for abdominal surgery in our unit of General Surgery. Methods: All patients were diagnosed by means of clinical exam and Patients and Methods: Between January 2004 and December 2005, abdominal CT scan, and classified according to Hinchey. All stage I 145 relaparotomies were performed in 116 patients (66% men) at our patients clinically and analytically stable, and a selected group of institution. The mean age (M‘‘bSD) of patients was 64‘‘b16. stage II (abscess <2cms), were sent home after assessment and a first Results: Indications for relaparotomy were (n; % mortality): peri- dosis of i.v. antibiotics. They were treated as outpatients with oral tonitis (41; 39%), bleeding (26; 19%), abscess (25; 20%), exploration metronidazole and ciprofloxacine during 7–10 days. Every patient laparotomy (17; 23.5%) and abdominal wall surgery (7; 0%). The was assessed 10 days later at the outpatient clinic, and had an imaging percentage of mortality in the series was 25.9% (30/116). Mortality of test (colonoscopy or barium enema) performed one month after the patients with one single relaparotomy was 20% (19/93) vs. 48% if acute episode. they were re-operated twice or more (P = 0,01). Patients who died Results: 60 patients were included and the average length of treat- were older (61 vs. 77 years; P < 0.0001), had higher ASA scores at ment was 8,8 days. Only 3 patients required admission in their evo- first surgery (P = 0,012), and more SIRS criteria (P = 0,038). Mor- lution because of persistence of symptoms, which improved with i.v. tality was associated with past history of vascular cerebral accident antibiotics. 4 cases of polyposis and one adenocarcinoma were (P = 0,036), active malignancy (P = 0,04) and previous treatment diagnosed at one month. Only 8 patients underwent an elective colon with antiaggregants (P = 0.02). Pre-operative data associated with resection on follow-up. mortality were anastomotic leaks (P = 0,005), ileus (P = 0,0005), Conclusion: Outpatient treatment of ACD is safe and effective wound infection (P = 0,04), and the need for total parenteral nutri- in many cases who would have been previously admitted to tion (P = 0,04), antibiotics (P = 0,042) or vasoactive drugs hospital. (P = 0,001). Discriminant analysis identified age, past history of

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vascular cerebral accident or active malignancy and need for vaso- and tenderness were the only clinical findings in 95,3% with preoper- active drugs as independent variables predictive for mortality. ative diagnosis of acute appendicitis in 5 of 8 patients. Seven patients Conclusions: Advanced age, past medical history of vascular cerebral underwent laparoscopic ileocecectomy and one had diverticulectomy. accident or active malignancy and the need for vasoactive drugs are Discussion: Because of the difficulties in diagnosis and surgical risk factors associated with mortality after relaparotomy and should treatment, cecal diverticulitis has received much discussion in the be considered when planning re-operation. literature and many questions remain unanswered. Right-sided diverticulitis is easily confused with acute appendicitis because it occurs at a somewhat younger age than that in sigmoid diverticulitis. 260 Cecal diverticulitis needs a high index of suspicious for achieving a Brief Hospital Stay and Outpatient Treatment is preoperative diagnosis. Diverticulectomy should be performed in Safe and Efficient in Selected Acute Cholecystitis patients with small diverticulum with limited inflammatory reaction. Right colectomy should be performed in patients with perforation of Patients the diverticulum, cecal phlegmon or abscess formation. J. Lago-Oliver, D. Serralta, I. Arjona, M. Sanz, F. Ture´gano-Fuentes University Hospital Gregorio Maran˜ o´ n 262 Complete Blunt Small Bowel Transection without Introduction: Acute cholecystitis counts among the most frequent surgical emergencies admitted to hospital. Although the gold-stan- Peritoneal Contamination, a Case Report dard treatment is surgical, in an increasing number of patients (long C. Rey, M. Sanz, D. Serralta, A. Navarro, F. Ture´gano-Fuentes prehospital evolution, advanced age, high surgical risk) i.v. antibiotics University Hospital Gregorio Maran˜ o´ n treatment is the safest option. We have observed that, in most of these patients, clinical and analytical stability are reached within the Prognosis of small bowel injuries depends on a prompt treatment. An first 48 hours; however, a long stay is usually needed to complete i.v. initial absence of clinical signs and the low sensitivity of imaging treatment. We designed a protocol together with the Hospital At studies often delays treatment. Home Service (HAHS) at our institution in order to reduce this Case Report: An 18 years old male patient suffered a frontal crash extended length of stay. while driving a motorbike. On primary survey he was hemodynam- Aim: To determine whether a brief hospital stay and close follow-up ically stable and conscious (RTS of 12). He had an open femur treatment with the HAHS is a safe and efficient treatment for se- fracture, a wound over the left hemipelvis with abdominal pain but lected acute cholecystitis patients. no tenderness. A CT scan revealed a bilateral iliac wing fracture and Methods: We reviewed the charts of all the patients diagnosed of some perisplenic fluid. He was admitted to the SICU and, on the fifth acute cholecystitis who were treated by the HAHS between 2004 and day, a falling hematocrit value prompted a repeated CT scan. A small 2006. We analyzed their demographic characteristics, medical his- gas bubble was found adjacent to the gastrohepatic ligament, but a ´ tory, clinical picture and evolution. non operative management was decided based on the patients sta- Results: 28 patients were included, with an average age of 66 years. bility and absence of abdominal signs. On the tenth day, while on the Most of them had 2 or more risk factors. Time since the start of the ward and resuming oral intake, he suffered a rather sudden onset of symptoms to diagnosis was of 2,6 days. Only in one patient the tachycardia and abdominal pain, with peritoneal signs. An urgent treatment failed, and he needed readmission and emergency chole- laparotomy revealed no peritoneal contamination, and a small cystectomy. Average follow-up and treatment by HAHS was of 9,6 inflammatory mass at the root of the transverse mesocolon which days, and cost savings was of 5.290,8 euros per patient. involved a complete transection of the first loop of small bowel. The Conclusion: A brief hospital stay and outpatient treatment is safe and proximal cut edge was occluded by the serosa of the distal loop. efficient in selected acute cholecystitis patients at our institution. A small resection was done, and the patient was discharged home 12 days later. Discussion: The peculiar anatomical disposition of the cut edges of 261 the bowel in this patient prevented leakage and peritoneal signs, with Cecal Diverticulitis: A Diagnostic Challenge a very late diagnosis but no adverse consequences. O. Goletti, G. Basili, L. Lorenzetti, C. Angrisano, E. Preziuso Health Unit 5 Pisa - Pontedera Hospital - General Surgery Unit, Italy 263

Introduction: Cecal diverticulitis is a rare inflammatory condition The Small Bowel and Colon Injuries in Politrauma that mimics acute appendicitis. From 70 to 100% of patients with Patients: One-Center Experience cecal diverticulitis undergo emergency celiotomy for presumed acute R. Gheorghe appendicitis and a cecal phlegmon or a mass is present in 30 to 50% Medical University of all cases. Because of the problems concerning preoperative diagnosis and controversies in the management, the choice of the best Key words: Politrauma, small bowel, colon, diagnosis, treatment therapy on the surgeon’s part is still open. The indications to operate Aim: To establish an optimal diagnostic and treatment policy in are the same that in case of sigmoid diverticulitis: recurrent episodes, intestinal injury in politrauma patients. obstructing mass, abscess, fistula or perforation. Material and Methods: We present the treatment results of 123 pts with Method and Results: A total of 1300 patients with a clinical diagnosis of intestinal injury in politrauma pts treated in Emergency Hospital right acute abdomen observed in our surgical department between during 1998–2006. M/F ratio was 6,2:1, mean age 37,98 ± 1,25 years. 1995 and 2006 were analysed. Eight patients had a pathologically Blunt trauma – 73(59,3%), penetrating trauma – 50(40,7%). Small confirmed diagnosis of cecal diverticulitis. Right lower quadrant pain bowel injury was established in 95(77,2%), colon injury – in 61(49,6%)

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 75 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

cases. 52(42,3%) pts had associated limbs trauma, 61(49,6%) - thoracic present a case of intestinal primary localization with fistula, associ- trauma, 74(60,2%) - head injury. Intestinal gr.I-II injury was diagnosed ated with a plastic TB peritonitis. in 45, of gr.III-IV in 50 pts; colonic gr.I-II injury - in 50, and gr.III-IV in Case Report: A 53 years-old woman from Eritrea presented with a 10 pts (AAST). ISS – 33,45 ± 1,91, RTS – 7,18 ± 0,11. progressive increase of abdominal volume, hyperpirexy and weight Results: 122 pts were operated. Surgery volume depended upon the loss for the past five months. TC showed pleural bilateral effusion, intestinal injury grade. Postoperative complications - 41(33,3%) pts, ascitis and enlarged mesenteric lymph-nodes. A contrast meal was mortality - 17,9%. performed and showed three nodules covered by normal mucosa and Conclusions: In open trauma wound location, evisceration, and brought the suspect of jejunum-colic fistula. One day after contrast wound channel exploration is useful establishing the diagnosis. In meal, the patient presents an acute bowel perforation with perito- hemodinamically-stabile politrauma pts the first line investigation nitis. A laparotomy was performed and the entire visceral surface of must be the plane abdominal X-ray or abdominal USG, and repeated peritoneum was full of yellow-white nodules; since the small bowel abdominal USG within 1–2h. Surgery must be decided upon the was totally encapsulated in a plastic peritonitis, the research of per- following factors: trauma mechanism, clinical signs and investigation foration wasn’t done. Only the toilette of entire abdominal wall was outcomes. In small bowel injury, admitted after 12h from onset – performed and five drains were placed. After an anti-TB therapy was Maydl jejunostomy or ileostomy must be considered as elective started. The perforation closed by itself with the patient’s general procedures. In colonic injury, admitted within 6h from onset, simple condition improving. suture or primary anastomosis must be considered. In gr.V injury or Conclusions: In a case like this, with such a complicated bowel pre- diffuse peritonitis colostomy is indicated. Mortality is significantly sentation, it could be dangerous to research for the perforation. No higher in blunt abdominal trauma (P < 0,001). attempt should be made to locate it. It exists the risk to damage the adherent intestinal loops and focal fistula may result in the postoperative period. The explorative laparotomy associated to medical 264 anti-TB therapy is an effective treatment. Rate of Complicated Meckel’s Diverticulum and their Management 266 F. Hoxha, A. Krasniqi, D. Limani Spontaneous Perforation of Common Bile Duct University Clinical Centre Of Kosova-Prishtina A. Sezer, C. Ibis, H. Oner, I. Coskun, A. Altan Trakya University Faculty of Medicine, Department of General Background: To elucidate rate of complicated Meckel’s Diverticulum Surgery, Turkey and management problems in our experience. Aim: To present our experience in treatment of complicated Mec- Spontaneous perforation of common bile duct is a very rare pathology. kel’s Diverticulum (MD) during a perid 2001–2004 at the single According to the literature it may be associated increased intraductal tertiary care hospital. pressure from a spasm of the sphincter of Oddi, necrosis of a portion of Design: Retrospective study. the bile duct wall, secondary to a calculus, infection, diverticulum, and Setting: University Clinical Centre in Prishtina, Kosovo. necrosis of a portion of the bile duct wall secondary to thrombosis of Methods: A retrospective random chart review of all patients with mural vessels. A-77 year old-female was admitted to the emergency Meckel’s Diverticulum surgically treated during the period 2001– room with acute abdomen. Abdominal computed tomography scans 2004 was analyzed, 3250 patients undergo appendectomy, from which revealed diffuse intraperitoneal free fluid, cholecystolithiasis. 28 had Meckel’s Diverticulum. Nine of them has been with inflam- Explorative laparotomy revealed diffuse intraperitoneal bile contam- mation, and one with ectopic gastric mucous with severe hemorrhage. ination, and a -0.5mm- sized perforation of the supraduedonal portion In addition, Meckel’s diverticulum was found incidentally in 18 pa- of the common bile duct. Neither cholecystoduedonal fistula formation tients who were undergoing intra-abdominal surgery (10 patients for nor choledocolitihasis were detected. After the primary repair of the acute Appendicitis, one for incarcerated inguinal hernia, one for perforated area of the common bile duct a T-Drain was inserted. volvulus sigmae, and 6 for acute ileo-ileal invagination). Operative cholangiography revealed no calculi, and no stricture. Results: Four of MD incidentally founded has not been resected, at Cholecystectomy was performed. The patient died on the 3th postop- 17 cases we have done resection of the small intestine, and in 7 cases erative day most probably due to the intra-abdominal sepsis. we have done cuneiform resection. At one of the patients from the last group we had to complete the resection, because of fistula, Morbus Crohn disease was founded in the histopathology samples. 267 Conclusion: Resection of suspected and unexpected Meckel diver- Acute Bowel Obstruction due to Intestinal ticulum can be performed safely with a low complication rate. Malrotation with Volvulus: Case Report of two Adults 265 L. Ansaloni, F. Catena, F. Coccolini, S. Di Saverio, A. Pinna Intestinal Perforation in Patient with Plastic TB St.Orsola-Malpighi University Hospital, Italy Peritonitis Introduction: Although malrotation is a well-recognized condition L. Ansaloni, F. Catena, F. Coccolini, S. Gagliardi, A. Pinna presenting with bowel obstruction in the neonate and the young St. Orsola-Malpighi University Hospital, Italy child, it is rarely seen in adults. Usual presentation in the adult is with intermittent episodes of abdominal pain and very rarely presents with Introduction: Even if it’s rare, abdominal primary localization of TB acute abdomen. We report two patients with intestinal malrotation is the sixth most frequent form of extra-pulmonary localization. We presenting in urgent setting.

76 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Case report: Case 1. a 26-year-old woman presented with a sudden 38.0 % wounds of a pancreas were localized in the head, 26.8 % in a onset of abdominal pain of 6-hours duration. At laparotomy the entire body, in 35.3 % in a tail. Bruises and hematomas of a pancreas are small bowel, caecum, ascending colon and half of transverse colon marked in 50.7 %, regional wounds in 12.7 %, damage of the main were cyanosed and necrotic. A 360 anticlockwise volvulus affecting pancreatic channel to 9.9%, transversal break in 14 %, pancreadu- small bowel and ascending colon was found. A right hemicolectomy odenal wounds in 12.7 %. Hematomas of a pancreas were evacuated and partial small bowel resection with ileostomy was performed. 48 dissected by sections on the top and bottom edges. At edges pancreas hours later a second look was performed to check for the viability of wounds bleeding has been stopped, without stitching. At wounds with the residual small intestine. One month later the last laparotomy was damage of the main pancreatic cannel and transversal break the performed in order to create the ileo-colic anastomosis. Case 2. a 63- resection was conducted. At pancreaduodenal wounds the antral year-old woman presented with a 12 hours duration abdominal pain. resection with a gastroenteroanastomosis or pancreaduodenal At laparotomy the caecum, ascending colon and half of transverse resection were performed. Anastomoses and stitching wounds were colon were cyanosed and necrotic. A volvulus affecting cecum and the separated from contact with a pancreas. Operations ﬁnished with ascending colon was evident due to a mobile cecum and ascending cholecystostomy, omental bursa and retroperitoneal space were colon. A right hemicolectomy with ileo-transverse anastomosis was drained. As a result of developed surgical tactics at ﬁre-gun wounds performed. The postoperative period was uneventful and the patient of a pancreas it was possible to reduce frequency of postoperative was discharged in the 8th postoperative day. purulent - septic complications to 11.1 % and a lethality to 5.3 %. Discussion: Although rotational abnormalities of the intestine are rare in adult life, malrotation with volvulus should be considered in adults who present with unexplained acute onset of abdominal pain. 270 Successful Operative Treatment of Blunt Trauma 268 Involving Complete Laceration of the Duodenum Laparostomy for Severe Intraabdominal Infections and Head of Pancreas in 11 Years Old Child D. Gonullu, F. Koksoy, O. Demiray, A. Cihan, O. Yucel G. Makovec, A. Pleskovic, M. Tonin Taksim Teaching And Research Hospital, Istanbul, Turkey Clinical Center Lubljana, Department of Abdominal Surgery

Severe intra-abdominal infection is a life-threatening condition.The Introduction: Duodenal injury secondary to blunt trauma continues cornerstone of surgical treatment is the elimination of the infectious to pose a diagnostic and treatment challenge. The purpose of this focus. PURPOSE: The aim of this study was to evaluate the use of case is to evaluate the cause, radiological findings, and management laparostomy in the management of patients with severe intra- of duodenal injuries from a Level I pediatric trauma center. abdominal infection. METHODS: From 2000 through 2006 we ret- Case report: 11-year old boy fell with the bicycle and suffered blunt rospectively analyzed the outcomes of 37 patients treated by planned abdominal injury. Soon after reception in hospital signs of diffuse relaparotomy with Bogota bag closure. We applied this treatment for peritonitis revealed. Suspicion of hollow organ perforation was con- patients with pancreatic necrosis (n = 10), infections complicating firmed and identified with emergency ultrasound and CT scan. CT scan malignant colorectal disease operations (n = 14), and severe intra- alone identified retroperitoneal hematom, head of pancreas edema abdominal infections due to benign diseases (n = 13). Severity of and free fluid while extra luminal air was not present. Surgical man- patient’s disease is measured preoperatively by Acute Physiology and agement was required immediately. At the operation, huge laceration Chronic Health Evaluation (APACHE ) II scores and Mannheim of duodenum and laceration of head of pancreatic was found. Duo- ´ Peritonitis Yndex. RESULTS: The mortality rate was 45% (16/37). denal repair was not possible so pyloric exclusion with gastrojejunos- The patients who died had higher APACHE II scores (24.83 vs tomy sec Rouxu was performed. Pancreas was sutured directly. After 22.42), and Mannheim Peritonitis Index ( 22.28 vs 17.5).The patients surgery the child had been transferred to intensive care unit for four who survived were reoperated 1.6 (1–3) times and those who died days and after five days he left the hospital without any complications. were reoperated 4.7 times more. The mean time of laparostomy was 9 Discussion: Diagnosis of duodenal and pancreatic injuries is fre- days. In 5 patients the laparostomy was closed primarily and for the quently delayed, and optimal treatment is often controversial (1). others the wound was left open to heal secondarily by granulation Blunt abdominal trauma remains the most prevalent mechanism for and contraction. CONCLUSION: Patients with high APACHE II ve pediatric duodenal injuries. Patients undergoing pyloric exclusion for Mannheim scores treated with Bogota bag have had the highest severe duodenal trauma had a lesser morbidity and a shorter hospital mortality rates since they had the major risk factors. Shorter lapa- stay (2). Pyloric exclusion remains an alternative for the treatment of rostomy period and low number of planned reoperations (1–3 times) severe duodenal injuries in selected children. were found to be the most important factor for best prognosis.

271 269 An Unusual Reason of Biliary Peritonitis: Treatment of Fire-Gun Wounds of a Pancreas A. Voynovskiy, E. Ashkhotov2, A. Koltovich3 Spontaneous Rupture of He Intra-Hepatic Biliary Ducts In this work we analysed observations of 71 patients with ﬁre-gun U. Aydin, P. Yazici, O. Unalp, A. Coker wounds of the pancreas. The bullet wounds were in 74.7 %, splinters Ege University School of Medicine, Department of General Surgery, of 18,3 %, secondary wounding shells of 7,0 %. All cases of a pan- Izmir, Turkey creas wounds were combined with wounds of other bodies of a belly cavity - in 49.3 % with a stomach – 45.1 % with a small bowel, 43.7 % Spontaneous rupture of the intrahepatic biliary ducts is a rare entity with liver, 35.2 % with a lien and in 26.8 % with wound of kidneys. In which causes the acute abdomen due to biliary peritonitis. We

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 77 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

present a case of 92-year-old woman with a 48-h history of upper 273 abdominal pain, nausea and vomiting. She was admitted to Emer- Management of Arterial Injury in Blunt Lower gency Department with acute onset of abdominal pain and peritoneal signs. Laboratory findings included leucocytosis, mild elevated bili- Extremity Trauma: A Retrospective Single Outcome rubin. Abdomen ultrasonography and computed tomography didn’t Study in a Swiss Mountain Trauma Center reveal the primary diagnosis but generalized free-fluid in the abdo- P. Stillhard, M. Wullschleger, C. Sommer, M. Furrer men and mild dilatation of the common bile duct. She underwent Surgical Department, Vascular and Trauma Unit, Kantonsspital exploratory laparotomy and pure bile fluid filled the abdominal Graubu¨ nden, Chur, Switzerland cavity was discovered. The main reason was forcefully detected as a leakage of a ruptured radicle bile duct at the third sector of the liver. Objective: Severe blunt leg trauma with vascular damage still cause Intraoperative cholangiography was proved the diagnosis. She amputation rates of up to 30%. The aim of this study is to investigate underwent a cholecystectomy, choledochotomy, repair of the perfo- the outcome of a one step surgical team approach by experienced ration with primary suture, and placement of a T-tube. She had an trauma and vascular surgeons in a Swiss mountain trauma center. uneventful recovery and was eventually discharged from hospital on Patients and Methods: 22 extremities of 21 patients (mean age 36.0+- the postoperative 14th day. We conclude that biliary peritonitis 19; m:f 18:3) treated by this combined one step approach during the should be considered in case of undiagnosed acute abdomen and last 10 years in our institute were analyzed. Arterial repair after blunt meticulous investigation of the source of the bile leakage should be extremity trauma represented 1.8% of all arterial operations in our performed during exploratory laparotomy in order to prevent death hospital during this time period. The severity of injury was scored by from sepsis. Mangled Extremity Severity Score (MESS 2–11). Hospital data were analysed retrospectively. Main endpoints were initial complications and limb salvage. We further tried to define a functional outcome score (1–6). Vascular Trauma, Mangled Extremity and DVT Results: The mean MESS was 5.9. The mean total time of ischemia was 5.2 hours. Arterial reconstruction was performed by end-to-end anastomosis in 12 cases or by greater saphenous venous interposition/ 272 bypass in 5 and ligature in 5 cases. The initial limb salvage rate was 95.5%. 4 polytraumatized patients died (19.0%) after an average Techniques and Outcomes in Extremity Vascular time of 2.5 days during hospital stay. Mean functional outcome score Injury: A 28-Month Wartime Report was 5.4. T. Rasmussen, W. Clouse, J. Eliason, M. Peck, Conclusion: Immediate and combined vascular and orthopaedic D. Jenkins reconstruction in non-iatrogenic blunt artery disruption in lower United States Air Force, USA extremity resulted in a limb salvage rate of 95.5%. Most patients had only minor functional deficits at long-term follow-up. Objective: The objective of this study is to present a 28-month experience with the management of extremity vascular injury from a Theater Hospital in Iraq including the description of forward (Level 274 II) surgical care and contemporary vascular adjuncts. Methods: From 1 September 2004 through December 31st 2006 The Treatment Outcome of Popliteal Artery Injuries vascular injuries treated at the United States Air Force Theater with Prolonged Ischemia Hospital in Balad Iraq were prospectively entered into a registry and R. Pak-Art, P. Phattranurakkul, K. Kritayakirana, S. Prichayudh, S. retrospectively reviewed. Sriussadaporn Results: During the study 7,640 battle injuries were evaluated and Chulalongkorn University 428 (5.6%) had a major vascular component which is twice that reported from the Vietnam War. Extremity vascular injuries were Background: Popliteal artery injury remains a serious condition may common and represented 74% (N = 319) of vascular injuries. Tem- lead to limb amputation. The shorter duration from accident to porary vascular shunts were used as an adjunct in 20% (N = 64) of hospital provides the better chance of limb salvage. The purpose of extremity injuries as one aspect of Level II surgical capability. Vas- this study was to evaluate the treatment outcome of popliteal artery cular reconstruction using autologous interposition vein grafts was injuries with prolonged ischemia (at least 6 hours). prevalent (N = 271). Wound management strategy included opera- Methods: From January 2003 to June 2006, all charts of patients with tive debridements and the negative pressure VAC dressing and re- popliteal artery injuries who admitted in King Chulalongkorn sulted in primary or delayed primary closure of 66% (N = 210) of Memorial Hospital were retrospectively reviewed. wounds. Infections resulting in anastomotic blowout or requiring Results: In those 30 months period of the study, there were 20 drainage occurred in 6.2% (N = 20) of patients. The early amputa- popliteal artery injuries. All but one caused by blunt mechanism. tion rate was 5% (N = 16) and mortality associated with vascular Three patients who arrived hospital less than 6 hours after injury injury 2.5% (N = 8). were excluded, and their limbs were well preserved without serious Conclusions: Extremity trauma predominates in wartime and the complication. Of the remaining 17 patients, the mean age was rate of vascular injury appears increased. Management of 29.76+/–11.7 years old, the duration from accident to hospital was extremity vascular injury includes prompt Level II care, the use of 15.76+/–11.03 hours, and the ISS was 13.06+/–7.45. Only 8 of 17 limbs temporary shunts and definitive vascular repair in theater. In this (47%) could be preserved after operative interventions. The duration large contemporary experience, these strategies result in excellent from accident to hospital in the salvage group was longer than in the limb salvage rates with remarkably low rates of infection and amputation group (18.00+/–13.87 vs. 13.78+/–8.10 hours), and the ISS mortality. in the salvage group was lower than in the amputation group

78 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

(9.50+/–2.20 vs. 16.22+/–9.10), respectively. There was no acute renal control CT shows closure of the Arteria iliaca communis where failure and no mortality in this series. leaving the aorta abdominalis as well as free liquid in the abdomen. Conclusion: Delayed treatment of popliteal artery injuries still had a Laparotomy reveals a complete rupture of the subcutaneous and high amputation rate. The duration from accident to hospital arrival muscular abdominal wall, ruptures in the mesentery of the small is not the only major factor for limb salvage rate. Injury Severity intestine at several locations, lesions of the serosa in the intestine Score may be one of indicators for amputation. and colon as well as a complete rupture of the intima of the AIC. The treatment of all lesions is carried out without any complications. Discussion: -is a delayed action justified when diagnosis is at 275 hand -are abdominal trauma with injured vessels and free liquid in the abdomen to be taken to laparatomy immediately. -is it possible Temporary Intraluminal Vascular Shunt in Patients to diagnose the amount of internal injuries by way of CT angiog- with Lower Limb Vascular Injuries and Severe raphy Concomitant Injuries F. Vojko, K. Nina 277 Teaching Hospital Maribor, Slovenia Pitfalls in the Management of Mangled Lower Temporary intraluminal vascular shunt in patients with lower limb Extremity: Scores or Sound Clinical Judgment vascular injuries and severe concomitant injuries Flis V, Kobilica N S. Frenyo, D. Tihanyi Department of vascular surgery. Teaching hospital Maribor, Slovenia National Institut of Traumatology and Emergency Medicine Background: Complete lower limb ischemia as a result of lower limb vascular trauma may be associated with high morbidity in patients Background: Several scoring systems exist which help to decide, with severe concomitant injuries. The purpose of this study was to whether limb salvage or primary amputation in severe open fractures determine the outcome of routine use of a temporary intraluminal of the tibia should be performed. The main dilemma still remains: if vascular shunt in such patients. Patients and methods: A retrospec- limb salvage is the main goal, the patient may end up with a poor tive review of patients with complex vascular injuries of lower limbs functioning appendage. Amputation on the other hand means phys- with severe associated injuries treated between January 1990 and ical and psychological burden on the patient and staff as well. December 2005 was undertaken. Demographic data, mechanism of Material and Methods: We present a 10 year material, where 25 injury, surgical management, associated injuries, complications and traumatic amputations of the lower extremity were performed. In 16 mortality were analyzed. Results: Seventeen patients with complex cases the leg was amputated at the site of trauma, and only the stump trauma and lower limb vascular injuries were identified (12 men, had to be corrected. In 6 cases we tried to salvage the whole or part average 34.3 years, and range 15–56 years). The mean weighted re- of the extremity, as it seemed to feasible according to the MESS, but vised trauma score, injury severity score (ISS) and penetrating had to amputate at a later date. In 3 cases salvage of the mangled leg abdominal (PATI) trauma index were 5.7, 27 and 22 respectively. By was considered, but ultimately primary amputation was decided. All all patients the primary surgical intervention was abdominal proce- 3 cases were brought in intubated, ie. examination of sensation of the dur and last procedure was final reconstruction of lower limb vascular leg could not be examined injuries. By all patients temporary intraluminal vascular shunt was Results: 3 pateients were lost due to traumatic shock (all polytrauma inserted in injured vessels prior to abdominal procedure. There were cases). In the group, where limb salvage was attempted, one patient two deaths in early postoperative period (30 days after injury) due to ended up with hip disarticulation due to anaerobic infection. One had multiple organ failure (11.1%). In surviving patients the limb salvage reamputation at femoral level, because of early infection and SIRS. 4 rate was 100%. Conclusion: Temporary vascular shunting allow had amputation due to late infection.. surgeons to start with most needed surgical procedure. It significantly Conclusion: Patient’s survival and functional outcome is more reduces total ischemic time, repeat operations and amputation rate. essential than survival of the mangled extremity. Scores are helpful, but have their limitations - sound clinical judgment takes priority in decision making. 276 Are Traumatic Vessel Injuries Treated in an Optimal Way in Subcentres? - a Case Report 278 M. Hessinger, M. Tomka, T. Ott, T. Cohnert Is Intermittent Pneumatic Compression Make Low Dept.Of Vascular Surgery, Medical University of Graz, Graz, Molecular Weight Heparin More Efficent in The Austria Prophylaxis of Venous Thromboembolism in After a car accident a 19-year old femal patient suffers from an Trauma Patients abdominal trauma and she is transferred from a peripheral hospital H. Yanar, M. Kurtoglu, K. Taviloglu, R. Guloglu, C. Ertekin to a surgery institution with a vascular surgery department as a Istanbul University, Medical School, Department Of Surgery, primary examination shows a pale and cool right lower limb. A CT Trauma and Surgical Emergency Service, Capa, Turkey angiography is carried out proving a subtotal closure of the right arteria iliaca communis and free liquid in the abdomen as well as an Introduction: Venous thromboembolism (VTE) cause morbidity and atrophy of both mm. recto adominis. The patient is controlled at mortality in traumatic injuries. The aim of this study was to evaluate the intensive care unit during the night and transferred to a vascular the efficacy and safety of intermittent pneumatic compression devices surgery centre the next day. In the first examination no pulse is felt (IPC) with or without low molecular weight heparin (LMWH) in in the inguinal region, the limb is cool and pale. The emergency prevention of venous thrombo-embolism in the trauma patients.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 79 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

Methods: From January 2000 to November 2002, 120 patients with intestine segment was ruptured completely. There were also multiple trauma were included in the study. Group A, B and C was treated perforations in the small intestine, and a serious hematoma located in with only IPC devices, IPC devices plus LMWH (40mg/day) and only the mesentery of 40 cm of ileal segment. We performed an end-to- LMWH (40mg/day) respectively and each group was consisted of 40 end anastomosis between a distal branch of the superior mesenteric patients. Color flow duplex (CFD) of the lower extremities was ob- artery in the mesentery of the ileal segment and a branch of the tained on the seventh day of hospitalization and before the discharge. superior mesenteric artery using separate sutures of 7.0 monofila- Calf and thigh circumferences were also measured daily and D-dimer ment polypropylene. The patient’s gastrointestinal passage returned was obtained in case of suspicious clinical signs of DVT. to normal on the postoperative day 2. His postoperative period was Results: Deep vein thrombosis developed in 4 (10%), 2 (5%), 2 (5%) uneventful and discharged from hospital on the postoperative day patients in Group A, B, and C respectively. Two patients (5%) in seven. In this case report, we emphasized the importance of preser- Group A and C and one patient (2.5%) in Group B showed clinical vation of injured mesenteric artery due to abdominal trauma which signs of pulmonary embolism and SCT revealed massive PE. None of could have been resulted in short bowel syndrome. the patients with PE survived. Eleven (27.5%), eight (20%) and thirteen (32.5%) patients were lost due to several reasons other than PE. Conclusion: IPC may be used safely in combination with or without 281 LMWH in the DVT prophylaxis. IPC may be considered DVT prophylaxis in patient who had contraindication for anticoagulation. Mangled Extremity- Connection Between Crushing No addictive effect of IPC to LMWH is apparent. and Thrombosis O. Lupescu1, M. Nagea2, G. Popescu2, C. Patru2 1Emergency Hospital, University Of Medicine And Pharmacy 279 Bucharest, Romania 2 Pseudoaneurysma of the Femoral Artery as a Late Emergency Hospital, Bucharest, Romania Complication After the Complex Femoral Shaft Introduction: Muscular crushing represents one of the most severe Fracture - Case Report disorders of modern traumatology, due to its’’ pathology. One of the J. Demel, L. Pleva, L. Pliska mechanisms activated by crushing is thrombosis, which can affect Traumacentre Of The Ostrava City different parts of the vascular system, from microcirculation to medium or great vessels. The authors of this prospective study 24yer old man was injured during traffic accident like a driver. He evaluate (clinical and using Doppler –ultrasound) the status of the had the complex fracture of the left humerus shaft, the complex arterial and venous axes of the crushed limbs. fracture of the left femoral shaft, depres fracture of the left tibial Material and Method: This study evaluates 50 patients operated lateral plateau, minimal cerebral trauma and multiple body contu- between 1.01.1997–1.01.2002 for muscular crushing, associated with sions. The humerus fracture was treated by the close reduction and femoral fractures ( 18 cases), tibial fractures (30 cases), compartment intramedulary nailing, the femur fracture was treated by the minimal syndrome (32 cases). Fasciotomy was performed in all 50 cases in invasive open reduction and intramedulary nailing, the depress of the order to excise the necrotic muscle, all the patients received LMWH tibial plateau was elavated and support by Chron OS and canulated therapy. LDH and CK values were monitorised. Clinical and ultra- screw. The soft elastic growing resistance of the left thigh appeared sound examinations were performed 1,2,6,12 ,24 and 48 months after ten days after the surgery. The pseduaneurysma of the femoral artery trauma. was diagnosed by the ultrasound. That situation was treated by Results: Acute peripheral ischaemia (API) was associated with initial mininvasive methode – implant the stentgraft. Resistance increased crushing in 9 cases and in other 2 cases, API appeared more than 16 during 10 days. The blood supply of the limb is full six month after hours after initial crushing and required surgery. Recurrent API was the injury. We suppose, that this management in cooperation with the clinically diagnosed in 2 of these 11 cases within the first week after invasive angiologist is a new chance for treatment this uncommon trauma; late post-traumatic arterial incomplete occlusion by throm- vessel injury in the concept of the minimal invasive care. botic material appeared in 4 cases. In 18 cases, crushing was followed by venous thrombosis Conclusions: Crushing produces metabolic and vascular distur- 280 bances, including activation of thrombosis. Following this, several Success of Microvascular Surgery; Vascular Injury parts of the circulatory system of the injured limb can be affected long time after crushing, which can be considered to be a Repair in a Patient with Total Mesenteric Injury ‘‘thrombotic disorder’’. due to Blunt Trauma U. Aydin, P. Yazici, O. Unalp, A. Guler Ege University School of Medicine, Department of General Surgery 282

Superior mesenteric injury is a rare entity but when it occurs, short Outcome and Complications of Limb Vascular bowel syndrome is one of the uninvited results of the emergency Repair Regarding Mess Preoperatively surgical procedures. We present a 19-year-old boy with blunt M. Ghoreishi1, S. Sehhat1 abdominal trauma which caused serious mesenteric injury. Because 1Isfahan Medical University ultrasound revealed free intraabdominal ﬂuid, he underwent emergency laparotomy. Adequate vascularization of approximately 20 cm Appropriate management of extremity injuries results in limb sal- of the proximal jejunal segment and 20 cm of the terminal ileum was vage but not indicated attempts may cause complications that can observed. Nevertheless, the mesentery of the rest of the small disturb management.We assessed outcome and complications of

80 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

patient, regarding MESS (Mangled Extremity Severity Score). tissue injury, assuming it is readily recognized, several therapeutic MESS was calculated for each patient operated due to extremity difficulties are encountered. Inadequate treatment can further com- vascular injuries from 1994 to 2004. Results were compared by promise the skin and subcutis and lead to delayed recovery. Man- Fisher’s Exact Test. Of 68 patients, 54 had MESS<7(group one) and agement for severe soft tissue injuries of trunk and extremities in 14 had MESS 7(group two). Intraoperative complications, including polytrauma patients is focused on: ‘‘h Stabilisation of underlying hypotension, need to vasopressors, and acid - base disturbance were fractures, which will contribute to soft tissue recovery. ‘‘h A step-wise 13%, zero and 29.6% in group 1 and 50%, 14.3% and 92.9% in soft tissue approach in wich initially as much soft tissue as possible is group 2, respectively. Postoperative complications, including spared. After preparation avulsed skin can be replaced on a vital mechanical ventilation, delay in extubation, reoperation, amputa- surface as a primary full-thickness graft with adequate drainage. ‘‘h A tion, mortality and cardiac arrest were 2%, 1.9%, 13.2%, 7.5%, planned subsequent operation is often necessary to determine the 1.9% , 3.8% in group 1 and 25%, 35.7%, 72.7%, 72.7%, 28.6% viability of the tissues and the need for a second debridement. ‘‘h In ,28.6% in group 2, respectively. Mean of bicarbonate and blood Morel-Lavallee injury early drainage and debridement has to be infused intraoperatively were 0.4 0.9 vial and 3.3 2.7 unit in group 1 considered, even if superficial layers appear vital. Minimal invasive and 2.4 3.3 vial and 7.3 5.4 unit in group 2, respectively. Mean of technique is preferred in order to preserve neural innervation and BUN and creatinine 24 hour after operation and hospital stay were blood supply to the injured skin. ‘‘h Vacuum assisted therapy offers a 18 6mg/dl, O.9 0.3mg/dl and 8.8 8.2 days in group 1 and 31 14mg/dl, new range of management options, especially for large wound sur- 1.6 1.2mg/dl and 17.7 11 days in group 2, respectively. Complica- faces. In this presentation our approach will be illustrated with pa- tions in patients with MESS 7 were significantly more than those tient cases. with MESS<7 (P = 0.001) and limb salvage, when not indicated, caused more complications. Keywords: Trauma - Vascular Repair - MESS - Amputation. 285 The Degree of Fracture Associated Soft Tissue 283 Injury Plays a Key Role in the Induction Successful Replantation of Both Legs Beside of Systemic Inflammation and Remote the Knee Joint Level Organ Dysfunction Following Bilateral A. Pamerneckas, G. Tamulaitis, V. Zˇ vinys, L. Velie`ka, Femur Fracture D. Ineìūra P. Kobbe1, D. Kaczorowski2, K. Mollen2, T. Billiar2, Kaunas University Hospital H. Pape1 1Department Of Orthopaedic Surgery, University Of Pittsburgh, 30 y.o. woodcutter sustained both leg amputation during this work. In USA two hours he was transported from small regional hospital. Replan- 2Department Of Surgery, University Of Pittsburgh, USA tation of left leg above the knee (MESS 5) was started and in 40 min. replantation of right leg below the knee (MESS 6) was started. Re- Purpose Patients with bilateral femur fracture are known to be at vascularisation was performed in 110 min. in left and in 130 min. in high risk for systemic complications, possibly mediated by immu- right leg from the moment of hospitalisation. Patient required 7 nologic changes (inflammatory state). The role of the fracture operations till recovery. Full weight bearing in 40 weeks. associated soft tissue injury in the induction of systemic inflammation following bilateral femur fracture is not known. In this study the systemic inflammatory response and the effect on the liver following bilateral femur fracture with severe and minor soft tissue Soft Tissue Injuries and Infections of injury are investigated. Material and Methods Animals: 6–8 week Prosthetic Materials old male C57/BL6 mice Groups: Control-group (no anaesthesia, no femoral catheterisation); Sham-group (6 hour anaesthesia, femoral catheterisation); Fx-group (6 hour anaesthesia, femoral catheterisation, bilateral femur fracture with minor soft tissue injury); Fx- 284 STI-group (6 hour anaesthesia, femoral catheterisation, bilateral Management of Severe Soft Tissue Injuries femur fracture with severe soft tissue injury). Parameter: Six hours after bilateral femur fracture serum IL-6 levels were determined. in Polytrauma Patients. Multimodality and Changes in liver permeability were assessed measuring the wet-dry- Multidisciplinary Approach ratio. Further cytokine levels and organ function studies are N. Van Den Oever, C. Van Der Vlies, C. Goslings, S. Strackee, pending. Results The Fx-STI-group showed significantly increased K. Ponsen serum IL-6 levels as compared to the Sham- and Fx-group. The Academic Medical Center, Amsterdam, The Netherlands wet-dry-ratio of the liver was significantly increased in the Fx-STI- group in comparison with the Sham-group. Conclusion The degree Overroll trauma can be accompanied by severe soft tissue injury. of fracture associated soft tissue injury plays a key role in the Superficial layers are either intact or large defects are present induction of systemic inflammation and remote organ dysfunction (respectively closed and open deglovement). Shear forces tear large following bilateral femur fracture. Animals with bilateral femur surfaces of skin, subcutis and muscle from underlying fascia or bone fracture with minor soft tissue injury did not develop systemic structures resulting in pseudocysts filled with blood, serous fluid or inflammation with end organ dysfunction. These results underline necrotic fat. In the pelvic region this type of lesion is referred to as the importance of the fracture associated soft tissue injury regarding Morel-Lavallee injury. In the optimal treatment of this severe soft the development SIRS and MODS.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 81 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

286 Results: 66/73 patients were followed up showing a stable arthodesis. Osteomyelitis of the Calcaneal Bone: Rare but Three had a chronic infection. We observed 3 periprosthetic fractures and two aseptic stem loosenings with necessity of intramedullary Devastating component exchange. One MRSA-reinfection was eradicated by 1 1,2 2 1 M. Frank , G. Matthes , K. Bauwens , P. Hinz , implant exchange after intermediate vancomycin spacer usage. One 1,2 A. Ekkernkamp patient died of cardiopulmonary failure. Average leg shortening 1 Department Of Orthopedic And Trauma Surgery, University of measured 2,7 (1,2 - 5) cm. Overall reinfection-rate was 4,5%. Four Greifswald, Germany patients showed sintering of the femoral component not requiring 2 Department Of Orthopedic And Trauma Surgery, Unfallkranken- surgical intervention. Twelve patients were mobilized using one stick, haus Berlin, Germany four used crutches. 58 patients quoted a very satisfactory, 8 a fair result. Background: Posttraumatic calcaneal osteomyelitis is a challenge for Conclusion: Knee arthrodesis following total knee replacement trauma surgeons. Apart from devastating physical consequences infection is safely achievable using an intramedullary cementless these complications have a high social impact because of the frequent modular titanium stem system. It is especially useful in situations and long-lasting disability that they cause. Successful treatment re- with extensive juxta-articular bone defects. Patient´s acceptance is quires a strict protocol. The treatment modalities reported in the high with early full weight-bearing and low re-infection rates. literature are variegating, effective algorithms have not yet been established. It is our objective to review the treatment protocols and outcome of post-traumatic calcaneal osteomyelitis. Methods: We reviewed our treatment algorithms and outcome of 288 patients suffering from calcaneal osteomyelitis. Septic Arthritis After ACL Reconstruction – Results, Conclusion: From July 2003 - June 2006 we treated 13 male should we Salvage or Relinquish patients (49.8 years) with posttraumatic calcaneal osteomyelitis. While 12 patients revceived osteosyntheses in external hospitals and the Graft? 1,2 2 1 1 were transferred to our hospital for infection-treatment, one patient A. Schulz , A. Paech ,I.Mu¨ller , B. Kienast , 1,2 revceived osteosynthesis in our department (in the same period of C. Ju¨rgens 1 time 107 calcaneal osteosyntheses have been made). In any case a fall BG Trauma Hospital Hamburg, Germany 2 from a ladder during work was cause of the injury. Four subjects University Hospital Lu¨ beck, Germany showed a II-III open fracture. In cases of closed soft tissue conditions osteosynthesis was performed after 9.4 days. After occurrence Septic arthritis is a rare complication after ACL surgery. There is of infection 3.3 inpatient treatments with an average total time of 75 no established guideline or recommendation regarding treatment days were necessary. All cases underwent serial debridements. Eight strategy. We studied the outcome with a focus on the result after patients received local or free flaps (M. abductor digiti minimi, M. salvage or removal of the graft. Methods: 24 patients met the latissimus dorsi). Follow-up information was available for ten pa- inclusion criteria. Treatment was based on grade of infection. tients. Eight of them did not show signs of recurrent infection. Options included arthroscopic treatment or arthrotomy. The graft Adhering to accepted standards of treating osteomyelitis, satisfactory was salvaged if possible without risk. Reasons for graft removal control rates in calcaneal infection can be achieved while salvaging were: the lower limb. • Severe infection of graft • auto-digestion of graft • Possible bony involvement of tibia, femur or graft block 287 • Non-functional graft Follow up included IKDC–forms, radio- Knee Arthrodesis After Total Knee Arthroplasty graphs and the Tegner/Lysholm scores at a mean of 66 months Infection Using an Intramedullary Modular postop. Titanium Stem Results: In all cases treatment of infection was successful; mean 2.2 T. Fehmer, T. Ka¨licke, F. Kutscha-Lissberg, G. Muhr, operations were required. In 7 cases salvage was possible, twice a re- L. O¨ zokyay graft was performed. In the subjective tests there was no significant Bergmannsheil Bochum, Germany difference in the outcome measures although the clinical tests showed a clear advantage of graft-retaining strategy. Introduction: Usage of an intramedullary modular titanium stem to Subjective: Remaining graft(n = 9) | No remaining graft (n = 15) perform knee arthodesis allows bridging of long juxa-articular bone Tegner score 4.5 | 3.4 defects following arthroplasty infection. Which results can be ex- Subjective IKDC 65.3 | 64.6 pected in this salvage procedure ? Lysholm Score 67.7 | 64.4 Methods: Retrospective analysis of 73 (42 ♀/31 ♂) pa- Clinical: Hop test 78.5% | 54.50% tients, (average age: 66,7y) who received a knee arthrodesis between Clinical IKDC (% normal/near normal) 44.40% | 26.65% 2001–2005 following total knee arthroplasty infection using an in- Radiological IKDC (% normal/near normal) 55.40% | 15.30% tramedullary modular titanium stem, consisting of a tibial and fem- Conclusions: If the graft is salvaged or re-graft is performed, clinical oral cementless stem component with a connection module over a 1– results are better. The subjective outcome does not appear to be 4 year follow-up period concerning re-infection rate, implant loos- influenced by this. Grafts should only remain if there is no doubt, the ening or periprosthetic fractures and patient activity level. Arthrod- subjective outcome does not appear to warrant an unnecessary risk. esis was performed with normalization of WBC and CRP with sterile Re-implantation should be discussed especially in young and active microbiology results of a properative joint puncture. patients.

82 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

289 an inferior gluteal artery injury. However, only one superior gluteal Early Loosening of Austin-Moore Hemiarthoplasty: artery injury and 4 inferior gluteal artery injury were found in lower zone injury group. In upper injuries group, 2 concomitant siatic nerve Septic or Aseptic? injuries were detected. The concomitant injuries in the lower zone R. Kakwani, A. Sinha, K. Wahab group occurred as rectum (in one patient) and testis (in one patient) Good Hope Hospital NHS Trust injuries. Conclusion: Mikulicz tampon may be reduced the need for angiog- Introduction: A retrospective audit to evaluate the results of Austin raphy in active bleeding gluteal injuries. Moore hemiarthroplasty conversion to Total hip arthroplasty for suspected aseptic loosening. Materials and Methods: A consecutive cohort of patients who had conversion of Austin-Moore hemiarthroplasty to Total hip 291 arthroplasty performed at our district general hospital between Post-Operative Dislocation Following August 2000 and May 2006 were included in the study. The total Hemiarthroplasty of Hip the Need for of 41 patients were divided into two groups depending on the duration between the primary hemiarthroplasty procedure and its Soft Tissue Balancing-A Lesson to be Learned revision to total hip arthroplasty – (1) Less than one year (16 N. Venkatram, M. Bhattacharyya, S. Sakka, B. Gerber patients) and (2) More than one year (25 patients). The data Department Of Orthopaedics, University Hospital Lewisham, collected included: age, sex, classification of the fracture, date of London, UK primary operation, surgical approach, inflammatory markers, indication and date of revision to total hip arthroplasty, and the final We report three elderly patients that underwent hemiarthroplasty of outcome. hip for old injuries of the neck of femur and had dislocations in the Results: The rate of infection after the revision to total hip early post-operative period. These patients had extensive capsular arthroplasty was found to be 25% (4/16 patients) in patients who release and soft tissue release in order to reduce the hip prosthesis underwent the revision operation within 1 year after the primary intra-operatively due to chronic contractures and change of the operation, whereas the infection rate was 8% (2/25 patients) for anatomy of the hip joint. All patients had operations performed those who had the revision operation more than a year after the through modified lateral approach with restoring of abductors. Post primary operation. The difference in infection rates between the operatively the immediate check x-rays showed good alignment of two groups was found to be statistically significant despite the small the prosthetic joints. Patients were mobilised full weight bearing. numbers. Following mobilisation it was noted the hip joints dislocated. Primary Discussion: The patients who have early loosening of the Austin- closed reduction was attempted and it was successful in only one Moore hemiarthroplasty within the 1 year of the primary procedure patient. However in this case a second dislocation happened which should raise a suspicion of occult infection. Despite near normal led to open reduction. During open reduction we found complete inflammatory markers, a two-staged conversion to total hip arthro- rupture of the abductors from the greater trochanter and there was plasty should be seriously considered. avulsed capsule the hip joint. There was no abnormality detected in the version of the prosthesis. These difficult cases soft tissue around the hip joint should be released but not lengthen to accommodate the prosthesis. We also find soft tissue closure was difficult as tissue 290 quality was poor in these elderly fragile ladies. Mikulicz Tamponade for Gluteal Stab Wounds: A Cheap but Useful Technique H. Yanar, R. Guloglu, K. Taviloglu, H. Coskun Antibiotics and Topical Sealants Istanbul University, Medical School, Department Of Surgery, Trau- ma And Surgical Emergency Service, Capa, Turkey

Background: Gluteal stab wounds are an uncommon but life- 292 threatening sequel of penetrating injuries. Increased Survival of Neutrophil Granulocytes Methods: Twenty-five victims of gluteal stab wounds with arterial injuries were treated at the Trauma and Emergency Surgery Service in Vac-Treated Compared to Epigard-Treated of Istanbul Faculty of Medicine between 1995 and 2004. Mikulicz Wounds tampon was placed all the patients to control bleeding which was L. Mica, L. Labler, L. Ha¨rter, O. Trentz, M. Keel removed after 24 hours. Patients with signs of active bleeding University Hospital of Zu¨ rich, Switzerland including expanding or pulsating hematoma and patients with ABI < 1 were underwent selective angiography after initial resusci- Temporary covering of extensive soft tissue defects is achieved tation. with an artificial skin, Epigard, or the VAC-system, a poly- Results: Active bleeding was seen in 15 patients after the removal of urethane foam combined with a continuous negative pressure in the Mikulicz tampon. The patients underwent selective angiography the wound. In VAC-treated wounds accumulation of neutrophil and the following vascular injuries were found: Superior gluteal ar- granulocytes (PMN) in the wound can be seen. In this study, tery injury in 10 patients and inferior gluteal artery injury in 5 pa- wound fluid from Epigard and VAC-treated wounds were tients. Either coil embolization (in 7 patients) or gel foam compared and induction of survival in PMN by wound fluid was embolization (in 8 patients) were used to stop bleeding. Nine of the measured. Wound fluid from VAC (n = 24) and Epigard-trea- upper zone injuries resulted to a superior and one of them resulted to ted (n = 20) patients was squeezed out of the foam and centri-

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 83 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

fuged, additionally patient’s serum was collected. Wound fluid, or Conclusions: These preliminary data showed that the use of icodex- patient’s serum was incubated with PMN (106/mL) from healthy trin 4% solution in ASIO is safe and reduces the risk of re- volunteers (n = 12) for 16 hours. Apoptosis of PMN was detected obstruction. by flowcytometry (FITC-Annexin-V / propidium iodine). Data are given as mean ± SEM; significance was set at p < 0.05 Student’s-t- test. Incubation of PMN with control, or patient serum had no 294 effect on the spontaneous PMN apoptosis (48.3 ± 1.5% and 45.7 ± 1.6% vs. 47.8 ± 3.7 % medium alone). However, incubation Outcome and Microbiological Analysis During with wound fluid significantly reduced apoptosis compared to cor- Sepsis After Severe Trauma responding serum (12.9 ± 1.1% vs. 45.7 ± 1.6%). Compared to T. Lustenberger, L. Mica, L. Labler, O. Trentz, M. Keel Epigard, VAC-fluid significantly inhibited PMN apoptosis University Hospital of Zu¨ rich, Switzerland (26.6 ± 1.8% vs. 10.8 ± 1.2%). Comparing wound fluid with corresponding serum shows that increased survival of PMN in VAC- During the late post-traumatic course septic complications are still treated wounds is a local, and not a systemic effect. The granula- the major killing factor. In this retrospective study the focus and the tion formation in VAC-treated wounds could be due to induction microbes species during sepsis were investigated. Trauma patients of inflammation in the wound and prolonged survival of local admitted to the emergency room of a level I trauma center from PMN. This could contribute to the accelerated wound healing seen January 1996 to December 2005 were analyzed. A total of 1171 pain VAC-treated wounds. tients with a survival of more than 3 days and a time to admission of less than 24 hours were included. Outcome measures were overall mortality and development of systemic inflammatory response syndrome (no SIRS, SIRS 2 or 3/4) or sepsis. Besides the focus of 293 infection, the detected microorganisms were characterized. Data are Prospective Controlled Randomized Trial on given as mean ± SD, significance level was set at p < 0.05, Anova. Of all the 1171 patients 230 (20%) developed a sepsis. Within the septic Prevention of Postoperative Abdominal group, 84 (37%) developed a severe sepsis and 74 (32%) septic Adhesions by Icodextrin 4% Solution After shock, the mortality was 17%. The main focus of infection was Laparotomic Operation for Small Bowel pneumonia (56%), followed by catheter infection (17%) and wound Obstruction Caused by Adherences infection (15%). The involved microorganisms were gram-positive in 51%, gram-negative in 46%, and fungal infections in 2%. The most (Popa Study: Prevention of Postoperative common microbes in the gram-positive group were Staphylococcus Adhesions): Prelimin aureus (38%), coagulase-negative Staphylococcus (21%) and F. Catena, L. Ansaloni, S. Di Saverio, L. D’Alessandro, Enterococcus (20%). In the group of gram-negative microorganisms A. Pinna Pseudomonas aeruginosa was represented with 22%, E. coli with General, Emergency and Transplant Surgery DPT, St Orsola-Mal- 21% and Enterobacteriacae with 19%. The posttraumatic morbidity pighi University Hospital, Bologna, Italy is determined by septic complications with a mortality of 17% in the septic group. Pneumonia is the most prominent focus of infection. Purpose: Adhesive small intestine occlusion (ASIO) is an important Gram-positive bacteria are the dominant microbes. cause of hospital admission and are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Icodextrin 4% solution (Adept, Shire Pharma- 295 ceuticals, UK) is a high-molecular-weight a-1,4 glucose polymer that is approved in Europe for use as an intra-operative lavage and a post- Do Trauma Patients Died of Ventilator Associated operative instillate to reduce the occurrence of post-surgery intra- Pneumonia ? abdominal adhesions. The current clinical study evaluates the safety M. Vartic, A. Chilie, C. Turchina, I. Grintescu, M. Beuran and effectiveness of icodextrin 4% for decreasing the incidence, ex- Clinical Emergency Hospital Bucharest, Romania tent, and severity of adhesions in patients after abdominal surgery for ASIO. Background: Ventilator associated pneumonia (VAP) is a common Methods: The study project is a prospective, randomized controlled infection in trauma patients in intensive care units (ICUs), but it is investigation. The safety and efficacy of icodextrin 4% is compared difficult to appreciate if the pneumonia is caused by the severity of to no antiadhesion treatment (control) in a parallel group, pro- trauma itself or just a complication like any other. spective, randomized study with a blinded evaluation of efficacy end Method: Trauma patients admitted in 2006 to the ICU with ISS > 15 points. Subjects with ASIO and surgical indication to laparotomy were identified from the clinical charts. Pneumonia was diagnosed are enrolled and randomized. Patients are submitted to adhesiolysis using cultures of tracheobronchial aspirate and at least one of the with bowel resection if necessary with or without anastomosis. The following: fever, suggestive aspect on chest X-ray and purulent spu- first group receives traditional treatment (control group) whereas tum. Risk factors for VAP, including ISS, age, transfusions, acidosis, the second group is treated with icodextrin 4% before abdomen brain and chest injury were analyzed. Logistic regression was per- closure. formed to identify independent factors for death. Results: Up to now 27 patients were randomized to have icodextrin Results: There were 910 trauma admissions; of these 142 (15.6%) 4% solution and 26 patients to have traditional treatment. The were admitted to the ICU, and 89 (62.7%) had ISS > 15. The inci- recurrence rate was 0% in the icodextrin groups vs 19.2% after a dence of VAP in this group was 46%. Patients with VAP had more mean period of 6.3 months (p < 0.05). No complications icodextrin - transfusions (2.1 vs. 0.4 units of blood), greater ISS (19.1 vs. 16.1), related were found. lower GCS score (6.4 vs. 13.7) but only ISS and GCS scores signifi-

84 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

cantly correlated with VAP (p = 0.001). Chest trauma AIS also Methods: Using an online questionnaire, we interviewed 1104 independently correlates with the incidence of VAP (p = 0.001). emergency physicians and paramedics in Germany. Replies were Overall mortality was 42.25% and the mortality in patients with VAP analysed statistically with the one-way Analysis of Variance was 55.6% compared to 28.3% in those without VAP (p < 0.0001). (ANOVA) test and the Turkey-Kramer Multiple Comparisons Age, ISS and VAP are independent predictors of mortality. test. Conclusion: VAP is independently associated with mortality in Results: 95% of emergency physicians and paramedics know their trauma patients, so adequate therapy must be promptly initiated area of responsibility in case of a mass casualty incident. 35% of especially in less severe injured patients. emergency physicians and 51% of paramedics are unaware of injury patterns and treatment strategies in patients following nuclear, chemical or biological contamination. 97% of the interviewed 296 emergency physicians and paramedics asked for specific further training regarding mass casualty incidents/terrorism. Antibiotic Prophylaxis in Severe Acute Conclusion: Prior to the Football World Cup 2006 in Germany, Pancreatitis: Experimental Evaluation of many practise drills were performed to prepare emergency medical Ertapenem Efficacy services for a mass casualty incident. However emergency physicians and paramedics are still insufficiently prepared for nuclear, F. Catena, L. Ansaloni, F. Gazzotti, S. Gagliardi, A. Pinna chemical and biological as well as conventional terror attacks. The Transplant, General and Emergency Surgery DPT, St Orsola- Mal- emergency training of emergency physicians and paramedics must pighi University Hospital Bologna, Italy be modified to accommodate the increase in catastrophes and terrorist threats. Objective: Secondary infection of the inflamed pancreas is the principal cause of death after severe acute pancreatitis (AP).Pro- phylactic antibiotics that were used in AP were always initiated after hours from induction of pancreatitis. The effectiveness of 298 antibiotics initiated earlier is unknown. The aim of this study was to Injuries to Expect From Major Urban Terrorist evaluate the effectiveness of ertapenem initiated when AP is in- Bombings in Trains: the Madrid, March 11, 2004, duced in rats. Method: 40 Sprague-Dawley rats were studied. AP was induced in Overall Experience from Seven Hospitals 1 2 3 rats by intraductal injection of 3% taurocholate. Rats were divided F. Ture´gano-Fuentes , P. Caba-Doussoux , J. Jover-Navaloń , 4 5 randomly into two groups: group 1 rats received normal saline as a E. Martıń-Pe´rez , D. Fernańdez-Luengas 1 placebo, group 2 received ertapenem 15 mg/kg after AP induction. University Hospital Gregorio Maran˜ o´ n 2 At 24 h, 20 rats (10 group I and 10 group 2) were killed for quanti- University Hospital 12 de Octubre 3 tative bacteriologic study. A point-scoring system of histological University Hospital Getafe features was used to evaluate the severity of pancreatitis. The 4 University Hospital La Princesa-Madrid 5 remaining 20 rats (10 group I and 10 group 2) were killed after 21 Universit Hospital La Paz, Spain days for quantitative bacteriologic study and survival analysis. Chi square, Student and Kaplan- Meier tests were used for survival Background: Most terrorist urban mass casualty events (MCE) in the analysis. last three years have targeted commuter trains at rush hour, pro- Results: All rats showed pathologic signs of acute pancreatitis. Er- ducing large numbers of casualties. tapenem administrated after induction of AP significantly reduced Methods: We describe the injuries sustained by casualties from the the prevalence of pancreatic infection and 24 hours mortality as Madrid, March 11, 2004, terrorist bombings, and the first 24 hours´ compared to controls. 21 days survival was significantly better in workload by the different specialties involved in their care at the 7 group 2 compared to group 1. hospitals which received most victims. Data were gathered of casu- Conclusion: Early antibiotic prophylaxis with ertapenem reduces alties who had injuries other than superficial bruises, transient pancreatic infection rate after AP and it has a beneficial effect on hearing loss from barotrauma without eardrum perforation, and/or survival. emotional shock. Results: The bombings resulted in 177 immediate fatalities, 9 early deaths and 5 late deaths. Most survivors had non-critical injuries, but 72 (14%) of 512 casualties assessed had an ISS >15. The critical Challenges in Disasters mortality rate was of 19.5%. The most frequently injured body region was the head, neck and facial area. Almost 50% of casualties had eardrum perforation, and 60% of them were bilateral. There were 43 297 documented cases of blast lung injury, with a survival rate of 82.4%. Maxillofacial and open long-bone fractures were the most prevalent. Preparedness of German Paramedics and Gustilo´ s grade III of severity predominated in tibia-fibular and Emergency Physicians for a Mass Casualty Incident humeral fractures. Upper thoracic (D1–6 segment) represented 65% P. Fischer, C. Burger, D. Wirtz, K. Kabir of all vertebral fractures. Abdominal visceral lesions were present in Department of Orthopaedics and Trauma Surgery, University of 25 (5%) patients. Orthopedic trauma procedures accounted for 50% Bonn, Germany of the case-load in the first 24 hours. Conclusions: Most fatalities from MCE as a result of terrorist Objective: The propose of this study is to assess the current state of explosions in trains are immediate, and most survivors will have non- preparedness of emergency physicians and paramedics for a mass critical injuries, some of them unusual in other types of trauma casualty incident. mechanisms.

Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 85 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

299 sisted closure in the interim between initial wound surgery and Level I Disaster During a Musical Boat Parade, secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming 21 Casualties results from microbiology and resistance patterns. This approach was M. Bemelman, L. Leenen effective in all but one patient who died due to severe fungal sepsis. Department of Surgery, University Medical Center Utrecht, Transferred patients from disaster areas should be isolated until their The Netherlands microbial flora is identified as they may introduce new pathogens into an ICU. For optimum treatment and care a multidisciplinary ap- A disaster is an event that disrupts a community and the need for proach is mandatory. medical care exceeds the normal resources. The authors present the details of a disaster during a musical boat parade in Utrecht, The Netherlands on August 2006. During this parade a stair collapsed onto the crowd and boats. In the first phase hundreds of calls were 301 made to dispatch with a great variety of reports and casualty numbers (10 to hundreds). Within 7 minutes the first ambulance at the scene The Java Earthquake Disaster Response: Answering classified the disaster as a level 1. All local ambulances (6), the the Call and Personal Implication Mobile Medical Team and the crisis management team were dis- B. Punt1,2 patched. The site was secured and a field hospital was initiated. In- 1Albert Schweitzer Ziekenhuis stead of using the process leap fogging all patients but one were 2Liverpool Hospital Sydney, Australia transported to our centre. The last patient is transported 90 minutes after the incident. Surgeon on call performed triage and 5 surgery The Java Earthquake occurred at 05:54 local time on 27 May 2006, in interns, 2 anaesthesiologists, 2 anaesthesiology interns, 6 nurses as- the Indian Ocean around 25 km south of the Indonesian city of sessed and treated 20 patients. (3 T1, 5 T2 and 12 T3). 87 x-rays, one Yogyakarta, on the southern side of the island of Java. The region ultrasound and 15 Ct scans were made. One patient went for emer- most seriously affected by the earthquake lies on the Bantul plain gency OR, 5 patients were admitted. The patient which went for that lies south of the town of Yogyakarta. This plain is very densely operation deceased 3 days later Conclusion: This disaster followed all populated. A total of 5.782 people died as a result of the earthquake, 4 recognized phases, chaos, initial response, site clearing and recov- while 36.299 people have been injured, 135000 houses damaged and ery. The decision to treat all patients in one centre presented an 600.000 people left homeless. Australia, through its international aid unexpected advantage concerning the psychological assimilation of agency AusAid, has deployed a medical team of 26 experts to this the trauma by the patients and an easy extraction of the patients. region on Tuesday the 30th. I was contacted and asked to join this deployment on Monday the 29th. Although personally and profes- sionally extremely interested there are some factors to consider in a very short time. I will discuss my personal experience following my 300 two weeks of deployment. One Year ago not Business as Usual: Wound Management and Infection Control During Tertiary 302 Medical Care Following the 2004 Tsunami Disaster 11-m, 2004: The Terrorist Bomb Explosions in in Southaest Asia M. Maegele1, D. Rixen1, C. Simanski1, R. Schwarz2, B. Bouillon1 Madrid, Spain. Prehospital Triage, Logistics and 1Cologne-Merheim Medical Center (CMMC), Department of Casualties Treated at the Closest Hospital Traumatology and Orthopedics, University of Witten-Herdecke, F. Ture´gano-Fuentes, D. Pe´rez-Dıáz, M. Sanz-Sańchez, Germany J. Lago-Oliver, D. Serralta-De Colsa 2Department of Microbiology, Cologne-Merheim Medical Center 1 University Hospital Gregorio Maran˜ o´ n, Spain (CMMC), Germany Background: At 07:39 a.m. on March 11th, 2004, ten terrorist bomb Following the 2004 tsunami disaster in southeast Asia severely in- explosions occurred almost simultaneously in four commuter trains jured tourists were repatriated via airlift to various European coun- in Madrid, Spain, killing instantly 177 people and injuring over 2000. tries. One cohort (n = 17, age 19–68 years) was triaged to the Methods: Review of the prehospital triage and the logistics involved Cologne-Merheim Medical Center (Germany) for further medical in the management of casualties taken to the closest hospital. Data care. We report on the tertiary medical care provided to this cohort from prehospital triage were gathered from EMS in Madrid. of patients with respect to complex wound management and infection Results: 312 patients were taken to the closest hospital, and 91 were control. Multiple large flap lacerations at various body sites were hospitalised, 89 of them (28.5%) for more than 24 hours. 62 patients characteristic. Lower extremities were mostly affected (88%), fol- only had superficial bruises or emotional shock, but the remaining lowed by upper extremities (29%), and head (18%). 2/3 of patients 250 patients had more severe lesions. Data on 243 of the latter were presented with combined injuries. Near-drowning involved the gathered for this report. Tympanic perforation occurred in 41%, aspiration of immersion fluids, marine and soil debris into the chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first respiratory tract and all patients displayed signs of pneumonitis and or second degree burns in 18%, eye lesions in 18%, head trauma in pneumonia upon arrival. Three patients presented with severe 12%, and abdominal injuries in 5%. Between 8.00 a.m. and 5 p.m., 34 sinusitis. Microbiology identified a variety of common but also surgical interventions were performed on 32 victims. 29 casualties uncommon isolates that were often multi-resistant. Wound man- were deemed in critical condition, and 2 of them died within minutes agement included aggressive debridement together with vacuum-as- of arrival. The other 27 survived to be admitted to intensive care

86 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL 1st Joint Congress EATES & ETS, May 23–26, 2007, Graz Abstracts

units, and 3 of them died, bringing the critical mortality rate to 17.2% physicians, 48 nurses, 19 paramedics, 57 medics, laboratory and (5/29). The mean ISS and APACHE II scores of critical patients were associated support personnel. There were 24 ambulances, 2 mobile 34 and 23, respectively. morgue vehicles, 11 sanitation vehicles, 3 hearse and 3 helicopter Conclusions: There was an overtriage to the closest hospital, and the ambulances. The field hospital treated approximately 108 patients time of the blasts proved crucial for the adequacy of the medical and over a period of 3 days, 28 surgical simulations were performed and a surgical response. variety of medical, surgical, orthopedic, and pediatric/neonatal care was provided. Conclusion: These results strengthen the importance of a multidis- 303 ciplinary, versatile, field hospital as an aid to an earthquake-affected population. The rapid establishment of the field hospital enabled the Istanbul Disaster Drill Management local medical facilities in order to organize and restore surgical and M. Kalemoglu hospitalization abilities in this disastrous situation. GATA Haydarpasa Teaching Hospital, Istanbul, Turkey

Background: Major earthquakes have the potential to be one of the most catastrophic natural disasters affecting mankind. Earthquakes 305 of significant size threaten lives and damage property by setting off a Istanbul 2006 Earthquake Drills chain of events that disrupts all aspects of the environment and sig- M. Kalemoglu nificantly impacts the public health and medical infrastructures of the GATA Haydarpasa Teaching Hospital, Istanbul, Turkey affected region. Methods: More than 5640 rescue workers, volunteers, medics and Background: This is Istanbul’s first exercise incorporating hospitals police officers attended a drill by the city authorities to see readiness and other healthcare providers, including long-term care facilities of the city in case a possible earthquake in Istanbul. There were 3 and clinics, pre-hospital care providers, auxiliary communication disaster exercises regions which were as Kartal, Baðcy´lar and Gaz- networks, blood banks, local public health and other local and re- iosmanpaþa County Municipality. gional governmental agencies. The Istanbul is subject to continuous Results: I am the director of the Kartal county disaster management seismic risk. and Kartal Field Hospital. There were 340 medical personnel in Methods: The three-day mock earthquake drill, which was November Hospital. We examined 108 patients with injury (20 ex). Our expe- 7–9 2006, is designed to test the earthquake preparedness of Istanbul riences have taught us that practice makes perfect and that it prob- city. More than 5640 rescue workers, volunteers, medics and police ably is unreasonable to expect everything to be orderly, sane, and officers attended a drill by the city authorities to see readiness of the appropriate during disaster management. The best we can hope for city in case a possible earthquake in Istanbul. probably is controlled chaos. We do believe that we have generated Results: Across the city, officials were put through realistic simula- an improved plan, that the plan is known, and that it is being revised tions of the chaos of what could be one of the world’s worst natural continuously. We can no longer rely on our goodwill and good disasters. Teachers screamed at their students to run out of schools as intentions to manage mass casualties in a disaster. fast as they could, rescue workers pulled fake corpses from rubble Conclusions: The lessons learned in this drill include a number of and firefighters and police sped to help rescue the injured from col- planning, education, orientation, and follow-up issues. It is not real- lapsed buildings. Nearby, sirens wailed as rescue workers rushed to a istic to believe that a drill can be perfectly planned and practiced; derailed train. In other scenarios, rescue teams assisted people therefore each drill provides another opportunity to improve on past trapped under the debris of a mosque and rushed to save passengers experience. of a ship sinking in the Bosporus. Conclusions: Disaster drills are an effective way to test a hospital’s preparedness for real-life disasters, but an extensive amount of coordination and time is necessary to host a successful drill with a 304 large number of victims. The lessons learned in this drill include a Istanbul 2006 Earthquake Drills and Kartal Field number of planning, education, orientation, and follow-up issues. Surgical Hospital M. Kalemoglu, I. Yy´ldy´ry´m, S. Okudur, S. Akadu¨rek, T. Cesur GATA Haydarpasa Teaching Hospital, Istanbul, Turkey Miscellaneous Objective: The drill is a planned activity that tests, develops, or maintains skills in a single or limited emergency response procedure. We aim to study: (1) pre-event hospital preparedness; (2) patient 306 evacuation and triage; (3) personnel and equipment reinforcement; (4) modes used for alarm and recruitment of hospital personnel; and Emergency Surgery for Acute non Cardiac (5) admission, discharge, and secondary transfer of patients. Complications After Cardiosurgery Methods: The active three-day mock earthquake drill, which was R. Caronna1, M. Schiratti1, M. Marengo1, G. Mazzesi2, P. Chirletti1 November 7–9 2006, is designed to test the earthquake preparedness 1University Of Rome - General Surgery N, Italy of Istanbul city. During a one-week mission (including preparation 2University of Rome - Cardiac Surgery, Italy phase) in the disaster area, the disaster relief provided to the disaster- affected population of east part of Istanbul was evaluated. Introduction: The authors report their experience on 56 patients Results: A medical unit of the GATA Haydarpasa Military Teaching observed, 36 of them surgically treated for acute non cardiac com- Hospital and Istanbul Governor’s Office. Medical Corps had 46 plications after cardiac surgery.

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Material and Methods: Of the 36 patients, 29 were operated for an 308 acute abdomen, 5 for digestive hemorrhage resistant to the medical Use of Biological Materials for Hernia Repair therapy, 1 for hemoperitoneum and 1 for a pulmonary abscess. In patients with acute abdomen for intestinal ischemia we realized 7 in Contaminated Fields ileocolic resections, 3 total colectomy, 1 right and 2 left emicolecto- F. Catena, L. Ansaloni, F. Gazzotti, S. Di Saverio, my; for acute colecistitis,11 cholecistectomies and 1 cholecistostomy; A. Pinna 2 patients underwent closure of peptic ulcer, 1 laparotomy for acute General, Emergency and Transplant Surgery DPT, St.Orsola-Mal- pancreatitis and 1 exploratory laparotomy for with infected ascites. pighi University Hospital, Bologna, Italy In patients with digestive hemorrhage, 5 had a gastroduodenal resection. Introduction: In complicated hernias contaminating surgical proce- Results: The postoperative 30 days mortality was 13.7% (4 out 29 dure are often performed and the use of polypropylene meshes can cases) for patients with acute abdomen and 20% (1 out 5) for pa- be hazardous. In case of polypropylene meshes infection also the tients with gastrointestinal hemorrhage. The 30 to 90 days mortality hernia repair can be problematic. In order to answer to these dis- was higher. The causes of death in these patients were MOF, advantages, porcine materials (small intestinal submucosa and por- ARDS and rebleeding. Most patients with MOF had liver and renal cine dermal collagen) have recently been used in humans for hernia failure probably related to splancnic intra and postoperative hyp- repairs. Aim of our study is to evaluate the safety and efficacy of operfusion. incisional, inguinal and femoral hernia repair using porcine materials, Conclusions: The emergency surgeon has to recognize in periopera- as a mesh, in complicated cases with contamination or infection. tive hypoperfusion (emergency cardiovascular surgery and use of Methods: A prospective study of hernia repair of complicated high and prolonged doses of inotropic drugs for postoperative he- inguinal, femoral and incisional hernias with contamination/ infection modinamic instability) the most important risk factor for the devel- using small intestinal submucosa and porcine dermal collagen grafts opment of acute complications. In this group of patients the highest was carried out at the Department of General, Emergency and mortality was observed long after the operation and is related to Transplant Surgery of St Orsola-Malpighi University Hospital irreversible ischemic hepatic and renal damage. Results: From january 2003 up to now 31 patients were submitted to Lichtenstein’s repair of complicated/ infected inguinal/femoral hernias or complicated/ infected incisional hernia repair using small intestinal submucosa mesh or porcine dermal collagen. In all patients 307 a contaminated surgical field was demonstrated with a positive microbiological culture. In 21 patients a contemporary bowel resec- Epidemiology of Trampoline Related Injuries tion was done. There were not major intraoperative or postopera- in North Wales tively complications related to the hernia repair with the exception of U. Rethnam, R. Yesupalan, A. Sinha 3 seromas. No recurrences and wound infections were observed after Glan Clwyd Hospital e mean follow-up of 21.4 months. Conclusions: Hernioplasty using the small intestinal submucosa and porcine dermal collagen meshes in complicated cases with contami- Background: Despite concerns about their safety, trampolines are nation has a promising safety and efficacy. still a very popular activity among children. This has led to an increase in trampoline related Orthopaedic injuries. We assess the epidemiology of trampoline related injuries encountered in a district hospital of North Wales. 309 Materials & Methods: This was a retrospective study conducted over Trauma in the Elderly in AL-Ain City a 4 year period. All trampoline related injuries were identified from F. Abu-Zidan, H. Eid, S. Adam, P. Barss, M. Grivna the database and data collated on age, sex, mechanism of injury, Trauma Group, Faculty Of Medicine, UAE University, Saudi Arabia season when injury was sustained, type of injury, treatment needed and final outcome. Objectives: To study the mechanism and outcome of trauma in Results: 76 patients were seen by the Orthopaedic team for tram- hospitalized elderly patients. poline related injuries between 2003 -2006. 84% patients were be- Methods: The data of Al-Ain Hospital Trauma Registry were collected low the age of 15. There was a female predominance. The incidence prospectively over 3 years (2003–2006). All elderly trauma patients steadily rose from 2 patients in 2003 to 37 patients in 2006. Most U+00AlY´ 60 years old were studied. Demography of patients, mech- injuries were outdoors and sustained during the summer. Injuries to anism of injury, physiological variables on admission, Injury Severity the upper limb predominated with fractures encountered in 72.3%. Scores (ISS), hospital stay and mortality were analysed. Fractures accounted for 67% of the total injuries. 72% of injuries Results: There were 121 patients (70 males and 51 females). Mean needed intervention like plasters, manipulations and surgeries. The (range) age was 69 years (60–100). 42% were UAE nationals. The tibia was the commonest bone fractured among the lower limb two most common mechanisms of injury were falls 67 (55%) followed while the distal radius accounted for the most fractures in the upper by road traffic collisions 39 (32%). The median (range) ISS of the limb. group was 5 (1–34). More than 40% of injuries occurred at home. Conclusion: Although a popular activity, trampolines are a hazard The mean (range) hospital stay was 12.4 (1–150) days. Overall to children. There is an increasing trend in the incidence of inju- mortality was 6%, including 7 patients, five of whom were pedestri- ries related to trampolines. Children should be explained the ans hit by cars. dangers of a trampoline and need to be supervised while playing. Conclusions: Low energy trauma (falls) was the most common cause With the popularity of the sport it may be impossible to ban the of trauma in the elderly. Mortality was high mainly from pedestrian trampoline. injuries.

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310 duodenoraphy with pyloric exclusion and ﬁne needle catheter jej- Current Status of Emergency Medicine in Jordan unostomy, left nefrectomy. We consider that the use of EEN was of real help in this case and we recommend it in all polytraumatised A. AL Issa patients and in all the cases where it can be used. Royal Medical Services, Jordan

Current Status Of Emergency Medicine In Jordan Atallah AL Issa MD, Consultant of emergency medicine, Director of emergency 312 department, King Hussein Medical Center, Amman - Jordan Ab- A Review F 1241 Trauma Cases: Study of the stract: Emergency Medicine in Jordan has undergone dramatic Distribution of Trauma Theatre Time changes in the last few years, centered on the quality of patient’s E. Collantes, E. Prempeh, C. Mauffrey care (encompassing safety, clinical outcome and patient satisfac- University Hospitals Coventry and Warwickshire tion). It is a well established and developed an emergency medical care system, both of, the pre hospital care system, which provides Introduction: Our trauma department has recently moved to a newly emergency medical care by Civilian Defense ambulances, while build University hospital. Our aim was to assess whether the move definitive emergency medical care provided by hospital- based had an impact on the activity in trauma theatres. emergency medical care system. The health care system is com- Method: A total of 1241 consecutive trauma operations were re- posed of four main sectors: Ministry of Health, The Royal Medical viewed, looking at transit times of patients to theatre, the duration of Services, University hospitals, and the private sector, the health induction of anaesthesia, time to prepare and drape the patient and coverage of the population are 31%, 29%, 11% and 9% respec- duration of surgery. Daily starting and finishing times were also tively, 20% of the population is uninsured. The King Hussein analysed. We looked at operations done from April 2006 to July 2006 Medical Center, which is the largest military, teaching and referral in our old site and compared the timings to the first 2 months in the hospital in Amman, was established emergency medicine training new University hospital. In a second phase, we looked at the most program and has Emergency Department, which provided emer- recent two months in our hospital. gency medical care for more than 105,000 patients in 2006. Finally Results: The mean number of cases done daily and the distribution of the emergency departments of The King Hussein Medical Center time in trauma theatre were not significantly different in the two and the other hospitals in Jordan are well organized, developed and hospitals although we noted that a learning curve was necessary in supported by well qualified emergency physicians, nurses and the new site. The efficiency of trauma theatre utilisation is far from paramedics. being optimal but seems to correspond with the findings in the general literature. Conclusion: Activity and theatre utilisation in trauma should be 311 monitored regularly in order to assess the time distribution of sur- Early Enteral Nutrition in a Patient with Severe gical cases. This monitoring enables the department to highlight causes of inefficiencies and improves the activity in trauma theatres. Multiple Injuries : Flail Chest, Renal Laceration and Late Duodenal Perforation. Case Presentation A. Nicolau, R. Ciupan, G. Plugaru, L. Marinescu, V. Merlan 313 Emergency Hospital Floreasca Skateboard Related Injuries in North Wales U. Rethnam, R. Yesupalan, A. Sinha We present the case of a 51 years old woman with multiple injuries. Glan Clwyd Hospital She suffered a car accident and at admission, the diagnosis were: anterior flail chest, blunt abdominal trauma with IIIrd grade kidney Background: Skateboarding has been a popular sport among teen- laceration, multiple extremities fractures, ISS = 50. We performed agers. Although a popular recreational activity it has attendant emergency nefrectomy, surgical fixation of the flail chest and bilateral associated risks. The injury pattern has changed with the develop- pleurostomy. Postoperatively the evolution was difficult, she was ment of both skateboard tricks and the materials used for skateboard intubated and mechanically ventilated. We started early enteral construction. We assess the epidemiology of skateboard related nutrition (EEN), after 24 hours on nasogastric tube. In the fourth Orthopaedic injuries in a district hospital of North Wales. postoperative day, CT scan identified only pulmonar bilateral con- Materials & Methods: This was a retrospective study conducted over tusion, without other lesions. In the seventh postoperative day, a 4 year period. All skateboard related injuries were identified from jaundice became apparent and the CT exam identified gas bubbles in the database and data collated on age, sex, mechanism of injury, the retroperitoneum. At surgery, we identified a second degree D2 season when injury was sustained, type of injury, treatment needed perforation. We performed duodenoraphy, pyloric exclusion, latero- and final outcome. lateral gastro-entero-anastomosis. We introduced a naso-gastro-en- Results: 45 patients were seen by the Orthopaedic team for skate- tero-duodenal tube into D2 for active suction. We also performed a board related injuries between 2003 –2006. 80% patients were males fine needle catheter jejunostomy for enteral nutrition. The postop- and 77% were under the age of 15. There was a decreasing trend in erative evolution was difficult, the patient was intubated, febrile, with the incidence of injuries in 2004 and 2005 but this has increased hemodynamic instability. EEN on the jejunostomy with 20–40–60 ml/ dramatically in 2006. 75% of injuries involved the upper limb with hour. Ten days after the reoperation, the general condition improved, most injuries being fractures. Most injuries occurred during summer. the fever decreased and the patient was detubated. Enteral nutrition 60% of injuries needed intervention like plasters, traction and was continued for 14 days after reoperation. The treatment involved manipulations. The distal radius was the commonest bone to be internal pneumatic stabilization and surgical fixation of the flail chest, fractured.

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Conclusion: Skateboarding should be restricted to supervised skate- of the lower limb was tibia in the trampoline group and ankle in the board parks, and skateboarders should be required to wear protec- skateboard group. The distal radius was most affected in both groups. tive gear. These measures would reduce the number of skateboarders Conclusion: Trampoline related injuries had a higher incidence injured in motor vehicle collisions, reduce the personal injuries while the seriousness of the injury was higher with the skateboard. among skateboarders, and reduce the number of pedestrians injured Safety education of children involved in these activities is essential in collisions with skateboarders. as forbidding them to take part or banning these activities is impossible.

314 Trampoline or the Skateboard. Which is the Worst 315 Evil? A Comparative Analysis Acute Traumatic Abominal Wall Hernia After Blunt U. Rethnam, R. Yesupalan, A. Sinha Abdominal Trauma Case Report Glan Clwyd Hospital D. Brett1, S. Michalski2, G. Muhr1, D. Seybold1 1Berufsgnossenschaftliche Universita¨tskliniken Bochum, Chirurgi- Background: Trampoline and skateboarding are popular recreational sche Klinik Und Poliklinik, Germany activities among children. There is evidence that these activities have 2Knappschaftskrankenhaus Bochum-Langendreer, Universita¨tskli- increased the incidence of injuries in children. We performed a nik, Chirurgische Klinik, Germany comparative analysis of injuries related to trampoline and skateboard. Our aim was to evaluate any difference in the pattern of injury Traumatic abdominal wall hernias are rare injuries despite the high and epidemiology of these two recreational activities. incidence of blunt abdominal trauma. Mechanisms of this special Materials & Methods: All trampoline and skateboard related injuries injury include a sudden increase in intraabdominal pressure and in a four year period were included. Data on the age & sex incidence, powerful extensive shear forces applied to the abdominal wall. The pattern of injury, season, type of injury, treatment and final outcome location is usually found at anatomic weak points in the lower of trampoline and skateboard related injuries were collated from the abdomen. Often significant intraabdominal injuries or injuries of the hospital trauma database. pelvis and thorax are associated. We describe a typical case of a Results: 121 patients were identified in both groups. Trampoline contusion trauma of the adomen leading to a traumatic abdominal injuries accounted for 62.8% patients. There was a male predomi- wall hernia beside the rectal sheath. In this case, parts of the small nance in the skateboard group as opposed to female predominance in bowel penetrated through the ruptured muscle of the abdominal wall the trampoline group. Most patients in both groups were under 15 up to the subcutis. After appropriate diagnosis, the patient under- years and injuries occurred in the summer. Fractures although went repair of the defect using a sheet of synthetic mesh. A Vipro-II- common in both groups, seemed more prevalent in the skateboard mesh was used to stabilize the abdominal wall. With this case, the group. The upper limb was affected more in both groups although the pathophysiology and therapy of traumatic abdominal wall hernia is incidence in skateboard injuries was higher. The most affected region illustrated.

90 Eur J Trauma Emerg Surg 2007 Æ Supplement II URBAN &VOGEL