[Polytrauma and air rescue. A retrospective analysis of trauma care in eastern Austria exemplified by an urban trauma center]

Biomechanical and histological analyses of the fracture healing process after direct or prolonged reduction

Background

Reduction of femoral shaft fractures remains a challenging problem in orthopaedic surgery. Robot-assisted reduction might ease reduction and fracture treatment. However, the influence of different reduction pathways on patients’ physiology is not fully known yet. Therefore, the aim of this study was to examine the biomechanics and histology of fracture healing after direct and prolonged robot-assisted reduction in an in vivo rat model.

Methods

144 male CD^® rats were randomly assigned to 12 groups. Each animal received an external fixator and an osteotomy on the left femoral shaft. On the fourth postoperative day, the 1× reduction groups received a single reduction maneuver, whereas the 10× reduction groups received the same reduction pathway with ten repetitions. The control groups did not undergo any reduction maneuvers. Animals were killed after 1, 2, 3 and 4 weeks, respectively, and the composition of the fracture gap was analyzed by µCT and non-decalcified histology. Biomechanical properties were investigated by a three-point bending test, and the bone turnover markers PINP, bCTx, OPG, sRANKL, TRACP-5b, BALP, and OT/BGP were measured.

Results

One week after the reduction maneuver, µCT analysis showed a higher cortical bone volume in the 1× reduction group compared to the 10× reduction group. Biomechanically, the control group showed higher maximum force values measured by three-point bending test compared to both reduction groups. Furthermore, less collagen I formation was examined in the 10× reduction group compared to the control group after 1 week of fracture healing. PINP concentration was decreased in 10× reduction group after 1 week compared to control group. The same trend was seen after 3 weeks.

Conclusion

A single reduction maneuver has a beneficial effect in the early phase of the fracture healing process compared to repeated reduction maneuvers. In the later phase of fracture healing, no differences were found between the groups.

Compliance With a National Standard by Norwegian Helicopter Emergency Physicians

OBJECTIVE

The "National Standard Requirements for Helicopter Emergency Medicine Services Physicians" gives recommendations on medical requirements for flight physicians. This study describes the level of formal competence, experience, and guideline compliance of Norwegian helicopter emergency medical service (HEMS) physicians.

METHODS

In May 2013, all HEMS physicians with full-time engagement at Norwegian HEMS bases were invited to participate in a cross-sectional survey using a structured, Web-based questionnaire.

RESULTS

A total of 108 (79%) of 136 physicians replied to the survey, and all bases were represented. The majority (89%) had specialist training, and more than 60% had longer than 6 years of experience as a flight physician. Over 60% had attended trauma, pediatric, and incubator courses, and all physicians worked regularly in an anesthesia department. Most physicians were participating in simulation and procedure training.

CONCLUSION

Many of the basic requirements of the guidelines were met by HEMS physicians, but room exists for improvements. Norwegian HEMS physicians are experienced, but a need exists for a more structured curriculum in emergency medicine for HEMS physicians based on the broad spectrum of presented medical conditions to ensure optimal quality of care and safety for all patients in Norway.

Repetitive reduction lead to significant elevated IL-6 and decreased IL-10 levels in femoral osteotomies: A quantitative analysis of a robot-assisted reduction process in a rat model

INTRODUCTION

The field of robot-assisted fracture reduction has been developed by several research groups over more than one decade by now, with the main goals of increasing the fracture reduction accuracy. However, the influence of different reduction paths to patients' physiology is not fully known yet. The aim of our study was to compare the impacts of a robot-assisted direct reduction path versus an artificially prolonged reduction path by measuring the cytokine responses in an in vivo rat model.

MATERIALS AND METHODS

Thirty-six male CD(©) rats were assigned into three groups with an external fixator and osteotomy on the left femur. Seven days later, the robot was attached and one group was reduced in a single attempt, while the other group underwent 10 attempts by the robot. The third group was the control group without reduction. Before, and as well as 6, 24 and 48h after the reduction process blood samples were collected. IL-1, IL-6, IL-10, IL-17, and MCP-1 concentrations where analysed via ELISA or cytometric bead assay. Muscle biopsies in the osteotomy area were collected 48h after the reduction process for histological analyses. Statistical significance was set at p≤0.05.

RESULTS

Analysis of the cytokines showed that the pro-inflammatory cytokine IL-6 of the Ten-Attempts reduction group significantly increased 6h after reduction compared to the control group. IL-6 further showed markedly elevated levels 6h after surgery in the Ten-Attempts reduction group compared to the Single-Attempt reduction group. On the anti-inflammatory side, IL-10 showed a significant decrease in the Ten-Attempts reduction group 6h after reduction compared to the Single-Attempt reduction and control group. Muscle biopsies showed a significant increase of pathological changes in both reduction groups and an increase in the severity of bleedings of the Ten-Attempts reduction group compared to the Single-Attempt reduction and control group.

CONCLUSION

A direct and gentle reduction procedure as feasible by the aid of a robot is preferable over a prolonged reduction in terms of cytokine response and tissue changes.

Factors influencing the injury pattern and injury severity after high speed motor vehicle accident--a retrospective study

INTRODUCTION

Motor vehicular accidents (MVA) are the leading cause of death among people under 40 years of age. Despite improvement in car safety and driver awareness of the use of safety devices, fatalities and severe injuries continue to occur.

MATERIAL AND METHODS

From 1997 to 2004, 13,678 patients after MVA were admitted to our institution. Out of this cohort, 584 (4.3%) patients suffered blunt major trauma defined as Injury Severity Score (ISS) >or=16 and at least one life-threatening injury in one body region. Preclinical data were recorded in 458 patients matching the inclusion criteria. The circumstances of the trauma scene such as weather conditions were analysed as well as technical crash data such as direction of impact, security devices used and type and severity of automobile damage. In a retrospective trial, the influence of preclinical variables on the injury pattern and on injury severity was investigated.

RESULTS

314 (68.6%) patients were male and 144 (31.4%) female. Injury severity (p=0.015) and rate of multiple injuries (p=0.012) were higher in patients after side-impact crashes. If automobiles with SIPS were used, injury severity was significantly reduced in case of side-impact crashes (p=0.003). Patients after frontal impact crashes had a higher rate of severe traumatic brain injury (TBI) compared to the overall cohort (p=0.014). Patients suffering blunt aortic (n=29) dissection were involved in frontal crashes with seat belt use (p<0.001). If patients were entrapped, injury severity (p=0.021) and rate of multiple injuries (p=0.018) were significantly higher. Rear-end collisions with trucks without rear protection led to higher mortality rates (p=0.011).

CONCLUSION

According to our data significant association between technical crash data and injury pattern and injury severity can be assumed. In case of high speed MVA in rural areas the trauma mechanism and the circumstances (i.e., impact direction, automobile deformation) should be considered to identify patients at high risk of severe blunt trauma and multiple injuries.

The experience of Teesside helicopter emergency services: doctors do not prolong prehospital on-scene times

BACKGROUND

The benefits of helicopter emergency medical services (HEMSs) attending the severely injured have been documented in the past. The benefits of doctors attending HEMS casualties have been demonstrated in particular in inner-urban and metropolitan areas. However, for UK regions with potentially less major trauma, concerns have been raised by ambulance services that a willingness of doctors to "stay and play" may lead to unnecessary delays on-scene without any additional benefit to the patient.

AIMS

To identify factors that do prolong on-scene time, establish whether doctors "stay and play" on-scene compared with paramedics and document how often advanced medical skills may have to be used by HEMS doctors working outside the London HEMS environment.

METHODS

Patient report form data were studied with regard to the number of and mean on-scene times of missions flown to (A) road-traffic collisions (RTCs), (B) other trauma calls (OTCs) and (C) medical emergencies. Trauma missions (categories A and B) were further subcategorised with regard to associated patient entrapment. Any advanced medical interventions (AMIs) performed by HEMS doctors were recorded and categorised. Finally, we looked at the difference in on-scene times for physician-paramedic partnerships (PPPs) and conventional paramedic crews (CPCs) for the above categories and subcategories.

RESULTS

A total of 203 patient report forms were identified and examined. In all, 44.3% of missions were flown to RTCs with a further 44.3% for OTCs and 11.4% to medical emergencies. AMIs were performed by HEMS doctors in 34.1% of PPP missions, with a prehospital rapid sequence induction rate of 3.8%. Overall mean on-scene time was 25 min, with no difference for PPP and CPC missions. The mean on-scene time was prolonged by 6 min for RTCs (p = 0.006) and by 23 min for patient entrapment (p<0.001). No significant differences were found for the comparison between PPPs and CPCs in any of the subgroups A-C. However, there seemed to be a trend towards reduced on-scene times of PPPs for medical emergencies and patient entrapments.

DISCUSSION

This study did not show any significant prolongation of mean on-scene times for PPP missions either overall or for any of the subgroups A-C. The fact that AMIs were performed in a large number of missions attended by HEMS doctors seems to further justify their current role in providing improved care at the roadside without leading to any delays in transfer to definitive care.