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ABSTRACTS
Abstracts
13th European Congress of Trauma and EmergencySurgery
May 12–15, 2012Basel, Switzerland
Congress Presidents
PD Dr. med. Dominik HeimFrutigen, Switzerland
Prof. Dr. med. Reto BabstLucerne, Switzerland
This supplement was funded by the European Society for Trauma and Emergency Surgery.
123
Eur J Trauma Emerg Surg (2012) 38 (Suppl 1):S1–S217
DOI 10.1007/s00068-012-0185-y
European Journal of Trauma and Emergency SurgeryOfficial Publication of the European Society for Trauma and Emergency Surgery
Supplement
Vol. 38, 2012
Abstracts for the 13th European Congress of Trauma andEmergency SurgeryMay 12–15, 2012 Basel/Switzerland
Organized by
European Society for Trauma & Emergency SurgerySwiss Society for Traumatology and Insurance Medicine
Swiss Society for General Surgery and Traumatology
Contents
S 4 Oral Presentations
S 66 Video Presentations
S 70 Poster Sessions
S 134 Posters
S 203 Index of Authors
S2 Abstract
123
Welcome address ECTES Basel 2012
Welcome to the 13th European Congress of Trauma and Emergency Surgery! For months a lot of work has been invested into this
congress. The first preparations even started 2 years ago. Since, the whole body of the congress has taken shape and we are happy
now to welcome you to this unique congress in Switzerland with the motto ‘‘many ways—one goal’’:
Apart from the quite wellknown instructional lectures courses and the keynotes with the free communications, the 12-to-12 lectures
at noontime, having been organized in the Milano Congress for the first time, promise very pragmatic, dogmatic, short lectures
from a very international faculty. Furthermore, ‘‘How I do it’’ sessions early in the morning will explain the very practical and
personal attitude of wellknown speakers to several topics of the five sections of ESTES. Guest symposia of AOTrauma, Efort,
Efost, SGC, SGOT, SOFCOT, EBJIS await you with topics and speakers, that will enrich the scientific programme. For the first
time in the history of the ESTES Congress we organized special sessions dedicated to the paramedics and the operating room
personal (ORP) on Monday, respectively Tuesday. The nurses will have a workshop on internal fixation of fractures with practical
exercises on Monday. So-called curtain-up sessions will shed light on the International committee of the Red Cross (ICRC) with its
headquarter in Geneva/Switzerland (Sunday). The university of Basel, the oldest one in Switzerland, will present itself with a very
special programme (Monday) and the trauma scene in countries like China, Japan, Thailand, Taiwan and India will be explained
and demonstrated on Tuesday. ECTES 2012 will really be an international meeting with a faculty from all over the world. ‘‘A
congress is meant to be more than just a textbook, a congress is meant to be communication, a presentation of personal opinions
and personal results and a start to animated discussions about new findings and new solutions to everyday’s and extraordinary
problems’’ (2nd announcement).
And we also promised that this ‘‘congress is meant to be more than just a congress’’! This congress will also live from the place,
where it is taking place: Basel, the modern and old town, the town, where carneval is ‘‘the three most beautiful days of the year’’, a
town, where people live for their football team (the Swiss evening is going to take place in the football stadium of this very club), a
town, where modern art, urban lifestyle and commerce meet. We will meet the alphorn player Eliana Burki with her group, George
Gruntz, the grand old man of jazz music, Max Lasser and his Ueberlandorchestra with its traditional swiss dance music in its today-
version the famous Carneval Clique ‘‘Bajass’’ from Basel and further surprise acts.
Don’t miss ECTES 2012 in Basel. Enjoy 3 days rich in medical and surgical science and art. Concerning art, some wise trauma-
man said some time ago ‘‘nailing is a technique, plating is an art’’—listen to both, listen to many other things and decide for
yourself, what’s best for your patient, as there are ‘‘many ways, but just one goal’’.
PD Dr. med. Dominik Heim and Prof. Dr. med. Reto Babst, Congress Presidents 2012
123
Abstract S3
ORAL PRESENTATIONS
OESOPHAGEAL INJURIES
O001
ROLE OF LAPAROSCOPY IN AN ACUTE CARE SURGERYDEPARTMENT: TWO YEAR EXPERIENCE
M. Di Grezia, A. Tufo, V. Cozza, A. Antinori, A. Di Giorgio,A. La Greca, P.L. Spada, M. Foco, S.C. Magalini, D. Gui
Department of Surgery, Catholic University of the Sacred Heart,
Rome, Italy
Introduction: Laparoscopic surgery has found its role in acute care
surgery as a diagnostic tool and as a therapeutic technique. A review
of the 2 year experience of a newly instituted Acute Care Surgery
Ward is reported.
Materials and methods: In the Acute Care Surgery Ward of the Cath-
olic University of the Sacred Heart in Rome, from April 2009 to July 2011,
737 patients have been operated on in acute/emergency setting; 205 out of
785 procedures were managed laparoscopically (27.8 %). We retrospec-
tively compared the whole classes of patients (205 laparoscopic vs. 461
laparotomic), and then as subgroup the appendectomy (69 vs. 108) and
cholecystectomy (103 vs. 50) patients who were predominant. The pri-
mary endpoint was to identify any correlation between surgical approach
and mortality, morbility, reoperation rate and length of hospital stay. The
secondary endpoint was to identify factors contributing to conversion.
Results: Patients laparoscopically managed were mainly women
(62.5 %), younger (45 vs. 57 years) and in ASA I–II class in 95 % of
cases. The laparoscopic approach was associated with a shorter hos-
pital stay (p = 0.0001), lower morbility (p = 0.0001), re-operation
(p = 0.003) and mortality rate (p = 0.0001). Conversion to laparot-
omy occurred in 18.0 % (45 out of 250) of the laparoscopic cases;
conversion rate was lower in younger patients (p = 0.0025) and in
appendicitis and cholecystitis patients (15.5 vs. 28.3 %) (p = 0.05).
Conclusion: Laparoscopic technique has a well established role in
acute care surgery. Main indications are appendicitis and cholecys-
titis, eventhough one-fifth conversion rate must be accepted.
Laparoscopy is spreading as a diagnostic/therapeutic tool in bowel
obstruction, perforations, and trauma.
Disclosure: No significant relationships.
O002
SINGLE INCISION VERSUS CONVENTIONALLAPAROSCOPIC APPENDECTOMY
E. Ozkurt, I.S. Sarıcı, H.T. Yanar, C. Ertekin, R. Guloglu, M.K. Gunay
General Surgery, Istanbul University Istanbul Faculty of Medicine,
Fatih, Turkey
Introduction: In this study, we analyzed the safety and feasibility of
single incision laparoscopic appendectomy (SILA) versus conven-
tional laparoscopic appendectomy (CLA).
Materials and methods: From February 20011 to September 2011,
50 consecutive patients without perforation analyzed. Operation
times, postoperative complications, pain scores and time of stay in the
hospital analyzed.
Results: Median age of the patients are 25 (range 17–42) for SILA
group and 27 (range 16–45) for CLA group. The male–female ratio
for SILA is 11/14 and 12/13 for CLA. Operation times and postop-
erative complication rates did not differ between the two groups.
Short-term operative outcomes such as visual analog pain score and
hospital stay were not different. The incision was shorter for SSLA
(19.9 ± 3.8 mm) than for CLA (29.2 ± 4.0 mm) (p \ 0.001).
Conclusion: The results of the current study suggest that SILA is a
feasible surgical alternative to CLA with an equivalent level of safety.
The data also demonstrated that SILA has better cosmetic results than
CLA.
References: 1. Single incision versus conventional multi-incision
appendicectomy for suspected appendicitis (review). The Cochrane
Library. 2011. 2. Single-site versus conventional laparoscopic
appendectomy: comparison of short-term operative outcomes. Surg
Endosc. 2011.
Disclosure: No significant relationships.
O003
LAPAROSCOPY IN SMALL BOWEL OBSTRUCTION:7TH YEARS OF EXPERIENCE
A. Cordovana, R. Paternollo, W. Zuccon, L. Del Re, M. Francese,V. Orvieni, C. Lunghi
General and Emergency Surgery, A. O. Fatebenefratelli, Milan, Italy
Introduction: The main causes of small bowel obstruction (SBO)
are: postoperative adhesions (32 %), tumors (26 %), hernias (25 %),
acute and chronic inflammation of the peritoneum and the ovaries.
The role of laparoscopy in the management of small bowel
obstruction is not universally defined due to very small series pub-
lished with high conversion (22–45 %) and morbidity (4–16 %)
rates.
Materials and methods: Between January 2002 and February 2009
42 patients had laparoscopic surgery for acute SBO. The best results
were reached in the treatment of single band (19 patients) and of
incarcerated inguinal hernias (6 patients). A terminal ileitis in a
Crohn’s disease was identified in one patient who underwent lapa-
roscopic-assisted ileocecal resection.
Results: We had a post-operative complication represented by a case
of peritonitis due to jejunal microperforation.
Conclusion: A strict selection of patients, considering their pre and
intra-operative predictors, is important to reduce complications and to
increase the laparoscopic technique success. Preoperative predictors
are: surgical and medical history, physical examination and radio-
graphic study. Intraoperative predictors that may increase conversion
rate and surgical postoperative complications are the following:
widespread adherence syndrome, bowel diameter [4 cm, operating
time. In this kind of surgery intestinal perforation, laparotomic con-
version and surgical experience are intra and postoperative
complication predictors. In an appropriated selected patient laparo-
scopic management of SBO is a feasible technique and appears to
convey the benefits of a minimally invasive approach.
123
S4 Abstract
References: 1. Wang, et al. Laparoscopic management of recurrent
adhesive small-bowel obstruction: long-term follow-up. Surg Today.
2009;39:493–9.
Disclosure: No significant relationships.
O004
DELAYED LAPAROSCOPY IN NOM FOR BLUNT HEPATICTRAUMA
P. Bisagni, A.A. Beneduce, E. Ortolano, V. Tomajer,M. Carlucci
Emergency and General Surgery, San Raffaele, Milano, Italy
Introduction: Currently most patients with complex liver injuries are
treated with non-operative management (NOM). The availability of
less invasive procedures has expanded the treatment options in these
cases.
Materials and methods: In the series of blunt trauma patients with
grade III–IV and V hepatic injuries elected for NOM, we selected a
subgroup of cases with persistent peritoneal inflammatory response
(fever, abdominal pain, leukocytosis, increased CRP, tachycardia,
hypotension). These patients underwent explorative laparoscopy.
Under general anesthesia, umbilical Hasson trocar was placed. Two
more trocar were placed. After peritoneal cavity exploration for
associated injuries, hemoperitoneum or biliary fluid collections were
aspirated and drainage were placed in the peritoneal cavity. In the
presence of persisting biliary fistula ERCP was the treatment of
choice.
Results: Among the 68 patients with blunt hepatic injuries candidated
to NOM observed in our institution in the last 2 years 15 (22 %) were
admitted for grade III or higher liver injuries. 6 (8.8 %) pts with
peritoneal inflammatory response after day 4 of observation under-
went laparoscopy. Finding were 4 cases biliary contamination (1
abscess) 1 hemoperitoneum, 1 hemoperitoneum associated with small
bowel segmentary infarction due to mesenteric laceration. No major
complications or mortality were observed after these procedures. In 2
cases postoperative ERCP and biliary drainage was needed for per-
sisting biliary fistula.
Conclusion: Delayed laparoscopy in NOM for blunt hepatic trauma
in presence of peritoneal inflammatory response can be considered as
a safe and useful diagnostic and therapeutic tool.
Disclosure: No significant relationships.
O005
EMERGENCY MANAGEMENT OF BENIGN ANALBLEEDING BY DOPPLER GUIDED TRANSANALHEMORROIDAL DEARTERIALIZATION
E. Cavazzoni1, W. Bugiantella1, L. Graziosi1, M.S. Franceschini2,A. Donini1
1Surgery, University of Perugia, Perugia, Italy, 2Radiology,
University of Perugia, Perugia, Italy
Introduction: Acute Anal bleeding form benign lesions such
hemorrhoids can be as dangerous as any other GI bleeding.
Especially due to the high incidence of patients taking antiplatelets
or anticoagulant therapy, anal bleeding can be extremely difficult
to manage nonoperatively or avoiding a treatment of the underlying
disease. Bleeding can also be harmful in patients with an under-
lying anemia. Concurrently, patients with recent coronary disease
or coronary stents shouldn’t interrupt anticoagulant or antiplatelet
therapy since the risk of fatal heart events is consistent. Paradox-
ically, the principal complication of conventional hemorrhoidal
surgical treatment is post operative bleeding, making the thera-
peutical decision more unclear.
Materials and methods: Nine consecutive patients admitted in
emergency for severe anemia and anal bleeding refractory to medical
treatment underwent Doppler guided transanal hemorrhoidal dearte-
rialization (THD) at a single institution.
Results: No major surgical complications occurred, especially
intraoperative or post operative bleeding requiring medical inter-
vention or blood transfusion. Hemorrhoidal bleeding control was
successfully achieved in all cases, as well as other hemorrhoidal
related symptoms. Ongoing antiplatelets therapy was never sus-
pended in patients under such medication. Patient’s overall
satisfaction was elevated, also in relation to a very low post oper-
ative pain.
Conclusion: Acute benign anal bleeding can be difficult to manage
and potentially harmful. THD seems to be an effective and safe
emergency treatment for acute hemorrhoidal bleeding in patients with
severe anemia and associated increased bleeding risk.
References: 1. Pescatori M. Postoperative complications after pro-
cedure for prolapsed hemorrhoids. Tech Coloproctol. 2008;12(1):
7–19. 2. Albaladejo P. Non-cardiac surgery in patients with coronary
stents: the RECO study. Heart. 2011;97(19):1566–72.
Disclosure: No significant relationships.
O006
LAPAROSCOPIC SURGERY IN ACUTE MECHANICALBOWEL OBSTRUCTION DUE TO INTRA-ABDOMINALADHESION
T. Yucel
Dr. Lutfi Kırdar Kartal Research and Training Hospital, Istanbul,
Turkey
Introduction: The most common cause of mechanical intestinal
obstruction in the emergency general surgical clinic is postoperative
adhesion causing obstruction. In recent years, conservative treatment
and laparoscopic surgery are taken into account in these cases.
Materials and methods: Laparascopic adhesiolysis was performed
for 9 out of 74 mechanical intestinal obstruction cases due to
postoperative adhesions at Dr. Lutfi Kirdar Kartal Training and
Research Hospital 2nd surgical clinic between 2005 and 2011 years.
All the patients had the symptoms of acute mechanical intestinal
obstruction and conservative treatment was considered ineffective
after 48 h.
Results: The 2 patients had pfannenstiel incision depending on
gynecological operation. All our laparascopic operations were applied
to 4 port and camera were entered into the left upper quadrant port
Abstract S5
123
openly. In one case acute abdomen was developed at the 3rd day after
operation and perforation at terminal ileum were determined in la-
paratomy. Loop ileostomy was performed. Mean postoperative
hospital stay was 5 (2–9) days and all cases were discharged
uneventfully.
Conclusion: As a result; conservative treatment for mechanical bowel
obstruction caused by adhesions was effective. But, cases that didn’t
respond to conservative treatment, we believed that laparascopic
surgery which is minimal invasive, can be effective and prevent the
new formation of postoperative adhesions.
References: 1. Suter M, Zermatten P, et al. Laparoscopic manage-
ment of mechanical small bowel obstruction. Surg Endosc.
2000;14(5):478–83. 2. Lujan HJ, Oren A, et al. Laparoscopic man-
agement as the initial treatment. JSLS. 2006;10(4):466–72.
Disclosure: No significant relationships.
O007
BEDSIDE LAPAROSCOPIC: AN INSTITUTIONEXPERIENCE OVER 5 YEARS
G. Cocorullo, G. Carollo, M.A. Di Maggio, T. Fontana, G. Gulotta
University of Palermo, Italy
Introduction: The acute mesenteric ischemia (AMI) is an uncommon
but serious disease (12.9/100,000 person-years) that is always asso-
ciated with other systemic disease and with unfavourable prognosis.
The incidence increased exponentially with age, equally distributed
among men and women after adjusting for population age and gender.
Cardiac failure, history of atrial fibrillation, and recent surgery have
all been associated with fatal AMI in particular for patients who
underwent cardiac surgery, as well as patients in ICU that frequently
have a ‘‘low flow’’ syndrome. The acute mesenteric ischemia has a
high mortality (59–93 %), it has a progressive nature, in fact many
AA took a second look after 24–72 h in order to evaluate the intes-
tinal morphology (46.3 %); Data from the literature confirm that a
second look is often negative.
Materials and methods: From January 2006 to October 2011 we
examined 25 patients (18 men and 7 women) aged 57–85 years and
with suspicion of AMI. These patients had already undergone dif-
ferent types of cardiac surgery. 8 of them (32 %) did not show
humoral test or abdominal clinical features suggestive of AMI.
Because of their critical conditions and the technical difficulty to
transport them to the radiology department to have the CT (gold
standard test for the diagnosis of AMI diagnosis), we decided to
perform a BEDSIDE laparoscopic. The bedside laparoscopic
approach is possible when patients are already intubated and in
pharmacological coma; as a matter of fact, with the introduction of
the optical laparoscopic, it allows us to test directly and in a short time
the morphology of the intestine.
Results: In 3 patients the outcome of exploration was negative
(12 %). In 3 other patients (12 %) we saw an initial but massive
ischemia, secondary to a ‘‘low flow’’ syndrome with exitus of the
patients. In 19 patients (76 %) AMI has been diagnosed, and then a
laparotomy was performed followed by the resection of the intestinal
tract involved.
Conclusion: The bedside laparoscopic is possible and safe; it can get
good results in a risk category of patients with a difficult case report
and when the diagnosis is not feasible. The significant reduction of
anesthesiological and surgical trauma makes the ‘‘laparoscopic sec-
ond-look’’ a substitute of the ‘‘surgical second-look’’ in all patients
operated on for AMI or with the risk of developing it. It needs to be
applied more frequently with precise instructions for use.
Disclosure: No significant relationships.
O008
IATROGENIC LESIONS OF BILIARY TRANCT DURINGLAPAROSCOPIC CHOLECYSTECTOMY: REVIEW
C. Puscu1, C. Iorga2, S. Stoian1, P.A. Radu1, M. Bratucu2,D. Garofil1, A. Manta1, G. Orosan1, V.D.E. Strambu2, F. Popa2
1General Surgery, Carol Davila Hospital, Bucharest, Romania,2General Surgery, University of Medicine ‘‘Carol Davial’’ Bucharest,
Bucharest, Romania
Introduction: Iatrogenic injury of the biliary tract have increased in
incidence in the first decade with the introduction of laparoscopic
cholecystectomy It is recognized that the incidence of these lesions is
twofold in laparoscopic surgery versus open surgery (0.4–0.6 vs.
0.2–0.3 %), and their gravity is given by recognition and surgical
difficulties, translated in increased postoperative morbidity and
mortality.
Materials and methods: A number of factors have been identified
with a higher risk of injury (male gender, complicated gallstone
disease, aberrant anatomy) and a number of technical steps have been
emphasized to avoid these injuries. Most accidents are recog-
nized intraoperatively or in the week following laparoscopic
cholecystectomy.
Results: Treatment has two components: conservative (non-surgical)
and surgical. Surgical treatment is reserved for the most severe cases
(lesions Strasberg D or E), and the solution is preferably biliary
reconstruction with a Roux-Y hepaticojejunostomy.
Conclusion: In conclusion, early detection of bile duct injuries
caused by laparoscopy, complete evaluation of the biliary duct, and
appropriate surgical modality and techniques are helpful to improve
the results of repair for laparoscopic bile duct injuries.
Disclosure: No significant relationships.
VASCULAR EMERGENCIES
O009
VERIFICATION OF THE ANKLE-BRACHIAL INDEX (ABI)IN PERIPHERAL VASCULAR TRAUMA
P. Niwawest, P. Wuthisuthimethawee
Department of Emergency Medicine, Songklanagarind Hospital,
Prince of Songkla University, Hat-Yai, Songkhla, Thailand
Introduction: Vascular injury in the lower extremities is common.
The authors propose that the ankle-brachial index (ABI) is a nonin-
vasive and low cost procedure to accurately predict vascular injury in
lower extremities injury.
S6 Abstract
123
Materials and methods: A prospective observational study enrolled
100 adult patients with lower extremities injury for an evaluation of
potential artery injuries using the ABI. Patients with an ABI lower
than 0.90 underwent arteriography or open surgical exploration.
Those with an ABI of 0.90 or higher were admitted for serial
examination for at least 24 h.
Results: Of the 100 patients, 36 patients had a vascular injury. Forty-
nine patients had an ABI lower than 0.90 and 33 patients had an
arterial injury. The remaining 51 patients had an ABI of 0.90 or
higher including 3 patients who had an arterial injury and 1 of these
had a severe muscle injury. The sensitivity of an ABI lower than 0.90
was 91.7 %, specificity was 75 % and the PPV was 67.3 %. The NPV
of an ABI of 0.90 or higher was 94.1 %. The accuracy of an ABI was
81 %. In a subgroup analysis, 18 out of 34 patients who had blunt
injury and 10 out of 15 patients who had penetrating injury had an
ABI lower than 0.90 and had vascular injury.
Conclusion: The ABI is a rapid, reliable, non-invasive procedure for
screening and diagnosis of vascular injury associated with lower
extremities injury. Selective arteriography based on the ABI is safe
and a routine ABI for all patients with lower extremities injury is
recommend.
References: 1. Mills WJ, Barei DP, McNair P. The value of the
ankle-brachial index for diagnosing arterial injury after knee dislo-
cation: a prospective study. J Trauma. 2004;56:1261–5. 2. Johansen
K, Lynch K, Paun M, et al. Noninvasive vascular tests reliably
exclude occult arterial trauma in injured extremities. J Trauma.
1991;31:515–22.
Disclosure: No significant relationships.
O010
ENDOVASCULAR STENTING OF BLUNT THORACICAORTIC INJURY IN MAJOR TRAUMA PATIENTS, UAEEXPERIENCE IN A SINGLE TRAUMA CENTER
N. Balalaa1, A.K. Abbas2, F. Alkwuaiti3, A. Saleh3, B. Safi4
1Surgery, Tawam Hospital, Abu Dhabi, United Arab Emirates,2United Arab Emirates University, ALAIN, United Arab Emirates,3Radiology, Tawam hospital, Alain, United Arab Emirates, 4Vascular
Surgery, Tawam, Alain, United Arab Emirates
Introduction: Blunt traumatic thoracic aortic injury is a life-
threatening condition. Historically, traumatic thoracic aortic rupture
was treated by open repair with or without cardiopulmonary bypass.
The aim of this study is to assess our results of single center
experience of endovascular repair of acute blunt traumatic thoracic
aortic injury.
Materials and methods: This retrospective study was done at Ta-
wam hospital. All patients with blunt thoracic aortic injury were
analyzed from January 2008 to September 2011. All cases were done
by both vascular surgeon and intervention radiologist. The Gore TAG
device was used in all cases.
Results: The total number of patients were seven. The male to female
ratio is 6:1. The mean (±SD) age of patients is 42.4 (25.1). UAE
nationals were 71.4 % compared with 28.6 % non UAE nationals. All
patients were involved in RTC. The mean GCS (range) was 14.9
(14–15). All seven patients (100 %) had spinal fractures, six (85.7 %)
had chest injuries, four (57 %) had pelvic fractures, three (42.9 %)
had abdominal injuries, two patients (28.6 %) had head injuries and
the same (28.6 %) had extremity fractures. The median (range) of
total hospital stay was 21 days (5–50). Endovascular procedure was
technically successful in all patients. Procedural complications 0 %.
The hospital mortality rate was 0 %. Follow up ranged from
10 months to 3 years.
Conclusion: Our data indicate that Thoracic Endovascular Aortic
Repair (TEVAR) is feasible and safe procedure to treat acute trau-
matic thoracic aortic injury. In this less invasive era, TEVAR might
be a promising alternative method to open repair for management of
such serious condition.
Disclosure: No significant relationships.
O011
THORACIC AORTIC RUPTURE: A NEW STERNALROTATION-THORACIC BUCKLING THEORY EXTENDS‘‘MANUBRIAL PINCH’’ TO EXPLAIN AUTOPSIES AFTERSIDE IMPACT. USE IN EARLY CARE AND FE-SAFETYENGINEERING
G.R.S. Treviranus
Psychiatry Psychotherapy Fmh, Practice, Berne, Switzerland
Introduction: Blunt thoracic aortic rupture (TAR) is the discon-
certing second fatal injury. Its mechanism remained elusive as the
retro-manubrial ‘‘osseous pinch’’ of Jeffrey Crass et al. (1992) did not
account for side impacts. Alternative models are discussed from 1893
to 2012.
Within the light-safety-vehicle CH-2000 project (1991 uni/ETHZu-
rich) I privately prepared a thesis which was received only by IAFS
president Wolfgang Bonte, untimely deceased in 2003.
Materials and methods: Among all models—’’fixed arch‘‘ (1893),
‘‘aortic torsion’’ (1906), ‘‘onward-falling heart’’ (1911), pure vertical
deceleration, ‘‘deceleration’’ (1944), ‘‘bending-burst’’ (1955),
‘‘submarining’’ (1967), pressure failure (1980), present ‘‘high-tech-
approaches’’ (2009)—only the surgically evident (Beitzke 1916) and
the ‘‘osseous’’ pinch (Crass 1992) withstood biomechanics.
The sagittal descent of the manubrium not accounting for blunt aortic
injuries both typical and higher by side-impact, a forensic recon-
struction of intra-crash translational and rotatory movements of the
sternum in the literature-cases and those from Zurich forensic institute
disclosed buckling-failures of the thoracic wall leading to the
pinching of the aorta.
Results: The rotatory-buckling approach to TAR accounted for all
injuries from Voigt (1967) and autopsies from the forensic IRM
Zurich by clinically recognizable types.
Conclusion: The key answers in TAR stem from the impact-induced
sternal movements and thoracic wall buckling-collapses during the
descent in the vertebro-costal joints leading to manubrial-vertebral
pinching as the only non-impalement ruptures of the aorta.
References: 1. Crass JR et al. A pro-posed new mechanism of TAR:
the osseous pinch. Radiology. 1990;176:645–9. 2. Voigt GE. Die
Biomechanik stumpfer Brustverletzungen (…). Hefte Unfallheilkd.
1968;96:1–115.
Disclosure: No significant relationships.
Abstract S7
123
O012
IMPROVEMENT IN MANAGEMENT OF TRAUMATICAORTIC INJURY AFTER INTRODUCTION OFA PROTOCOL FOR ATTENDANCE IN TRAUMA PATIENTS
A. Sanchez Canto, V. Padilla Morales, M. Genebat Gonzalez,A.M. Ferrete Araujo, M.A. Munoz Sanchez
Critical Care and Emergencies, Hospital Universitario Virgen del
Rocio, Sevilla, Spain
Introduction: Traumatic thoracic aortic injury (TTAI) is the second
cause of death in trauma patients. Most of these patients (80 %) die in
the actual location of the accident; but of those who survive, up to
50 % die within the next 24 h. Hence, immediate detection and
treatment is mandatory to improve survival related to TTAI. In our
Hospital, a protocol of attendance in trauma patients (PAT) was
started. Thus, the aim of this study was to compare the number of
cases diagnosed with TTAI, the treatment and mortality rates before
and after the introduction of this protocol.
Materials and methods: On January 1st, 2009 the PAT started.
Since then, urgent (\24 h) thoracic endovascular aortic repair
(TEVAR) was performed when indicated (grade III and IV lesions
according to CT scan findings). (1) Pre-protocol period: January
1st 2006–December 31st 2008; (2) Post-protocol period: January
1st 2009–February 28th 2011. All patients where a diagnosis of
aortic trauma and/or endovascular device was registered were
included.
Results: Seventeen cases were recorded: 76.5 % were male, mean age
was 40 years and 64.7 % showed grade III–IV lesions. In the Pre-pro-
tocol period, 6 cases were registered: 3/6 (50 %) died while 2/6 (33.3 %)
were treated with non-urgent TEVAR. In the post-protocol period 11
cases were registered: 5/11 (45.4 %) were treated with urgent TEVAR,
4/11 (36.4 %) with non-urgent TEVAR; no deaths were observed.
Conclusion: Since the introduction of PAT: a greater number of cases
were detected, urgent TEVAR has increased and the survival of
trauma patients related to TTAI has improved.
Disclosure: No significant relationships.
O013
This abstract was moved to ‘‘Visceral Trauma II’’.
O014
LONG TERM RESULTS AFTER STENT GRAFTPLACEMENT DUE TO ACUTE TRAUMATIC THORACICAORTIC LESIONS
F. Domaszewski1, J. Dumfarth2, M. Greitbauer1, D. Zimpfer3,P. Stampfl1, M. Schoder4, M. Funovics4, J. Lammer4, M. Grimm2,M. Czerny5, S. Hajdu1, G. Laufer3, M. Ehrlich3
1Traumatology, Medical University Vienna, Vienna, Austria,2Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria,3Cardiac Surgery, Medical University Vienna, Vienna, Austria,4Cardiovascular and Interventional Radiology, Medical University
Vienna, Vienna, Austria, 5Cardiac Surgery, Insel Hospital Berne,
Berne, Switzerland
Introduction: Technological developments have influenced the
diagnostic and therapeutic strategies in case of traumatic thoracic
aortic lesions. The aim of this study was to evaluate long-term results
after thoracic endovascular aortic repair (TEVAR) for acute traumatic
aortic injury.
Materials and methods: From June 1993 to May 2009 a total
number of 32 patients (28 men, mean age 43.9 years) were admitted
with acute traumatic thoracic aortic lesions. All patients sustained
blunt deceleration trauma. Hemodynamically unstable patients with
active intrathoracic hemorrhage underwent immediate thoracotomy.
Multislice CT-angiography was performed in all hemodynamically
stable patients.
Results: Emergency thoracotomy was performed in seven patients.
Mortality in this group was 100 %. Conservative treatment was
chosen for 3 patients, conventional open surgery for 7 patients. TE-
VAR developed to be the predominant treatment method in recent
years, especially in patients not suitable for surgery due to other
injuries. TEVAR was performed successfully in 15 patients without
method-related complications.
Conclusion: TEVAR has emerged as an innovative and minimally
invasive therapeutic option in this polytraumatic high-risk patient
cohort with excellent aortic-related survival. Although long term
durability could be proven, all patients should remain in life-long
surveillance.
Disclosure: No significant relationships.
O015
INSTABLE PELVIS FRACTURES WITH VASCULARINJURY
N.N. Tzachev1, A. Baltov2, N. Mladenov3
1Orthopaedic and Traumatology, Military Hospital, Sofia, Bulgaria,2Orthopaedics and Trauma, Military Hospital, Sofia, Bulgaria, 3Karil,
Military Hospital, Sofia, Bulgaria
Introduction: Unstable pelvic fractures result in high mortality.
There is no standard technique to control pelvic blood loss. Damage
control is of prime importance in treatment of unstable pelvic
fractures.
Materials and methods: We use the data of 10-year-period of
treatment of 25 patients with polytrauma and unstable pelvic fractures
treated according to an algorithm focusing on basic radiologic diag-
nostics, external fixation or C-clamp, and early angiographic
embolization. Study variables included demographics, data on the
type of fractures and other injury, pelvis damage control, complica-
tions of angiography, hemotransfusion and outcome.
Results: Three patients underwent angiographic embolization before
computed tomography scan. Applying the clinical algorithm, pelvic
hemorrhage was controlled in all but one patient who died before any
intervention could be initiated. The hourly need for red blood cell
transfusions decreased during 24 h after application of external fix-
ation or C-clamp and angiographic embolization when compared with
before the procedure. This is of prime importance for keeping the
damage control of the patient. The mean time for embolization was
45 min. One patient required reembolization because of hemorrhage
of osteosynthesis de bricolage. One patient developed gluteal
necrosis.
S8 Abstract
123
Conclusion: Application of a clinical algorithm focusing on basic
radiologic diagnostics, external fixation or C-clamp, and early
angiographic embolization was effective and safe to rapidly control
hemorrhage in hemodynamically instable trauma patients with pelvic
fractures.
Disclosure: No significant relationships.
O016
MIDTERM CLINICAL OUTCOMES OF VASCULARREPAIRS IN SUPRACONDYLAR HUMERAL FRACTURESIN CHILDHOOD
O. Tunalı1, Y. Saglam1, G. Dikmen1, M. S. Aksoy2, T. Akgul3,F. Dikici1
1Orthopedics and Traumatology, Istanbul University Faculty of
Medicine, Istanbul, Turkey, 2Vasculer Surgery, VKV American
Hospital, Istanbul, Turkey, 3Orthopedics and Traumatology, Sanlıurfa
Training Hospital, Sanlıurfa, Turkey
Introduction: Incidence of vascular injuries with pediatric supra-
condylar humeral fractures has been reported, 2–11 %. The purpose
of the study is to describe midterm clinical outcomes of vascular
repairs in supracondylar humeral fractures with vascular injuries.
Materials and methods: We reviewed 418 severely displaced
supracondylar humeral fractures in children treated over the last
8 years in single center and identified 7 patients (1.6 %) who
presented with suspected vascular injury. The mean age was
9.8 years (6–12). Vascular exploration was performed in all
patients detected vascular injury. Fixation of the fracture was
performed with smooth Kirschner wires. Prophylactic fasciotomy
was performed after vascular repair in 5 patients. Autologous
saphenus vein was used in all patients for vascular reconstruction.
The elbow was immobilized with plaster splint for 4 weeks. Wires
removed at 5–6 weeks postoperatively. At the last control, clinical
outcomes were evaluated by measuring range of motion, elbow
deformity and distal neurovascular status compared with the con-
tralateral side.
Results: The mean follow-up was 3.5 years (range 1.5–7). The
mean mangled extremity severity score (MESS) was 5 (range
4–7). Complications were by-pass graft thrombosis, soft tissue
contracture at antecubital fossa. We have no neurological com-
plication. At the last follow-up, mean flexion motion of the elbow
was 125; (range 80–135), the mean extension deficit was 10;
(range 5–15). We did not observe any elbow deformity in
radiological examination.
Conclusion: Early vascular exploration must be performed when the
patient still have suspected vascular injury after immediate reduction
in supracondylar humeral fracture. Prophylactic fasciatomy may
prevent long-term disabilities.
References: 1. Copley LA, Dormans JP, Davidson RS. Vascular
injuries and their sequelae in pediatric supracondylar humeral frac-
tures: towards a goal of prevention. J Pediatr Orthop. 1996;16:
99–103.
Disclosure: No significant relationships.
LARGE SCALE CHEMICAL EVENTS
O017
ADVANCED TRAUMA LIFE SUPPORT IN SLOVENIA:A NEW MODEL FOR IMPLEMENTATION GUIDED BYATLS EUROPE
R. Kosir1, B. Winter2, J. Kortbeek3, K. Brasel4, I. Schipper5
1Department For Traumatology, University Clinical Center Maribor,
Maribor, Slovenia, 2Adult Critical Care, Queens Medical Centre,
Nottingham, UK, 3Department of Surgery, Foothills Medical Centre,
Calgary, Canada, 4Department of Surgery, Medical College of
Wisconsin, Milwaukee, WI, USA, 5Surgery and Traumatology,
Leiden University Medical Center, Leiden, The Netherlands
Introduction: Advanced Trauma Life Support (ATLS�) represents a
standard way of initial poly-trauma care. ATLS courses have been
implemented in more than 60 countries worldwide. The ATLS
concept was developed and introduced by the American College of
Surgeons (ACS) in 1980. ATLS� teaches one safe way of initial
trauma care. The program’s vision is to promote a common lan-
guage and approach for the initial care of trauma patients.
Implementation of the program outside North America has required
extensive training of physicians from abroad travelling to the United
States and visits of ACS members to new member countries. This
was associated with significant expenses. The objective of this
presentation is to describe the system and costs of promulgation of
ATLS in Europe, following the establishment of the medical asso-
ciation of ATLS Europe.
Materials and methods: We describe the policies and processes
regulating promulgation of ATLS in Europe since 2006. The promul-
gation of ATLS in Slovenia in 2010 serves as example for cost analyses.
Results: ATLS Europe was established in 2006 and membership now
includes 16 European countries. Slovenia has participated in pro-
mulgation since 2006 and implemented ATLS in 2010. Since 2006
the ATLS Europe promulgation committee organizes and coordinates
introduction of ATLS for new member countries within Europe.
Leadership and training by ATLS Europe members has significantly
reduced minimal promulgation costs by more than one-third.
Conclusion: The novel approach of ATLS implementation, as sup-
ported and organized by the ATLS Europe promulgation committee,
facilitates ATLS implementation and reduces costs for European
countries.
Disclosure: No significant relationships.
O018
EFFECT OF HELICOPTER EMERGENCY MEDICALSERVICES (HEMS) CARE IN A COHORT OF 1,073POLYTRAUMATIZED PATIENTS
G.F. Giannakopoulos1, M.N. Kolodzinskyi1, H.M. Christiaans2,C. Boer2, E.S. De Lange-De Klerk1, W.P. Zuidema1, F.W. Bloemers1,F.C. Bakker1
Abstract S9
123
1Trauma Surgery, VU University Medical Centre, Amsterdam,
The Netherlands, 2Anesthesiology, VU University Medical Centre,
Amsterdam, The Netherlands
Introduction: To assess the effect of HEMS on the outcome of a
large polytraumatized (ISS C16) cohort.
Materials and methods: All polytraumatized patients treated at the
scene of the accident by EMS and/or HEMS, and transported to our
level-1 trauma centre during a period of 6 years were included and
retrospectively analyzed. Patients were divided in two groups
according to the presence of HEMS on-scene. Prehospital, inhospital
and outcome parameters were compared. The TRISS method was
used to calculate the probability of survival.
Results: Almost 40 % of all included patients (n = 446) received
additional HEMS care on-scene. Significant differences were seen in
demographic characteristics, showing that the HEMS-group was more
severely injured. The predicted survival was calculated using the
TRISS method, as well as the observed survival, both showing a
significantly higher outcome for the EMS group (0.88 vs. 0.66 and
87.7 vs. 71.3 %). Per 100 HEMS-dispatches, 5.4 additional lives were
saved. A correlation of the observed survival with the first measured
RTS on-scene showed a positive effect for the HEMS group when the
RTS reaches a value of 9 or lower.
Conclusion: On-scene HEMS care has a positive effect on the sur-
vival of polytraumatized patients, saving 5.4 additional lives per 100
HEMS deployments. This positive effect is especially seen in patients
with abnormal vital signs. Research and revision of dispatch criteria
are important in order to reach patients that benefit most form HEMS
care.
Disclosure: No significant relationships.
O019
TRANSFUSION POLICY AND REQUIREMENTS DURINGCIVILIAN BOMBING ATTACKS IN ISRAEL
M. Bala1, A. Kedar1, O. Zelig2, A. Rivkind1, M. Faroja1, G. Almogy1
1General Surgery, Hadassah-Hebrew University Medical Center,
Jerusalem, Israel, 2Blood Bank, Hadassah-Hebrew University
Medical Center, Jerusalem, Israel
Introduction: Knowledge of patterns of blood use in the care of mass
casualty settings is important for preparedness of medical center
resources, for maximizing survival when blood supplies are limited.
Materials and methods: 17 suicide terrorist bombing attacks which
were carried out in Jerusalem during the 5 year period were analyzed.
The study group consisted of 137 patients. Sixty-eight victims
(52.7 %) were injured inside a bus, 36 (27.3 %) in a semi-confined
space such as a restaurant, and 33 (20 %) in an open space.
Results: On arrival 946 units of blood were ordered for 79 patients
(58 %). A total of 524 PRBC units, 42 whole blood (WB) units, and
449 fresh frozen plasma units (FFP) were transfused to 53 patients
(39 %). Thirty patients (22 %) required transfusions at the first 2 h.
Massive transfusion was required in 14 patients (26.4 % of all
required transfusions). This group mortality was 35.7 %. The average
number of units infused was 28.5 per patient (range 10–59). These
patients also consumed 361 units FFP (80.4 % of total units infused)
72 platelets (84.7 % of total units infused) and 58 units Cryo (84.1 %
of total units infused).
The FFP to PRBC ratio was 1:2.1 in first 2 h (in 10 patients who
received FFP) and increased to 1:0.7 by the first 24 h.
Conclusion: More than 1/3 of mass casualties admitted following
civilian bombing attacks required transfusions, most in the first hours.
Twice blood products ordered than transfused reflects a known trend
for overtriage during initial assessment of victims of bombing attacks.
Disclosure: No significant relationships.
O020
ANALYSIS OF THE TWO MASS CASUALTY INCIDENTSAND EFFECT OF TRAINING FOR THEM
S. Herman
Traumatology, University Clinical Centre Ljubljana, Ljubljana,
Slovenia
Introduction: In the last 10 months there were 4 major incidents (MI)
in Slovenia involving multiple casualties. All were traffic accidents—
one railroad and three road crashes! MRMI (Medical Response in
Major Incidents) training in Slovenia follows MACSIM system for
training. Comparison of training and real situation is analysed.
Materials and methods: Two road crashes are analyzed with special
emphasis on hospital preparedness and training and actual reorgani-
sation during each incident.
Results: In the first incident (pile-up crash) there were 27 injured, 2
dead on scene and one later in hospital, 2 resuscitation victims and
further 8 heavily injured (3 required emergency surgery). In the
second incident (bus crash) there were 30 casualties, all were for-
eigners: 26 minor foreign children and 4 adults. No resuscitations, 3
needed (all of the multiple) emergency surgeries. Following guide-
lines for MACSIM training, hospital went on green alert. Staff
training proved valuable, but the hospital still lacks command room
for such occasions. In the first accident communication was only one
way (scene to ERl). Media coverage was huge, using PR staff proved
invaluable. The alarm ended in the first case 10:48 h and second after
7:40 h after the time of the crash. Remarkably government authorities
didn’t include hospital part of the response into their evaluation!
Conclusion: Training proved valuable, adopting infrastructure as
suggested in MACSIM would benefit even more. Government
authorities should realize that an intervention doesn’t end when scene
is cleared up!
References: 1. Lenquist S. Medical response to major incident and
disasters. Berlin: Springer; 2012.
Disclosure: No significant relationships.
O021
EVALUATION OF THE EMERGENCY MEDICAL SERVICESIN GREECE; REVEALING ASPECTS OF A MATURINGSYSTEM
I. Pappa1, D. Pyrros2, S. Stergiopoulos2, P. Vasilliu2
1General Surgery, Nathional & Kapodistrian University of Athens,
Athens, Greece, 2Attikon University Hospital, National and
Kapodistrian University of Athens, Greece, Athens, Greece
Introduction: The purpose of this study is the evaluation of the
Emergency Medical Services (EMS) system in Athens, Greece.
Materials and methods: Data were collected over a representative
month, March 2005.
Results: The analyses show that 90 % of the emergency calls do not
actually require immediate response. The median time required for
S10 Abstract
123
ambulance arrival to the scene was found to be 22 min and should be
improved. The uneven arrival times of ambulances among the various
territories of major urban Athens district, categorize rapid and slow
arrival areas. Our data reveal an unconceivable high cost of function
of ambulance transportation, mainly by maintaining active but
unnecessary personnel.
Conclusion: To our knowledge, this is the first official effort to light
upon the shortcomings of Helenic EMS system and suggest essential
solutions.
References: 1. Gonzalez RP, et al. Am J Surg. 2009;197:30–34. 2.
Harrington DT, et al. Ann. Surg. 2005;241(6).
Disclosure: No significant relationships.
O022
MILITARY MODEL OF DISASTER RELIEF HOSPITAL INBAM BY INDIAN ARMY FIELD HOSPITAL
H.C. Talan
Orthopaedic, primus hospital, ABUJA, Nigeria
Introduction: Earthquake stuck Bam in 26th Dec 2003 at 05:30 h at
6.5 Richter scale for 12 s. Disaster resulted 30,000 deaths and 41,000
injured. All health facilities were destroyed. Govt. of India established
field hospitals in Bam, IRAN under WHO supervision. AIM was to
establish 75 bedded Hospital to provide medical aid to earthquake
victims and to study the lesson learnt from disaster management.
Materials and methods: 75 bedded hospital was established in
tentage accommodation. There was no electricity and water supply.
With the help of genset and water trailor hospital was established.
There were 76 Army personnels including 2 General Surgeon, 2
Orthopaedic Surgeon, 2 Anaesthesists, Medical specialists, Paedia-
trician, Radiologist and paramedical staff, all sent by 5 IL-76
transport plane along with medical equipment, to establish self con-
tained hospital. One day all the tents were destroyed by storm and
trade container were modified to establish the hospital. SOPs for
standard protocol was established.
Results: 2 Surgical team and 1 Medical team were organised as quick
relation team. Total OPD in 3 months was more than 50,000. Admission
of 609 patients, Emergency 207, Total major and minor surgery 503, of
which 307 were major surgeries, Gen surgery 112, Orthopaedic surgery
195. Maximum number of disaster patients were in first 2 weeks.
Conclusion: Disaster team established field hospital which provided
emergency care in first 2 weeks later on rehabilitation of earthquake
victims. Team learnt many health lessons for improvement of disaster
management.
Reference: 1. WHO Communique April 2004. Disaster in Bam
IRAN.
Disclosure: No significant relationships.
O023
AEROMEDICAL EVACUATION FOR TRAUMA PATIENTSIN THAILAND: A 3-YEAR EXPERIENCE FROM BANGKOKHOSPITAL MEDICAL CENTER
E. Surakarn
Trauma Center, Bangkok Hospital Medical Center, Bangkok Hospital
Group, Bangkok, Thailand
Introduction: Aeromedical evacuation is a fast and effective mode of
patient transport. Trauma patients in remote area who need definitive
surgical care can be benefited from short on-the-way time and
appropriate in-flight medical care. Air ambulance is not widely used
in Thailand due to limited resource, and is not considered to be a
standard mode of medical transport. We report result of aeromedical
evacuation service for trauma patients provided by Bangkok Hospital
Medical Center.
Materials and methods: Data of trauma patients transferred by air
ambulance during 2008–2010 was reviewed. In-flight medical care
were provided by flight physicians and flight nurses. On-the-way
mortality and time to definitive surgical treatment were analyzed.
Results: 132 trauma patients were successfully transferred by air
evacuation from referring hospitals for higher level of care in
Bangkok. 87 cases were transferred by fixed-wing aircrafts. 45 cases
were transferred by helicopter. 60 cases needed endotracheal intu-
bations with ventilatory supports. 7 cases needed intercostal
drainages. Fluid resuscitation, immobilization, sedation and pain
control were provided. No on-the-way mortality. Critical care and
definitive surgical treatment for major trauma patients can be deliv-
ered in first 24 h after admission to receiving hospital.
Conclusion: Aeromedical evacuation of trauma patients with
appropriate in-flight medical care is feasible and safe. It is an
important link of trauma system in Thailand where definitive trauma
care is not always accessible from remote areas.
References: 1. McVey J. Air versus ground transport of the major
trauma patient: a natural experiment. Prehosp Emerg Care.
2010;14(1):45–50. 2. David L. Aeromedical evacuation of the trauma
patient. Trauma. 1999;1(1):12–22.
Disclosure: I am a flight surgeon in Department of Aviation Medi-
cine, Bangkok Hospital Medical Center.
O024
MORTALITY IN A RURAL TRAUMA SYSTEM: ANEVALUATION OF INTER-FACILITY TRANSFERS
S.E. Greer, P. Kispert, R. Gupta
Section of General Surgery, Dartmouth Hitchcock Medical Center,
Lebanon, NH, USA
Introduction: Injury related mortality is higher in rural areas com-
pared to urban for similar severity scores. Prolonged time to definitive
care is a significant contributing factor. The hypothesis of this study
was that delays in time to request transfer result in higher mortality
rates.
Materials and methods: A retrospective analysis was performed
with concurrently collected trauma and transport registry data of
patients arriving by air medical transport at a rural Level I trauma
center. Data abstracted include time to request transfer (TRT), time to
definitive care (TDC), age, ISS, GCS, and mortality. Negative TRT
numbers reflect request prior to patient arrival at referring hospital
based on scene EMS patch. Statistical analyses were performed using
Fisher’s exact test or Student’s t test.
Results: In 528 patients, the mean TRT was 66 min and mean TDC
was 186 min. Mortality was significantly higher in patients with TRT
\1 h compared to TRT[1 h (13.2 vs. 5.3 %, p = 0.015). There was
no difference in mortality in patients with TDC \3 h compared to
TDC[3 h (12.9 vs. 8.2 %, p = 0.25). ISS was similar between these
groups. TRT was significantly shorter in patients with GCS = 3–12
(45.1 min) compared to patients with GCS = 13–15 (79.9 min,
Abstract S11
123
p = 0.0002). Mortality remained significantly higher in the TRT\1 h
group when head injury was excluded (8.7 vs. 2.3 %, p = 0.03).
Conclusion: Mortality was higher when time to request transfer was
shorter. However, there was no difference in mortality with shorter
time to definitive care. In a maturing trauma system, this suggests an
early recognition of the critically injured patient, with or without head
injury, at referring hospitals.
Disclosure: No significant relationships.
NEUROTRAUMA
O025
THE NEUROPROTECTIVE EFFECTS OF RILUZOLE IN THEEXPERIMENTAL TRAUMATIC BRAIN INJURY IN RATS
H. Ozeveren1, H.Z. Toklu2, S. Arbak3, Z. Berkman4, S. Kemaloglu1
1Neurosurgery, Dicle University Medical Faculty, Diyarbakir,
Turkey, 2Farmakoloji, Marmara Universitesi Eczacılık Fakultesi,
Istanbul, Turkey, 3Histopathology, Marmara University Medical
Faculty, Istanbul, Turkey, 4Neurosurgery, Haydarpasa Egitim
Arastırma Hastanesi, Istanbul, Turkey
Introduction: One of the underlying mechanisms of traumatic brain
injury is thought to be the oxidative damage due to the generation of
free radicals. Riluzole, a glutamate release inhibitor, has been shown
to have neuroprotective effects in several animal models. The aim of
our study was to investigate the putative protective effect of riluzole
against trauma-induced brain injury.
Materials and methods: The groups were: control (sham), riluzole
(6 mg/kg, i.p.), trauma and trauma + riluzole (6 mg/kg, i.p.), 2 days
after brain injury, neurological examination scores were measured
and animals were decapitated and the brain tissues were taken for the
histologic and biochemical evaluations. Brain edema, blood–brain
barrier (BBB) permeability were evaluated by wet-dry weight method
and Evans blue (EB) extravasation respectively.
Results: The neurological examination scores mildly increased in
trauma groups 2 days after the induction of trauma. Although the
scores were decreased in the riluzole treated group, they were still
significantly higher than the control. The trauma caused a significant
increase in brain water content and Evans blue (EB) extravasation.
Riluzole treatment reduced BBB permeability but not to influenced on
brain edema. It also decreased MDA and MPO activity.
Conclusion: According to the results of this study, riluzole appears to
have a protective effect for TBI-induced oxidative stress, of the brain.
References: 1. Toklu HZ, Uysal MK, et al. The effects of riluzole on
neurological, brain biochemical, and histological changes in early and
late term of sepsis in rats. J Surg Res. 2009;152(2):238–48.
Disclosure: No significant relationships.
O026
SERUM CLEAVED-TAU PROTEIN AND CLINICALCORRELATION WITH TRAUMATIC MILD HEAD INJURY;PRELIMINARY STUDY IN THAI POPULATION
P. Wuthisuthimethawee
Emergency Medicine, Prince of Songkla University, Hat-Yai,
Thailand
Introduction: Head injury is the one of most common emergency
department presentations of traumatic patients. Currently, the diag-
nosis is based on indirect measurements of nerve cell pathology from
the history and Glasglow coma scale score (GCS). The objective is to
determine the correlation of serum cleaved-tau protein in mild trau-
matic head injury (GCS 13–15) patients.
Materials and methods: Blood specimens from 12 healthy persons
and 44 adult patients with traumatic mild head injury (MHI) were
collected at the emergency department to measure the cleaved-tau
protein level by using the Anti-Tau phosphoSerine 396 kit. A brain
CT scan was done on all patients. The serum cleaved-tau protein level
was positive at a cut-off point of 0.1 pg/ml. An intracranial lesion was
defined by any abnormality detected by the brain CT scan.
Results: The mean age of traumatic MHI patients was 34.9 ± 15.6
years old (15–74). The median GCS was 15. The median time of
injury to arrival at the emergency room was 30 min. There were 11
intracranial lesions detected by brain CT scan (33.3 %). The serum
cleaved-tau protein could not be detected either in healthy or trau-
matic mild head injury patients.
Conclusion: Without correlation with traumatic MHI, the serum
cleaved-tau protein was unreliable in early detection and decision
making in traumatic MHI patients at the emergency department.
References: 1. Shaw GJ, Jauch EC, Zemlan FP. Serum cleave tau
protein levels and clinical outcome in adult patients with closed head
injury. Ann Emerg Med. 2002;39(3):254–7.
Disclosure: No significant relationships.
O027
NEUROPROTECTIVE EFFECTS OF SILDENAFIL ONEXPERIMENTAL TRAUMATIC BRAIN INJURY ON RATS
C. Gocmez1, S. Ercan2, S. Kemaloglu1, A. Aktas1, O. Evliyaoglu1
1Neurosurgery, Dicle University Medical Faculty, Diyarbakir,
Turkey, 2Neurosurgery, Dicle University, Diyarbakir, Turkey
Introduction: We aimed to examine the protective effects of silde-
nafil on traumatic brain injury (TBI) with histopathological and
biochemical parameters. By the primer injury which effects the
morbidity, and mortality of TBI, the secondary injuries as posttrau-
matic biochemical cascades, ischemia, and hypoxia are important.
Sildenafil released the vasodilatation by relaxing the smooth muscle
of systemic arterial and venoses. The neuroprotective effects of sil-
denafil are unknown.
Materials and methods: 21 Sprague Dawley rats were separated into
3 groups (n = 7). ‘‘The weight drop injury model’’. Group 1: non-
traumatic Saham group, Group 2: non-treated TBI group, Group 3:
sildenafil (100 mg/kg) treated TBI group. The whole brain and serum
were collected for histopathological and biochemical study. The
histopathological sections were examined under light microscope.
Results: The compare of total antioxidant status (TAS), total oxidant
status (TOS), Nitric oxide (NO), and Plasma nitrite/nitrate (PNOx)
between groups, NO level was significantly high in group 3
(p = 0.013). Even though the TAS level was significantly high in
group 3 (p = 0.02), there was no significantly differences of TOS
level in groups (p = 0.225). Disappearing Nissl granules, occurred
picnotic situation in cell nucleus, and acidophilic staining in neuron
cells, which describe the neuron degeneration were observed in
trauma group. The neuron degeneration markers were not seen in
sildenafil treated trauma group.
Conclusion: Our study has showed that sildenafil decrease the oxy-
gen radicals and effects the recovery on experimental TBI in rats.
S12 Abstract
123
Reference: Al-Saeedi FJ. Perfusion scanning using 99mTc-HMPAO
detects early cerebrovascular changes in the diabetic rat. BMC Med
Phys. 2008;8:1.
Disclosure: This study has been financed by Dicle University sci-
entific support action source.
O028
TELEMEDICINE FOR ACUTE NEUROSURGICALPROBLEMS: CLINICAL EXPERIENCE FROM A SINGLECENTRE IN THE HORN OF AFRICA
R. Dulou1, A. Montcriol2, A. Bertani3, C. Brevart4, F. Rongieras5
1Neurosurgery, Military Academic Hospital VAL DE GRACE,
PARIS, France, 2Anesthesiology and Intensive Care Unit, Military
Academic Hospital STE ANNE, TOULON, France, 3Orthopedic and
Trauma Department, HMC BOUFFARD, Djibouti, ARMEES,
France, 4HMC BOUFFARD, Djibouti, ARMEES, France,5Orthopedic and Trauma Surgery, Military Academic Hospital
DESGENETTES, Lyon, France
Introduction: We present our initial experience as a general-surgical
group managing acute neurosurgical patients by telemedicine in order
to cope with the absence of a neurosurgical unit in the Republic of
Djibouti.
Materials and methods: Selected CT images from patients with
acute neurosurgical diagnoses were captured by standard camera
and forwarded in JPEG format via internet to a neurosurgical unit
for consultation. This was accompanied by a telephone conference.
One of four possible management decisions was then chosen: (1)
observation only; (2) transfer to a neurosurgical centre; (3) orga-
nization of a neurosurgical mission to Djibouti; (4) surgery by non-
neurosurgeons.
Results: There were 28 neurosurgical cases during a 24-month
period (november 2009–november 2011). Observation was chosen
for eleven (39 %), and seventeen (61 %) required surgery. Fifteen of
these were operated in Djibouti: 10 by general surgeons and 5 by a
neurosurgeon from a mobile neurosurgical unit. One patient refused
surgical intervention, and one was transferred to a nearby country
for neurosurgery. In all cases telemedicine facilitated diagnostic
confirmation and guided non-neurosurgeons to safely perform spe-
cific operations in ten (36 %). Five patients (18 %) died, 2 after
surgery.
Conclusion: These results suggest that telemedicine dramatically
improves quality of management of neurosurgical cases by non-
neurosurgeons by facilitating more accurate diagnoses and providing
specific guidance for operations performed by non neurosurgeons.
These were straightforward, life-saving procedures including intra-
cranial hematomas, depressed skull fractures, and abscesses.
Moreover, we believe that general surgeons deployed to such remote
areas should receive additional training in a specific list of such
neurosurgical procedures.
Disclosure: No significant relationships.
O029
This abstract has been withdrawn.
O030
CRANIOCEREBRAL GUNSHOUT WOUND
U. Ozkan1, S. Kemaloglu2, S. Ercan2, K. Kamasak2, C. Gocmez2
1Neurosurgery, Dicle University, Medical Faculty, Diyarbakir,
Turkey, 2Neurosurgery, Dicle University Medical Faculty,
Diyarbakir, Turkey
Introduction: Gunshot wounds (GSWs) to the head are the most
lethal of all gunshot wounds, and most patients do not survive to
see a neurosurgeon. Assault, suicides and accidents are the three
causes of gun shout wound to the head. It has been frequent to see
the crimes related of civilian gun shot wounds. In this study,
neurological damage related to gun shot wounds to the head, other
organ wounds, surgery, and other related complications has been
observed.
Materials and methods: Between 1993 and 2011, 186 patients who
has gun shot wounds applied to neurosurgery department at Dicle
University Medical Faculty and were treated at the same facility. A
retrospective statistical analysis of the medical records of the
patients in our series was performed to determine the risk factors
for the onset of complications, which have unfavorable effects on
outcomes.
Results: 186 patients (124 male, 62 female) were treated. The aver-
age age was 28. Diffuse brain injury caused the major deaths, (62 %)
in our patient group. Also the sites of cranial penetration were iden-
tified. Postoperative complications often dictated a fatal outcome in
our patients were identified. The microorganism most encountered
was Staphylococus epidermidis.Conclusion: A selective treatment policy is recommended for
patients with GCS 3–5. Early aggressive resuscitation, surgery and
vigorous control of intracranial pressure offers the best chance of
achieving outcome. Water tight dural closure, debridement, removal
of all foreign materials reduce complication rates and exerts favorable
effects on outcome.
Disclosure: No significant relationships.
O030A
RESPIRATORY FAILURE DURING ED-TREATMENT OFELDERLY PATIENTS WITH ISOLATED TRAUMATICBRAIN INJURY PREDICTS POOR OUTCOMES
M. Hofbauer, M. Winnisch, L.L. Hochtl, R. Ostermann, R. Kdolsky
Department of Trauma Surgery, Medical University Vienna, Vienna,
Austria
Introduction: Although several prognostic models have been
developed to predict outcome for patients with severe traumatic brain
injury (TBI), currently no study describes the impact of respiratory
failure during Emergency Department treatment on mortality in
elderly patients. The purpose of the present study was to outline the
role of respiratory failure on mortality in elderly patients with isolated
severe TBI and determine whether a decline of the respiratory failure
is a reliable predictor for poor outcome.
Abstract S13
123
Materials and methods: All elderly patients (age C65 years) with
isolated severe head injury, admitted to an urban Level I trauma
center, during a period of 16 years (from January 1992 to December
2008) were identified from the trauma registry. Stepwise logistic
regression analysis was used to identify risk factors for a poor
prognosis and outcome.
Results: The logistic regression found following variables influencing
the mortality: respiratory failure (p \ 0.0005, OR 9.369), pupillary
response (p \ 0.0212, OR 3.393) and ISS score (p \ 0.0001, OR
1.179). A significant (p \ 0.0001) larger risk of death was also found
for patients with midline shift [15 mm.
Conclusion: Our study shows a strong correlation between respi-
ratory failure, pathological pupil response and substantial midline
shift, and poor outcomes in elderly patients with isolated severe
TBI.
Reference: Demetriades D, Kuncir E, et al. Mortality prediction of
head Abbreviated Injury Score and Glasgow Coma Scale: analysis of
7,764 head injuries. J Am Coll Surg. 2004;199:216–22.
Disclosure: No significant relationships.
O031
LONG-TERM OUTCOME IN POLYTRAUMATIZEDPATIENTS WITH VERSUS WITHOUT BRAIN INJURY
T. Gross1, M. Schuepp2, C. Attenberger3, H. Pargger2, F. Amsler3
1Traumatology, Kantonsspital Aarau, Aarau, Switzerland,2Anaesthesiology, University Hospital Basel, Basel, Switzerland,3Carcas, University Basel, Basel, Switzerland
Introduction: Knowledge is lacking on the longer-term outcome in
patients following polytrauma depending whether or not brain injury
is involved. This pilot study on a prospective series of 211 consec-
utive polytrauma patients (injury severity score, ISS [16)
investigated potential discriminators in the characteristics and quality
of life (QoL) between patients with (TBI) and without (NTBI) major
traumatic brain injury.
Materials and methods: Uni- and multivariate testing of pro-
spectively collected data (patient, trauma, treatment characteristics,
and functional outcome variables [2 years following injury) was
conducted and revealed 170 multiply-injured patients who sur-
vived (30-day mortality, 18.0 %) at median 2.5 years following
trauma, of whom 111 patients (39.5 ± 20.9 years; ISS 27.9 ± 8.2;
TBI: n = 45; NTBI n = 66) participated in this longer-term
investigation.
Results: Significantly fewer TBI patients (71 %) lived independently
compared to NTBI patients (95 %; p = 0.003). Stepwise logistic
regression analysis demonstrated a significant association of TBI
survivors as being smokers, presenting a worse Trauma and Injury
Severity Score, Simplified Acute Physiology Score II score, and
undergoing a shorter hospital resuscitation time until first computed
tomography (p = 0.004). Among scores tested, the mental component
of the Short Form (SF)-36 discriminated best between TBI- and
NTBI-patients (p = 0.001), demonstrating a significantly reduced
QoL in TBI survivors.
Conclusion: This investigation found several major differences in the
characteristics and longer-term outcome between polytraumatized
patients with and without TBI. Both, patients with and without TBI
suffer from a reduction in quality of life, but TBI patients are doing
even worse.
Disclosure: No significant relationships.
DIAPHRAGMATIC INJURIES
O032
COLONIC STENTING AS A BRIDGE TO SURGERYREDUCES MORBIDITY AND MORTALITY IN LEFT-SIDEDCOLORECTAL CANCER OBSTRUCTION (LCCO):A PREDICTIVE RISK SCORE-BASED COMPARATIVESTUDY
F. Coccolini1, V. Cennamo2, F. Catena3, C. Vallicelli3, E. Poiasina1,S. Magnone1, R. Manfredi1, M. Pisano1, M. Giulii Capponi1,L. Ansaloni1
1General and Emergency Surgery, Ospedali Riuniti, Bergamo, Italy,2Gastroenterology Dept., Bellaria hospital, Bologna, Italy, 3General
and Transplant Surgery Dept., Sant’Orsola-Malpighi hospital,
Bologna, Italy
Introduction: Although patients with acute left-sided colorectal
cancer obstruction (LCCO) have traditionally undergone emergency
surgery, actually colonic stenting as a ‘‘bridge to surgery’’ can be
considered an alternative to surgery. As recently studies showed
conflicting results with use of colonic stenting, the Physiological and
Operative Severity Score for the enumeration of Mortality and mor-
bidity (POSSUM) model, and its Portsmouth (P) and Colorectal (CR)
modifications can be used to predict postoperative mortality and
morbidity after colorectal surgery and stenting in LCCO. The aim of
the present study is to compare stent placement as a bridge to surgery
versus emergency surgical resection in patients with LCCO using
P-POSSUM and CR-POSSUM.
Materials and methods: From January 2008 to December 2009, the
physiological and operative scores, morbidity and mortality predicted
by the P-P OSSUM and CR-POSSUM scores were collected in all
consecutive patients with LCCO who underwent surgical resection
directly (Group A) or after stent placement (Group B).
Results: Eighty-six patients were enrolled (Group A-41 and Group
B-45). The observed 30-day mortality rate was 9.8 % (4/41) in Group
A and 2.4 % (1/45) in Group B. The 30-day morbidity rate was 61 %
(25/41) in Group A and 29 % (13/45) in Group B. The mean values of
P-POSSUM morbidity (A = 70.5 % vs. B = 34.3 %; p = 0.001),
P-POSSUM mortality (A = 13.6 % vs. B = 2.4 %; p = 0.001) and
CR-POSSUM mortality (A = 15.1 % vs. B = 4.9 %; p = 0.001)
were significantly lower in the Group B patients than in the Group A
patients.
Conclusion: Bridge-to-surgery strategy reduces the surgical risks in
LCCO, and P-POSSUM and CR-POSSUM scores represent a good
tool for comparing the two strategies.
Disclosure: No significant relationships.
O032A
ONLINE SURVEY OF X-RAYS OF MIDSHAFTCLAVICULAR FRACTURES: WHICH TREATMENT WOULDYOU CHOOSE?
S.A. Stegeman1, N.C. Fernandes2, P. Krijnen1, I. Schipper1
1Trauma Surgery, Leiden University Medical Centre, Leiden, The
Netherlands, 2Radiology, Leiden University Mecdical Centre, Leiden,
The Netherlands
S14 Abstract
123
Introduction: The choice of treatment for midshaft clavicular frac-
tures is not straightforward, but depends on fracture characteristics
such as comminution, angulation and dislocation. An online survey
was conducted amongst surgeons, aiming to determine the preferred
treatment for different types of midshaft clavicular fractures.
Materials and methods: All members of the Dutch Society for
Trauma Surgery were invited to participate in an online survey. They
were asked to determine the treatment for 20 randomly selected
midshaft clavicular fractures based on anteroposterior X-rays. Prede-
fined treatment options were: non-operative treatment, non-locking
plate fixation, locking plate fixation, intramedullary fixation, and
other. The respondents’ background and experience were documented.
Results: For the 3 non-dislocated clavicular fractures 97.7 % of the
102 respondents preferred non-operative treatment over operative
treatment. For the 17 dislocated fractures, conservative treatment was
preferred more frequently for 2B1 than for 2B2 fractures (54 vs.
27 %, p \ 0.001). The most often preferred method of fixation was
the locking plate fixation (22 % for 2B1 and 56 % for 2B2). Back-
ground and experience of the respondent influenced choice of
treatment for dislocated fractures: Orthopedic surgeons preferred
more often non-operative treatment for dislocated midshaft fractures
than trauma surgeons (p = 0.048). For operative treatment trauma
surgeons preferred locking plate fixation, whereas orthopedic sur-
geons preferred non-locking plate fixation (p \ 0.001).
Conclusion: For non-dislocated fractures non-operative treatment is
generally preferred. For dislocated fractures, the choice of treatment
strongly depends on the fracture type and on background and expe-
rience of the surgeon. This lack of consensus calls for evidence-based
treatment guidelines for dislocated midshaft clavicular fractures.
Disclosure: No significant relationships.
O033
LONG-TERM SURVIVAL FACTORS IN PERFORATIONWITH COLORECTAL CANCER
Y. Tsutsumi, A. Tsuchiya, K. Ishigami, T. Komeno, K. Yuzawa,T. Terashima, M. Koizumi, H. Ueki
Surgery, National Hospital Organization Mito Medical Center,
Ibaraki, Japan
Introduction: The perforation due to colorectal cancer is serious
abdominal emergency and has high mortality rate in acute phase. But
there is no consensus about the long-term prognosis related with
cancer itself. The purpose of this study is to assess the long-term
prognostic factors of this condition.
Materials and methods: Between January 2003 and October 2011,
30 patients underwent emergency operation with intestinal perforation
with colorectal cancer. Of these, 2 patients were excluded from death
in acute phase. The other 28 patients were included and the demo-
graphic data, site of perforation, operative procedure (including
resection of primary cancer or not) and prognosis were analyzed using
Kaplan–Meier estimates and logrank test.
Results: Of 28 patients, overall 5-year survival was 72.9 %. 5
patients had distant metastasis and 23 patients had none at the time of
operation. 5-year survival was 0 % in metastasis group and 87.7 % in
without metastasis group (p = 0.0001). 24 patients underwent the
operation with primary cancer removal and 4 patients did not. 5-year
survival was 77.1 % in removed group and 0 % in unremoved group
(p = 0.0146). Except for the patient with metastasis and remaining
primary lesion, perforation was observed at the oral site of primary
cancer in 16 patients and at the cancer site in 5 patients. 5-year
survival was 88.2 % in the oral site group and 42.9 % in the cancer
site group (p = 0.0152).
Conclusion: Our study demonstrates that long-term survival factors
in perforation with colorectal cancer were no metastasis, primary
cancer removal and oral site perforation.
Disclosure: No significant relationships.
O034
RELIABILITY OF INJURY GRADING SYSTEMS FORPATIENTS WITH BLUNT SPLENIC TRAUMA
D.C. Olthof1, C.H. Van Der Vlies2, M.J. Scheerder3, R.J. De Haan4,L.F. Beenen3, J.C. Goslings1, O.M. Van Delden3
1Trauma Unit Department of Surgery, Academic Medical Center,
Amsterdam, The Netherlands, 2Maasstad Ziekenhuis, Rotterdam,
The Netherlands, 3Radiology, Academic Medical Center, Amsterdam,
The Netherlands, 4Academic Medical Center, Amsterdam, The
Netherlands
Introduction: The most widely used grading system for blunt splenic
injury is the American Association for the Surgery of Trauma (AAST)
organ injury scale. A few years ago a new grading system was
developed. This ‘Baltimore CT grading system’ is superior to the
AAST system in predicting the need for angiography and emboliza-
tion or surgery. The present study assessed inter- and intraobserver
reliability between radiologists in classifying splenic injury according
to both grading systems.
Materials and methods: Computed tomography (CT) scans of 83
patients with blunt splenic injury admitted between 1998 and 2008 to
an academic Level 1 trauma center were retrospectively reviewed.
Inter and intra-rater reliability were expressed in Cohen’s or weighted
Kappa values.
Results: Overall weighted interobserver Kappa coefficients for the
AAST and ‘Baltimore CT grading system’ were respectively substantial
(kappa = 0.80) and almost perfect (kappa = 0.85). Average weighted
intraobserver Kappa’s values were in the ‘almost perfect’ range (AAST:
kappa = 0.91, ‘Baltimore CT grading system’: kappa = 0.81).
Conclusion: Inter- and intraobserver reliability for grading splenic
injury according to the AAST and ‘Baltimore CT grading system’ are
equally high. Because of the integration of vascular injury, the
‘Baltimore CT grading system’ supports clinical decision making. We
therefore recommend use of this system.
Disclosure: No significant relationships.
O035
THE SWISS EXPERIENCE WITH EMBLOLIZATION IN THETREATMENT OF PEDIATRIC BLUNT ABDOMINALTRAUMA
N. Lutz1, S. Altermatt2, H. Hacker3, G. La Scala4, C. Aufdenblatten5,A. Joeris6
1Pediatric Surgery, University Hospital of Lausanne, Lausanne,
Switzerland, 2Kinderspital, Zurich, Switzerland, 3Kinderspital,
Luzern, Switzerland, 4Hopital des enfants, HUG, Geneva,
Switzerland, 5Kinderspital, St Gallen, Switzerland, 6Inselspital, Bern,
Switzerland
Abstract S15
123
Introduction: In Switzerland, an estimated 80 children are hospi-
talized each year with significant intra-abdominal injuries (AIS 3
and above). As conservative management is successful in more
than 95 % of the cases, embolization is rare. On the contrary to
adults for whom validated embolization guidelines are used, chil-
dren with blunt abdominal injuries are embolized on a case-by-case
basis.
Materials and methods: The aim was to analyze the clinical pre-
sentation and characteristics of children undergoing embolization for
blunt abdominal trauma, assess the embolization technique and the
outcome. A retrospective multicenter case study from the Swiss
Pediatric Trauma working Group (Swiss PTG) was performed.
Demographics, radiological and medical data was collected from each
pediatric patient who underwent embolization following blunt
abdominal trauma. Participating clinics included Bern, Basel, Luzern,
Lausanne, Geneva, Zurich and St Gallen.
Results: Between 2004 to 2011, an arterial embolisation was per-
formed in 18 Between 2004 and 2011, an arterial embolization was
performed in 18 children aged 5 to 16 years for bleeding of 7 spleens,
7 livers, 3 kidneys and 1 colon. On computed tomography, intrave-
nous contrast extravasation was noted in 14 and a pseudoaneurysm in
4 cases. Embolization was performed between 1.5 h and 53 days
following trauma. Coils were used in 16 cases and/or Gelfoam/par-
ticles in 3. Local anesthesia was used in 13 and general anesthesia
was necessary in 5 cases. Blood transfusion was required in seven
cases. One case required re-embolization. Two children required
surgery for ongoing bleeding. Post-interventional complications
included death in two, drainage of a bilioma in one and a perirenal
abscess in one hemophiliac child. All complications were not directly
related to the embolization. No significant organ-function loss was
noted in embolized spleen, liver and colon.
Conclusion: In Switzerland, over a period of 8 years, less than 3 % of
the estimated significant pediatric intra-abdominal organ injuries were
embolized. The procedure was performed following radiological
evidence of unstable vascular lesion. Hemodynamic instability, blood
transfusion or polytrauma were not a prerequisite for embolization. In
this case series, embolization under local or general anesthesia had a
high success rate up to 53 days following trauma. Complications
directly related to the embolization were rare. Guidelines regarding
embolization in children with intra-abdominal injuries are needed and
should be validated.
Disclosure: No significant relationships.
O036
PRESERVED SPLENIC FUNCTION AFTER SPLENICARTERY EMBOLIZATION IN CHILDREN
J. Skattum1, C. Gaarder2, R.J.V. Lokke3, T.L. Titze4,A.G. Bechensteen5, I. Aaberge6, L.T. Osnes7, H.E. Heier8,P.A. Naess2
1Traumatology, Oslo University Hospital, OUS, Ulleval HF, Oslo,
Norway, 2Traumatology, Oslo University Hospital OUS, Ullevaal HF,
Oslo, Norway, 3Imaging and Intervention, Oslo University Hospital
OUS, Ullevaal HF, Oslo, Norway, 4Immunology and Transfusion
Medicine, Oslo University Hospital OUS, Ullevaal HF, Oslo,
Norway, 5Pediatric Hematology and Oncology, Pediatric Department,
Oslo University Hospital OUS, Ullevaal HF, Oslo, Norway,6Bacteriology and Immunology, Norwegian Institute of Public
Health., Oslo, Norway, 7Immunology and Transfusion Medicine,
Oslo University Hospital OUS, Ullevaal HF, Oslo, Norway,8Immunology and Transfuion Medicine, Oslo University Hospital
OUS, Ullevaal HF, Oslo, Norway
Introduction: Background: Non-operative management (NOM) for
blunt splenic injuries was introduced to reduce the risk of over-
whelming post splenectomy infection (OPSI) in children. To
increase splenic preservation rates, splenic artery embolization
(SAE) was introduced in our institutional treatment protocol in
2002. In the presence of clinical signs of ongoing bleeding, SAE
was considered also in children. To our knowledge, the long term
splenic function after SAE performed in the pediatric population has
so far not been evaluated and constitutes the aim of the present
study.
Materials and methods A case control study was conducted in
patients up to 17 years of age. Patients were identified through the
institutional registries. Data were collected from patient charts and
computed tomographic scans were reviewed. A total of 11 SAE
patients were included and 11 healthy volunteers served as matched
controls. Clinical examination, medical history, general blood counts,
immunoglobulin quantifications and flowcytometric analysis of lym-
phocyte phenotypes were performed. Peripheral blood smears were
examined for Howell-Jolly bodies and abdominal ultrasound was
performed.
Results: At a mean of 4.6 years after SAE, no significant differ-
ences could be detected between the SAE patients and their
controls.
Conclusion: This study indicates preserved splenic function after
SAE for splenic injury in children. Mandatory immunisation to pre-
vent severe infections is probably unnecessary.
Disclosure: No significant relationships.
O037
THROMBOSIS PROPHYLAXIS AND OUTCOME OFNON-OPERATIVE MANAGEMENT OF BLUNTSPLENIC INJURIES
G. Tomasch, P. Kornprat, D. Nagele-Moser, S. Uranues
Department of Surgery, Medical University Graz, Graz, Austria
Introduction: Non-operative treatment (NOM) of spleen injuries is
the preferred management in hemodynamically stable patients. Low-
molecular-weight heparins (LMWH) are effective in preventing
thromboembolic complications after trauma, but the dose and timing
of administration of LMWH in patients with NOM remains contro-
versial because of the unknown risk of bleeding. This study aims to
identify if and when LMWH has a negative influence on the outcome
of NOM of splenic injuries.
Materials and methods: Prospectively collected data of 139 patients
with blunt spleen injuries between 2005 and 2009 were reviewed.
Demographic data, details of the event, concomitant injuries,
administration of LMWH and surgical outcomes were considered.
Computer tomography (CT) follow-up was used to monitor the suc-
cess of NOM.
Results: Eighty-nine patients (64 %) were treated with NOM while
50 (36 %) were operated (OT). Forty (45 %) with NOM did not
receive LMWH; 29 (33 %) received LMWH early (within the first
24 h), and 20 (22 %) received it late (after 48 h). The early LMWH
group had less severe injuries than the late LMWH group. Five
S16 Abstract
123
patients (17 %) were converted from NOM to OT, although the
grade of splenic injury was less than in the LMWH late group, with
higher-grade spleen injury. There was no case of pulmonary
embolism or deep venous thrombosis in the group that did not
receive LMWH.
Conclusion: This study suggests that the use of LMWH in trauma
patients with blunt splenic trauma treated non-operatively could be
associated with a certain rate of failure when LMWH is adminis-
trated immediately after trauma, and high doses of LMWH should
only be given in carefully selected patients with high risk of
thrombosis.
Disclosure: No significant relationships.
O038
DIAPHRAGMATIC TRAUMA AND THE ASSOCIATEDINJURIES SPECTRUM
A. Rekha, V. Pai
General Surgery, Sri Ramachandra Medical College,
Sri Ramachandra University, Chennai, India
Introduction: The aim of the study was to look at the incidence of
diaphragmatic injuries over a 5 year period in Sri Ramachandra
Medical College, Chennai, India, to study the spectrum of associated
injuries including the mode of injury, to study the investigations
useful in diagnosis and to review the different methods of manage-
ment and thus analyze outcome. A review of literature is also
included.
Materials and methods: This was a retrospective study between June
2006 to June2011. All operative registers and medical records of this
period were perused. All patients with diaphragmatic injuries formed
the study population.
Results: Of the 35000 patients who presented with trauma, 1501 had
abdominal injuries and 11 patients had diaphragmatic injury, which
accounted for less than 1 %. Males accounted for 81.8 % of the study
group and maximum clustering was seen in the 4th decade of life.
97 % sustained injuries in road traffic accidents and 80 % had asso-
ciated orthopedic, 67 % head, 3 % vascular and 43 % had abdominal
injuries. Chest X-ray (43 %) and CT (92 %) were useful in diagnosis.
Closure with a non absorbable suture or a mesh (9 %) was the
mainstay in management.
Conclusion: Diaphragmatic injuries accounted for less than 1 % of
injuries at our hospital. There were associated orthopedic injuries and
the CT helped clinch the diagnosis. Suture with non absorbable suture
or mesh were used in surgery and laparoscopic repair is the way
ahead.
References: 1. Clarke DL, Greatorex B, Oosthuizen GV, Muckart DJ.
The spectrum of diaphragmatic injury in a busy metropolitan surgical
service. Injury. 2009;40(9):932–7 (Epub 2009 Jun 18). 2. Hanna WC,
Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic
diaphragmatic injury: lessons learned from 105 patients over
13 years. Ann Thorac Surg. 2008;85(3):1044–8. 3. Matsevych OY.
Blunt diaphragmatic rupture: four year’s experience. Hernia.
2008;12(1):73–8 (Epub 2007 Sep 22).
Disclosure: No significant relationships.
THORACIC DAMAGE CONTROL/VASCULAR
INJURIES
O039
FLAIL CHEST MANAGEMENT: CONSERVATIVE VERSUSSURGICAL TREATMENT
P. Moreno De La Santa Barajas1, M.D. Polo Otero1, M. LozanoGomez1, C. Delgado Sanchez-Gracian2, S. Leal Ruiloba3, M. ChorenDuran4, E. Pena Gonzalez5, C. Trinidad2
1Thoracic Surgery, Hospital POVISA, Vigo, Spain, 2Radiology,
Hospital POVISA, Vigo, Spain, 3Anaesthesia, Hospital POVISA,
Vigo, Spain, 4Medical Records, Hospital POVISA, Vigo, Spain,5Thoracic Surgery, Hospital Xeral, Vigo, Spain
Introduction: Conservative treatment is the commonest way to treat
the flail chest. Since the availability of new materials, particularly the
titanium, there is an increasing tendency to the surgical management
(open reduction and internal fixation, ORIF). We review both ways of
treatment and comparing results.
Materials and methods: Between 2001 and 2010, 163 patients were
admitted in our institution with flail chest. In order of treatment
patients were divided: Group 1: 106 patients were managed in the
conservative way. Group 2: 57 patients were treated with surgery
(ORIF). Both groups were homogeneous about demographic data:
sex, age, trauma mechanism, number of broken ribs, and associated
injuries.
Results: We found several differences between both groups: Length
in ITU: Group 1 versus Group 2 (45 vs. 9 days, p = 0.01);
Mechanical ventilation: Group 1 versus Group 2 (30 vs. 3,7 days,
p = 0.01); Full recovery time: Group 1 versus Group 2 (186 vs.
135 days, p = 0.04); Mortality: Group 1 versus Group 2 (17 (16 %)
versus 2 (3 %), p = 0.03); Chest infection; Group 1 versus Group 2
(36 (33 %) vs. 5 (10 %), p = 0.04. We not found differences in other
complications or other chest injuries.
Conclusion: The surgical stabilization of flail chest, is a good option
because: Reduce the mortality ratio. The ITU staging and needs for
mechanical ventilation are shortened. Reduce pulmonary infections.
The recovery time is faster.
Disclosure: No significant relationships.
O040
TREATMENT OF BLUNT TRAUMATIC SUBISTHMICAORTIC RUPTURE IN POLITRAUMATIC PATIENTS
T. Mastropietro1, S. Manfroni1, C. Cataldi1, F. De Pasquale2,P. Cao2, D. Antonellis1
1Emergency Surgery, ACO San Camillo, Rome, Italy, 2Vascular
Surgery, san camillo Hospital, Rome, Italy
Introduction: The diagnosis and the management of blunt thoracic
aortic rupture has undergone many significant changes over the last
Abstract S17
123
decade. The liberal use of computer tomography (CT) scan has
increased the diagnosis of thoracic aortic injuries and the endovas-
cular stent-grafts has replaced open repair with a reduction of
mortality and procedure-related paraplegia. Rarely an aortic rupture is
isolated, often is associated with other complex thoracic and
abdominal injuries with a high mortality. The management of these
patients is a big challenge in the trauma care.
Materials and methods: From 2002 to 2008 we have treated 29
patients with thoracic subistmic aortic rupture associated with other
thoracic and abdominal injuries. The diagnosis of thoracic aortic
rupture has made with CT scan.
Results: 29 Patients average age 40 (18–85 years) 27 Males 2
Females. 6 covered of left subclavian artery, 1 left carotid–subclavian
bypass Mortality: Overall 2, 29 (traumatic cerebral haemorrhage) In-
Hospital related procedure: 0 % Late related procedure 5.5 % (1
aortic-bronchial fistula died 6 month after) No endoleak No
paraplegia.
Conclusion: 80–85 % of blunt thoracic aortic injuries patients died
on the scene. Traditionally the treatment of the traumatic subistmic
thoracic aortic rupture was the thoracotomy and the placement of
vascular prosthesis; the range of mortality was between 8 and 33 %.
Endovascular procedure has changed the treatment of this injury with
a reduction of mortality and morbidity. Todays the gold standard is
the endovascular treatment with a mortality less than 8 %.
Disclosure: No significant relationships.
O041
OPERATIVE TREATMENT OF MULTIPLE RIBFRACTURES AND FLAIL CHEST. A PROSPECTIVECONSECUTIVE STUDY
D. Pazooki1, H.P. Granhed1, A. Yarollahi2, M. Fagevik-Olsen1,M. Tagliati3
1Surgery, Sahlgrenska University Hospital, Goteborg, Sweden,2Surgery, trauma, Sahlgrenska University Hospital, Gothenburg,
Sweden, 3Surgery, trauma, Sahlgrenska University Hospital,
Goteborg, Sweden
Introduction: Multiple rib fractures are common in multitrauma and
high energy trauma. Complications from mechanical ventilation are
well studied. The results of surgical treatment have so far not been
convincing. Previously used osteosynthesis is by today’s fracture
surgical measures not optimal. The modern plate technique with
locked angle screws offers a completely new opportunity to fix these
small often osteoporotic bones.
Materials and methods: From September 15 2010 until September
15 2011, 31 patients with unstable thoracic cage have been operated
with the ‘‘Matrix RIB Compact system’’. Length-of mechanical
ventilation and ICU-stay was documented. During first year clinical
follow-up including, chest X-ray, the quality of life instrument EQ 5-
D, standardized spirometry and thoracic movement at breathing
(RMMI) was performed.
Results: All patients except two were extubated within 24 h. Sig-
nificant infections in the lungs or pleura have not been seen. On
X-ray, infiltration is frequently seen at the inferior part of the lung.
The patients have early problems with numbness and pain, but the
pain disappears at 3 months. At 6 months the patients have a feeling
of stiffness and dysesthesia around the scar. They are painfree. Early
data from EQ 5.D, standardized spirometri and RMMI will be
presented.
Conclusion: Promising results with low rate of complications and fast
recovery. We have so far no indication why surgical treatment of the
unstable thoracic cage should not be recommended. Further conclu-
sions will be available.
Reference: Tanaka H. NICE London: 2010. Olsen, MF.
Disclosure: No significant relationships.
O042
THE ADDITIONAL VALUE OF COMPUTED TOMOGRAPHYOF THE CHEST DURING THE INITIAL ASSESSMENT OFBLUNT TRAUMA PATIENTS. WHAT ARE THE BENEFITS?
H.R. Tromp, P. Vatankhah, G.F. Giannakopoulos, F.W. Bloemers,F.C. Bakker
Traumatology, VU medical centre, Amsterdam, The Netherlands
Introduction: Primary aim of this study was to assess the additional
value of computed tomography of the chest (CCT) in the initial
assessment of patients sustaining high energy blunt trauma to the
chest.
Materials and methods: We retrospectively investigated all patients
presented at the emergency department of the VU medical centre
between November 2005–2007. A cohort of consecutive adult trauma
patients who underwent a CXR and/or CCT after high energy blunt
trauma, were included. The radiological findings of these patients
were collected. The added value of CCT was evaluated by comparing
the radiological findings by both CXR and CCT.
Results: Overall 1,076 patients were included. CXR examination was
performed in 1,032 patients (95.9 %) of whom 108 (10.0 %) were
also examined by CCT. Injuries were found in 172 radiographs
(16.0 %). These injuries were confirmed by CCT in 62 patients
(5.8 %). Though in some patients additional injuries were found, CCT
revealed no life threatening injuries needing immediate surgery. Of
the remaining 860 patients (79.9 %) with no injuries on CXR, a CCT
examination was performed in 40 patients (3.7 %). CCT revealed
missed injuries in 23 patients. None had a life threatening injury.
Conclusion: Even though CCT is more sensitive in detecting injuries
caused by high energy blunt trauma to the chest, its added clinical
value above CXR is very low. Found injuries on CCT do not nec-
essarily cause a change in patient’s treatment. The use of CCT is
recommendable only when radiological and clinical signs raise sus-
picions of occult injuries. Its routine use should therefore be
discouraged.
Disclosure: No significant relationships.
O043
COMPARISON OF DIFFERENT THORACIC TRAUMASCORING SYSTEMS IN REGARDS TO PREDICTION OFPOST-TRAUMATIC COMPLICATIONS AND OUTCOME INBLUNT CHEST TRAUMA
M. Winkelmann1, P. Mommsen2, C. Zeckey3, H. Andruszkow3,M. Frink3, F. Hildebrand2
1Traumatologic Department, Hannover Medical School, Hannover,
Germany, 2Trauma Department, hannover medical school, Hannover,
Germany, 3Trauma Department, Hannover Medical School,
Hannover, Germany
S18 Abstract
123
Introduction: As accurate assessment of thoracic injury severity in
the early phase after trauma is difficult, we compared different tho-
racic trauma scores regarding their predictive ability for the
development of post-traumatic complications and mortality.
Materials and methods: 287 multiple trauma patients (ISS C16) age
[16 years with severe blunt chest trauma (AISchest C3) admitted
between 2000 and 2009 to Level I Trauma center were included.
Exclusion criteria were severe traumatic brain injury (AIShead C3)
and penetrating thoracic trauma. The association between AISchest,
Pulmonary Contusion Score (PCS), Wagner-Score and Thoracic
Trauma Severity score (TTS) and duration of ventilation, length of
ICU stay, development of post-traumatic complications and mortality
was investigated. Statistical analysis was performed with v2-test,
ANOVA, logistic regression and receiver operating characteristic
(ROC) curve.
Results: Patients’ mean age was 42.7 ± 17.0 years, the mean injury
severity score was 28.7 ± 9.3 points. Overall 60 patients (21.6 %)
developed ARDS, 143 patients (51.4 %) SIRS, 110 patients (39.6 %)
sepsis and 36 patients (13.0 %) MODS. 22 patients (7.9 %) died.
Among the examined thoracic trauma scores only the TTS was an
independent predictor of mortality. With the TTS showing the best
prediction power, the TTS, PCS and Wagner-Score were independent
predictors of ventilation time, length of ICU stay and the development
of post-traumatic ARDS and MODS.
Conclusion: Thoracic trauma scores combining anatomical and
physiologic parameters like the TTS seem to be most suitable for
severity assessment and prediction of outcome in multiple trauma
patients with concomitant blunt chest trauma.
Disclosure: No significant relationships.
O044
IMMEDIATE THORACOTOMY FOR PENETRATINGINJURIES; TEN YEARS EXPERIENCE AT A DUTCH LEVEL1 TRAUMA CENTER
O.J.F. Van Waes1, P.A. Van Riet2, E.M.M. Van Lieshout1,D. Den Hartog1
1Department of Surgery-traumatology, University Medical Center
Rotterdam, Rotterdam, The Netherlands, 2Department of Surgery-
traumatology, Erasmus MC, University Medical Center Rotterdam,
Rotterdam, The Netherlands
Introduction: An Emergency Department thoracotomy (EDT) or an
Emergency thoracotomy in the operation room (ET) are both bene-
ficial in selected patients following thoracic penetrating injuries.
Since outcome descriptive European studies are lacking, the aim of
this retrospective study was to evaluate the ten-year experience at a
Dutch level 1 trauma center.
Materials and methods: Data of patients who underwent an imme-
diate thoracotomy after sustaining penetrating thoracic injury between
October 2000 and January 2011 were collected from the Trauma
Registry and hospital files. Descriptive and univariate analyses were
performed.
Results: Of 56 patients, 12 underwent an EDT and 44 an ET. Forty-
six patients sustained one or multiple stab wounds versus 10 with one
or multiple gunshot wounds. Patients who had undergone an EDT had
lower GCS (p \ 0.001), lower pre-hospital and hospital RTS
(p \ 0.001 and p = 0.009, respectively) and lower SBP (p = 0.038).
Witnessed loss of signs of life occurred generally in EDT patients and
was accompanied with a 100 % mortality. Survival following EDT
was 25 %, but significantly lower than in the ET group (75 %;
p = 0.002). Survivors had lower ISS (p = 0.011), a lower rate of pre-
hospital (p = 0.031) and hospital hemodynamic instability
(p = 0.003), and a lower prevalence of concomitant abdominal injury
(p = 0.002).
Conclusion: Overall survival rate in our study was 64.3 %. Outcome
of immediate thoracotomy performed in this level I trauma center is
similar to outcomes obtained in high incidence regions like the US
and South Africa. This suggests that trauma units where immediate
thoracotomies are not part of the daily routine can achieve, if proper
trained, similar results.
Disclosure: No significant relationships.
O045
EARLY THORACOTOMY IN TRAUMA: REPORT OF 5YEARS
R. Mazzani1, P. Orlandi1, C. Bricchi1, D. De Matteis1, A. Agostinelli2,L. Ampollini3, A. Volpi1
11st Anesthesia and Intensive Care, Azienda Ospedaliero
Universitaria di Parma, Parma, Italy, 2Cardiac Surgery, Parma, Italy,3Thoracic Surgery, Parma, Italy
Introduction: Severe Thoracic injuries influence the mortality and
morbidity of trauma patients [1]. In the last years a new approach, the
abbreviated thoracotomy, has been described to decrease the pre-
dicted mortality [2, 3].
Materials and methods: 819 patients with major trauma (ISS higher
than 15) presenting in a level I trauma centre in the period from
September 2006 to April 2011 were reviewed.
Results: Patients with a chest lesion were 417 (50.3 %). The overall
mortality of trauma patients in our hospital was 18.5 %. For patients
with thoracic traumas the mortality was of 16.3 %. Only 6.4 % (27
patients) required early thoracotomy and between them 8 patients
died (29.6 %). The patients deceased presented in one case lacera-
tion of the cava vein, 2 brain trauma, 3 pelvic trauma, in one case
abdominal hemorrhagic trauma, in one case maxillo-facial trauma.
In the survivors group (19 pt) 12 patients were hemodynamically
stable (63.1 %) and 6 patients were unstable (31.5 %) at the arrival,
in one patient the arriving pressure was not recorded. In the
deceased group (8 pt) instead 2 were stable (25 %) and 6 unstable
(75 %).
Conclusion: This approach, the abbreviated thoracotomy, is well
described by Rotondo in 2004 [2] with a decreased mortality from
the predicted of 59–36 % in this patients [3]. In our center the
mortality between patients subjected to early thoracotomy was
29.6 %. The hemodynamic instability remains the principal mortality
risk factor in agreement with literature [4]. Also the greater timing
for intervention in surviving patients is in agreement with literature
in which was seen that delayed repair is safe in hemodynamically
stable patients.
References: 1. Thorac Surg Clin. 2010;20:475–85. 2. Rotondo MF,
Bard MR. Damage control surgery for thoracic injuries. Injury Int J
Care Injured. 2004;35:649–54. 3. Vargo DJ, Battistella FD.
Abbreviated thoracotomy and temporary chest closure: an appli-
cation of damage control after thoracic trauma. Arch Surg.
2001;136(1):21–4. 4. Duwayri Y, J Abbas, et al. Outcome after
thoracic aortic injury: experience in a level-1 trauma center. Ann
Vasc Surg. 2008;22:309–13.
Disclosure: No significant relationships.
Abstract S19
123
O046
THORACIC DAMAGE CONTROL: EXPERIENCES INOPERATIONAL AREA, AFGHANISTAN (2001–PRESENT)
S. Pellek
Cardio-vascular and Thoracic Surgery, Military Hospital-State Health
Center, Budapest, Hungary
Introduction: Civilian trauma is typically characterised as penetrat-
ing or blunt injuries. The casualties in this military environment
present with injury patterns, that are not seen in routine surgical
practice at home. The military surgeon needs to acquire and maintain
a wide range of skills including a variety of surgical fields.
Materials and methods: The medical challenges are often more
complicated than just a simple clinical case problem. Their solution
requires not only clinical skills, but also effective communication,
cool head and confidence. Fragments of high-energy explosive gre-
nades main cause of death are thoracic, abdominal and head injuries.
Results: Should the patient remain unstable, the amount of chest tube
output may immediate thoracotomy. The resuscitative thoracotomy in
combat zone should be limited to patients in extremis with penetrating
thoracic injuries.
Conclusion: The thoracic cavity can be packed once hemorrhage
control has been achieved. Temporary closure of both cavities can be
used and the patient returned to the ICU and return to the OR for
definitive treatment.
References: 1. War Surgery in Afghanistan and Iraq ISBN 978-0-
981822-80-8
Disclosure: The United States Operation and NATO ISAF started in
Afghanistan in 2001 as a consequences of the attacks on the World
Trade Center and Pentagon on 9/11.
POLYTRAUMA
O047
PROFILING OF HIGH MOBILITY GROUP BOX PROTEIN 1(HMGB1) AND MACROPHAGE MIGRATION INHIBITORYFACTOR (MIF) IN MULTI-SYSTEM INJURY
D. Rittirsch, V. Schoenborn, L. Harter, S. Marsmann, C.M.L. Werner,H.P. Simmen, G.A. Wanner
Surgery, Division of Trauma Surgery, University Hospital Zurich,
Zurich, Switzerland
Introduction: Within the inflammatory network, various entities are
connected in a multi-directional manner by pleiotropic key mediators.
These ‘central hubs’ include the proinflammatory cytokine macro-
phage migration inhibitory factor (MIF) and high mobility group box
protein I (HMGB1). As the prototypical alarmin, HMGB1 signals
‘danger’ to the host and triggers the inflammatory response.
Materials and methods: Levels of MIF and HMGB1 were deter-
mined by proteomic analyses in plasma or serum from patients with
multiple injury (injury severity score ISS [16; n = 32) at different
time points (day0, d1, d2, d3, d5, d7, d10, d14, d21) after trauma.
Results: Levels of MIF showed an early peak on d0, followed by a
rapid decline and secondary peaks on d3, d5 and d10. During the
further course, MIF concentrations stayed elevated. The concentration
of MIF (d1) reflected the severity of injury. High levels of MIF (d1)
were associated with the development of multi-organ failure (MOF).
The pattern of HMGB1 release also showed its peak at d0. After a
decline to the nadir at d5, HMGB1 levels rose to reach a second peak
on d7, followed by a gradual decrease at the later time points. Similar
to MIF, levels of HMGB1 (d1) correlated with the ISS and the
development of MOF.
Conclusion: In contrast to its role as a late mediator in sepsis,
HMGB1 is released early after multi-system trauma. The profile of
MIF in trauma suggests a novel role for MIF as an alarmin. MIF and
HMGB1 represent early markers for systemic inflammation and
potential therapeutic targets for ‘molecular damage control’.
Disclosure: No significant relationships.
O048
FRACTURES OF THE FOOT IN POLYTRAUMATIZEDPATIENTS: IS A LATE DIAGNOSIS REALLY A PROBLEM?
A. Ahrberg1, B. Leimcke1, A.H. Tiemann2, C. Josten1
1Department of Traumatology and Reconstructive Surgery,
University of Leipzig, Leipzig, Germany, 2Klinik Fur Unfallchirurgie,
BG Kliniken Halle, Halle, Germany
Introduction: Overlooked fractures of the feet are a known problem
in the care of the traumatized patient with usually no influence on the
survival but on the long-term result and quality of life of the patient.
How many of these fractures are overlook in the polytrauma care in a
Level I trauma center and what are the consequences for the patients?
Materials and methods: Out of 4 years we retrospectively identified
54 polytraumatized patients with fractures of the feet. Patients were
divided in 2 groups: immediately (IDF) and delayed diagnosed
fractures (DDF) and evaluated according to Hannover Outcome
Score, SF-36 Health Survey, AOFAS and Hannover Scoring System.
Results: In 155 fractures on 58 feet most of them were on the cal-
caneus (20 %) and metatarsals (41.3 %). 40 fractures (25.8 %) in 21
cases were diagnosed delayed most of them on the cuboid (40 %) and
the naviculare (33.3 %). In average, the DDF were found after
11 days. Reasons for DDF were initially not performed or inadequate
X-rays. There was no significant difference in ISS, GCS, Polytrauma
Score or duration of stay in hospital. Patients with DDF had worse
results in all scores yet no higher rate of complications.
Conclusion: The examination of the feet shouldn’t be neglected in
the care of the polytraumatized patient and should be performed
accurately at the latest during Second Survey. Injuries of the same leg
and especially the same foot are important indicators. A failure in
diagnosing injuries of the feet can lead to a worse result in the care of
the polytraumatized patient!
Disclosure: No significant relationships.
O049
ROLE OF INTERLEUKIN-33 AND ITS SOLUBLE RECEPTORSST2 IN MULTIPLE INJURY
D. Rittirsch, V. Schoenborn, L. Harter, S. Marsmann, C.M.L. Werner,H.P. Simmen, G.A. Wanner
Surgery, Division of Trauma Surgery, University Hospital Zurich,
Zurich, Switzerland
S20 Abstract
123
Introduction: The inflammatory response following trauma is highly
complex and still inadequately understood. Endogenous danger sig-
nals (alarmins) play a crucial role in triggering the immune response.
The novel cytokine interleukin-33 (IL-33) is known to act as an
alarmin in various inflammatory conditions. Its soluble decoy receptor
sST2 functions as an endogenous antagonist of IL-33.
Materials and methods: Plasma from patients with multiple injury
(n = 32; injury severity score ISS [16) was analyzed by ELISA for
IL-33 and sST2 at different time points (day 0, d1, d2, d3, d5, d7, d10,
d14, d21) after trauma.
Results: Levels of IL-33 were increased in 14 of 32 patients, peaking
at the day 0. While high levels of IL-33 (d0–d5) were associated with
thoracic injury, there were no further correlations of IL-33 with the
injury pattern or secondary complications. All patients showed ele-
vated levels of sST2 with a sharp peak at d1. Increased sST2 levels at
d3 and d5 were associated with the development of sepsis and sepsis-
associated multi-organ failure. The sST2 concentrations (d2) corre-
lated with the ISS. Patients with abdominal or thoracic trauma showed
significantly elevated levels of sST2 (d2). In patients who underwent
splenectomy, levels of sST2 were depressed or even non-detectable
during the later course (d5–d21) as compared to patients with an
uninjured spleen.
Conclusion: These findings show for the first time that IL-33 and
sST2 contribute to systemic inflammation after trauma. While the
mechanisms of action and release of IL-33 remain somewhat enig-
matic at present, sST2 represents a promising marker for the
inflammatory response after trauma.
Disclosure: No significant relationships.
O050
ABBREVIATED INJURY SCALE: NOT A RELIABLE BASISFOR SUMMATION OF INJURY SEVERITY IN TRAUMAFACILITIES
K.G. Ringdal1, N.O. Skaga2, M. Hestnes3, P.A. Steen4, J. Røislien5,M. Rehn1, O. Røise6, A.J. Kruger1, H.M. Lossius1
1Department of Research, Norwegian Air Ambulance Foundation,
Drøbak, Oslo, Norway, 2Department of Anesthesiology, Division of
Emergencies and Critical Care, Oslo University Hospital Ulleval,
Oslo, Norway, 3Oslo University Hospital Trauma Registry,
Department of Research and Development, Division of Emergencies
and Critical Care, Oslo University Hospital Ulleval, Oslo, Norway,4Institute of Clinical Medicine, Faculty of Medicine, University of
Oslo, Oslo, Norway, 5Department of Biostatistics, Institute of Basic
Medical Sciences, Faculty of Medicine, University of Oslo, Oslo,
Norway, 6Division of Emergencies and Critical Care, Oslo University
Hospital Ulleval, Oslo, Norway
Introduction: Injury severity is most frequently classified using the
Abbreviated Injury Scale (AIS) as a basis for the Injury Severity
Score (ISS) and New Injury Severity Score (NISS), which are used in
outcome prediction. European trauma registries recommended the
AIS 2008 edition, but the levels of inter-rater agreement and reli-
ability of ISS and NISS, associated with its use, have not been
reported.
Materials and methods: Nineteen Norwegian AIS-certified trauma
registry coders were invited to score 50 real, anonymized patient
medical records using AIS 2008. Rater agreements for ISS and NISS
were analyzed using Bland–Altman plots with 95 % limits of
agreement (LoA). A clinically acceptable LoA range was set at
±9 units. The reliability was analyzed using a two-way mixed model
intraclass correlation coefficient (ICC) with a 95 % confidence
interval (CI) and hierarchical agglomerative clustering.
Results: Ten coders submitted their coding results. Of their AIS
codes, 2,189 (61.5 %) agreed with a reference standard, 1,187
(31.1 %) real injuries were missed, and 392 non-existing injuries were
recorded. All LoAs were wider than the predefined, clinically
acceptable limit of ±9, for both ISS and NISS. The joint ICC (range)
between each rater and the reference standard was 0.51 (0.29, 0.86)
for ISS and 0.51 (0.27, 0.78) for NISS. The joint ICC (range) for
inter-rater reliability was 0.49 (0.19, 0.85) for ISS and 0.49 (0.16,
0.82) for NISS.
Conclusion: Based on AIS 2008, ISS and NISS were not reliable for
summarizing anatomic injury severity in this study. This result limits
their use as benchmarking tools for trauma system performance.
Disclosure: No significant relationships.
O051
FIXATION OF PELVIC RING INJURIES USING THESTOPPA APPROACH
J.D. Bastian, S. Tomagra, K.A. Siebenrock, M.B.J. Keel
Department of Orthopaedic and Trauma Surgery, University of Bern,
Inselspital, Bern, Switzerland
Introduction: The Stoppa approach was introduced as an alternative
to the ilioinguinal approach for fixation of anterior pelvic ring inju-
ries. The aim was to describe our experience in treatment of pelvic
ring injuries using this approach.
Materials and methods: Lateral compression or vertical shear pelvic
injuries were treated operatively using the Stoppa approach between
07/2004 and 08/2011 in a consecutive series of 63 patients (52 years,
16–88). Surgical data, complications, need for revision surgery and
union rates were assessed retrospectively. Patients with a radiographic
follow up of less than 3 months were excluded to the study. Patients
were subdivided in two groups (group A B60 years, group B
[60 years).
Results: Data were available in 43 patients (50 years, 16–79) with a
mean follow up of 14 months (3–67). For anterior fixation recon-
struction plates (26/43 unilateral, 17/43 bilateral; 30/43 bridging the
symphysis), for posterior fixation screws (20/43), anterior plates (2/
43), posterior ilio-iliacal plates (2/43) were used or lumbopelvic
stabilization (2/43) was performed. The mean delay to surgery was
5 days (0–35), operation time was 160 min (70–360), overall blood
loss was 750 milliliter (200–2,400). All surgeries completed
uneventfully and fractures consolidated in postoperative course.
Revision surgery was necessary in 3/30 in group A (hardware failure
in 2/30 due to non-compliance, 1/30 infection) and in 3/13 in group B
(1/13 posterior non-union, hardware failure in 1/13 due to non-com-
pliance, 1/13 failure).
Conclusion: The modified Stoppa approach provided adequate
exposure for reduction and fixation of pelvic ring injuries. Surgical
treatment of pelvic ring injuries even in the elderly might be
favourable.
Disclosure: No significant relationships.
Abstract S21
123
O052
OUR EXPERIENCE WITH THE TRAUMAREGISTER DGU
D. Brilej1, R. Komadina2, M. Vlaovic2, B. Buhanec3
1Department of Traumatology, GENERAL AND TEACHING
HOSPITAL CELJE, CELJE, Slovenia, 2GENERAL AND
TEACHING HOSPITAL, CELJE, Slovenia, 3Traumatology
Department, SB Celje, Celje, Slovenia
Introduction: Trauma registries are the basis for programmes that
aim to improve the quality of treatment of severely injured patients
during the entire course of therapy.
Materials and methods: Patient data from General Hospital Celje
(GHC) began to be added to Trauma register DGU in 2006. Data were
collected on a cohort of patients who met the criteria: ISS of C18;
injuries with AIS score 5 in individual regions; severe injury (AIS 4)
and affected vital signs; and at least two fractures of long tubular
bones, pelvis or vertebrae and affected vital signs. All necessary
information on pre-hospital care was taken from the Prehospital Unit
Protocols. On admission to the hospital data on vital signs, diagnos-
tics and therapy before management in the intensive care unit were
recorded using the Protocol of the Slovenian Trauma Society. During
intensive care, routine data were recorded using existing protocols.
Information on completion of therapy was added after complete
documentation.
Results: 277 patients treated at GHC during the 4-year period met the
inclusion criteria and were added to Trauma register DGU. Average
age was 47.6, 84 % of them were men. Mostly they suffered blunt
trauma. The average ISS score was 26.3. At admission 33 % of them
were comatose, 28 % of them were in shock. The mortality rate was
18.6 %. The predicted mortality (RISC prognosis) was 20.2 %.
Conclusion: Results showed that the quality of treatment was com-
parable to international standards. The structure of Trauma register
was demonstrated to be suitable for the working methods and the
current state of trauma documentation in Slovenia.
Disclosure: No significant relationships.
O053
ASSESSMENT OF THE LONG-TERM QUALITY OF LIFE INMULTIPLY INJURED PATIENTS WITH THE SF-12 HEALTHQUESTIONNAIRE
R. Pfeifer1, B.A. Zelle2, N. Sittaro3, C. Probst4, H. Pape1
1Orthopaedic Trauma Surgery, University Clinic Aachen, RWTH
Aachen University, Aachen, Germany, 2University of Pittsburgh
Medical Center, Pittsburgh, PA, USA, 3Hannover Life RE-Insurance,
Hannover, Germany, 4Hannover Medical School, Hannover,
Germany
Introduction: Prior studies indicate that severe injuries may perma-
nently affect the quality of life and life satisfaction. Long-term
investigations in polytrauma patients are rare and the exact impact on
long-term outcome is unclear. The aim of this investigation is to
analyze the long-term consequences of polytrauma on quality of life
using the SF-12 health questionnaire.
Materials and methods: Patients treated at level one trauma center
were invited for a follow up examination. All patients met the fol-
lowing inclusion criteria: Injury Severity Score (ISS) C16, age
between 3 and 60 years. Patients were asked to respond to SF-12
health questionnaire containing following 8 items: Physical Func-
tioning; Role Physical; Role Emotional; Vitality; Mental Health;
Social Functioning; Bodily Pain; General Health. All items were
compared with the levels registered in German representative
population.
Results: 637 patients were evaluated. The average follow up was 17.5
(10–28) years; ISS was 20.7 (4–54) points, mean age 26.4 (3–60)
years. All 8 items of the SF-12 score were markedly below levels
recorded in a representative German population. Age-related stepwise
decrease of SF-12 items was registered. Employed patients demon-
strated superior outcome scores in all items. Early retired (\65 years)
felt to be more restricted than unemployed patients. In addition, social
environment (marriage) and financial situation (income losses)
affected the long-term quality of life as well. Post-traumatic cosmetic
impairments negatively influenced the outcome.
Conclusion: The present study demonstrates inferior long-term
([10 years) quality of life in patients with severe trauma. Age,
occupation status, socio-economic consequences significantly affec-
ted the long-term results.
Disclosure: No significant relationships.
O054
NEW OPERATIVE STRATEGY IN GERIATRIC TRAUMA?INNOVATIVE INTRAMEDULLARY STABILIZATION BYMEANS OF A PHOTODYNAMIC POLYMER SYSTEM:INITIAL CLINICAL EXPERIENCE
S. Heck1, S. Gick2, R. Rabiner3, D. Pennig2
1Clinic for Trauma Surgery, orthopaedics, Hand- and Reconstruction
Surgery, St. Vinzenz-Hospital, Koln, Germany, 2St. Vinzenz-
Hospital, Koln, Germany, 3IlluminOss Medical Inc., East Providence,
USA
Introduction: In osteoporotic bone implant failure is a frequent
complication. The minimally-invasive technique presented allows the
surgeon to stabilize fractures in poor quality bone with early onset of
mobilisation and weight bearing.
Materials and methods: The method used integrates the properties
of light cured (photodynamic) plastics, used successfully for decades
in dentistry, filled into Dacron (PET) balloon catheters that have been
used in interventional radiology and cardiology. In Seldinger-tech-
nique a balloon catheter is inserted into the marrow cavity which has
been previously expanded with use of a flexible cannulated drill. The
balloon is filled with liquid plastic monomer, and using a system of
visible blue light at a wavelength of 436 nm, is converted into a hard
polymer.
Results: So far two patients were treated after suffering a new fracture
of the humeral shaft just at the proximal end of the inserted plates for
their initially treated distal humerus fracture. The proximal screws of
both distal humeral plates were removed, the implant introduced in an
antegrade fashion, the plates refixed to the stable bone/plastic-complex
and finally the implant was locked with a screw proximally. Herewith
a very stable situation could be achieved. Postoperative immobilisa-
tion time was 6 days in an above elbow cast following physiotherapy.
Conclusion: The patient customized implant is characterized by its
high restoring force and its excellent rotational stability. The lack of
X-ray-density provides full assessment of the entire bone. Addition-
ally it offers the opportunity of increasing stability by locking with
screws, placed at any angle, at any reasonable place anatomically.
Disclosure: No significant relationships.
S22 Abstract
123
THE EMERGENCY ROOM
O055
PREHOSPITAL TREATMENT TIMES IN GERMANY:A MULTIVARIATE ANALYSIS OF 15,103 PATIENTS FROMTHE TRAUMAREGISTER� DGU
H. Wyen1, R. Lefering2, S. Wutzler1, M. Maegle3, A. Wafaisade3,T. Brockamp3, F. Walcher1, I. Marzi1
1Department of Trauma, Hand and Reconstructive Surgery,
University Hospital of the J.W. Goethe University, Frankfurt,
Germany, 2Institute For Research In Operative Medicine (ifom),
University Witten, Herdecke, Cologne, Germany, 3Department of
Trauma and Orthopedic Surgery, University of Witten, Herdecke,
Cologne-Merheim Medical Centre (CMMC), Cologne, Germany
Introduction: The prehospital treatment time of multiply injured
patients of some 70 min and the on-scene-treatment-time (OST) of
some 30 min were not reduced since 1993. Therefore the required OST
should be analyzed regarding the timely impact of different parameters.
Materials and methods: We performed a retrospective data analysis
of all multiple injured patients from the TraumaRegister� DGU from
January 1993 to December 2010. Exclusion criteria were missing or
implausible data regarding prehospital timelines. With OST as inde-
pendent variable, different models of multivariate regression were
performed to identify parameters with relevant impact on the OST.
Results: 15,103 datasets were included in this study. Based on the mean
OST (32.7 ± 18.6) min and an absolute term of 16.2 (±1.5) min, we
identified seven procedures and nine environmental parameters with
significant impact on this time. Intubation (+9.3 ± 0.8 min) and being a
car occupant (+8.0 ± 0.8 min) led to the most prolonged OST. A GCS
B8 (-4.5 ± 0.7 min) and need for CPR (-2.8 ± 1.7 min) results in its
most relevant reduction. Admission to a Level III facility led to a
reduced overall prehospital time (60 ± 24.6 min) compared to Level I
and II trauma-centers (L I: 70.0 ± 28.5 min, L II: 66.8 ± 27.4 min).
Over the time we observed an increasing mean age and GCS of patients
and decreasing injury severity.
Conclusion: There are characteristic parameters which have signifi-
cant impact on prehospital treatment times. Current treatment
concepts should be re-evaluated with respect to these results, espe-
cially in urban areas.
Disclosure: No significant relationships.
O056
BIOCHEMICAL PROFILE AND OUTCOMES IN TRAUMAPATIENTS SUBJECTED TO OPEN CARDIOPULMONARYRESUSCITATION: A PROSPECTIVE OBSERVATIONALTRIAL
B. Schnuriger1, P. Talving2, K. Inaba2, G. Barmparas2, B.C. Branco2,L. Lam2, D. Demetriades2
1Department of Visceral Surgery and Medicine, Bern University
Hospital, Bern, Switzerland, 2Division of Acute Care Surgery,
LAC + USC Medical Center, Los Angeles, CA, USA
Introduction: The objective of this study was to prospectively assess
the electrolyte profile, coagulation parameters, and acid–base status
from intra-cardiac blood samples in trauma patients subjected to
resuscitative Emergency Department thoracotomy (EDT).
Materials and methods: All patients who underwent resuscitative
EDT following trauma were considered for inclusion. Prior to the
injection of any resuscitative medications, a sample of intra-cardiac
blood from the right chamber was obtained for analysis.
Results: A total of 22 patients had intra-cardiac blood samples
obtained. Twelve patients never regained a pulse, and 10 patients
transiently regained a perfusing rhythm for a mean of 51 ± 69 min.
90 % (20/22) of patients presented with severe acidosis (pH \7.20).
The pCO2 was \45 mmHg in 68 % (15/22) of patients, and the pO2
level was[75 mmHg in 77 % (17/22) of patients. Patients who never
regained a pulse, had a significantly higher lactate level compared to
those with return of a pulse (17.1 ± 2.6 vs. 10.6 ± 4.9 mmol/L,
p = 0.018). The sodium and potassium levels were higher for those
who never regained a rhythm when compared to those who regained a
pulse (sodium: 155 ± 14 vs. 147 ± 9 mmol/L, p = 0.094; potassium:
6.0 ± 1.1 vs. 4.6 ± 1.0 mmol/L, p = 0.014). Severe hyperkalemia
(potassium [5.5 mmol/L) occurred significantly more often in
patients without regain of a heart beat (p = 0.030). A hypocoagulo-
pathic state (INR[1.2 and/or prothrombin time[15 s. and/or platelet
count\100,000/lL) was noted in 96 % of patients.
Conclusion: Most patients undergoing resuscitative EDT have nor-
mal blood gas levels. Severe lactic acidosis, hyperkalemia and
hypernatremia are associated with decreased probability for return of
cardiac function. These findings might have therapeutic implications.
Disclosure: No significant relationships.
O057
DO TERTIARY SURVEYS IMPROVE TRAUMA CARE?A SYSTEMATIC REVIEW AND META-ANALYSIS
G.B. Keijzers1, G.F. Giannakopoulos2, C. Del Mar1, F.C. Bakker2,L.M. Geeraedts Jr3
1Emergency Medicine, Gold Coast Hospital, Gold Coast, Australia,2Trauma Surgery, VU University Medical Centre, Amsterdam, The
Netherlands, 3Trauma Surgery, VU University Medical Center,
Amsterdam, The Netherlands
Introduction: Tertiary surveys (TSs) are often advocated for reduc-
ing missed injuries in hospitalized trauma patients.
Materials and methods: An electronic search (without language or
publication restrictions) of the Cochrane Library, Medline and Ovid
was used to identify studies assessing TS. ‘Missed injuries’ were
defined as either any injury: (1) missed at primary and secondary
survey and detected by TS; or (2) that escaped detection by TS. Two
authors independently selected studies. The risk of bias of was
assessed using the Newcastle-Ottawa scale for observational studies.
Results: Ten observational studies met our inclusion criteria, (none
were randomized), and had variable risk of bias. Three studies reported
outcome data on missed injuries for both intervention and control
cohorts. Meta-analysis was performed by missed injury definition. TS
lead to increased detection of injuries missed at initial assessment, (OR
2.82, 1.02–7.78, P = 0.04) with considerable heterogeneity (I2 = 81
%, P = 0.02). Only one study reported a decrease in missed injuries
not detected by TS (OR 0.66, 0.44–0.90, P \ 0.01). No studies
reported outcome data on long-term health outcomes.
Conclusion: Routine tertiary surveys may improve trauma care,
either by increasing detection of injuries missed during initial man-
agement including the first 24 h, or by decreasing missed injuries as a
result of TS performance. This evidence is based on few studies.
There is a lack of consistent outcome definitions, moderate risk of
bias inherent to observational studies, and absence of long-term
Abstract S23
123
outcomes. Future studies should address these shortcomings. A gen-
eral classification for missed injuries is proposed.
Disclosure: No significant relationships.
O058
DAMAGE CONTROL ICU RESUSCITATION: CONCRETEADVANTAGES IN USING HYPERTONIC SALINE
J.M. A. Gallesio, P. Rosen, D.N. Holena, B. Sarani, C.A. Sims,J. Enberg, J.L. Pascual
Department of Surgery, University of Pennsylvania, Philadelphia, PA,
USA
Introduction: Hypertonic saline (HTS) resuscitation of ICU patients
may reduce fluid requirements significantly. It remains unclear if HTS
also reduces transfusions and if fluid-sparing benefits particularly
affect the renal function of patients with damage control open
abdomens (DCA).
Materials and methods: A four-year (01/07–01/11) retrospective
review was performed of all ICU patients having received HTS for
resuscitation in a tertiary academic institution. Demographics,
hemodynamics, electrolytes, fluid/transfusion needs, and oxygen
requirements were compared 24 h before and 24 h after HTS
administration in the entire group and DCA cohort. Paired t test/Chi
square analysis established significance at p \ 0.05.
Results: 70 patients [mean age 54 (17–86), 64 % male] requiring
intravascular repletion received a mean of 641 (250–1,375) ml of 3 %
HTS. Hospital length of stay was 35 (1–248) d. Hemodynamics did not
differ before or after HTS. 4.1 ± 0.99 units of packed red blood cells
(PRBC) were given the day before, 0.98 ± 0.18, the day after HTS
(p = 0.002). Acidosis was reduced (base excess -4.20 ± 0.71 to -
3.35 ± 0.65 mEq/L, p = 0.03), and lung function, improved (SaO2/
FiO2 165 ± 6.9–178 ± 6.5, p = 0.01) after HTS. Mean BUN, and
creatinine levels rose (p \ 0.05)but increaseswere less than10 %. In the
DCA subgroup (n = 24), crystalloid and PRBC requirements fell by 55
and 82 % respectively (p = 0.01). As expected, mean hemoglobin level
decreased while Na+ and Cl- levels rose (p = 0.006). Furthermore,
their lung function improved (163 ± 7.2–187 ± 6.2, p = 0.007) but
renal function worsened (creatinine 1.5 ± 0.2–1.72 ± 0.2 mg/dL,
p = 0.006). Total group mortality was 30 %, heart failure, 8.3 %, MI
incidence, 2.8 % and hemodialysis use, 2.9 %.
Conclusion: HTS is associated with decreased fluid, red blood cell
transfusion requirements, and improved respiratory function in DCA
patients requiring intravascular repletion. While resultant electrolyte
changes are negligible, clinical effects on renal function remain a
concern. A prospective trial is needed to further delineate advantages
of HTS resuscitation in ICU.
Disclosure: No significant relationships.
O059
THE MANAGEMENT OF ANKLE FRACTURES ATA GENERAL HOSPITAL AND THE POTENTIAL HEALTHECONOMICS OF INITIAL HOME THERAPY
R. Karthigan1, M.R. Ricks2, H. Dabis2
1Trauma and Orthopaedic, Epsom and St Helier Hospital, London,
UK, 2Trauma and Orthopaedic, Epsom and St Helier Hospital,
London, UK
Introduction: Ankle fractures are a common presentations to Acci-
dent and emergency departments and swelling is a well recognised
complication and cause of delay for an operation. We decided to
assess the length of stay at a south London district general hospital
and whether it would be suitable to implement a system to send the
patient home to bring them back in for an operation.
Materials and methods: A retrospective Audit was carried out
looking at the management of Ankle fractures using a proforma
system. We acquired the data from the patients medical notes along
with electronic records and X-ray’s over a 3 month period.
Results: There were 28 patients included in the Audit of which 18
patients had unimalleolar, 5 patients bimalleolar and 5 patients with
trimalleolar ankle fractures. 23 patients went onto have an open
reduction and internal fixation of the ankle and 5 patients underwent a
manipulation under anaesthetic and application of plaster. The aver-
age length of time from admission to operation for all types of ankle
fractures was 1.2 days with an average 2.75 days from operation to
discharge. Thirty percent of the delayed operations were due to
swelling with fifty percent due to a full trauma list.
Conclusion: The Audit shows that ankle fractures are managed very
effectively at this hospital with the majority having an operation on
the same or next day. The main reason for delay was due to a full
trauma list and not swelling. A home therapy programme was intro-
duced to address the full trauma list and swelling.
Disclosure: No significant relationships.
O060
INTERDISCIPLINARY POLYTRAUMA SIMULATION TEAMTRAINING
S. Kuhn1, C. Lott2, W. Marx1, H. Buggenhagen2, T. Ott2,P.M. Rommens1
1Trauma Surgery, Universitatsmedizin Mainz, Mainz, Germany,2Anaesthesia, Mainz, Germany
Introduction: Trauma is the leading cause of death below the age of
40 in Europe. The initial management of trauma patients is dependant
on the efficiency of the trauma team. The goal of our project is to
establish advanced simulation training aimed at the main medical
professionals involved in trauma care.
Materials and methods: One trauma surgeon, two anesthetists, one
radiologist, one trauma nurse, one anesthesia nurse and one X-ray
technologist formed each team (multi year experience in their
field). Instructor one led the scenario, while instructor two pri-
marily operated the simulator. Schedule of the team training:
Scenario 1: Assessment of the primary survey and the treatment of
the potentially life-saving procedures, Lecture Primary Survey,
Lecture Current Protocol, Instructor led demonstration of a stan-
dardized treatment, 7 simulation-based scenarios incl. debriefing,
Workshop Team resource management, Scenario 2: Assessment of
the primary survey and the treatment of the potentially life saving
procedures. Scenario 1 and 2 were video recorded and assessed for
the completeness and duration of the individual items of the pri-
mary survey and until the potentially life saving procedures,
definitive airway, immobilization of the c-spine, thorax decom-
pression, pelvic stabilization, were initiated. 8 per- and post-
training scenarios were compared.
Results: Showed a significant improvement for both completeness
and duration for the primary survey. Additionally there was a sig-
nificant improvement in time until life-saving procedures were
initiated.
S24 Abstract
123
Conclusion: Interdisciplinary polytrauma simulation team training is
an effective method to educate key members of a trauma team.
Disclosure: No significant relationships.
O061
RELEVANCE OF INCIDENTAL FINDINGS IN MAJORTRAUMATIZED PATIENTS AT A LEVEL I TRAUMACENTRE
M. Ruesseler, A. Schill, H. Wyen, S. Wutzler, F. Walcher, I. Marzi
Department of Trauma, Hand and Reconstructive Surgery, University
Hospital of the J.W. Goethe University, Frankfurt, Germany
Introduction: The multislice computed tomography (MSCT) is the
gold standard in the initial evaluation of trauma patients. Besides
providing information regarding the presence or absence of acute
trauma-related injuries, MSCT scans also reveal pathologies unrelated
to the trauma which may or may not be clinically significant. The aim
of the present study is to determine the frequency and clinical
importance of incidental findings in major traumatized patients at a
level one trauma centre.
Materials and methods: This is a retrospective analysis of pro-
spectively collected data on 1.971 major traumatized patients from
2006 to 2009. A total 1.840 patients (93.4 %) underwent an initial
MSCT. The MSCT was retrospectively reviewed regarding unex-
pected findings not related to trauma. These incidental findings were
divided into a 4-point score based on clinical importance and urgency
regarding initiation of further steps.
Results: 839 (45.6 %) of the patients had one or more incidental
findings. A total of 223 tumor findings were noted (11.4 % of all
incidental findings). 119 were suspicious for malignant processes or
metastasis. Furthermore, 362 cystic changes were found, among those
182 renal cysts, as well as 219 vascular changes, hereof 29 aneu-
rysms. 116 (6.3 %) of these patients had degenerative findings.
Regarding the clinical importance, 120 (6.1 %) of the incidental
findings required urgent follow-up (score 4) and 412 (21 %) of the
incidental findings required a follow-up prior to discharge (score 3).
Conclusion: MSCT in major traumatized patients reveals one or more
incidential findings in approx. 50 % of the patients. Hereof, 27 %
require an urgent or rapid follow-up.
Disclosure: No significant relationships.
O062
IMMEDIATE TOTAL-BODY CT SCANNING IN INJUREDPATIENTS: A CASE-MATCHED SERIES
J.C. Sierink1, T.P. Saltzherr1, L.F. Beenen2, M.J. Russchen1,J.S.K. Luitse1, M.G. Dijkgraaf3, J.C. Goslings1
1Trauma Unit Department of Surgery, Academic Medical Center,
Amsterdam, The Netherlands, 2Radiology, Academic Medical Center,
Amsterdam, The Netherlands, 3Clinical Epidemiology, Biostatistics
and Bioinformatics, Academic Medical Center, Amsterdam, The
Netherlands
Introduction: Safe, accurate and rapid diagnostic procedures in
injured patients make sure treatment can be planned and carried out as
soon as possible. Our aim was to compare immediate total-body CT
scanning with conventional imaging supplemented with selective CT
with respect to mortality in trauma patients.
Materials and methods: Between 2009 and 2011, 155 pilot patients
for the REACT-2 trial received immediate total-body CT scanning.
Inclusion criteria were predefined vital parameters and clinical sus-
picions for severe injury. Exclusion criteria were age \18 years,
known pregnancy, referred patients and patients who are too unstable
to undergo a CT scan. Pilot patients were matched on age, sex and
Injury Severity Score (ISS) with controls from a historic cohort
(2006–2007) who underwent conventional imaging and selective CT.
Of 48 pilot patients admitted during daytime, several time intervals
were prospectively registered.
Results: Pilot patients were comparable to controls with respect to
age (42 vs. 42 years), sex (71 vs. 72 % men), ISS (18 vs. 18) and
mechanism of injury (96 vs. 94 % blunt). Median hospital stay was
9 days in the pilot group versus 7 days in the control group
(P = 0.009). Overall mortality was 14.8 % in both groups. In 48 pilot
patients, median time from admission to scanning was 11.7 min
(scanning time 7.4 min) and all relevant diagnoses were known
within 29.6 min.
Conclusion: Mortality rate in injured patients who underwent a total-
body CT is comparable with matched patients who received con-
ventional imaging. With the use of immediate total-body CT all
relevant diagnoses can be known within 30 min.
Disclosure: No significant relationships.
IMPLANT REMOVAL
O063
THE IMPLANT REMOVAL TRIAL: RESULTS OF A DUTCHPROSPECTIVE MULTICENTRE CLINICAL COHORTSTUDY
D.I. Vos1, M.H.J. Verhofstad2, C. Van Der Werken3
1Trauma Surgery, Amphia Hospital, Breda, The Netherlands,2Traumacentrum Brabant, St. Elisabeth Hospital, Tilburg,
The Netherlands, 3UMCU, Utrecht, The Netherlands
Introduction: The indication for surgical removal of metal implants
after fracture healing is not well defined with ongoing discussion in
literature and different policies from country to country. Currently
surgeons decide at their own discretion to remove or to leave metal
implants in after fracture healing. Many patients relate complaints and
symptoms like pain, swelling and stiffness, after their fracture has
healed, to the presence of the metal implant. The question is whether
these problems are really due to the implant or exist anyway because
of the injury, the subsequent surgery, the healed fracture or scar
tissue.
Materials and methods: We performed a prospective multicentre
clinical cohort study in the Netherlands in order to evaluate implant
removal surgery related complications, complaints of the patients
before and after surgery, functional outcome and social consequences,
by using questionnaires, clinical investigations and radiographs.
Results: In 6 hospitals a total of 304 adult patients with a healed
fracture, after osteosynthesis with a plate or intramedullary nail of the
clavicle, humerus, radius, ulna, femur or tibia participated in the
study. The follow up after nail removal was 6 months, after plate
removal 1 year. Preliminary results showed a significant reduction of
complaints of the patient after implant removal and the overall
Abstract S25
123
complication rate seems to be low. The final and detailed results of
this study will be presented.
Conclusion: Implant removal after fracture healing in symptomatic
patients reduces complaints and has a low complication rate.
Disclosure: This study has been supported by the AO foundation,
Davos Switzerland.
O064
A NEW METHOD FOR HARVESTING AUTOLOGOUSSPONGIOSA, THE RIA METHOD. PROMISING LOWERMORBIDITY
B.T. Szelle1, R. Haverlag2
1Traumatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The
Netherlands, 2Traumatology and Surgery, Onze Lieve Vrouwe
Gasthuis, Amsterdam, The Netherlands
Introduction: Autologous spongiosa is considered as the ‘‘gold
standard’’ in treatment for pseudoarthrosis, one of the difficulties in
obtaining autologous spongiosa is its high morbidity [1]. The pre-
ferred location for harvesting spongiosa is the iliac crest with a 19.3
percent complication rate [2]. It is now possible to harvest spongiosa
from the intra-medullary canal of the femur withe the RIA (Reamer/
Irrigator/Aspirator) method and it is recorded that only 6 percent
developed a complication. Therefore we see this as a reason for us to
use this technique in our clinic and to analyze whether we also see a
lower morbidity.
Materials and methods: Until now we have used the RIA method in
9 patients for obtaining autologous spongiosa. We recorded the VAS
score and the SF-12 questionnaire was completed by these patients.
In addition all patients over the past 10 years in our clinic, who
underwent a treatment with autologous spongiosa harvested from the
iliac crest, were approached to complete the SF-12 questionnaire and
to submit a VAS score noting.
Results: The first results show a considerably shorter recovery period
from pain and regaining full function with the RIA method compared
to the iliac crest.
Conclusion: Based on our experience and the VAS measurement
from the 9 patients with problems in bone healing, we believe that
RIA method has a promising future in obtaining autologous spongi-
osa, especially because of the reduced morbidity.
References: 1. Bauer TW, Muschler GF. Bone graft materials. An
overview of the basic science. 2. Dimitriou R. Complications fol-
lowing autologous bone graft harvesting from the iliac crest and using
the RIA.
Disclosure: No significant relationships.
O065
RESULTS AFTER USE OF THE REAMER-IRRIGATOR-ASPIRATOR; MORE ADVERSE EVENTS THAN EXPECTED
P. Reynders
Traumatology, UZ Gasthuisberg Leuven, Tielt-Winge, Belgium
Introduction: The Reamer-Irrigator-Aspirator was originally
designed as a one-pass reamer for intramedullary nailing of the
femur. The reamer combines a very sharp reamer-head with a sys-
tem that continuously irrigates the endomedullary canal with saline
and an aspirator that removes the saline mixed with morselized
bone.
Materials and methods: We retrospectively studied all consecutive
patients who underwent a RIA-procedure in the period 01-01-
2008–01-07-2010. For RIA bonegrafting, success was defined by
complete bony healing at the grafted site, as seen on a plain
radiograph. Failure was defined by persisting non-union of the
treated site or by secondary surgery for non-union or delayed
union.
Results: Of a total of 32 patients, ten patients healed uneventfully.
Delayed healing was noticed in eight cases. Ten patients failed to
heal. There were nine complications (28 %). Five cases of cortical
bone erosion and two cases of bone fractures were noticed, both in
the trochanteric region. In the group of complications, two patients
had an intra-operative drop in oxygen saturation (below 90 %)
together with a decrease in exhaled carbon dioxide (below
25 mmHg).
Conclusion: The system is not very forgiving however and good
surgical technique is mandatory. It is essential to control the guide
wire in both the AP and lateral views so that it passes through the
exact center of the medullary canal. Even then, eccentric reaming and
cortical violation is possible.
Reference: 1. Giannoudis PV, Tzioupis C, Green J. Surgical tech-
niques: how I do it? The Reamer/Irrigator/Aspirator (RIA) System.
Injury. 2009;40:1231–6.
Disclosure: No significant relationships.
O066
LONG-TERM OUTCOME AFTER OPERATIVETREATMENT OF MAISONNEUVE TYPE ANKLEFRACTURES
K.T.A. Lambers, M.P.J. Van Den Bekerom, J.N. Doornberg,S.A.S. Stufkens, C.N. Van Dijk, P. Kloen
Department of Orthopaedic Surgery, Academic Medical Center,
Amsterdam, The Netherlands
Introduction: Maisonneuve type ankle fractures have an estimated
incidence of 5 % of all surgically treated ankle fractures. The aim of
this study was to report long term results of surgically treated Mai-
sonneuve type fractures. The second aim was to indentify predictors
of outcome.
Materials and methods: Fifty Maisonneuve type ankle fractures
were included. Long-term follow up averaged 21 years after surgery
(range 9–35 years). The results were evaluated according to three
standardized outcomes instruments: (1) Foot and Ankle Ability
Measure (FAAM), (2) American Orthopaedic Foot and Ankle Society
(AOFAS) ankle-hindfoot scale and (3) Center for Epidemiologic
Studies Depression Scale (CES-D). Osteoarthritis was graded
according to the van Dijk- and revised Takakura scoring systems.
Bivariate and multivariate analyses were performed to identify pre-
dictors of long-term outcome.
Results: A total of 96 % had good to excellent AOFAS scores.
Seventy-one percent of the patients reported no pain. A total of 89 %
had good to excellent FAAM scores. Radiographic evidence of
arthrosis was seen in half of the patients.
Multivariate analysis identified pain as the most important indepen-
dent predictor of long term ankle function according to AOFAS
S26 Abstract
123
scores and FAAM scores explaining 93 and 63 % of variation in
scores. Analyzing pain as a dependent variable; depression, ankle
range of motion and a subsequent surgery where significantly corre-
lated to higher pain scores in bivariate analyses. However in
multivariate analysis for predictors of pain, only 7 % of variation
could be accounted for by ankle range of motion (inversion).
Conclusion: Long-term functional outcome at an average of 21 years
after Maisonneuve type ankle fractures treated with one or two syn-
desmotic screws are good to excellent in the vast majority of patients.
The most important predictor of long term functional outcome is
patient reported pain –not physician reported function, nor posttrau-
matic arthrosis. In this series, there was no significant association
between posttraumatic arthrosis and perceived pain.
Disclosure: No significant relationships.
O067
FIXATION OF SYNDESMOSIS RUPTURE: WHY WAITAFTER SURGERY FOR A 3-D POSITION CONTROL?
R. Kraus1, C. Candrian2, R. Rosso3, M. Arigoni4
1Klinik Fur Chirurgie, Kantonsspital Aarau, Aarau, Switzerland,2Chirugie Generale E Ortopedia, Ospedale Regionale di Lugano,
Lugano, Switzerland, 3Chirurgie Generale E Ortopedia, Ospedale
regionale di Lugano, Lugano, Switzerland, 4Chirurgia Generale E
Ortopedia, Ospedale Regionale di Lugano, Lugano, Switzerland
Introduction: Malposition of the fibula after fixation of syndes-
mosis lesions has been shown to be a frequent problem and occurs
in up to 50 % of the cases in some studies. Many authors therefore
recommend a postoperative control with a CT-scan after such
procedures. But why not perform this control during surgery? The
O-arm surgical imaging system enables intraoperative 2-D and 3-D
image acquisition. In this study we present our experience with the
intraoperative use of the O-arm in the treatment of syndesmotic
injuries.
Materials and methods: We treated 7 syndesmotic lesions by fixa-
tion with screws using a intraoperative control with the O-arm. The
tibio-fibular joint was first reduced and fixed under conventional
fluoroscopy. The position of the joint was then controlled with a 3-D
image acquisition. If the position was satisfactory then definitive
fixation. If the joint position was wrong then reduction was changed
before definitive fixation was carried out. Finally a last 3-D control
with the screw was performed.
Results: 5 patients were treated primary. 2 of these patients needed a
change in reduction of the tibio-fibular joint after intraoperative 3-D
imaging. The other two patients showed a good reduction result. The
postoperative CT-scan of further 2 patients showed a malposition of
the tibio-fibular joint which was then corrected in a second operation
under intraoperative 3-D imaging control.
Conclusion: Although our study population is very small there seems
to be a clear advantage in intraoperative 3-D imaging control of
syndesmosis fixation. Indeed two of the primary treated patient would
have been fixed in a wrong position without intraoperative 3-D
imaging. Further studies are needed to confirm our preliminary
findings.
Reference: 1. Sjoerd A, et al. Evidence-based treatment of Maison-
neuve fractures. J Foot Ankle Surg. 2011;50:62–7.
Disclosure: No significant relationships.
O068
APPLICATION OF POSITIONING-SCREWS AND TESTINGOF THE METHOD IN CASE OF ANKLE INJURIES:ASSESSMENT OF SCREW POSITION, FINDING THE RIGHTREDUCTION OF DISTAL TIBIOFIBULAR JOINT
A. Kocsis1, J. Szita2, I. Kadas2, Z. Magyari2, Z. Fejer3
1Iv. Trauma Department, Peterfy S. Hospital, Trauma Centre,
Budapest, Hungary, 2Peterfy S. Hospital, Trauma Centre, Budapest,
Hungary, 3Department of Human Morphology and Developmental
Biology, Budapest, Hungary
Introduction: Weber C-type ankle-fractures are usually followed by
distal tibiofibular joint injury, so the use of positioning-screws is
mandatory. Although we achieved good radiological results during
the follow-ups, we recognized several complications not caused by
the surgical procedure.
Materials and methods: In our institute AO/C1 and C2 type fractures
are treated by plates and positioning screws. During surgery, the
reduction of distal tibiofibular joint is verified by intraoperative meth-
ods: X-ray amplifier and assessment of movement-range of the joint.
Despite the well-executed surgery and satisfactory radiological
results, we observed complaints during the follow-up. These com-
plications led us to make additional CT-scans.
Results: Comparison of the CT-scans and X-rays proved that the
standard radiography (AP and Mortise views) is not enough to judge
the reduction. Beside excellent X-ray results we observed on CT-
scans, that the fibula didn’t fit into the tibial joint surface. The second
most common error were the altitude and direction of screws which
caused the implant-loosening or synostosis of the tibiofibular joint.
Incidental finding was that distal joint-break does not occur in every
Weber C-type fractures, but also Weber B-type fractures can be fol-
lowed by break.
Conclusion: Stability of distal tibiofibular joint must be always
verified during the surgery, including Weber-B type fractures. If
instability occurs, positioning-screws must be used, but if the joint is
stable, crews should be avoided to achieve early weight-bearing. The
result of reduction cannot be verified only by AP or Mortise views: a
third, accurate lateral direction must be done to check the fibula’s
position in sagital axis.
Disclosure: No significant relationships.
O069
COMPLICATIONS OF DISTAL THIRD TIBIA FRACTURES
M. Rackham1, D. Huynh1, B. Ramasamy2, P. Stavrou3, L.D. Iselin1
1Orthopaedic and Trauma Service, Royal Adelaide Hospital,
Adelaide, Australia, 2Royal Adelaide Hospital, Adelaide, Australia,3Royal Adelaide Hospital, Adelaide Orthosports Clinic, Adelaide,
Australia
Introduction: Distal third lower limb fractures are commonly seen in
motor vehicle and motorbike accidents with a high morbidity. They
are generally known to have a prolonged healing time even if
uncomplicated. The aim of our study was to assess the management of
complications and reoperations in a level 1 trauma centre.
Abstract S27
123
Materials and methods: Retrospective trauma databank review of
250 distal third lower limb fractures treated in a level 1 trauma centre
from 2001 till 2011. Analysis: Fracture classification according to the
AO, assessment of complications (infections, angular deformity, mal-
and non-union), planned and unplanned reoperations (removal of
metal work, corrective surgery).
Results: 247 patients. Gender distribution M:F 180:67. Mean age 43
(17-–84). Fixation ORIF:IM-nail equally distributed. Complications
in 25 %. Reoperations in 15 %.
Conclusion: A greater number of cases with ORIF showed deep
infections, while more patients treated with an IM-nail had mal-
alignments. No difference with regard to time to union, non-union and
hardware failure between ORIF and IM nailing were found.
Reference: 1. Janssen KW, Biert J, van Kampen A. Treatment of
distal tibial fractures: plate versus nail. A retrospective outcome
analysis of matched pairs of patients. Int Orthop. 2006;31(5):
709–14.
Disclosure: No significant relationships.
O070
MANAGEMENT OF DISTAL TIBIAL METAPHYSEALFRACTURES: INTRAMEDULLARY NAILING VERSUSPLATE FIXATION
M. Al-Najjim1, C. Fenton2
1Trauma and Orthopaedics, North Staffordshire University Hospital,
6TB, UK, 2Trauma and Orthopaedics, Scunthorpe General Hospital,
7BH, UK
Introduction: Fractures of the distal tibia are common consequences
of foot balling or road traffic accidents and it counts for 7.2 % of
distal end tibial fractures [1]. The aim of the study to perform a
systematic review of the available literature comparing the outcomes
of intramedullary nailing to plate and screw fixation in the treatment
of distal metaphyseal fractures of the tibia.
Materials and methods: Medline and EMBASE databases were
searched for English language articles up to September 2010. Articles
were considered for review if they satisfied the following inclusion
criteria: Randomised Controlled Trials (RCT) comparing intramed-
ullary nailing to plate and screw fixation of distal metaphyseal tibial
fractures. Adult patients above 17 years of age and including both
genders. Extra articular fractures or those with only a minimally
displaced extension into the ankle joint. Outcome measures of interest
are imaging time; wound healing problems, operating time, the time
to union of the fracture and mobility following surgery. Critical
appraisal of the selected studies was carried out using the CASP
appraisal tool for RCT.
Results: Two articles were identified from the search that met the
inclusion criteria. Measured outcomes in both studies were; the
duration of surgery, time to radiological union, wound complication
rates, radiation exposure and operating time, angulation, range of
movement and functional ankle score. Both trials demonstrated
superior results in the intra-medullary nail group with less operating
time (P).
Conclusion: Both techniques are reliable methods for treating distal
tibial metaphyseal fractures. Intra-medullary fixation was shown to be
superior to the plate fixation group particularly when there is asso-
ciated extensive soft tissue injury. There is relatively less radiation
exposure to both patients and operating staff and is a shorter proce-
dure meaning less anaesthetic time.
Reference: 1. Ovadia DN, Beals RK. Fractures of the tibia plafond.
J Bone Joint Surg (Am) 1986;68-A:543–51.
Disclosure: No significant relationships.
SOFT TISSUE MANAGEMENT
O071
THE USE OF WOUND VAC SYSTEMS IN THE TREATMENTOF SEVERE COMBAT INJURIES THE AFGHANISTANEXPERIENCE
R.S. Breederveld1, M. Timmers2
1Surgery, Red Cross Hospital, Beverwijk, The Netherlands,2Emergency Department, Red Cross Hospital, Beverwijk, the
Netherlands
Introduction: Combat injuries, especially caused by Improvised
Explosive Devices, are frequently high energy blast wounds causing
intense devitalization and contamination, thus leading to an high risk
of complications. Basic treatment principle is repetitive irrigation
and debridement with secondary closure at the end. Based on spo-
radic data from the literature we used a novel wound management
strategy.
Materials and methods: Primary treatment of blast injuries to the
extremities consisted of a rapid but intensive irrigation and debride-
ment then a second irrigation and debridement took place after 48 h
followed by placement of a Wound VAC (Vacuum Assisted Closure)
Another 48 h later the VAC system was removed and if wound
inspection showed a vital wound definitive closure took place, either
directly or with a skin graft.
Results: 23 Patients were treated this way, in the Multinational
Medical Facility in Kandahar Air Field, Afghanistan. Only 2 I&D
procedures were necessary in 15 of these wounds before definitive
closure and 3 procedures were done in 8 wounds. Mean period of time
from the incident until definitive closure was 5 days. Follow up varied
from 0 to 9 weeks. There were only 3 major complications: one
patient needed a lower leg amputation because of necrosis and 2
patients needed a reoperation because of late infection during the
postoperative period.
Conclusion: Early treatment of combat wounds with a severe soft
tissue loss with a VAC system, results in a rapid and almost
uncomplicated wound healing.
Disclosure: No significant relationships.
O072
KEEP IT SIMPLE: REPLACEMENT OF COMPLEX PLASTICSURGERY IN SOFT TISSUE DEFECTS BY DERMALSUBSTITUTES
M. Ohlbauer1, B. Wallner1, M. Militz2
1Department of Reconstructive Surgery, BG Trauma Center Murnau,
Murnau, Germany, 2Department of Septic Surgery, BG Trauma
Center Murnau, Murnau, Germany
Introduction: Despite successful defect coverage by means of
complex skin flaps, particularly large and deep problematic wounds
after soft tissue loss are very susceptible to surgical revision because
S28 Abstract
123
of contour and scar deformities. Matriderm�, a dermal substitute
consisting of a native collagen matrix supplemented by an elastin
hydrolyzate was first used for the treatment of burns. Subsequently, its
use was extended to reconstructive surgery, especially in defect
coverage after soft tissue loss.
Materials and methods: In 25 patients with soft tissue defects of
lower extremity operative debridement showed exposed tendons, joint
capsules, free bone or free periosteal structures. In all patients after
accurate debridement defect coverage was performed in a one-step
procedure with 1 mm Matriderm� and unmeshed split skin grafts in
combination with negative pressure wound therapy for 1 week for
fixation of the split skin grafts.
Results: One-year follow up showed an excellent functional outcome:
Up until now, no areas with unstable scars have occurred, no surgical
scar revision were required. The patients were still able to wear
normal footwear, clinical gait analysis showed perfect functional
outcome. In children, the skin areas treated with Matriderm� seem to
grow as well.
Conclusion: The application of dermal substitutes in patients with
soft tissue defects treated so far represents an excellent reconstruction
method, from initial coverage to scar development.
Disclosure: No significant relationships.
O073
FASCIO-CUTANEOUS SUPRACLAVICULAR ARTERYPERFORATOR FLAP: A SIMPLE AND RELIABLE METHODIN RECONSTRUCTION OF FACIAL AND NECKPOST-TRAUMA &/OR POST-BURN INJURIES
T.M. Seif1, H. Helmy2, T. Said2, A.G. Elsharkawy2, H.O. Elwan2
1Surgery, Kasr Eleini Hospitals, Cairo University, Giza, Egypt,2Kasr Eleini, Cairo, Egypt
Introduction: Post-traumatic, and post-burn defect in the face and
neck represent a challenging sector of reconstructive surgery. We aim
to introduce the role of supraclavicular artery perforator flap to
evaluate the functional and aesthetic outcome.
Materials and methods: This prospective study included patients
presenting with post-trauma and/or post-burn facial and neck defects
along the period of 8-2008 to 10-2011. Patients included had a defect
causing functional &/or aesthetic insult in the face and neck. All
patients were treated with fascio-cutaneous supraclavicular artery
perforator flap. Patients were preoperatively evaluated by physical
examination and with pocket Doppler.
Results: 13 flaps were done in 11 patients. Modes of trauma were
flame-burn in 9 cases, blasts in 1 case, and bullets in 1 case. Two
patients had bilateral flaps done while 3 had additional split thick-
ness grafts to cover the defects and 3 had split thickness graft to
cover the donor site. Cutaneous nerve supply of the flap was pre-
served in 9 flaps, mean operative time was 2.5 h and the mean
postoperative hospital stay was 6 days. Complications included 2
cases of donor site dehiscence and 3 cases of partial loss of split
thickness grafts.
Conclusion: Fascio-cutaneous supraclavicular artery perforator
flap is a very versatile and reliable flap for the coverage of the
face and neck defects with acceptable aesthetic and functional
outcome.
Disclosure: No significant relationships.
O074
USE OF A COLLAGEN MATRIX DERMAL REGENERATIONIN THE TRAUMA SURGERY. EARLY RESULTS INCRITICAL SITUATIONS
E. Sagnak, F. Renken, A. Paech
Traumatology, University Lubeck, Lubeck, Germany
Introduction: Coverage of deep traumatic defect wounds is the main
indication for the use of autologous skins grafts. Scar contractures and
poor skin quality often result in bad functional results especially in
highly strained regions as joints and tendons. Usage of collagen–
elastin matrix e.g. Matriderm with split-thickness skin grafts in
traumatic joint and tendon associated defect wounds may result in
better function.
Materials and methods: In this study 10 traumatic defect wounds of
the upper and lower leg were treated with the simultaneous applica-
tion of Matriderm (R), a bovine based collagen and elastin-
hydrolysate based dermal substitute, and split-thickness skin grafting
(STSG). The study was designed as a prospective observatory and
comparative study. Data were assessed 1 week, 6 week and 3 month
after surgery. Following criteria were assessed: take in time, Graft
survival, skin quality (Vancouver Burn Skin Score) and quality of
life.
Results: Compared to average STSG, survival of simultaneous matrix
application did not alter graft survival. Although time of surface
remodeling seems to be prolonged graft quality and quality of life
were higher compared to control group with single STSG. Even joint
function was less affected.
Conclusion: The use of Matriderm (R) and STSG simultaneously
offer better results in treatment of traumatic defect wounds. Graft
quality can be improved and a better joint function can be reached.
Further studies with a higher number of patients may can prove higher
impact.
Reference: Recommendation of Dr. Heim.
Disclosure: No significant relationships.
O075
LOWER LIMB OPEN FRACTURE MANAGEMENT WITHEARLY PLASTIC SURGEON INVOLVEMENT: DOES ITMAKE A DIFFERENCE?
H.M.T. Fawi1, P. Inaparthy2, R. Clifton2
1T&O, A6 Link, Univ. Hosp. of Wales, CF14 4XW, UK,2Addenbrookes, 0QQ, UK
Introduction: The potential risk of complications following lower
limb open fracture can be devastating, early and efficient management
of these fractures is of paramount importance. We evaluated the
current practice towards the management of open fractures in our
Department compared to early years to assess the early intervention
with plastic surgeons involvement.
Materials and methods: This is a retrospective study looking at all
lower limb fractures admitted between 2004–2010 to Addenbrook’s
Hospital. We looked at timing and types of antibiotics used,
involvement of plastic surgeons, timing and grade of surgeons, timing
of definitive skeletal stabilisation and the outcomes were identified.
Abstract S29
123
Results: In over 70 % of times intravenous antibiotics were admin-
istered within 3 h of the time of injury. The choice of antibiotic
varied. In 47.5 % of cases plastic surgeons were involved (mainly
type II and above open fractures). 40 out of 40 patients were operated
on within 24 h of the injury. In over half of patients, consultant grade
operated on the patients, no patients were operated on by less than a
middle grade surgeon. Vacuum form dressing was not used in most
patients. No patients developed deep infection. Most patients had
their definitive fixations within 72 h. One patient needed bone
transport for major bony defect.
Conclusion: Early involvement of plastic surgeons and senior tier of
orthopaedic surgeons including middle grades reduced the risk of
complications significantly. Early communication with plastic sur-
geons team allowed definitive treatment to be done within 72 h. No
evidence of complication attributed to the level of the operation
surgeons having most being middle grade or above. No patients
developed a major complication with this regime.
References: 1. Vanrensberg, L. Open fractures. http://www.rcsed.ac.
uk/fellows/lvanrensburg/classification/commonfiles/open.htm, http://
www.bapras.org.uk. 2. Patzakis et al. Clin Orthop. 1989;(243):
36–40 (BOA/BAPRAS updated guidelines)
Disclosure: No significant relationships.
O076
NEGATIVE PRESSURE WOUND THERAPY WITHPOLYHEXANID SOLUTION INSTILLATION ASTREATMENT FOR POSTTTRAUMATIC OSTEOMYELITISIMPROVES OUTCOME
G.N. Jukema1, M. Timmers2, A. Bernards3, R. Nelissen3,J. Van Dissel3, H.P. Simmen1
1Division of Trauma Surgery, University Hospital Zurich, Zurich, The
Switzerland, 2Red Cross Hospital, Beverwijk, The Netherlands,3Leiden University Medical Centre, Leiden, The Netherlands
Introduction: Posttraumatic infection is a hard to treat complication
with a high rate of recurrence. Introducing a novel therapy a retro-
spective, case control cohort study for patients with posttraumatic
osteomyelitis was performed. Aim was to to heal posttraumatic
osteomyelitis and to reduce the risk of recurrence of infection.
Materials and methods: Negative Pressure Wound Therapy
(NPWTi) is a novel form in which the foam is instillated with a fluid.
In this study an antiseptic polyhexanid 0.2 % solution was used. The
foam was instillated 3 times a day. Negative pressure settings were in
the range 125–400 mmHg. In the period of 1.1999–2.2003 30 patients
with posttraumatic osteomyelitis were included and treated with
NPWTi technique. The average time of treatment was 22.4 days
(6–60).In 93.9 % infected wounds became sterile after a mean of
11.4 days (range 3–38). Time for follow up was up to 84 months. For
comparison a historical control group with standard treatment
(debridement, lavage, gentamycin beads) of 94 patients (male 58,
mean age 47 years matched for severity of osteomyelitis for a period
of 20 years (1982–2002). In both groups antimicrobial substances
were administered (max. 12 weeks).
Results: Both groups were statistical comparable. However in the
NPWTi group the rate of recurrence of infection was 10 versus
58.5 % in the controls. The duration of hospital stay was shorter and
the number of admissions and surgical procedures was statistical
significant smaller as compared with the controls (all p \ 0.0001).
Conclusion: NPWTi seems to be favourable for the treatment of
posttraumatic osteomyelitis and reduces the risk for recurrence.
Disclosure: No significant relationships.
O077
WOUND COMPLICATIONS OF SURGICAL MANAGEMENTOF ANKLE FRACTURES IN DIABETICS: A SIMPLIFIEDAPPROACH TO MANAGEMENT
M..A. Siddiqi, Z. Idrees
Department of Orthopaedics, Liaquat National Hospital, Karachi,
Pakistan
Introduction: Ankle fractures in diabetic patients present a unique
management challenge. Wound complications are a major concern.
Problems associated with bone union are affected by injury to surgery
time. Initial stabilization with K-wires or external fixators has been
advocated until the swelling has decreased to allow internal fixation.
Materials and methods: We retrospectively reviewed prospectively
collected data of 50 diabetics treated for displaced ankle fractures
from January 2008 to March 2011 at Liaquat National Hospital,
Karachi. We used a simplified clinical approach for initial stabiliza-
tion using closed reduction and management in plaster with elevation
for 2 weeks or until wrinkle sign appears before undertaking surgery.
We also performed few percutaneous internal fixations to minimize
the surgical footprint. Outcome measures guaged were wound com-
plications and functional outcome using AOFAS score.
Results: Using our simplified protocol of reduction and close clinical
monitoring, we have experienced satisfactory results in comparison
with internationally quoted figures of wound complication rate and
functional outcome.
Conclusion: From our study we demonstrate that closed reduction
and watchful waiting is a good alternative to rigid external fixation or
percutaneous pinning to maintain ankle reduction before definitive
surgery. Delaying operative intervention does not compromise overall
functional outcome and union rates.
Reference: 1. Chaudhary SB, et al. Complications of ankle fracture in
patients with diabetes. J Am Acad Orthop Surg. 2008; 16(3):159–70.
Disclosure: No significant relationships.
O078
TREATMENT PROBLEMS IN OPEN ANKLE INJURIES
M. Nagea1, O. Lupescu2, C. Patru3, G.I. Popescu4, D. Sucoveschi1,D. Lupescu5
1Orthopedic and Trauma Clinic, Clinical Emergency Hospital
Bucharest, Bucharest, Romania, 2Orthopedics and Trauma Clinic,
Clinical Emergency Hospital Bucharest, University of Medicine and
Pharmacy, Bucharest, Romania, 3Orthopedics and Trauma Clinic,
Clinical Emergency Hospital Bucharest, Bucharest, Romania,4Orthopedic and Trauma Clinic, University of Medicine and
Pharmacy, Bucharest, Romania, 5General Medicine, University of
Medicine and Pharmacy, Bucharest, Romania
Introduction: Skin injury which characterizes the open trauma makes
sometimes quite difficult the choice between different techniques,
especially concerning the incision and the type of bone stabilization,
which are definitely influenced be the time from trauma and mainly
by the injury of the skin.
S30 Abstract
123
Materials and methods: We analyze 16 patients with open trauma of
the ankle, operated between 01.01.2005–01.01.2007, age
24–52 years. The injuries were both bony and capsule-ligamentous in
13 cases, 3 patients had open dislocations without fractures; surgery
was performed immediately after arriving in our hospital. Following
Gustillo–Andersen classification, the injuries were type I-2 cases, type
II-6 cases, type III-8 cases, from which type IIIA-2 cases, III B-3
cases and III C-3 cases. Different therapeutical problems were raised
for each type of open injury requiring different surgical techniques.
Results: The circumstances influencing post-operative outcome were:
the time between trauma and surgery, the type of the skin and soft
tissue injuries. Septic complications appeared in 12.5 % cases with
Staphylococcus aureus. Because of irreversible ischemia, amputation
was indicated in 1 case.
Conclusion: The treatment of open trauma of the ankle is difficult
since the cutaneous injury narrows the therapeutical options and post-
operative complications are more frequent. The key of success in
these cases is represented by early surgery adapted to the soft tissue
injury.
Reference: 1. Bucholz R, Heckman JD. Rockwood and Green’s
fractures in adults. 6th ed. Philadelphia: Lippincott, Williams &
Wilkins. 2005.
Disclosure: No significant relationships.
COLD AND HOT
O102
CO-EXISTENCE OF ATLS AND ETC. COURSES INSLOVENIA
M. Grunfeld1, R. Kosir2
1Prehospital Unit, HEALTH CENTRE KRANJ, Kranj, Slovenia,2Department for Traumatology, University Clinical Center Maribor,
Maribor, Slovenia
Introduction: Two courses, the ATLS and the ETC both teach the
approach to the initial care of trauma patients in an effort to promote a
common language to the initial care of polytraumatized patients. The
difference being that ATLS as American model teaches the vertical
approach, whereas the ETC teaches the horizontal, team approach, as
this is the way major trauma patients are taken care of in centers all
over Europe.
Materials and methods: To describe the relationship between ATLS
and ETC team approach courses in Slovenia, a country of 2 million
inhabitants, with a total of 5,500 doctors (2.25 per 1,000 population)
and a limited budget for CME.
Results: Both these courses target the same population of merely 800
doctors involved in primary trauma care in Slovenia. So do we really
need both courses in such a small country? Each course teaches the
initial approach to the trauma patient, but from different perspectives.
Conclusion: We believe that initial training of ATLS principles
combined with following training in ETC principles complement each
other. Based on a short period of co-existence of both courses in
Slovenia we see, that the coexistence of both courses would enable
doctors involved in the initial trauma care to improve their knowledge
and skills in a two-stage structured manner rarely practiced in other
countries.
Disclosure: No significant relationships.
O079
CRITICAL HYPOTHERMIA IN MOUNTAIN RESCUE
S. Hungerer1, T. Geiser1, V. Buhren2
1Heli Rescue, BG Trauma Center, Murnau, Germany, 2Trauma
Surgery, BG-Unfallklinik Murnau, Murnaum, Germany
Introduction: The principle ‘‘no patient is dead until rewarmed and
dead’’ is the basic guideline for the resuscitation of patients with
accidental deep hypothermia. We report about two patients who were
rescued in the mountains with deep hypothermia of 17 and 24 �C.
Both patients survived, although their clinical course and outcome
differed in the end. The algorithm for the treatment of deep hypo-
thermia proved valid in both cases.
Materials and methods: We present the rescue and resuscitation of
two patients referring to the algorithm of the treatment of deep
accidental hypothermia.
Results: Case I: Winter, -12 �C, 17 years old patient, exhausted and
alcoholized found after 5 h search without injuries, asystolic and
17 �C body temperature. Due to weather conditions the resuscitation
time summed up to over 2 h until the rewarming with ECC was started.
The young man regained walking abilities and mental status recov-
ered stepwise. On day 55 after resuscitation the patient died because
of a non ischemic bowel necrosis (NIBN).
Case II: Winter, -10 �C, 26 year old patient suffered a fall of more than
80 m and landed headlong in a snowdrift. He was found after 18 h. The
rescue helicopter was requested for the certification of death. The patient
was still breathing and HR was 26/min. Inhospital external rewarming was
performed and the patient recovered without major handicap.
Conclusion: The algorithm of the treatment of deep accidental
hypothermia proved to be successful for the initial treatment of both
patients. The non ischemic bowel ischemia is a complication, prob-
ably attributable as longterm-sequel of the deep hypothermia.
Disclosure: No significant relationships.
O080
EDUCATION IN MOUNTAIN RESCUE FOR DOCTORSIN SWITZERLAND
M. Brodmann Maeder
University Emergency Centre, Inselspital, University Hospital, Bern,
Switzerland
Introduction: Since 1990 the Swiss Society of Mountain Medicine
organizes courses in mountain medicine. The structure emphasizes
the practical outdoor work in combination with lectures. Mountain
guides train the participants in mountain rescue techniques, supple-
mented by medical workshops. The content is based on the
requirements for the International Diploma in Mountain Medicine.
Materials and methods: The participants are asked to evaluate the
lectures, workshops, their class teacher and the course organization on
a Likert Scale from 1 (very poor) to 5 (excellent). The components of
the ratings are: Presenter’s competence, relevance of the topic, pre-
sentation technique and general impression, and knowledge, skills,
attitude and leadership of the class teacher.
Results: 207 forms were ready for evaluation. Almost all the lectures
and workshops get ratings between 4 and 5 (mean 4.1–4.9, SD ±0.2
Abstract S31
123
to 1.0), highest in the speakers’ competence and the relevance of the
topics. The mountain guides mostly get excellent ratings.
Conclusion: The Swiss courses in mountain medicine with emphasis
on mountain rescue are highly appreciated. The mix of practical
training and theoretical lectures is successful, and surprisingly the
lectures and the workshops get equally high ratings. All the faculty
members receive a summary of the evaluation, and this helps to
constantly improve the courses.
Reference: available on request.
Disclosure: No significant relationships.
O081
LOWER LIMB AMPUTATIONS IN WAR SURGERY:RECENT EXPERIENCE OF THE NATIONAL MILITARYHOSPITAL OF KABUL
L. Mathieu1, A. Marty2, A. Ramaki3, A. Najib3, I. Wardak3,W. Ahmadzai3, F. Rongieras1, S. Rigal4
1Orthopedic and Trauma Surgery, Military Academic Hospital
Desgenettes, France, 2Military Academic Hospital Legouest, Metz,
France, 3Orthopedic and Trauma Surgery, National Military Hospital,
Kabula, Afghanistan, 4Orthopedic and Trauma Surgery, Military
Academic Hospital Percy, Clamart, France
Introduction: The present study documents short-term clinical out-
comes for soldiers of the Afghan National Army undergoing lower
extremity amputation during the current war against terrorism.
Materials and methods: Fifty five afghan soldiers wounded on the
battlefield between 2010 and 2011 and managed by a lower limb
amputation were included in this retrospective study. Trauma injuries
were caused by landmines in 48 cases, and bullet or rocket shell in 7
cases. All patients were male with a mean age of 22.4 years
(17–28 years). Ten of them sustained a bilateral amputation. There
was 40 below knee amputations (BKA) and 25 through or above knee
amputations. Primary amputations were performed in regional mili-
tary hospitals closed to the battlefield before evacuation to the
National Military Hospital in Kabul for the definitive treatment. A
delayed primary closure and revision amputation was performed in 39
cases (60 %) with a mean delay of 21 days (15–30 days). In 26 cases
(40 %) a primary closure was done.
Results: Patients were reviewed with a mean follow-up of 6 months
(1–19 months). An infection occurred in five patients among whose
four had been treated with primary closure. Six others patients needed
subsequent surgery because of sharp bony ends causing pain and soft
tissue damage. At the last follow-up, only 16 patients with BKA wore
a functional prosthesis.
Conclusion: This study supports the strategy of a two times proce-
dure for lower limb amputations in war surgery, and underlines limb
prosthesis issues in Afghanistan.
Disclosure: No significant relationships.
O082
SURGICAL TREATMENT OF THE WOUNDED FROM THEBLAST MINE INJURIES
A. Koltovich1, I. Paltyshev2
1General Surgery, Main Military Clinical Hospital of Internal Troops
of the Ministry of Interior of Russia, Moscow, Russian Federation,
2Main Military Clinical Hospital of Internal Troops of the Ministry of
Interior of Russia, Moscow, Russian Federation
Introduction: Aim: To improve the results of treatment of wounded.
Materials and methods: 235 wounded were treated with severe
multiple, combined and the combined mine blast injuries. All victims
were between the ages of 18 and 45 men. The average time of service,
qualified medical assistance was 82.3 min. Orthopedic injuries were
in 189 (80.4 %) cases, head 170 (72.3 %), thoracic injuries 113
(48.1 %), abdomen 102 (43.4 %), neck and pelvis 40 (17 %) injured.
Early total care was used in 162 (68.9 %) injured, Damage control in
73 (31.1 %) wounded.
Results: Diagnostic and treatment algorithm and tactics Damage
control allowed shorten the duration of preoperative preparation with
52–41 min. A duration of surgery, performed in the first hours after
injury, was less than twofold. In the early postoperative period, 21
died (8.9 %), in 5 (6.9 %) was used damage control tactic and 16
(9.9 %) were operated simultaneously.
Conclusion: Using Damage control has reduced the mortality at the
stage of quality health care from 9.9 to 6.9 %.
Disclosure: No significant relationships.
O083
OBSERVATIONAL STUDY OF COMBATMUSCULOSKELETAL INJURIES IN A HOSPITALIN THE HORN OF AFRICA DURING A 3-YEAR INTERVAL
F. Mottier1, P.Y. Cordier2, A. Bertani3, F. Chauvin1, F. Rongieras4
1Orthopedic and Trauma Surgery, Military Academic Hospital
Desegnettes, Lyon, France, 2Military Academic Hospital Laveran,
Marseille, France, 3Orthopedic Department, HMC Bouffard, Djibouti,
Armees, France, 4Orthopedic and Trauma Surgery, Academic military
hospital Desegnettes, Lyon, France
Introduction: Orthopedic injuries sustained in the Horn of Africa’s
civilian conflicts from June 2008 to October 2011 that were treated in
a single French military hospital in the Republic of Djibouti were
reviewed. The goal of this study was to analyze the extremity
wounding patterns in this kind of conflict and to compare them to
previous wars.
Materials and methods: A detailed description of the musculoskel-
etal combat casualty surgical care, distribution of wounds,
mechanisms of injury, length of hospitalization was performed using
a prospective centralized casualty database. A retrospective review
was then conducted.
Results: A total of 68 combat casualties sustained 121 individual
combat lesions. 45 % of these were penetrating soft-tissue wounds
and 37 % were open fractures. The most common fracture in the
upper extremity was in the hand (71 %) and in the lower extremity the
tibia and fibula (48 %). Gunshot accounted for 60 % of the mecha-
nisms of injury. Combat extremity wounds were a consequence of
accident (25 %), act of war (65 %) or assault (10 %). The average
length of hospitalization was 22 days. 42 % of patients with fracture
were lost to follow up after initial healing but before fracture union.
Conclusion: Most wounds sustained in the Horn of Africa’s civilian
conflicts are extremity injuries. These results are similar to the casu-
alties reported in previous wars, but there are some differences:
Gunshot lesions are more prevalent; Accidental and self-inflicted hand
and foot fractures are more common; Many more patients are lost to
follow up before final fracture union due to widely dispersed geo-
graphic areas of origin.
S32 Abstract
123
Disclosure: No significant relationships.
O084
ANALYSIS OF THE LONG-TERM OUTCOME IN MULTIPLYINJURED PATIENTS WITH INJURIES BELOW THE KNEEJOINT
R. Pfeifer1, B.A. Zelle2, N. Sittaro3, C. Probst4, H. Pape5
1Orthopaedic Trauma Surgery, University Clinic Aachen, RWTH
Aachen University, Aachen, Germany, 2University of Pittsburgh
Medical Center, Pittsburgh, PA, USA, 3Hannover Life RE-Insurance,
Hannover, Germany, 4Hannover Medical School, Hannover,
Germany, 5University Clinic Aachen, RWTH University, Aachen,
Germany
Introduction: Prior studies indicate that fractures distal to the knee
joint have a major impact on long-term functional recovery. This soft
tissue envelope and delayed treatment were discussed as possible
factors leading to these inferior results. Therefore, we analyzed
whether fracture pattern and anatomic site of fractures below the knee
joint have an impact on long-term recovery.
Materials and methods: 637 severely injured patients treated
between 1973 and 1990 in a level I trauma center were recruited to
the follow-up examination. Inclusion criteria: ISS C16 points, follow-
up [10 years, fractures below the knee joint. Numerous clinical
parameters (pain, limping, instability), scores (SF-12, HASPOC), and
functional results (range of motion, disabilities) were analyzed
regarding to the fracture distribution.
Results: 167 patients have met the inclusion parameters. Mean age
27.5 (3–55) years, male 75 %, ISS 19.6 (16–50) points, follow-up 17
(10–289) years. Outcome: In comparison to other fractures patients
with proximal tibia fractures were more frequently associated with
chronic pain (80 %, p \ 0.05). Functional disabilities (pain associated
with stairs climbing and housework) were more frequently reported
by patients sustained proximal tibia fractures (73.3 and 60 %) and
patients with foot injuries (78.6 and 64.3 %) (p \ 0.05). Limb length
differences were more frequently measured in patients with tibia shaft
fractures (37.3 %) and distal tibia fractures (28 %) (p \ 0.05).
Conclusion: 10 and more years after trauma high percentage of
patients with injuries distal to the knee joint report chronic pain and
persistent functional impairments. Worse long-term outcome was
more often associated with injuries of proximal tibia and foot injuries.
Disclosure: No significant relationships.
O085
A REVIEW OF 100 CASES ACS GRADED COLONICINJURIES ADMITTED TO BAGHDAD TEACHINGHOSPITAL 1
I.F. Sakran
General Surgery, Baghdad Medical College, Medical City Office, Iraq
Introduction: In Iraq nearly 95 % of colonic injuries are caused by
penetrating trauma (gun shot, blast injuries, stab injuries, or iatrogenic
trauma), blunt injuries are rare.
Materials and methods: A (100) patients with documented colonic
injuries admitted to the surgical wards at Baghdad Teaching Hospital
spanning the years 2006–2008.
Results: Colonic injuries were caused by bullet injuries in 50 % of
cases, sigmoid colon was involved part (32 %), 64 % of cases were of
grade 2, Common associated organ injury was small intestine (60 %),
primarily sutured in 48 % of cases, while other 48 % of cases ended
with colostomy. Morbidity recorded in 32 % of cases, most frequently
with grade 2 and in cases treated by colostomy.
Conclusion: (1) ACS grading system for colonic injuries is a useful
method in scoring these injuries and is beneficial in the follow up. (2)
A systolic blood pressure of less than 90 at presentation, association
with multiple injured organs and severe degree of contamination are
important adverse risk factors. (3) Most of the postoperative mor-
bidity and mortality was due to extra colonic injuries and their
complications.
References: 1. Maxwell RA. Current management of colon trauma. 2.
Imes PR. War surgery of the abdomen. 3. Burch JM, Laurance WA.
Trauma to colon and rectum.
Disclosure: No significant relationships.
O086
WAR WOUNDED PATIENT MANAGEMENT INA HOSPITAL LOCATED IN THE HORN OF AFRICA:A 3-YEAR OBSERVATIONAL STUDY
F. Mottier1, P.Y. Cordier2, A. Bertani1, R. Gorioux1, F. Chauvin1,F. Rongieras1
1Orthopedic and Trauma Surgery, Military Academic Hospital
Desgenettes, Lyon, France, 2Military Academic Hospital Laveran,
Marseille, France
Introduction: The Horn of Africa is central to a zone of major
geopolitical instability dominated by the Somali civil war and piracy
in the Gulf of Aden. Here we present the characteristics of war-
wounded patients transferred to a single-centre located in this region.
Materials and methods: All gunshot-wounded and explosion-injured
patients treated between June 2008 and October 2011 were prospec-
tively classified and then their medical records were retrospectively
reviewed.
Results: 82 wounded people were treated. Their injuries were caused
by acts of war (61 %), assaults (18 %), or accidents (21 %). 61 % of
these injuries were ballistic wounds and the 39 % remaining were
caused by explosions. 65 % of the patients were admitted more than
24 h after injury. The average ISS score was 9. Four patients present a
hemorrhagic shock (5 %) and one died (1.2 %). Lesions occurred
more frequently on upper extremities (45 %) and on lower extremities
(45 %) than in the abdomen (11 %), thorax (8 %), or cervical-cranial
region (15 %). The median hospitalization time was 14.5 days
(1–126). The median number of surgical interventions per patient was
2 (0–15).
Conclusion: Patients reaching the hospital were likely those less
severely injured due to long evacuation delays. Therefore the rates of
hemorrhagic shock and mortality were both low. We dealt mostly
with only moderately severe injuries of the extremities. However
these often required major surgical care, especially those cases with
delayed complications (infection, fracture coverage). Due to the
widely dispersed geographic origins of these patients many were lost
to follow up following initial treatment and wound healing.
Disclosure: No significant relationships.
Abstract S33
123
HAND SURGERY AND EMERGENCY
O087
SENSITIVITY OF ULTRASONOGRAPHY IN THEDIAGNOSIS OF SCAPHOID FRACTURES
A. De Zwart1, S. Rhemrev2, J. Puylaert3, F. Beeres4, I. Schipper5
1Surgery, LUmc, Amsterdam, The Netherlands, 2Traumatology,
Medisch Centrum Haaglanden, Den Haag, The Netherlands,3Radiology, Medisch Centrum Haaglanden, Den Haag, The
Netherlands, 4Surgery, LUmc, Leiden, The Netherlands, 5Surgery and
Traumatology, Leiden University Medical Center, Leiden, The
Netherlands
Introduction: Initial scaphoid radiographs detect about 80 % of all
clinically suspected scaphoid fractures [1]. Alternative imaging
techniques are therefore being investigated. Prior to evaluating the
diagnostic value of Ultrasonography (US) in occult scaphoid fractures
we evaluated its diagnostic performance in evident (on conventional
radiograph) scaphoid fractures. The purpose of this study is to eval-
uated if US misses evident scaphoid fractures as it will not be
appropriate for the triage of occult scaphoid fractures.
Materials and methods: Patients who visited our emergency
department between January 2009 and January 2010 with a recent
wrist trauma and a diagnosed scaphoid fracture on conventional
radiographs were included. An US was made within 3 days after
trauma by an experienced radiologists. The radiologists were blinded
for the radiographical results.
Results: In a period of 1 year, 13 patients were included with a
radiographic evident scaphoid fracture. In all patients US demon-
strated an unequivocal hematoma around the scaphoid, on bases of
which the diagnosis of scaphoid fracture was stated.
Conclusion: US diagnosed all the scaphoid fractures evident on
radiographs (100 % sensitivity). US therefore seems to be a helpful
tool for diagnosing suspected scaphoid fractures.
Reference: 1. Beeres FJP, Hogervorst M, den Hollander P, Rhemrev
S. Outcome of routine bone scintigraphy in suspected scaphoid
fractures. Injury. 2005;36(10):1233–6.
Disclosure: No significant relationships.
O088
THE LUCERNE CAST (LUCA): FUNCTIONAL TREATMENTOF PROXIMAL PHALANGEAL FINGER FRACTURESWITHOUT IMMOBILIZING THE WRIST
U. Hug1, U. Von Wartburg2, S. Schibli3, A. Jandali4, M. Calcagni5,T. Franz2
1Hand and Plastic Surgery, Cantonal Hospital of Lucerne, Luzern,
Switzerland, 2Cantonal Hospital Lucerne, Luzern, Switzerland,3Cantonal Hospital Chur, Chur, Switzerland, 4Cantonal Hospital
Winterthur, Winterthur, Switzerland, 5University Hospital Zurich,
Zurich, Switzerland
Introduction: Conservative treatment of extraarticular fractures of the
proximal phalanges of the triphalangeal fingers is well established.
Dynamic splinting in intrinsic plus position of the metacarpophalangeal
(MCP) joints without restriction of interphalangeal (IP) joint motion
supports a faster rehabilitation. The aim of this study was to identify any
necessity of immobilization of the wrist.
Materials and methods: A prospective randomized multicenter
study was run from September 2008 to September 2010 in four
hospitals in Switzerland. 77 patients with 86 fractures were treated by
dynamic splinting as described, either with or without immobilization
of the wrist. A minimum follow-up of 3 months was obtained in all
cases.
Results: In 73 of 77 patients, fracture consolidation was achieved
after 4 weeks (3–7 weeks). Total active motion of the finger joints
was not different between the two groups at any time. Wrist
motion was better in the LuCa group only after cast removal.
Subjective patient satisfaction was high for both groups (mean 9.5
for LuCa, 8.7 for long cast on VAS). Radiological assessment
showed no significant differences in terms of time until consoli-
dation, dorsal angulation or lateral deviation. In 4 of 77 patients, 3
irreducible fractures and a closed extensor tendon rupture required
surgery.
Conclusion: Conservative treatment of extraarticular fractures of the
proximal phalanges of the fingers by dynamic splinting is effective.
Long casts including the wrist and short casts excluding the wrist
(LuCa) showed comparable clinical and radiological results after
12 weeks. Patient’s satisfaction is higher in the LuCa group.
Disclosure: No significant relationships.
O089
PERCUTANEUS STABLE FIXATION OF THE V-THMETATARSAL AVULSION AND THE JONES FRACTURE
W. Friedl
Orthopedic,trauma and Hand Surgery, Klinikum Aschaffenburg,
Aschaffenburg, Germany
Introduction: The avulsion fracture of the MT V bone and the Jones
fractures are typical fractures under tension and therefore often
require osteosynthesis. Failure and soft tissue problems in fracture
healing in nonoperative and tension belt fixation are high.
Materials and methods: To avoid soft tissue problems due to the
open reduction and implant on the bone surface on the lateral foot a
percutaneous technique with a 3.5 mm XXS locked compression nail
(S&N) was developed. The locking is performed on both sides of the
fracture with one 2 mm threaded wire and the dynamic compression
of the fracture is performed with a set screw through the nail. From
Jul 1999 to Jan 2006 77 patients were treated according to the above
technique, prospectively analysed and re-evaluate at least 6 months
after surgery.
Results: The AOFAS of the patients preoperative was 22 and
postoperative 96. No pseudarthrosis or implant failures occurred but
in 53 patients (69 %) implant removal was performed according to
the wish of patients and in part due to local discomfort. The dis-
comfort rate was strictly correlated to the length of the locking wires
over the bone surface. 95 % of the patients returned to the same
activity level.
Conclusion: The XXS nail is a new method for minimal invasive and
stable fixation of MT V fractures with full weight bearing capacity
and shows a low complication rate. However in most cases implant
removal was indicated.
Disclosure: No significant relationships.
S34 Abstract
123
O090
TREATMENT OF CHRONIC SCAPHOLUNATEDISSOCIATION BY MODIFIED DORSALLIGAMENTOPLASTY
D. Ira1, J. Pilny2, I. Cizmar3, M. Krticka4, M. Masek4
1Department of Trauma Surgery, University Hospital, Brno, Czech
Republic, 2District Hospital, Pardubice, Czech Republic, 3University
Hospital, Olomouc, Czech Republic, 4University Hospital, Brno,
Czech Republic
Introduction: Purpose of this study is to present the clinical results of
a study of chronic scapholunate dissociation treated by modified
dorsal ligamentoplasty.
Materials and methods: Fifty-two patients who presented with
chronic dynamic or static scapholunate instability underwent recon-
struction of scapholunate ligament with tendon graft. Forty patients
(23 with diagnosis of dynamic and 17 with static form) were available
for follow-up evaluation at an average of 31 months.
Results: Thirty-seven of 40 patients expressed satisfaction with final
outcome. Postoperative pain relief, increase of postoperative grip
strength, improvement of DASH score and closure of SL gap were
statistically significant when compared with preoperative values. No
statistically significant differences in postoperative pain, range of
wrist motion, grip strength, DASH, Mayo wrist or Martini scores
between patients with static and dynamic form of scapholunate dis-
sociation were noted.
Conclusion: Modified dorsal ligamentoplasty provides sufficient
restoration of stability, pain relief and wrist functional improvement
for patients with both forms (dynamic and static) of scapholunate
instability. We recommend this procedure for both forms but dynamic
form preferentially. In the case of static form we propose to augment
stabilization with capsulodesis.
Reference: Kim RY, Strauch RJ. Scapholunate instability. Curr Opin
Orthop. 2007;18(4):322–7.Pilny J, Cizmar I, et al. Chirurgie Zapesti.
1. vyd. Praha:Galen;2006:169.
Disclosure: No significant relationships.
O091
RADIATION EXPOSURE DUE TO CT OF THE SCAPHOID INDAILY PRACTICE
A. De Zwart1, S. Rhemrev2, M. Pillay3, F. Beeres2, P. Krijnen1,I. Schipper4
1Surgery, LUmc, Amsterdam, The Netherlands, 2Surgery, MCH
Haaglanden, The Hague, The Netherlands, 3Radiation Specialist,
MCH Haaglanden, The Hague, The Netherlands, 4Surgery and
Traumatology, Leiden University Medical Center, Leiden, The
Netherlands
Introduction: CT is often used for the triage of occult scaphoid
fractures. Since adequate alternatives for the diagnosis of suspected
scaphoid fractures exist, it is important to quantify the radiation
exposure related to a CT. Currently, no such data are available. The
purpose of this study was to determine the exact scaphoid CT related
radiation exposure for the patient.
Materials and methods: Five different CT protocols, all used in
daily practice for the scaphoid CT in different hospitals, were used for
quantification of the radiation exposure. Two protocols concerned a
CT of the scaphoid with and three protocols without plaster cast of the
hand. For measurements we used a PMMA (polymethylmetacrylate)
phantom. For all protocols i.e. the Dose Length Product (DLP) and
scatter dose to the head (scatter in) were measured. The ‘scatter in’
was measured at 20 cm distance cranial to the scaphoid (position of
the head).
Results: The three CT protocols of the scaphoid performed without
a cast resulted in an average DLP of 47.2 mGycm and the ‘scatter
in’ was 7.3 lSv. CT protocols of the scaphoid with a plaster cast
showed an average DLP of 72.1 mGycm and the ‘scatter in’ was
9.0 lSv.
Conclusion: A CT of the scaphoid results in a considerable radiation
exposure to the head of the patient. If the hand is immobilized in a
plaster cast direct radiation and ‘scatter in’ are higher. We therefore
recommend to perform CT’s of the hand and wrist without a cast
whenever possible.
Disclosure: No significant relationships.
O092
IMPACT OF ULNAR STYLOID FRACTURES INNON-OPERATIVELY TREATED DISTAL RADIUSFRACTURES
M.K. Van Valburg, M. Wijffels, P. Krijnen, I. Schipper
Traumatology, Leiden University Medical Centre, Leiden,
The Netherlands
Introduction: Distal radius fractures (DRFs) can be accompanied by
ulnar styloid fractures (USFs). The effect of an USF on DRF stability
in non-operatively treated patients is unknown. This study evaluated
the influence of an USF on dislocation of non-operatively treated
DRFs.
Materials and methods: Standardised anteroposterior and lateral
wrist radiographs of 178 non-operatively treated DRFs, taken after
trauma, after fracture reduction and at last follow-up, were evaluated.
DRFs with an USF were compared to DRFs without an USF with
respect to dislocation. Radiographic evaluation included dorsal tilt,
radial inclination and radial shortening.
Results: USFs were present in 88 patients with DRFs (49.4 %). On
the trauma radiograph, the US fracture group had significantly more
dorsal tilt, less radial inclination and more radial shortening compared
to the no US fracture group. No differences were found in AO-clas-
sification between groups. At the final follow-up radiographs, reduced
DRFs with an accompanying US fracture showed significantly less
radial inclination and more radial shortening compared to the no US
fracture group.
Conclusion: From this study can be concluded that presence of an
USF is related to more dislocation of the distal radius, after trauma
and at last follow-up, despite closed reduction. In general, plaster cast
alone seems inadequate to maintain the initial reduction position of
the distal radius fragment if an USF is present. The clinical impli-
cation of this finding is that presence of an USF in DRFs may indicate
early surgical fixation in order to prevent malunion and subsequent
functional impairment.
Disclosure: No significant relationships.
Abstract S35
123
O093
EXPERIENCES AND RESULTS WITH A MODIFIEDDYNAMIC TRACTION DEVICE FOR EARLY FUNCTIONALTHERAPY OF INTRAARTICULAR FRACTURES OFPROXIMAL INTERPHALANGEAL JOINT OF THE FINGERS
G. Mattiassich, M. Mayrhofer-Stelzhammer, W. Huber, L. Dorninger,A. Kroepfl
Trauma Department, UKH Linz, Trauma Center, Linz, Austria
Introduction: Therapy of comminuted intra-articular fractures of
the middle phalanx remains difficult and controversial. Satisfactory
functional results are difficult to achieve. There are different
operative and non-operative approaches to manage the problem.
Early motion and dynamic traction with different systems have
been used. We report our four-years experience with a modified
single-pin dynamic traction device for the proximal interphalangeal
joint (PIP).
Materials and methods: Twenty-six patients were treated for intra-
articular fractures of the base of the middle phalanx between 2007 and
2011. Patient’s records were analysed, focused on complications and
duration of therapy. Thirteen patients were available for radiological
and clinical reevaluation.
Results: Twenty-six patients with a mean age of 36 years were
treated between 2007 and 2011. Thirteen patients required additional
procedures in order to achieve an anatomical articular surface or
correct articular subluxation. The modified dynamic traction device
was used for 34 days (8–53 days), overall treatment took 76 days
(66–154 days). Four pin infections were encountered. Thirteen
patients were available for reevaluation. Mean follow up was
33 months (9–44 months). Mean DASH Score was 6.5. Ninety per-
cent of patients were satisfied with functional outcome. The mean
range of motion in PIP joint was 72� (30–110�).
Conclusion: Dynamic traction therapy of intraarticular PIP joint
fractures as single therapy or in combination with osteosynthesis is an
adequate concept of treatment to achieve best possible functional
outcome. Good compliance and highly motivated patients as well as
regular controls and physiotherapeutic guidance is of immanent
importance. Based on our experience we recommend this technique to
treat intraarticular fractures of the PIP joint.
Disclosure: No significant relationships.
O094
ACUTE WRIST TRAUMA: WHAT NOT TO MISS! DOES CTHELP?
V. Shuen, R. Thiagarajah, P. Suresh, A. Gafoor
Radiology, Plymouth Hospitals NHS Trust, Plymouth, UK
Introduction: Scaphoid is the most frequently fractured carpal bone.
Occult fractures imperceptible on initial radiographs make diagnosis
challenging. Missed Scaphoid fractures lead to long term disability.
Most of these patients are young. Inappropriate immobilisation will
have social and economic implications for both the patient and
society. It is important that there is accurate management of these
fractures.
Materials and methods: In our institution CT of the Wrist was
included in the diagnostic pathway for management of suspected
Scaphoid fractures. CT scan of the wrist was performed in 100 patient
with a second negative radiograph and high index of clinical
suspicion.
Results: 15 were diagnosed with scaphoid fractures on CT. 4 non-
scaphoid fractures were also diagnosed on CT scans.
Conclusion: We will discuss the pathway for management and the
various fractures that mimic scaphoid fractures clinically. In sum-
mary, CT wrist is invaluable in diagnosing occult scaphoid fracture
but also in detecting other occult fractures which may mimic the
symptoms of a scaphoid fracture.
Disclosure: No significant relationships.
EDUCATION
O095
INDIVIDUAL AND TEAM TRAINING WITH FIRST TIMEUSERS OF THE PELVIC C-CLAMP. WILL THEYREMEMBER?
H. Koller, P. Keil, F.J. Seibert
Teaching Hospital Mug, UKH-Graz, Graz, Austria
Introduction: Pelvic ring injuries with associated hemorrhage from
the presacral venous plexus are major contributors to morbidity and
mortality in trauma patients. The pelvic C-Clamp is an often
reported, yet seldom used device for both skeletal and hemodynamic
stabilization. In a recent study we have already addressed this issue
and the importance of regular training sessions. As an extended
follow up this study aimed to prove the Australian findings
including a team training session, but more important a re-evalua-
tion after 12 months time.
Materials and methods: 32 participants were trained in using the
clamp. After 12 months the single training was repeated with 18 of
the 32 participants.
Results: Evaluation of the 2010 data showed that 57/64 pins
(89.15 %) were placed inside the safe area. During the re-evaluation
in 2011 not a single pin could be placed inside the target area. This
means a loss of 4/36 pins (11.1 %) placed either inside the target or
the safe area and shows significantly reduced results over all evalu-
ated parameters without any further educational introduction in
C-clamp placement.
Conclusion: The majority of 57 pins were placed into the safe area
after one single training session. This correlates and proves the
Australian data and supports the theory, that educated and skilled
physicians should be able to handle the device properly. The data
of the 2011 re-evaluation show, that retention of the skills can not
be provided without constant training. Thus we recommend
constant education in using the device with an interval of
6–12 months.
References: Koller H, Balogh ZJ. Single training session for first time
pelvic C-clamp users: correct pin placement and frame assembly.
Injury. 2011.
Pohlemann T, et al. Pelvic emergency clamps: anatomic landmarks
for safe application. J Orthop Trauma. 2004.
Disclosure: No significant relationships.
S36 Abstract
123
O096
INJURY BURDEN AT THE COMMUNITY LEVEL:SURGEONS OVERSEAS ASSESSMENT OF SURGICALNEEDS (SOSAS), A POPULATION-BASED SURVEY INRWANDA
R.T. Petroze1, R. Groen2, F. Niyonkuru3, M. Mallory1, E. Ntaganda3,T.G. Guterbock4, P. Kyamanywa3, A. Kushner2, J.F. Calland1
1Department of Surgery, University of Virginia, Charlottesville,
VA, USA, 2Surgeons OverSeas (SOS), New York, NY, USA,3Faculty of Medicine, National University of Rwanda, Butare,
Rwanda, 4Center For Survey Research & Department of Public
Health Sciences, University of Virginia, Charlottesville, VA, USA
Introduction: Over 2 billion people in low-income countries lack
access to basic, life-saving surgical care, but there is a dearth of
population-level data. In particular, injuries play a growing role in
premature morbidity and mortality, with 90 % of global injury deaths
occurring in low-income countries [1–3]. We describe the use of a
survey tool that evaluates the prevalence of surgical conditions at the
population level with a focus on the burden of traumatic injuries and
barriers to injury care in Rwanda.
Materials and methods: SOSAS is a survey tool for a cross-
sectional cluster-based population study that was designed using
Demographic and Health Surveys (DHS) guidelines and the
World Health Organization (WHO) Guidelines for Conducting
Community Surveys for Injuries and Violence [4–5]. Questions
were structured anatomically and designed around a representative
spectrum of surgical conditions to include congenital, acquired,
malignant and injury-related conditions. The first full-country
survey was conducted in Rwanda in October–November 2011
with computer-based entry on iPads. Households were sampled
based upon population-weighted sampling frames from the
National Institute of Statistics with representation of all 30
districts.
Results: A total of 1627 households (3191 individuals) were sampled.
Analysis is currently ongoing with initial results for injury-related
conditions expected early-mid January 2012. Results will include
prevalence and basic epidemiology of injury-related conditions,
geographic distribution, and functional outcomes/injury-related
disability.
Conclusion: The resulting data from SOSAS will be key in deter-
mining injury epidemiology as well as long-term effectiveness of
programs and interventions.
References: 1. WHO/OMS (2009) Global status report on road
safety: time for action. Geneva: World Health Organisation. 2.
Injury: a leading cause of the global burden of disease. WHO 2000.
http://whqlibdoc.who.int/publications/2002/9241562323.pdf. Acces-
sed 30 November 2009. 3. Weiser TG, Makary MA, Haynes AB,
Dziekan G, Berry WR, Gawande AA; Safe Surgery Saves Lives
Measurement and Study Groups. Standardised metrics for global
surgical surveillance. Lancet. 200926;374(9695):1113–7. 4. Sethi D,
Habibula S, McGee K, Peden M, Bennett S, Hyder AA, Klevens J,
Odero W, Suriyawongpaisal P. Guidelines for conducting commu-
nity surveys on injuries and violence. Geneva: World Health
Organization. 2004. 5. Macro ICF. Rwanda Demographic and
Health Survey 2005.
Disclosure: No significant relationships.
O097
ANALYSIS OF A REGIONAL TRAUMA RESCUE SYSTEM:DEPLOYMENT AND RESULTS OF AIR VERSUS GROUNDRESCUE
S. Guenkel1, M. Koenig1, K. Spengel1, R. Albrecht2, M. Bruesch3,C.M.L. Werner1, H.P. Simmen1, G.A. Wanner1
1Surgery, Division of Trauma Surgery, University Hospital Zurich,
Zurich, Switzerland, 2Swiss Air Rescue REGA, Zurich REGA
Airport, Switzerland, 3Institute For Anaesthesiologie, Univeristy
Hospital Zurich, Zurich, Switzerland
Introduction: The effect of helicopter emergency medical service
(HEMS) versus ground bound emergency medical service (EMS) is
still controversially discussed. In the present study, the current
practice of the rescue system in Switzerland was analyzed.
Materials and methods: In a 1 year period 365 consecutive severely
injured patients admitted to our trauma center were included; divided
into four groups: patients primarily admitted to our level-I trauma
center by HEMS, EMS with or without a physician and patients
secondarily referred from peripheral hospitals. Epidemiology, injury
pattern and outcome were evaluated using the recently established
Revised Injury Severity Classification (RISC) score.
Results: 68.6 % of the patients were male; the average age was
49.8 years. The dominant injury mechanism was blunt trauma with
94.1 %. The mean ISS was 23.0 and the mean RISC score 91.4.
Overall mortality was 16.2 %. The mean prehospital time in HEMS
was 50 min, in EMS with physician 53 min and in EMS without
41 min. In this study survivors had a significant shorter preclinical
time (47 vs. 57 min) than non survivors. HEMS and EMS transported
patients with the attendance of a physician showed lower difference
between de facto and predicted outcome (6.3 % higher mortality than
predicted) than without physician (13.3 %). There was no difference
in actual and predicted outcome in the secondarily transferred patient
group.
Conclusion: Using the RISC score a tendency towards a better out-
come for HEMS rescued patients could be seen. Despite the longer
transport distance the prehospital time of HEMS is shorter than that of
EMS with physician on board. Factors promoting a significant better
outcome are short preclinical time, attendance of a physician during
the transport, and treatment in a level I trauma center.
Disclosure: No significant relationships.
O098
IMPROVING PERFORMANCE AND AGREEMENT ININJURY CODING WITH THE ABBREVIATED INJURYSCALE; A COURSE HELPS
P. Joosse1, M. De Jongh2, C.C.H.M. Van Delft-Schreurs Msc2,M.H.J. Verhofstad3, J.C. Goslings1
1Trauma Unit, Dept. of Surgery, Academic Medical Center,
Amsterdam, The Netherlands, 2Traumacentrum Brabant, St. Elisabeth
Hospital, Tilburg, The Netherlands, 3Trauma Center Brabant, St.
Elisabeth Hospital, Tilburg, The Netherlands.
Abstract S37
123
Introduction: Trauma databases and consequent methods to compare
outcome between hospitals or regions are as effective as its injury
coding is valid and reliable. Reliability in injury coding can possibly
improve by training and education. The main objective of this study is
to assess the influence of a dedicated training program on the per-
formance and agreement in injury coding using the Abbreviated
Injury Scale version 1990 update 1998.
Materials and methods: Twelve participants followed a one-day
course in injury coding. The Abbreviated Injury Scale unique code for
47 injuries was recorded before (pre-test), during (test) and after
(post-test) the course. The ability to assign the correct unique code
and the correct severity score was calculated, as well as the inter
observer agreement for all three tests.
Results: The median valid percentage of correct unique codes was
71.3 % in the pre-test, 86.2 % in the test, and 83 % in the post-
test. Improvement was significant for test compared to pre-test. The
median valid percentage of correct severity scores was 85.9 % in
the pre-test, 90.5 % in the test, and 91.5 % in the post-test.
Improvement was significant for test compared to pre-test. Fleiss
kappa’s fell within the substantial to almost perfect range and
improved significantly during and after the course compared to the
pre-test.
Conclusion: The results of this study emphasized the use of training
in AIS coding to improve ability to assign correct codes and to reduce
variability. It is advisable that everyone who uses the Abbreviated
Injury Scale is well trained by a dedicated course.
Disclosure: No significant relationships.
O099
SETTING UP AN ACUTE CARE SURGERY SERVICE:A CANADIAN PERSPECTIVE
K. Khwaja, T. Razek, L. Feldman
Surgery and Critical Care, McGill University Health Centre,
Montreal, QC, Canada
Introduction: Acute Care Surgery (ACS) or Emergency Surgery
services are being developed across North America, managing
patients with important comorbidities and significant physiologic
disturbances. Care of such patients is managed primarily by Trauma
and General Surgeons. After introduction of an ACS service at
McGill University HealthCentre in June 2011, a review was con-
ducted to examine the processes and outcomes.
Materials and methods: Goals were established before creation of an
‘ACS Service’. Performance indicators were identified to measure
success of this initiative. A retrospective chart review was conducted
pre-ACS to document time of patient presentation to definitive care.
Housestaff and Consultant satisfaction was evaluated with surveys
pre-and-post initiation of the ACS service. Feedback was obtained on
regular basis from stakeholders prior and post creation of the service.
A prospective database was created to monitor patient outcomes and
performance indicators.
Results: Goals for creating an ACS service were identified as: (1)
Improving patient care, (2) Improving surgical trainee education, (3)
Improving patient flow and hospital efficiency, (4) Promoting
research opportunity. A number of performance indicators demon-
strated significant improvements like decreased time to first contact
with patient by surgery (103 vs. 211 min, p \ 0.05). Satisfaction was
related to level of surgical trainee and consultant subspeciality.
Dedicated OR time for ACS was identified as a key component for a
successful ACS service.
Conclusion: Emergency surgery or ACS services are growing in
number in Canada and the USA. Clear goals should be identified and
monitored prospectively after the initiation of such a service. Key
stakeholders must be identified and provide regular feedback so
appropriate modifications are done.
Disclosure: No significant relationships.
O100
TRAUMA SURGEONS DECREASE MORTALITY BY 50.6 %AT ROYAL ADELAIDE HOSPITAL
P.C. Bautz
Trauma Surgery and Trauma Dept, Royal Adelaide Hospital,
Adelaide, SA, Australia
Introduction: Damage control in trauma surgery is an international
standard. Royal Adelaide Hospital (RAH) is the main level 1 Trauma
Centre (TC) in Adelaide, South Australia (SA), receiving 75 % of SA
trauma. Prior to trauma surgeons (TS) being recruited, Trauma
Standardised Mortality Ratio (SMR) was 0.83 under non-trauma
surgeons. TS recruited following Australasian Surgical College
Review of RAH.
Materials and methods: SMR analysed from RAH Trauma Database
2005–2009. Two trauma surgeons attended major resuscitations,
performed damage control surgery, supervised ICU trauma victims,
and performed subsequent definitive surgery.
Results: RAH SMR reduced from 0.83 to 0.42 over a 4.5 year period.
Conclusion: TS significantly influence trauma management in a TC.
A 7 min response time, resuscitative thoracotomy, damage control
packing with laparostomies, and personal attendance halved mortality
in major trauma. Workload for 2 TS in a level 1 TC represents an
unsustainable workload.
Disclosure: No significant relationships.
O101
DO WE REALLY NEED SO MANY IMAGE TESTS FOR THEDIAGNOSIS OF ACUTE APPENDICITIS?
E. Membrilla Fernandez1, P. Sanchez Velazquez2, M. ClimentAgustı1, I. Martınez-Casas1, J. Sancho Insenser1, L. Grande Posa1
1General and Digestive Surgery, Hospital Universitari del Mar,
Barcelona, Spain, 2General Surgery, HOSPITAL DEL MAR,
Barcelona, Spain
Introduction: Appendectomy is the most common emergency sur-
gery and despite the massive use of imaging tests, clinical outcome
have not improved. It increased the proportion of perforated and
gangrenous appendicitis. Aim: To assess how many abdominal
ultrasound and abdominal computed tomographies were performed to
patients operated on for acute appendicitis during year 2010. To
assess if the proportion of perforated appendicitis and surgical
interventions without appendicitis were reduced.
Materials and methods: A retrospective study was carried out with
201 consecutive patients operated on for acute appendicitis. There
were 114 men (57 %) and 87 women (43 %) with a mean age of
35 years (7–100). The mean postoperative stay was 3.76 days and the
S38 Abstract
123
procedure lasted 78 ± 12 min. 122 patients (61 %) were operated on
by laparoscopy and 79 (39 %) via McBurney incision. The conver-
sion rate was 7.4 %.
Results: Only 18 patients were operated without imaging test (9 %).
Overall, 31 (15 %) patients had perforated appendicitis whereas 7
(3.5 %) had a non inflamed appendix. There were no significant
differences between the proportion of perforated appendicitis between
those with or without image tests (18 vs. 6 %; P = 0.48). Ultraso-
nography yield an overall predictive value (OPV) of 77 % (97 % TP
and 5 % TN) whereas CT scan had an OPV of 91 % (96 % TP and
50 % TN; P = 0.007).
Conclusion: We must carefully select which patients will benefit
from image tests. CT is superior in overall predictive value.
Disclosure: No significant relationships.
O102
This abstract was moved to ‘‘Cold and hot’’.
SPORT INJURIES/TIBIAL HEAD FRACTURES
O103
FUNCTIONAL TREATMENT FOR ACUTE ANKLE SPRAINS:SOFTCAST WRAP VERSUS MOKCAST. A PROSPECTIVERANDOMIZED SINGLE-CENTRE TRIAL
D.T. Mensch1, O.J.W. Verhoof1, P.R. De Reuver1, A. Van Noort2,M.P. Van Den Bekerom2, T.S. Bijlsma3
1Surgery, Spaarneziekenhuis, Hoofddorp, The Netherlands,2Orthopaedic Surgery, Spaarneziekenhuis, Hoofddorp, The
Netherlands, 3Department of Surgery-traumatology, Spaarne
Ziekenhuis, Hoofddorp, The Netherlands
Introduction: In the Netherlands about 600,000 patients suffer an
ankle sprain annually of which approximately 200,000 are sports
injuries. For conservative treatment, various publications stated that
functional treatment results in better outcome than cast immobilisa-
tion. A semi-rigid softcast wrap is often preferred as treatment, yet is
not adjustable and cannot be worn in standard footwear. In this study,
the wrap is prospectively compared to a MOKcast (lace-up softcast
brace) which claims similar rigidity, whilst being adjustable and
removable.
Materials and methods: All patients aged 18–60 with a grade II or
III ankle sprain in our A&E department were approached to partici-
pate. All consenting subjects received a RICE (Rest, Ice,
Compression, Elevation) treatment and were re-examined after
1 week. All subjects were randomised between wrap and MOKcast
treatment, both with a treatment duration of 3 weeks. Follow-up was
performed at 4 weeks, 2 and 4 months after trauma and consisted of
Karlsson Score Scale (KSS), physical examination, VAS pain, com-
plication registration, and patient satisfaction scales for treatment and
functional result (1–10).
Results: Forty-eight versus 52 patients were randomised to the wrap
versus MOKcast group. KSS-scores were not significantly different.
VAS scores for pain were significantly in favour of the wrap after day
15 (p = 0.009–0.03). Satisfaction with treatment was significantly in
favour of MOKcast at 4 months (p = 0.04), whilst result satisfaction
was not significantly different (p = 0.17).
Conclusion: Both wrap and MOKcast are safe treatment options with
good functional outcome. Subjects prefer a tailored and adjustable
treatment, even despite higher pain ratings in the MOKcast.
Disclosure: No significant relationships.
O104
BIOMECHANICAL COMPARISON OF INTRAMEDULLARYVERSUS EXTRAMEDULLARY STABILIZATION OFINTRAARTICULAR FRACTURES OF THE TIBIA PLATEAU
F.W. Hogel1, S. Hoffmann2, V. Buhren3, P. Augat2
1Unfallchirurgie, BG-Unfallkllinik Murnau, Murnau, Germany,2Biomechanics, BG-Unfallklinik, Murnau, Germany,3Unfallchirurgie, BG-Unfallklinik Murnau, Murnau, Germany
Introduction: Fractures of the proximal tibia occur often and are
great challenge for surgeons to stabilize. Fractures of the tibia plateau
are a domain of plate osteosynthesis but locked nails were developed
to stabilize these fractures.
Materials and methods: 16 fresh frozen human cadaveric tibiae were
osteotomized in the meta-diaphyseal intersection with an osteotomy
gap of 10 mm and single osteotomy through the medial epicondyle
simulating an 41-C.2 fracture. Stabilization was performed with an
angle stable locked nail (n = 8) and two additional screws. Eight
human tibiae were treated with two screws and a 5 hole locked plate.
Bones were tested in a cyclic protocol with increasing loads under
compression. Stiffness and fracture gap movement were measured as
well as failure mode.
Results: No significant differences were found between the two
implants regarding load until failure. The nail obtained stiffness
values of 927 N/mm and the plate 564 N/mm which was found to be
significant. Fracture gap movement was not significantly different
between the extra- and intramedullary implants in x-, y- and z-axis
except for dislocation of the proximal-lateral and proximal-medial
fragments. Clinically a cut-out of the proximal screws was found
when using the Targon-Tx and screw breakage was observed in the
specimen treated by the LCP–PLT as failure mode.
Conclusion: Nailing of proximal tibia fractures leads to a stiffer
implant-bone construct than plating. While no adverse effects were
found after nailing intrarticular tibia fractures it seems to be an
alternative to plating.
Reference: 1. Lang GJ, et al. Proximal third tibia fractures—should
they be nailed? Clin Orthop Relat Res. 1995.
Disclosure: No significant relationships.
O105
FIRST RESULTS USING DYNAMIC LOCKING SCREWS(DLS) FOR VERY DISTAL TIBIA FRACTURES
Y.P. Acklin, G. Hassig, C. Sommer
Department of Surgery, Kantonsspital Graubunden, Chur,
Switzerland
Introduction: The locked screw-plate construct is often cited as
being to rigid and prolonging healing mainly in shaft fractures. The
Abstract S39
123
newly introduced DL-screws allow 0.2 mm motion between the screw
shaft and screw head which should optimize the cis-cortex healing.
The purpose of this study was to analyze the first clinical handling test
of DL-Screws in distal tibia fractures.
Materials and methods: Over a 14-months period, data was acquired
prospectively. Only distal metadiaphyseal tibia fractures not suitable
for a tibia nail were treated with minimal invasive plate osteosyn-
thesis and DLS. Cortical and locking head screws were used for the
distal plate fixation to minimize soft tissue irritation over the medial
malleolus and DLS were used only in the proximal part. Patients were
evaluated clinically and radiological at 6 weeks, 3 and 6 months until
fracture union.
Results: 20 patients with distal tibia fractures were treated in the
above-mentioned technique. 15 patients were local resident and could
be evaluated. 13 healed after a median time of 3.3 months, one
delayed union occurred and one fracture showed only partial healing
after 6 months. One superficial surgical site infection occurred in the
postoperative period. We observed no implant associated complica-
tions until fracture union.
Conclusion: The clinical handling with the new dynamic locking
screws showed to be equal to the well known locking head screws.
For the detection of superior healing tendency, larger studies will be
necessary.
Disclosure: No significant relationships.
O106
THE USE OF WEIGHTBEARING RADIOGRAPHS TOASSESS THE STABILITY OF SUPINATION-EXTERNALROTATION FRACTURES OF THE ANKLE
F. Krause1, M. Weber2
1Orthopaedic Surgery, Inselspital University of Berne, Berne,
Switzerland, 2Orthopaedic Surgery, Zieglerspital Bern, Bern,
Switzerland
Introduction: Isolated lateral malleolar fractures usually result from
a supination-external rotation injury and may include a deltoid liga-
ment rupture. The necessity of operative treatment is based on the
recognition of a relevant medial soft-tissue disruption. Currently used
tests to assess ankle stability include manual stress radiographs and
gravity stress radiographs, but seem to overestimate the need for
fracture fixation.
Materials and methods: We investigated the use of weightbearing
radiographs to distinguish stable and unstable isolated lateral malle-
olar fractures induced by the supination-external rotation mechanism
(SER) in 77 patients. Patients with stable fractures (SER type II and
III) were treated non-operatively. So far sixty-seven patients were
evaluated by questionnaire and AOFAS ankle hindfoot score. Mini-
mal follow-up was 12 months (mean 62).
Results: In the preliminary results 70 of 77 (90 %) patients were
found to have stable fractures (SER type II) and were treated non-
operatively. The AOFAS score was 96.1 points on average (range
85–100) at latest follow-up. Four patients reported minor com-
plaints but none had radiographic signs of ankle arthrosis or
instability.
Conclusion: The use of weightbearing radiographs is an easy, pain-
free, safe and reliable method to exclude the need for operative
treatment, with excellent clinical outcome in the majority of the
patients seen at latest follow-up. The delay of 3–10 days until the
decision about surgical treatment is well accepted by the patients.
References: 1. Lauge-Hansen N, Ankelbrud I. Dissertation, Copen-
hagen: Munskgaard. 1942. 2. Yde J, Kristensen KD. Acta Orthop
Scand. 1980;51(4):695–702. 3. Egol KA, et al. J Bone Joint Surg Am.
2004;86(11):2393–8.
Disclosure: No significant relationships.
O107
INTRAMEDULLARY OSTEOSYNTHESIS OF AND ANKLEFRACTURES WITH A STRAIGHT LOCKED NAIL: XS NAIL
W. Friedl
Orthopedic,trauma and Hand Surgery, Klinikum Aschaffenburg,
Aschaffenburg, Germany
Introduction: Because of soft tissue problems in the ankle area and
higher loading capacity of intramedullary implants with length and
rotation stability the straight XS Nail was introduced 2000 for ankle
fracture osteosynthesis in our Hospital.
Materials and methods: The XS nail is a 4.5 mm and the XXS a
3.5 mm straight nail witch is locked by threaded wires witch are
placed with an aiming device an allows also dynamic fracture site
compression with a set screw. From 05.2000 to 03.2002 214 ankle
fractures were stabilised with a XS or XXS nail (locked straight nail
of 4.5 and 3.5 mm). The mean age was 51 year, 59 % were woman.
35 % were Weber B and 25 % type C fractures. The re-examination
after 6 months could be performed in 91 Patients and was evaluated
according to the Ovadia score (clinical and radiological).
Results: In the ankle fractures study in 2 patients haematoma revi-
sions and in 2 patients with the primary used oblique insertion of the
nail a proximal fibula fracture occured. In one case a spilt skin graft
was needed. In no case infection of the bone was seen, in no case
fracture or implant dislocation occurred. At re-examination 71 %
showed an excellent and 25 % a good result. Only 3 Patients were
classified as fair (1) or unsatisfactory; in 1 due to algodystrophia.
Conclusion: The Xs nail is a new option for ankle stabilisation. It
improves the stability and reduces the complication of ankle osteo-
synthesis due to the lack of implant under the skin on the bone surface
and due to the higher biomechanical stability of intramedullary
implants.
Disclosure: No significant relationships.
O108
COMPARISON OF THE ARTHROSCOPIC FIXATIONTECHNIQUES OF DISLOCATED ABRUPTION OF THETIBIAL INSERTION OF THE ANTERIOR CRUCIATELIGAMENT: BIOMECHANICAL CADAVERIC STUDY WITHNEW MEASURING DEVICES
V. Senekovic1, M. Balazic2
1Department of Traumatology, University Medical Centre Ljubljana,
Ljubljana, Slovenia, 2Department of Machining Technology
Management, Faculty of Mechanical Engineering, University of
Ljubljana, Ljubljana, Slovenia
Introduction: Anterograde fixation of the ACL abruption with a
cannulated screw and washer allows immediate mobilization, weight
bearing and fast rehabilitation. Another techniques is with
S40 Abstract
123
transosseous sutures. It doesn’t exist any biomechanical study which
can prove that both techniques assures similar strong fixation. For
such cadaveric tests we need reliable testing devices. We decided to
construct machines for measuring of the resistance of fixations on
cyclic load and pull-out strength.
Materials and methods: Comparative cadaveric biomechanical
study: fixation with two OrthocordTM transosseous sutures and fixa-
tion with a cannulated screw and washer. We constructed computer
controlled cyclic device to make repetitive motion of the knee and the
pull out strength testing device. We tested 10 cadaveric knees with
screws and 10 knees with sutures fixation.
Results: Average time for one fixation with a cannulated screw and
washer was 20 min, for fixation with transosseous sutures was
48 min. After cyclic loading we didn’t see any dislocation of frag-
ments. Mean pull out strength at fixation with cannulated screw was
207.42 N, mean pull out strength at fixation with transosseous sutures
was 294.32 N—statistical significant stronger. Both testing devices
were proved successful for such measuring.
Conclusion: Fixation with strong transosseous sutures is stronger—it
allows immediate mobilization and weight bearing like fixation with
screws. Procedure with transosseous sutures is significant longer and
more difficult what is disadvantage. Fixation with cannulated screw
and washer is fast and easy. But later on we have to remove implants
what is disadvantage. Both new machines were proved successful for
such measuring.
Disclosure: No significant relationships.
O109
MEDIUM TO LONG-TERM OUTCOMES FOLLOWINGMENISCAL REPAIR SURGERY: THE BRADFORDEXPERIENCE
T. Knapp, P. Loughenbury, S.R. Bollen, G. Radcliffe
Department of Trauma and Orthopaedics, Bradford Royal Infirmary,
Bradford, UK
Introduction: This study aimed to investigate the medium to long-
term outcomes following meniscal repair surgery in a tertiary referral
centre for soft tissue knee injuries.
Materials and methods: Retrospective review of case notes of
patients undergoing meniscal repair between July 1995 and July 2011.
Patient demographics, mechanism of injury and details of surgical
repair were noted. Outcome measures included surgeon reported
outcomes, return to sports and need for revision arthroscopy/arthro-
plasty surgery.
Results: 109 meniscal repair procedures in 106 patients. Median
follow-up 6 years 6 months (3 months to 15 years 6 months).
Sporting injuries (n = 65) included those sustained during football
(42), rugby (8), skiing/snowboarding (2) and other sports (13). 26
were performed using all-inside techniques, 80 using inside-to-out
techniques and 3 were open procedures. There were 3 postoperative
complications (1 superficial and 1 deep infection; 1 postoperative
failure of suture). Concurrent anterior cruciate ligament (ACL) or
multi-ligament reconstruction was required for 35 patients (15
simultaneous and 20 staged). Overall surgeon reported outcomes at
final discharge were good (n = 87), neutral (n = 18) or poor
(n = 4). 59 case notes commented on a return to sports (49 same
level; 8 decreased level; 2 unable to return). 37 patients required a
second arthroscopic evaluation (excluding staged ligament recon-
struction) where 23 repairs required resection, 10 had healed and 2
underwent a second repair (23 % overall observed failure rate). No
patients required arthroplasty procedures. A significant difference
was seen in the failure rate when performed alongside an ACL
reconstruction (11 %, 4/35) compared with when the ACL was
intact (28 %, 21/74).
Conclusion: These results represent the initial development of
meniscal repair techniques in a specialist centre. Overall success
rates of 77 % at median follow-up 6 years are reported. Better
results are seen when performed alongside ACL or multi-ligament
reconstruction.
Disclosure: No significant relationships.
SPORT INJURIES/SPINE
O110
3D-BASED NAVIGATION IN POSTERIOR STABILISATIONSOF THE CERVICAL AND THORACIC SPINE: NECESSITYOR LUXURY?
J.S. Jarvers1, A. Franck1, J. Adermann1, U. Spiegl2, S. Glasmacher1,C. Schmidt1, C. Josten1
1Department of Traumatology, Plastic- and Reconstructive Surgery,
Spine Center, University of Leipzig, Leipzig, Germany, 2Department
of Trauma and Reconstructive Surgery, Spine Center, University of
Leipzig, Leipzig, Germany
Introduction: Navigated surgical procedures in spinal surgery have
been established due to an increasing demand for precision. Espe-
cially 3D-C-arms connected with navigation systems are being used
more often. This study analyses the experiences with 3D-based nav-
igation in the posterior cervical and high thoracic spine.
Materials and methods: A 3D-C-Arm (Vision Vario 3D, Ziehm)
was connected with a navigation system (Vector vision, Brainlab) and
since 10/2007 used for the placement of overall 471 Screws (74
cervical/397 thoracic) at 69 patients. Of those 16 Patients had to
undergo operations in the posterior cervical and 53 patients at the
thoracic spine with different entities.
Results: Scan-time intraoperatively took 60 s on average, data-
transfer to the navigation-system another 10 s. Application-time
including anti-collision-check needs approx. 6 min [5;18]. In total
374/471 (79.4 %) screws could be inserted assisted with navigation,
317/471 (67.3 %) were controlled intraoperatively. Regarding the
cervical spine in 87.83 % (65/74) of the screws were navigated,
66.2 % (49/74) controlled intraoperative. In the thoracic spine 78 %
(311/397)could be placed with navigation, 61.7 % (245/397) were
controlled intraoperatively. Occasionally, scan-setup was problem-
atic, especially in regard to identification of the C-arm by the camera
of the navigation- system as well performance of the collision-free
scans. Correct placement was seen for each screw, thus correlating
well with the intraoperative findings.
Conclusion: The application of the combination of intraoperative 3D-
imaging and navigation for posterior instrumentation spine is reliable
in clinical use. User- and software-dependant sources of error could
be solved during the first course of the series. Image-quality at the
cervical spine is depending on individual bone density, and possible
metal artifacts. Additionally, it has the advantage of skipping pre-
operative acquisition of data as well as the matching-process.
Furthermore, exposure to radiation is reduced due to the possibility of
sparing pre- and postoperative CT.
Disclosure: Teaching/presentations for Ziehm Imaging.
Abstract S41
123
O111
DENSIPROBE SPINE: FIRST CLINICAL EXPERIENCEWITH INTRAOPERATIVE MEASUREMENT OF BONEQUALITY
L.M. Benneker1, A. Popp2, D. Schiuma3, R. Schwyn3
1Orthopedic Surgery and Traumatology, Inselspital, University
Hospital Bern, Bern, Switzerland, 2Osteoporosis, Inselspital,
University Hospital Bern, Bern, Switzerland, 3AO Research Institute,
Davos, Switzerland
Introduction: DensiProbe Spine consists of a modified pedicle probe
and an electronic system to measure bone quality intraoperatively.
The objective of this pilot study with 30 patients is to investigate
safety, handling and feasibility of the newly developed DensiProbe
Spine measurement device under clinical conditions.
Materials and methods: 30 patients, undergoing dorsal, multilevel,
transpedicular instrumentation of the lumbar and thoracic spine, were
selected for this prospective monocentric case series. All patients
underwent areal BMD measurement by DXA. The DensiProbe device
was used on one side for each instrumented level, and a transpedicular
bone biopsy of the contralateral side was collected and apparent BMD
measurements were performed by micro-CT. All measurements were
performed by one surgeon who was blinded to the BMD and peak
torque data. Subjective impression of bone strength was reported and
cement augmentation of the screws performed when indicated.
Results: In all patients the handling of the DensiProbe was feasible
and unproblematic. No adverse events related to the measurement
occurred. Operation time was prolonged by 1.5 min per level, but
mainly due to the collection of the bone biopsy. In one patient implant
migration was reported, and in eight cases the screws were augmented
with cement. A significant correlation (p \ 0,001; R = 0.427)
between apparent BMD and break-away torque was found.
Conclusion: Intraoperative measurement of bone quality is safe and
feasible. The results of peak torque measurement correlates to local
bone density and allows the surgeon to apply adequate treatments and
could help to reduce complications and costs.
Disclosure: No significant relationships.
O112
BIOMECHANICAL STUDIES ON STRUT GRAFT FITTINGFOR COMBINED ANTERIOR/POSTERIORINSTRUMENTATION OF A CALF SPINE FRACTUREMODEL
A. Pizanis1, F. Vossen1, J.H. Holstein1, K. Schwieger2, T. Pohlemann1
1Trauma-, Hand- and Reconstructive Surgery, University of Saarland,
Homburg, Germany, 2AO Institute, Davos, Switzerland
Introduction: Anterior spine fusion with strut grafts is used for
reconstruction of the injured anterior spinal column, in fractures
mostly stabilized by internal fixator. Compression of the grafts and a
maximum of contact on adjacent vertebral bodies are a prerequisite
for a correct bone fusion. The aim of this study was to investigate the
occurring compressive forces and contact areas on the strut graft
under different surgical setups and loading.
Materials and methods: Standardized calf-spine cranial burst frac-
ture model with bisegmental fixation by Fixateur interne, strut graft
imitations. Assessment of compressive force and contact areas online
at different time points. Study groups (N = 9): Pressfit strut grafts
1 mm oversize (PF), without oversize (IF), without oversize but
compressed by anterior implant (TF), purely experimental group with
a pressfit strut graft, but excised caudal disc filled with PMMA (Z).
Results: Primary strut graft compression highest in PF with contact
area at 80 % of max. In IF, compressions at 72 N and contacts up to
63 %. By using an additional implant anteriorly (TF), the compres-
sive force and contact area could be significantly increased. Excentric
cyclic loading led to decreases of compressive forces and contact
areas. These were significantly diminished in Z and TF.
Conclusion: By pressfit technique, the strut graft fitting can be
realized with good primary compression and contact to adjacent bone,
however cyclic loading decreases both. Compressive force and con-
tact at the graft can be effectively increased using an additional
anterior implant. These effects could influence decisions regarding the
surgical technique.
Disclosure: No significant relationships.
O113
VATS VERSUS OPEN THORACOTOMY FOR THORACICAND LUMBAR SPINE FRACTURES IN MULTIPLE TRAUMA
O. Linchevskyy1, S. Panfiorov2
1Thoracic Surgery, National medical academy for postgraduate study,
Kyiv, Ukraine, 2Clinical hospital # 17, Kyiv, Ukraine
Introduction: The objective of this study was to compare VATS
versus thoracotomy regarding feasibility in anterior spinal column
reconstruction in multiple trauma patients.
Materials and methods: In a single institution 5,837 patients with
blunt polytrauma were admitted during 2004–2010. In 445 patients
with spinal fractures 257 spinal surgeries was done. Transthoracic
approach was performed in 61 patients with A3, B and C fractures
ranged from Th3 to L2 level. Corpectomy, cord decompression,
titanium cages placement, screw-rod-screw anterior stabilization was
achieved in all cases. Anterior reconstruction of Th11–L2 required
diaphragmotomy. We retrospectively compared two groups of con-
secutive patients: 44 patients operated through thoracotomy during
2004–2008, and 17 operated by VATS in 2009–2010.
Results: Median ISS score 21 (range 11–41) was the same for tho-
racotomy and VATS groups. Diaphragmotomy was needed in 8 of 17
VATS and 19 of 44 thoracotomies. The median operating time for
VATS was 340 min (range 200–545) and 325 min (range 115–525)
for thoracotomy. The median blood loss was 500 ml (range
100–1,600) and 500 ml (range 200–1,800) respectively. The median
chest tube duration was 4 days (range 2–7) for VATS and similar
4 days (range 3–14) for thoracotomy. Among approach related mor-
bidity, we observed 6 cases of pleural effusion, 2 atelectasis/
pneumonia and 2 wound seroma in 44 thoracotomy patients. In 17
VATS patients were 3 pleural effusions and 1 skin necrosis of the
wound edges. All revealed differences were not significant. There
were no failures or dislocation of the anterior instrumentation in both
groups.
Conclusion: Feasibility of anterior spinal reconstruction is equal for
VATS and thoracotomy, with respect of operating time, blood loss,
and morbidity. Better cosmesis of VATS and less surgical trauma,
especially for Th3–Th4 and Th11–L2 levels are obvious.
References: 1. De Giacomo T, Francioni F, Diso D, Tarantino R,
Anile M, Venuta F, Coloni GF. Anterior approach to the thoracic
spine. Interact Cardiovasc Thorac Surg. 2011;12(5):692–5. 2. David
S42 Abstract
123
EA, Gaffey AC, Mason RB, Marshall MB. Modified French-window
thoracotomy for exposure of the anterior thoracic spine. Interact
Cardiovasc Thorac Surg. 2011;12(4):523–5.
Disclosure: No significant relationships.
O114
CORRELATION BETWEEN ETHNICITY AND INCIDENCEOF FRAGILITY FRACTURE AMONG RESIDENTS OFSOUTH LONDON AGED 55 AND OVER
M.I. Weiter1, S. Brannigan2, C. Moniz3, A.M. Phillips2
1Medizin/Orthopadie, University of Heidelberg, Heidelberg,
Germany, 2Orthopaedics, King’s College Hospital, London, UK,3King’s College Hospital, London, UK
Introduction: Age and gender are decisive for the incidence of fra-
gility fracture (FF). However, the effect of ethnicity on bone health
remains controversial. Given the relevance of FF, this study seeks to
investigate the impact of African descent on risk of fracture.
Materials and methods: A retrospective audit was conducted among
the notional population of 39,583 patients that form King’s College
Hospital’s trauma catchment population over the age of 54. Patients
seen with a non-vertebral/non-hip fragility fracture (NVNH FF)
between the 1st of April 2009 and 30th of September 2010 were
included. Demographic data of the catchment population was
obtained from the Office for National Statistics. The null hypothesis
was that ‘fracture risk’ was independent of ‘ethnicity’.
Results: Analysis involved 30,656 white and 6,007 black patients
(self-reported). Of those who suffered FF 89.0 % were white and
11.0 % black; among the population without FF 83.5 % were white
and 16.5 % black respectively. The risk was significantly lower for
black patients (p \ 0.0002). The relative risk reduction was 36.6 %.
The incidence of NVNH FF found per 1,000-person-years was 15.5
for women and 8.1 for men.
Conclusion: Most previous studies on racial disparity in FF were
conducted in the USA. The 36.6 % risk reduction observed in this
study concurs with previous findings among black Americans [1]. We
thus hypothesise that the protective effect of being black does not
exclusively apply to Americans. Knowledge of ethnic risk predispo-
sition will play a key role for individual risk assessment and targeted
prevention of osteoporosis.
Reference: 1. Cauley JA, et al. Bone mineral density and…. JAMA.
2005;293(17):2102–8.
Disclosure: No significant relationships.
O115
RADIOLOGICAL EVALUATION AFTER ANTERIORCOLUMN RECONSTRUCTION WITH ALLOGENIC TIBIADIAPYHSIS IN TH12 AND L1 FRACTURES
P. Wendsche1, J. Kocis2, J. Chmelova3
1Consultant, Trauma Hospital (Urazova nemocnice), Brno, Czech
Republic, 2Spinal Unit, Trauma Hospital, Brno, Czech Republic,3Radiodiagnostic Department, Military hospital Olomouc, Olomouc
Czech Republic, Czech Republic
Introduction: Criterion for good results in the Th–L junction is the
reconstruction of the anterior column without postoperative loss of
correction. Autologous cancellous bone graft insertion as the appli-
cation of hydroxylapatite granules could not lead to satisfied results
Also allogenic corticocancelleous grafts did not lead to satisfied
results. Since 2005 we have been used allogenic tibia diaphysis.
Materials and methods: This retrospective study evaluates radio-
logical results in patients, who had surgery in 2005 and 2006. The
procedure of the reconstruction of the anterior spinal column was
thoracoscopically assisted. The spine was stabilized with inherent-
stable spine devices, either by the isolated anterior approach or by the
combined approach. In 2011, X-rays and CT scans have been per-
formed to evaluate the Beck angle and the grade of bone healing in
the boarder zones. The evaluation was performed by an independent
radiologist.
Results: 27 patients came for examination. The loss of correction on
maximally followed-up X-rays has been 1.1�. The ratio of bone
healing in the boarder zones has been following:
0 % 25 % 50 % 75 % 100 %
Proximal 0 0 6 10 11
Distal 1 3 4 4 15
We had not seen in this study any complication with the allogenic
bone graft.
Conclusion: Allogenic tibia diaphysis for reconstruction of the
anterior spinal column lead to certain results without any higher risk
of infection, without any relevant loss of correction and with notable
healing results.
Disclosure: No significant relationships.
O116
TREATMENT OF SACRAL FRACTURE WITH SPINALINSTRUMENTATION SYSTEM
Y. Yagata1, Y. Ueda1, S. Mizuno2, K. Koshimune2, K. Toda2, Y. Ito2
1Othopaedic Surgery, Hyogo Emergency Medical Center, Kobe,
Japan, 2Kobe Redcross Hospital, Kobe, Japan
Introduction: Sacral fractures used to be treated with sacral bars,
iliosacral (IS) screws or conventional posterior plate fixation. But they
have some problems. Sacral bar and IS screw fixation are less inva-
sive, but the stability of fracture site seems to be not enough. Posterior
plate fixation is slightly invasive.
To fix sacral fractures firmly and less invasively, we contrived a new
method with spinal instrumentation system.
Materials and methods: We make 5 cm skin incisions just above
each side of post. sup. spine of ilium. Resect the spine to provide the
space for screw head, then insert two pedicle screws to both sides of
ilium. After that, make a tunnel under the soft tissue between two
incisions and path two rods through the tunnel. Reduce the fracture
and fix rods to the heads of pedicle screws. Finally, set two transverse
fixators between the rods.
Abstract S43
123
We indicate this method for AO type B and some C1 sacral fractures.
17 patients were treated with this method and evaluated clinically and
radiologically.
Results: Average operating time was 105 min, and average hemor-
rhage was 125 ml. Two of 68 pedicle screws were inserted miss
directionally, but no remarkable symptoms. There was no operation
site infection, and no skin trouble.
Correction loss was not seen in any case. We performed implant
removal on 3 cases after bony union, because of irritation around
screw heads. The surface of rods are smooth, so the removal was very
easy.
Conclusion: Pedicle screw and rod system is a practical and effective
method for treatment of sacral fracture.
Disclosure: No significant relationships.
P150
EPIDEMIOLOGY AND PREDICTORS OF CERVICAL SPINEINJURY IN ADULT MAJOR TRAUMA PATIENTS:EUROPEAN MULTICENTRE COHORT STUDY
R.M. Hasler1, A.K. Exadaktylos1, O. Bouamra2, L.M. Benneker3,M. Clancy4, R. Sieber5, H. Zimmermann1, F. Lecky2
1Emergency Medicine, Inselspital, University Hospital Bern, Bern,
Switzerland, 2Emergency Medicine, Trauma Audit and Research
Network, Salford, UK, 3Orthopedic Surgery, Inselspital, University
Hospital Bern, Bern, Switzerland, 4Emergency Medicine,
Southampton General Hospital, Southampton, UK, 5Emergency
Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
Introduction: Trauma causes 10 % of deaths worldwide and is the
leading cause of death in people aged 5–44 years in developed
countries. Patients with cervical spine injuries are a high risk
group, with the highest reported early mortality rate in spinal
trauma.
Materials and methods: Prospective European cohort study on
predictors for cervical spine injury in adult major trauma patients of
the Trauma Audit and Research Network from 1988–2009. Uni-
variate and multivariate logistic regression analyses were used to
determine predictors for cervical fractures/dislocations or cord
injury.
Results: 250,584 patients were analysed. Median age was 47.2 years
(IQR = 29.8–66.0) and Injury Severity Score 9 (IQR = 4–11).
60.2 % were male. 6,802 patients (2.3 %) sustained cervical spine
fractures/dislocations alone. 2,069 (0.8 %) sustained spinal cord
injury with/without fractures/dislocations. 39.9 % of cervical fracture/
dislocation and 25.8 % of cervical cord injury patients suffered
injuries to other body regions. Age 65 years (ORs 1.45–1.92), Glas-
gow Coma Score (GCS) 2 m (OR 2.74, 95 % CI 2.53–2.97) were
predictive for cervical fractures/dislocations.
Conclusion: Cervical spine trauma occurred in 3.5 % of major
trauma patients. Major trauma patients with a lowered GCS or
SBP (2 m), male gender and/or aged 35 years are at increased
risk of underlying cervical spine injury and merit careful pro-
tection and appropriate cervical spine imaging at initial
evaluation. This might especially be helpful in patients initially
presumed as non-polytraumatised or with less obviously recog-
nisable injuries.
Disclosure: No significant relationships.
SPORT INJURIES I
O117
MR IMAGING VERSUS RADIOGRAPHY OFACROMIOCLAVICULAR JOINT DISLOCATION
G. Oberleitner1, U. Nemec2, C. Fialka1, C. Krestan2
1Traumatology, Medical University of Vienna, Wien, Austria,2Radiology, Medical University of Vienna, Vienna, Austria
Introduction: Acromioclavicular (AC) joint injuries are usually
diagnosed by clinical and radiographic assessment using the Rock-
wood classification, which is crucial for treatment planning. In view
of the implementation of magnetic resonance (MR) imaging in the
visualization of the AC joint, this study sought to demonstrate AC
joint dislocation on MR imaging compared to radiography.
Materials and methods: This prospective study enrolled 44 patients
with suspected unilateral AC joint dislocation after acute trauma. All
patients underwent digital radiography and 1.0 Tesla MR imaging
using a surface phased array coil, and including coronal proton-den-
sity-weighted (w) turbo-spin-echo and coronal 3D T1-w fast-field-
echo water-selective sequences. The Rockwood classification was
used to assess AC joint injuries on radiography and MR imaging.
Furthermore, on MR imaging, an adapted Rockwood grading was
used for dedicated evaluation of the AC joint ligaments. The grading
of AC joint dislocation diagnosed by radiography and MR imaging
were compared.
Results: Of 44 patients with Rockwood injuries type I to IV on
radiography, the grading on radiography and MR imaging was con-
cordant in 23/44 (52.3 %) patients. On MR imaging, the grading was
down-staged in 16/44 patients (36.4 %), and up-staged in 5/44
(11.4 %). At adapted grading, MR imaging specified additional lig-
amentous lesions in 11/44 (25 %) patients, compared to the common
classification.
Conclusion: MR imaging changes the Rockwood classification
obtained from radiography in a considerable number of patients. In
addition to clinical assessment and radiography, MR imaging may
provide important ligamentous findings, which may have an impact
on therapeutic management.
References: 1. Rockwood CA, Jr. Subluxation of the shoulder. The
classification, diagnosis, and treatment. Orthop Trans. 1979;4:306–7.
2. Rockwood CJ, Williams G, Young D. Disorders of the acromio-
clavicular joint. In: Rockwood CJ, Matsen FA III, editors. The
shoulder. 2nd ed. Philadelphia: WB Saunders; 1998. p. 483–553.
Disclosure: No significant relationships.
O118
MINIMAL INVASIVE PLATE OSTEOSYNTHESIS (MIPO) OFCLAVICLE FRACTURE WITH LOCKING PLATE (LCP): 10YEARS EXPERIENCE
T.S. Mueller, C. Sommer
Surgery, Kantonsspital Graubuenden, Chur, Switzerland
Introduction: The unstable shoulder girdle with a fracture of the
clavicle (floating shoulder, ipsilateral serial rib fractures) or the
S44 Abstract
123
comminuted fracture of the clavicle with loss of length and axis is a
classical indication for a plate osteosynthesis. The goal of our study
was to test the practicability of the MIPO-technique in clavicle
fractures in unstable shoulder girdles.
Materials and methods: Between 2001 and 2011 we included, out of
internally fixed 240 shaft fractures in total (1529 plate, 889 elastic
nail), 26 patients with either a floating shoulder (n = 9), a clavicle
fracture in combination with ipsilateral serial rib fractures (n = 11) or
a comminuted fracture of the clavicle (n = 6), in our study.
Results: 25/26 fractures healed without complications. Clinical and
radiological length measurement showed no significant differences to
the contralateral side (range: +5 mm to -5 mm). In all patients a very
good functional result was achieved with an average DASH score of
5.3 (0–28). One implant failure occured 2 years after the initial
trauma in a road workman.
Conclusion: Based on our experience of more then 10 years with the
MIPO technique in clavicle fractures, we establish that the technique
can lead to good functional and cosmetic results. The advantage its
low invasiveness which better preserves the vascular supply of the
fracture fragments.
Reference: Smekal V, et al. Shaft fractures of the clavicle: current
concepts. Arch Orthop Trauma Surg. 2009;129(6):807–15.
Disclosure: No significant relationships.
O119
THE HUMERUSBLOCK NG: A NEW CONCEPT FORFIXATION OF PROXIMAL HUMERAL FRACTURES
A. Brunner1, H. Resch2, R. Babst3, W. Schmolz1
1Department for Trauma Surgery and Sports Medicine, Medical
University Innsbruck, Innsbruck, Austria, 2Trauma Surgery and
Sports Injuries, University Hospital Salzburg, Salzburg, Austria,3Trauma Surgery, Cantonal Hospital Lucerne, Luzern 16, Switzerland
Introduction: The Humerusblock NG represents the latest generation
of percutaneous fixation devices for fixation of proximal humeral
fractures. It enables minimally invasive semi-rigid angular stable
fixation and allows guided sintering of the head fragment to permit
and maintain fracture compression. This study performs in vitro
testing of the Humerusblock NG with fresh frozen cadavers using a
shoulder joint abduction motion test bench and cyclic loading in
abduction/adduction.
Materials and methods: Six fresh frozen human cadavers were
tested in a dynamic shoulder joint abduction motion test bench,
simulating abduction between 15� and 45�. Two fracture models were
evaluated. First, a stable wedge fracture with intact medial hinge was
loaded for 500 cycles. Thereafter, an unstable fracture with a gap of
5 mm was loaded for another 500 cycles. Analysis of fracture gap
motion, varus tilting and radiological measurement of implant
migration was performed.
Results: The stable fracture model showed a slow constant mean
maximum fracture sintering. The unstable fracture model showed
initial closure of the gap during the first 20 cycles. Thereafter, a slow
constant sintering was measured comparable to the stable fracture
model. Maximum varus tilt was 3.17� for the stable and 3.68� for the
unstable fracture pattern. Radiological analysis showed no change of
the tip apex distance and a significant sintering of the implants fixa-
tion pins in the unstable fracture model.
Conclusion: The Humerusblock NG allows for angular stable und
dynamic fixation of two part proximal humeral fractures. It enables
closure of the fracture gap under load and maintains fracture com-
pression during the healing process.
Disclosure: No significant relationships.
O119A
THE COMPARISON OF COLONIC STENTING ANDEMERGENCY SURGERY IN THE MANAGEMENT OFACUTE COLONIC OBSTRUCTION DUE TO INCURABLECOLORECTAL CANCER
I.S. Sarıcı, E. Ozkurt, H.T. Yanar, C. Ertekin, R. Guloglu,M.K. Gunay, B. Kaya, H. Bakkaloglu
General Surgery, Istanbul University Istanbul Faculty of Medicine,
Fatih, Turkey
Introduction: Acute colonic obstruction because of advanced colonic
malignancy is a surgical emergency. This study describes our results
of self-expanding metallic stents and emergency surgery in the
treatment of left-sided colonic and rectal obstruction resulting from
advanced malignancies.
Materials and methods: From January 2006 to September 2011, 122
patients with acute left sided colonic obstruction caused by advanced
colorectal cancer admitted to our emergency department. Insertion of
self-expanding metallic stents was attempted in 34 patients and 88
patients underwent to surgery.
Results: Stent placement was successful in 30/34 patients (88.2 %).
Eighty-eight patients underwent surgery, we performed palliative
colostomy to 32/88 (36.3 %) patients due to extensive disease, 56/88
(63.7 %) patients underwent colonic resection, 22/56 (39.2 %) had
prophylactic ileostomy and 21/56 (37.5 %) had colonic resection with
end colostomy. There was no procedure-related mortality and the
morbidity was 8.8 % (3/34) in stent group. Total hospital mortality
was 19.3 % (17/88) and hospital morbidity was 23.8 % (21/88) in
surgery group.
Conclusion: The results of this study demonstrated that the man-
agement of acute left-sided, malignant colorectal obstruction with
metallic stent decompression is an effective and safe method com-
pared to surgery for the patients who can undergo systemic
chemotherapy.
References: 1. Management of malignant left-sided large bowel
obstruction: a comparison between colonic stents and surgery. ANZ J
Surg. 2010. 2. Self-expanding metallic stents for acute left-sided
large-bowel obstruction: a review of 130 patients. Colorectal Dis
Disclosure: No significant relationships.
O120
INTEROBSERVER VARIABILITY OF COMPUTEDTOMOGRAPHY FOR DIAGNOSIS OF SUSPECTEDSCAPHOID FRACTURES
A. De Zwart1, S. Rhemrev2, L. Kingma3, S. Meylaerts2, I. Schipper1,M. Otoide4, F. Beeres2
1Surgery, LUMC, Leiden, The Netherlands, 2Surgery, MCH
Haaglanden, Hague, The Netherlands, 3Radiology, UMCG,
Groningen, The Netherlands, 4Statistics, LUMC, Leiden, The
Netherlands
Abstract S45
123
Introduction: Computed tomography (CT) is often advocated for the
diagnosis of suspected scaphoid fractures. The primary aim of this
study is to determine the interobserver variability of CT for suspected
scaphoid fractures.
Materials and methods: Four radiologists evaluated CT scans of 150
patients with a clinically suspected scaphoid fracture and a negative
radiograph, for the presence or absence of a scaphoid fracture and to
localize the fracture. The interobserver agreement was calculated
using the Kappa statistic.
Results: The number of observed scaphoid fractures ranged from 11
to 22 between the radiologists, with a Kappa value of 0.51. The Kappa
value for the localization of the fracture was 0.48. The radiologists
scored in total 48 fractures of the distal radius and 97 other carpal
fractures.
Conclusion: Agreement of CT between four radiologists, for pres-
ence of a scaphoid fracture and its location, was moderate.
Considerable numbers of scaphoid fractures are therefore likely to be
under- and/or overdiagnosed in daily practice when CT is used to
exclude or confirm a scaphoid fracture. This should be kept in mind
when interpreting clinical and research results of CT in patients with
suspected scaphoid fractures.
Disclosure: No significant relationships.
O121
AVULSION FRACTURE OF THE SUPINATOR CREST OFTHE PROXIMAL ULNA IN THE CONTEXT OF COMPLEXELBOW JOINT INJURIES
K. Schmidt-Horlohe, Y. Kim, P. Wilde, A. Bonk, R. Hoffmann
Abteilung Fur Unfallchirurgie Und Orthopadische Chirurgie,
Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt
am Main, Germany
Introduction: While performing CT examinations, a previously
undescribed small fracture fragment of the supinator crest of the ulna
was frequently observed within our patient population.
Materials and methods: Four orthopedic surgery investigators ret-
rospectively evaluated all of the CT scans of the elbow joints that
were performed between June 1, 2010, and December 12, 2010.
Conventional X-ray images of the lateral and anterior-posterior view
were interpreted in terms of their ability to detect the aforementioned
fragment.
Results: A total of 152 CT scans were evaluated. The fragment in
question was concordantly discovered in 17 patients (11.2 %). The
average age of the 7 female and 10 male patients was 40 years
(9–71 years, SD = 14.9). The fragment size varied between a few
millimeters and 2.5 cm. Multifragmented fractures were observed. In
82.3 % of the cases, associated radial head fractures were diagnosed.
In 29.4 % of the cases, a coronoid process fracture was present. In
23.5 % of the cases, distal humerus fractures were found. The frag-
ment of the supinator crest could be delineated using a conventional
X-ray diagnosis in only one patient.
Conclusion: In a significant percentage of the population presented
here, a previously undescribed fracture fragment of the supinator crest
of the ulna could be detected. The most frequent associated injuries
were found in fractures of the radial head, the proc. coronoideus, and
the distal humerus. The etiology of these lesions is unknown; how-
ever, bone avulsion in the annular or the lateral ulnar collateral
ligament seems to be the most likely cause.
Disclosure: No significant relationships.
O122
ELBOW ARTHROPLASTY AS PRIMARY TREATMENT OFCOMPLEX DISTAL HUMERAL FRACTURES IN ELDERLYPATIENTS
J.A. Almodovar Delgado, A. Beano Aragon, J. Olaguibel Moret
Orthopaedic Trauma Unit, Hospital Ramon y Cajal, Madrid, Spain
Introduction: Having obtained good outcome in the treatment of
complex non traumatic disorders of the elbow with arthroplasty in
elderly patients and according with the literature, we began using it in
fractures that could not be resolved with open reduction and internal
fixation.
Materials and methods: From January 2005 to December 2010, ten
patients have been reviewed.Nine were women.The average age was
79 years (range 65–88). The AO classification were used to evaluate
them. All arthroplasties were performed using the same constrained
implant.The Mayo Elbow Performance Score and the Disabilities of
the Arm, Shoulder and Hand Questionnaire were used to assess
postoperative function.
Results: Eight fractures were classified as C3 and two as B3.The
mean flexion arc was 1208 range (105–140), the loss of extension was
258 range (5–40). The mean supination was 708 and pronation
758.The mean Mayo Elbow performance score was 91 (75–100) and
the mean DASH score was 22 (12–65). A triceps-sparing approach of
Bryan-Morrey were used in all the cases.The mean operative time was
120 min (95–140). The mean length of follow up was 25 months
(12–55). There were two cases of transient cubital neuroapraxia
recovered spontaneously and three cases of heterotopic calcification.
Conclusion: We think that the use of Elbow Arthroplasty as primary
treatment improves the quality in the management of this kind of
fractures in elderly patients.
Reference: 1. Gambisario R, Riand N, et al. Total elbow replacement
for complex fractures of the distal humerus. An option for the elderly.
J Bone Joint Surg. 2001;83B:974–8.
Disclosure: No significant relationships.
O123
REPAIR OF DISTAL BICEPS TENDON RUPTURES USINGBONE ANCHORS: TECHNIQUE, FUNCTIONAL OUTCOMEAND COMPARISON WITH OTHER FIXATION METHODS
C. Zosso1, T. Hotz2, M. Rudin2, K. Kach2
1Department of Surgery, Kantonsspital Winterthur, Winterthur,
Switzerland, 2Kantonsspital Winterthur, Winterthur, Switzerland
Introduction: Rupture of the distal tendon of biceps muscle is a rare
injury. Nonoperative treatment has been shown to lead to a relevant
decrease in flexion and supination strength of the elbow. Therefore
operative repair of the tendon is generally recommended. The purpose
of this study is to present the results of surgical repair using bone
anchors in a single-incision technique and compare them with the
results of other fixation techniques.
Materials and methods: Retrospective review of 31 patients (2
women, 29 men) treated for acute complete distal biceps tendon
rupture between 1998 and 2010 using above-mentioned method. The
patients were interviewed and underwent a clinical examination. They
S46 Abstract
123
also were asked to complete two different rating systems for evalu-
ation of the elbow (MEPI, DASH).
Results: Average age at injury time was 47 years (range
32–68 years). The mean time between injury and surgery was 6 days
(range 0–27 days). At a mean follow-up of 70 months (range
10–152 months), patients presented satisfactory subjective and
objective clinical results. Dynamometric tests showed satisfactory
results both regarding maximum strength and endurance tests. One
reoperation because of heterotopic ossification was done. One patient
had to be reoperated for rerupture caused by a second accident.
Neurologic complications or radioulnar synostosis didn’t occur.
Conclusion: Distal biceps tendon ruptures can easily and safely be
reattached to the radial tuberosity by using a single-incision technique
and bone anchors with a low complication rate. This method produces
excellent clinical outcomes comparable or better than other repair
techniques.
Disclosure: No significant relationships.
SPORT INJURIES/DISTAL RADIUS FRACTURES
O124
MINIMUM 3 YEARS EXPERIENCE IN MANAGINGFLOATING SHOULDER INJURIES
F.F. Adam1, H.H. Refae2
1Orthopaedic Surgery and Traumatology, Assiut University Hospital,
Assiut, Egypt, 2Orthopaedics, South Valley University Hospital,
Qena, Egypt
Introduction: Floating Shoulder Injuries are exceedingly rare inju-
ries,receive little attention in the literature,get inadequate attention in
the acute management of polytraumatized patients and carries high
morbidity and mortality rates.
Materials and methods: This is a prospective analysis of 12 patients
with floating shoulder injuries, surgically treated between and fol-
lowed for a minimum of 3 years. All patients were victims of high-
energy trauma and had other life-threatening injuries. Surgery was
performed after stabilization of the patients general condition aiming
at reconstructing the superior shoulder suspensory complex (sssc), the
main attachment of the upper extremity to axial skeleton. Parameters
such as pain, range of movement, muscle power, performance of
activities of daily living (ADL), and return to pre-trauma work were
used for functional assessment.
Results: All patients had surgical stabilization of both clavicular and
glenoid neck fractures except one who had early fixation of only the
clavicle. Active range of motion exercises began 3–5 days postop-
eratively. All fractures healed in 3 months. Full range of motion was
attained within 2–3 months in all patients. All patients had excellent
results; 10 patients had no pain, and 2 had mild pain on exertion.
Ten manual workers returned to their previous occupation and 2
patients returned to a lighter work within 6–9 months. No patient
had a significant deformity of the shoulder. Complications included
suprascapular nerve palsy in one patient that recovered spontane-
ously after 4 months and a case of superficial scapular wound
infection.
Conclusion: Early recognition and surgical stabilization of both
bones in floating shoulder injuries significantly improve the functional
outcome and reduce the associated morbidity.
Disclosure: No significant relationships.
O125
ANALYSIS OF THE INTER: AND INTRAOBSERVERAGREEMENT IN RADIOGRAPHIC EVALUATION OFWRIST FRACTURES USING THE MULTIMEDIAMESSAGING SERVICE
S. Brunetti, A. Ferrero, G. Garavaglia, G.J. Petri, S. Lucchina,C. Fusetti
Ortopedia E Traumatologia, Chirurgia Della Mano, Ospedale
Regionale Bellinzona e Valli, Bellinzona, Switzerland
Introduction: Orthopaedic surgeons are often asked to evaluate
X-rays of patients admitted to the A&E Department with the suspi-
cion of a wrist fracture or, in case of an evident fracture, to decide the
correct treatment. The aim of this study was to evaluate the feasibility
of a correct interpretation of the images of injured wrists on the screen
of a last generation mobile phone, in order to evaluate if the specialist
could make the right diagnosis and choose the correct treatment.
Materials and methods: Five orthopaedic and one hand surgeons
have evaluate the X-rays of 67 patients who sustained an injury to
their wrist. In case of fracture they were asked to classify it according
to the AO and Mayo classification systems. The evaluation of the
images was accomplished through the PACS and using a mobile
phone, at a different time. In order to check the inter- and intra-
observer reliability, the same pattern was followed after a few
months.
Results: The mobile phone showed basically the same agreement
between the observers highlighting the worsening of the inter- and
intra-observer reliability with the increment of the variables consid-
ered by a classification system.
Conclusion: The present paper confirms that a last generation mobile
phone can already be used in the clinical practice of orthopaedic
surgeons on call who could use it as a useful device in remote or
poorly served areas for a rapid and economic consultation.
Disclosure: No significant relationships.
O126
ASSESSMENT OF A NOVEL BIOMECHANICAL FRACTUREMODEL FOR DISTAL RADIUS FRACTURES
S.F. Baumbach1, E. Dall’Ara2, P. Weninger3, A. Antoni3, H. Traxler4,P.K. Zysset2
1Chirurgische Klinik Und Poliklinik, Innenstadt, LMU, Munich,
Germany, 2Institute of Lightweight Design and Structural
Biomechanics, Vienna University of Technology, Vienna, Austria,3Ludwig Boltzmann Institute for Experimental and Clinical
Traumatology, Lorenz Boehler Trauma Hospital, Vienna, Austria,4Abteilung Fur Systematische Anatomie, Medical University of
Vienna, Vienna, Austria
Introduction: Distal radius fractures (DRF) are one of the most
common fractures and often treated by plate osteosynthesis, which are
validated through biomechanical tests. A recent publication [1]
challenges the current standard biomechanical fracture model [2, 3].
The aim of the study was to develop a new model for DRF (AO-
23.A3) and compare its biomechanical behavior to the current gold-
standard.
Abstract S47
123
Materials and methods: Polyaxial angle-stable volar plates
(ADAPTIVE, Medartis) were mounted on 10 pairs of fresh frozen
radii. The osteotomy location (New: 10 mm wedge 8 mm/12 mm
proximal to the dorsal/volar apex of the articular surface; Gold-
standard: 10 mm wedge 20 mm proximal to the articular surface) was
alternated within each pair. Each specimen was tested in cyclic axial
compression (increasing load by 100 N per cycle) until failure or -
3 mm displacement. Parameters assessed were displacement, work
and stiffness calculated for each cycle and ultimate load.
Results: 7 female and 3 male pairs of radii aged 74.3 ± 9.0 years
were tested. In most cases (7/10) the two groups showed similar
mechanical behavior at low loads with increasing differences at
increasing loads, which became significant at 700 N. The new model
showed greater displacement (p = 0,044), more dissipated work
(p = 0.025) and lower stiffness values p = (0.009). The average final
loads resisted were significantly lower in the novel model
(860 N ± 232 N vs. 1250 N ± 341 N; p = 0.001).
Conclusion: The herein introduced novel biomechanical fracture
model for DRF better mimics the in vivo fracture side and shows a
significantly different biomechanical behavior with increasing loads
when compared to the current gold-standard.
References: 1. Baumbach et al. J Orthop Res. 2011;29(4):489–94. 2.
Strauss et al. J Trauma. 2008;64(4):975–81. 3. Rausch et al. Injury.
2011.
Disclosure: The osteosynthetic material was provided by Medartis
with no oblications to the author. The study was supported by a IBRA
(International Bone Research Association) small grand.
O127
MEASURING SPATIAL AND TEMPORAL PARAMETERS OFGLENOHUMERAL MOVEMENT IN BOTH HEALTHYPEOPLE AND ROTATOR CUFF PATIENTS DURINGDIFFERENT SELF-DETERMINED SPEEDS
A.K. Singh1, J. Bergmann2, R. Pollock2, D. Newham2, J. Sinha1
1Department of Trauma and Orthopaedics, King’s College Hospital,
London, 9RS, UK, 2Department of Physiotherapy, King’s College
London, 1UL, UK
Introduction: The purpose of this study is to explore spatial and
temporal changes in glenohumeral movement when the speed of
movement is changed in both healthy asymptomatic adults and rotator
cuff patients.
Materials and methods: Seven healthy participants and eight pre-
operative patients participated in this study. Participants were asked to
move the arm in several predetermined motion patterns at normal and
fast speeds. Five range of motion (ROM) tasks were performed both
passively and actively. The active ROM tasks were measured at a
self-selected speed and during the maximum speed the patient was
willing (or capable) to perform. Subjects were instructed to reach a
maximal joint angle in each active ROM task. The arm was moved by
the experimenter, during the passive ROM tasks. Subjects were asked
to perform each task three times.
Results: No significant differences were found between the passive
and active range of motion task for both the control and pre-operative
patients. However, there was a significant (P \ 0.05) difference in
duration between the slow and fast speed tasks for both groups, the
range of motion did not differ significantly (P [ 0.05) between the
normal and fast speed condition. The mean difference in angular
velocity, between control and pre-operative patients went from 14�/s
during normal speed to 29�/s in the fast speed condition, increasing
the level of significance between groups. The results in the frontal
plane, mirrored those found for the sagittal plane.
Conclusion: There is an increase in differences in angular velocity
between groups when the task was performed at greater speeds.
Disclosure: No significant relationships.
O128
TREATMENT OF DISPLACED LATERAL CLAVICLEFRACTURES WITH THE SUPERIOR ANTERIOR CLAVICLEPLATE WITH LATERAL EXTENSION: EARLYEXPERIENCE IN 20 PATIENTS
D. Tiren, D.I. Vos, J.P.M. Vroemen
Trauma Surgery, Amphia Hospital, Breda, The Netherlands
Introduction: Displaced lateral clavicle fractures have a high per-
centage of non-union and delayed union when treated conservatively.
Operative stabilisation results in a high percentage of union. Many
techniques and methods have been used to stabilise these fractures, all
with a high percentage of union, but none without peri- or post-
operative complications.
Purpose of this study was to evaluate our early experience with the
Synthes LCP superior anterior clavicle plate with lateral extension in
displaced lateral clavicle fractures.
Materials and methods: All consecutive patients treated with this
plate between 2009 and 2011 were evaluated. Twenty patients were
included [mean age 45, m:f ratio (14/6)].
Results: The union rate was 100 %. All patients returned to daily
work within 1–6 weeks. The functional outcome (Constant Score)
was excellent to good in all cases. No major complications were
encountered. Nine patients required implant removal after fracture
consolidation because of a prominent lateral end of the plate, over the
acromion and in several cases because of a limited shoulder move-
ment at the extremes. In six cases the most lateral-ventral 2.7 mm
screw perforated the AC joint.
Conclusion: The LCP superior anterior clavicle plate with lateral
extension is an implant that sufficiently fixes the soft metaphyseal
small lateral end of the clavicle using methods familiar to trauma
surgeons. Pain and impingement complaints related to the implant
was not an issue in our series. Caution is advised with the position of
the plate and the most lateral 2.7 mm screws.
Disclosure: No significant relationships.
O129
OVERCONSUMPTION OF RADIOGRAPHY IN ACUTEWRIST INJURIES; A CALL FOR A CLINICAL DECISIONRULE
A. Bentohami1, M.S.H. Beerekamp2, J. Vallinga2, T.S. Bijlsma3,B.A. Dijkman, Van4, M. Maas5, J.C. Goslings2, N.W.L. Schep2
1Trauma Unit, Department of Surgery, AMC, Amsterdam, The
Netherlands, 2Trauma Unit, Department of Surgery, Academic
Medical Center, Amsterdam, The Netherlands, 3Department of
Surgery-traumatology, Spaarne Ziekenhuis, Hoofddorp, The
Netherlands, 4Department of Surgery, Flevo Hospital, Almere,
The Netherlands, 5Radiology, Academic Medical Center, Amsterdam,
The Netherlands
S48 Abstract
123
Introduction: In most hospitals a wrist radiographic series is carried
out routinely to confirm or rule out a possible fracture following wrist
trauma [1]. Probably, a substantial part of the wrist radiographic
series does not show a fracture. This overconsumption of X-rays may
lead to unnecessary radiation exposure and waiting time for the
patient, as well as additional costs to the healthcare system. The
primary aim of this study was to determine which percentage of
radiographs, requested for suspicion of a wrist fracture, showed a
fracture.
Materials and methods: A retrospective cohort study was performed
in three Dutch hospitals (one teaching, one non-teaching and one
academic hospital) to determine the percentage of positive radio-
graphs in adults with acute trauma of the wrist. The following
anatomic structures were defined as wrist: the distal metaphysis of the
radius, the distal metaphysis of the ulna and all carpal bones (sca-
phoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate,
hamate).
Results: Out of 1742 patients clinically suspected of a wrist fracture,
846 patients (49.0 %) had one or more fractures according to the wrist
radiographic series. Median age was 52.6. Most patients (63.5 %)
were female.
Conclusion: The current use of radiographic examination in patients
with acute wrist injuries has a 49 % yield of a fracture and is not
efficient enough. Future aim is to develop a clinical decision rule for
performing radiography following acute wrist trauma.
Reference: 1. Gleadhill DN, Thomson JY, et al. Can more efficient
use be made of X-ray examinations in the accident and emergency
department? Br Med J (Clin Res Ed). 1987;294(6577):943–7.
Disclosure: No significant relationships.
O130
TREATMENT OF DISTAL RADIUS FRACTURES WITH THELOCKING COMPRESSION PLATE: LONG TERMFUNCTIONAL AND RADIOLOGICAL RESULTS
S. Tsitsilonis, D.B. Macho, A. Disch, N.P. Haas, F. Wichlas
Center for Musculoskeletal Surgery, Charite University Medicine,
Berlin, Germany
Introduction: The therapy of distal radius fractures with locking
compression plates has gained importance [1]. The aim of the present
study was to evaluate the long term results of the operative treatment
with the locking compression plate (LCP, Synthes�).
Materials and methods: For the means of the study 128 patients
(mean age 59 years, 45 men, 83 women, 130 fractures) treated with a
2.4 mm or 3.5 mm LCP were examined at a mean follow up of
23 months. The fractures were classified according to AO; 56.1 %
were C-Fractures. We measured wrist range of motion and grip
strength, the opposite side served as control. Subjective and objective
function was evaluated with DASH and Gartland–Werley score,
respectively. The reduction of the radius fracture (radial inclination,
volar tilt) was radiologically evaluated in anteroposterior and lateral
view.
Results: Mean wrist ROM was: flexion 47.2� (SD 15.0�), extension
53.3� (12.4�), ulnar abduction 33.7� (9.5�), radial abduction 18.4�(6.7�), pronation 86.6� (11.7�) and supination 71.7� (13.1�). The
values obtained 79.9 % (flexion) to 97.7 % (pronation) of the
opposite side. Mean grip strength was 23.0 kg (15.2 kg). The mean
DASH and Gartland Werley scores were 18.9 (21.1) and 3.5 (4.2),
respectively. Mean radial inclination was 13.6� (11.3�) preopera-
tively and 22.3� (4.2�) at follow-up examination. Respective values
for volar tilt were -15.4� (19.1�) and 7.8� (4.4�). In eight cases
complications occured, in six cases an implant removal was
necessary.
Conclusion: The long term outcome after treatment with LCP is
satisfying. The high rate of tendon ruptures reported in the literature
was not confirmed in this study. The problem of wrist pain even after
anatomical reduction should be addressed.
Reference: 1. Lattmann T, Meier C, Dietrich M et al. Results of volar
locking plate osteosynthesis for distal radial fractures. J Trauma.
2011;70(6):1510–8.
Disclosure: No significant relationships.
O131
CLINICAL AND RADIOLOGICAL RESULTS OFARTHROSCOPIC STABILIZATION FOR THE ACUTEACROMIOCLAVICULAR JOINT DISLOCATIONS
L. Kovacic, B. Sluga, M. Veselko, V. Senekovic
Department of Traumatology, University Medical Centre Ljubljana,
Ljubljana, Slovenia
Introduction: A wide range of surgical techniques is used for the
treatment of acute acromioclavicular (AC) joint dislocation. Early and
late postoperative complications are common. Recently, some authors
described arthroscopic techniques as well. The purpose of this study
was to evaluate the clinical and radiological results after arthroscopic
coracoclavicular AC joint stabilization.
Materials and methods: Fourty-five consecutive patients (3 females,
42 males; mean age 38.6 years, range 16–66) with acute AC joint
dislocation Rockwood V were included in prospective observational
study. Patients were treated with arthroscopic coracoclavicular sta-
bilization technique using ThightRope� (Arthrex�) implant. All
operations were performed by the same surgeon. The time interval
from trauma to surgery averaged 11.7 (range 2–32) days. Fourty
patients (88.9 %) were available for follow-up.
Results: At 1 year follow-up the mean Constant score was 93.1
(range 80–99) relative Constant score was 97.1 (range 82.6–100).
The SSV averaged 86.9 (range 70–100). Simple shoulder test was
11.8 (range 11–12). On clinical examination there were 19/40
(47.5 %) anatomical AC joints. On radiological examination there
were 19/40 (47.5 %) clavicles in anatomical position, 19/40
(47.5 %) subluxated less than 5 mm and 2/40 (5 %) with complete
dislocation. Clavicle was vertically stable in 29/40 (72.5 %) patients
and horizontally stable in 19/40 (47.5 %) patients. AC joint redis-
location occurred during first 6 months. We observed 2 transient
incomplete ulnar nerve injuries, 1 coracoid fracture, 1 distal implant
migration, 2 capsulitis, 5 skin irritations over the clavicle button
which subside with time.
Conclusion: AC joint reconstruction and stabilization can be per-
formed safely and effectively with arthroscopic technique. Despite the
presence of posterior instability and subluxation of the AC joint ex-
ellent clinical results were observed both in terms of Constant score
and patient satisfation. We advise restriction of sports and heavy
labour for 6 months, because of AC joint redislocation during this
period.
Disclosure: No significant relationships.
Abstract S49
123
BASIC RESEARCH
O132
ENHANCEMENT OF ORTHOTOPIC BONEREGENERATION BY NON-VIRAL SONOPORATIONGENE THERAPY
G.A. Feichtinger1, S. Schutzenberger2, A.T. Hofmann2, P. Slezak2,M. Kaipel2, A.P. Mchale3, M. Van Griensven2, H. Redl2
1Molecular Biology, LBI for experimental and clinical traumatology,
Vienna, Austria, 2LBI for experimental and clinical traumatology,
Vienna, Austria, 3School of Biomedical Sciences, University of
Ulster, Coleraine, UK
Introduction: Sonoporative gene transfer, a minimal invasive non-
viral gene transfer method, has been shown to trigger expression of
plasmid vectors in vivo [1]. The combination of Bone Morphogenetic
Protein 2 (BMP2) and Bone Morphogenetic Protein 7 (BMP7) in a co-
expression strategy has been proven highly osteoinductive [2, 3].
Therefore, the aim of this study was to design and test a BMP2/BMP7
co-expression plasmid for its regenerative potential in in vivo models.
Materials and methods: BMP2 and BMP7 were cloned into a
modified pVAX1 constitutive expression plasmid and an inducible
TetON system for co-expression. Induction of osteogeneic differen-
tiation was tested in vitro in C2C12 cells with an osteocalcin specific
reporter system [4] and standard methods. Subsequently, the plasmids
were administered in an ectopic mouse model and 3 days post frac-
ture in a rat femur non-union model, using sonoporation. Animals
received 5 treatments on 5 subsequent days. Controls received
luciferase plasmid, which allowed monitoring of gene transfer effi-
cacy through bioluminescence imaging. All animals were imaged
using an in vivo uCT on days 28 and 56.
Results: Bioluminescence showed strong luciferase expression after
sonoporation. lCT images showed ectopic bone formation in muscle
and significantly enhanced bone volume as well as unions in critical
size femur defects after treatment with BMP2/BMP7 sonoporation.
Conclusion: Therefore, we conclude, that sonoporative gene transfer
is an effective non-viral method to mediate transient transgene
expression in ectopic and orthotopic settings and to improve bone
regeneration in orthotopic settings.
References: 1. Li YS, et al. Cancer Lett. 2009;273:62–9. 2. Zhu W,
et al. J Bone Miner Res. 2004;19:2021–32. 3. Kawai M, et al. BMC
Musculoskelet Disord. 2006;7:62:1471–4. 4. Feichtinger, GA et al.
Tissue Eng Part C Methods. 2010;17:401–10.
Disclosure: No significant relationships.
O133
PRODUCTIVE CAPACITY OF ALVEOLAR MACROPHAGESAND KUPFFER CELLS AFTER FEMORAL FRACTURE ANDBLUNT CHEST TRAUMA IN A MURINE TRAUMA MODEL
C. Neunaber1, S. Oestern2, H. Andruszkow1, M. Frink1,F. Hildebrand1
1Trauma Department, Hannover Medical School, Hannover,
Germany, 2Trauma Surgery, University Medical Center Schleswig–
Holstein, Kiel, Germany
Introduction: Specific cellular and inflammatory factors that con-
tribute to the severity of lung contusion are not fully elucidated.
Therefore, we investigated alterations of the productive capacity of
alveolar macrophages (AM) and Kupffer cells (KC) after femoral
fracture with or without blunt chest trauma.
Materials and methods: After anaesthesia with isofluran femoral
fracture was induced in 40 male C57BL/6N mice using a guillotine
mechanism. Additional 40 mice underwent a combined trauma of
femur fracture and lung contusion. Lung contusion was induced by
dropping a 300 g weight from 50 cm height onto the chest of the
mice. Animals were sacrificed 0, 6, 12, 24 h and 3 days after trauma
induction. Cytokine concentrations were measured in plasma and
supernatant of cultivated AM and KC by FACS. Pulmonary and
hepatic infiltration of PMN was determined by Ly6G-staining.
Results: Combined trauma led to a significant higher amount of
plasma MCP-3 6 h and 3 days after the insult compared to isolated
femur fracture. In the supernatant of cultivated AM and KC MCP-1,
IL-6, MIP-1a, MIP1-b, RANTES and TNF-a concentrations were
significantly increased in combined trauma group. In the isolated
femur fracture group we found only increased concentrations of the
cytokines in the supernatant of KC after 6 h. Pulmonary and hepatic
infiltrations of PMNs were increased in both groups after 6 h, but in
the combined trauma model the effect was prolonged over 24 h to
3 days.
Conclusion: An isolated femur fracture exerts already inflammatory
effects, but the combination of femur fracture and lung contusion
results in an increased and prolonged activation of the inflammatory
response.
Disclosure: No significant relationships.
O134
COMPARISON OF NEUROPROTECTIVE EFFECTS ONALPHA LIPOIC ACID TO METILPREDNIZOLONE ATEXPERIMENTAL SPINAL CORD TRAUMA
S. Ercan1, S. Kemaloglu2, A. Aktas3, O. Evliyaoglu4, C. Gocmez2,K. Kamasak2, A. Ceviz2
1Neurosurgery, Dicle University, Diyarbakir, Turkey, 2Neurosurgery,
Dicle University Medical Faculty, Diyarbakir, Turkey, 3Histology and
Embryology, Dicle University Medical Faculty, Diyarbakir, Turkey,4Biochemistry, Dicle University Medical Faculty, Diyarbakir, Turkey
Introduction: Traumatic and ischemic injuries of spinal cord are
active at malfunctioning of damaged tissue at primary and secondary
mechanisms. Alpha Lipoic acid at diabetic neuropathy, is well known
agent at neuroprotective. The effects of alpha-liphoic acids are not
studied on spinal cord injuries. In this study, our purpose was to
present the effects of Alpha Lipoic acid on neuroprotective, especially
with comparison of Methylprednizolone.
Materials and methods: 50 Sprague–Dawley rat were divided in 5
groups (n = 10) to create spinal cord trauma with Tator method.
Group 1: Only laminectomygroup. Group II: Laminectmy + spinal
cord injury (SCI) group. Group III: Laminectomy + SCI + alpha
lipoic acids (ALA) (100 mg/kg), Group IV: Laminectomy +
SCI + Methyl-Prednisolone (30 mg/kg). GroupV: Laminectomy +
SCI + ALA + Methyl-Prednisolone group. 24 h after applications,
blood were drawn from all of the rats under Ketamine anesteshia and
histopathological and biochemical materials were taken at injured
spinal cord immediately.
S50 Abstract
123
Results: There were not any difference among the groups in motor
functions. Comparision of the antioxidant values among the groups
show the results of a significant statistical differences between Group
I and the groups with ALA. The difference between the Groups with
ALA and Groups with methylprednisolone was the oxygen radicals
were significantly low. The most significant difference was between
the group with monoteraphy and the group, gave the combine treat-
ment. At histopathologic examination, group which gave combine
treatment, showed more vasodilatation.
Conclusion: Our results reveal that the effects of Alpha-Lipoic acids
on rats with spinal cord trauma lower the anti-oxidants formation.
Disclosure: No significant relationships.
O135
AUGMENTATION OF HIP IMPLANTS IN OSTEOPOROTICBONE: HOW MUCH CEMENT IS NEEDED AND WHERESHOULD IT GO?
A. Sermon1, L. Fliri2, R.G. Richards3, S. Boonen4, M. Windolf2
1Department of Traumatology, University Hospitals Gasthuisberg,
Leuven, Belgium, 2Biomedical Services, AO Research Institute,
Davos Platz, Switzerland, 3AO Research Institute Davos, Davos
Platz, Switzerland, 4University Hospitals Gasthuisberg, Leuven,
Belgium
Introduction: Several studies have proven the beneficial effect of
cement augmentation of proximal femoral nail antirotation (PFNA)
blades on implant purchase in osteoporotic bone [1, 2]. However,
there is a considerable variation in cement distribution around the
implant [2, 3]. It is the purpose of this in vitro study to investigate
the effect of different localisations and amounts of polymethyl-
methacrylate (PMMA) to be used to achieve sufficient implant
purchase.
Materials and methods: 36 polyurethane foam specimens with low
density were instrumented with a PFNA blade and subsequently
augmented. Six study groups were formed with varying location of
the cement cloud and amount of PMMA used. All specimens
underwent increasing cyclic axial loading until construct failure.
Movement of the blade was monitored by taking X-rays. Six healthy
cadaveric femoral heads were instrumented and tested in an ana-
logue manner without cement augmentation to establish a
benchmark value. Data were analysed using conventional statistical
methods.
Results: The experiments revealed a biomechanically inferior local-
isation at the base and caudal to the blade. Furthermore, there was an
inverse correlation between the distance of the PMMA cloud to the
apex of the femoral head and the number of cycles to failure
(R = 0.77).
Conclusion: Both, localisation and amount of cement surrounding a
hip implant have an influence on implant purchase in osteoporotic
bone. However, all tested configurations revealed comparable per-
formance to a benchmark group of non-augmented healthy cadaveric
specimens. The importance of the cement localisation inside the
femoral head can therefore be diminished.
References: 1. Injury. doi:10.1016/j.injury.2011.04.010. 2. J Trauma.
doi:10.1097/TA.0b013e31821852ed. 3. Injury. doi:10.1016/j.injury.
2011.07.010.
Disclosure: No significant relationships.
O136
EX VIVO EVALUATION OF THE POLYMERIZATIONTEMPERATURES DURING CEMENT AUGMENTATIONOF PFNA BLADES
L. Fliri1, M. Lenz1, J. Stucki2, A. Boger3, M. Windolf1
1Biomedical Services, AO Research Institute Davos, Davos Platz,
Switzerland, 2AO Research Institute, Davos Platz, Switzerland,3University of Applied Sciences, Ansbach, Germany
Introduction: Previous studies have clearly demonstrated superior
biomechanical behaviour of augmented proximal femoral nail anti-
rotation (PFNA) blades compared to non-augmented ones with
respect to implant cut-out [1–3]. Nevertheless, there is concern about
thermal bone necrosis due to exothermic curing of polymethylmeth-
acrylate (PMMA) based bone cements. The objective of this study
was to quantify the temperatures arising around perforated titanium
PFNA blades when augmenting with PMMA.
Materials and methods: Cylindrical samples from 6 pairs of fresh
frozen human cadaveric femoral heads implanted with a PFNA blade
were placed in a 37 �C water bath and augmented with 3 and 6 ml
PMMA, respectively. During augmentation, temperatures were mea-
sured using 6K-type thermocouples which were placed at controlled
distances around the implant. With help of pQCT images, the loca-
tions of all thermocouples with respect to the cement-bone interface
were reconstructed.
Results: No temperatures higher than 45 �C were measured in the
interface-region and the surrounding cement-free cancellous bone. In
the same regions, the longest exposure time above 41 �C was 8.5 min
and was measured in a 6 ml sample. Average maximal temperature
was significantly lower for the 3 ml group compared to the 6 ml
group (p = 0.017).
Conclusion: The results of this study suggest that augmentation of
titanium PFNA blades is not associated with a risk of thermal bone
necrosis when using up to 6 ml of PMMA. However, larger amounts
of cement lead to higher temperatures. PMMA application should
therefore be kept low to minimally alter the biological system.
References: 1. PMID:21824697. 2. PMID:21768899. 3. PMID:
21601203.
Disclosure: The authors are not compensated and there are no other
institutional subsidies, corporate affiliations, or funding sources sup-
porting this work unless clearly documented and disclosed. Synthes
GmbH partially funded this study and provided all implants.
O137
A COMPREHENSIVE CARE PATHWAY FOR THETREATMENT OF HIP FRACTURES
E. Flikweert1, M. Stevens2, G. Izaks2, K. Wendt2
1Traumasurgery, University Medical Center Groningen, Groningen,
The Netherlands, 2University Medical Center Groningen, Groningen,
The Netherlands
Introduction: In elderly people a fractured hip is a common injury.
These fractures have a strong negative effect on activities of daily
Abstract S51
123
living and quality of life. To improve the perioperative care for these
patients a multidisciplinary comprehensive care pathway was devel-
oped in the UMCG.
Materials and methods: A comprehensive care pathway was
developed and introduced at UMCG. The role of every participant is
described from the arrival at the emergency room until discharge from
the nursing home. Main features are multidisciplinary cooperation
between surgeons, geriatricians and anesthesiologists, a preoperative
workup protocol, and a postoperative protocol together with the
physical therapist and nursing home physician. The data were col-
lected prospectively. The endpoint was at 6 months after the
operation. The results 2 years after introduction of the care pathway
were compared to a historical control group.
Results: During 2 years 256 patients were treated according to the
comprehensive care pathway. This means an increase of 77 %. The
median hospitalization was significantly reduced from 13 days to
7 days, the mean fasting time from 15 to 9 h, the 30-days mortality
from 9 to 5 %. Of the patients 75 % were discharged to a nursing
home for a mean of 6 weeks. The median Harris Hip score 6 months
after the operation was 81.
Conclusion: The introduction of the comprehensive multidisciplinary
care pathway was successful. The care for these frail patients has
ameliorated.
References 1. Beaupre LA, et al. Best practices for elderly hip
fracture patients: a systematic overview of the evidence. J Gen Intern
Med. 2005;20:1019–25.
Disclosure: No significant relationships.
O138
DO SURROGATE BONE MATERIALS HAVE SIMILARPROPERTIES TO CADAVERIC BONE? VALIDATION OFA NEW COMPOSITE MATERIAL FOR APPLICATION INORTHOPAEDIC BIO-MECHANICAL RESEARCH
P. Upadhyay1, N. Baraza1, S. Shaunak2
1Trauma and Orthopaedics, University Hospital Coventry and
Warwickshire, Coventry, UK, 2Trauma and Orthopaedics, Heartlands
Hospital, Birmingham, UK
Introduction: Ideally biomechanical testing of implants would be
performed in real bone, but legislation, inability to obtain large
number of specimens and large inter-sample variation necessitates the
use of simulated bones in most cases. We have investigated the
characteristics of glass fibre reinforced epoxy polyurethane foam and
compared it to cadaveric bone.
Materials and methods: Composite tibiae composed of glass fibre
reinforced epoxy polyurethane foam was tested using a specially
designed test rig able to simulate the movements of anatomical joints
for ultimate compressive, tensile and torsional stress. Simulated tibiae
were then strained at various rates (0.5, 1, 5, 10, 50 and 500 mm/min)
and the dynamic response was analysed.
Results: The ultimate compressive and tensile strength of the com-
posite tibiae correlated well with published data on cadaveric tibiae.
Analysis of the dynamic response showed the existence of a critical
velocity similar to real bone at various strain rates. At low strain rates
typical shear type failure pattern was noted and high rate failure was
typified by splintering and multiple fragments.
Conclusion: A surrogate tibia made from glass fibre reinforced epoxy
polyurethane foam shows similar mechanical properties to a real tibia.
Disclosure: No significant relationships.
O139
APPLICATION OF ENRICHED WITH PLATELETSFIBRINOUS GEL IN TREATMENT OF LONG BONEFRACTURES (EXPERIMENTAL-CLINICAL STUDY)
A.V. Kalashnikov1, A.G. Zubenko2, A.T. Brusko3, L.M. Panchenko4,Y.I. Pavlishen5
1Traumatology and Orthopaedics aor Adults, The Institute of Trauma
and Ortopaedics, Kiev, Ukraine, 2Traumatology, 9 City Clinical
Hospital of Zaporizhzhia, Zaporizhzhia, Ukraine, 3Pathophysiology
and Pathomorphology, The Institute of Trauma and Ortopeadics,
Kiev, Ukraine, 4Immunology, The Institute of Trauma and
Ortopeadics, Kiev, Ukraine, 5Ortopeady, Khmelnitskiy Oblast
Hospital, Khmelnitskiy, Ukraine
Introduction: For optimization of reparative osteogenesis critical are
effective osteoplastic materials such as autologous enriched with
platelets fibrinous gel (EPFG).
Materials and methods: In the experiment on 36 rabbits were
observed healing the standard hole defect of tibia metadiaphysis
within the period of observation 14, 25 and 45 days. Control animals
group defect was not filled, in the second group the defect was filled
by EPFG, the third group hole defect was filled with a bone autograft,
the fourth group hole defect was filled with EPFG and autograft.
Results: After combined application of autologous bone tissue and
EPFG, defect elimination area exceeded the similar control group
animals’ area by 1.7 times, and in 1.2 times—after separate appli-
cation of only autologous bone tissue or EPFG. Combined use of
autologous graft and EPFG activated bone cortical layer formation.
Positive EPFG effect has been observed In vitro on multilayer colo-
nies and differentiation of bone marrow mesenchymal stem cells.
Clinical application of EPFG in a group of 35 patients with tibia
fractures showed significant (p \ 0.05) reduce of fractures healing
time (to 1.35 ± 0.18 months) and disability period, compared to
control group patients, where the EPFG was not applied.
Conclusion: These results demonstrate the positive effect of com-
bined use of autologous bone and EPFG.
References: 1. Adda F. Concentres plaquettaires and platelet rich
fibrin : une nouvelle strategie en paro-implantologie/D.U. d’implan-
tologie. Paris XII. 2001.
Disclosure: No significant relationships.
SPORT INJURIES II
O140
MODIFIED STOPPA APPROACH IN ACETABULARFRACTURES: INDICATIONS AND LIMITATIONS
O. Farouk1, A. Kamal2, M. Badran1, M. Refai1, M. Dawood1
1Orthopaedic Department, Assiut University Hospitals, Assiut, Egypt,2Trauma Unit, Assiut University Hospitals, Assiut, Egypt
Introduction: The ilioinguinal approach is widely used for ORIF of
acetabular fractures with some limtations. To solve these limitations,
a modified Stoppa approach was described.
The aim of this study was to evaluate technical aspects, operative
results, and associated complications of this modified Stoppa
approach in acetabular fractures.
S52 Abstract
123
Materials and methods: Modified Stoppa approach was used in 26
patients with acetabular fractures. Inclusion criteria were anteriorly
displaced fractures as anterior wall, anterior column, associated both-
column fractures, anteriorly displaced T-shaped and transverse frac-
tures. Through a single window approach by transverse splitting of
rectus abdominis muscle, an intrapelvic view of the fracture site was
obtained. The fracture was exposed by retracting iliac vessels ante-
riorly and obturator nerve and vessels posteriorly.
Results: This modified Stoppa approach provides access to pubic
body, superior ramus, iliopectineal line up to anterior sacroiliac
joint, quadrilateral plate, and medial aspect of posterior column. A
lateral window was required in 9 patients for reduction and fixation
of associated high anterior column fracture. Good to excellent
reduction was achieved in 24 out of 26 patients. Infection was
reported in one patient that resolved by wound excision. Vascular
or nerve injury was not reported. DVT was reported twice, and
resolved on anticoagulants. Obturator neuralgia was reported in
three patients.
Conclusion: Modified Stoppa approach allows adequate exposure of
acetabular fractures but not posterior wall and posterior column
fractures. The advantage of modified Stoppa approach is the excellent
intrapelvic view allowing reduction and fixation of quadrilateral plate
and posterior column. It also avoids dissection of inguinal canal
(middle window).
Disclosure: No significant relationships.
O141
CHARACTERIZATION OF NON-SURVIVING PELVICFRACTURE PATIENTS
J.H. Holstein
Trauma, Hand, and Reconstructive Surgery, University of Saarland,
Homburg, Germany
Introduction: Background: Pelvic fractures, particularly when com-
bined with multiple trauma, represent a life-threatening injury.
Purposes: To identify (1) causes and time point of death, (2)
demography, and (3) pattern and severity of injuries of non-surviving
patients with pelvic ring fractures.
Materials and methods: Cohort study. Post hoc, we studied pro-
spectively collected data on 5,340 individuals, which were
documented in the German Pelvic Trauma Registry between 04-30-
2004 and 07-29-2011. Demographic data and parameters indicating
the type and severity of injury were recorded for those patients who
died in hospital (non-survivors) and compared with data of surviving
patients.
Results: A total of 238 subjects (4 %) died at a median of 2 days after
trauma. The main cause of death was massive bleeding (34 %),
predominantly from the pelvic region (62 %). Fifty-six per cent of
non-survivors but only 43 % of survivors were male (p \ 0.001).
Non-survivors were characterized by a significantly higher incidence
of C type and complex pelvic injuries, significantly less isolated
pelvic ring fractures, a significantly lower initial blood hemoglobin
concentration and systolic arterial blood pressure, significantly higher
Injury Severity and Polytrauma Scores (ISS and PTS), as well as
significantly more units of packed red blood cells (RBC) transfused
within the first 12 h after trauma compared to survivors. No signifi-
cant differences between survivors and non-survivors were found in
age and need of RBC transfusion later than 12 h after trauma.
Conclusion: The non-surviving pelvic fracture patient is character-
ized by male gender, severe multiple trauma, major hemorrhage, and
a short survival time.
Disclosure: No significant relationships.
O142
FLOPPY POSITIONING OF THE PATIENT FORTREATMENT OF COMPLEX ACETABULAR FRACTURES
L. Buchler, J.D. Bastian, K.A. Siebenrock, M.B.J. Keel
Department of Orthopaedic and Trauma Surgery, University of Bern,
Inselspital, Bern, Switzerland
Introduction: In the management of complex acetabular fractures a
single approach can result in non-anatomic reduction due to insuffi-
cient fracture visualization, whereas the use of an extended
iliofemoral approach is associated with high morbidity. This paper
presents a technique for floppy positioning of the patient, which
allows a simultaneous anterior and posterior approach to the
acetabulum.
Materials and methods: Between 1998 and 2010, a consecutive
series of 17 patients (mean age 37, 19–79 years; 12 primary, 5 revi-
sions) from 381 operatively treated acetabular fractures were treated
using a flexible, semi-lateral positioning to allow simultaneous
anterior (Stoppa, ilioinguinal) and posterior approaches.
Results: The mean follow up was eight years (0.3–12.6), overall
mean operating time was 6 h (1.5–12), blood loss was 1.8 l (0.3–6.5).
No complications related to the floppy positioning were observed and
all surgeries completed uneventfully. Two intraoperative injuries
occurred (bladder, superior gluteal nerve). Reduction was considered
anatomic in 10 cases with excellent or good results. A primary total
hip arthroplasty was implanted in four cases. In the postoperative
course heterotopic ossification occurred in four cases (BBrooker II), a
deep infection in one, early posttraumatic osteoarthritis in two.
Conclusion: The floppy positioning allows the simultaneous use of
anterior and posterior approaches for joint preserving treatment of
complex fractures as well as fracture fixation with combined primary
hip arthroplasty.
Disclosure: No significant relationships.
O143
CUMULATIVE 20-YEAR SURVIVORSHIP AFTER OPENREDUCTION AND INTERNAL FIXATION OF 1208ACETABULAR FRACTURES
M. Tannast1, S. Najibi2, J.M. Matta2
1Inselspital, University of Bern, Department of Orthopaedic Surgery
and Traumatology, Bern, Switzerland, 2The Hip and Pelvis Institute,
Santa Monica, CA, USA
Introduction: The aims of the study were (1) to determine the
cumulative 20-year survivorship of the hip after open reduction and
internal fixation of displaced acetabular fractures; (2) to detect factors
predicting the need for total hip arthroplasty (THA) or hip arthrodesis;
and (3) to create a predictive model for clinical practice that calcu-
lates the probability for the need of early THA or hip arthrodesis.
Abstract S53
123
Materials and methods: 1,208 acetabular fractures operated by a
single surgeon over a 26-year period were analyzed. The cumulative
20-year Kaplan–Meier survivorship analysis of the hip was calculated
with THA/hip arthrodesis as endpoints. A multivariate Cox-regression
analysis was performed to find negative predictors which were then
used to construct a nomogram predicting the individual probability
for the need of an early THA.
Results: The cumulative 20-years survivorship of the native hip was
79 % at 20 years. Significant independent negative predictors were
non-anatomical reduction, age [40 years, anterior dislocation,
postoperative incongruence of the acetabular roof, involvement of
the posterior wall, acetabular impaction, femoral head cartilage
lesion, initial displacement of the articular surface [20 mm, and the
utilization of the extended iliofemoral approach. Based on these
factors, a nomogram is presented for prediction of the need for an
early THA.
Conclusion: Open reduction and internal fixation of acetabular
fractures can successfully prevent the need for subsequent THA
after 20 years in nearly 80 % of all cases. The number of evaluated
fractures and the length of follow-up are unique for acetabular
fractures in particular and for any type of articular fractures in
general.
Disclosure: No significant relationships.
O144
IS STANDARDIZED PERCUTANEOUS SI SCREWPLACEMENT OPERATION POSSIBLE?
Z. Zigman, M. Tomazevic, A. Kristan, M. Cimerman
Dpt. of Traumatology, University Clinical Centre Ljubljana, Slovenia,
Ljubljana, Slovenia
Introduction: Numerous ways how to place the sacroiliac (SI)
screw were proposed. The misplacement of SI screw represents a
critical complication. Placement of the screw should be perpendic-
ular to the fracture plane of the sacrum in a sacrum fracture and to
the SI joint in the SI joint dislocation. In sagittal sacrum fractures
the plane of the SI screw should be therefore in a transverse
direction. Is it possible?
Materials and methods: 25 consecutive pelvic CT scans of mature
patients were analyzed. CT scans were done due to regular patients
workup after trauma. Analysis of pelvic anatomy was done on the
uninjured side on raw images from multislice CT scan in three planes
using special software for osteosynthesis simulation. The placement
of the virtual screw in straight transverse direction to the S1 body was
analyzed.
Results: We analyzed 25 pelvises, 6 female, 19 male. In placement of
the virtual screw to the center of the S1 body in straight transverse
direction 28 % of the screw trajectories were placed outside of the
bone (44 % women, 18.8 % men). In any other position in the body of
the S1 the result was worse, due to either placement in the foramina or
in front of the pedicle.
Conclusion: Placement of SI screw needs precise advanced preop-
erative planning and cannot be done as a standardized procedure.
Compromise between fracture plane perpendicularity and screw axis
should be tolerated.
Reference: 1. Gansslen A, Hufner C, Krettek C. Percutaneous ilio-
sacral screw fixation of unstable pelvic injuries by conventional
fluoroscopy. Oper Orthop Traumatol. 2006;18(3):225–44.
Disclosure: No significant relationships.
O145
NEW PLATE FOR RECONSTRUCTION QUADRILATERALSURFACE OF THE ACETABULUM
S. Jaroslav
Liberec, Regional Hospital Liberec, Liberec, Czech Republic
Introduction: Problem of reconstruction of quadrilateral surface of
the acetabulum exist. Conventional illioiquinal approach with clover
leaf plate neutralize femoral head pressure indirectionally. New
plate—omega pelvic plate—applied through modified Stoppa
approach directly presses quadrilateral surface laterally. Collection of
20 patients operated through modified Stoppa aproach with this new
plate contains optimal indications, complications, Harris hip score,
technical problems.
Materials and methods: The group included 20 patients operated
through modified Stoppa with omega pelvic plate in years 2009–2011.
12 patients with combined procedure—Kocher–Langenback approach
first and Stoppa secondary. 8 patients Stoppa approach alone. Age
average 41.8 years. Postoperative control CT was done in 10 cases.
Average of follow up was 12 month (9–26 months).
Results: In the Stoppa approach alone group, the average values were
operative time 94 min, X-ray exposure 3.1 min. The combined
approach showed the average operative time 120 min., X-ray expo-
sure 4.6 min. Matta radiological score: 10 patients 1 mm dislocation,
8 patients 1–2 mm, 2 patients more than 2 mm. Harris hip score was
81.4 % (50–98). One patient had n. obturatorius palsy, one serious
corona mortis bleeding. 3 times were observed massive ossification.
No deep infection, no metal loosening in this group.
Conclusion: New plate is progress in reconstruction of quadrilateral
surface with its direct press to the medial bone. Less invasive mod-
ified Stoppa approach has similar results than more extensive
ilioingional approach.
Disclosure: No significant relationships.
O146
FEMOROACETABULAR IMPINGEMENT PREDISPOSES TOTRAUMATIC POSTERIOR HIP DISLOCATION
S.D. Steppacher, C.E. Albers, K.A. Siebenrock, M. Tannast, R. Ganz
Inselspital, University of Bern, Department of Orthopaedic Surgery
and Traumatology, Bern, Switzerland
Introduction: Traumatic posterior hip dislocation in adults is gen-
erally understood as the result of a high energy trauma. Besides a
reduced femoral antetorsion morphologic risk factors are unknown.
We observed that hips with a traumatic posterior hip dislocation had
evidence of femoroacetabular impingement (FAI) morphology of the
femur and the acetabulum. We questioned if hips with a traumatic
posterior hip dislocation (1) present with a cam-type deformity and/or
(2) a retroverted acetabulum.
Materials and methods: We retrospectively compared the mor-
phology of 53 consecutive hips (53 patients) after traumatic posterior
hip dislocation with 156 normal hips (80 patients) based on the
anteroposterior pelvic- and cross-table axial radiographs. We mea-
sured (1) the axial and the lateral alpha angle for detection of a cam-
deformity, and (2) the cross-over sign, retroversion index, ischial
S54 Abstract
123
spine sign, posterior wall sign, and the ratio of anterior to posterior
acetabular coverage to describe the acetabular orientation.
Results: (1) The posterior dislocation group presented with a sig-
nificantly increased axial and lateral alpha angle. (2) Hips with
traumatic posterior dislocation had a significantly higher prevalence
of the cross-over and ischial spine sign, an increased retroversion
index, and a higher ratio of anterior to posterior acetabular
coverage.
Conclusion: Hips with posterior traumatic dislocation typically
present with a FAI morphology including a cam-type deformity and a
retroverted acetabulum. An explanation for these findings could be
that the early interaction between the aspherical femoral head and the
prominent acetabular rim acts as a fulcrum. This makes these hips
more susceptible for traumatic dislocation.
Disclosure: No significant relationships.
O147
TACTILE THREE-DIMENSIONAL BONYMANUFACTURING USING 3D PRINTER FOR ASSISTANCEOF ACETABULAR FRACTURE SURGERY
T. Niikura1, M. Sugimoto2, S.Y. Lee1, T. Koga1, Y. Dogaki1,E. Okumachi1, T. Waki1, R. Kuroda1, M. Kurosaka1
1Orthopaedic Surgery, Kobe University Graduate School of Medicine,
Kobe, Japan, 2Gastroenterology, Kobe University Graduate School of
Medicine, Kobe, Japan
Introduction: We describe the manufacturing three-dimensional
physical models of the bony pelvis by application of rapid prototyping
prior to surgery for acetabular fractures.
Materials and methods: The bone area of interest is extracted
from the DICOM (digital imaging and communication in medi-
cine) data of CT scans. The DICOM data are converted to the STL
(standard triangulated language) data using three-dimensional
reconstruction software; OsiriX (open-source DICOM application).
The STL data are used to manufacture three-dimensional physical
models using the layered manufacturing process. The model is
built in successive layers using a three-dimensional printer. The
mirror image of the contralateral uninjured pelvis is also prepared.
The finished product is a solid, durable model of acrylic based
photopolymers. The material we used is biocompatible and can be
sterilized.
Results: The manufacturing was successfully done for five patients
with acetabular fractures; four both column fractures and one
anterior column fracture. One patient accompanied spino-pelvic
dissociation. The three-dimensional physical models assisted sur-
geons understand the personality of complex fractures. The
assessment of the intra-articular fracture pattern also could be
easily done. The life size model of the mirror image of the con-
tralateral uninjured pelvis was useful to bend the plates suitably
and achieve stable fixation. We could take the models to the
operative field and re-assess the fracture pattern intraoperatively.
These models were also valuable for educating young surgeons and
explaining the complex fracture pattern to the patients and their
families.
Conclusion: Tactile three-dimensional bony manufacturing for ace-
tabular fractures is useful in the assessment, preoperative planning,
intraoperative maneuver, education and information.
Disclosure: No significant relationships.
VISCERAL TRAUMA I
O148
DIFFERENTIATED APPROACH IN PENETRATINGABDOMINAL TRAUMA, ONE CENTER EXPERIENCE
S. Tintari, G. Rojnoveanu, G. Ghidirim, I. Gagauz, V. Gafton,R. Gurghis, V. Colesnic
Department of Surgery No.1 ‘‘nicolae Anestiadi’’, Medical University
‘‘Nicolae Testemitanu’’, Chisinau, Moldova, Chisinau, Moldova
Introduction: The approach of traumatized with penetrating
abdominal wounds is ranging from mandatory laparotomy to non-
operative in selected cases. Tactics are practiced according to the
clinical policy and surgeon’s personal preferences. Purpose: com-
parative analysis of the results of various approaches in penetrating
abdominal wounds.
Materials and methods: Study was performed in 2006–2010,
includes 469 consecutive patients with penetrating abdominal trauma
hospitalized in Chisinau’s emergency hospital (level 1 academic
trauma center). During the reporting period tactical approach evolved
from exploratory laparotomy (2006–2007), to diagnostic laparoscopy
(2008–2009) and finally the nonoperative approach (2010–present).
Results: The incidence of positive laparoscopy increased from 39.5 to
82.4 %. The rate of therapeutic laparotomies was 47.5–54.5 % for
‘‘routine’’ laparotomy group, 56.7–65.8 % for diagnostic laparoscopy
group and 94.4 % for clinical examination group. The rate of com-
plications after non-therapeutic laparotomy was 43 %. The hospital
stay for patients undergoing uncomplicated non-therapeutic laparot-
omy was 6.2 ± 0.3, for those with complications it was
9.65 ± 0.9 days.
Conclusion: Mandatory laparotomy for penetrating abdominal
trauma causes an unacceptably high rate of nontherapeutic interven-
tions. Diagnostic laparoscopy, reduces the incidence of unnecessary
laparotomies, but the method has low accuracy and generate a large
number of useless procedures. Selective nonoperative approach
minimizes the rate of invasive interventions and significantly reduces
the hospital stay. Patients with penetrating abdominal trauma require
an individual approach based on clinical assessment.
Disclosure: No significant relationships.
O149
RELAPAROTOMY FOR BOWEL OBSTRUCTION AFTERNON-THERAPEUTIC LAPAROTOMY IN PENETRATINGABDOMINAL TRAUMA
S. Tintari, G. Rojnoveanu, G. Ghidirim, S. Ignatenco, I. Gagauz,V. Gafton
Department of Surgery No.1 ‘‘nicolae Anestiadi’’, Medical University
‘‘Nicolae Testemitanu’’, Chisinau, Moldova, Chisinau, Moldova
Introduction: In a lot of surgical clinics laparotomy is still used as
the standard of care in the management of penetrating abdominal
trauma (PAT). One of the arguments for this tactics is the harm-
lessness of exploratory laparotomy in the absence of significant
abdominal injury and uneventful postoperative recovery.
Abstract S55
123
Materials and methods: A retrospective review was performed of all
patients who underwent non-therapeutic laparotomy for penetrating
abdominal trauma in our clinic and were readmitted with bowel
obstruction.
Results: Overall 198 laparotomies were performed during 64 months,
67 (33.8 %) non-therapeutic interventions were identified. The annual
rate of therapeutic laparotomies ranged from 47.5 to 94.4 %. There
were 5 patients with bowel obstruction. Respectively, surgical rein-
tervention required 3 of them (the overall incidence 4.5 %) diagnosed
with small bowel obstruction (SBO) from which two patients
underwent early surgical intervention, during the first postoperative
week and one, late, after 32 months. Types of surgery were: adhesi-
olysis, bowel resection with anastomosis and bowel resection with
enterostomy. Prolonged intestinal paresis or fever [3 postoperative
days seemed to represent risk factors for relaparotomy. Hemoperito-
neum and previous abdominal surgery didn‘t qualify as additional risk
factor for SBO in PAT patients.
Conclusion: Non-therapeutic laparotomies for penetrating abdominal
wounds determine the significant risk for bowel obstruction and as a
consequence, surgical reintervention. Surgeons should pay special
attention to close follow-up of this category of patients.
Disclosure: No significant relationships.
O150
HEPATIC ARTERY PSEUDOANEURYSM REVEALED BYA MASSIVE HEMORRHAGE IN THE POSTOPERATIVEPERIOD OF A WHIPPLE PROCEDURE: EMERGENCYTREATMENT USING A PERCUTANEOUSLY INSERTEDCOVERED STENT
P. Rivier, L. Gruner, X. Barth, O. Monneuse
General and Trauma Surgery, Hospices civils de Lyon Universite
Lyon I, Lyon Cedex 03, France
Introduction: Hepatic artery pseudoaneurysm is a rare post Whipple
procedure complication which represents a major therapeutic chal-
lenge. Its treatment using embolization has to be considered carefully
due to the bile duct necrosis risk.
Materials and methods: A 51 year old Caucasian male presenting with
a history of chronic pancreatitis developed on Cystic Dystrophy in Het-
erotopic Pancreas, underwent a Whipple procedure. On the 10th
postoperative day, he presented with massive hematemesis and hemor-
rhagic shock. The contrasted CT revealed an 18 mm diameter
pseudoaneurysm, located on the hepatic artery: the patient was operated
on with pseudoaneurysm ligation and drainage of a biliary fistula. The
patient recovered well for a 15 days uneventfull period. On the 25th
postoperative day, occurred suddenly a recurrent hemorrhagic shock with
angiocholitis. An emergency CT revealed a 22 mm diameter hepatic
artery pseudoaneurysm with dilated intra hepatic bile duct and hemobilia.
Results: As far as the risk of ischemic cholangitis was expected
following a new surgical approach or an embolization, the decision
was made to percutaneously implant a covered stent inside hepatic
artery, thought a radiologic approach. The immediate post procedure
arterial control was correct with a good stent’ permeability and no
extravasa. In a few hours the patient’s blood pressure went back to
normal range and a percutaneous biliary drainage was inserted 2 days
later to manage the persistent angiocholitis.
Conclusion: The following period remained uneventfull with normal
arterial and biliary imaging controls and normal liver biological
controls. The patient discharged from hospital 35 days after getting
the covered stent.
Disclosure: No significant relationships.
O151
OUTCOME AFTER TRAUMA LAPAROTOMY IN A MAJORSCANDINAVIAN TRAUMA CENTER
S. Groven1, P.A. Naess1, T. Eken1, N.O. Skaga2, C. Gaarder1
1Department of Traumatology, Oslo University Hospital, Ulleval,
OSLO, Norway, 2Department of Anesthesiology, Oslo University
Hospital, Ulleval, OSLO, Norway
Introduction: Our group has recently shown that the start of a long-
lasting performance improvement for the total trauma population
coincided with formation of a dedicated trauma service in 2005. The
aim of this study was to evaluate the impact of these structural
changes on patients with abdominal injuries undergoing laparotomy.
We hypothesized that the previously demonstrated effect of a formal
Trauma Service on mortality rates for the total trauma population
would be visible also in this subgroup, with a concomitant decrease in
laparotomy rates.
Materials and methods: Institutional trauma registry data for 460
consecutive trauma patients undergoing laparotomy during the period
2002–2009 were retrospectively explored. Based on the previously set
cut off point for change in performance, period 1 was defined as
2002–2004 and period 2 as 2005–2009. Chi square and Fisher’s Exact
tests were used for analyses of categorical data, and Student’s t test
and Mann–Whitney U test were used for normally and non-normally
distributed non-categorical data, respectively. P less than 0.05 was
regarded as significant.
Results: No significant differences could be detected for age, gender,
injury mechanism, pre-injury ASA-PS, GCS or ISS. There was a
steady increase in admitted patients with abdominal injuries, while
the number of patients in need of laparotomy was constant. There was
a significant decrease in crude mortality from 37.2 % in period 1 to
19.9 % in period 2. Causes are being explored.
Conclusion: We have demonstrated a significant decrease in mor-
tality in the group of trauma patients undergoing laparotomy after the
formation of a formal Trauma Service.
Disclosure: No significant relationships.
O152
PANCREATIC INJURIES IN 41 PATIENT WITH SEVEREABDOMINAL TRAUMA
P. Gregoric1, K. Doklestic2, D. Radenkovic3, B. Karadzic2,M. Pandurovic2, D. Bajec3
1Clinic For Emergency Surgery, Clinical Center of Serbia Faculty of
Medicine, Belgrade, Serbia, 2Clinical Center of Serbia, Belgrade,
Serbia, 3Clinical Center of Serbia Faculty of Medicine, Belgrade,
Serbia
Introduction: Pancreatic injuries are not common but related with
specific morbidity and high mortality rates.
Materials and methods: Total of 41 patients with pancreas injury
treated at the Clinic for Emergency Surgery of Clinical Center of
Serbia during the 6 year period retrospectively analyzed.
Results: In this study 18 (43.9 %) patients undergoing abdominal
exploration, 14 (34.1 %) undergoing suture and hemostasis, 5
(12.2 %) patients underwent distal pancreatectomy with splenectomy.
Two (4.8 %) patient had pancreaticoduodenectomy. Two patients had
S56 Abstract
123
distal pancreaticojejunostomy. The overall complication rate was
41.9 %. The specific complications occurred in 22.6 % of patients:
pancreatic fistula (9.68 %), pancreatitis (6.45 %), and intraabdominal
abscess (6.45 %). Mortality rate was 26.2 %, in most cases death was
the result of severe associated organs injuries.
Conclusion: Although mortality rates after pancreatic trauma are
high, death was usually the result of major associated injuries.
Reference: 1. Lin BC et al. Management of blunt major pancreatic
injury. J Trauma. 2004;56:774–8.
Disclosure: No significant relationships.
O153
MINIMAL INVASIVE TREATMENT OF ABDOMINALGUNSHOT INJURY: CASE REPORT
A. Kocsis1, A. Nemeth2, Z. Magyari1
1Iv. Trauma Department, Peterfy S. Hospital, Trauma Centre, Buda-
pest, Hungary; 2Peterfy S. Hospital, Trauma Centre, Budapest,
Hungary
Introduction: A 35 years old male was injured by a near, direct shot
from an airgun.
Materials and methods: By the imaging methods taken during the
hospital admission, we recognized, that the bullet was situated in the
central region of the liver, affecting four segments of it. The pene-
trating wound was found between the ninth and tenth ribs on the right
side.
Because of urgency and actual blood shortage in our hospital, we
decided to perform laparoscopy supplemented by laparotomy.
Results: During the surgery, first of all we made a right subcostal
incision to have an accurate exploration. No serious blood-loss or
bowel injuries were recognized. After the abdominal assessment we
performed the debridement of the shot wound. Following these pro-
cesses we used the shot tunnel itself to introduce the laparoscopic
forceps into the intraabdominal space. Guided by an intraoperative
X-ray device, we followed the shot tunnel inside the liver, and
removed the bullet without any difficulties. After the removal we
coagulated the tunnel and sutured the affected surface of the liver.
Conclusion: The surgical procedure took only 20 min. In the post-
operative period we did not recognized any blood-loss (by laboratory
assessment and ultrasonography) or abdominal complications. The
patient was discharged after 4 days of observation.
Concluding the case, we can say that this minimal invasive treatment
followed by strict observation is a safe method to treat isolated liver
injuries.
Disclosure: No significant relationships.
O154
NONOPERATIVE MANAGEMENT OF AAST-OIS GRADE IVHEPATIC INJURIES
T. Zago1, B.M. Pereira1, B. Nascimento2, T. Calderan3, E.S. Hirano3,G.P. Fraga3
1Division of Trauma Surgery, University of Campinas, Campinas,
Brazil, 2Bartolomeu Nascimento, Toronto, Canada, 3Surgery,
University of Campinas, Campinas, Brazil
Introduction: The treatment of complex liver injuries remains a
challenge for surgeons. The mortality rate for liver injuries grade IV
in the literature vary. The non-operative treatment for such injuries is
a reality but not a consensus.
Materials and methods: 748 patients with hepatic trauma were
admitted to our service. 74 patients with blunt hepatic trauma were
treated non-operatively. Inclusion criteria for non-op liver injuries
management were hemodynamic stability, absence of clinical signs of
peritonitis and no bowel injuries shown on CT scan. Age, gender,
mechanism of injury, SBP, RTS, admission ISS, CT scan findings,
presence of associated abdominal injuries, need for surgical inter-
vention, need for blood transfusions, complications related to liver
and non-liver related complications mortality and hospital LOS, were
analyzed.
Results: The mean age of patients was 34 years old. The mechanisms
of injury are distributed as follows: motor vehicle crash, pedestrian hit
by a car, and tother different mechanism of blunt trauma. The mean
SBP on admission was 119 mmHg. The mean RTS was 7.53, ISS
average was 21.6. 71.4 % required blood transfusion. Associated
abdominal injuries were found 21.4 %. Complications unrelated to
the liver occurred 14.3 %. Non-operative management failed in one
patient only (7.2 %). The mean hospital LOS was 11.14 days. None
of the patients deceased.
Conclusion: The non-operative treatment can be performed in all
trauma centers with 24 h operating room, trained surgical team, blood
bank and image diagnosing methods available.
References: 1. Asensio JA, et al. Approach to the mgmt of complex
hepatic injuries. J Trauma. 2000. 2. Coimbra R, et al. NOM reduces
the overall mortality of grades 3/4 blunt liver. Int J Surg. 2006
Disclosure: No significant relationships.
O155
VACUUM ASSISTED CLOSURE (VAC) AS RESECTIONSPARING TREATMENT IN ACUTE MESENTERICISCHEMIA (AMI)
E. Giorgini1, S. Maggioli2, A. Biscardi2, S. Villani2, S. Di Saverio2,G. Tugnoli3
1Emergency and Trauma Surgery, Maggiore hospital, Bologna, Italy,2Maggiore Hospital, Bologna, Italy, 3Emergency and Trauma
Surgery, Maggiore Hospital, Bologna, Italy
Introduction: AMI is still considered a hostile scenario in Emer-
gency Surgery [1]. Mortality, post operative complications and
prognostic factors have been analysed in two groups of patients (A/B)
treated or not with VAC and second look laparotomy.
Materials and methods: From June 2009 to September 2011 we
collected 9 cases of AMI; the range age is 73 years. Major comor-
bidity was hypertension blood pressure (77 %). One patient was under
OAC for AF. Bloody stool (33 %), acute abdominal pain (88 %),
hypercoagulability (22 %) nausea-vomiting (44 %) occurred. CT-
scan was perfomed in 100 % (2) showing fluid collection (100 %),
total mesenteric-portal thrombosis (22 %); small bowel oedema
(44 %) and simulations of intestinal volvulus (11 %).
Results: Group A (22 %) was submitted to extended bowel resection.
Group B was treated with VAC and second look laparotomy 24 h later;
33 % of them did not need any resection and 77 % was submitted to
resection less than expected. Total mortality rate was 0 % (\30 days
p.o.) and 11 % ([30 days p.o). Regression analysis showed tissue
perfusion factors at the admission, flogistics index and intestinal
necrosis they have been significant prognostic factors of mortality.
Abstract S57
123
Conclusion: In cases of suspicious of AMI the surgery in two times is
recommended [1]. The first laparotomy allows to identify the diag-
nosis and to place VAC foam. The second one is an explorative
laparotomy with eventual resection. VAC avoids eventual compli-
cations, shows immediate improvements and can spare surgical
resection [3].
References: 1. Meng X. Surg Today. 2010;40:700–5. 2. Rhee RY.
J Vasc Surg. 1994;20(5):688–97. 3. G. Zagli, J Anaesth. 2011;106(1):
151–2.
Disclosure: No significant relationships.
ECTES/ESS SESSION: BASIC SCIENCE/
TRANSLATIONAL MEDICINE
O156
INCIDENCE AND COURSE OF PSYCHIATRIC MORBIDITYIN THE FIRST 12 MONTHS FOLLOWING TRAUMATICINJURY
J. Mouthaan1, M. Sijbrandij2, J.S.K. Luitse3, B.P.R. Gersons1,J.C. Goslings4, M. Olff1
1Department Psychiatry, Center for Anxiety Disorders, Academic
Medical Center, Amsterdam, The Netherlands, 2Faculty of Social
Sciences, Clinical and Health Psychology, Utrecht University,
Utrecht, The Netherlands, 3Trauma Unit, Department of Surgery,
Academic Medical Center, Amsterdam, The Netherlands, 4Trauma
Unit, Department. of Surgery, Academic Medical Center,
Amsterdam, The Netherlands
Introduction: Injury patients at a Level-I trauma center have been
shown to be at considerable risk of psychiatric morbidity. Previous
studies showed that 33–58 % develop a psychiatric disorder
4–6 months post-trauma (Shalev et al. 1998; McFarlane et al. 1997).
Whether these findings apply to the Dutch population, is yet
unknown. Furthermore, the reported rates of psychiatric disorders
vary between studies as a result of methodological differences. Many
studies relied on self-reported symptoms alone. In this study, the
incidence and course of trauma-related psychiatric disorders are
studied by means of clinical assessment.
Materials and methods: Between 2005 and 2009, adult Level-I
trauma center patients of the AMC and VUmc hospitals in
Amsterdam were consecutively included after a traffic accident or
assault. Patients who were suicidal or who had severe psychiatric
symptoms or diminished cognitive abilities were excluded. Clinical
assessments of depressive disorder, PTSD and other anxiety disor-
ders took place at 1 week, 1 month, 6 months and 12 months post-
trauma.
Results: We included 852 patients with a mean age of 43.4 years (SD
15.9). Most patients were males (64.4 %) and suffered a traffic
accident (65.6 %). 22.3 % were severely injured (ISS [ 15). The
incidence of psychiatric disorders was highest within the first
6 months. Rates of psychiatric disorders were around 20 %, with
female patients exhibiting significantly more psychiatric morbidity
than male patients.
Conclusion: Almost one in four adult traumatic injury patients will
suffer from psychiatric sequelae of their traumatic experience. These
patients could benefit from early identification and psychological
treatment.
Disclosure: No significant relationships.
O157
OUTCOMES AFTER MASSIVE TRANSFUSION AREEQUIVALENT TO THOSE AFTER SUPRA-MASSIVETRANSFUSIONTRANSFUSION
D.N. Holena1, C.A. Sims2, J.L. Pascual2, P.M. Reilly2, C.W. Schwab2
1Department of Surgery, University of Pennsylvania, Philadelphia,
PA, USA, 2Department of Surgery, University of Pennsylvania, PA,
PA, USA
Introduction: Massive transfusion (MT) ([10 u PRBC (packed red
blood cells)/24 h) is associated with significant morbidity, mortality,
and resource utilization in trauma patients. The degree to which
transfusion beyond MT contributes to these outcomes is not clear. We
hypothesized that patients undergoing Supra-Massive Transfusion
(SMT; [50 uPRBC/24 h) would have significantly increased mor-
bidity, mortality, and hospital length of stay (HLOS) compared to
those undergoing MT.
Materials and methods: Data were collected prospectively from
2000 to 2009. Inclusion criteria: C10 u PRBC within 24h of admis-
sion. Demographic data, shock index, injury severity score, and
transfusion data were collected. Univariate analysis between MT and
SMT groups was performed using Mann–Whitney test or Chi squared.
Study endpoints included mortality, complications, and HLOS. Sig-
nificance was set at p \ 0.05.
Results: 191 patients were identified (MT 176, SMT 15) Median age
was 29 years, 84 % were male, 74 % were African American; 68 %
sustained penetrating trauma. Median ISS was 26, and 68 % of
patients were in shock or moribund on presentation. Baseline vari-
ables were not significantly different between groups except for blood
product transfusion (36 u (IQR 26–54) in MT group versus 101 u
(IQR 89–132) in SMT group, p \ 0.001). In endpoint analysis
between the MT and SMT groups, no significant differences were
seen in mortality (49 vs. 47 %, p = 1.0), overall complication rate
(57 vs. 53 %, p = 0.79), or HLOS (6 days (IQR 1–20) vs. 7 days
(IQR 1–7), p = 0.85).
Conclusion: Outcomes between SMT and MT are equivalent. Once a
patient has undergone MT, continuation of aggressive transfusion
therapy appears warranted regardless of volume of blood products
transfused.
Disclosure: No significant relationships.
O158
DERIVATION AND VALIDATION OF A NOVEL, EASY-TO-CALCULATE AND ACCURATE TRAUMA SEVERITYSCORE FROM JAPAN TRAUMA DATABANK
A. Shiraishi1, K. Morishita1, D. Saitoh2, Y. Otomo1
1Shock, Trauma and Emergency Medical Center, Tokyo Medical and
Dental University Hospital of Medicine, Tokyo, Japan, 2Division of
Traumatology, National Defense Medical College Research Institute,
Tokorozawa, Saitama, Japan
Introduction: To derivate and validate a novel trauma severity score
which concepts were easy-to-calculate, using parameters available in
primary survey (PS score) or both primary and secondary survey (SS
score) and maintained compatibility with the Trauma Injury Severity
Score (TRISS).
S58 Abstract
123
Materials and methods: Score derivation and validation cohorts
were randomly dichotomized subjects from Japan Trauma Data-
bank. On a basis of multivariate logistic regression model for in-
hospital death, we re-categorize raw parameters used in TRISS
which are available in the primary survey into integers to form the
PS score. The SS score were similarly developed with the
parameters available in both the primary and secondary survey.
Receiver operating characteristics (ROC) analysis compared score
PS and SS versus the Revised Trauma Score (RTS) and TRISS,
respectively.
Results: From the derivation cohort (N = 12,397), the PS score
was designed as sum of re-categorized parameters including injury
type (0–2), age (0–4), Glasgow Coma Scale (0–7), respiratory rate
(0–2) and systolic blood pressure (0–6) and named as TRIAGES
(Trauma Rating with Injury type, Age, Glasgow coma scale,
rEspiratory rate and Systolic blood pressure) score. The SS score
was a sum of TRIAGES score plus the Injury Severity Score
divided by 10, and named as TRIAGES + score. ROC analysis
demonstrated improved accuracy of TRIAGES score (C-statistics
value of 0.955) and TRIAGES+ score (0.964) compared with RTS
(0.934) and TRISS (0.948) on the validation cohort (N = 12,371),
respectively.
Conclusion: TRIAGES/TRIAGES+ score is accurate and easy-to-use
in clinical setting along with trauma care in chronological order,
however needed external validation in the future.
Disclosure: No significant relationships.
O159
WHOLE BLOOD FAILS TO IMPROVE UPON BLOODCOMPONENT THERAPY WHEN RESUSCITATINGPATIENTS WITH LIFE-THREATENING COAGULOPATHY
S.A. Savage1, B.L. Zarzaur, Jr.2, H. Hancock3, M.A. Croce2,T.C. Fabian2
1General Surgery, University of Tennessee Health Sciences Center,
Memphis, TN, USA, 2University of Tennessee Health Sciences
Center, Memphis, TN, USA, 3United States Air Force, Lackland
AFB, TX, USA
Introduction: Military reports indicate fresh whole blood is associ-
ated with improved survival in trauma-perhaps by reducing
coagulopathy. Fresh whole blood (FWB) is not practical in civilian
settings, however, preserved whole blood (PWB) may provide similar
benefits. The purpose of this study was to determine if preserved
whole blood has a significant benefit in correcting coagulopathy and
endpoints of resuscitation when compared to component therapy.
Materials and methods: 32 female Yorkshire swine underwent
femur fracture, hemorrhage and liver laceration plus hypothermia.
Animals were randomized to 5 groups: control (unresuscitated),
PRBC:FFP at a ratio of 6:1 and 1:1, FWB or PWB (whole blood
refrigerated for less than 2 weeks). Animals were followed for 6 h
after resuscitation with serial coagulations studies (TEG, INR, PT and
PTT), CBC, ABG and hemodynamic measurements.
Results: All groups showed significant coagulopathy and hypotension
at end-shock. INR of PWB and controls were significantly higher than
other resuscitation groups late in resuscitation. R-time and K-time of
resuscitation groups were significantly different than controls imme-
diately after blood administration. Fresh whole blood produced
similar results to component therapy groups in regards to reversal of
coagulopathy.
Conclusion: Preserved whole blood is inferior to component therapy
and whole blood in correcting coagulopathy. Whole blood, fresh and
preserved, was comparable to standard therapy at normalizing end-
points of resuscitation. While whole blood remains important in
austere environments, preserved whole blood has no role in civilian
trauma resuscitations.
References: 1. Ho KM, Leonard AD. Lack of Effect of Unrefriger-
ated Young Whole Blood Transfusion on Patient Outcomes after
Massive Transfusion in a Civilian Setting. Transfusion. 51:1669–75.
2. Spinella PC, Holcomb JB. Resuscitation and transfusion principles
for traumatic hemorrhagic shock. Blood Rev. 2009;23:231–40. 3.
Alexander JM, Sarode R, McIntire DD, et al. Whole blood in the
management of hypovolemia due to obstetric hemorrhage. Obstet
Gynecol 113(6):1320–6. 4. Spinella PC. Warm fresh whole blood
transfusion for severe hemorrhage: US military and potential civilian
applications. Crit Care Med. 2008;36(7):S340–5. 5. Cho SD, Hol-
comb JB, Tieu BH, et al. Reproducibility of an animal model
simulating complex combat-related injury in a multiple-institution
format. Shock. 2009;31(1):87–96.
Disclosure: No significant relationships.
O160
MODE OF FLUID REPLACEMENT AFFECTS RISK OFORGAN INJURY AFTER HEMORRHAGIC TRAUMATICSHOCK
A. Zifko1, C. Penzenstadler1, M. Jafarmadar2, A. Khadem2,A. Kozlov2, H. Redl2, S. Bahrami2
1Experimental and Clinical Traumatology, Ludwig Boltzmann
Institute, Wien, Austria, 2Experimental and Clinical Traumatology,
Ludwig Boltzmann Institute, Vienna, Austria
Introduction: Aim: We compared the effects of instant (iR) versus
gradual (gR) reperfusion on organ dysfunction after hemorrhagic-
traumatic shock (HTS).
Materials and methods: Male rats were subjected to HTS and ran-
domized to receive an instant (n = 8) or gradual (n = 9) reperfusion.
iR animals were resuscitated by infusion of Ringer’s solution (RS) at
75 ml/kg/h. gR animals were resuscitated by infusion of RS at 30 ml/
kg/h to maintain a mean arterial blood pressure (MAP) of
50-55 mmHg for 40 min, followed by 75 ml/kg/h infusion rate. Sham
operated animals (n = 8) served as controls. The experiment was
terminated 100 min post-shock.
Results: Compared to sham animals, iR animals showed higher wet/
dry ratio of the lung and lower plasma ceruloplasmin/transferrin ratio,
whereas gR animals showed significantly higher values of the cell/
organ damage parameters LDH, CK and ALT at end of observation.
When comparing the two shock groups, the iR group showed sig-
nificantly higher MAP and heart rate during early reperfusion,
whereas blood cell counts and gas analysis, ceruloplasmin/transferrin
ratio, wet/dry ratio, peroxiredoxin-4 and thiobarbituric acid-reactive
substances did not differ.
Conclusion: Conclusion: Instant reperfusion after HTS is associated
with enhanced risk of lung injury, while gradual reperfusion is
associated with increased damage to other organs such as liver.
Disclosure: No significant relationships.
Abstract S59
123
O161
SERUM LACTATE: A HARBINGER OF POST-TRAUMATICPULMONARY COMPLICATIONS AND FAT EMBOLISMSYNDROME
V.G. Goni1, N.R. Gopinathan1, V.K. Viswanathan2,S.B. Kanthakumar1
1Orthopedics, PGIMER, Chandigarh, India, 2Orthopedics, PGIMER,
Chandigarh, Chandigarh, India
Introduction: Fat embolism syndrome is one of the annihilating
pulmonary complications following high energy trauma situations.
With the background that a delay in diagnosis may have devastating
consequences, early, easily accessible, relatively inexpensive pre-
dictive investigations may prove important especially in developing
nations.
Materials and methods: The prospective trial included a total of 67
young, polytrauma patients, in whom the role of nine easily avail-
able, rapidly performable clinical or laboratory investigations (or
observations obtained at admission) in predicting the later occur-
rence of fat embolism syndrome was assessed. All the patients also
underwent continuous monitoring with of oxygen saturation with
pulsoximetry.
Results: The correlation between the initial serum lactate (within
12 h of injury) and occurrence of hypoxia was statistically significant.
Although the correlation with the development of FES (Gurd’s cri-
teria) was approaching significance (p = 0.07), further larger scale
studies may be required to conclude upon its implications. The role of
continuous pulsoximetry was also established with a sensitivity of
24-h monitoring of oxygen saturation in predicting later pulmonary
deterioration approaching 100 %.
Conclusion: The combination of three predictive factors including
polytrauma (with NISS[17), serum lactate[22 mmol/l at admission
(within 12 h of injury) and at least a single episode of fall in oxygen
saturation (SaO2 below 90 % in the initial 24 h) serves as a harbinger
of development of grievous post-traumatic pulmonary complications,
especially fat embolism syndrome.
Disclosure: No significant relationships.
O162
CK-MB/CK RATIO AS AN INDIRECT PREDICTOR FORSURVIVAL IN PATIENTS WITH POLYTRAUMA
F.M. Kovar1, G. Endler1, V. Vecsei1, S. Hajdu1, T. Heinz1,O.F. Wagner2, A. Silke1
1Trauma Surgery, Medical University Vienna, Vienna, Austria,2Medical University Vienna, Medical and Chemical Laboratory
Diagnostics, Vienna, Austria
Introduction: Accurate assessment of injury severity is critical for
decision making related to the prevention, triage and treatment of
critically injured patients. Early estimation of mortality risk of
severely injured patients is mandatory for adequate therapeutic
strategies. Current risk stratification relies on clinical diagnosis and
scoring systems. In our study we speculated whether a simple
laboratory test: the CK/CKMB ratio could help improving risk pre-
diction in severely traumatized patients.
Materials and methods: In a 9 year period, 328 non-selected
trauma patients where included in our retrospective study at a Level
I trauma center. Inclusion into the present study was according to
the following criteria: (1) ISS score above 16 and (2) rescue period
under 2 h.
Results: The mean age of our study population was 34.6 years
(range from 6.7 to 81), 234 (71.4 %) were males and 94 (28.6 %)
were females. Mean ISS was 29 (range from 17 to 57) with an
overall mortality of 78 (23.8 %). Negative correlation between ISS
(Injury Severity Score) and leukocytes was shown. A positive
correlation was detected for liver enzymes and CK-MB. Correla-
tion between ISS and Na+ was significant. No correlation between
ISS and K+ and Hb/Ht could be observed. Exitus was associated
with ISS, alteration in Thrombocytes, CK, CK-MB, CRP, Crea and
Na+.
Conclusion: In our study population, CK-MB levels showed a sig-
nificant correlation with overall survilance in polytrauma patients. In
our opinion this might suggest that CK-MB levels could be taken as
an indirect predictor for survival.
Disclosure: No significant relationships.
O163
SYSTEMIC INFLAMMATORY RESPONSE AND ORGANDYSFUNCTION FOLLOWING HAEMORRHAGIC SHOCKAND PULMONARY VERSUS SYSTEMIC IL-10ADMINISTRATION
R. Pfeifer1, P. Lichte2, H. Schreiber1, H. Pape2, P. Kobbe2
1Orthopaedic Trauma Surgery, University Clinic Aachen, RWTH
University, Aachen, Germany, 2University Clinic Aachen, RWTH
University, Aachen, Germany
Introduction: Interleukin-10 (IL-10) is known to suppress the sys-
temic inflammatory response after trauma. This analysis studied
systemic inflammation and organ dysfunction in animals treated with
either nebulized or systemic IL-10 after experimental haemorrhagic
shock (HS).
Materials and methods: In C57/BL6 mice a pressure controlled HS
was performed for 1.5 h. Pulmonary or systemic recombinant
mouse IL-10 (50 lg/kg dissolved in 50 ll PBS) or PBS only was
administered after resuscitation. 6 and 24 h. following trauma, mice
were sacrificed and serum levels of IL-6, IL-10, KC, LBP and
MCP-1 were determined by ELISA. Pulmonary and liver inflam-
mation were analysed by standardised myeloperoxidase (MPO) kits
and histology.
Results: Six hours after traumatic stimulus, systemic administration
of IL-10 significantly reduced the serum IL-6 and KC levels when
compared with levels measured after nebulized IL-10 administration.
Moreover, after IL-10 aerosol exposure lung MPO activity signifi-
cantly decreased. However, liver MPO activity was reduced only with
systemic IL-10 injection. At 24 h. following HS, no effects on sys-
temic inflammatory response were registered.
Conclusion: Our study demonstrates that systemic and local admin-
istration of IL-10 differentially affects the systemic cytokine
response. Pulmonary protection is possible without altering the sys-
temic inflammatory response and the susceptibility to infection.
Disclosure: No significant relationships.
S60 Abstract
123
VISCERAL TRAUMA II
O164
MORTALITY STUDY OF FACTORS ASSOCIATED WITHPELVIC FRACTURES IN THE TRAUMA PATIENT
J.D. Turino-Luque1, N. Zambudio-Carroll1, A. Mansilla-Rosello2,S. Gil Loza2, T. Torres Alcala2, F. Huertas Pena2, J.A. Ferron-Orihuela2
1Cirugıa General, Hospital Virgen de las Nieves, Granada, Spain,2Cirugıa General, Hospital Universitario Virgen de las Nieves,
Granada, Spain
Introduction: Pelvis fracture is a cause of mortality in the trauma
patient, although the complex nature of this type of patients is due
to the involvement multiple organs and tissues. The goal of this
study is to analyze the causes associated with mortality in pelvic
fractures.
Materials and methods: Retrospective study of pelvic fractures
treated in the emergency department from 1999 to 2009. Com-
pound fracture was defined as one affecting two or more pelvic
branches.
Data recorded: age, sex, etiology, organ and system injuries, hospital
stay, mortality, blood transfusions, treatment, complications. Statis-
tical analysis using SPSS 17.0, considered significant at p \ 0.05.
Results: 790 patients were included in the study, 16.1 % (n = 127)
had pelvic fracture. 40.9 % (n = 52) were complicated fractures,
requiring surgery 34.6 %. Most common cause: traffic accidents
(61.4 %) and precipitation (19.7 %). 22.8 % overall mortality.
Compound fractures (n = 52): Average age 37.4. Precipitation
53.3 %. Mortality 28.8 %. Causes 73.3 % bleeding.
Simple fractures (n = 75): Average age 36.4. Traffic accident 64.1 %.
36.4 %. Mortality 18.6 %. Causes 35.7 % bleeding, 28.6 % respiratory
complications. Statistically significant differences were only detected
in the presence of retroperitoneal hematoma (p = 0.004).
Multivariate analysis identified risk factors associated with mortality
in the presence of pelvic fractures were retroperitoneal hematoma
(p = 0.052, OR 2.648, 95 % CI 0.994–7.055). In this case the type of
trauma if we consider the accident (OR = 1) precipitation was pre-
sented as a risk factor (p = 0.027, OR 3.062, 95 % CI 1.137–8.245).
Conclusion: Pelvic fracture in the trauma patient requires complex
interdisciplinary management.
Most common cause of death in compound fractures is hemorrhage.
In simple fractures death is caused by medical problems.
Main risk factors detected were: precipitation and retroperitoneal
hematoma.
Disclosure: No significant relationships.
O165
TWENTY YEARS OF SPLENIC PRESERVATIONIN TRAUMA: LOWER EARLY INFECTION RATETHAN IN SPLENECTOMY
W.P. Schweizer1, S. Paulet-Gerber1, C. Seiler2
1Hirslanden Kliniken Sh Und Zh, Zentrum fur minimalinvasive
Chirurgie, Schaffhausen, Switzerland, 2Universitatsklinik, Inselspital,
Bern, Switzerland
Introduction: Background: Retrospective studies concerning the
operative preservation and nonoperative management of splenic
injuries in patients with splenic trauma have been published. Only few
studies have analyzed prospectively the results and early complication
rates of a defined management in splenic injury.
Materials and methods: Methods: From 1986 to 2006, adult patients
with blunt splenic injuries were evaluated prospectively with the
intent of splenic preservation. Hemodynamically unstable patients
underwent laparotomy. Stable patients were treated conservatively
regardless of the grade of splenic injury determined by ultrasound
and/or CT-scan.
Results: Results: In a twenty year period, 155 patients were prospec-
tively evaluated. In 98 patients (63 %) the spleen could be preserved by
nonoperative (64 patients, 65 %) or operative (34 patients, 35 %)
treatment and 57 patients (37 %) underwent splenectomy. There were
no differences in age, gender or trauma score between the groups, but a
higher early infection rate in patients with splenectomy compared to
patients with splenic preservation (p \ 0.005) was observed, even if the
patients were matched with respect to multiple trauma using the injury
severity score (ISS) (p \ 0.01).
Conclusion: Conclusion: Splenic preservation in adult patients with
blunt splenic injury either by operative or nonoperative treatment
leads to lower early infection rates than in patients with splenectomy
and should therefore be advocated.
References 1. Schweizer W, Bohlen L, Dennison A, Blumgart LH.
Prospective study in adults of splenic preservation after traumatic
rupture. Br J Surg. 1992;79(12):1330–3.
Disclosure: No significant relationships.
O166
SURGICAL MANAGEMENT OF SEVERE LIVER TRAUMAAFTER BLUNT INJURIES
V.M. Mutafchiyski, I.R. Takorov, V.I. Mihaylov, N.N. Vladov
Hand and Transplant Surgery, Military Medical Academy, Sofia,
Bulgaria
Introduction: Liver is the most commonly affected abdominal organ
after blunt trauma. The death rate is higher in blunt trauma cases
compared to penetrating abdominal trauma. These patients require
close attention, rapid evaluation, accurate classification and well-
structured action protocol. Although the nonoperative treatment of
liver trauma patients has become a gold standard it is not always
possible. In cases with severe (high-grade) liver trauma it is suc-
cessful in no more than 20 % of cases.
Materials and methods: We present eight cases, managed in our
department during the last 2 years. Five men and three women, with a
median age 41.3 years. All patients were classified according to
AAST classification of liver trauma. One of them was with IIIrd grade
liver trauma, 4 were with IVth grade and 3 with Vth grade.
Results: Surgery was used in seven cases. The following protocol was
applied: (1) Damage control (DC) laparotomy with packing and/or
suture of bleeding vessels; (2) DC resuscitation using massive ha-
emotransfusion protocol; (3) Definitive hemostasis and repair: right
hepatectomy in 2 cases, bisegmentectomy in 3 and repacking in 1 case.
High rate of postoperative complications was observed abdominal
abscess in 3 cases, late hemorrhage in one, bile leak in one and wound
disruption in one case. The median hospital stay was 28.5 days. Two
of the presented patients died despite of the treatment applied.
Conclusion: Operative approach in cases of blunt liver injury is
mandatory when hemodynamic instability is present. The increased
Abstract S61
123
transfusion requirement is the other important factor precluding the
operative treatment. The application of DCS increased the survival
after severe liver trauma, despite of the high complications rate. The
definitive treatment of patients with severe liver trauma must be
performed in high-volume centers where there are possibilities for
adequate image diagnostic, highly experienced surgical and intensive
care teams and multidisciplinary approach.
Disclosure: No significant relationships.
O167
BLUNT HOLLOW VISCUS PERFORATIONS DUE TOABDOMINAL CONTUSIONS: DIAGNOSTICPARTICULARITIES AND PROGNOSTIC FACTORS FORDEATH
A.E. Nicolau1, M. Craciun1, V. Merlan1, G. Dinescu2, A. Kitkani2
1Chirurgie, Spitalul Clinic de Urgenta Bucuresti, Bucharest, Romania,2Spitalul Clinic de Urgenta Bucuresti, Bucharest, Romania
Introduction: Blunt hollow viscus perforations (HVP) due to
abdominal contusions are difficult to diagnose early and are associ-
ated with a high mortality.
Materials and methods: Our paper analysis retrospectively data
from patients operated for HVP between January 2005 and January
2009, the efficiency of different diagnostic tools and prognostic fac-
tors for death.
Results: There were 62 patients operated for HVP. 48 were poly
trauma patients.The mean age was 41.5 years, the mean ISS was
32.94 and 23 patients had associated solid viscus injuries (SVI).
Abdominal X-ray was false negative for 30/35 patients and abdominal
ultrasound was false negative for 16/60 patients. Abdominal CT was
initially false negative for 7/38 patients: for 4 of them the abdominal
CT was repeated, for 3 patients a laparoscopy was performed. Direct
signs for HVP on CT were present for 3/38 patients. Diagnostic
laparoscopy was performed for 7 patients with suspicion for HVP,
and was positive for 6, and false negative for a duodenal perforation.
There were 15 deaths (15.2 %), caused by haemodynamic instability
(3/6 patients) and associated lesions: solid organ injuries for 9/23
cases, pelvic fracture for 6/14 patients, cerebral trauma for 12/33
patients. Multivariate analysis showed that the prognostic factors for
death were ISS value (p = 0.023) and associated cerebral trauma
(p = 0.017).
Conclusion: HVP due to abdominal contusions have a high mortality,
early diagnosis is difficult, repeated abdominal CT and the selective
use of laparoscopy for haemodynamic stable patients with equivocal
clinical examination and diagnostic imaging are salutary. Prognostic
factors for death were the ISS value and associated craniocerebral
trauma.
Disclosure: No significant relationships.
O168
CONTRAST ENHANCED ULTRASOUND (CEUS) INFOLLOW-UP OF BLUNT SPLENIC TRAUMA
M. Zago1, H. Kurihara1, D. Mariani1, A. Casamassima2, F. Butti1,R. Foa1
1General Surgery, Policlinico San Pietro, Ponte San Pietro (BG),
Italy, 2Emergency Dept., Istituto Clinico Citta Studi, Milano, Italy
Introduction: Non Operative Management (NOM) is nowadays the
standard for stable blunt splenic trauma. The role and value of follow-
up (FU) is a debated issue. Early CT is usually performed to rule out
pseudoanevrysms.
Materials and methods: From January 2004 to May 2009, 100 blunt
abdominal trauma patients were admitted with one (21 %) or more
(79 %) solid organ injuries, with mean ISS 23.8. Fifty-seven had
splenic injuries (mean ISS 23.6). Twenty-seven had immediate sur-
gery, 30 (52.6 %) underwent NOM, 7 with angioembolization (mean
OIS 1.92). CEUS was performed with Sonovue� (Bracco-Italy) in
NOM patients on day 0 (after the initial CT-scan), on day 2 and day 5
in all patients; then with B-mode US according to grade and evolution
of the lesions. Patients with grade III subcapsular hematoma under-
went long term CEUS follow-up. Analysis of the costs of a standard
CT follow-up and the CEUS protocol was also performed. All NOM
patients had late phone FU.
Results: Overall mortality rate of patients with splenic injuries was
15.7 % (9 pts). Eight out 27 pts operated on (29.6 %) died; one NOM
patient (3.2 %) died for massive pulmonary embolism. NOM failure
was decided in one patient (3.2 %) with bilateral adrenal trauma and
recurrent hypotension. CEUS detected one pseudoanevrysm on day 5,
treated by percutaneous CEUS-guided trombin injection, and one
rebleeding in a subcapsular hematoma on day 28, treated by rean-
gioembolization. No other early and late complications were
observed. Comparison of costs with the standard FU with CT showed
a significant saving of money and radiations (629 € vs. 443 €,
p \ 0.0001; 39.9 vs. 119.7 mSv, p \ 0.05).
Conclusion: CEUS follow-up allowed detection of all life-threaten-
ing conditions. CEUS was always feasible, can safely replace CT for
the follow-up of splenic NOM and reduce costs and radiation
exposure.
References: 1. Valentino M. Contrast enhanced ultrasonography in
blunt abdominal trauma: considerations after 5 years of experience.
Radiol Med. 2009;114:1080–93. 2. Xu HX Contrast enhaced US: the
evolving applications. World J Radiol. 2009;31:15–24.
Disclosure: No significant relationships.
O169
EARLY INFECTION RATE IN PATIENTS SUSTAININGBLUNT SPLENIC INJURY
M. Teuben1, L. Leenen2
1Surgery, University Medical Centre Utrecht, Utrecht,
The Netherlands, 2University Medical Centre Utrecht, Utrecht,
The Netherlands
Introduction: The treatment of blunt splenic injury (BSI) has
changed from operative therapy towards predominantly nonopera-
tive management (NOM). This is a result of the recognition of the
spleen’s role in the immune system. Literature suggest a relation-
ship between type of treatment and early infection rate. Therefore,
we evaluated the impact of treatment of the splenic injury on early
infection rate.
Materials and methods: We analyzed all adult patients with BSI that
were admitted to our level one trauma centre between 2000 and 2011.
Patient demographics, grade of splenic injury, ISS, hemodynamics,
management and outcome were documented. Patients were divided
into groups based on the treatment they underwent; group I: NOM,
group II: total splenectomy, group III: spleen preserving procedure
(SPP). Early infectious complications, ICU-stay, hospitalization time
en mortality were compared between groups.
S62 Abstract
123
Results: A total of 135 patients (99M/36F) with a median(IQR) age
of 31 (21–54) were included. Fifty-seven patients were treated by
NOM and seventy-eight patients underwent surgical therapy. Seventy
splenectomies were performed and eight patients were treated using a
Vicryl mesh.
The most frequent infectious complications were pneumonia (n = 16)
and wound infections (n = 8). Patients treated by NOM had a sig-
nificantly lower infection rate (12 infections), compared to Group II
(25 infections) and patients treated by SPP’s (6 infections). The
mortality rate was 7.4 %. Mortality was not associated with early
infectious complications.
Conclusion: Early infectious complications are more frequently seen
in patients treated by total splenectomy or SPP as compared to NOM.
There is no difference between patients treated by splenectomy and
patients treated by SPP.
Disclosure: No significant relationships.
O170
SMALL INTESTINUM INJURIES
S.D. Sekulic1, A.S. Sekulic-Frkovic2, A.S. Sekulic3, J.S. Vasic4
1Surgical Clinic, C.H.C.Pristina-Gracanica, Gracanica, Serbia,2Pediatric Clinic, C.H.C Pristina, Gracanica, Serbia, 3C.H.C Pristina,
Gracanica, Serbia, 4Surgical Clinic, C.H.C Pristina, Gracanica, Serbia
Introduction: Small intestinum injuries appears in about 30 % of
abdominal injuries. They are mostly penetrating (80 %) or blunt
trauma (20 %).
Materials and methods: Material and methodology: Work is
15 years period study (1996–2010) of operated patients due to
abdominal injuries at Surgical clinic, C.H.C Pristina, GraAa-
nica. We established the diagnosis based on anamnesis, clinical
inspection, ultrasound examination or available radiological
method.
Results: Out of 736 (9.1 %) of abdomen injuries, we had
249 (33.6 %) injuries of small intestinum. Males were 203 (81.5 %)
and females 46 (18.5 %), avearage age was 29.8 years old. Joint
injuries of small bowel appeard at 167 (67.1 %) of injured, isolated
appeared at 82 or (32.9 %). Penetrating injuries of small intestinum
are found at 209 (83.9 %), and injuries caused by blunt force at 40
(16.1 %). According to scale for organ injuries, penetrating injuries
were at III and IV level (multiple perforations) and blunt injuries at
I, II and V level (single). After establishing of diagnosis and quick
short reanimation all injured were operated, with penetrating injuries
within first 6 h after reception, and with blunt injuries during 24 h.
At penetrating (knife, fire arms) multiple injuries of intestinum
resection with T-T anastomosis was performed at 90.1 % of
patients. At blunt injuries with single perforation we performed a
suture. Complications occured at 47 (18.8 %) out of which: enteral
fistula at 3 (1.2–6.3 %), infection of wound at 20 (8.03–42.6 %) of
cases, and the rest were shock complications, cardiovascular,
respiratory or urinary. We had death outcome at 6 (2.4–12.8 %) of
cases.
Conclusion: It’s essential to make quick differenciation of uninjury
and cause of injury. Resection with T-T anastomosis is method of
choice at multiple perforations. Death outcome depends on injury.
Disclosure: No significant relationships.
O013
SHORT AND LONG-TERM SURVIVAL AND DESCRIPTIVEDATA AFTER ANGIOEMBOLIZATION FOR TRAUMA
C.H. Montan1, M. Hedberg2, C.M. Wahlgren1
1Department of Vascular Surgery, Karolinska Institute, Stockholm,
Sweden, 2Karolinska Institutet, Stockholm, Sweden
Introduction: To present short- and long-term outcome data after
angioembolization (AE) for trauma, at our center, and time aspects of
the initial procedure.
Materials and methods: Retrospective analysis of all trauma patients
undergoing AE at Karolinska University Hospital, Stockholm, during
a 6-year period (2003–2009). Data collected from local trauma reg-
istry and medical records.
Results: A total of 120 AE were performed in 105 trauma patients
(99 blunt vs. 6 penetrating). 12 (11 %) were reintervention AE and
13 diagnostic angiograms. The sites for AE were, splenic artery
35 % (n = 40), iliac artery and vein 34 % (n = 39), hepatic artery
12.5 % (n = 14), renal artery 11.5 % (n = 13) others 7 % (n = 8).
6 were AE at multiple sites. 30-day mortality rate was 15 % for
the whole group and 29 % for patients undergoing laparotomy
before AE (n = 10/35) and 9 % in the group who did not require
laparotomy. Perioperative AE was performed in 13 patients with a
mortality rate of 46 % (n = 6). Mean ISS was 29.5 (two-year
survival rate is under investigation). Time from admission at
emergency department until treatment with AE showed a mean of
2.59 h.
Conclusion: AE is feasible in trauma patients with ongoing bleeding
where open surgery either is non sufficient for hemostasis or in
cases where AE is preferred as primary hemostatic treatment,
especially in splenic, iliac, hepatic and renal injuries. Mortality rates
are comparable to previous reports. Time from admission at ED to
AE can probably be significantly shortened which might improve
outcome.
Disclosure: No significant relationships.
SPORT INJURIES: LOWER EXTREMITY
O171
REGENERATION OF THE ANTERIOR CRUCIATELIGAMENT USING SILK SCAFFOLDS AND A CUSTOM-MADE BIOREACTOR SYSTEM
A. Teuschl1, M. Hohlrieder2, K. Cicha3, M. Van Griensven4,J. Stampfl3, H. Redl5
1Austrian Cluster for Tissue Engineering, Ludwig Boltzmann Institute
for Clinical and Experimental Traumatology, Vienna, Austria,2A.M.I. Agency for Medical Innovations, Feldkirch, Austria,3Institute for Materials Science and Technology, TU Vienna, Vienna,
Austria, 4Ludwig Boltzmann Institute for clinical and experimental
Traumatology, Vienna, Austria, 5Experimental and Clinical
Traumatology, Ludwig Boltzmann Institute, Vienna, Austria
Abstract S63
123
Introduction: The aim of the study is to generate a tissue engineered
silk scaffold with mechanical properties similar to the human anterior
cruciate ligament (ACL) that could possibly guarantee long-term
clinical success in anterior ACL regeneration/replacement.
Materials and methods: The silk scaffold was made of white raw
Bombyx mori silkworm fibers in a wire-rope design.
To investigate the alterations in the mechanical properties due to the
preparation process (sericin removal), pull-to-failure tests were per-
formed. Furthermore cytotoxicity has been evaluated in vitro (direct
and indirect leaching tests). In parallel to the fabrication process of
the silk scaffold, a bioreactor system has been developed that enables
the mechanical stimulation of our constructs.
Results: Mechanical properties (maximum load/stiffness) of our silk
scaffolds (2023 ± 109 N/336 ± 40 N/mm) were comparable to the
human ACL1 (2160 ± 157 N/242 ± 28 N/mm). Cell culture experi-
ments proved the non-toxicity of our silk constructs. First bioreactor
tests showed a significant production of ECM proteins on the scaf-
folds under biaxial mechanical stimulation.
Conclusion: With a braided design a silk scaffold could be generated
matching mechanical properties of the human ACL. Furthermore we
could build up a novel bioreactor system that we can use to investi-
gate cell and tissue growth on our scaffold under biaxial mechanical
loading.
Reference: 1. Woo et al. Am J Sports Med. 1991;19:217–25.
Disclosure: No significant relationships.
O172
CONTROLLED IMMEDIATE FULL WEIGHTBEARINGGIVES FASTER RECOVERING AFTER MALLEOLARSYNTHESIS
F. Carlier1, S. Troussel2
1Orthopedic, Grand Hopital de Charleroi, Charleroi, Belgium,2Orthopedics, Grand Hopital de Charleroi, Charleroi, Belgium
Introduction: After malleolar synthesis, rehabilitation is critical for
the return to normal life. We prospectively studied the effect of early
full weightbearing in a articulated metallic ankle splint.
Materials and methods: From october 2010 until june 2011 we
prospectively managed 49 malleolar fractures, 27 uni and 22 bimal-
leolar. All fractures were operated in accord of the AO principles.
Serie A included 25 fractures (16 uni and 10 bimalleolar), they wore
the articulated metallic splint. Serie B included the other 24 fractures
(12 uni and 12 bimalleolar), patient were immobilised in a less rigid
plastic and straps splint. In serie A, patients were allowed of full
weightbearing with the splint as soon as the pain permit it. All of
these patients were prescribed physiotherapy at the therapist of their
choice. They were followed every 2 weeks with X-ray to check for
secondary displacement. In serie B, patients were prescribed phys-
iotherapy after a short period of cast immobilisation followed by soft
splint. They were not allowed of full weightbearing untill 2 months or
callus formation.
Results: All fractures united in both series. We had no secondary
displacement in serie A. In serie A, all patients experienced a quicker
return of autonomy at home even in elderly and a quicker return to
work. 8 patients had scar irritation with the articulated metallic splint
without any infection. It resolved by removing the splint several hours
per day without weightbearing.
Conclusion: Immediate full weightbearing in an articulated metallic
ankle brace gives a quicker return to normal after malleolar synthesis.
Disclosure: No significant relationships.
O173
FRACTURE CLASSIFICATION AND CLINICAL RESULTSBY CT EVALUATION OF FEMORAL TROCHANTERICFRACTURES TREATED WITH PFNA-II
E. Shoda
Orthopaedic Surgery, Hyogo prefectural Nishinomiya Hospital,
Nishinomiya, Japan
Introduction: Short femoral nail is the most popular instrumentation
for femoral trochanteric fractures. Fracture classification and evalua-
tion of surgical results were usually based on plain X-ray. However,
some cases of delayed union, non-union, and blade cut out were
classified to stable fracture in X-ray. In this study, fracture was clas-
sified by 3D-CT and clinical results were investigated in each group.
Materials and methods: 34 femoral trochanteric fractures treated
with PFNA-II were investigated. Eleven males and 23 females, and
average age at surgery was 81.0 year-old (65–100). Nail insertion
hole was made by custom made Hollow Reamer. Fracture was clas-
sified with 3D-CT according to modified Nakano’s classification.
Clinical results including sliding amount of blade and postoperative
complications were investigated.
Results: Fracture is classified to 2 part, 3 part (5 subgroups), and 4
part with combination of 4 fragments; Head (H), Greater trochanter
(G), Lesser trochanter (L), and Shaft(S). 5 subgroups of 3 part fracture
were (1) H + G(small fragment) + L-S, (2) H + G(big frag-
ment) + L-S, (3) H + G-L + S, (4) H-L + G + S, and (5) H + L+G-
S. Numbers of each group were 7 cases in 2 part, 5 cases in 3 part (1),
10 cases in 3 part (2), 6 cases in 3 part (3), 4 cases in 3 part (5), and 2
cases in 4 part. Sliding amount of blade was 2.6 mm in 2 part, 9.4 mm
in 3 part (1), 4.9 mm in 3 part (2), 9.4 mm in 3 part (3), 11.9 mm in 3
part (5), and 20 mm in 4 part. Complications such as varus deformity,
shortening of femoral neck occurred in 2 cases in 3 part (1), 1 case in
3 part (2), 3 cases in 3 part (3), 3 cases in 3 part (5), and 2 cases in 4
part. Nonunion was recognized in 1 case of 3 part (3).
Conclusion: Femoral trochanteric fracture was classified by Evans
classification or AO classification. However, it is very difficult to
classify the fracture by plain X-P. Classification with 3D-CT is very
usefull to distinguish which the fracture is stable or unstable. 3 part
(3), (4), (5) and 4 part fracture are considered in unstable. Sliding
amount is larger and also many complications were seen in these
unstable groups.
Disclosure: No significant relationships.
O174
LONG TERM FOLLOW-UP OF A COMPARISON OFHEMIARTHROPLASTY WITH TOTAL HIP REPLACEMENTFOR DISPLACED INTRACAPSULAR FRACTURE OF THEFEMORAL NECK
E.F. Hilverdink1, M.P.J. Van Den Bekerom1, I.N. Sierevelt1,C.N. Van Dijk1, J.C. Goslings2, E.L.F.B. Raaymakers1
1Orthopedic Surgery, AMC, Amsterdam, The Netherlands,2Trauma Unit, Department of Surgery, Academic Medical Center,
Amsterdam, The Netherlands
Introduction: The aim of this study was to analyse the long term
functional outcome after a displaced intracapsular fracture of the
S64 Abstract
123
femoral neck in active patients aged over 70 years without osteoar-
thritis or rheumatoid arthritis of the hip, randomised to receive either
a hemiarthroplasty or a total hip replacement (THR).
Materials and methods: We initially studied 252 patients of whom
4 (19 %) were men, with a mean age of 81.1 years (70.2–95.6).
They were randomly allocated to be treated with either a cemented
hemiarthroplasty (137 patients) or cemented THR (115 patients).
At the long term follow-up of nearly 12 year, 50 patients were
still alive with in the HA (n = 32/137) and in the THR (n = 18/
115).
Results: We have a follow-up of 12.4 (SD 2.3) years in the hemi-
arthroplasty and 11.3 (SD 2.1) years in the THR group. At five and
12 year follow-up no differences were observed in the modified
Harris hip score, revision rate of the prosthesis, local and general
complications, or mortality. The intra-operative blood loss was lower
in the hemiarthroplasty group (7 %, [500 ml), THR group (26 %,
[500 ml) and the duration of surgery was longer in the THR group
(28 %,[1.5 h vs. 12 %, [ 1.5 h). There were no dislocations of any
bipolar hemiarthroplasty than in the eight dislocations of a THR
during follow-up untill 5 year.
Conclusion: Even on the long run of 12 years, we do not recommend
THR as the treatment of choice in patients aged over 70 years with a
fracture of the femoral neck in the absence of advanced radiological
osteoarthritis or rheumatoid arthritis of the hip. Because of a higher
intra-operative blood loss (p: 0.001), an increased duration of the
operation (p: 0.001) and a higher number of early and late disloca-
tions (p = 0.002).
Disclosure: No significant relationships.
O175
REAMED VERSUS UNREAMED INTRAMEDULLARY NAILIN TREATMENT OF TIBIAL SHAFT FRACTURES. RESULTSOF PROSPECTIVE RANDOMIZED STUDY
J. Trlica, T. Dedek, K. Smejkal, I. Zvak, T. Holecek, J. Koci, M. Frank
Surgery, University Hospital Hradec Kralove, Hradec Kralove/Czech
Republic
Introduction: The aim of our study was to compare the results of the
treatment of tibial shaft fractures (TSF) by reamed or unreamed in-
tramedullar nail.
Materials and methods: Prospective randomized study. There were
104 TSF included during the period from 10/05 to 6/10. Factors of
injury severity, course of surgery and early or delayed complications
were recorded. X-ray was performed every 4 weeks till the fracture
was healed. Functional results were evaluated at least 1 year after
surgery.
Results: 49 TSF were treated by unreamed tibial nail. There were 15
females and 33 males in this group. Injury severity score (ISS) ranged
from 4 to 25 (ø 6.63). There were 45 closed (0.-16; I.-22; II.-7) and 4
open fractures (I.-2; II.-1; III.A-1). In the group of patients with
reamed nail were 48 patients with 48 fractures. ISS ranged from 4 to
18 (ø 6.13). There were 35 closed (0.-17; I.-13; II.-5) and 13 open
(I.-5; II.-5; III.A-3) fractures in this group. X-ray healing was same in
both groups (18, 12 unreamed versus 17, 92 reamed nail). We had 4
patients in unreamed nail group and 6 patients in reamed nail group
with delay union (28–44 weeks). We recorded one nonunion in
reamed nail group. We had no infection, loss of reduction or re-
operation in both groups. Follow-up was 90 %.
Conclusion: There is no significant difference in clinical and func-
tional results in either group. We suggest that both methods are
comparable.
References: 1. Court-Brown CM. J Orthop Trauma. 2004;18:96–101.
2. Bhandari M. J Bone Joint Surg Am. 2008;90:2567–78.
Disclosure: No significant relationships.
O176
MID-TERM RESULTS OF OPERATIVE TREATMENTOF TARSAL NAVICULAR FRACTURES AND A NEWFRACTURE CLASSIFICATION
T. Schmid1, M. Weber2, F. Krause3
1Department of Orthopedic Surgery, Inselspital Berne, Berne,
Switzerland, 2Zieglerspital Berne, Berne, Switzerland, 3Orthopaedic
Surgery, Inselspital University of Berne, Berne, Switzerland
Introduction: Tarsal navicular fractures are very uncommon frac-
tures. We report preliminary results of 24 patients with navicular
fractures treated at our institution. A new classification system is
introduced allowing better prediction of outcome.
Materials and methods: 24 patients over a 12-year-period fulfilled
the inclusion criteria until April 2011. Average age was 35 years
(range 17–61), average follow up 65 months (range 11–57). Clinical
outcome was measured by AOFAS midfoot score and VAS-Hann-
over-Questionnaire. Hindfoot alignment, talonavicular and subtalar
motion were assessed. Osteoarthritic changes of the talonavicular and
naviculocuneiform joints were graded according to Kellgren–Law-
rence. According to the new classification avulsion fractures of the
dorsal–proximal lip or the tuberosity were classified as type Ia and Ib.
Sagittal split fractures of the body as type II. Type III fractures were
separated in fractures with talonavicular luxation and lateral plantar
fragmentation (type IIIa) or multiple fragmentation of the proximal
navicular joint surface (type IIIb).
Results: Overall results showed an AOFAS-Score of 84.4 and a VAS-
Hannover-Questionnaire-Score of 75.5. Using the new classification 4
patients showed type I fractures, 6 type II, 5 type IIIa and 9 type IIIb.
The proposed classification showed significant correlation of fracture
type and AOFAS Score (Spearman’s coefficient -0.39, p = 0.030),
of fracture type and Hannover Score (-0.36, p = 0.041), and of
fracture type and talonavicular osteoarthritis (0.53, p = 0.004).
Conclusion: At mid-term follow-up, ORIF of tarsal navicular frac-
tures leads to appropriate clinical outcome but is closely related to the
severity of the initial fracture comminution. A new classification with
close correlation to clinical and radiological outcome is proposed.
Disclosure: No significant relationships.
O177
NON-OPERATIVE TREATMENT OF ACUTE RUPTUREOF THE ACHILLES TENDON
T.M. Ecker1, F. Krause1, T. Muller2, M. Weber3
1Orthopaedic Surgery, Inselspital, Berne, Switzerland, 2Department
of Orthopedic Surgery, Inselspital, Berne, Switzerland, 3Orthopaedic
Surgery, Zieglerspital Bern, Bern, Switzerland
Abstract S65
123
Introduction: Treatment of acute rupture of the Achilles tendon is
categorized into operative and non-operative treatment. Surgery is
associated with a significantly lower number of re-ruptures but also an
increased complication rate, whilst not leading to accelerated reha-
bilitation or improved functional outcome. We developed and
evaluated a customized conservative treatment algorithm.
Materials and methods: Ninety-one patients were prospectively
followed up for a mean of 30.6 ± 20.1 (9.38–88.1) months. A short
ankle cast in 20� equinus position was worn in a special rehabilitation
boot equipped with 2 removable heel inlays for 6 weeks. Full weight-
bearing was allowed immediately. After 6 weeks, the cast was
removed and patients wore the boot for another 6 weeks, removing
one heel inlay every 2 weeks with a final 2 week period of planti-
grade ambulation in the boot. A special physical therapy algorithm
was absolved.
Results: The mean Thermann score was 82.2 ± 13.4 (35–100) points.
Subjective satisfaction was rated ‘‘very good’’ and ‘‘good’’ in 92.3 %
of patients. There were 5 re-ruptures, three with an adequate trauma
and two without, the latter undergoing surgical repair subsequently.
The complication rate was 6.6 %, including deep venous thrombosis
(2), plantar fasciitis, intratendinous seroma, pressure ulcer, transient
hypaesthesia, and development of Sudeck syndrome in one case.
Conclusion: Our treatment algorithm promotes fast rehabilitation
through immediate full weight-bearing and physical therapy. The re-
rupture rate is lower, while the complication rate matches results after
conservative treatment reported in other studies. Concluding, con-
servative treatment is a valuable option for acute rupture of the
Achilles tendon.
Disclosure: No significant relationships.
O178
CALCANAIL A NEW INTERNAL DEVICE FOR CALCANEALFRACTURES
M. Goldzak1, P. Simon2, T. Mittlmeier3
1Orthopedie Traumatologie, Clinique de l’Union, Saint Jean, France,2Chirurgie Orthopedique et Traumatoloque, Hospital Saint Luc Saint
Joseph, Lyon, France, 3Universitatsklinikum Rostock, Rostock,
Germany
Introduction: Calcaneal fractures are often well enough treated by
open reduction and internal fixation, but also by percutaneal pinning
as well as non operative procedures. Many surgeons who were con-
fronted to these fractures had only a short experience. We propose a
new implant to ease up the operative procedure with a standard
technique based upon our expertise in calcaneal fracture management.
Materials and methods: We presented a cadaveric implantation and
a surgical procedure based upon our intra focal dorsal approach
published in the AFCP (French Foot and Ankle Association) mo-
nography in November 2010. The Calcanail features and our first
clinical implantation outcomes were included in this presentation
with a tridimensional CT reconstruction after and before the
implantations. A biomechanical cadaveric study comparing screws,
plating and the Calcanail were performed by construct stress in
compression and extensometry measurements. The access from the
heel is done by drilling through the calcaneal tuberosity with a
hollow reamer and the use of a talo-calcaneal distractor allows a
direct intra-focal access to articular fragments. The nail allows an
angular stable fixation and fragment compression. We performed a
biomechanical test of cadaver bone with extensometry devices and
hydraulic press.
Results: We compared our construct to plating and screwing in a
calcaneal bone by mechanical tests. The stability and rotational forces
were neutralized at the same level of triangulation plating. Our first
implantations were controlled by post operative tridimensional CT
reconstructions.
Conclusion: The Posterior intra-focal approach standardizes the
surgical procedure. Calcanail is a locking nail used to fix the reduc-
tion with an angular and rotational stability proven by biomechanical
tests.
References: 1. Utheza G, Flurin PH, Colombier JA. Les fractures
thalamiques du calcaneum: description et anatomopathologie.apport
de la tomodensitometrie R.C.O. 1993;79:47–57. 2. de J.-P. Avaro,
S.R. Babin, R. Badet, et al. Les fractures du calcaneum sous la
direction de J.-L. Rouvillain avec la collaboration. Editeur. Sauramps
medical, Montpellier Description (24 9 16 cm) EAN13:9782840
233848.
Disclosure: Sharing the inventor patent with two other colleagues and
the french brand FH (Fournitures Hospitallieres). We are not a con-
sultant, but we have shares of the device.
VIDEO PRESENTATIONS
DISASTER AND MILITARY SURGERY
V01
INTERNATIONAL WEEK OF TRAUMA OF MADEIRA
P.M. Ramos
Cirurgia Geral, Hospital Dr.Nelio Mendonca, 089, Portugal
Introduction: Madeira international week of trauma was an event
that we realize in 2010, where we did several courses: atls, atcn, dstc,
dpntc, fast and e-fast, mrmi.
Content: the video shows all the education and training programme
that we did in this event, where we gave formation to 160
professionals.
Discussion: We think this kind of program is useful for professionals
and the results were good.
References: Madeira international week of trauma
Disclosure: No significant relationships.
V02
TRAUMA SYSTEM PLANNING IN THE UNITED STATESUSING AN INTERNET BASED POPULATION MAPPINGAPPROACH
B. Carr1, C.W. Schwab2, C. Wolff3, C. Branas4
1Emergency Medicine and Epidemiology, University of
Pennsylvania, Philadelphia, PA, USA, 2Department of Surgery,
University of Pennsylvania, PA, PA, USA, 3University of
Pennsylvania, Philadelphia, PA, USA, 4Biostatistics and
Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
Introduction: Injured adults treated at trauma centers in the US have
decreased mortality rates relative to those treated at non-trauma
centers. In 2010, 87 % of the US population had access to a trauma
S66 Abstract
123
center within an hour. Healthy People 2020 has set the goal of 91.4 %
population access. We sought to develop an interactive internet based
mapping application to facilitate the strategic expansion of the trauma
system’s reach. We used data about the location of residence of the
population, location of certified trauma centers, location of air
ambulances, prehospital care times, and estimated driving and flying
distances to calculate access to care for the US. We obtained popu-
lation data from the US census bureau and data about US trauma
centers from the Trauma Inventory and Exchange Program. We used
Geographic Information Systems to visually demonstrate access to
care in a scalable manner.
Content: Our internet based application calculates population access
to trauma care, using shade maps to demonstrate geographies within
reach of a trauma center. Users can zoom to small geographies and
enable a number of variables including allowing prehospital providers
to cross state lines and to use air ambulances. Users can choose to
display hospitals, trauma centers, air ambulance depots, and geopo-
litical boundaries (counties, voting districts). Users can customize
maps for printing or inclusion in presentations.
Discussion: We have developed a scalable tool that benchmarks
access to trauma care in the US and allows end users including pre-
hospital and trauma systems planners to make strategic planning
decisions that will optimize access to trauma care locally and
nationally.
References: http://www.traumamaps.org.
Disclosure: No significant relationships.
V03
SECOND ITALIAN MRMI (MEDICAL RESPONSE TOMAJOR INCIDENTS): A CONFIRMATION
R. Faccincani1, P. Bergonzi2, M.T. Cibelli2, A. Rossodivita3,R. Sannicandro1, M. Spessot1, M. Carlucci1
1Emergencies, IRCCS San Raffaele, Milano, Italy, 2ICU, IRCCS San
Raffaele, Milano, Italy, 3Cardio-thoracic Department, IRCCS San
Raffaele, Milano, Italy
Introduction: Major emergencies, crisis and disasters have become
more frequent during recent decades. They affect more and more
people, challenging health sector programmes and essential services.
Preparedness is the key of success in the management of such events
and education and training are the key of preparedness. MRMI
(Medical Response to Major Incidents) is a training course already
validated for its educational value and quickly becaming popular all
around Europe. Also in Italy 2 MRMI courses, October 2010 and
April 2011, has been held and for 2012/13 other 3 are planned within
a project funded by the Italian Ministry of Health.
Content: We show images from the last MRMI course in Milan.
Discussion: The organization of a 2nd MRMI course in Milano after
the first edition in October 2010 shows the interest of the public for
the educational proposal. The tool seems to be so good that even the
Italian Ministry of Health is ready to fund a programme to expand the
MRMI philosophy in Italy.
References: Lennquist S. Introduction to the third ‘‘Focus-on’’ issue
specially devoted to papers within the field of the ESTES section for
Disaster and Military Surgery.
Disclosure: No significant relationships.
EMERGENCY SURGERY
V04
LAPAROSCOPY IN UNUSUAL CASES OF ABDOMINALEMERGENCIES: HOW I DO IT?
G. Basili, N. Romano, D. Pietrasanta, G. Biondi, O. Goletti
General Surgery Unit, Pontedera hospital, Pontedera, Italy
Introduction: We represent a variety of particular cases in which
laparoscopic approach in emergency allowed an accurate diagnosis
and treatment even in complex clinical scenarios.
Content: The first is a case of ovarian vein thrombosis, a potentially
serious postpartum complications. The patient described was sub-
mitted to explorative laparoscopy with a diagnosis of acute
appendicitis. At surgery a tumoration at the level of the right ovarian
vein was discovered; laparoscopic ultrasound confirmed the diagno-
sis. Anticoagulation therapy and antibiotics were instituted and the
patients was discharged without evidence of any complications. The
second is a case of cecal diverticulitis observed in patients with a
thickening of cecal wall, submitted to laparoscopic right colectomy.
The relevance of this pathology is related with the fact that signs and
symptoms are often indistinguishable from acute appendicitis. The
last is a particular case of acute small bowel obstruction related to a
strangulation of a small bowel loop by the left gonadic vessels. The
particularity of the case is due to the pathophysiology of the occlusion
itself.
Discussion: Laparoscopy has gained widespread acceptance in
common surgical practice as a diagnostic and therapeutic tool. Acute
emergency situations often pose a diagnostic challenge to the general
surgeon. Laparoscopy offers the possibility of undertaking at the same
time the adequate diagnosis, appropriate treatment and/or the best
abdominal approach.
References: 1. Sauerlenad S, Agresta F, Bergamaschi R, et al. Lap-
aroscopy for abdominal emergencies: evidence-based guidelines of
the European Association for Endoscopic Surgery. Surg Endosc.
2006;20:14–29.
Disclosure: No significant relationships.
V05
LAPAROSCOPIC TREATMENT OF SMALL BOWELOBSTRUCTION
V.M. Mutafchiyski, I.R. Takorov, S.K. Segeev, N.N. Vladov
HPB and Transplant Surgery, Military Medical Academy, Sofia,
Bulgaria
Introduction: Acute small bowel obstruction is a relatively common
cause of emergency hospital admission and is most frequently due to
postoperative adhesions. According to the European Association for
Endoscopic Surgery consensus statement in the case of clinical and
radiological evidence of small bowel obstruction nonresponding to
conservative management laparoscopy may be performed using an
Abstract S67
123
open access technique. If adhesions are found at laparoscopy, cautious
laparoscopic adhesiolysis can be attempted.
Content: From April 2010 to April 2011, 5 patients underwent lap-
aroscopy for definitive diagnosis and treatment of intestinal
obstruction. Average patient age was 43 years (range 32–64). The site
of obstruction in all cases was small bowel and the reason—postop-
erative adhesions in 3 cases, migration of a gastric band in one and
intussusception in one. We present a compilation of two video clips:
the first case is with an adhesive small bowel obstruction in a 32-years
old man, treated successfully by means of laparoscopic adhesiolisis
and desobstruction; the second one present laparoscopic management
of a migrated gastric band.
Discussion: Laparoscopy successfully diagnosed the site of obstruc-
tion in all patients. All of them were successfully treated
laparoscopically without conversion to laparotomy. There were neither
intraoperative nor postoperative complications. Mean postoperative
stay was 3 days (range 2–4). We have found that in experienced hands,
laparoscopy is a safe and effective technique for the management of
acute small bowel obstruction.
References: 1. Catena F, Saverio S, Kelly M, et al. Bologna guide-
lines for diagnosis and management of adhesive small bowel
obstruction (ASBO). 2010 evidence-based guidelines of the world
society of emergency surgery. World J Emerg Surg. 2011;6:5. 2.
Milingos S, Kallipolitis G, Loutradis D, et al. Adhesions: laparoscopic
surgery versus laparotomy. Ann N Y Acad Sci. 2000;900:272–285. 3.
EAST Practice Parameter Workgroup for Management of Small
Bowel Obstruction: Practice management guidelines for small bowel
obstruction. Chicago (IL): Eastern Association for the Surgery of
Trauma (EAST) 2007;42. 4. Augestad K, Delaney C. Postoperative
ileus: impact of pharmacological treatment, laparoscopic surgery and
enhanced recovery pathways. World J Gastroenterol. 2010;16(17):
2067–74.
Disclosure: No significant relationships.
V05A
MINIMALLY INVASIVE ROBOTIC APPROACH FOR ANINCARCERATED INGUINAL HERNIA
S. Paun, I. Negoi, R. Ganescu, M. Beuran
General Surgery, Emergency Hospital of Bucharest, Bucharest,
Romania
Introduction: Robot-assisted laparoscopic preperitoneal inguinal
hernia repair in an integrated operating room is not a frequent surgical
procedure but only in few high-volume centers.
Content: Case-report and video presentation of a transabdominal
properitoneal incarcerated inguinal hernia repair performed in
Emergency Hospital of Bucharest.
Discussion: A 34-year-old male patient was admitted for right
inferior quadrant and right inguinal pain. From the patient medical
history we have noticed an appendicular inflammatory mass
treated by conservative treatment 2 years ago. Clinical examination
revealed a right incarcerated inguinal hernia. Abdominal CT
revealed no signs of recurrent appendicitis. By a robot-assisted
laparoscopic approach it was performed painstaking pericecal ad-
hesiolysis, noticing no signs of appendicitis. Inguinal exploration
showed an incarcerated Nyhus III B hernia, repaired by a transab-
dominal pre-peritoneal technique. Robotic approach was particulary
useful in hernial sac content adhesiolysis. Discharged after 2 days.
Conclusions: Minimally invasive robotic surgery is not a common
approach for inguinal hernia repair due to its prohibited costs, but in
selected, complicated cases it offers real benefits for surgical dis-
section and hernia repair.
References: 1. Paun S, et al. Robotic approach for abdominal her-
nias– a Romanian experience. MIRA. 2011.
Disclosure: No significant relationships.
SKELETAL TRAUMA
V06
OPEN REDUCTION OF THE DISTAL RADIUS: THE SPOONTECHNIQUE
R.T. Auer, D. Seligson
Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
Introduction: Fractures of the distal radius are commonly encoun-
tered by both orthopaedic traumatologists and the general
orthopaedist. In younger patients these fractures may present late or
with a high degree of displacement. Literature suggests that improved
clinical outcomes in patients under 65 are related to the restoration of
anatomical alignment of the distal radius. The aim of this presentation
is to demonstrate an open reduction technique that aids in restoring
anatomic volar tilt while maintaining the proper reduction.
Content: The video presentation demonstrates the technique of the
spoon maneuver which helps correct difficult to reduce fractures of
the distal radius. Using a fulcrum beneath the plate, the locked distal
screws lever the metaphysis back to an anatomic position where it can
then be locked into place proximally.
Discussion: Adequate reduction of distal radius fractures are associ-
ated with improved clinical outcomes in younger patients. This
reduction maneuver allows the surgeon to improve the volar tilt and
maintain the reduction. The spoon technique is appropriate and suc-
cessful in the younger patient with an extra-articular or simple intra-
articular fracture pattern. Those patients with osteoporotic bone or
complex intra-articular fractures would not benefit from this tech-
nique. Proper patient selection and pre operative planning would help
select fractures amenable to the spoon maneuver.
References: 1. Grewal, et al. Adverse outcomes risk in extra-articular
distal radius fractures. J Hand Surg. 2007;32A:962–70.
Disclosure: No significant relationships.
V07
FOUR CORNER FUSION USING VA-LIF PLATE
P. Drac, M. Homza, I. Cizmar
Traumatology, Faculty Hospital Olomouc, Olomouc, Czech Republic
Introduction: Four-corner arthrodesis is an accepted method for the
treatment of SNAC and SLAC wrist. We refer about our experience
with a new locking plate in the treatment of the grade III SNAC and
SLAC wrist.
Content: A total of 9 patients with SNAC or SLAC wrist degener-
ative changes were treated by four-corner arthrodesis using VA-LIF
plate at our department from July 2010. During follow-up examina-
tions we analysed the radiological (union/non-union, carpal height
ratio and ulnar translatiob ratio) and functional outcomes (range of
S68 Abstract
123
motion, wrist strength, DASH questionaire). Video-sequence of the
surgery shows advantages and technical pitfalls of this procedure.
Discussion: Using VA-LIF allows early wrist mobilization and
positive functional outcomes. Adherence to recommended surgical
technique is the best way to prevent complications and subsequent
poor functional results.First experience with the usage of VA-LIF is
promising. The only limitation of our study is a small group of
patients.
References: 1. Cohen MS, Kozin SH. Degenerative arthritis of the
wrist: proximal row carpectomy versus scaphoid excision and four-
corner arthrodesis. J Hand Surg. 2001;26-A:94–104.
Disclosure: No significant relationships.
V08
INTERACTIVE PREOPERATIVE PLANNING IN DISTALRADIUS FRACTURE
E. Varga1, B. Erd}ohelyi2, E. Varga Jr3
1Department of Trauma Surgery, University of Szeged, Szeged,
Hungary, 2Institute of Informatics, University of Szeged, Szeged,
Hungary, 3University of Szeged, Szeged, Hungary
Introduction: Highly complex fractures require surgical interven-
tions which mandate specific experience and proficiency. The
preparation of mechanical model [using a Finite Element Analysis
(FEA)] before surgery is feasible to promote optimal surgical solu-
tion. A computerized system (TraumArt) is presented to facilitate the
above process.
Content: The system builds up from different modules with special
tasks. The first module segments the bone from the gray scale CT
scans. Then the 3D structure is constructed from the segmented
volume model. A mesh simplification algorithm is developed to
eliminate the complexity of the surface. A surgical planner is created
in the fourth module, where distinct procedures can be tested. The 3D
editing function like slicing, drilling and implant insertion are visu-
alized. The surgeon applies forces to the model and exports the data to
the FEA system. Four different possible virtual surgery will be pre-
sented on video in a real distal radius fracture case. (VCP, VA-LCP,
Dorsal Plating wit two LCP-s, Juxtaarticular LCP) The best solution
will be also presented in a life surgery.
Discussion: Several complications could be avoided by TraumArt
system, while more scrupulous and prompt assessment capabilities
could be provided for surgeons. This method offers new possibilities
that complement current visual analytic methods and it will have
great perspective in the postgraduate education.
References: 1. OllA� K, Erdohelyi B, Varga E, Halmai CS, Kuba A.
MedEdit: a computer assisted planning system for orthopedic-trauma
surgery information technology interfaces; ISBN 953-96769-6-7,
IEEE Catalog No: 03EX645 2002. 2003; p. 507–12. 2. OllA�, Er-
dohelyi, Varga, Kuba (2006): MedEdit: a computer assisted image
processing and navigation system for orthopedic trauma surgery acta
cybernetica. 2006;17:589–603. 3. B ErdA‘helyi, E Varga, A Kuba.
Surgical planning tool with biomechanical simulation. In: Proceed-
ings of the international conference on computer assisted radiology
and surgery. 2007; p. S262–S263. 4. Rasko B, Erdohelyi E, Varga L,
Seres, Piffko J. Finite element analysis of mandible virtual model.
J Cranio Maxillofac Surg. 2008;36(1):S204. 5. Varga Endre a€‘‘Er-
dohelyi BalA¡zs (2010) MA ± tA�tek tevezA�se szA¡mA-
tA3gA�ppel OTKA kiadvA¡ny 38–40, 2010.
Disclosure: No significant relationships.
VISCERAL TRAUMA
V09
LAPAROSCOPY IN SMALL BOWEL OBSTRUCTION
G. Tomasch, S. Uranues
Department of Surgery, Medical University Graz, Graz, Austria
Introduction: The most common causes of acute small intestinal
obstruction are postoperative adhesions (64.8 %) and strangulated
hernias (14.8 %). This video presents the selection criteria, technique
and outcome of laparoscopic treatment of small bowel obstruction.
Content: The video is a case presentation of a 40-year-old man
admitted with the typical symptoms of mechanical obstruction. The
preoperative work-up, trocar sites, insertion of the first trocar and
technical considerations are demonstrated.
Discussion: Three trocars were used for laparoscopic adhesiolysis. A
dense band subsequent to conventional appendectomy was identified
as the cause of the obstruction. After sharp dissection of the band, the
content of the dilated bowel oral to the obstruction immediately flo-
wed aboral through the obstruction site.
Conclusion: With strict selection, laparoscopic treatment of small
intestinal obstruction is a valuable option in visceral acute surgery.
Patients with an isolated focal obstruction seem to benefit from lap-
aroscopic surgery on the basis of reduced perioperative morbidity and
short hospitalization.
References: 1. Wang Q, Hu ZQ, Wang WJ, Zhang J, Wang Y, Ruan
CP. Laparoscopic management of recurrent adhesive small-bowel
obstruction: long-term follow-up. Surg Today. 2009;39(6):493–9. 2.
Catena F, et al. Bologna guidelines for diagnosis and management of
adhesive small bowel obstruction (ASBO): 2010 evidence-based
guidelines of the World Society of Emergency Surgery. World J
Emerg Surg. 2011;6:5
Disclosure: No significant relationships.
V09A
ROBOTIC SURGICAL MESH REPAIR FORINCARCERATED MORGAGNI-LARREY HERNIA
S. Paun, I. Negoi, R. Ganescu, M. Beuran
General Surgery, Emergency Hospital of Bucharest, Bucharest,
Romania
Introduction: Morgagni–Larrey hernia is a rare form of diaphrag-
matic hernia characterized by a defect between the septum
transversum and the costal margin of the diaphragm, most frequently
occurring on the right side.
Content: The authors from the Emergency Hospital of Bucharest
present a video showing their technique for minimally invasive
robotic mesh repair of an incarcerated left-side sternocostal hernia.
Discussion: A 49-year-old woman was admitted in emergency setting
for retrosternal pain and dyspnoea. Chest X-ray showed an 4 cm
elevation of the left diaphragm. Abdominal CT revealed a left anterior
diaphragmatic hernia with an incarceration of the transverse colon.
Through a minimally invasive DaVinci robotic approach, a left
sternocostal hernia with colonic incarceration was revealed. After
gently robotic adhesiolysis, the herniated organs were brought back
Abstract S69
123
into the abdomen. The 9 cm hernia defect has been fixed using a
15/15 cm dual mesh. The recovery was uneventful.
Conclusions: Minimally invasive robotic approach for sternocostal
Morgagni–Larrey hernia is safe and offers increased dexterity to the
surgeon, shorter in-hospital stay and little morbidity.
References: 1. Paun S, et al. Robotic approach for abdominal her-
nias—a Romanian experience. MIRA. 2011.
Disclosure: No significant relationships.
V10
DELAYED LAPAROSCOPIC SPLENECTOMYFOR TRAUMA
M. Zago1, D. Mariani2, H. Kurihara1, R. Foa1, F. Butti1,A. Casamassima3
1General Surgery, Policlinico San Pietro, Ponte San Pietro (BG),
Italy, 2Emergency Dept, Policlinico San Matteo, Pavia, Italy,3Emergency Dept., Istituto Clinico Citta Studi, Milano, Italy
Introduction: The role of laparoscopy in splenic trauma management
is currently limited. Hypotensive patient must be considered not
suitable for laparoscopy. On the contrary, a minimally invasive
approach is recommended for delayed splenic surgery in stable patient.
Content: The case of a 78 years-old female patient with altered
mental status and a delayed diagnosis of a grade 3 blunt splenic lesion
is presented. At the end of the workout, a slightly ongoing bleeding
after 7 day of unrealized NOM was the indication for laparoscopic
splenectomy. The video shows technical aspects of a delayed lapa-
roscopic splenectomy for trauma and discuss indications and limits of
laparoscopic surgery in trauma patients.
Discussion: Laparoscopy is the ideal approach for delayed splenec-
tomy for trauma in stable patients, both for complications of
angioembolization (infarction, abscesses) and for selected patients
after failed NOM. Up to now laparoscopy should not be considered a
systematic adjunct to a well monitored NOM.
References: 1. Ramson KJ, Kavic MS. Laparoscopic splenectomy for
blunt trauma: a safe operation following embolization. Surg Endosc.
2009;23:352.
Disclosure: No significant relationships.
SKELETAL TRAUMA/VASCULAR EMERGENCIES
V11
TOTAL IVC RESECTION, WITH PRESERVATIONOF RENAL FUNCTION
P. Vasilliu
General Surgery, National and Kapodistrian University of Athens,
Athens, Greece
Introduction: There are rare indications and random reports on
inferior vena cava resection.
Content: We report a case of a recurrent vena cava sarcoma re-
operated after 4 years after its initial resection (R1), with an inno-
vative anastomosis that preserved renal function.
Discussion: Radical surgical en bloc resection without reconstruction
is a surgical option for the treatment for IVC leiomyosarcomas.
Reference: 1. Kyriazi MA, et al. Ann Vasc Surg. 2010;24(6):
826.e13–7.
Disclosure: No significant relationships.
V12
FLIP OSTEOTOMY APPROACH IN PIPKIN IVFRACTURES-DISLOCATION
F. Castelli
Dea, Niguarda Ca’ Granda, Milan, Italy
Introduction: The traumatic acetabular labral avulsion may interfere
with an anatomic reduction and/or contribute to the unsatisfactory late
results in associated acetabular fractures. The optimum surgical
approach and fixation technique remains controversial, with inability
to address all problems through simultaneous single surgical approach
and technique.
Content: This technique is influenced by the trochanteric slide
osteotomy described by Ganz et al. (5) as to reduces the probability of
AVN femoral head ioatrginacally with modified use of Spring Plate
advocated by Mast et al. (6) in 1989 to stabilise periarticular ace-
tabular fragments.The capsule is first incised anterolaterally along the
long axis of femoral neck to prevent injury to deep branch of the
MCFA. The capsulotomy must remain anterior to the lesser trochanter
in process to avoid insult to main branch of MFCA. The hip now can
be dislocated,leg is flexed, externally rotated to fix fracture femoral
head. The goal of surgery was to obtained reduction of acetabular
wall with reattachment of labrum with fixation of femoral head
without further compromising the blood supply of femoral head.
Discussion: The advantage of this technique is the simultaneous
exposure and fixation of femoral head, acetabulum, and labrum
without further compromising the blood supply to femoral head, thus
reducing the chance of avascular necrosis.
Reference: 1. Ganz R. Surgical dislocation of the adult hip: a tech-
nique with full access to femoral head and acetabulum without the
risk of avascular necrosis. J Bone Joint Surg. 2001;83-B.
Disclosure: No significant relationships.
POSTER SESSIONS
DISASTER AND MILITARY SURGERY,
EDUCATION, SPINE
PS001
ROAD TRAFFIC ACCIDENTS IN SCHOOLCHILDREN INRWANDA: AN URGENT NEED FOR PRIMARYINTERVENTIONS DURING THE WHO-ROAD SAFETYDECADE
A.H. Kiefer, D. Ndayizeye
Surgery, Butare University Teaching Hospital, Huye, Rwanda
Introduction: Road traffic accidents (RTAs) are an increasing burden
also for developing countries where traffic is increasing but the
awareness for road safety behaviour is still very limited. To show the
impact of RTAs on vulnerable groups as children we performed a
S70 Abstract
123
retrospective study at Butare University Teaching Hospital, Rwanda.
The period covered was the time from 01.01.2007 to 31.09.2009.
Materials and methods: 118 schoolchildren (3–12 years) that had
been hospitalized after being involved in road traffic accidents were
included in the study.
Results: Of those 81.4 % children were male, 17 % of them belonged
to the age group 3–5 years, 83 % to the age group 6–12. The road
traffic accidents were mainly caused by motorised traffic participants
(64.4 %), but more than a third was also caused by bicycle drivers.
Concerning the multiple injury pattern of the patients, the lower
extremity was mostly affected (43.2 %), followed by injuries of the
upper extremities and head injuries. Chest, abdominal and pelvic
injuries were less frequent.
In the 118 patients 47 operations were performed, meaning that
about 40 % of the patients needed further surgical interventions. The
main interventions were osteosynthesis (79 %), trepanations (13 %)
and laparotomies (4 %). The mortality rate was 4.2 %. 43.2 % of the
patients stayed in the hospital for a period of 1–3 weeks, but nearly a
third was hospitalised for more than 3 weeks.
Conclusion: Our data once again demonstrates that there is an urgent
need to include education on safe road behaviour in school programs
and community awareness campaigns. This should convince politi-
cians, stakeholders and international organisations to take immediate
action.
Disclosure: No significant relationships.
PS002
LESSONS LEARNED FROM EXPERIENCE OF VISCERALMILITARY SURGEONS IN THE FRENCH ROLE 3 MEDICALTREATMENT FACILITY IN KABUL (AFGHANISTAN)
S. Bonnet1, F. Gonzalez2, V. Duverger1, F. Pons2
1Department of Visceral and Vascular Surgery, HIA Begin, Saint-
Mande, France, 2Department of General and Thoracic Surgery, HIA
Percy, Clamart, France
Introduction: The aim was to evaluate quantitatively and qualita-
tively the activity of visceral surgeons assigned to the Medical
Treatment Facility (MTF) (role 3) in Kabul International Airport
(KAIA) to identify skills and qualifications required by visceral
surgeons.
Materials and methods: Between July 2009 to December 2010 all
the patients operated by the visceral surgeons were eligible for
inclusion in this study, including soldiers from International Security
Assistance Force, soldiers from Afghan National Security Forces, non
afghan civilian personnel and local afghan civilians. The circum-
stances of surgical treatment were: ‘‘war-related’’ injuries, non-
hostile-related traumatic emergencies, non-traumatic emergencies and
elective surgery. Mechanisms and types of injuries, affected organs
and surgical procedures were collected.
Results: Over the studied period, visceral surgeons have supported
261 patients (26.9 %) achieving a total of 438 surgical procedures.
‘‘War-related’’ injuries represent 31.7 % of surgical activity, non-
hostile-related traumatic emergencies 26 %, non-traumatic emergen-
cies 24.2 % and elective surgery 18.1 %. Non-traumatic emergencies
and elective surgery do not require special skills. Non-hostile-related
traumatic emergencies and ‘‘War–related’’ injuries are more chal-
lenging: combined injuries in 56 % of cases, needing for Damage
Control Resuscitation procedures, treatment of severe burns and 30 %
of patients with life-threatening thoracic or vascular injuries requiring
life-saving emergency surgical procedures.
Conclusion: A wide range of skills and qualifications are required in
a role 3 MTF for a visceral surgeon. An advanced course for abroad
deployment surgery has been created to provide necessary skills
required in life-threatening situations, particularly with thoracic and
vascular surgery. However careful assessment is mandatory to ana-
lyse and determine what could be improved to decrease fatalities.
Disclosure: No significant relationships.
PS003
PROFILE OF TRAUMA RELATED DEATHS AMONGCHILDREN FROM 10 TO 18 YO A LARGE CITY IN BRAZIL
A.M.A. Fraga1, M.C. Reis2, G.P. Fraga3, T. Fernandez1,J.M. Bustorff-Silva3
1Pediatrics, University of Campinas, Campinas, Brazil, 2Pediatric
Emergency, University of Campinas Clinical Hospital, Campinas,
Brazil, 3Surgery, University of Campinas, Campinas, Brazil
Introduction: Trauma is considered to be the main cause of death
among people from 1 to 44 years of age in developed countries.
Children under 18 are prone to trauma, with 875,000 deaths annually.
In Brazil, 20,471 deaths under 19 years old occurred only in 2008.
Knowing their causes can help to produce health care policies to
diminish this killing.
Materials and methods: Retrospective study using the Metropolitan
Coroner database of trauma related deaths among children from 10 to
18 years old, collected in 2002–2008 period in the city of Campinas
in Sao Paulo State, Brazil. Demographics data and injury mechanism
were described.
Results: There were 530 coroner examinations among children with
ages between 0 and 17 years who died from external causes from
2002 to 2008. 76 % of them with ages over 10 yo. 94 from 10–14 yo
and 309 from 15–17. 97.3 % of all gunshot deaths were over 10 yo
(86.4 % over 15 yo). 68.1 % of traffic related deaths occurs over
10 yo, and all the motorcycles related deaths occurs in this age group.
Conclusion: In children the age group more prone to preventable
deaths are children over 10 years old. Directing efforts to produce
laws and education toward this age group can diminish these figures.
The importance of trauma vigilance can produce reliable data to help
to promote these efforts.
References: 1. Canturk N, Esiyok B, Ozkara E, Canturk G, Ozata
AB, Yavuz F. Medico-legal child deaths in Istambul: data from the
Morgue Department. Pediatr Int. 2007;49:88–93. 2. Hoyt DB,
Coimbra R. Trauma systems. Surg Clin N Am. 2007;87(1):21–35.
Disclosure: No significant relationships.
PS004
SURGICAL MANAGEMENT OF STINGRAY INJURIES INDJIBOUTI: A TWO YEARS FOLLOW-UP PROSPECTIVESTUDY
G. Greff1, R. Gorioux1, A. Bertani2, F. Mottier1, L. Mathieu1,F. Chauvin1, F. Rongieras3
1Orthopedic and Trauma Surgery, Military Academic Hospital
DESGENETTES, Lyon, France, 2Orthopedic Department, HMC
Abstract S71
123
BOUFFARD, Djibouti, ARMEES, France, 3Orthopedic and Trauma
Surgery, Academic military hospital DESGENETTES, Lyon, France
Introduction: In Djibouti, the stingray is the most venomous marine
species encountered. Its bite can inject thermolabile hemolytic and
neurotoxic venom. Without surgical treatment, the wound healing is
slow due to necrosis of neighborhood soft tissue.
The objectives of our study were assessed at 2 years a multidisci-
plinary protocol.
Materials and methods: This is a prospective study between July
2008 and 2010.
At the patient arrival, warm compresses were applied to the wound. A
loco-regionale anesthesia was made to allow a complete surgical
debridement of the dart penetration axis and a copious irrigation.
Then the patient was hospitalized with an analgesic treatment in the
ALR relay. Care facilities were made every 2 days at home until
wound healing. The outcome measurements were the time of healing
and the absence of infection.
Results: 27 patients were included in the study. The injury location
was the foot or ankle in 26 cases and the chest in one case. Upon
arrival to the emergency, initial VAS was on average of 75 mm
(maximum 100) and 3 h after 13 mm. On the 27 patients treated, 26
were followed. 21 were cured within 2 weeks. Only 2 patients had a
secondary infection that required prolonged care and antibiotic
therapy.
Conclusion: In our protocol, treatment with heat and ALR allowed an
effective analgesia and a complete surgical debridement.
This data of 26 cases are not sufficient to assess the impact of our
protocol on these injury evolution but our results are encouraging as
the other results published in the literature.
Disclosure: No significant relationships.
PS005
HELICOPTER VERSUS GROUND EMERGENCY MEDICALSERVICE: A RETROSPECTIVE ANALYSIS OF A GERMANRESCUE HELICOPTER BASE
C. Schroter1, N. Bradt1, C. Zeckey1, H. Andruszkow1, M. Petri1,M. Frink1, F. Hildebrand1, C. Krettek1, C. Probst2, P. Mommsen1
1Trauma Departement, Hannover Medical School, Hannover,
Germany, 2Hannover Medical School, Hannover, Germany
Introduction: In consideration of rising cost pressure in the german
health care system, the usefulness of helicopter emergency medical
sevice (HEMS) in terms of time- and costeffectiveness is controver-
sially discussed. The aim of the present study was to investigate
whether HEMS is associated with significantly decreased arrival and
transportation times compared to ground EMS.
Materials and methods: In a retrospective study, we evaluated 1.548
primary emergency missions for time sensitive diagnosis (multiple
trauma, traumatic brain and burn injury, heart-attack, stroke an
pediatric emergency) performed by a german HEMS using the
medical database (NADIN) of the german air rescue service. Arrival
and transportation times were compared to calculated ground EMS
times.
Results: HEMS showed significantly reduced arrival times at the
scene of heart-attack, stroke and pediatric emergencies. In contrast,
HEMS and ground EMS showed comparable arrival times in patients
with multi trauma, traumatic brain and burn injury due to an increased
flight distance. HEMS showed a significantly decreased transportation
time to the closest centre capable of specialist care in all diagnosis
groups (p \ 0.001).
Conclusion: The results of the present study indicate the time
effectiveness of german air ambulance services with significantly
decreased transportation times.
Disclosure: No significant relationships.
PS006
USING AN ELECTRONIC BULLETIN BOARD PLATFORMIN A DISASTER TABLE TOP EXERCISE
C.P.J. Wee1, C.C.W. Chong2, G.H. Lim2
1Department of Emergency Medicine, Singapore General Hospital,
Singapore, Singapore, 2Emergency Medicine, Changi General
Hospital, Singapore, Singapore
Introduction: We evaluate the use of an electronic bulletin board
system in running a tabletop disaster exercise.
Materials and methods: 2 tabletop exercises were carried out for 26
members of the Singapore Disaster Site Management Command
(DSMC) through an online bulletin board. The first exercise was held
with the participants grouped in the same room according to their
roles in DSMC. This exercise was held via the electronic platform
without radio communications. As events unfolded, the participants
were updated and responded via the electronic bulletin board. The
second exercise was held with the groups in different rooms and with
communications via radio and their ‘‘actions’’ were logged into the
bulletin board. Upon completion, there was a written survey.
Results: 88.5 % of the participants had found the exercise helpful in
their role in DSMC during an actual deployment. Most (96.2 %) felt
that the exercise had helped identify issues in current DSMC oper-
ating procedures. Most find the electronic bulletin board easy to use
and learn, and that it helped in their learning (61.5, 88.5 and 73.1 %
respectively). Using the electronic platform was an effective (76.9 %)
and efficient way (65.4 %) of conducting the tabletop exercise.
53.8 % of participants prefer the use of the electronic bulletin board
and 61.5 % felt that it was more realistic using the electronic
platform.
Conclusion: It is concluded that the use of the electronic platform is
easy and preferred.
References: 1. Prehosp Disaster Med. 1999;14:43–52. 2. Ann Emerg
Med. 2008;52(3):211–22, 222.e1–2. 3. Injury. 1990;21:58–60. 4.
Public Health Rep. 2008;123:96–101. 5. Public Health Rep.
2010;125:Supplement 5:100–106. 6. JOEM. 2009;51(9):990–1.
Disclosure: No significant relationships.
PS007
USEFULNESS OF WHOLE FRESH BLOOD TRANSFUSIONIN THE SURGICAL MANAGEMENT OF WARHEMORRHAGIC SHOCK REQUIRING MASSIVETRANSFUSION
S. Bonnet1, V. Reslinger1, L. Raynaud2, A. Benois3, F. Pons4,V. Duverger5
1Department of Visceral and Vascular Surgery, HIA Begin, SAINT-
MANDE, France, 2Intensive Care Unit, HIA Legouest, Metz, France,3Intensive Care Unit, HIA Robert Picque, Villenave d’Ornon, France,
S72 Abstract
123
4Department af General and Thoracic Surgery, HIA Percy, Clamart,
France, 5Department of Visceral and Vascular Surgery, HIA Begin,
Saint-Mande, France
Introduction: Hemorrhage accounts for 30–40 % of trauma fatalities
and is the leading cause of preventable death in trauma [1]. Hae-
mostatic surgery is improved by an early and aggressive correction of
trauma-induced coagulopathy [2]. Fresh whole blood (FWB) brings
all the blood components, including platelets and fully functional
clotting factors [3].
Materials and methods: We report the case of two patients with a
left basi-thoracic stab wound responsible for a massive hemothorax as
the source of hemorrhagic shock who had surgery at the Medical
Treatment Facility in Kabul International Airport.
Results: The existence of hemorrhagic shock with externalized
hemorrhage and biological coagulopathy led immediately to initiate
collection of FWB. Left anterolateral thoracotomy was performed in
both cases to achieve hemostasis of active bleeding from intercostal
arteries. In the same time, early and aggressive correction of
coagulopathy was started including early transfusion of packed red
blood cells (PRBC) followed by FWB, administration of freeze-
dried plasma, recombinant Factor VIIA, clotagene, infusion of
hypertonic fluid solutions and norepinephrine. At the end of surgical
procedure, hemoglobin concentration, prothrombin time and fibrin-
ogen level were normalized with favourable outcome for both
patients.
Conclusion: The use of FWB as a primary resuscitation fluid pro-
vides RBC, platelets and coagulation factors and simultaneously
contributes to the correction of acidosis and hypothermia [4]. In sit-
uations like combat casualty care, the use of FWB is useful and
should be considered in association with haemostatic surgery.
References: 1. Tieu BH. World J Surg. 2007;31:1055–64. 2. Duch-
esne JC. J Trauma. 2009;67:33–37. 3. Duchesne JC. J Trauma.
2010;69:976–90. 4. Repine TB. J Trauma. 2006;60:S59–69.
Disclosure: No significant relationships.
PS008
EFFORTS TO IMPROVE THE TEAM PERFORMANCE INOUR DEPARTMENT: SOPS AND TML FOR THE TORSOSTAB WOUND
J. Takamatsu, Y. Mizobata
Department of Critical Care and Emergency Medicine, Osaka City
University, Graduate School of Medicine, Osaka, Japan
Introduction: To make the good trauma care team, we created the
standard operating procedures (SOPs). The Two Minutes Lesson
(TML) as a tool for summarizing the SOPs was introduced in October
2010. We hypothesized that the establishment of our common rec-
ognition would have enhanced our team performance by confirming
the SOPs through the daily TML. We aimed to verify this hypothesis
in the case of torso stab wounds.
Materials and methods: 23 patients who underwent an operation of
44 torso stab wounds were included. The patients were divided into
two groups: group A consisted of 14 patients in the period before
September 2010 and group B consisted 9 patients in the period after
introduction of the SOPs and the TML. We had collected the data of
the patient characteristics, causes, Injury Severity Scores (ISS),
Trauma Scores, Injury Severity Scores (TRISS), organ injuries, and
outcomes.
Results: The patient characteristics were as follows: sex(group A;
male 12, female 2 vs. group B; male 5, female 4, p = 0.16), age
(50.9 ± 15.2 years old vs. 61.6 ± 13.8 years old, p = 0.05), cause
(suicide 5, others 9 vs. suicide 8, others 1, p = 0.03), injured area
(thoracic area, thoracoabdominal area, abdominal area; 2: 5: 7 vs. 0:
7: 2, p = 0.41), ISS (13.2 ± 9.9 vs. 11.9 ± 6.5, p = 0.36), TRISS
(93.4 ± 14.1 vs. 84.7 ± 27.9, p = 0.17). There was no significant
difference about severity between 2 groups. In group A, 4 patients had
no organ injury despite surgeries. In group B, only 1 patient had no
organ injury. There was no significant difference (p = 0.61), but 3 of
no organ injured patients in group A would have been performed non-
operative management according to the algorithm of SOPs. All
patients in both groups were discharged.
Conclusion: The SOPs helped to form a common understanding. The
TML was effectual in Penetration of the SOPs. It is thought that the
SOPs contribute to improve the team performance for trauma care in
terms of accuracy, safety, and rapidity.
Disclosure: No significant relationships.
PS009
TRAUMA QUALITY IMPROVEMENT EFFORTSIN LOW-MIDDLE INCOME COUNTRIES
A.M. Rubiano1, G. Estebanez1, A.I. Sanchez2, A. Cabrera1,J.C. Puyana2
1Trauma and Emergency, Neiva University Hospital, MEDITECH
Foundation, NEIVA, Colombia, 2Trauma Surgery, University of
Pittsburgh, Pittsburgh, PA, USA
Introduction: Trauma quality improvement (TQI) is an important
process related to patient safety (1). There are few experiences in low
and middle income countries (LMIC) due to lack in legislation,
resources and administrative organization (2). We hypothesized that
TQI programs could bring benefits to large trauma facilities in LMIC,
reducing preventable trauma deaths.
Materials and methods: This pilot study took place on a university
hospital in Colombia. Improvements in the processes of care included
the use of structured protocols for trauma care, patient safety check
list application, trauma care training, and data analysis in mortality
and morbidity (M&M) meetings. Trauma care knowledge in trauma
team members and death from severe trauma patients (ISS[25) were
compared before and after the TQI implementation.
Results: 51 trauma team members were evaluated. After TQI
implementation, care knowledge improved from likert scale score of
2–4. Adherence to protocols improved from 48 to 88 %. 26 deaths
were analyzed, 13 before and 13 after TQI implementation. Poten-
tially preventable death rates reduced from 15 to 8 %, In deaths in
which the management could be improved, rates reduced from 54 to
46 %. Non-preventable death rates increased from 31 to 46 %.
Conclusion: QI in trauma care can be implemented in hospitals from
LMIC, despite scarcity of resources. Trauma care knowledge and
adherence to trauma care protocols could lead to minimization of
potentially preventable deaths and improvements in patient safety.
References: 1. Juillard CJ et al. World J Surg. 2009;33:1075–1086. 2.
Mock CN, et al. J Trauma. 1998;44:804–812.
Disclosure: No significant relationships.
Abstract S73
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PS010
CONTROVERSIES IN PLASTERING TRAININGAND TECHNIQUES: AN ANALYSIS OF REGIONALORTHOPAEDIC TRAINEES AND A SCIENTIFICAPPROACH IN ASSESSING WHICH MATERIALSARE BEST SUITED IN THE PRESENCE OF SWELLING
A. Mumith1, R. Walker1, N. Kelsall1, M. Goodwin2
1Trauma and Orthopaedic Department, Dorset County Hospital,
Dorchester, UK, 2Trauma and Orthopaedic Department, Royal
Bournemouth General Hospital, Bournemouth, UK
Introduction: We examine the current trends in plastering education
within the regional orthopaedic training programme. Surveys revealed
substantial variability in techniques and materials used which were
not evidence based. This prompted us to complete an experimental
study to analyse the optimal dressing combination to allow post-
operative swelling in the forearm.
Materials and methods: An online survey was designed based on
published evidence and senior advice comprising of 3 sections cov-
ering demographics, training and current practice.
Backslabs were applied to a volunteer’s forearm. An empty fluid bag
was placed underneath that was filled whilst recording its pressure.
The amount of saline required to achieve a pressure of 21.4 mmHg
(maximum compartment pressure of flexor compartment at rest) was
measured. These measurements were repeated with wet and dry
application of open and closed weave bandaging.
A set length of wet/dry and closed/open weave bandaging was put
under a standard 100g force. The increase in length of the bandaging
material under tension was measured.
Results: The survey concluded that trainers and trainees held a
variety of opinions regarding materials and techniques used in plas-
tering without any scientific basis. Open weave bandaging (wet and
dry) required significantly greater volumes of fluid required to reach
the compartment pressure and stretched approx 35 % further under
tension compared to closed weave bandaging. To note, dry bandages
allow for greater simulated swelling when compared to wet bandages.
Conclusion: Dry open weave bandaging allows for greater swelling
of the splinted forearm simulated by the significantly greater volume
of fluid required to reach the compartment pressure.
Disclosure: No significant relationships.
PS011
EDUCATION AND TRAINING IN TRAUMA SURGERY
M.R. Sa, A. Oliveira, L.F. Pinheiro
Cirurgia1, Hospital S.Teotonio Viseu, Viseu, Portugal
Introduction: At a time when the trauma is considered a worldwide
epidemic, the education and training of the surgeon in approach and
treatment of multiple trauma are mandatory. The frequency of trauma
courses, internationally certified, can contribute to the training of
professionals in order to change for the better the outcome of complex
clinical situations.
Materials and methods: The authors report the case of a man that
was victim of aggression by bullet in the epigastrium. The patient was
in class III of shock for massive hemothorax. We made an exploratory
laparotomy followed by thoracotomy with pulmonary tractotomy and
diaphragmatic repairs. The immediate postoperative period was
complicated with cardiac tamponade, which was relieved by peri-
cardiocentesis and treated with pericardiotomy. Discharged to the 9th
day, without other complications.
Results: Although only 15–30 % of penetrating chest trauma
requiring surgery, most general surgeons have little contact with
surgical procedures in the chest. The principles and techniques used in
this clinical case were acquired in trauma courses and only performed
in animal models.
Conclusion: The improvement of surgical care of trauma patients
also undergoes by the frequency of internationally certified courses
with mandatory periodic updating.
Reference: 1. Boffard KD. Aphorisms and quotations for the surgeon.
Moshe Schein. The global burden of disease. WHO manual of
definitive surgical trauma care. Advanced Trauma Life Support For
Doctors, ACS.
Disclosure: No significant relationships.
PS012
SIRS IN ISOLATED ORTHOPAEDIC TRAUMA:CASE REPORT
K. Senohradski1, A. Lesic2, J. Mihajlovic3, M. Bumbasirevic2
1Operating Theater, Clinic of Orthopaedic Surgery and
Traumatology, Belgrade, Serbia, 2Clinic of Orthopaedic Surgery
and Traumatology, Belgrade, Serbia, 3Clinic for Anesthesiology
and Reanimation, Belgrade, Serbia
Introduction: SIRS syndrome is one of the most serious complica-
tions in injured patients. The incidence and mortality of systemic
inflammatory response syndrome (SIRS) is very high, in surgical ICU
patients, SIRS occurs in [80 % patients. The major determinants of
outcome of patients with sepsis are the severity of underlying dis-
eases. We report about SIRS syndrome in patient with isolated tibia
fracture.
Materials and methods: 84 years old male patient sustained in a
traffic accident as an pedestrian an isolated, closed, comminuted
fractures of both tibia. Other systems were without injuries He was
initially treated in Level I trauma center in Serbia.
Results: His condition had worsened and after 48 h he had been
transported in Emergency Center of Belgrade with three of four signs
of SIRS (temperature was 38.5 �C or heart rate was 105/min, respi-
ratory rate was 22/min). He came with unilateral external fixation of
both tibia with clinical signs of compartment syndrome. We have
done additional fasciectomy, but sepsis and MODS (acute renal and
respiratory failure) had been developed after 2 weeks of treatment at
the intensive care unit the outcome was fatal.
Conclusion: The outcome of septic syndromes is related to under-
lying comorbidities and the severity of the inflammatory response and
its sequelae, reflected in sepsis, shock and organ dysfunction The
patient in our case was very old with very significant comordities due
to his age.
Reference: 1. Pittet D, Rangel-Fausto MS, Li N. Systemic inflam-
matory response syndrome, sepsis, severe sepsis and septic shock:
incidence, morbidities and outcomes in surgical ICU patients. Int
Care Med. 1995;21:302–9.
Disclosure: No significant relationships.
S74 Abstract
123
PS013
MADEIRA SIMULATION CLINICAL CENTER
P.M. Ramos
Cirurgia Geral, Hospital Dr. Nelio Mendonca, 089/Portugal
Introduction: We present the Madeira Simulation Clinical Center.
Materials and methods: Madeira Simulation Clinical Center is
beginning his activity this year-2011, with a special program of
education and training. We are associated with Medsimlab, and this is
a project for education and training pre and pos graduate.
Results: We have a possibility to do education and training in several
areas, surgery, trauma, catastrofe, obstetric, anesthesiology, nurse,
pediatric and internal medicine.
Conclusion: This is a project to our future, future of education and
training for our students, doctors, interns and specialists.
Disclosure: No significant relationships.
PS014
EMERGENCY ROOM OF NELIO MENDONcA HOSPITAL
P.M. Ramos
Cirurgia Geral, Hospital Dr. Nelio Mendonca, 089, Portugal
Introduction: The emergency room in a hospital is a specific place
where professionals are working with continuous stress, and need to
be efficient, efficacy and rapid in their attitudes.
Materials and methods: we present the statistics of our emergency
room since 2007/2011.
Results: The results will be presented after Dec 2011, based on the
Manchester triage.
Conclusion: we concluded that we have near 1,500 patients a year in
our hospital, coming to our hospital always because is the only one
who is differentiated.
Disclosure: No significant relationships.
PS015
EMERGENCY ROOM TEAM SIMULATION TRAINING:AN EXCELLENT METHOD FOR QUALITY CONTROLAND IMPROVEMENT
A. Hartmann, H. Resch
Traumasurgery, General Hospital Salzburg, Salzburg, Austria
Introduction: It is well documented, that recurrent training
improves structured processes in emergency situations. The military
and the aviation are the best examples supporting this concept.
Under time pressure in emergency room well trained work pro-
cesses are obvious for successful treatment of multiple injured
patients. ATLS and ETC. courses are aiming this strategy, but are
especially worthful for small clinics with limited resources dealing
with complex trauma problems.
Materials and methods: Our concept based on teamwork-focused
trauma simulation in the own facility is tailor made for training level
1 trauma centers. In that case at least ten persons are working toge-
ther. Communication, team working and leadership are becoming the
most important factors influencing the treatment process in the
emergency room. A team simulator setup can fulfill the demands in
training these non-technical, also called soft skills, which are not well
educated on university: Work load management, solution finding,
situation awareness, teamwork and communication. Combined with
training in the own facility it also addresses a system check: algo-
rithms and checklists can be revised and needed equipment
questioned Crises resource management and human factors can be
trained for the whole emergency room team. Nevertheless it is a
perfect tool in education for newcomers or rarely in the emergency
room involved medical employees.
Results: See conclusions.
Conclusion: On the excellent experience of our team training we
want to promote this simulation team training situated in the own
emergency room being useful for checking the whole process treating
life threatened patients and training soft skills for all medical per-
sonnel in the emergency room.
Disclosure: No significant relationships.
PS016
CERVICAL SPINE IMMOBILISATION IN TRAUMA
E. Battaloglu
Trauma and Orthopaedics, West Midlands Deanery, Core Surgical
Training, Birmingham, UK
Introduction: To evaluate the emergency management for trauma
patients with suspected cervical spine injury in a level 1 trauma
centre.
Materials and methods: Prospective study of adult trauma patients
brought to the emergency department of a UK level 1 trauma centre
with pre-hospital warning. Two cohorts of patients were collected to
assess variation of care dependant upon time of presentation and
levels of staffing. Evaluation was made of pre-hospital spinal
immobilisation, ATLS assessment and spinal clearance procedure, as
outlined in British Orthopaedic Association Standards for Trauma
(BOAST 2); the imaging modality chosen, adequacy and appropri-
ateness of imaging, reporting and clinical clearance and precaution
removal. The overall duration of immobilisation would be derived
and critical delay points identified.
Results: A total of 32 patients were opportunistically captured into
the study and assessment of there care revealed that 25 % of patients
presented by ambulance services were incorrectly immobilised. Mean
time for patients to spend on spinal hard board was 63 min. Computer
tomography was the imaging modality chosen in 85 % of patients,
taking a mean duration of 95 min, however significant difference
existed between day time scans and out of hours scans. Only one
patient required secondary magnetic resonance imaging for acute
evaluation. Mean duration of cervical spine precaution immobilisa-
tion was less than 2 h out of hours, however patients presented during
day time hours were on average delayed at over 3 h. No patients were
identified to have cervical spine injury.
Conclusion: There are significant delays occurring in the clearance of
spinal precautions from trauma patients presenting to a major trauma
centre.
Abstract S75
123
Disclosure: No significant relationships.
PS017
MANAGEMENT OF FAILED VERTEBRAL BODYSTENTING FOR TREATMENT OF VERTEBRALFRACTURES: REPORT OF TWO CASES
J.C. Henning, M.B.J. Keel, L.M. Benneker, J.D. Bastian
Department of Orthopaedic and Trauma Surgery, University of Bern,
Inselspital, Bern, Switzerland
Introduction: Vertebral body stenting (VBS) was introduced for
treatment of vertebral fractures. In contrast to balloon kyphoplasty,
expandable metallic stents are utilized in VBS to maintain the cor-
rection of the vertebral body height. The presented report describes
complications in the use of VBS and their management in two
patients.
Materials and methods: A 69 year-old patient presented to an out-
side hospital with persistent right-sided lumboischialgia 8 months
after VBS for a 3rd lumbar vertebral fracture (AO A 2.3, case 1). A
53 year-old suffered from persistent pain after 2 months of conser-
vative treatment of a 1st lumbar vertebral fracture (AO A 3.1, case 2).
In preoperative MRI the fracture was not consolidated. VBS was
performed at our institution. Efforts to expand the cage failed.
Removal of the cage resulted in avulsion of one metallic stent with
approximatively 1 cm of the injection drain remaining attached.
Results: In case 1, radiographic examination revealed fracture non-
union with secondary dislocation of the right-sided metallic stent. The
stent was removed by open corpectomy from an anterior approach.
Fracture treatment consisted of monosegmental anterior fusion. In
case 2, stent removal and fracture stabilization was performed four
days after failed VBS by thoracoscopical partial corpectomy, biseg-
mental fusion and cage interposition. In the postoperative course both
patients had resolution of their initial complaints.
Conclusion: VBS failed in a split fracture pattern or a partially
consolidated fracture and required implant removal. The application
of VBS might be limited so that treatment of specific fractures as well
as the timing of VBS has to be well defined.
Disclosure: No significant relationships.
PS018
HEMORRHAGIC SHOCK DURING ELECTIVE LUMBARDISCECTOMY
G.I. Perez-Navarro, I. Molinos-Arruebo, P.A. Cano-Jimenez,V.M. Borrego-Estella, J.J. Aguaviva-Bascunana, L. Novel-Carbo,G.C. Inaraja-Perez, S. Saudi-Moro, L. Bentue-Olivan,J.A. Franco-Hernandez, M. Toro-Nunez, S. Martinez-Nuez,S. Rasal-Miguel, S. Laglera-Trebol
Anestesia Y Reanimacion, Universitary Miguel Servet Hospital,
Zaragoza, Spain
Introduction: Lumbar discectomy is a common surgical procedure in
a Neurosurgery Department, with a small number of complications,
however, isn0t exempt from them, which can become life threatening
to the patient. We want to show vascular ones after surgical iatro-
genic. Few anesthesiologists and surgeons have experienced this
injury.
Materials and methods: Female, 58 yo, NKDA, PH:SAH treated
with ARBs. Preoperative OK. Scheduled for lumbar discectomy:
slipped disc L4–L5. In the last maneuvers using the rongeur, surgeons
warning of potential injury to a vascular structure in the most anterior
region of the vertebral body. Then SBP dropped along with tachy-
cardia and decreased exhaled CO2. After immediate closure, patient
was positioned in supine and abdomen showed distended. Radiology
was called and ECO identified lot of free fluid. In clinical situation of
hemorrhagic shock, vascular surgery was called too, after exploring
place and evidence right iliac artery bleeding, placed aortobifemoral
prosthesis. At the end, patient was transferred to SICU and discharged
16 days later without peripheral perfusion or neurologic disease.
Results: An early diagnostic and treatment allowed life threatening
didn0t becomes a fatal end.
Conclusion: This complication has a low incidence. Most frequent
risk factor to vascular injury the use of the rounger beyond the
anterior spinal ligament. Intervertebral space where more often is
described this complication is L4–L5. Vascular injuries may be acute
or chronic. Early diagnosis is necessary.
References: 1. Bilbao G, et al. Neurocirugıa. 2004;15:279–84. 2.
Papadoulas S. et al. Eur J Vasc Endovasc Surg. 2002;24 :189–95. 3.
DeSaussure RL. J Neurosurg. 1959;16:222–9. 4. Erkut B, et al. Acta
Neurochir Wien. 2007;149:511–6.
Disclosure: No significant relationships.
PS019
POSTERIOR INSTRUMENTATION ANDMONOSEGMENTAL SPONDYLODESIS IN COMBINATIONWITH CEMENT AUGMENTATION FOR THE TREATMENTOF THORACOLUMBAR BURST FRACTURES
S. Hoppe, M.B.J. Keel, L.M. Benneker
Department of Orthopaedic and Trauma Surgery, University of Bern,
Inselspital, Bern, Switzerland
Introduction: Anterior stabilization with cages/iliac bone graft and
corpectomy in addition with posterior spondylodesis is the gold
standard for the treatment of anterior unstable Magerl type A and B
fractures of the thoracolumbar junction. Whether vertebroplasty/
kyphoplasty in combination with posterior stabilisation provides
enough stability to avoid progression of kyphposis, especially after
implant removal to unblock the caudal non-fused segment, is unclear.
Materials and methods: Retrospective case series of all patients
treated with posterior stabilization in combination with vertebro-
plasty/kyphoplasty between 2000 and 2010 with secondary implant
removal 8–12 months after the index operation. All cases were
assessed for clinical outcome and loss of reduction after implant
removal by lateral radiographs.
Results: 20 (m: 13; f: 7) (age: 40.9 ± 14.4 years) out of 59 patients
treated with bridging dorsal instrumentation with transpedicular ver-
tebroplasty underwent implant removal. Fractures were classified as
A 3.2.1 in 15, A 3.1 in 3 and B 2.3 in 2 cases. The fracture location
was Th 12 in 5, L1 in 11, L2 and L3 in 2 cases. The implant removal
was performed 9.6 ± 3.2 month after initial surgery. In all but one
S76 Abstract
123
cases increase of kyphosis was found 6 month later. The mean
increase of kyphosis was 5.7� ± 3.1� (max 12�; min 0�). Regarding
loss of lordosis there were no significant differences between the
fracture location and types.
Conclusion: Cement augmentation of the ventral column provides
enough stability in combination with dorsal instrumentation for
unstable A and B fractures even after implant removal. After implant
removal some increase of kyphosis in the segment above the aug-
mented vertebra is to be expected.
Disclosure: No significant relationships.
VISCERAL TRAUMA
PS020
OUTCOMES OF LAPAROSCOPIC AND OPENAPPENDECTOMY IN 2620 CASES. WHAT IS THEADVANTAGE?
C. Mauricio Alvarado, M.L. Reyes Dıaz, J.R. Naranjo Fernandez,F. Oliva Mompean
General Surgery, Hospital Universitario Virgen Macarena,
Seville, Spain
Introduction: Several studies have demonstrated the superiority of
the laparoscopic approach in acute appendicitis with conflicting
results.
Materials and methods: A retrospective observational study design
was used to analyze outcomes of open appendectomy (OA) and
laparoscopic appendectomy (LA) procedures from 2004 to 2010.
Results: A total of 2,620 appendectomy procedures performed. OA
was performed in the 49.43 % and LA was performed in 50.57 %.
The mean of length of hospital stay was OA 3.5 versus LA 2.98 days
(p = n.s.), complications after surgery rate was OA 21.87 % versus
LA 17.55 % (p = n.s.), mortality rate was OA: 0.07 % versus LA: 0
(p = n.s.), 30-day readmission rate was OA 1.3 % versus LA 0.9 %
(p = n.s.), intensive care unit admissions in OA 0.3 % versus LA
0.04 % (p = n.s.). Wound infection was the most common compli-
cation in the OA 3.05 % versus 1.45 % (p = n.s.), intraabdominal
abscess with peritonitis was the most common complication in the LA
4.34 % versus OA 2.86 % (p = n.s.) and conversion from LA to OA
was in 1.83 %, The mean cost (euros) by OA is 1,200 ± 900 versus
LA 3,500 ± 1,430. No clinical difference were observed between OA
versus LA. OA resulted in notably but non significantly reduced
intraabdominal abdominal abscess with peritonitis.LA is more
expensive (p B 0.001) compared with OA.
Conclusion: In our hospital seems to be there si no statistically sig-
nificant advantages in performing laparoscopic versus open approach
for acute appendectomy, more over laparoscopic procedure is more
expensive.
References: 1. Ann Surg. 2011. 2. Surg Endosc. 2006;20:1060J. 3. Br J
Surg. 1999;86(1):48–53. 4. Ann Surg. 1994;219(6):725–8. 5. J Gastro-
intest Surg. 1999;3(1):67–73. 6. Am J Surg. 1996;171(5):533–7. 7.
Arch Surg. 1997;132(7):708–11. 8. Ann Surg. 2005;242(3):439–48. 9.
Can J Surg. 2009;52(2). 10. Surg Endosc. 2006;20:1060–8. 11. Ann
Surg. 2006;243(1). 12. Ann Surg. 2005;242(243). 13. Ann Surg.
2004;239(1).
Disclosure: No significant relationships.
PS021
THE EVALUATION OF THE APPLICATIONS FROM THETIME OF PAIN ONSET TO SURGERY IN CHILDRENUNDERGOING APPENDECTOMY
C. Emuce1, D. Selimen2
1Child Clinic, Zeynep Kamil Education and Research Hospital,
Istanbul/Turkey, 2Surgery, Marmara University, Istanbul, Turkey
Introduction: This study has been carried out to find out the corre-
lation between the treatment applied to the children with a abdominal
pain before they are taken to hospital and the perforation. Acute
appendectomy is the most commonly encountered reason for
abdominal pain in emergency surgery units. For various reasons and a
result of late intervention; a simple appendectomy case may result in
perforation, increasing mortality and morbidity. Abdominal pain is
the most common reason for acute appendectomy patients to seek
help in a hospital. Many traditional and modern medical methods of
treatment are used to this end. Traditional medicine is that type of
medicine that is passed into one generation from the previous one.
Materials and methods: The study was planed between 01.01.2010
and 01.01.2011 in the Pediatric Surgery Clinic of a Training and
Research Hospital in Istanbul on 61 patients operated due to acute
appendectomy and perforated appendectomy.
Results: 59 % of the patients were male and 30.3 % were under
5 years old. Mothers of patients were graduates of primary schools
with a rate of 69.6 %. Families were from the Black Sea Region of
Turkey with a rate of 54.5 %. Hot application was by far the most
preferred type of treatment by families, with a percentage of 36.4 %.
Conclusion: It’s proven that informing parents about the complica-
tions which may arise from inappropriate methods and late arrivals,
will help to shorten the elapsed time before referring to the hospital
and that way unwanted results in acute abdomen status will be pre-
vented and mortality and morbidity will decrease.
References: 1. Adamidis D, Roma-Giannikou E, et al. Fiber intake and
childhood appendicitis. Int J Food Sci. 2. KA ± rA ± AYtA ± roAYlu
A�,(2005)Akut abdomen in children,GA�ncel Pediatri 2:54–56.
Disclosure: No significant relationships.
PS022
FACTORS RELATED TO THE FAILURE OFNON-OPERATIVE MANAGEMENT IN BLUNTSPLENIC INJURIES
A.F.Z. Barragat De Andrade, J.F. Castro, S.V. Starling,D.A.F. Drumond
General and Trauma Surgery, Hospital Joao XXIII, FHEMIG,
Belo Horizonte, Brazil
Introduction: This study analyses the factors related to the failure of
non-operative management (NOM) in blunt splenic injuries at our
institution.
Materials and methods: From November 2004 to December 2010,
the medical records of the 446 patients managed non-operatively for
Abstract S77
123
blunt splenic injuries were reviewed and analysed on history,
abdominal CT findings and causes of the NOM failure.
Results: 446 patients admitted to NOM of blunt splenic injury, 34
(7.6 %) had NOM failure. The NOM failure was more common
between 11 to 20 years old. The time gap between admission and
surgery was bimodal, one peak in the first 24 h and another peak
between 5 to 8 days. The spleen injury grading was: Grade II 2
patients, Grade III 19 patients and Grade IV 13 patients. Hypo-
tension was present in 12 patients. CT scan contrast blushing
happened in 2 (5.9 %) patients and both of them underwent sur-
gery. The presence of intraperitoneal free liquid moderate in 21
patients and large in 8 patients. The most common cause of NOM
failure was active bleeding and associated hypotension in 18
(54 %) patients.
Conclusion: NOM failure of the blunt splenic injuries is more
common in patients rated grade III and IV injuries and moderate to
large haemoperitoneum. CT scan contrast blushing is an important
predictor for NOM failure. Haemodynamic instability was the main
factor related to NOM failure of blunt splenic injuries.
References: 1. Peitzman, AB et al. Surgical treatment of injuries to
the solid abdominal organs: a 50-year perspective from the Journal of
Trauma. Review article. J Trauma. 2010;69:1011–21.
Disclosure: No significant relationships.
PS023
GALLSTONE PANCREATITIS MANAGEMENT: ARE WEFOLLOWING THE GUIDELINES?
A.A. Shafi1, G. Al Saied2
1General Surgery, King Fahad Medical City, Riyadh, Saudi Arabia,2General Surgery and Critical Care Medicine, King Saud bin
Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Introduction: Advances in management of biliary pancreatitis were
summarized in major international guidelines. Speedy diagnosis and
stabilization, followed by definitive treatment during the index
admission have been shown to reduce complications and cost.
Materials and methods: 75 consecutive patients admitted with
gallstone pancreatitis from January 2008 to June 2011 were audited
retrospectively to assess the Ranson’s severity score, method of CBD
clearance, and if cholecystectomy was done during index admission.
Complications of treatment, readmissions and length of stay were
recorded. We excluded severe cases, pregnancy, ASA [ III and ICU
admissions. We used practice guidelines of the American College of
Gastroenterology and Japanese guidelines for gallstone pancreatitis as
reference.
Results: 68 patients fulfilled our criteria. Etiology was confirmed in
all patients within 48 h. CBD clearance was done in 35 patient
(51 %). 27 (40 %) patients had index admission laparoscopic chole-
cystectomy while 41 (60 %) were discharged for interval
cholecystectomy. Among delayed group, 9 (22 %) were readmitted
with recurrent pancreatitis while 2 (8.3 %) patients in surgery early
group were readmitted with obstructive jaundice (p \ 0.16). Con-
version to open surgery occurred in 4 patients (10 %) in the delayed
surgery group and none in the index admission surgery group
(p \ 0.098). 8 patients (20 %) had complications in the delayed
surgery group as compared to 3 patients (p \ 0.43) in the index
admission surgery group. Median length of hospital stay was
12.5 days and 9.5 days respectively (p \ 0.028).
Conclusion: Management of gallstone pancreatitis could be improved
in terms of the timing of the cholecystectomy. We anticipate a
reduction of readdmissions and length of overall hospital stay with
adherence with the published guidelines.
References: 1. Practice guidelines in acute pancreatitis. Am J Gas-
troenterol. 2006;101:2379–400. 2. JPN Guidelines for the
management of acute pancreatitis. J Hepatobiliary Pancreat Surg.
2006;13:2–6.
Disclosure: No significant relationships.
PS024
ON-DEMAND VERSUS PLANNED RELAPAROTOMY INTHE TREATMENT OF SEVERE INTRA-ABDOMINALINFECTIONS
M. Anastasiu, R. Popescu, N. Micu, R. Dedu, A. Ivan
Emergency and General Surgery, Emergency County Hospital,
Buzau, Romania
Introduction: Secondary peritonitis is reputed for its high morbi-
mortality and significant medical costs due to the long hospital stays
and health care utilization.
Materials and methods: We prospectively analyzed the patient
outcomes and medical costs of on-demand versus planned relapar-
otomy in the severe secondary peritonitis for 69 patients admitted and
treated in 2 county hospitals between 2008–2010. There are recorded
patients’ age, infection source and microbiological findings, ASA
score and Mannheim Peritonitis Index, major comorbidity, number of
relaparotomies and hospital stays. All statistical analyses were per-
formed using SPSS for Windows, survival curves were constructed
with the Kaplan–Meier method and differences between 2 strategies
were tested using the v2 test.
Results: All patients enrolled in study (35 on-demand and 34 planned
relaparotomy) were observed 12 month after index laparotomy for
additional outcomes. Cumulative mortality was 26 % (9/35) in the on-
demand group and 32 % (11/34) in the planned group (95 % CI -6.8
to 14 %; p = 0.34). Major morbidity in survivors occurred in 37 %
(13/35) of patients in the on-demand group and 41 % (14/34) of
patients in the planned group (95 % CI -9 to 18 %; p = 0.54).
Patients in the on-demand group had shorter median ICU stays (8 vs.
13 days; p = 0.002); medical cost per patient were reduced by 19 %
using the on-demand strategy.
Conclusion: However the morbi-mortality rate was not statistically
different between the on-demand and planned relaparotomy groups,
there are noted significant reductions in relaparotomies number and in
medical costs for the first group.
References: 1. Lamme B. Meta-analysis of relaparotomy for sec-
ondary peritonitis. Br J Surg. 2002;1516–24.
Disclosure: No significant relationships.
PS025
THE EFFECT OF ANKAFERD BLOOD STOPPER ONCOLONIC ANASTOMOSIS HEALING
B. Citgez1, U. Ekici1, M. Uludag1, I. Akgun1, G. Yetkin1, N. Balat2,O. Ozcan3, N. Polat4, A. Akcakaya1
1Second General Surgery, Sisli Etfal Training and Education
Hospital, Istanbul, Turkey, 2First Department of Obstetrics and
S78 Abstract
123
Gynecology, Sisli Etfal Training and Education Hospital, Istanbul,
Turkey, 3Department of Biochemistry and Clinical Biochemistry,
GATA Haydarpasa Training Hospital, Istanbul, Turkey, 4Pathology,
Sisli Etfal Training and Education Hospital, Istanbul, Turkey
Introduction: Ankaferd Blood Stoper (ABS), even not stated for the
gastrointestinal system, is reported to increase the secondary wound
healing and decrease inflammation and necrosis. We aimed to
investigate the effects of ABS on the healing of primary colonic
anastomosis.
Materials and methods: Forty-eight healthy adult female Sprague–
Dawley (SD) rats were randomly divided into control group
(n = 24) and experimental group (n = 24). The experimental group
was treated by wrapping the anastomosis with 5 ml of ABS. The
control group was not treated. At 3 days and 10 days after the
operation, the adhesion formation, fibroblast migration, acute
inflammation, neovascularization, collagen formation of colonic
anastomosis were observed, bursting pressure of the anastomosis
was assessed, and the hydroxyproline (HP) content of the anasto-
mosis was detected.
Results: The collagen of the experimental group on the 3th and 10th
postoperative days were significantly higher than those of the control
group (p \ 0.05). There was no significant difference between the
experimental group and the control group for acute inflammation,
fibroblast migration, neovascularization, adhesive score, HP, and
bursting pressure (p [ 0.05).
Conclusion: The ABS may increase the collagen formation of colonic
anastomosis, but does not interfere with the healing of colonic
anastomosis.
Disclosure: No significant relationships.
PS026
GIST AND NEUROFIBROMATOSIS 1 (NF1).GASTROINTESTINAL BLEEDING IN A PATIENT
N. Zambudio-Carroll1, J.D. Turino-Luque2, M.J. Alvarez-Martin1,A. Mansilla-Rosello1, J.A. Ferron-Orihuela1
1Cirugıa General, Hospital Universitario Virgen de las Nieves,
Granada, Spain, 2Cirugıa General, Hospital Virgen de las Nieves,
Granada, Spain
Introduction: Gastrointestinal stroma (GIST), are the most fre-
quently encountered connective tissue neoplasias in the digestive
tract. It is possible to differentiate this tumor from other intestinal
sarcomas thanks to the immunohistochemical differential marker
CD117 (KIT) and the source of the genetic mutation in c-kit, which
codifies the protein receptor of the tyrosine kinase family (KIT). This
tumor is being treated with Imatinib.
Materials and methods: Female patient, age 47, with a clinical
history of Mac Cune–Albright syndrome, operated for congenital
tibia-fibula pseudoarthrosis. On admission the patient presented Hb:
7.8 g/dl, BP: 100/60 mm/Hg, 84 bpm, and a rectal exam with mela-
ena traces. Following admission a selective arteriography was
performed. The images showed a small, rounded hypervasculated
lesion dependent on the jejunal branches. The images shown could be
related to an intestinal tumor (leiomyoma) or a possible intestinal
angiodysplasia.
Results: An emergency intervention was performed and upon finding
two lesions in the first jejunal handle a resection was done on 15 cm.
of the jejunum containing the lesions; a manual end-to-end anasto-
mosis was done. The pathological report found a GIST tumor.
Conclusion: Neurofibromatosis (NF) is an autosomal dominant
genetically inherited disorder. The gene responsible for NF1 encodes
a protein called neurofibromin which works as a negative regulator of
the Ras-kinase pathway. This is the reason why patients with NF
present an elevated risk of developing malignant tumors. Gastroin-
testinal (GI) problems in patients with NF1 can present themselves in
different forms like gastrointestinal stroma tumors (GIST), as in this
case, which began with considerable bleeding.
References: 1. Beltran MA, Cruces KS, Barra C, Verdugo G. Mul-
tiple gastrointestinal stromal tumors of the ileum and
neurofibromatosis type 1. J Gastrointest Surg. 2006;10:297–301.
Disclosure: No significant relationships.
PS027
METHODS OF ABDOMINAL CLOSURE: BOGOTA BAGVERSUS VACUUM-ASSISTED CLOSURE
E. Ozkurt, I.S. Sarıcı, H.T. Yanar, C. Ertekin, R. Guloglu, M.K. Gunay
General Surgery, Istanbul University Istanbul Faculty of Medicine,
Fatih, Turkey
Introduction: It sometimes strokes surgeons the wrong way while
struggling with closure of the open abdomen and its complications.
The authors reviewed their experience in the management of ‘‘trau-
matic or nontraumatic open abdomen’’ using the vacuum-assisted
closure (VAC), in order to assess its morbidity, and the outcome of
abdominal wall integrity.
Materials and methods: A retrospective review was performed using
the trauma registry to identify the patients undergoing temporary
abdominal closure (TAC) from January 2000 to October 2011.
Inclusion criteria for the research were TAC and survival to definitive
abdominal closure. Data collected included age, injury severity score
(ISS), number of operating room procedures, primary fascial closure
rate and complications. Complications were defined as intraabdomi-
nal infections, dehiscence, and hernia.
Results: During the study period 156 patients had one of the types of
TAC. Patients met inclusion criteria and were stratified according to
method of TAC. Median age of the patients are 61 (range 17–91). The
male–female ratio is 92/64. The main reason for the open abdomen is
intestinal obstructions. Bogota bag (BB) was performed to 98 patients
and VAC to 58 patients. The survival ratio for BB is 16.3 % (16/98)
and 69 % (40/58) for VAC. The mean closure day for BB is 24 and
for VAC is 6. The complication ratios are 50 % for BB and 20 % for
VAC.
Conclusion: The vacuum assisted closure (VAC) is superior to
Bogota bag. It had a significantly higher rate of closure, less operation
rates, and lowest complication rates.
References: 1. Vacuum-assisted closure of the open abdomen in a
resource-limited setting.
Disclosure: No significant relationships.
Abstract S79
123
PS028
TRAUMATIC INJURIES OF THE PANCREAS: A RAREEVENT AND A DIAGNOSTIC CHALLENGE BUTASSOCIATED WITH GOOD LONG-TERM PROGNOSIS
C. Kim-Fuchs1, A.S. Wenning2, E. Angst1, B. Gloor2, D. Candinas2
1Department of Visceral Surgery and Medicine, Bern, Switzerland,2Visceral Surgery, Department of Visceral Surgery and Medicine,
Bern, Switzerland
Introduction: Only 1–5 % of the patients with blunt abdominal
trauma and 8 % of the patients with penetrating trauma acquire an
injury of the pancreas. Concurrent injuries are present in up to 70 %
of these patients, explaining the delay in the diagnosis of a pancreatic
injury.
Materials and methods: Retrospective analysis of our prospective
trauma database between 2002–2009. The primary diagnostic test was
a CT scan. Pancreatic injuries were graded according to the Moore
classification. Patients were followed by questionnaire, abdominal
ultrasound and measurement of blood glucose and stool elastase.
Results: 6 patients (4 male, 2 female) with a traumatic injury of the
pancreas, out of how 2,148 patients with possible abdominal trauma
at the emergency station. The median age 28 years (19–80. Distri-
bution of the injuries: grade I, III, IV and V: 1 patient each, grad II: 2
patients. 5 patients (83 %) suffered concurrent intraabdominal inju-
ries, one patient incurred concurrent rib fractures. 3 patients were
treated by interventional drain placement, 2 by a left resection of the
pancreas and 1 by direct suture of the pancreas. Mean time in hos-
pital: 8 days (10–47). The median follow up: 56 months (1–98).
There were no exocrine pancreatic insufficiency, nor diabetes.
Conclusion: Traumatic injuries of the pancreas are rare and should be
sought actively in blunt and penetrating abdominal trauma. Although
they affect young patients and result in prolonged hospitalization the
long-term prognosis is good with a normal exocrine and endocrine
function of the pancreas.
Disclosure: No significant relationships.
PS029
WANDERING SPLEEN’S TORSION. A RARE CAUSE OFACUTE ABDOMEN
A. Mansilla-Rosello1, J.D. Turino-Luque2, J.M. Avella3, A. BustosMerlo3, M. Carrasco1, T. Torres Alcala1, J.A. Ferron-Orihuela1
1Cirugıa General, Hospital Universitario Virgen de las Nieves,
Granada, Spain, 2Servicio De Cirugıa General Y Aparato Digestivo,
Hospital Universitario Virgen de las Nieves, Granada, Spain, 3Cirugıa
General, Hospital Virgen de las Nieves, Granada, Spain
Introduction: Wandering spleen is a very rare disease caused by the
loss or weakening of the ligaments that help to hold the spleen. It is
most commonly diagnosed in children as well as women between the
ages of 20 and 40. Blocking of the arteries and/or torsion in the spleen
pedicle can results in abdominal pain or swelling. Lack of visible
symptoms—except in incidents of abdominal pain—makes the dis-
ease difficult to diagnose, though imaging techniques can be used to
confirm its occurrence. We present a case of this disease in a young
woman.
Materials and methods: A 36 years old woman, went to the emer-
gency service with abdominal pain about 3 days duration, constant
and abruptly began in epigastrium and generalized in the following
hours, associated with nausea and vomiting. No fever and chills.
Results: Physical examination at admission: blood pressure:
104/64 mmHg, heart rate :91, eupneic, O2 SAT 99 %, temperature
35.8 �C. Glasgow 15/15. No signs of neurological deficit. ACR:
rhythmic tones without murmurs rubs. Breath sounds without noise
superimposed. At abdomen exploration, a palpable and painful mass
lower abdomen was found, with diffuse and generalized defense.
Analytical: 19850 Leucocytes/ll (83 % pmn), haemoglobin 13.8 g/dl,
LDH 591 U/ll; PCR 22. Normal coagulation (INR 1.12). GSV: lactic
acid 1.8. Ultrasound and CT scan: wandering spleen and inflamma-
tory changes at the level of cecal appendix with free fluid in small
quantity. Judgement Diagnosis: acute abdomen. It was decided urgent
hospitalization and surgery. At laparotomy an aberrant spleen with
torsion of the pedicle and the splenic vein thrombosis was found, with
irrecoverable ischemic signs. Splenectomy was performed without
incidents. Postoperative evolution was favorable. It has done service
consultation to preventive vaccination program (pneumococcus,
haemophilus, meningococcus). The patient was discharged on day
five of the postoperative course.
Conclusion: It should be take into account the diagnosis of wandering
spleen in cases of sudden onset of abdominal pain with palpable
abdominal mass in young patients. The diagnosis and treatment
should be early to avoid splenectomy.
Disclosure: No significant relationships.
PS030
THE MANAGEMENT OF IATROGENIC ESOPHAGEALPERFORATION AS A RESULT OF BARIATRICPROCEDURES
G. Doulami1, D. Theodorou2, E. Menenakos2, Z. Vrakopoulou1,N. Kokoroskos2, A. Larentzakis1, M. Natoudi2, G. Zografos2
1Department of Foregut Surgery, National and Kapodistrian
University of Athens, Athens, Greece, 2National and Kapodistrian
University of Athens, Athens, Greece
Introduction: Esophageal perforation is a condition that requires
urgent management and can have fatal results. The use of esophageal
bougies as sizers is a common practice during bariatric operations.
The insertion of these instruments in a patient under anesthesia carries
a substantial risk for iatrogenic perforation. We report two cases of
esophageal perforation during bariatric procedures and we describe
the optimal management of this condition.
Materials and methods: Two women undergoing laparoscopic ba-
riatric procedures (LSG and LAGB respectively) suffered esophageal
perforation during bougie insertion, that was not recognized at the
time of surgery. Both injuries were diagnosed postoperatively by
imaging studies which were triggered by the development of sepsis.
Patients were managed with an esophagogastrectomy, a salvage cer-
vical esophagostomy, and feeding duodenostomy. One patient
survived and eventually was reconstructed with colon interposition
and the other patient expired from multiple organ failure.
Results: Iatrogenic perforation is the commonest cause of esophageal
perforation. The insertion of balloon inflated bougie is a common
practice in bariatric procedures. It is an invasive procedure that in
most cases is performed by the anesthesia team. The complication
should be recognized immediately. This is best achieved by the
S80 Abstract
123
co-operation of the surgical and anesthesia team with direct obser-
vation during insertion. Another indicator is the appearance of blood
on the bougie at the end of the procedure. Surgical management
depends on the time of recognition, patients condition and local
inflammation. When such a complication occurs, early management,
debridement and aggressive drainage is of crucial importance.
Conclusion: High index of suspicion and early management of this
fatal complication is of crucial importance. The insertion of bougie in
the esophagus under anesthesia should be considered as a serious step
that requires co-operation of the surgical and anesthesia teams.
Disclosure: No significant relationships.
PS031
MANAGEMENT OF PANCREATIC INJURIESIN CHILDREN, CASE SERIES
A.S. Ghasoup, O.G. Sadieh, A.A. Mansoor
Surgical Department, Al Bashir Hospital, Amman/Jordan
Introduction: Trauma is the leading cause of death in children,
abdominal trauma is common, injuries to the liver, spleen and kidneys
are common in abdominal trauma in children and many of these
injuries are now treated non-operatively where as pancreatic injuries
are uncommon and are rarely described in children in Jordan.
Materials and methods: All children less than 10 years of age
referred with pancreatic injury between May 2000 and May 2010
were reviewed retrospectively.
Results: Ten children (seven boys and three girls) aged between 2.5
and 11 years sustained to pancreatic injuries: three with grade I
(minor contusion),three with grade II (major contusion without duct
injury or tissue loss),two with grade III (distal transection and duct
injury), one with grade IV (proximal transection) and the last one with
pancreatic transection and extensive duodenal injury. Grade I and II
were successfully managed without surgery, the two children with
grade III injuries were treated conservatively, but each developed a
symptomatic pseudocyst that failed to resolve with percutaneous
drainage so underwent spleen-sparing distal pancreatectomy, the child
with grade IV transected pancreatic neck was treated by Roux-en-Y
jejunostomy drainage and the last one 2.5 years old boy was treated
with Whipple procedure, all children made a full recovery without
complications.
Conclusion: the management of pancreatic injuries in children
depends on the site of injury, timing of referral and presence of
associated injuries.
Disclosure: No significant relationships.
PS032
MORBIDITY AND MORTALITY OF PATIENTS WITHABDOMINAL TRAUMA SUBMITTED TO LAPAROTOMYIN A REFERENCE HOSPITAL IN TRAUMA IN BRAZIL
N.A. De Liz, G.S. Silverio, N.T. Kruel, N.A. Liz, O. Franzon,R.N. Goulart
Surgery Department, Hospital Regional de Sao Jose, Sao Jose,
SC, Brazil
Introduction: In Brazil, the trauma is the second leading cause of
death responsible for mowing approximately 150,000 lives each year.
Materials and methods: Conducted a retrospective, descriptive
cross-sectional study of 328 trauma patients undergoing abdominal
laparotomy, from January 2000 to July 2008.
Results: The male sex prevailed with 88.41 % (n = 290). The
mechanisms of blunt trauma accounted for 37.80 % (n = 124), with
cars and motorcycles accounted for 33.06 and 37.90 % respectively.
In penetrating trauma 73 % (n = 204). The order of the main struc-
tures in penetrating trauma has affected the small intestine, liver and
large intestine. In blunt mechanism injuries occurred mainly in the
spleen, liver and small intestine. The mortality rate was 7.62 %
(n = 25), 52 % (n = 13) due to blunt trauma and 48 % (n = 12)
relative to penetrating trauma. The most frequent cause of death was
hypovolemic shock in both mechanisms of trauma. The total number
of severe postoperative complications was 10.67 % (n = 35) of the
abscess, were the most prevalent. Of the total patients, 15.81 %
underwent re-operation. The causes were: fistula, evisceration,
abscess, peritonitis, ‘‘damage control’’ and hemorrhage.
Conclusion: Abdominal trauma is still prevalent among young peo-
ple, especially in male patients. Hypovolemic shock remains the
leading cause of death in abdominal trauma surgery. The thoracic
trauma injury was more associated extra-abdominal, followed by
fractures of long bones.
References: 1. Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic per-
itoneal lavage remains a valuable adjunct to modern imaging
techniques. J Trauma. 2009;67:330.
Disclosure: No significant relationships.
PS033
RECTAL INJURY BY CLEANSING ENEMA: A REALAND UNDERESTIMATED PROBLEM?
R. Bini, J. Micari, R. Leli
General and Emergency Surgery Dept, S. Giovanni Bosco Hospital,
ASLTO2, Torino, Italy
Introduction: Rectal perforation secondary to cleansing enema is a
poorly described, and may be underestimated, injury in the chronic
constipated elderly population. Herein we described our experience.
Materials and methods: We selected patients admitted to our ward
for acute abdominal pain with a past history of fecal impaction or
chronic constipation and recent procedure of irrigation enema. Clin-
ical findings, laboratory tests, standard radiogram an basal CT were
performed in all patients. Diagnosis of rectal perforation was treated
surgically by diversion loop colostomy, direct suture of the rectal
perforation and drainage.
Results: We identified 10 patients (6 w and 4 m) with ages ranging
between 61 and 90 years. Main comorbidities were hypertension,
cardio vascular disease and dementia. Symptoms and signs included
fever were present in about 60 %, whereas abdominal pain with
peritoneal signs in the 70 % and elevated white blood cell and
C-reactive protein level in only 50 % of the cases. Standards abdomen
X-ray were positive in only the 30 % of the cases but basal tc scan
reach the 100 % of positivity. One patient died for sepsis and lung
failure during the intensive care observation.
Conclusion: Acute abdominal pain secondary to cleansing enema is
often nonspecific, especially in chronic constipated patient with his-
tory of dementia. Clinical diagnosis is delayed in most cases and not
confirmed by blood tests and standard abdominal X-ray. Basal CT
allowed us to identified patients who needed surgery. Diversion
Abstract S81
123
colostomy associated with suture represent a safe procedure with high
successful rate.
References: 1. Paran H. Dis Colon Rectum. 1999;1609–12.
Disclosure: No significant relationships.
PS034
MANAGEMENT OF UNDIAGNOSEDPHEOCHROMOCYTOMA IN A PATIENT WITH ACUTEAPPENDICITIS: A CHALLENGING AND DIFFICULTSURGICAL CONDITION
A. Coskun1, M. Yildirim1, S. Akay2, N. Erkan1
1General Surgery, Izmir Bozyaka Training and Research Hospital,
Izmir, Turkey, 2Emergency Department, Izmir Bozyaka Training and
Research Hospital, Izmir, Turkey
Introduction: Pheochromocytoma is a rare catecholamine secreting
neuroendocrine tumor taking origin mostly from adrenal glands.
Typical symptoms include episodes of hypertension, headache, pal-
pitations and diaphoresis.
Materials and methods: Here in we present a patient with acute
appendicitis and undiagnosed pheochromocytoma that lead surgical
difficulties.
Results: A 24-years-old male presented to our emergency department
with abdominal pain. Physical examination showed marked tender-
ness with rebound in the right lower quadrant consistent with acute
appendicitis. Leucocytosis of 16.000/mm3 and positive ultrasound for
appendicitis granted for operation. Prior to operation room, his blood
pressure raised to 240/130 mmHg while heart rate was 125/min.
Vitals were stabilized to 140/90 mmHg and 88/min by intravenous
nitrates and beta blockers. Appendectomy was done without com-
plications. Laboratory tests and radiological studies were made for
malignant hypertension. Urine vanyl mandolic acid level (23 mg/
24 h) and right adrenal mass measuring 4 9 4 cm in abdominal MRI
that supports the diagnosis of pheochromocytoma were found. Right
adrenalectomy was made electively 2 months later and pathology
revealed pheochromocytoma. The postoperative period was
uneventful and he has been following for 6 months without any
antihypertensive treatment.
Conclusion: A clinical challenge arises when a patient with a pre-
viously undiagnosed pheochromocytoma presents with a surgical
emergency. Intense antihypertensive therapy is needed for stabilizing
patients perioperatively. Severe hypertension observed in acute stress
like acute appendicitis must alert physicians for pheochromocytoma.
References: 1. Bensghir M, Elwali A, Lalaoui SJ, et al. World J
Emerg Surg. 2009;4:35. 2. Tarant NS, Daconay RG, Mecklenburg
BW, et al. Anesth Analg. 2006;102:641–3.
Disclosure: No significant relationships.
PS035
PLACE OF DAMAGE CONTROL SURGERY IN SEVEREACUTE HAEMORRHAGIC NECROTIZING PANCREATITIS
M. Imperato, J. Jarry, N. Bourilhon, P. Michel
Digestive and Visceral Surgery Department, HIA DESGENETTES
(Military Hospital), Lyon, France
Introduction: Haemorrhage during necrotizing pancreatitis is a rare
but severe complication.
Radiological embolization and emergency surgery can be solutions to
avoid a fatal outcome.
Through one case report and the literature, we analyse the place of
damage control surgery in such situation.
Materials and methods: A 45 yo man with multi-organ failure
revealing an acute necrotizing pancreatitis was admitted to the ICU.
Ranson Score (2nd day) was 7 and the scannographic score was E. He
presented a mixed acidosis, an ARDS with major septic shock needed
artificial ventilation, amine continuous infusion and haemofiltration.
After an improvement, 11 days after, he presented a massive haem-
orrhagic shock with ACS without specific vessels’ identification on
CT-scan.
Results: The patient was operated. No clearly origin of the haemor-
rhage was found so he had a vacuum assisted closure. But given its
inefficacy we were compelled to realize an economical necrosectomy
with a large packing of pancreatic area while the patient had massive
transfusion, and one factor VIIa administration. We managed to sta-
bilize him and depacking was realised 72 h after. The patient
discharged ICU 8 days after.
Conclusion: Because of the rarity of spontaneous major haemor-
rhage, especially in patients with necrotizing pancreatitis, data have
been limited to small series or case reports. Surgery in the first days
must be avoided but sometimes necessary. In such dramatical situa-
tion, damage control surgery can also be an effective solution.
References: 1. Sermoneto et al. Int Wound J. 2010;7:525. 2.Bradley
et al. Ann Surg. 2010;251:6. 3. Olejnik et al. Hepatogastroenterology.
2008;55:315.
Disclosure: No significant relationships.
PS036
FIRST EPISODE OF POSTOPERATIVE ADHESIVE ILEUS.ANALYSIS OF 67 CASES
G. Georgiou, C. Christidis, F. Kodonas, F. Filippou, A. Kambouris,A. Chiotis
Surgical, Xanthi General Hospital, XANTHI, Greece
Introduction: In this study we prospectively examined all patients
treated with the first episode of postoperative obstructive ileus to
determine time interval and indication of previous laparotomy, the
sort of incision performed and the subsequent treatment.
Materials and methods: Sixty-seven consecutive patients with first
episode of post operative obstructive ileus were admitted in our
hospital from January 2006 until September 2011.
Results: Forty-four males and 23 females, mean age 54 were eval-
uated. In 3 cases the cause of obstruction was not correlated with
adhesions. Time interval, between last operation performed and first
episode of obstructive ileus, ranged from 10 days to 53 years. Twenty
cases (31.2 %) presented in the first postoperative year.
Previous implicated operations were mostly for the treatment of intra-
abdominal inflammatory lesions in 21 (32.8 %) and malignancies in 9
(14 %) cases.
Vertical incisions were performed in 65.6 % cases. Nineteen out of 64
patients (29.7 %) were treated operatively.
Conclusion: The likelihood of first postoperative episode of adhesive
bowel obstruction is increased in males. Almost, one out of three
cases occurs in the first year postoperatively. Previous laparotomy
for intra-abdominal inflammations has higher risks to trigger off
adhesive ileus. Vertical incision tends to be a predisposing factor.
S82 Abstract
123
Non-operative was the treatment of choice in 70.3 % of our cases.
More cases are needed to draw safer conclusions.
References: 1. Miller G, Borman J, Shrier I, Gordon PH. Natural
history of patients with adhesive small bowel obstruction. Br J Surg.
2000;87(9):1240–7. 2. Ellis H. The clinical significance of adhesions:
focus on intestinal obstruction. Eur J Surg Suppl. 1997;577:5–9.
Disclosure: No significant relationships.
PS037
HEPATECTOMY LIKE TREATMENTOF POST-TRAUMATIC HIGH FLOWBILIARY FISTULAS
L. Alvarez Llano, Y. Mohamed Al-Lal, R. Franco Herrera,M.D. Perez Dıaz, F. Turegano Fuentes
Cirugıa General Ii, Hospital Gregorio Maranon, Madrid, Spain
Introduction: The liver is one of the most commonly injured organs
after abdominal trauma. Conservative treatment can be performed in
stable patients and this way, we can reserve surgery for those patients
with hemodynamic instability that does not allow other types of
therapy. The most common complication of hepatic trauma is the
infection, but there are other much complication as high flow biliary
fistula, who are the reason for our communication.
Materials and methods: We report two patients with posttraumatic
high flow biliary fistulas after IV grade liver trauma who were treated
conservatively initially and subsequently required surgical treatment
for the final resolution thereof.
Results: The closed liver trauma has excellent results with conser-
vative treatment; surgical treatment is reserved for those cases with
massive bleeding that may lead the patient instability or continuous
bleeding requiring repeated transfusions. Despite the good results of
conservative treatment may appear different complications. The
most common is infection, being less frequent biloma and/or biliary
fistula, with an estimated frequency between 1 and 6 %. Treatment
of biliary fistula should be individualized; treatment is available by
ERCP endoscopic who control the leak through prosthesis, or
interventional vascular techniques, reserving surgery for patients
with high debit biliary fistulas that do not resolve with conservative
treatment.
Conclusion: As in the published series, the frequency of posttrau-
matic high flow biliary fistulas in our center is low. Its diagnosis
requires a high index of suspicion. Treatment should be individual-
ized for each patient and use the surgical treatment in the case of
persistent high flow fistulas.
Disclosure: No significant relationships.
EMERGENCY SURGERY I
PS038
FACTORS AFFECTING CLINICAL OUTCOME OFLOW-VOLTAGE ELECTRICAL INJURIES IN CHILDREN
M.T. Gokdemir1, O. Sogut1, H. Kaya1, M. Cevik2
1Emergency Medicine, University of Harran, Sanliurfa, Turkey,2Pediatric Surgery, Harran University, Sanliurfa, Turkey
Introduction: In this paper, clinical features of low-voltage
(220–240 V) electrical injuries and their effects on mortality were
evaluated among children.
Materials and methods: In this study, 36 patients who were younger
than 18 years old, were injured due to low-voltage electrical shock
because of home accident and/or carelessness, and were presented to
the Emergency Department in the period from January 2009 to
October 2011 were evaluated retrospectively. The patients, who were
18 years old and over, and those not demonstrating electrical entry
wound on physical examination were not included in the study. For
statistical analyses, Fisher’s exact test was used for categorical vari-
ables and Mann–Whitney U test was used for continuous variables.
Results: In 34-month period, totally 36 patients (27 boys [75 %] and
9 girls [25 %]) were injured as a result of home accident and/or
carelessness. The median age of the patients was 9.19 ± 4.10 (range
2–17). Five (13.9 %) of 36 patients presented because of low-voltage
electrical injury resulted in death. A statistically significant relation-
ship was found between mortality and age, unconsciousness at the
time of admission to the emergency unit, presence of clinical shock,
sinus tachycardia, high lactate dehydrogenase enzyme levels
(p = 0.004, p = 0.013, p = 0.005, p = 0.003, p = 0.001, respec-
tively). There was also a statistically significant relationship between
mortality and hospital stay, intensive care unit stay, positive blood
cultures (p = 0.005, p = 0.002, p = 0.024, respectively). However,
gender, presence of electrical exit wound, severity of the burn, surface
area of the burn (%), accompanying flash burn, elapsing time to
transfer the patient from scene of accident to hospital, incomplete
bundle branch block and/or ST-wave changes on ECG, increased
troponin T and CK-MB were not found to be effective on mortality.
Conclusion: Low-voltage electrical injuries are common and cause to
death more often than estimated. Nearly all injuries occur in home
environment as a result of carelessness and/or home accident. Edu-
cational projects about the prevention from electrical injuries must be
developed for children and parents.
Disclosure: No significant relationships.
PS039
PAIN MANAGEMENT IN ACUTE TRAUMA: INTRAVENOUSACETAMINOPHEN VERSUS MEPERIDINE IN PAINMANAGEMENT OF ACUTE TRAUMA PATIENTS
S. Paydar, A. Tadayyon, A. Taheri Akerdi, M. Musavi,A. Hosseinzadeh, M.A. Akrami, F. Ghaffarpasand, S. Bolandparvaz,H.R. Abbasi
Trauma Research Center, Shiraz University of Medical Sciences,
15711, Iran
Introduction: To compare the effects of early administration of
intravenous acetaminophen and Meperidine on trauma patients’ pain
and vital signs level of consciousness.
Materials and methods: This randomized clinical trial was per-
formed in Shahid Rajaei hospital including 503 alert patients
(GCS = 15) with rib or/and long bone fractures being randomly
assigned to receive intravenous acetaminophen (1 g) at admission and
Meperidine (25 mg) 6 h later (group 1) and intravenous Meperidine
(25 mg) at admission and acetaminophen (1 g) 6 h later. Pain
severity, heart rate, blood pressure, level of consciousness and
respiratory condition were recorded 1 and 4 h after administration.
Results: The pain severity decreased significantly in both groups in
those with single fractures (p = 0.001, p = 0.028 respectively);
however the pain severity didn’t decrease significantly in those with
Abstract S83
123
multiple trauma (p = 0.112, p = 0.098). There wasn’t any significant
difference between two groups regarding pain severity at 1
(p = 0.128) and 4 (p = 0.235) h. None of the patients developed
respiratory distress, decreased LOC and hypotension.
Conclusion: In acute phase of trauma, intravenous analgesics could
be used to reduce patients’ pain.
References: 1. Berben SA, et al. Guideline ‘Pain management for
trauma patients in the chain of emergency care. Ned Tijdschr Gene-
eskd. 2011.
Disclosure: No significant relationships.
PS040
FUNCTIONAL RESULTS AFTER CHEST WALLSTABILIZATION WITH A NEW SCREWLESS FIXATIONDEVICE
F. Al-Shahrabani1, P. Moreno De La Santa Barajas2, J. Bremerich3,M. Tamm4, D. Lardinois1
1Thoracic Surgery, University Hospital Basel, Basel, Switzerland,2Thoracic Surgery, Hospital POVISA, Vigo, Spain, 3Radiology,
University Hospital Basel, Basel, Switzerland, 4Pneumology,
University Hospital Basel, Basel, Switzerland
Introduction: Objective: Prospective study of chest wall integrity
and pulmonary function in patients who underwent chest wall sta-
bilization with a new screwless fixation device (STRATOSTM
,
MedXpert, Germany).
Materials and methods: Since 2008 till now, 80 patients with a mean
age 54 years (22–88) underwent chest wall stabilization. Indications
included antero-lateral flail chest and dislocated rib fractures with
shrinkage. Titanium rib clamps were placed and fixed to the stable
parts of the most effected ribs and connected by titanium plates.
Clinical outcome, pulmonary function testing and dynamic assess-
ment of the chest wall mobility by cine MRI were preformed
6 months following surgery.
Results: 42 (52.5 %) patients had various combination of injuries of
the thorax, head, abdomen and extremities. Median number of sta-
bilised ribs was 4.17 (2–9) with a medium delay from admission till
operation of 5.4 days (1–14). Due to local infection, the implants
were removed in 2 (2.5 %) cases. Pulmonary function testing at
6 months after the operation was done till now in 61 (76.25 %)
Patients. The data show no restriction. Cine MRI showed symmetrical
movement of the chest wall.
Conclusion: Our results suggest that in selected patients, extended
chest wall injury accompanied by respiratory insufficiency can be
effectively stabilised by screwless titanium fixation device.
Disclosure: No significant relationships.
PS041
SPLENIC AUTOTRANSPLANTATION: EVALUATION WITHSCINTIGRAFIC EXAMS
M. Beuran1, M. Vartic2, M. Avram1, A. Chiotoroiu1, I. Negoi1,C. Vartosu1
1General Surgery, Emergency Hospital of Bucharest, Bucharest,
Romania, 2Intensive Care Unit, Emergency Hospital of Bucharest,
Bucharest, Romania
Introduction: Since 2001 we performed splenic autotransplantation
in more than 40 patients to treat splenic trauma; 22 patients required
splenic implants. The aim of the present study was to evaluate the
survival and function of splenic implants using spleen imaging with99mTc labeled heat-damaged erythrocytes.
Materials and methods: During surgery the spleen was totally
removed. A slice of spleen was cut in 20 fragments (dimensions of
1 9 1 9 2 cm) and then sutured on the greater omentum. All 22
patients with splenic rupture and autotransplantation underwent
spleen imaging with 99mTc labeled heat-damaged erythrocytes in
1–2 months after procedure (early scans).
Results: Splenic autotransplants were faintly showed on early
scans, and the intensity of radioactivity in autotransplants was
lower than that in liver. The increase of intensity of the tracer
accumulation in autotransplants was significant higher on follow-up
scans.
Conclusion: It is feasible, efficacious and safe to perform splenic
implants after total removal of the spleen. Follow-up scintigrafic
exams confirmed the function of the splenic autotransplant.
References: 1. Chiotoroiu AL, Beuran M, Venter MD, Rosu
O-Managementul leziunilor traumatice splenice la adult. Revista de
Medicina si Farmacie. 2008,54:122–6.
Disclosure: No significant relationships.
PS042
WAITING TIMES FOR EMERGENCY DEPARTMENTDOCTORS AND FOR CONSULTANTS
A. Kebapci1, T. Taymaz2
1Nursing, Koc University, Istanbul, Turkey, 2Emergency, American
Hospital, Istanbul, Turkey
Introduction: The emergency department plays a vital role in
patient care and an important role in communities and society. EDs
are getting crowded every year and this cause the longer waiting
times. It’s important for especially critically patients. Beside this,
ED patient satisfaction is based in large part on the amount of time
spent waiting to be seen. We aimed to examine the waiting times in
our ED.
Materials and methods: Between January 01-2010 and July
01-2010; 14381 patient were seen in ED. Patient files of first 2 days of
every month were detected (968 patients). Their triage levels, the time
when triage nurse saw the patient, the time when doctor saw the
patient, consultations and waiting time for consultation were recorded
and analyzed by Medcalc, a statistic program.
Results: Mean waiting time between triage nurse saw the patient and
doctors examination was 2.1 ± 3.1 min, waiting time for the con-
sultant was 11.6 ± 13.2 min. 336 consultation were needed. The
most frequent consultations were orthopedics (8.8 % of all patients),
cardiology (6.4 %), general surgery (5.7 %), 45.5 % of patient had
come between 08.00 am–06.00 pm and 54.5 % had come between
06.00 pm–08.00 am.
Conclusion: Various values were reported in many study. In Turkey,
waiting times for doctor’s examination were reported 2–14 min. But
waiting time in USA were higher (between 22 min–4 h) in a lot of
studies. The percentage of waiting more than 2 h; in Australia 29 %,
Canada 48 %, New Zealand 27 %, England 36 %, US 34 % in the
study. Waiting time in ED is a quality indicator and our results are
satisfying for waiting times either ED doctors or consultants.
Disclosure: No significant relationships.
S84 Abstract
123
PS043
DECREASED BLOOD PRESSURE INCREASES THEPROBABILITY OF REQUIREMENT OFANGIOEMBOLIZATION IN PELVIC FRACTURE PATIENTSWITHOUT CONTRAST EXTRAVASATION ON COMPUTEDTOMOGRAPHIC SCAN
H.C. Huang1, C.Y. Fu1, R.J. Chen1, H.J. Tung2, H.C. Tsuo2
1Trauma and Emergency Surgery, Taipei Medical University-
Wanfang Hospital, Taipei, Taiwan, 2School of Medicine, Taipei
Medical University, Taipei, Taiwan
Introduction: In the management of pelvic fracture, the contrast
extravasation (CE) on computed tomography (CT) is indicative to
need for angioembolization. However, in some patients without CE
on CT scan, the angioembolization is still needed for hemostasis upon
hemodynamic deterioration. We attempted to define the characteris-
tics of pelvic fracture patients without CE on CT scan but requiring
angioembolization.
Materials and methods: During the 6-year investigated period, we
focused on pelvic fracture patients without CE on CT who then
received angioembolization. The fracture type and the level of
decreased SBP (comparison between SBP on arrival and measured
lowest SBP) were analyzed.
Results: In total, 14.4 % patients without CE on CT scan received
angioembolization. Patients with episode of SBP less than 90 mmHg
or SBP decreased over 30 mmHg had a higher rate of need for an-
gioembolization. Furthermore, these patients presented with a higher
rate of unstable pelvic fracture.
Conclusion: In the management of pelvic fracture patients without
episode of hypotension or SBP decreased over 30 mmHg, more
attention should be paid to the higher probability of retroperitoneal
hemorrhage, even the CT scan revealed no CE.
Disclosure: No significant relationships.
PS044
OUTCOMES OF EMERGENCY SURGERY IN ELDERLYPATIENTS (OVER 90 YEARS)
A.V. Kyriakidis1, I. Alexandris1, K. Athanasiou1, I. Perisinakis1,G. Katsagounos1, E. Panagitodi1, C. Papadopoulos2, I. Mpesikos2,I. Tsagaris2
1Department of General Surgery, General Hospital of Amfissa,
Amfissa, Greece, 2Department of Anesthesiology, General Hospital of
Amfissa, Amfissa, Greece
Introduction: The continuous increase of average mean age and the
expanding aging population presenting with advanced disease ensues
that surgeons and anesthesiologists have to cope more often with
acute surgical problems in this group of people.
Materials and methods: We have carried out a study concerning 65
patients above 90 years of age that presented to our surgical depart-
ment the last 2 years and underwent surgery urgently. We operated 34
men and 31 women. All patients were operated within the first 24 h
after their admission to the hospital. The cause was in 21 patients
strangulated hernia, in 23 ileus, 6 presented with perforated ulcer, 14
with acute cholocystitis, 1 with mesenteric artery thrombosis.
Results: The operative mortality rate was 0 %. Complications were
observed in 10 patients (15.3 %). 3 patients died postoperatively
(4.6 %). 2 patients died due to due to myocardial infarction and 1
patient died due to pulmonary embolism.
Conclusion: The choice of anesthesia that was preferred and the early
surgical management of the emergency surgical cases played an
important role in reducing the mortality rate in the elderly group of
patients that were operated in our department. We believe that
combined epidural and spinal anesthesia should be the anesthesia
strongly recommended in surgery in elderly patients.
Disclosure: No significant relationships.
PS045
PREDICTIVE VALUE OF C-REACTIVE PROTEINFOR DIAGNOSIS OF ACUTE PERFORATED ANDNON-PERFORATED APPENDICITIS IN EMERGENCYDEPARTMENT
S.H. Woo, Y.J. Moon, U.J. Lee
Emergency Department, Incheon St’s Mary’s hospital, Incheon,
Korea
Introduction: This study was to determine the relationships between
C-reactive protein (CRP) level of acute perforated and nonperforated
appendicitis in emergency department.
Materials and methods: We retrospectively investigated 200
patients who was diagnosed to appendicitis in emergency medical
center. All patients were operated for suspected acute appendicitis
and diagnosis was confirmed by histology after operation. The
patients were divided two groups: group A with nonperforated
appendicitis and group B with perforated appendicitis. We assessed
and compared epidemiologic, clinical and laboratory data between
two groups. For comparison of diagnostic value, the receiver oper-
ating characteristic (ROC) curve and the logistic regression analysis
were done.
Results: Of the 200 patients, 149 patients were group A, and 51
patients were group B. The mean CRP level in the group B was higher
than in patients with group A (109.25 ± 87.18 aZZ/L vs.
20.39 ± 39.34 aZZ/L, p \ 0.05). Also WBC counts was higher in the
group B (15.43 ± 5.58 9 1000/aZ• vs. 12.47 ± 4.5 9 1000/aZ•,
p \ 0.05). Though the area under the ROC curve (AUC) of CRP level
was greater than WBC counts (0.853 vs. 0.659), so CRP level was
found to be significantly superior to WBC count in predicting per-
forated appendicitis. In logistic regression analysis, CRP level (odds
ratio 1.024, 95 % CI 1.016–1.035) was only independent predictor of
perforated appendicitis.
Conclusion: Increased CRP level in patients who were suspected
appendicitis in emergency medical center was valuable in predicting
perforated appendicitis. In such circumstances, we should consider
the necessities of preoperative antibiotics, the surgical techniques and
the early aggressive management for postoperative complications.
Disclosure: No significant relationships.
Abstract S85
123
PS046
EARLY ENTERAL NUTRITION THROUGHA NASOGASTRIC TUBE IN PATIENTS WITH PERITONITIS
Y.P. Yovtchev1, G. Minkov1, A. Petrov1, T. Vlaykova2, S. Nikolov1
1Surgical Diseases, University Hospital, Stara Zagora, Bulgaria,2Chemistry and Biochemistry, Medical Faculty, Stara Zagora,
Bulgaria
Introduction: Peritonitis remains unresolved surgical and therapeutic
problem in the emergency surgery with hight morbidity and mortality
ranging from 30 to 60 %. This study was designed to investigate the
feasibility and efficacy of early postoperative enteral feeding through
a nasogastric tube in patients with peritonitis.
Materials and methods: For a period of 15 years (1995–2010)
during the surgical clinic 483 patients have undergone with purulent
peritonitis. 120 of them were receiving feedings of a balanced diet
formula through a nasogastric tube in early postoperative period. The
control group of patients were managed with the conventional regi-
men of intravenous fluid administration. All patients underwent
assessment for severity of sepsis and nutritional status at admission.
Nutritional status and nitrogen balance were repeated. The groups
were compared for incidence and duration of complications.
Results: 84 % of study group achieved positive nitrogen balance on
the seven postoperative day as compared to 32 % in the conven-
tionally managed group. The risks of morbidity from wound infection,
wound dehiscence, pneumonia, sepsis, average loss of weight were
significantly lower in the study group: p \ 0.002; p \ 0.05;
p \ 0.0034; p \ 0.005 and p \ 0.04 respectively. The mortality rate
was similar in the control and study groups.
Conclusion: Early enteral nutrition through a nasogastric tube is save
and is associated with beneficial effects such as lower weight loss,
early achievement of positive nitrogen balance, reduce the duration of
postoperative ileus, morbidity and infective complications in patients
operated with purulent peritonitis.
Disclosure: No significant relationships.
PS047
ACUTE RENAL FAILURE AND SYSTEMICMANIFESTATIONS DUE TO VIPER BITE
J. Massalis1, E. Lazaridou2, E. Papadema3, M. Kollia1, T. Floros1,P. Gkanas1
1Surgery, Nafplio General Hospital, Nafplio, Greece,2Anesthesiology, Nafplio General Hospital, Nafplio, Greecel,3Radiology, Nafplio General Hospital, Nafplio, Greece
Introduction: Animal bites are a substantial health problem in rural
areas while poison inoculation by snakes can lead to clinical mani-
festations. With the presentation of the following case we are stating
that viper bites can lead to acute renal failure and very serious clinical
manifestations.
Materials and methods: We are referring to a 27 year old patient,
who was sent to our hospital from a smaller unit 24 h after a viper
bite, which was in the right upper arm with acute renal failure and
multiple clinical manifestations. In particular the patient had hypo-
tension, coagulation disorders, oedema (hemorrhagic) with phlegmon
and encysted fluid (U/S finding) in the right upper arm and thoracic
wall. Other findings were unilateral pleural collections, myositis,
rhabdomyolysis and multifactoral acute renal failure with severe
hemolysis.
Results: The patient was administered pharmaceutical therapy: anti-
venom shot, RBC and FFP transfusion, intravenous fluids and
monitoring of CVP as well as antibiotics. Even though the patient had
severe nephrotoxic, hemotoxic and cytotoxic disorders due to the
snake bite, recovery was successful after being bedridden for 10 days
without any surgical procedures.
Conclusion: Snake bite inoculation can lead to severe multisystemic
reactions with the need to closely monitor patients and surgical
intervention in the case of necrotic myositis-fasciitis.
Disclosure: No significant relationships.
PS048
IMMUNOHORMONAL CONSEQUENCES ANDMANAGEMENT TACTICS IN SPLEEN INJURY
I. Bihalskyy, S. Chooklin
Department of Surgery, Medical University, Lviv, Ukraine
Introduction: Splenectomy often leads to multiple complications in
the nearest and remote postoperative period and can have the unfa-
vourable consequences.
Materials and methods: 111 patients, which underwent the surgical
interventions on lien by its injury, were examined. The complex value
of the immune status of organism (leukocytes’ subpopulations,
immunoglobulins, immune complexes, phagocytic activity of neu-
trophils, synthetic function of monocytes) and radioimmunologic
determination of hormones and eicosanoids were performed. It is
necessary to mark, that combined injury of the spleen was established
in 74 out of 141 patients, when, except of spleen, other organs were
damaged. Out of 141 operations in 111 the splenectomy, in 15 cases
the splenectomy with the tissue autotransplantation of the lien in the
greater omentum and in 15 cases the organ preservation operations
were performed.
Results: Purulent-septic postoperative complications were marked in
37 patients. This was connected with inadequation of the immune
answer. The autotransplantation of the lien tissue, to some extent,
normalised immunohormonal parameters and activised the compen-
satory functions. However, the hemocoagulative disorders intensified.
In the remote terms, the post splenectomy syndrome manifested itself
in patients, which underwent the splenectomy in childhood. It was
connected with the serious disturbances in the hormonal and immune
regulation and hemostasis too. At that predisposition the infections
and thrombohemorrhagic processes prevailed. The autotransplanta-
tion of the lien tissue could not afford defense of the organism in full
value.
Conclusion: Thus, at the traumatic injury of the spleen the prevalence
must be given to the organ preservative operations. The immuno-
hormonal monitoring is necessary for these patients.
Disclosure: No significant relationships.
S86 Abstract
123
PS049
TRAUMATIC DIAPHRAGMATIC INJURY: A MARKER OFSERIOUS INJURY CHALLENGING TRAUMA SURGEONS
M. Pol, A. Gupta, S. Kumar, B. Mishra, M. Singhal, S. Sagar
Trauma Surgery, Jpn Apex Trauma Center, All India Institute of
Medical Sciences, Delhi, India
Introduction: Traumatic diaphragmatic injuries (TDI) is occult
marker of serious injury and are often association with other visceral
injuries causing substantial morbidity and mortality. Aim: To study
prevalence, identify the predictors of mortality and study the accuracy
of investigations.
Materials and methods: Retrospective analysis of TDI from January
2007 through October 2011. Ed records, operative details, and
autopsy reports were reviewed to determine characteristics of injury,
treatment and outcome. Statistical analyses were performed using the
SPSS ver.15 software.
Results: TDI was identified in 64 individuals. 32 cases underwent
surgery, in 7 cases preoperative diagnosis was made. 32/37 nonsur-
vivors were brought dead to the hospital. Mean age was 26.22 among
survivors and 37.04 among nonsurvivors, the mean injury severity
scores (ISS) was 19.33 in survivors and 42.11 among nonsurvivors.
Bilateral sides of diaphragmatic injury were noted in 12 cases.
Pearson Chi square test suggested that increased ISS (p \ 0.000001),
increased NISS (p \ 0.000001), increasing age (p value of 0.022) and
bilateral TDI (p = 0.006) are the predictors of the mortality. The
prevalence of TDI was 2.35 %, and CT scan did not replace intra-
operative diagnosis of TDI in our study.
Conclusion: TDI is a marker of serious injury challenging trauma
surgeons. Those with increased ISS, increased NISS, increasing age
and bilateral involvement of diaphragm are at the greatest risk of
mortality. Intraoperative visualization of diaphragm is the most reli-
able way of diagnosing TDI.
References: 1. Reid J. Diaphragmatic hernia. Edin Med Surg.
1840;53:104–7. 2. Scharff JR, Naunheim KS. Traumatic diaphrag-
matic injuries. Thorac Surg Clin. 2007;17:81–5.
Disclosure: No significant relationships.
PS050
DAMAGE CONTROL FOR SEVERE POST-PARTUMHEMORRHAGE
F. Guinaudeau1, J. Jarry2, M. Imperato2, V. Nguyen2, F. Milou1,P. Michel2
1HIA Desgenettes, Lyon, France, 2Visceral Surgery,
HIA Desgenettes, Lyon, France
Introduction: Postpartum hemorrhages represent the main cause of
maternal mortality in France. According to the latest national
epidemiological survey, they are responsible of 116 maternal
deaths over the period 2001–2006 which represent an incidence of
2.4 per 100,000 births. Although the concept of damage recently
extended to gynaecologic surgery, its indications and technique
remain relatively unknown since it is rarely performed in obstet-
rical surgery.
Materials and methods: We report the case of a 35 years old patient,
carrying a twin pregnancy, who underwent cesarean section at
33 weeks of amenorrhea in a context of pre-eclampsia. She presented
a severe refractory postpartum hemorrhage which was not stopped in
spite of an emergency hysterectomy and ligation of hypogastric
arteries. The surgeon decided to perform a damage control with a
pelvic packing which was successful. The patient was transferred to
the intensive care unit and the packing was removed after 48 h. The
patient was discharged home the 26th postoperative day in good
health.
Results: The traditional management of postpartum hemorrhage
include direct and selective vascular ligation with suture or vascular
clip, insertion of topical agents, bilateral ligation or embolization of
uterine or hypogastric arteries, and even hysterectomy. However, in
case of refractory hemorrhage, a damage control procedure with
pelvic packing appears to be an effective lifesaving solution. The
pelvic packing technique is simple and requires little equipment and
training.
Conclusion: Damage control with pelvic packing is an effective
salvage procedure for refractory postpartum hemorrhage. Thus,
obstetricians and gynaecologists should master its indication and
technique.
Disclosure: No significant relationships.
PS051
PRIMARY SURVEY AND COMPLEMENTARY EXAMS:STUDY OF THEIR PREDICTIVE VALUE TO ANTICIPATETHE NEED FOR SURGERY IN PATIENTS WITH TORSOSTAB WOUNDS
I. Martınez-Casas, J. Sancho Insenser, M. Climent Agustı,E. Membrilla Fernandez, M.J. Pons Fragero, J. Guzman Ahumada,L. Grande Posa
General and Digestive Surgery, Hospital Universitari del Mar,
Barcelona, Spain
Introduction: Observation is the gold standard for the treatment of
stable patients with stab wounds. In spite of it, there are different
management algorithms and consensus to define optimal observation
times is lacking. The aim of the study is to analyze the value of
primary survey (PS) and complementary exams (CE) to predict the
need for surgery or anticipate complications in order to minimize
observation times.
Materials and methods: Retrospective analysis of a prospectively
maintained polytrauma patients registry, selecting those with torso
stab wounds (TSW). Main variable of the study is the need for sur-
gery. Different parameters concerning PS and CE are considered for
bivariate analysis.
Results: Between 2006 and 2009, 198 patients were attended for
potentially penetrating TSW. Mean ISS was 7.8. Half of patients pre-
sented with multiple wounds accounting for a total of 251, witch
distributed in 23 % cervical, 46 % thoracic and 31 % abdominal.
Mortality was 0.5 %. Seventy-three patients were operated on. Surgery
was immediate in 59 % of cases, 27 % early and 14 % late. Only 2
patients had surgery after 24 h, both had normal PS but positive com-
puted tomography. The need for surgery was associated with lower RTS
score, evisceration, active bleeding or penetrating wound identified on
examination. Initial and successive haemoglobin levels were signifi-
cantly lower in surgical patients. Positive CT was also associated with
surgery. 18 % of patients had complications and they concentrate in
surgical patients. Complication rate was not significantly different
when comparing late with immediate or early surgeries. Ten per cent of
patients with normal PS and CE required surgery.
Abstract S87
123
Conclusion: None of the studied parameters could individually pre-
dict the need for surgery. PS seems to be of greater importance to
decide to operate on but liberal policy must exist for the use of CT
scan. Observation for 24 h is recommended in stable patients with
potentially penetrating stab wounds.
Disclosure: No significant relationships.
PS052
IN THE MANAGEMENT OF PATIENTS WITHCONCOMITANT UNSTABLE HEMODYNAMICS ANDNEGATIVE SONOGRAPHIC EXAMINATIONS: THEBENEFITS OF APPLICATION OF SELECTIVE COMPUTEDTOMOGRAPHY AND ANGIOEMBOLIZATION
H.C. Tsuo1, H.J. Tung1, C.Y. Fu2, R.J. Chen2
1School of Medicine, Taipei Medical University, Taipei, Taiwan,2Trauma and Emergency Surgery, Taipei Medical University-
Wanfang Hospital, Taipei, Taiwan
Introduction: The sonographic examination can rapidly identify free
fluid in the abdominal or thoracic cavity, which is indicative of
hemorrhaging requiring emergency surgery in multiple-trauma
patients. In patients with negative sonographic examination results, it
is difficult to identify the site of the hemorrhage and to plan treatment
accordingly. We attempted to delineate the role of selective computed
tomography (CT) scanning and transarterial angioembolization(TAE)
in the management of such unstable patients.
Materials and methods: During the 80-month investigated period,
patients with concomitant unstable hemodynamics and negative so-
nographic examination results were identified. Their demographic and
time to starting embolization were recorded. The initial systolic blood
pressure (SBP) in the ED were compared with the SBPs after TAE.
Results: A total of 39 patients were enrolled, and 87.2 % required
TAE with significantly improvement. There were 19 patients who
received TAE without CT scan because the site of hemorrhage was
obvious. Seventeen patients received a CT scan during the time
required for angiography preparation. Eleven of them received sub-
sequent TAE on the basis of the CT scan findings, and the treatment
plan was changed in the other six patients. There was no significant
difference between patients with or without a CT scan with respect to
the time interval between arrival and starting embolization.
Conclusion: The TAE is suggested in the management of patients
with concomitant unstable hemodynamics and negative sonographic
examination results. During the time interval required for angiogra-
phy preparation, a CT scan provides valuable information for further
decision making without delaying definitive treatment.
Disclosure: No significant relationships.
PS053
ANEMIA TOLERANCE: PATIENT BLOOD MANAGEMENTIN SURGERY AND TRAUMA PATIENTS
C.W. Hoenemann1, O. Hagemann2, D. Doll1
1Chefarzt der Abteilung fur Anaesthesie und Operative
Intensivmedizin, Marienhospital Vechta, Vechta, Germany,2Abteilung fur Anasthesiologie und Operative Intensivmedizin,
Marienhospital Vechta, Vechta, Germany
Introduction: Anemia is highly prevalent in trauma patients. Acute
anemia in patients with trauma or surgery is multifactorial, including
blood lost during accident and surgery or inhibition of erythropoiesis
due to trauma- or surgery-induced inflammation. Allogenic blood
transfusion (ABT) is commonly used to rapidly and effectively restore
hemoglobin (Hb) levels and is life-saving. Allogenic blood, however,
is a rare and expensive resource. ABT is not a risk-free therapy,
because it may increase the rate of fluid overload, transfusion-related
acute lung injury or postoperative infection.
Materials and methods: We report on surgical patients, who were
hospitalized in our trauma and intensive care unit.
Results: Due to the blood loss the Hb decreased in some patients
down to 4.6 g/dl. Depending on age and co morbidities acute anemia
was tolerated. Patients got alternatively 500–1,000 mg ferric-carb-
oxymaltose (ferinject(c)) as 250 ml infusion, some combined with
erythrocyte substitution. Due to iron substitution some patients gained
up to 3 g/dl Hb within 3–4 days due to endogenous erythropoesis.
The infusion of ferinject was well tolerated and there were no adverse
events.
Conclusion: Our reports describe the correction of acute anemia in
patients with surgery or trauma. Anemia was in some patients well
tolerated down to Hb levels of 4.6 g/dl. Iron substitution with ferin-
ject (c) proved to be effective, fast and safe in treating anemia.
References: 1. Shander et al. Am J Med. 2004;116(Suppl 7A):58S–
69S. 2. Garcia-Erce et al. Med Clin (Barc). 2003;120:161–6. 3.
Goodnough LT, et al. Br J Anaesth. 2011;106:13–22. 4. Beris P, et al.
Br J Anaesth. 2008;100:599–604.
Disclosure: lecturer for vifor pharma Gmbh, Munich.
PS054
BICYCLE HANDLEBAR: A SERIOUS CAUSE OFABDOMINAL PENETRATING TRAUMA IN CHILDREN
H.M. Fernandes, A.L.C. Silva, V. Castro, C. Santos Costa,T.N. Santos
Surgery Department, Alto Ave Hospital Center, Guimaraes, Portugal
Introduction: Trauma is the leading cause of morbidity and mortality
in the pediatric population. The abdomen is the third most commonly
injured anatomic region in children, after head and extremities.
Abdominal trauma accounts for 8–10 % of all trauma admissions to
pediatric hospitals. Penetrating injuries are less common than blunt
abdominal trauma and account for 8–12 % of pediatric abdominal
trauma.
Materials and methods: The authors present the clinical case of a
9 years old male patient, with a history of bicycle accident.
Results: The patient was presented to the emergency room with a
penetrating abdominal trauma by bicycle handlebar. There was no
significative description of head, thoracic or limbs trauma. At phys-
ical examination, a gastric evisceration was present at midline of the
abdomen and a laparotomy was performed. At the surgery, were
identified lacerations of pars flacida, root of mesentery and sero-
muscular layer of jejunum loop, all corrected with interrupted 3-0
absorbable sutures. No other lesions were found. The postoperative
course was uneventful.
Conclusion: The majority of the cases of abdominal trauma by
handlebars results in blunt trauma, although the penetrating trauma
may be a complication. The abdominal wall of a child has a thinner
musculature providing less protection to underlying structures and is
more vulnerable to rupture.
S88 Abstract
123
Although nonoperative intervention is increasingly used in selected
patients, surgical therapy for PAT is indicated in hemodynamic
instability, peritonitis, diffuse and poorly localized pain that fails to
resolve and, as in this case, the presence of evisceration.
References: 1. JacobsLM, et al. Advanced trauma operative man-
agement: surgical strategies for penetrating trauma. Woodbury: Cine-
Med, Inc; 2004. 2. Lam JP, et al. Delayed presentation of handlebar
injuries in children. BMJ. 2001;322(7297):1288–9.
Disclosure: No significant relationships.
PS055
OUR SURGICAL TREATMENT RESULTS OF HEARTINJURIES
H.T. Keceligil, S.M. Yucel, M. Bahcivan, M.K. Demirag, S. Celik,F. Kolbakir
Cardiovascular Surgery, Ondokuz Mayıs Unıversity Medical Faculty,
Samsun, Turkey
Introduction: Cardiac injuries have very high mortality rate and
require emergency diagnosis and surgical treatment. In this article we
aimed to share clinical characteristics and results of patients whom
operated due to cardiac injuries in our clinic.
Materials and methods: In our clinic (Ondokuz Mayis University
Hospital) nearly 25-year period, eighteen patients were operated due
to cardiac injury. Twelve patients were male and six patients were
female. The average age of the patients was 44.7. The etiology of
cardiac injury was stab wound in nine patients (50 %), iatrogenic
causes in seven patients (38.9 %) and gunshot wounds in two patients
(11.1 %).
Results: Mortality occured in three patients (16.6 %). The most fre-
quently injured cardiac cavities, respectively right ventricle in seven
patients (38.8 %), left ventricle in four patients (22.2 %), coronary
arteries in four patients (22.2 %), left atrium in one patient (5.6 %),
right atrium in one patient (5.6 %) and left ventricle-left atrium in one
patient (5.6 %). Median sternotomy was performed in fourteen
patients (77.8 %) and left anterior thoracotomy was performed in four
patients (22.2 %).
Conclusion: Cardiac injuries are highly lethal pathologies. For this
reason, diagnostic methods and supporting therapy should be applied
so fast. Emergency surgical approach should be applied without
delay.
References: 1. Antoniades L, Petrou PM, Eftychiou C, Nicolaides E.
A penetrating heart injury resulting ventricular septal defect. Hellenic
J Cardiol. 2011;52(1):71–4.
Disclosure: No significant relationships.
PS056
IMPLEMENTING AN ACUTE CARE SURGERY SERVICE:THE CANADIAN EXPERIENCE
M. Sudarshan1, M. Al-Habboubi2, E. St.Louis3, X. Tan2, K. Khwaja2
1Trauma Surgery, McGill University, Montreal, Canada, 2MUHC,
Montreal, Canada, 3McGill, Montreal, Canada
Introduction: We implemented an Acute Care Surgery (ACS) ser-
vice at a large Canadian teaching hospital and analyzed how such a
service impacts time to see patient, morbidity and mortality.
Materials and methods: Data from the ACS service was collected
prospectively over a 3 month period. A retrospective review of all
general surgery admissions from the emergency room (pre-ACS) over
a 1 year period was also conducted. Factors were compared including
length of stay, complications, and in-hospital mortality.
Results: 121 admissions were identified prospectively from the ACS
service and 527 patients upon retrospective review of the pre-ACS
service. In-hospital mortality was 2 % for the pre-ACS group and
2.4 % for the ACS group (NS, p = 0.73). 29 % of patients in the pre-
ACS had a length of stay of [7 days compared to 20 % in the ACS
group (p B 0.0001). 89 % of patients in pre-ACS group had no in-
hospital complications compared to 80 % of patients in the ACS
group (p = 0.0087). The average time to first contact with the patient
after consult request was 211 min in the pre-ACS group and 103 min
in the ACS group. Charlson co-morbidity index was [5 for 38 % of
the pre-ACS and 28 % for the ACS group (p = 0.024).
Conclusion: Our results suggest an ACS service can reduce the time
to first contact with patient possibly reducing emergency room bur-
den, with patients having a shorter length of stay. In-hospital
complications were higher but the Charlson co-morbidity index was
also higher for the ACS group as well.
Disclosure: No significant relationships.
PS057
PROGNOSTIC FACTORS FOR MORBIDITY ANDMORTALITY IN THE ACUTE CARE GENERAL SURGERYPOPULATION
M. Sudarshan1, E. St.Louis2, M. Al-Habboubi2, X. Tan3, K. Khwaja3
1Trauma Surgery, McGill University, Montreal, Canada, 2McGill
University, Montreal, Canada, 3MUHC, Montreal, Canada
Introduction: Our objective is to classify prognostic factors in
emergency general surgery patients that can lead to prediction and
early identification of patients with increased morbidity or mortality,
guiding more aggressive resuscitation and earlier intervention for this
important population.
Materials and methods: A retrospective review of all general sur-
gery admissions from the emergency room at a large Canadian
teaching hospital over 1 year was conducted. Several factors were
analyzed from the history, physical exam and laboratory measures
and were correlated with in-hospital complications, the requirement
for surgery, length of stay in hospital, and mortality.
Results: 527 patients were admitted to the general surgery ward from
the emergency room. Most common conditions included acute
appendicitis (21.6 %) and acute cholecystitis (8.5 %) and small bowel
obstruction (12.5 %). The presence of more than 3 co-morbidities and
an age of more than 60 were predictive (p \ 0.05) of worse outcomes
in terms of mortality, increased length of stay, increased in-hospital
complications and conservative management of the surgical condi-
tion. Presence of tachycardia (p \ 0.05) was associated with a higher
rate of mortality and longer length of stay. Increased urea (p \ 0.05)
levels were found in those with higher mortality and increased rate of
complications. Duration of surgery directly correlated with the
number of in-hospital complications.
Conclusion: Our results demonstrate that by identifying unique key
prognostic indicators on first contact, it is possible to gauge the risk of
Abstract S89
123
adverse outcomes for the emergency general surgery patient
population.
Disclosure: No significant relationships.
SKELETAL TRAUMA: PELVIS AND
POLYTRAUMA
PS058
THE USE OF INTRAOPERATIVE COMPUTERTOMOGRAPHY IN ACETABULAR AND PELVICRING FRACTURES
D. Olsson, H. Eckardt
Orthopedic Traumecenter, Rigshospitalet, København Ø, Denmark
Introduction: Malreduced acetabulum fractures cause severe post-
operative coxarthrosis, and intraoperative evaluation of the reduction
and osteosynthesis of acetabulum fractures is important. Two-
dimensional fluoroscopy shows only tangential views of the acetab-
ulum roof. We have used intraoperative imaging with an O-arm
(Medtronic�) to evaluate the reduction and questioned whether the
intraoperative CT-like images improve reduction after acetabulum
fracture.
Materials and methods: This is a retrospective review of retro-
spective and prospective collected data. Between October 2010 and
September 2011 there have been done 24 operations on the pelvis
with the O-arm at Rigshospitalet, Denmark. These patients fracture
type, trauma mechanism etc. have been recorded by the surgeon in a
database. As controls all patients that have been treated for a trau-
matic pelvic fracture between November 2009–October 2010 was
identified. In all 80 control patients (41 acetabular and 39 pelvic ring
fractures). Data have been collected in digital patient records. Pre
operative radiographic pictures where used to classify the type of
fracture, and divide the patients and controls after fracture type. The
routine postoperative radiograph where used to evaluate the reduc-
tion. Chi2 scores was calculated comparing the quality of reduction
between the groups.
Results: In the O-arm group 10/19 (53 %) had anatomic reduction of
their fracture and 2/19 (10 %) had a poor result. In the control group
17/41 (41 %) had anatomic reduction and 12/41 (29 %) had a poor
result. The differences were not significant. In complex fracture types
(t-type and two-column) the reduction with the o-arm was signifi-
cantly better than in the control group. Operation time and functional
outcome was not different between groups.
Conclusion: Intraoperative imaging with the O-arm produces CT-like
reconstructed three-dimensional images, which facilitates intraoper-
ative evaluation of reduction, and offers a possibility to correct
malreduced fractures before closing the wound. Our results showed a
tendency towards better results when the O-arm is used for intraop-
erative evaluation of acetabulum fractures.
References: 1. Atesok K, et al. The use of intraoperative three-
dimensional imaging (ISO-C-3D) in fixation of intraarticular frac-
tures. Injury. 2007;38(10):1163–9. 2. Kendoff D, et al. Intraoperative
3D imaging: value and consequences in 248 cases. J Trauma.
2009;66(1):232–8.
Disclosure: No significant relationships.
PS059
THE ANTERIOR–POSTERIOR COMPRESSION TYPEPELVIC FRACTURE HAS AN INCREASED RISK OFBILATERAL INTERNAL ILIAC ARTERY HEMORRHAGE
H.J. Tung1, C.Y. Fu2, H.C. Tsuo1, R.J. Chen2
1School of Medicine, Taipei Medical University, Taipei, Taiwan;2Trauma and Emergency Surgery, Taipei Medical University-
Wanfang Hospital, Taipei, Taiwan
Introduction: The anterior-posterior compression (APC) pelvic
fracture creates a complete diastasis of the anterior pelvis, which
might be associated with bilateral sacroiliac joint injuries and further
bilateral arterial injuries. We evaluated the correlation between APC
pelvic fracture and the need for bilateral internal iliac artery (IIAs)
embolization.
Materials and methods: During the 86-month investigational period,
the patients with bilateral contrast extravasation (CE) revealed by
angiography were compared with the patients with unilateral CE
revealed by angiography. Among the patients with only unilateral
positive findings (CE or hematoma formation) on computed tomo-
graphic (CT) scanning, the characteristics and risk factors of patients
who required bilateral IIAs embolization were analyzed.
Results: Eighty-four patients were enrolled in the current study. The
rate of APC pelvic fracture among patients who received bilateral
IIAs embolization was 70 % (21/30), which was significantly higher
than the rate among patients who received unilateral IIA embolization
(29.6 %, 16/54) (p \ 0.05). Of the patients with only unilateral
positive findings on CT scanning, 24.1 % (14/58) underwent bilateral
IIA embolization because of bilateral CE revealed by angiography.
There were also more patients with APC pelvic fracture in this group
(79.4 vs. 31.3 %, p \ 0.05).
Conclusion: In the management of APC pelvic fracture, more
attention should be paid to the higher probability of bilateral hem-
orrhage. Bilateral IIAs embolization should be considered in patients
with APC pelvic fracture.
Disclosure: No significant relationships.
PS060
TREATMENT OF UNSTABLE SACRAL FRACTURE WITHA MODIFIED GALVESTON TECHNIQUE
K. Koshimune1, Y. Ito2, T. Takigawa3, Y. Yagata4, Y. Ueda4
1Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe/Japan, 2Kobe
Redcross Hospital, Kobe, Japan, 3Orthopaedic Surgery, Okayama
University Hospital, Okayama, Japan, 4Orthopaedic Surgery, Hyogo
Emergency Medical Center, Kobe, Japan
Introduction: AO type C pelvic ring fracture is extremely unstable
and requires rigid fixation. The Galveston technique is one of the
strongest fixation methods for such unstable sacral fracture. However,
surgical site infection due to big skin incision is a common compli-
cation of this technique. To overcome this surgical demerit, we have
modified and developed the original Galveston technique. The
S90 Abstract
123
purpose of this study was to investigate the usefulness of the modified
minimum invasive Galveston technique.
Materials and methods: Patients: nine cases (3 male, 6 female; mean
age 41 years) were included in this study. All cases were AO type C
pelvic ring fracture associated with unstable sacral fracture and were
treated with the modified Galveston technique. Causes of the injury
were traffic accident in 3 cases, diving in 5 cases and fall in 1 case.
Surgical records were reviewed retrospectively. Surgical method: The
modified Galveston technique coordinated lumbar pedicle screws,
iliac screws, and rods construct. Our method utilized IsoC-3D navi-
gation system. Lumbar pedicle screws were inserted percutaneously
using a navigation system. Two screws were inserted into iliac under
direct vision with a small skin incision. A rod was connected between
iliac screws and lumbar pedicle screws. Fracture reduction was
applied if necessary.
Results: Average amount of blood loss was 205 ml, and average
operation time was 213 min. No serious complications including
surgical site infection were observed.
Conclusion: There are many surgical options for sacral fracture such
as iliosacral screw fixation, iliosacral plate system, and sacral bar
system. Although these methods can be applied less invasively,
appropriate fracture reduction and rigid stability are not achieved. Our
modified Galveston method is a minimum invasive technique pro-
viding a sufficient stability. The modified Galveston technique dose
not need to expose damaged sacrum, that enables to reduce blood
loss, operation time and surgical site infection. We believe that our
less invasive technique is suitable for multiple trauma patients. Our
modified Galveston technique can be a useful surgical method for an
unstable sacral fracture.
Disclosure: No significant relationships.
PS061
CLINICAL RESULTS OF OPERATIVE TREATMENTTHROUGH SINGLE LESS INVASIVE ANTERIORAPPROACH (STOPPA MODIFICATION) FOR ASSOCIATEDFRACTURES OF THE ACETABULUM
T. Noda1, T. Ozaki1, Y. Shimamura1, Y. Kinami1, R. Nakahara1,Y. Yamakawa1, T. Kanazawa1, M. Inoue1, K. Ogawa2
1Department of Orthopaedic Surgery, Okayama University Graduate
School of Medicine, Dentistry and Pharmaceutical Sciences,
Okayama, Japan, 2Division of Orthopaedic Trauma, Fukuyama City
Hospital Emergency Medical Center, Hiroshima, Japan
Introduction: The use of a single nonextensible approach for the
treatment of associated fractures of the acetabulum has been popular
in recent years. And several modifications of the anterior approach
have been reported. We assessed clinico-radiological outcomes of the
modified Stoppa approach combined with lateral window of the ili-
oinguinal approach (MS + LW) for the treatment of associated
acetabular fractures.
Materials and methods: 24 patients treated with MS + LW approach
were included in this study. Average age of the patients was 56 years
old. There were 19 both column fractures, three anterior column
posterior hemitransverse, and two T-type fractures. Retrospective data
on the 24 patients was analyzed.
Results: Average time to operation was 10 days. Average blood loss
was 1593 ml, and average operative time was 264 min. 58 % of the
reductions were graded anatomical (0–1 mm), 38 % were graded
imperfect (2–3 mm), and 4 % were graded poor ([3 mm). Clinical
outcomes (Matta) were 33 % excellent, 58 % good, 4 % fair, and 4 %
poor. Four patients had an incomplete obturator nerve palsy and one
patient had an incomplete sciatic nerve palsy postoperatively. One
patient underwent a total hip arthroplasty due to posttraumatic
arthritis. Average follow-up period was 11 months.
Conclusion: Use of the single MS + LW approach for the treatment
of associated acetabular fractures without posterior wall allows good
visualization and access to the quadrilateral surface and posterior
column. Anatomical or nearly anatomical reductions and Good out-
comes were obtained in the majority of these complex fractures such
as both column fractures. MS + LW approach is one of good options
as alternative to the classical ilioinguinal approach.
Disclosure: No significant relationships.
PS062
TREATMENT FOR IPSILATERAL PELVIC AND FEMORALFRACTURES (THE FLOATING HIP INJURY)
Y. Yamakawa1, T. Noda1, T. Ozaki1, R. Nakahara1, Y. Shimamura1,Y. Kinami2, K. Saiga3
1Orthopaedics, Okayama University, Okayama, Japan, 2Department
Of Community Medicine, Okayama University Graduate School,
Okayama/Japan, 3Orthopaedics, Tottori Municipal Hospital, Tottori,
Japan
Introduction: Ipsilateral pelvic and femoral fractures are called
floating hip injury and it has been difficult to treat and challenging for
orthopaedic trauma surgeons.
Materials and methods: From 2003 to 2011, we have experimented
with 11 patients of treatment for floating hip. Nine patients except for
two of whom died soon after injury were included in this study.
Regarding the area of their femoral fractures, four patients had
proximal femoral fractures, four patients had mid-shaft femoral
fractures, and one patient had a distal femoral fracture. And regarding
pelvis, six patients had pelvic ring fractures, two patients had ace-
tabular fractures, and one patient had both.
Results: Internal fixation was performed from the day of injury to
12 days after injury, with an average of 5.5 days. Regarding the
pelvic fractures, temporarily external fixation was performed in 5 out
of 6 patients for pelvic ring fractures. Internal fixation was performed
from 4 to 13 days after injury, with an average of 8.4 days. Five
patients were treated separately the pelvic fractures and the femoral
fractures in two periods, while the other 4 patients were performed
internal fixation on the same operation. We performed internal fixa-
tion in the following order: (1) Femoral fracture, (2) Pelvic fracture.
One patient had a deep infection after pelvic surgery. Seven patients
regained their ability to walk on their own.
Conclusion: Our strategy that damage control surgery by performing
temporarily external fixation and/or staged management should be
applied and the femoral fractures should be internally fixated first,
was effective for floating hip injuries.
Disclosure: No significant relationships.
Abstract S91
123
PS063
PROBLEMS AFTER KOCHER LANGENBECK APPROACHFOR POSTERIOR ACETABULAR FRACTURES
M. Nagea1, O. Lupescu2, G.I. Popescu1, C. Patru3, D. Lupescu4,D. Sucoveschi1.
1Orthopedic and Trauma Clinic, Clinical Emergency Hospital
Bucharest, Bucharest, Romania, 2Orthopedics and Trauma, Clinical
Emergency Hospital Bucharest, Bucharest, Romania, 3Orthopedics
and Trauma Clinic, Clinical Emergency Hospital Bucharest,
Bucharest, Romania, 4General Medicine, Clinical Emergency
Hospital Bucharest, Bucharest, Romania
Introduction: The Kocher Langenbeck approach offers good condi-
tions for reduction and fixation of fractures of the posterior wall of the
acetabulum. The authors evaluate the long term results of this
approach and identify some problems.
Materials and methods: The authors analyse 28 cases operated
between 01.10.1999 and 01.01.2009 for posterior acetabular fractures,
using this approach, assessing the impairment of walking, the inci-
dence of post-operative nervous complications and the problems of
the implant position. The late complications which were not clearly
related to the approach itself were excluded so were those due to
general complications.
Results: The problems concerning only the approach in the studied
group were: malfunction of the posterior muscles in 5 cases, 2 of them
having walking impairment. Nervous complications appeared in 3
cases, and malposition of the implant appeared in 4 cases. In 2 cases
intra-articular position of the screws was demonstrated by post-
operative CT scans, so secondary screw removal was necessary in
these cases.
Conclusion: Despite the major advantages in posterior wall fracture
surgery, the posterior approach can produce by itself some problems
because it involves the posterior muscles and is closely related to
the koint and the sciatic nerve. The important issue is how these
problems can be avoided in order to improve the outcome of the
patients.
References: 1. Letournel E, Judet R. Fractures of the acetabulum.
New York: Springer; 1993. 2. Giannoudis PV, et al. Operative
treatment of displaced acetabular fractures. A metaanalysis. J Bone
Joint Surg [Br]. 2005;87-B:2–9.
Disclosure: No significant relationships.
PS064
TRANSCATHETER EMBOLOTHERAPY AFTER EXTERNALSURGICAL STABILIZATION IS A VALUABLE TREATMENTALGORITHM FOR PATIENTS WITH PERSISTENTHEMORRHAGE FROM UNSTABLE PELVIC FRACTURES:OUTCOMES OF A SINGLE CENTRE EXPERIENCE
W. Metsemakers1, P. Vanderschot1, S. Nijs1, S. Heye2, G. Maleux3
1Trauma Surgery, University Hospitals Leuven, Leuven, Belgium,2Interventional Radiology, University Hospitals Leuven, Leuven,
Belgium, 3Interventional Radiology, Leuven, Belgium
Introduction: The management of hemodynamically unstable
patients with severe pelvic fractures remains a challenge. Various
treatment strategies have been advocated. Our study describes the
management and outcome of this patient population, with emphasis
on the use of angiographic embolization (AE).
Materials and methods: Between January 2002 and July 2010 we
retrospectively identified patients with unstable pelvic fractures from
the University of Leuven trauma registry. We treated 648 consecutive
pelvic fractures. In this group there were 14 hemodynamically
unstable patients with severe pelvic fractures who underwent angio-
graphic embolization.
Results: The median age in the angiographic embolization-group was
59 years and the median ISS (Injury Severity Score) was 36. Of the
14 patients, 12 (86 %) received initial external fixation, 2 where
treated with a C-Clamp (14 %). In total 3 (21 %) patients died during
the period of hospitalization, none of them because of uncontrolled
hemorrhage. Pelvic packing was only performed for open fractures or
during a damage control laparotomy. The complication rate due to
angiographic embolization was extremely low.
Conclusion: Angiographic embolization is a save and life saving
procedure for the hemodynamically unstable patient with pelvic ring
disruption. Early identification of patients who would benefit from
this procedure is of primordial importance. In our opinion primary
surgical treatment remains the strategy of choice, followed by
angiographic embolization for patients who do not respond to the
initial therapy. Pelvic packing is reserved for patients with open
fractures and those in need for a damage control laparotomy. The key
to successful management lies in the multidisciplinary approach of
every individual patient.
Disclosure: No significant relationships.
PS065
EARLY DIAGNOSIS OF AVASCULAR NECROSIS USINGMRI AND NUCLEAR SCAN IN POSTTRAUMATICPOSTERIOR DISLOCATION OF HIP
N.R. Gopinathan1, L. Kumar2, R.K. Sen1, V.K. Viswanathan1
1Orthopaedics, PGIMER, Chandigarh/India, 2Orthopedics, PGIMER,
Chandigarh, India
Introduction: Avascular necrosis of femoral head is one of the
dreaded complications of the posterior dislocation of hip. Most
commonly affected are young persons. It is very important to diag-
nose the AVN early in those cases where hip has been dislocated for
more than 12 h. the present study has thus been planned to assess the
role of MRI and SPECT in the early diagnosis of the condition.
Materials and methods: The study was conducted in patients
attending orthopaedic trauma services in PGIMER, Chandigarh with
the diagnosis of dislocation or fracture dislocation of hip joint. All
those patients of age between 15 and 50 years, where reduction has
been delayed for more than 12 h, were enrolled in the study after
getting written informed consent for the study. the patients were
followed up with serial clinical examination, SPECT and MRI at 6, 12
and 24 weeks.
Results: In the present series we were able to diagnose one case of
AVN clinically, nuclear scan and MRI has detected all 5 AVN cases.
MRI diagnosed 3 cases at 6 weeks and 2 cases at 12 weeks. Nuclear
scan diagnosed 2 cases at 6 weeks and 3 cases at 12 weeks.
Conclusion: Nuclear scan is more specific than MRI to diagnose
AVN in traumatic cases.
MRI is highly sensitive for screening of AVN. If AVN appears early
on MRI i.e. around at 6 weeks, it is less likely to regress or disappear.
Appropriate time for screening the AVN by MRI and nuclear scan
(SPECT) is around 12 weeks and patients should be further observed
S92 Abstract
123
for next 3 months to assess the AVN progression. Preventive mea-
sures should be taken up during this period to prevent collapse of the
femoral head.
Disclosure: No significant relationships.
PS066
SURGICAL MANAGEMENT OF PERSISTENT MOREL–LAVALLEE LESIONS ASSOCIATED WITH CLOSEDPELVIC RING INJURY
D. Jurisic1, B. Hreckovski2, V. Pitlovic2, D. Rosko2, J. Jankovic2,D. Vidovic3
1Surgery, General Hospital, Slavonski Brod/Croatia, 2Surgery,
General Hospital, Slav.Brod, Croatia, 3Traumatology, University
Hospital ‘‘Sisters of Mercy’’, Zagreb, Croatia
Introduction: Closed internal degloving injury is a significant soft-
tissue injury associated with a pelvic trauma in which the subcuta-
neous tissue is torn away from the underlying fascia, creating a cavity
filled with hematoma and liquefied fat.
Materials and methods: We had a two patients with a Morel–Lav-
allee lesions associated with a closed pelvic ring trauma. They had
large and painful subcutaneous cavity formation filled with serosan-
guinous fluid.
Results: After sequential aspirations of the large quantities of seroma,
we decided to open the cyst, irrigate, debride free necrotic tissue and
to put the suction drain inside the cyst. As the drainage was constant
over the next 2 weeks, we explored the cavity and performed cap-
sulotomy with several ‘‘marionette’’ sutures and Penrose drain for
48 h with adequate result. Pelvic ring trauma was treated conserva-
tively in both patients.
Conclusion: Obliteration of dead space with capsulotomy and
‘‘marionette’’ sutures appears to be effective in treatment of persistent
Morel–Lavallee lesions.
Disclosure: No significant relationships.
PS067
VERTICAL PELVIC INSTABILITY WITHCONTRALATERAL COLLUM FEMORIS FRACTUREIN PEDIATRIC PATIENT: CASE REPORT
T. Akgul, F. Yucel, G. Ozdemir, O. Tunali
Orthopaedic, Sanlıurfa Training Hospital, Anlıurfa, Turkey
Introduction: This paper present unilateral pelvic vertical instability
with contralateral collum femoris fracture which is rare pathology in
pediatric age and its success treatment.
Materials and methods: 5 years old girl were referred our hospital
with car accident. Initial examination included clinical examination,
cranial, thorax and pelvic ct. Clinical examination could not per-
formed correctly because of patient’s emotional instability and
worrisome. Patient’s right leg position were fleksiyon, abduction and
external rotation. Echimosis and swollen at right side of pelvic region.
There were not event anteroposterior pelvic instability with exami-
nation. Pelvic X ray showed pubic fracture and right collum femoris
fracture. Patient’s hemogram value, blood pressure and urinary uptake
were normal initially. Pelvic ct showed sacral fracture with no
deplacement.
Results: Patient were operated with closed reduction and percuta-
neous pinning for collum femoris fracture. Clinical pelvic
examination was performed under general anesthesia. Examination
showed pelvic vertical gross instability. pelvic belt were applied and
unilateral longitudinal were started immediately. Three pediatric
erythrocyte were given for hemodynamic resuscitation. After healing
dermabrasion, pelvic cast treatments were performed for pelvic
fracture. Cast was removed after 8 weeks. At the last con-
trol, 4 months from accident patients were mobilized without any
obstacle.
Conclusion: Pelvic fracture must be examined carefully at pediatric
age. it can treat with pelvic belt and cast combination.
Disclosure: No significant relationships.
PS068
GROIN PAIN: AVULSION FRACTURE OF ANTERIORINFERIOR ILIAC SPINE IN A SKELETALLY MATURESOCCER PLAYER
A. Imerci1, L. Surer2, U. Canbek3, G. Adam4, A. Kaya5
1Orthopedics and Traumatology, Erzurum Palandoken State Hospital,
Turkey, Erzurum, Turkey, 2Orthopaedics and Traumatology, Erzurum
Regional Education and Research Hospital, Erzurum, Turkey,3Department of Orthopaedics and Traumatology, Izmir Karsıyaka
State Hospital, Izmir, Turkey, 4Department of Radiology, Izmir
Kemalpasa State Hospital, Izmir, Turkey, 5Orthopaedics and
Traumatology, Izmir Tepecik Education and Research Hospital,
Izmir,Turkey
Introduction: Groin pain in athletes is not infrequently a cause of
frustration and aggravation to both doctor and patient [1]. Complaints
in the groin region can prove difficult to diagnose. Acute groin pain is
fairly common in sports-related activities and usually relates to a
musculoskeletal etiology. This is particularly common in sports that
require sharp cutting movements, as in kicking and running sports,
especially soccer.
In this case, a rarely seen avulsion fracture of anterior inferior iliac
spine of a 24 year old amateur soccer player who accomplished his
skeleton development, was reported.
Materials and methods: A 24 year of male amateur soccer player
applied our emergency room with his left groin pain that was began
after shooting. In physical examination, left hip ROM was full and
painful. He was tender to palpation over the anterior aspect of his left
iliac crest. Plain radiological examination of his pelvis revealed the
separation of part of his anterior iliac crest apophysis when compared
to the contralateral, asymptomatic side. This was consistent with a
diagnosis of an avulsion fracture of the AIIS.
Results: In emergency room, the differential diagnosis of patients that
skeletally mature and have acute groin pain, avulsion fractures of
pelvic ring must be kept in mind. Diagnosis is dependent on a high
index of suspicion.
Conclusion: The emergency physicians and sports physicians should
be aware of the complex anatomy in the groin region, keep in mind
the many diagnostic possibilities and approach the physical exami-
nation in a systematic manner.
References: Renstrom P, Peterson L. Groin injuries in athletes.
Disclosure: No significant relationships.
Abstract S93
123
PS069
COMPUTER NAVIGATION USED BY OSTEOSYNTHESISOF PELVIS
R. Madeja, L. Pleva, J. Demel
Traumacentrum, University hospital Ostrava, Ostrava/Czech
Republic
Introduction: Navigation in traumatology presents a new technique,
which enables to carry out a wide range of osteosyntheses with a
reduced use of the X-ray during the operation. Its principle is based
upon a transfer of input X-ray images into the navigating computer,
which consequently monitors the movement of bone fragments during
repositioning, as well as some instruments in the course of
osteosynthesis.
Materials and methods: Navigation is mainly used with certain
osteosyntheses in the area of pelvis, femur and cruris. First, a set of
special sensors is inserted into the bone; basic X-ray projections of the
fracture follow. These images are downloaded in the navigating
computer. The use of navigation enables repositioning of the fracture
and insertion of osteosynthetic material.
Results: In our centre, we have been using the navigation in trau-
matology since 2006. Since then we have been carrying some
osteosyntheses of the pelvis, femur and cruris under the navigation
system. Fractures in the area of SI spine and pelvis prove to be the
most suitable. With the increasing amount of experience, the time
required for the initial insertion of sensors and downloading the
fracture images is shortening, the radiation time during the operation
is also reduced.
Conclusion: Navigation enables a more precise osteosynthesis of
some types of fractures. It significantly reduces the impact of ionizing
radiation upon the patient and the staff. A good management of the
operation technique results in shortening of the operation time, mainly
due to the reduction of repeated X-ray projections during the securing
of the osteosynthetic material.
Disclosure: No significant relationships.
PS070
TRAUMA MORTALITY HAS IMPROVED IN SERIOUSLYINJURED PATIENTS AFTER INTRODUCING JAPANADVANCED TRAUMA EVALUATION AND CAREPROTOCOL
K. Hondo, A. Shiraishi, Y. Otomo
The Shock Trauma and Emergency Medical Center, Tokyo Medical
and Dental University Hospital, Tokyo, Japan
Introduction: It is widely believed that standardization of trauma
care can minimize the preventable trauma death nevertheless the
evidences lacked. Our study purpose is to elucidate a temporal change
in trauma mortality after introducing our standardized trauma care
protocol (Japan Advanced Trauma Evaluation and Care, JATEC) in
2002.
Materials and methods: We selected subjects from the Japan
Trauma Databank (JTDB) with the Abbreviated Injury Scale of a%¥3
injuries in any region and complete datasets to estimate the Trauma
Injury Severity Score (TRISS). After dichotomizing the subjects into
the former (from 2004 to 2006) and the latter group (from 2007 to
2009), a logistic regression analysis after adjustment for TRISS
estimated relative risk of in-hospital death of the latter group in ref-
erence to the former group. We also performed a similar sub-analysis
stratified by TRISS probability of death (PD) of 0.5.
Results: A total of 17890 out of 42336 subjects registered in JTDB
matched the selection criteria. Relative risk of in-hospital death in the
latter group versus the former was; odds ratio (OR): 0.75 [95 %
confident interval (95 % CI) 0.66–0.85], P.
Conclusion: Trauma mortality in Japan improved especially in
trauma patients with mild severity. We speculated that JATEC might
contribute to rescue more trauma patients from the preventable
trauma death.
References: Kunihiro M. Trauma systems in Japan—history, present
status and future perspectives. J Nippon Med Sch. 2005;72:194–202.
Disclosure: No significant relationships.
PS071
SURVEY ON TRAUMATIC CARDIAC INJURY DUE TOTRAFFIC ACCIDENTS USING THE JAPAN TRAUMA DATABANK
N. Kutsukata1, Y. Sakamoto1, K. Mashiko2, S. Tominaga3,T. Nishimoto4
1Emergency Medical Center, Emergency Disaster Medicine, Saga
University Hospital, Saga City, Japan, 2Emergency and Critical Care
Medicine, Chiba Hokusoh Hospital, Nippon Medical School, Inzai,
Chiba Prefecture, Japan, 3College of Science and Technology, Nihon
University, Tokyo, Japan, 4College of Engineering, Nihon University,
Fukushima, Japan
Introduction: Japan formally started a trauma record system, the
Japan Trauma Data Bank (JTDB), in 2004 and currently 147 facilities
across Japan provide data. In this retrospective study, we used JTDB
data to survey traumatic cardiac injury due to traffic accidents from an
epidemiological standpoint.
Materials and methods: Data organization was conducted by the
Quality Assessment Identification Committee of the Japanese Asso-
ciation for Acute Medicine Clinic and the Trauma Registry
Investigation Committee of the Japan Trauma Society, and from the
resulting JTDB Annual Report 2004–2007, the number of cases
involving cardiac injury with the injury code of AIS90 420299.4
(from The Abbreviated Injury Scale 1990 Revision, Update 98)
regarding traffic accidents involving four-wheeled vehicles. Those
injured were divided into four cohorts—those in automobiles, on
motorcycles, on bicycles, and pedestrians—and the number of cases
involving aortic injury and incidence rate was compared for each.
Results: Among 114 institutions nationally, there were 29,924 cases
of trauma, 8957 cases of blunt traffic injury. In the 4 cohorts, there
were 9987 cases involving automobiles, 9244 involving motorcycles,
5193 involving bicycles, and 5500 involving pedestrians, and cardiac
injuries were 52 (0.17 %), 41 (0.13 %), 19 (0.16 %), and 12 (0.04 %),
respectively.
Conclusion: Cardiac injuries caused by traffic accidents occurred
most frequently in automobile accidents. We determined that the
automobiles cohort had the highest occurrence rate and the pedestrian
cohort the lowest.
Disclosure: No significant relationships.
S94 Abstract
123
PS072
IMAGING AND TRANSFER PROTOCOLS WITHINA REGIONAL TRAUMA SYSTEM: A UK EXPERIENCE
E. Battaloglu1, D. Conroy2
1Trauma and Orthopaedics, West Midlands Deanery, Core Surgical
Training, Birmingham, UK, 2Medical School, University of
Birmingham, Birmingham, UK
Introduction: Assessment of the imaging and transfer protocols of
the major trauma centre and trauma units in the West Midlands
region. Accurate, co-ordinated and well rehearsed protocols are
required for all units dealing with severely injured patients, especially
when operating within a regional trauma network. However, with the
establishment of foundation trusts and the business style management
of hospitals in the United Kingdom, will co-operative care systems
suffer?
Materials and methods: Qualitative assessment of imaging and
transfer protocols between the major trauma centre and the 11 trauma
units (hospitals) in the West Midlands region of the United Kingdom.
Results: Significant variation of trauma protocols occurs between
individual trauma units operating within the regional trauma network.
The classification and management of severely injured trauma
patients differs to compromise working efficiency and co-ordinated
care.
Conclusion: The establishment of extended trauma networks requires
cohesive and co-ordinated care pathways and protocols to be in place
to expediate the severely injured patient’s journey to the site of
definitive care. The United Kingdom is currently converting the
trauma care systems from individual institutional care to regional
trauma networks. However, the transition needs uniformity and clarity
to operate a prompt and accurate service in such time sensitive situ-
ations. The West Midlands region has significant improvements to
make in order to elevate the standards of care in trauma.
Disclosure: No significant relationships.
PS073
MULTIVARIATE STUDY OF INTRA-ABDOMINALINJURIES IN POLYTRAUMATIZED PATIENTS
J.D. Turino-Luque1, N. Zambudio-Carroll1, A. Mansilla-Rosello2,E. Corral2, A. Vilchez Rabelo2, M. Carrasco2, J.A. Ferron-Orihuela2
1Cirugıa General, Hospital Virgen de las Nieves, Granada, Spain,2Cirugıa General, Hospital Universitario Virgen de las Nieves,
Granada, Spain
Introduction: Abdominal pathology is one of the main reasons for
consultation in hospital emergencies, a significant number are asso-
ciated with polytraumatized patients. Identify the risk factors
associated with intra-abdominal injuries in polytraumatized patients.
Materials and methods: Based on a retrospective study of patients
admitted to our emergency department who were diagnosed with a
polytraumatic injury over an 11-year period. Database included: age,
sex, etiology and associated pathology.
Data were analyzed with SPSS Statistics software 17. Significance
level considered was p \ 0.05.
Results: A total of 790 patients were treated for multiple trauma
injuries, 77.5 % had some type of intra-abdominal injury. Affected
organs were: spleen (42.2 %), liver (29.2 %) and retroperitoneal
hematoma (10.8 %). 33.6 % of patients with liver injury had multiple
injuries (p \ 0.0016, OR 1.884), 40.9 % had rib fractures
(p \ 0.0014, OR 1.647), and kidney involvement occurred in 52.9 %
of cases (p \ 0.001, OR 2.397). Splenic involvement was associated
with trauma patients in 46.6 % (p \ 0.001). Rib fractures existed in
56.9 % (p \ 0.013, OR 1.62). Kidney injury was associated in 57.4 %
(p = 0.068, OR 1.599). The type of trauma if we consider the traffic
accident (OR = 1), precipitation was presented as a risk factor in the
splenic lesions (p \ 0.001, OR 2.913). 13.7 % patients presenting
retroperitoneal hematoma suffered multiple injuries (p \ 0.021, OR
4158). Spinal (p \ 0.001, OR 3.107) and hip pathologies (p \ 0.001,
OR 3.48) are risk factors.
Conclusion: Risk factors associated to liver injury include renal
injury, rib fracture and multiple trauma.
Splenic involvement is affected in precipitation, rib fractures or renal
injury.
Main risk factors in retroperitoneal hematomas are: multiple trauma,
spine and hip fractures.
Disclosure: No significant relationships.
PS074
SPECTRUM OF ALL-TERRAIN VEHICLE INJURIESIN ADULTS: A CASE SERIES AND REVIEW OF THELITERATURE
E.S. Concannon1, A. Hogan1, W. Khan2, K. Barry1
1General Surgery (Mr Kevin Barry Service, F.a.c.s.), Mayo General
Hospital, Castlebar, Ireland, 2Mayo General Hospital, Castlebar,
Ireland
Introduction: Serious injury secondary to all terrain vehicle usage
has been widely reported since the 1970s. All-terrain vehicles (ATV)
or ‘quad bikes’ are four wheeled vehicles used for agricultural work,
recreation and adventure sport. Data collected in the US indicates that
ATV related injury and fatality is increasing annually. Legislation
governing licensing, vehicle standards and concomitant use of a
helmet/safety belt only applies to the use of these vehicles on public
roads in most European countries and US States.
Materials and methods: This case series describes 3 cases of sig-
nificant ATV related trauma in adults presenting to one regional
hospital in the West of Ireland over a 12 month period. One case
resulted in fatality secondary to multiple injuries, including a dis-
placed C2 fracture. One patient required craniotomy for a evacuation
of an extradural haematoma and another underwent emergency lap-
arotomy with splenectomy.
Epidemiology, mechanisms of injury, spectrum of injury in adults and
preventative measures to reduce the number of ATV related injuries
and fatalaties are discussed with a review of the literature.
Results: Not applicable.
Conclusion: ATV injury is associated with significant morbidity and
mortality, the rates of which surpass that of motorcycle trauma. A
paucity of research outside of North America is highlighted by this
case series. Mandatory reporting of ATV related injury, educational,
training and more stringent legislative measures are suggested as
injury prevention strategies.
References: Fonseca AH, Ochsner MG et al. All-terrain vehicle
injuries: are they dangerous? A 6-year experience at a level I trauma
center after legislative regulations expired. Am Surg. 2005;71(11):
937–40.
Disclosure: No significant relationships.
Abstract S95
123
PS075
KNEE MOMENT LOSS DUE TO MISDIAGNOSEDTRAUMATIC PATELLAR DISLOCATION INMULTITRAUMA PATIENT: TREATMENT OFA COMPLEX CASE
N.M. Elmadag1, M. Erdil2, N. Tuncer3, K. Bilsel2, I. Tuncay1
1Orthopaedic & Traumatology, Bezmialem Vakif University,
Istanbul, Turkey, 2Orthopaedic & Traumatology, Bezmialem Vakif
University, Istanbul, Turkey, 3Orthopaedics & Traumatology
Department, Bezmialem Vakif University, Istanbul, Turkey
Introduction: The aim of this study is to show the problems due to
misdiagnosed traumatic patella dislocation while treating tibia plateau
fracture and evaluate the functional outcomes.
Materials and methods: CASE REPORT : 31-year-old man
appealed to our clinic with restriction of his left knee ROM and
follow-up for his right tibial fracture treated with external fixator in
January 2010. He had a traffic accident and he was taken to
another hospital in June 2009. Right tibial shaft fracture and left
tibial plateau fracture was diagnosed. Tibial shaft fracture was
treated with circular external fixator and tibial plateau fracture was
treated with plate and screws. In physical examination, right knee
ROM was 0–110�. In left knee there was no motion and fixed
3 9 3 cm mass was seen on anterolateral side of knee. In X-ray
callus formation were detected in both tibias with dislocated left
patella. We operated for the removal of the fixator and restricted
ROM. We detected the ruptured medial retinaculum and dislocated
patella with contracted quadriceps tendon and we performed V–Y
quadricepsplasty. Medial retinaculum repair with suture anchor and
patellar reduction was performed. In addition we applied an hinged
external fixator to gain knee ROM gradually.
Results: We started passive knee motions with external fixator and
quadriceps strengthening exercises immediately with full weight-
bearing. At the first year follow-up 90 degrees ROM of left knee with
4/5 quadriceps strength was achieved.
Conclusion: Detailed physical and X-Ray examination is important
in multi-trauma patients. Misdiagnosed pathologies could be much
harder to treat after the initial intervention.
References: 1. Hing CB, Smith TO, Donell S, Song F. Surgical
versus non-surgical interventions for treating patellar dislocation.
Cochrane Database Syst Rev. 2011;11:CD008106. 2. Anoumou NM,
Kouame M, Gogoua D, Kone B, Guedegbe F, Arame F, Varango G.
Traumatic patellar dislocation: report of a case. Can J Surg.
2008;51(1):E1–2. 3. Stefancin JJ, Parker RD. First-time traumatic
patellar dislocation: a systematic review. Clin Orthop Relat Res.
2007;455:93–101. 4. Tucker JB, Corsetti J, Gregg JR. Arthroscopi-
cally assisted proximal quadricepsplasty for patellar instability. Clin
Sports Med. 1993;12(1):81–9.
Disclosure: No significant relationships.
PS076
ENDOCRINE, METABOLIC AND IMMUNE RESPONSEINDUCED BY TRAUMA
J.P.S. Gandara, J.A.S. Da Silva, G.H. Cainelli, E. Achar,M.A.F. Ribeiro Jr
Surgery, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil
Introduction: Trauma is characterized by cell injury and subsequent
inflammatory response, resulting in endocrine and metabolic changes.
The increasing migration and activation of neutrophils in peripheral
tissues leads to increased tissue damage resulting in organ dysfunc-
tion. The anti-inflammatory response leads to a decrease in the
amount of T lymphocytes that results in reduced production of
cytokines, compromising the quantity and responsiveness of these
cells predispose patients who have suffered trauma to acquire infec-
tions, sepsis and failure multiple organs.
Materials and methods: Review of literature using the databases
PubMed/Medline, Lilacs and Ebsco. We selected articles which
contain aspects relevant to the objectives and details of the metabolic,
endocrine and immune responses in the presence of trauma.
Results: Inflammatory response can be characterized by an increased
expression of inflammatory mediators due to cell injury. The anti-
inflammatory response leads to a decreased number of T cells
becoming less responsiveness predisposing patients who have suf-
fered trauma to acquire infections leading to sepsis and multiple organ
failure.
Conclusion: Trauma leads to an inflammatory response that results in
organic changes, resulting in an increased metabolism in order to
restore homeostasis, however, an extension of the hypermetabolic
state results in a systemic inflammatory response leading to multiple
organ dysfunction. In view of this larger studies are needed to better
understand the metabolic response to trauma and thus establish an
effective therapy for control of organic change as a result of trauma.
References: Tzioupisa CC, Katsoulisa S, Manidakisb N, Giannoudisa
PV The immuno-inflammatory response to trauma. Trauma.
2005;7:171–83.
Disclosure: No significant relationships.
EMERGENCY SURGERY II
PS077
HANDLEBAR HERNIA WITH ASSOCIATED VISCERALPERFORATION: AN UNUSUAL CASE
L.J. Cook, D. Debnath, I.J. Laidlaw, C.R. Baker
General Surgery, Frimley Park Hospital, Frimley, UK
Introduction: Traumatic abdominal wall hernias from handlebar
injuries are a rare phenomenon and are not normally associated with
intra-abdominal injuries. We present an unusual case of a handlebar
hernia associated with small bowel perforation in a cyclist.
Materials and methods: A 51 year old gentleman attended our
Emergency Department following a bicycle accident. He was alert
and stable, but complaining of severe lower abdominal pain. Exam-
ination showed a diffuse left abdominal wall swelling with an
associated handlebar imprint, but no skin breakage. Differential
diagnosis included rectus sheath haematoma or traumatic hernia.
Results: CT scan showed herniation of small bowel through a large
defect in the left abdominal wall. At laparotomy, the herniated bowel
was perforated in two places with some faecal contamination. Small
bowel resection of the affected segment was performed together with
repair of the abdominal wall defect with mass closure. The patient
made a full recovery.
Conclusion: Handlebar hernias occur as a result of a sudden
application of a blunt force to the abdominal wall. There may be
minimal signs on examination which can lead to misdiagnosis of a
haematoma. This is a rare phenomenon, the majority of reports
involving children. This case is especially unusual as there was
S96 Abstract
123
associated visceral perforation within the hernia. We conclude that
when cyclists present with a similar mechanism of injury, partic-
ularly if associated with a handlebar imprint, there should be a low
threshold for urgent imaging.
References: van Bemmel AJM, et al. Handlebar Hernia: a case report
and literature review on traumatic abdominal wall hernia in children.
Hernia. 2011;15:439–42.
Disclosure: No significant relationships.
PS078
BLUNT TRAUMATIC RUPTURE OF THORACIC AORTADIAGNOSED IN A DISTRICT HOSPITAL. WHAT NEXT?
E. Varada1, G. Georgiou2, F. Kodonas3, A. Kampouris3, A. Chiotis3
1Surgery, Xanthi General Hospital, Xanthi/Greece, 2Surgical
Department, General Hospital of Xanthi, Xanthi, Greece, 3General
Hospital of Xanthi, Xanthi, Greece
Introduction: The aim of this report is to present our experience with
post traumatic aortic ruptures and discuss the options and dilemmas
we faced during their management.
Materials and methods: We evaluated the records of 6 patients with
post traumatic aortic rupture diagnosed in our institution. They were
all victims of MVC. Concomitant injuries included rupture or lacer-
ation of intra-abdominal solid organs in 2 cases, pelvic fracture in one
and severe head injury in one case.
Results: One patient died on the Radiological Department. Two
patients underwent immediate surgical intervention due to their hae-
modynamic instability. One of them expired during operation. The
other survived and was transferred postoperatively to a tertiary centre,
and his aortic rupture was successfully repaired. The rest of the patients
were transferred immediately after diagnosis was made to tertiary
centres. Only one of these patients survived (mortality 66.6 %).
Conclusion: Rupture of thoracic aorta following blunt chest trauma is
a true emergency requiring early recognition and prompt intervention.
Such cases present rarely in district hospitals but they have usually
unfavourable outcome. A question is raised whether is justified, for an
experience trauma surgeon, to be trained to use endovascular stents
for treating such life threatening vascular injuries.
References: 1. Emerg Med J. 2004;21:414–9. 2. Circulation.
1999;99:498–504. 3. Ann Thorac Surg. 1996;62:577–8.
Disclosure: No significant relationships.
PS079
SEVERE LIVER TRAUMA-MANAGEMENT AND OUTCOMEOF 177 CASES
K. Doklestic1, A. Karamarkovic2, P. Gregoric2, D. Radenkovic2,D. Markovic2, B. Karadzic2, M. Pandurovic2, D. Bajec2
1Clinic for Emergency Surgery, Clinical Center of Serbia Faculty
of Medicine, Belgrade, Serbia; 2Clinical Center of Serbia Faculty
of Medicine, Belgrade, Serbia
Introduction: Severe liver injuries still represent diagnostic and
therapeutic challenge.
Materials and methods: The retrospective study included 177
patients with severe liver trauma grades 3, 4, 5, who were surgically
treated because of bleeding and hemodynamic instability.
Results: The most common mechanism of injury was blunt trauma
(74.6 %). The severity of liver injury was significantly higher in
penetrating trauma (p = 0.003). The overall complication rate was
30 %. Specific liver-related surgical complication rate was 4 %. The
mortality rate was 18 %. There was significant difference in mortality
in penetrating wounds compared to blunt trauma (p = 0.008). The
mortality was significantly higher in more severely injured patients
with grade 4 and 5 liver injuries (p = 0.015).
Conclusion: Bleeding from the severe liver injury is still a major
cause of death and the most important criterion for the choice of
treatment is progressive hemodynamic unstability.
References: Gao JM, et al. Liver trauma: experience in 348 cases.
World J Surg. 2003;27:703–8.
Disclosure: No significant relationships.
PS080
AN ATTEMPT TO DETERMINE HEPATIC PORTALVENOUS GAS SEVERITY: CORRELATION OF GASDISTRIBUTION AND SEVERITY
H. Koami
Surgery, Urasoe General Hospital, Urasoe city, Okinawa, Japan
Introduction: Although hepatic portal venous gas (HPVG) is con-
sidered to have poor prognosis, a number of recent conservatively
treated cases have been reported. However, few studies have reported
its pattern of progression, and its relationship with severity. Here we
hypothesized that the distribution of HPVG correlates with severity.
Materials and methods: We conducted a retrospective review of 28
patients diagnosed with HPVG by MDCT between August 2008 and
September 2011. Patients were divided into two groups based on the
area of gas distribution as follows: Group L (left lobe; 13 patients)
and Group LR (both lobes; 15 patients). Collected data included
demographics, clinical characteristics, MDCT findings, presence of
bowel necrosis, and outcome.
Results: The groups were similar with regard to demographics,
clinical findings, vital signs, and laboratory data. MDCT findings
revealed that Group LR had significantly more cases than Group L of
small intestine dilatation (93.3 vs. 61.5 %; p = 0.042) and pneuma-
tosis intestinalis (100 vs. 53.8 %; p = 0.002). Between Group L and
Group LR there was no respective significant difference in the
number of surgeries performed, presence of intestinal necrosis, and
mortality.
Conclusion: No significant correlation was confirmed between dis-
tribution of HPVG and clinical severity. However, Group LR was
considered pathologically more severe than Group L.
Disclosure: No significant relationships.
PS081
SUCCESSFUL SURVIVAL AFTER SURGICALMANAGEMENT OF POSTTRAUMATIC PERICARDIALRUPTURE AND CARDIAC LUXATION
S. Stabina, A. Kaminskis, D. Soldatenkova, G. Pupelis
General and Emergency Surgery, Riga East Clinical University
Hospital ‘‘Gailezers’’, Riga, Latvia
Abstract S97
123
Introduction: Mortality in high-energy thoracoabdominal trauma is
considerably elevated in cases of blunt pericardial rupture because
patients mostly die before hospitalization. We present successful
survival after posttraumatic pericardial rupture with cardiac luxation
and prognostic TRISS score 3.8 %.
Materials and methods: A 38-year-old man after fall from the height
was delivered to the hospital with bradycardia 45 beats/min, arterial
pressure 80/50 mmHg, breathing 10 times/min and arterial pulse O2
saturation 92 %. FAST was negative. At the time of admission Hb
was 10.10 g/dL, Eritrocytes—3.22 10 e6/mkL and Platelates-86
10 e3/mkL. Hemorrhagic shock was absent and patient underwent CT
scan. Double sided haemopneumothorax, double sided pulmonary
contusion, haemopericardium, pneumomediastinum, second degree
splenic rupture, multiple rib fractures on both sides were found.
Additionally fracture of thoracic and lumbar vertebrae (Th3-Th 6, L1,
L2) and dissection of descendent aorta was revealed. Laparocentesis
was negative and pericardial puncture failed.
Results: Bilateral chest drains were inserted and patient was promptly
delivered to the operation theatre. During the left side thoracotomy
longitudinal pericardial rupture was found. Reposition of the heart,
suturation of the pericardium and lung was done. For achievement of
complete hemostasis partial resection of the ribs and drainage of the
thoracic cavity was performed finally. During the operation fibrilla-
tion and asystole occurred three times. Prolonged ventilatory support
was necessary for 27 days after surgical intervention because of
posttraumatic pneumonia and flail chest. The patient was discharged
after 50 day hospitalization without neurological deficits.
Conclusion: Patients with severe trauma can be successfully treated,
despite prognostically low survival rate.
Disclosure: No significant relationships.
PS082
MANAGEMENT OF LIVER TRAUMA. INITIALEXPERIENCE WITH CONSERVATIVE APPROACH
D. Soldatenkova1, M. Mukans2, I. Kazaka2, G. Pupelis3
1General and Emergency Surgery, Riga East Clinical University
Hospital ‘‘Gailezers’’, Riga, Latvia, 2Emergency and General
Surgery, Riga East University Hospital Gailezers, Riga, Latvia, 3Riga
East Clinical University Hospital ‘‘Gailezers’’, Riga, Latvia
Introduction: Conservative approach is recommended in grade III–
IV liver injury in haemodynamically stable patient. Aim of the study
was assessment of first experience in conservative management of
liver trauma in Riga’s East Clinical University hospital.
Materials and methods: Five-year experience in the management of
liver trauma was retrospectively analysed. Injury severity score (ISS)
and American Society of Anaesthesiology score (ASA) was used for
risk assessment at admission. Management strategy was based on
hemodynamic stability of the patient and grade of liver injury eval-
uated by CT scan. Hospital stay and main outcomes were analyzed
considering operative and nonoperative management.
Results: A total of 75 patients mean age 37 (range 17–63 years)
were treated in our institution during the period from January 2005
till April 2011. In 54 cases liver was injured after blunt trauma, in
21 case due to penetrating injury. Patients with penetrating injuries
underwent operative intervention. 27 patients with blunt liver injury
were managed conservatively including 7 with grade I (ISS—17,
ASA II–III E), 13 with grade II (ISS—26, ASA II–IV E), four with
grade III (ISS—26, ASA—II–III E), and three with grade IV injury
(ISS—34, ASA III E). The mean hospital stay of conservatively
managed patients was 9.85 days, and for those who underwent
surgical intervention 14.4 days, p = 0.027. Overall mortality
reached 9.3 %.
Conclusion: Conservative management of liver trauma is justified in
haemodynamically stable patients after thorough risk assessment and
CT scan based injury grading in centers with sufficient expertise.
Disclosure: No significant relationships.
PS083
BLUNT TRAUMA OF LOWER LIMBS ARTERIES: UNUSUALMECHANISM
J. Konecny, L. Veverkova, M. Reska, I. Capov, J. Ciernik
1st Department of Surgery, 1st Department of Surgery, St. Anne‘s
University Hospital, Faculty of Medicine, Masaryk University, Brno,
Brno, Czech Republic
Introduction: Blunt periferal vascular trauma is less frequent than
penetrating and usually is in lower limb connected with luxation of
hip or knee joint, or with fracture of femur or tibia. An arterial dis-
section means rupture of the part of arterial wall in its intima or media
and blood subsequently flows in between individual layers of the
arterial wall. The damage to the intima results from pressure and
stretching and is connected to ischemic complications.
Materials and methods: In our traumatology department in last
6 years we operated on more than 3,500 patients. We treated only 2
patients with blunt trauma of lower limb arteries without fracture or
dislocation of joint when vascular operation was required by ischemic
complications. In this cases we found intimal lesion and arterial
dissection. The 25-year-old woman suffered an intimal lesion in AFC
l. sin. and the 36-year-old man in AP l. dx.
Results: In the first case the diagnosis was based on the gradually
developed ischemy and the conducted AG. In the second case it was
based on clinical examination and a spiral CT. We renewed the
continuity of the arteries using an autologous venous graft.
Conclusion: The literature describes blunt arterial trauma in con-
duction with tibial and femoral fractures or hip and knee dislocations.
The damage mechanism of intimal dissection is often linked to
hyperextension of a limb. However, in our cases a compressive
mechanism was involved and joint and bone trauma was not found.
References: Manual of Definitive Surgical Trauma Care, p. 147.
London: Arnold;2003.
Disclosure: No significant relationships.
PS084
MANAGEMENT OF CERVICAL ESOPHAGEALPERFORATION IN EMERGENCY SURGERY
J.D. Turino-Luque1, N. Zambudio-Carroll1, M.J. Alvarez Martın1,A. Garcıa Navarro1, J.M. Avella1, A. Bustos Merlo1, J.A. Ferron-Orihuela2
1Cirugıa General, Hospital Virgen de las Nieves, Granada, Spain,2Cirugıa General, Hospital Universitario Virgen de las Nieves,
Granada, Spain
Introduction: For many years the method of choice for treating
patients with esophageal perforation has been subject of considerable
S98 Abstract
123
discussion. When a diagnosis and the initiation of optimum treatment
are delayed, mortality rates rise steeply. This article reviews two cases
involving a perforated healthy esophagus. Analyze the diagnosis and
management of cervical esophageal perforation.
Materials and methods: Clinical cases that occurred in our hospital
from 2006 to 2011 were reviewed. Data was obtained and recorded
on: age, sex, previous pathology, surgical risk value, symptoms,
diagnostic tests, treatment, discharged/dead.
Results: Only two out of all cases that occurred in cervical
esophagus.
Characteristics of patient: Case 1: Male 58 years. NIDDM Congenital
spastic hemiparesis and cognitive delay ASA III. Case 2: Female.
84 years. Heart failure. Alzheimer’s disease ASA III–IV.
Reason for inquiry: dysphagia, odynophagia and dyspnea of 96 and
24 h of onset, respectively. Investigations: Case 1: Negative laryn-
goscopy. CT foreign body in Killian’s space, subcutaneous
emphysema and upper mediastinum. Removal of foreign body with
rigid bronchoscope previous surgical treatment. Case 2: Laryngos-
copy evidence of esophageal foreign body Killian’s space is removed.
Posterior CT shows cervical subcutaneous emphysema and medias-
tinum. Surgical treatment: Wide cervicotomy with drainage of
cervical collections, upper mediastinum and neck. Evolution: Clinical
improvement with oral tolerance and no evidence of gastroesophageal
transit flight. Case 1: discharge. Case 2: 22 days after surgery patient
developed chronic decompensated heart disease and was discharged
dead.
Conclusion: Cervical esophageal perforation carries significant
morbidity and mortality. Early surgical procedure is essential.
The best surgical intervention is a broad cervicotomy with cervical
drainage.
Disclosure: No significant relationships.
PS085
DIAPHRAGMA RUPTURE: DIFFICULT DIAGNOSIS, EASYTREATMENT
D. Kusy1, M. Forman1, M. Carda1, K. Havlıcek2, J. Siller2
1Traumatology, PKN a.s, Pardubice, Czech Republic, 2Clinic Of
General Surgery, PKN a.s, Pardubice, Czech Republic
Introduction: Diaphragm rupture is often a result of severe blunt or
penetrating thoracoabdominal trauma. In Europe more than 90 %
rupture happens during blunt trauma. It usually develops in radial
location. During initial examination it could be missed due to another
more severe trauma in combination with occasional modest indica-
tions. 85 % ruptures are diagnosed during laparotomy where 80 % of
ruptures occur on left side. The treatment in acute diagnosis are
straightforward. Laparotomy is used when there is abdominal trauma
or posterolateral thoracotomy is used when rupture occurs on the right
side.
Materials and methods: We would like to show, several cases of
diaphragm rupture. X ray and CT scan images supplemented with
images during surgery.
Results: Majority of patients are healed with a good result if diag-
nosis is undertaken early. Treatment in case of early diagnosis is
rather straight forward compared to treatments of delayed diagnosis
where treatment is hindered by complications.
Conclusion: It is vital to consider diaphragm rupture during an
examination of patient following severe trauma. Occasionally it is
difficult to find rupture on initial X-ray or CT particularly on the right
side. The treatment of acute diaphragm rupture is simpler compared
to treatment of delayed diagnosis, when visceral organs are usually
fixed in thorax.
References: 1. Sabiston DC. Texbook of surgery, 14th edn. 2. Hanna
WC. Acute traumatic diaphragmatic injury. Thorac Surg Clin. 2009.
Disclosure: No significant relationships.
PS086
RECTUS SHEATH HAEMATOMA: SURGICAL ORCONSERVATIVE TREATMENT?
G.H. Cainelli1, J.A.S. Da Silva1, J.P.S. Gandara2, C.M. De Oliveira3,W.A. Saad3, E. Achar1, M.A.F. Ribeiro Jr1
1Surgery, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil,2Surgery, Universidade Cidade de Sao Paulo, Guarulhos-SP, Brazil,3Surgery, Universidade Cidade de Sao Paulo, 03071000, Brazil
Introduction: Hematoma of the rectus abdominis is not a very fre-
quent complication in the surgical clinic, where we have a break from
creating an epigastric mass clinical intra-abdominal pain, associated
with important systemic changes, including hypovolemic shock. The
treatment has been much discussion about the use of conservative or
surgical therapy. To this end we conducted a comparative study,
based on a critical review of the literature in an attempt to elucidate
the best indication, benefit, and conduct regarding the treatment of
hematoma of the rectus abdominis.
An important aspect of conservative treatment is offering a lower risk
of life to patients in view of the invasive treatments that may con-
tribute to the development of hemodynamic shock.
Materials and methods: We performed a critical review of the
literature and assembled a table with the main treatment forms.
Results: In the above table we can see a total of 39 patients whose
therapy used was conservative, in 21, surgery in this subgroup 5
including the use of local hemostatic and ligation of blood
vessels, and 13 patients underwent embolization therapy through
angiography.
Conclusion: We conclude with this study that although there are
disagreements among the authors as the best therapy to be instituted
in cases of hematoma of the rectus abdominis, conservative treatment
is still the most used in the clinic with a favorable prognosis and often
relapsing.
Reference: 1. Carkman S, Ozben V, Zengin K, Somuncu E, Karatas
A. Spontaneous rectus sheath hematoma: an analysis of 15 cases.
Turkish J Trauma Emerg Surg. 2010;16(6):532–6.
Disclosure: No significant relationships.
PS087
SEVERE LIVER TRAUMA: MANAGEMENT ANDOUTCOME OF 177 CASES
K. Doklestic1, A. Karamarkovic2, P. Gregoric2, D. Radenkovic3,D. Markovic3, B. Karadzic3, M. Pandurovic3, D. Bajec2
1Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade,
Serbia, 2Clinical Center of Serbia Faculty of Medicine, Belgrade,
Serbia, 3Clinical Center of Serbia, Belgrade, Serbia
Introduction: Severe liver injuries still represent diagnostic and
therapeutic challenge.
Abstract S99
123
Materials and methods: This retrospective study included 177
patients with severe liver trauma grades 3, 4, 5, who were surgically
treated because of bleeding and hemodynamic instability.
Results: The most common mechanism of injury was blunt trauma
(74.6 %). The severity of liver injury was significantly higher in
penetrating trauma (p = 0.003). Damage control surgery was pre-
ferred in the patients affected by hypothermia, coagulopathy and
acidosis. In others definitive surgical repair was applied. The overall
complication rate was 30 %. Specific liver-related surgical compli-
cation rate was 4 %. The mortality rate was 18 %. The results showed
significant difference in mortality in cases of penetrating wounds
compared to blunt trauma (p = 0.008). Considering OIS, there was
no liver-related death in patients with grades 3, however, liver-related
mortality of grades 4 and 5 was 37.1 %. The correlation of severity of
injuries and mortality rates showed that the mortality is significantly
statistically higher in more severely injured patients with grade 4 and
5 liver injuries (p = 0.015).
Conclusion: Bleeding from the severe liver injury is still a major
cause of death and the most important criterion for the choice of
treatment is progressive hemodynamic unstability.
Reference: Gao JM, et al. Liver trauma: experience in 348 cases.
World J Surg. 2003;27(6):703–8.
Disclosure: No significant relationships.
PS088
TRANSMEDIASTINAL AND TRANSCARDIAC GUNSHOTWOUND WITH HEMODYNAMIC STABILITY
Y. Mohamed Al-Lal1, J. Martın Gil2, L. Alvarez Llano2,T. Sanchez Rodriguez2, M. Sanz Sanchez2, M.D. Perez Dıaz2,F. Turegano Fuentes2
1General Surgery Ii, Hospital Gregorio Maranon, Madrid, Spain,2Cirugıa General Ii, Hospital Gregorio Maranon, Madrid, Spain
Introduction: Patients with cardiac gunshot wounds have a dismal
survival and rarely make it to the ER. They are very rare in our
community.
Materials and methods: Our aim was to present the case of a patient
with a chest gunshot wound with a transcardiac trajectory and pul-
monary injury, who was taken to our ER with hemodynamic stability.
Results: 43 years old male patient who sustained a gunshot wound to
the thorax. The entrance wound was below the left clavicle, with no
exit wound, and he underwent OTI and rapid transfer to our center.
On primary survey he had decreased breath sounds on the right
hemithorax, and was hemodynamically stable. Chest X-ray showed a
right hemothorax, and a chest tube gave an immediate output of
1200 cc of blood. An echocardiogram showed a moderate peri-
cardial effusion, with good cardiac mobility. A sternotomy
disclosed a small hemopericardium, with an entrance wound in the
outflow tract of the right ventricle, and the exit wound through the
right atrium, with the bullet going into the periphery of the right
lung parenchyma. Both holes were sutured with 3.0 Prolene over
Teflon pledgets, lung hemostasis performed, and a pacemaker was
inserted into the right ventricle. He made an uneventful recovery.
A postoperative echocardiogram showed good cardiac mobility
without any septal defect.
Conclusion: Cardiac gunshot injuries have a high mortality and few
patients make it to the ER. Low-velocity missiles usually cause less
damage, and the occasional patient can present with hemodynamic
stability even in the presence of a transcardiac wound.
Disclosure: No significant relationships.
PS089
TRAUMATIC ARTERIOVENOUS FISTULA WITH FALSEANEURYSM OF THE PROFUNDA FEMORIS ARTERYFOLLOWING MOTOR VEHICLE ACCIDENT
G. Sirin, M.F. Ozdemir
Cardiovascular Surgery, Universal Hospitals Group Diyarbakir
Hospital, Diyarbakir, Turkey
Introduction: Traumatic pseudoaneurysm of the deep femoral
artery (DFA) is usually secondary to endovascular intervention or
to mycotic infection which is widely encountered in drug abusers.
The majority of the cases are generally asymptomatic and present
only with a pulsatile-mass. However, on some occasions, clinical
signs of compression (pain, neurological or venous symptoms) may
occur.
Materials and methods: 21-year-old man was admitted to hospital
with pain and swelling in left groin. The patient had history of
motorcycle accident 1 month ago. In his physical examination,
pulsatile-mass along with thrill in the left groin was detected. The
laboratory findings were normal. The duplex-ultrasound scan
showed an aneurysmatic dilatation of the DFA and arteriovenous
fistula between DFA and deep femoral vein. Multi-slice comput-
erized tomography angiography revealed an aneurysm originating
from DFA with dimensions of 12 9 8 9 9 cm and an arteriove-
nous fistula. In the operation, the aneurysm sac was opened and
DFA was ligated through the fistula. Fistula was divided. The
hematoma was evacuated.
Results: The postoperative course was uneventful. No limb ischemia
was observed. The patient was discharged home on postoperative 5th
day. There was no fistula in the follow up color doppler USG on
postoperative 1st month.
Conclusion: We suggest early surgical treatment of post-traumatic
AV fistulas and pseudoaneurysms due to rapid progress of the disease.
Surgical treatment is still safe and effective method of treatment.
Reference: Hadzimehmedagic A, VranicH, Gavrankapetanovic I,
Beæirbegovic S, Kacila M, Hadzihasanovic B, Talic A. Treatment of
rare posttraumatic false aneurism and A–V fistula of the deep femoral
artery and vein. Med Arh. 2010;64(1):53–4.
Disclosure: No significant relationships.
PS090
SUPERIOR MESENTERIC ARTERY THROMBOSIS,FATALITY OR NOT?
M. Semiao1, R. Rainho2, M. Mega2, L. Silveira2
1General Surgery, Centro Hospitalar Cova da Beira, Covilha,
Portugal, 2Hospital Amato Lusitano, Castelo Branco, Portugal
Introduction: Thrombosis of the superior mesenteric artery (TSMA),
although rare, is a surgical emergency with poor prognosis, largely
due to its nonspecific presentation.
The authors present a case of nonfatal TSMA.
Materials and methods: A 55 year old man was admitted to the
emergency room for sudden intense epigastric pain, with no irradia-
tion. He had a past history of chronic alcoholism, three acute
myocardial infarctions (AMI), and self suspended the chronic medi-
cation, including warfarin. He was admitted to the intensive care unit
S100 Abstract
123
with a diagnosis of new AMI. About 12 h later clinical suspicion of
TSMA was confirmed by CT and CT angiography of abdomen and
pelvis. We carried out an emergency thrombectomy with laparostomy
and ‘‘second look’’ 33 h later and performed a segmental necessity
resection of 370 cm of small intestine, remaining 120 cm of proximal
jejunum and 20 cm of the terminal ileum. After 4 days the laparos-
tomy was closed.
Results: Recovery was complicated by alimentary vomiting that
resolved spontaneously, and frequently diarrhea which stabilized in
three to four episodes with medication. Patient was discharged by the
50th postoperative day, and maintained oral anticoagulation with
warfarin.
Conclusion: The study of risk factors associated with high clinical
suspicion for a diagnosis and early intervention are key factors in
reducing morbidity/mortality of this disease.
References: Renner P, et al. ‘‘Intestinal ischemia: current treatment
concepts’’. Langenbecks Arch Surg. 2011;396:3–11.
Disclosure: No significant relationships.
PS091
TRAUMATIC DIAPHRAGMATIC RUPTURE INA REFERENCE TRAUMA HOSPITAL IN BRAZIL
N.A. De Liz, N.A. Liz, N.T. Kruel, O. Franzon, G.S. Silverio
Surgery Department, Hospital Regional de Sao Jose, Sao Jose, Brazil
Introduction: The diaphragmatic injury has been known since 1541,
initially related to military trauma.
Materials and methods: Cross-sectional retrospective study of 23
patients with diaphragmatic injury confirmed by exploratory lapa-
rotomy, during the period January 2006 to December 2009.
Results: The age group of 20–29 years was the most prevalent
(60.9 %). The most frequent etiologic agent in this study was the
bullet wound from a firearm (n = 17). Four patients had a stab
wound, while only two patients had blunt trauma. Nineteen patients
underwent preoperative chest radiograph, was conclusive for the
diagnosis of thoracic trauma in 5 of these patients. The most affected
side was the left (60.8 %). The mortality rate was 17.4 %, mainly in
the first 24 h following the trauma.
Conclusion: The diaphragmatic rupture remains a diagnostic chal-
lenge. The initial radiological evaluation, when performed, does not
always identify this injury. The presence of associated injuries is
usually the main indication for surgery, allowing the diagnosis of
diaphragmatic injury in the trans-operative.
References: Demetriades D, Kakoyiannis S, Parekh D, Hatzitheofilou
C. Penetrating injuries of the diaphragm. Br J Surg. 1988;75:824.
Disclosure: No significant relationships.
PS092
PORTAL VEIN GAS: ITS TRUE ROLE IN PERFORMING ANURGENT EXPLORATORY LAPAROTOMY
I. Lintzeris1, X. Agrogianni2, T. Ziagos3, I. Pontikis3
1Surgery, General Hospital of Tripolis, tripolis, Greece, 2Medicine
School, University of Athens, Athens, Greece, 3General Hospital of
Tripolis, Tripolis, Greece
Introduction: Air in the portal venous system is a relatively rare but
ominous sign, indicative of serious intra-abdominal pathology such as
mesenteric vascular occlusion, bowel necrosis, abdominal sepsis.
Materials and methods: We conducted a review of English medical
literature searching the terms and conditions under which the radio-
graphic finding of portal venous gas consists an indication for surgery
intervention and performance of exploratory laparotomy.
Results: Current data suggests that gas in the portal vein may be the
outcome of several pathological conditions of ischaemic or not origin.
It is not a specific diagnostic entity but a diagnostic clue in patients
presenting with abdominal symptoms and signs. When it is the only
finding, patients should be treated conservatively with antibiotics and
it must act as a trigger for further assess the underlying disease. An
emergent laparotomy is justified only when this radiographic finding
is combined with a deteriorating clinical state.
Conclusion: Finding gas in the portal vein during an ultrasound or
computed tomography scan of the abdomen should be promptly
evaluated along with concomitant signs and manifestations.
References: 1. Kesarwani V, et al. Hepatic portal venous gas: A case
report and review of literature. Indian J Crit Care Med
2009;13(2):99–102. 2. Franken J, et al. Hepatic Portal Venous gas.
J Gastrointestin Liver Dis 2010;19(4):360.
Disclosure: No significant relationships.
PS093
EPIDEMIOLOGICAL PROFILE OF TRAUMADIAPHRAGMATIC REFERENCE IN PUBLICHOSPITAL TRAUMA IN BRAZIL HOSPITAL
N.A. De Liz, N.A. Liz, N.T. Kruel, G.S. Silverio, R.N. Goulart,O. Franzon
Surgery Department, Hospital Regional de Sao Jose, Sao Jose, Brazil
Introduction: The diaphragmatic injury has been known since 1541,
initially related to military trauma. After the invention of the auto-
mobile and the rise of urban violence, has seen a significant increase
in its frequency, especially among young people.
Materials and methods: Cross-sectional retrospective study, con-
ducted by reviewing medical records of 23 patients with
diaphragmatic injury confirmed by exploratory laparotomy, during
the period January 2006 to December 2009 in St. Joseph Regional
Hospital.
Results: The average age of patients with the diagnosis of dia-
phragmatic injury was 25.6 years. The age group of 20–29 years was
the most prevalent (60.9 %). The most frequent etiologic agent in this
study was the bullet wound from a firearm (n = 17). Four patients
had a stab wound, while only two patients had blunt trauma. Nineteen
patients underwent preoperative chest radiograph, was conclusive for
the diagnosis of thoracic trauma in 5 of these patients. The plus side
was predominantly affected the left (60.8 %). The mortality rate was
17.4 %, more prevalent in the first 24 h following the trauma.
Conclusion: The diaphragmatic rupture remains a diagnostic chal-
lenge. The initial radiological evaluation, when performed, does not
always identify this injury. The presence of associated injuries is
usually the main indication for surgery, allowing the diagnosis of
diaphragmatic injury in the trans-operative.
Reference: Bodanapally UK, Shanmuganathan K, Mirvis SE, et al.
MDCT diagnosis of penetrating diaphragm injury. Eur Radiol.
2009;19:1875.
Disclosure: No significant relationships.
Abstract S101
123
PS094
NONIATROGENIC POSTTRAUMATIC ANEURYSMOF THE DISTAL RADIAL ARTERY
S.A. Haller1, L. Gurke2, C. Glaser1, A.M. Mols3
1Surgery, Gesundheitszentrum Fricktal, Rheinfelden, Switzerland,2Universtares Zentrum fur Gefasschirurgie Aarau-Basel,
Universitatsspital Basel, Basel, Switzerland, 3Chirurgie,
Kantonsspital Olten, Olten, Switzerland
Introduction: Aneurysms of the distal radial artery are extremely
rare. The majority are iatrogenic pseudoaneurysms following arterial
cannulation.
Materials and methods: Case report.
Results: Case of a male demonstrating a swelling on the radial part of
his left volar distal forearm after a massive bump. Palpable radial and
ulnar pulses distal to the swelling, no thrill. X-rays showed a con-
solidated fracture with dorsal angulation of the distal radius.
Ultrasound revealed distinct turbulences in the distal radial artery
with suspicion of dissection or hematoma of vessel wall. MR-angi-
ography showed a distal aneurysm with long and high-grade stenosis
of left radial artery proximally, strong distal collaterals via interosseus
artery and obstructed ulnar artery. Operation was considered to be
risky for ischemia of the hand and oral anticoagulation was started.
Swelling disappeared after 5 weeks. Duplex ultrasound after
5 months showed remaining tandem-stenosis of distal radial artery,
hyperplastic interosseus artery with connection to the radial artery and
a very small but pending ulnar artery.
Conclusion: Very few reports of radial artery aneurysms originating
from non-penetrating trauma. Our patient remembers swelling of his
left forearm since childhood. We suppose, he developed the aneurysm
after a fracture at the age of 11. The poststenotic aneurysm, being
non-symptomatic after developing a bypass via the interosseus artery,
became apparent after blunt trauma 22 years later. We state a non-
iatrogenic, but post-traumatic aneurysm of the distal radial artery as
an extremely rare condition.
References: 1. Turowski GA, et al. Aneurysm of radial artery fol-
lowing blunt trauma to wrist. Ann Plast Surg. 1997;38(5):527–30. 2.
Amrani A, et al. False aneurysm of radial artery: Unusual compli-
cation of both-bone forearm fracture in children. Cases J. 2008;1:170.
Disclosure: No significant relationships.
PS095
HEMORRHAGIC SHOCK ‘‘STAGE III’’: UNCOMMONBLUNT TRAUMA. DIAPHRAGMATIC HERNIA
G.I. Perez-Navarro1, I. Molinos-Arruebo2, G.C. Inaraja-Perez2,V.M. Borrego-Estella2, L. Novel-Carbo2, J. Gil-Bona1, N. Pena DeBuen2, N. Pardos2, J. Ungria-Murillo1, I. Arazo-Iglesias1, M.E.Tarancon1, J.J. Aguaviva-Bascunana2, S. Laglera-Trebol1
1Anestesia Y Reanimacion, Universitary Miguel Servet Hospital,
Zaragoza, Spain, 2Anesia Y Reanimacion, Universitary Miguel Servet
Hospital, Zaragoza, Spain
Introduction: Traumatic injuries of the diaphragm are a known
consequence of severe trauma, usually of the blunt type. Its incidence
is increasing due to car accidents. Diagnosing a traumatic
diaphragmatic rupture is still a challenge for physicians, with a
delayed diagnosis in more than half of cases, with the consequent
development of latent hernia and it involves an increase risk of morbi-
mortality.
Materials and methods: Male, 47 yo, NKDAs, no PMH. Patient
suffered MVC accident minutes before admission to ER. Rear seat
passenger. Did not wear seatbelt. He was cold and sweaty. Felt pain in
left shoulder, upper left abdomen and right groin. 1st survey: A:
airway was intact. B: right breath sounds ok. No left sounds. C:
2positive radial and pedial pulses. Abdomen was soft but tenderness.
Pelvic stable. No vertebral steps-off or tenderness. D: GCS15, no
LOC.BP: 83/51. HR 123 bpm. O2 86 %. MTP was activated. CXR:
Trachea and mediastinum shift to the right hemithorax. Likely intra-
thoracic stomach herniation 5&6 ribs were fracture. Pelvis XR: pelvic
branches fracture. CAT-scan: stomach, spleen and splenic colonic
flexure intra-thoracic herniation. Splenic hematoma too. Then was
transferred to OR where were treated all injuries.
Results: Approximately 60–70 % of hernias are left-sided, 20–25 %
are right-sided, and 9–15 % are bilateral. Prognosis is generally good
but may have high mortality in some cases. Surgical repair is nec-
essary, even in small ones.
Conclusion: Pain in upper abdomen and lower thorax, dyspnea,
cyanosis and hypotension are typical symptoms of diaphragmatic
injury. These symptoms may be masked by concomitant severe
injuries to other organs. With larger lesions and herniation of the
abdominal contents, signs as breath sound decrease and bowel
sound may be heard. Early diagnosis and treatment is required.
References: 1. Sacco R, et al. Acta biomedica. 2003;74:71–3. 2.
Jorge Llanos C, y cols. Rev Chilena de Radiologıa. 2005;4:166–9. 3.
Reber PU, et al. J Trauma. 1998;44:183–8. 4. Abid Khan M, et al.
PMI. 2008;4:281–84.
Disclosure: No significant relationships.
PS096
A PAEDIATRIC CASE OF A GASTRIC RUPTURE AFTERA NON-MOTOR-VEHICLE BLUNT ABDOMINAL TRAUMA
S. Bikos, S.G. Koulas, G. Pafitanis, S. Spyrou, E.C. Tsimogiannis
Surgery, General Hospital of Ioannina, Ioannina, Greece
Introduction: Isolated gastric rupture after blunt abdominal trauma is
rare. In current literature gastric rupture from blunt abdominal trauma
ranges between 0.02 and 1.7 %. This document reports the first non-
motor-vehicle case of an isolated gastric rapture after blunt abdominal
injury, which repaired after early diagnosis and aggressive surgical
treatment.
Materials and methods: A 14-year-old boy attended our emergency
surgical department after sustained a blunt abdominal trauma fol-
lowing a fall from his bicycle. He presented with pain and left para-
umbilical abdominal ecchymoses. Examination revealed surgical
emphysema and a palpable abdominal wall dimple. Radiological
examination with CT scan determined the need for exploratory
laparotomy.
Results: The operation revealed, extensive rupture of the left lateral
border of the rectus abdominus muscle, free intra-peritoneal position
of the nasogastric tube with gross spillage of gastric contents and
pneumoperitoneum observed with 7–8 cm full thickness rupture of
anterior stomach wall, from the lesser towards the greater curvature.
Primary, two-layer closure was performed. On the 5th post-operative
day due to uncontrollable upper GI bleeding and ineffective inter-
ventional gastroscopy, a second operation was performed. An ulcer-
S102 Abstract
123
like lesion found next to the previously repaired rupture and after
repair a biopsy was taken. He was discharged on the 15th postoper-
ative day.
Conclusion: We present this case report focusing on the pediatric
patient to illustrate isolated gastric injury in terms of mechanism of
injury, clinical presentation, and surgical management.
References: 1. Tejerina EA, et al. Gastric rupture from blunt
abdominal trauma. Injury. 2004;35:228–31. 2. Allen GS, Moore FA,
Cox CS. Hollow visceral injury and blunt trauma. J Trauma.
1998;45:69–75.
Disclosure: No significant relationships.
GERIATRIC FRACTURES AND OTHERS
PS097
SURGICAL TREATMENT OF HIP FRACTURES INELDERLY. AFFECT OF EARLY SURGERY ON MORTALITY
I. Bisbinas, D. Georgiannos, V. Lampridis, T. Michail,I. Theodoroudis, M. Savvidis, G. Gouvas
Orthopaedic, 424 General Military Hospital, Thessaloniki, Greece
Introduction: AIM: Aim of this study is to highlight the surgical
treatment of hip fractures as a first priority procedure, in order to
diminish the postoperative mortality risk.
Materials and methods: Material and method: During 2007–2010,
147 elderly patients with low-energy hip fractures were treated sur-
gically in our Department. Mean age 77 years (67–95 years). 10 cases
were undisplaced neck of femur fractures, treated with cannulated
screws. 65 cases were displaced basicervical fractures, treated with
hemiarthroplasty and 72 cases of intertrochanteric fractures treated
with intramedullary gamma nailing. 112 patients received surgical
treatment within 48 h from their injury and 35 patients after 48 h
(mean time 3–8 days), due to medical problems or/and anticoagula-
tive medication.
Results: After a mean follow-up of 6 months (3–12 m), the first
group had a mortality rate of 5.3 % (6 pts) at 6 months. On the
other hand, the second group had a significantly increased mortality
rate of 14.3 % (5 pts) early postoperatively and 22.5 % (5 pts) at
6 m postop.
Conclusion: Hip fractures in elderly, even after low energy injuries,
are associated with high mortality rates. Optimally such patients
should have surgical treatment within 2 days after injury. An opera-
tive delay more than 48 h is an important predictor of increased
mortality within 6 months postoperatively.
Disclosure: No significant relationships.
PS098
BILATERAL DYAPHISEAL FEMORAL FRACTURESSECONDARY TO CHRONIC TREATMENT WITHBIPHOSPONATES
I. Aunon-Martin, J. Pretell Mazzini, J.L. Leon Baltasar,V. Rodriguez-Vega, C. Resines Erasun
Trauma and Orthopaedic Surgery, Hospital 12 de Octubre, Madrid,
Spain
Introduction: Osteoporosis is a disease of great relevance, and bi-
phosponates are a useful treatment in the prevention as well as hip
fractures. Recent studies have shown association between sub-
trochanteric/dyaphyseal low energy fractures and chronic treatment
with biphosponates.
Materials and methods: A 79 year-old women with no relevant
medical background except high blood pressure, was diagnosed of
osteoporosis about 5 years ago by her primary care physician and
began biphosponates treatment, complaining of bilateral tigh pain for
the last 2 years associated with gate issues.
Results: The patient complained of acute left tigh pain associated
with unability to walk. Plain X-rays revealed a left transverse femoral
fracture as well as a thickening and incomplete lateral cortex right
femoral fracture. Surgical treatment was performed in a sequential
manner using intramedullary fixation. At 12 months follow-up frac-
ture healing was achieved as well as a good functional outcome.
Conclusion: The usual fracture pattern in these cases is described like
a transverse or short oblique without communication, precluded by
cortical thickening as well as incomplete lateral external cortical
fracture. Based on this fact, chronic treatment with biphosponates
should be used with cautious. Finally, the treatment of these fractures
is based on an early diagnosis and intramedullary fixation when
needed.
References: 1. Odvina, et al. J Clin Endocrinol Metab.
2001;28:524–31. 2. Capecci, et al. J Bone J Surg Am. 2009;91:2556-
61.
Disclosure: No significant relationships.
PS099
A META-ANALYSIS TO DETERMINE THE EFFECT OFPREINJURY WARFARIN ON MORTALITY IN TRAUMAPATIENTS
J. Batchelor, S. Ahmed
Emergency Medicine, Manchester Royal Infirmary, Manchester, UK
Introduction: Previous studies regarding the effect on mortality in
trauma patients on preinjury warfarin have produced conflicting and
varied results. The aim of this meta-analysis was to determine the
effect and magnitude of effect of preinjury warfarin on trauma
patients.
Materials and methods: Studies comparing trauma patients on
preinjury warfarin to trauma patients not on preinjury warfarin were
included in the meta-analysis. The search was performed using
Medline via the Pubmed interface, no limits were placed on the
language. The key words Trauma AND warfarin were used. A second
search was performed using the terms Trauma AND anticoagulation
AND Mortality. Cross referencing was also performed. In total nine
papers were suitable for the meta-analysis.
Results: Nine papers were found to suitable for the meta-analysis.
There were two case control studies and seven retrospective cohort
(nested case control) studies. Significant heterogeneity was present as
measured by the Q test (Q value = 147.015, df = 8, p = 0.000) and
also the I-squared test (I2 = 94.558). Heterogeneity was predomi-
nantly due to the great variation in the size of the cohort studies. The
preferred model for this meta-analysis is the Fixed effects model
which produced a common OR 1.953 (95 % CI 1.889–2.019,
p = 0.000).
Conclusion: The results of this meta-analysis has shown that prein-
jury warfarin does appear to increase mortality in trauma patients.
The results are, however, heavily weighted towards two large studies.
Abstract S103
123
Disclosure: No significant relationships.
PS100
PORPHYROMONAS GINGIVALIS AS A RARE CAUSEFOR SEPTIC OSTEOMYELITIS IN THE FEMUR
C. Wichmann1, B. Martens1, C. Ebnother1, A. Platz2, M. Rancan2
1Trauma and Emergency Surgery, Stadtspital Triemli, Zurich,
Switzerland, 2Surgery, Division of Trauma Surgery, Triemli Hospital,
Zurich, Switzerland
Introduction: We present rare case of a 46-year old male patient with
septic-osteomyelitis of the femur caused by this unusual bacterium.
Porphyromonas gingivalis is a gram-negative, anaerobe bacterium
often causing periodontal disease.
Materials and methods: The patient was admitted to our emergency-
unit because of crampy pain of the thigh. MRI showed osteomyelitis
of the proximal femur with large intermuscular abscesses. Treatment
included repetitive surgical debridement with intramedullary reaming
and administration antibiotics. All blood-cultures were negative and
biopsy samples showed myositis without fasciitis. Gram-staining as
well as Grocott, PAS and Ziehl–Neelsen were also negative. By PCR-
testing finally, Porphyromonas gingivalis was detected in three sam-
ples. Multiple granuloma in the upper and lower jaw were found as
source of infection.
Results: At the last follow-up 3 months postoperatively, the patient
showed good recovery without clinical signs of ongoing infection and
healed osteomyelitis in the MRI.
Conclusion: To our knowledge, this is the second documented case
of osteomyelitis by porphyromonas gingivalis and the first case
documented for femur. Welkerling et al. previously presented a
case of osteomyelitis affecting the ulna in a 41-year old man [1].
Furthermore, this corroborates the importance of radical surgical
debridement including intramedullary reaming in the management of
septic osteomyelitis.
Disclosure: No significant relationships.
PS101
THE OUTCOMES OF MANAGEMENT ORTHOPAEDICTRAUMA IN ELDERLY PATIENTS (OVER 85 Y.O.)
A. Zaharopoulos1, V. Pipi1, G. Tsimpouris1, C. Christodoulopoulos1,A. Fasoylas1, I. Vezyrgiannis1, E. Kallitsoynaki1, L. Hantzis1,K. Makris1, A.V. Kyriakidis2
1Orthopaedic Department, General Hospital of Amfissa, Amfissa,
Greece, 2Department of General Surgery, General Hospital of
Amfissa, Amfissa, Greece
Introduction: The continuous increase of average mean age and the
expanding aging population presenting with advanced disease ensues
that surgeons and anesthesiologists have to cope more often with
acute surgical problems in this group of people.
Materials and methods: Our study involves 248 patients over 85 y.o.
that were referred to our hospital during the period 2004–10/2011 and
suffered of an orthopaedic trauma. 135 patients suffered of a fracture
of the femoral neck and a Thomson replacement of the femoral head
was performed, 101 patients suffered of an intertrochanteric fracture
and a Richards or Gamma nail procedure was performed, nine
patients were referred due to femoral shaft fracture and 4 patients due
to fracture of the radius and the ankle joint and internal fixation was
performed.
Results: The type of anaesthesia that was performed was epidural,
subdural or regional blockage. The intraoperative mortality rate was
0 %. Complications were observed in 15 cases (6.1 %). Three patient
died (1.2 %).
Conclusion: Managing orthopaedic trauma in elderly patients is a
decision that should be made as the intraoperative and post-operative
mortality rates are low and the early mobilization of these patients is
very important for their further outcome and their quality of life.
Disclosure: No significant relationships.
PS102
DIVERGING SCREW ANGLES ARE DISADVANTAGEOUSFOR THE STABILITY OF LOCKED PLATE CONSTRUCTS
D. Wahnert1, M. Windolf1, S. Brianza1, S. Rothstock1, M.J. Raschke2,K. Schwieger3
1Biomedical Services, AO Research Institute, Davos, Switzerland,2Trauma, Hand and Reconstructive Surgery, University Hospital
Munster, Munster, Germany, 3AO Institute, Davos, Switzerland
Introduction: Until now no detailed biomechanical investigation was
performed to look at the mechanical impact of the screw angulation of
internal fixators. Therefore, the aim of this study was to investigate
the static and cyclic strength of angulated angular stable screw and
plate constructs.
Materials and methods: We used cellular rigid polyurethane foam
(0.32 g/cm3) and bovine cancellous bone blocks. Custommade
stainless steel plates with two conically threaded screw holes with
different angulations (0�, 10� and 20� divergent) and 5 mm self-
tapping locking screws were used. Biomechanical testing included
(1) static pull-out test and (2) cyclic pull and bending test with 8
specimens per group and test. The bovine cancellous blocks were
only tested under static pull-out. Additionally we performed an
FE-Analysis for the static pull-out test of the 0� and 20�configuration.
Results: We found a significant higher pull-out force in both the foam
model and the bovine cancellous bone for the 0� constructs. In the FE-
Analysis a 47 % higher amount of damage in the 20� divergent
constructs compared to 0� configuration was determined. Under
cyclic loading the mean number of cycles to failure was significant
higher for the 0� group followed by 10� and 20� divergent
configuration.
Conclusion: In our laboratory setting we could clearly show a bio-
mechanical disadvantage of a diverging locking screw angle for both,
static and cyclic loading.
Disclosure: No significant relationships.
S104 Abstract
123
PS103
HEMODYNAMICALLY UNSTABLE GERIATRIC PELVICFRACTURES, OUR EXPERIENCE
V. Guimera Garcıa, P. Caba, G. Parra Sanchez, J.L. Leon Baltasar,A.A. Jorge Mora, I. Aunon, C. Resines Erasun
Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de
Octubre, Madrid, Spain
Introduction: Being the fastest growing sector in Spain, the geriatric
population has shown to have an increased mortality rate when sus-
taining pelvic fractures. The aim of this study is to analyze our
outcomes in a geriatric group with hemodynamically unstable pelvic
fractures.
Materials and methods: Retrospective case series from our trauma
database for a 5-year period (2004–2009). Inclusion criteria: Age
[60 years. ISS [9. Hemodynamic instability: first measure of SBP
\90 mmHg, and sustain a pelvic fracture. Data retrieval included:
Demographics, SBP, ISS, NISS, ICU stay, Hospital stay, mortality
and systemic response. Fractures were classified according to Tile/AO
and treatment recorded (angiography/external fixation/laparotomy).
Our treatment protocol for hemodynamically unstable pelvic fractures
was applied.
Results: 32 patients met inclusion criteria. Mean age was
72.06 years. Mean ISS: 30.4. Tile A was the most common fracture in
45 % of cases. In 62 % of patients angiography was performed.
External fixation and laparotomy were required in 15 and 9 %,
respectively. Mortality rate was 43 %.
Conclusion: As previous studies stated, older patients are more likely
to bleed from pelvic fractures thus requiring angiography and die
despite aggressive resuscitation protocols. This fact should help cli-
nicians to recognize that stable pelvic fractures in geriatric population
are at an increased risk of bleeding and early death.
References: 1. Henry SM et al. Pelvic fracture in geriatric patients: a
distinct clinical entity. J Trauma 2002;53:15–20. 2. Dechert TA, et al.
Elderly patients with pelvic fracture: interventions and outcomes. Am
Surg. 2009;75(4):291–5. 3. Tosounidis G, et al. Complex pelvic
trauma in elderly patients. Unfallchirug. 2010;113(4):281–6.
Disclosure: No significant relationships.
PS104
DISTAL RADIUS FRACTURE FIXATION WITH VOLARLOCKING PLATES AND ADDITIONAL BONEAUGMENTATION IN OSTEOPOROTIC BONE:A BIOMECHANICAL STUDY IN A CADAVERIC MODEL
F.W. Hogel1, S. Mair2, P. Augat2
1Unfallchirurgie, BG-Unfallkllinik Murnau, Murnau/Germany,2Institute for Biomechanics, BG-Unfallklinik Murnau, Murnau/
Germany
Introduction: Fractures of the distal radius represent the most com-
mon fractures in adults. Volar locked plating has become a popular
method for treating these fractures, but has been subject to several
shortcomings in osteoporotic bone, such as loss of reduction and
screw purchase. In order to overcome these shortcomings, cement
augmentation has been proposed.
Materials and methods: AO-type 23-A3.3 fractures were made in 8
pairs of fresh frozen osteoporotic cadaveric radial bones. All speci-
mens were treated with volar plating, and divided into cement
augmentation or non-augmentation groups (n = 8/group). Constructs
were tested dynamically and load to failure, construct-stiffness,
fracture gap movement and screw cutting distance were measured.
Results: Cement augmentation resulted in a significant increase in
cycles and load to failure, as well as construct stiffness at loads higher
than 325 N. When compared to the non-augmented group, fracture
gap movement decreased significantly at this load and higher, as did
screw cutting distance at the holes of the ulnar column.
Conclusion: Cement augmentation improves biomechanical proper-
ties in volar plating of the distal radius.
Reference: Figl M, Weninger P, Liska M, Hofbauer M, Leixnering
M. Volar fixed-angle plate osteosynthesis of unstable distal radius
fractures: 12 months results. Arch Orthop Trauma Surg. 2009;129(5):
661–9.
Disclosure: No significant relationships.
PS105
MINIMAL INVASIVE LONG PHILOS�-PLATEOSTEOSYNTHESIS FOR METADIAPHYSEAL FRACTUREOF THE PROXIMAL HUMERUS. COMPLICATIONS ANDFOLLOW-UP IN A SERIES OF 58 PATIENTS
T. Lamdark, A. Platz, M. Rancan
Surgery, Division of Trauma Surgery, Triemli Hospital, Zurich,
Switzerland
Introduction: We reported on excellent results in 29 patients using
this technique [1]. Objective of this paper was to review complica-
tions and feasibility in 58 consecutive patients.
Materials and methods: 58 patients were operated in MIPO-tech-
nique with long PHILOS�-plates, with a deltoid-split approach
proximally and an intermuscular approach with exposure of the radial
nerve distally [1]. Data were collected prospectively and evaluated
retrospectively.
Results: Two patients died for medical reasons, another refused
follow-up. 55 patients were followed-up to a mean of 8.3 months. We
found eight complications (14.5 %). One incidental finding of plate
deformation 20 months postoperatively without discomfort. One
subacromial impingement without operative intervention. Four
patients (7.3 %) were reoperated. One loose proximal screw was
removed 6 weeks postoperatively. Two cases of implant failure and
secondary dislocation were revised using the same technique. One
necrosis of the humeral head required implant removal and showed
fracture consolidation after 3 months. Two cases (3.6 %) showed
neurological complications. One sensible deficit of the radial nerve
and one probably pre-existing combined hyposensitivity of the hand.
No motor deficit of the radial nerve, injury to the axillary nerve,
infection or non-union were found.
Conclusion: After a mean follow-up of 8.3 months in these 55
patients with minimal invasive long PHILOS�-plate osteosynthesis,
eight complications (14.5 %) occurred. Three (5.5 %) needed major
surgical revision, whereas five (9.0 %) were managed by simple
revision or conservatively. These results confirm this method to be
safe and well applicable for the treatment of metadiaphyseal fractures
of the proximal humerus.
Reference: M. Rancan et al. Injury 2010.
Disclosure: No significant relationships.
Abstract S105
123
PS106
This abstract has been withdrawn.
PS107
CORRECTION OSTEOTOMY OF DISTAL RADIUSMALUNION WITHOUT GRAFTING
D. Tiren, D.I. Vos
Trauma Surgery, Amphia Hospital, Breda, Netherlands
Introduction: Radial corrective osteotomy is an established but
challenging treatment for distal radius malunion that improves wrist
function, pain complaints and may help limit the need for salvage
procedures. The need for a perfectly shaped graft filling the osteot-
omy-gap, adds to the complexity of the operation in terms of
preoperative planning, additional morbidity and lengthened operating
and tourniquet time.
Purpose of this study was to evaluate the results of our correction
osteotomy of distal radius malunions without a bone graft.
Materials and methods: Patients with malunion of the distal radius
were operated on through a dorsal approach. An opening wedge
osteotomy was performed and stabilisation was provided with two
dorsal columnar plates. The osteotomy gap was not augmented with a
bone graft. Postoperatively patients were mobilised in a volar splint
until wound healing afterwards full range of motion was advised.
Heavy duties were prohibited until healing of the osteotomy gap.
Results: Ten consecutive patients were treated between 2009 and
2011 in our hospital. The mean age was 50 years (range 18–72) the
male to female ratio was 3:7. All patients went on to radiographic
union with a filling of the osteotomy gap within a mean period of
4 months (range 2–6 months). No implant related complications were
observed. All patients had satisfactory results in terms of function and
pain.
Conclusion: Correction osteotomy and stabilisation with angular
stable columnar fixation without augmentation of the osteotomy gap
with bone graft is a safe and feasible option in patients with malunion
after a distal radius fracture.
Disclosure: No significant relationships.
PS108
THE OUTCOME OF THE SYNTHESTM LCP EXTRAARTICULAR DISTAL HUMERUS PLATE
H.M.T. Fawi1, D. Parfitt2, R. Prasad2, K. Mohanty2, A. Ghandour2
1 Univ. Hosp. of Wales, CF14 4XW, UK, 2University Hospital of
Wales, CF14 4XW, UK
Introduction: Extra articular distal humeral fractures are challenging
injuries. Due to the strong rotational forces at the elbow and the
unique anatomy of the distal humerus this has traditionally been
surgically treated by bicolumnar–biplanar plating.
Instead we started using the new LCP DHP Synthes plate and eval-
uated the outcomes.
Materials and methods: Eleven patients with extra articular distal
humeral fractures (13-A(1-3)) underwent fixation using the new plate.
A posterior approach to the humerus was used. Postoperative care
involved poly-sling immobilisation for 2 weeks until the wound had
healed followed by early physiotherapy.
Demographic information was collected, including sex, age, laterality
and AO classification in addition to the mechanism of injury.
Assessment of these patients included functional outcome scoring
(Oxford Elbow Scores), patient satisfaction, radiographic assessment,
complications, and the ultimate range of motion achieved.
Results: Follow-up ranged from 3 to 6 months until discharge. Four
females and seven males, average age was 35.6 years. Five were left
sided injury and six were right. Union was achieved in all patients
(average time was 3 months). All patients achieved full range of
motion (0–140�). Overall Excellent Oxford Elbow scores. Overall
patients satisfaction rating was ‘very good’.
Conclusion: This plate has a unique design and is contoured to fit
distal humerus without impinging on the olecranon fossa, with
advantages of locking screw fixation and combi-holes options.
Managing extra articular fractures of the distal humerus with this
plate has become our technique of choice in our department due to the
excellent results. We recommend its use, but due to the small number
of patients treated so far further experience is needed.
References: Surgical Approaches to the Elbow. Clinical Orthopae-
dics & Related Research. Innovative techniques for the osteosynthesis
of distal humeral fractures Use of Orthogonal or Parallel Plating
Techniques to Treat Distal Humerus Fractures Review Article.
Disclosure: No significant relationships.
PS109
WHIPLASH INJURIES IN SPORTS ACTIVITIES IN GREECEAND GERMANY
C. Matzaroglou1, A. Kurth2, N. Karaiskaki3, D. Panagiotopoulos1,E. Heristanidu1, B. Habermann2, K. Kafchitsas2
1Orthopaedic Surgery, Patras University, Rio Patras, Greece,2Orthopaedic Surgery, Johannes Gutenberg University, Mainz,
Mainz, Germany, 3Ent Department, Johannes Gutenberg University,
Mainz, Mainz, Germany
Introduction: We assess qualitatively and quantitatively the potential
risk in athletic activities to sustain cervical whiplash type spine injury
and chronic whiplash syndrome.
Materials and methods: We gathered information from sports
accidents type whiplash, that occurred between 2008 and 2009. Two
hundred-thirty-eight patients with WSI injuries were recorded in
sports in Orthopaedic Departments and classified according to Quebec
Task Force (QTF) classification. The most of them classified in grade
0 according QTF (198/238). All the other patients (40/328 with
chronic musculoskeletal signs) returned for the 6-months, 1-year and
2-year follow-up appointment. All these patients (average age,
25.5 years old) underwent clinical, laboratorial and health related
quality of life scales (SF 36) and psychometric examinations (HADS).
The mean posttraumatic interval was 28 months. Statistical analysis
was performed using the GraphPad Prism 2.01.
Results: Categories of Sports activities as causes of Chronic WAD
[Whiplash Associated Disorders] in our patients were: Soccer (11),
Indoor Soccer 5 9 5 (22), Basketball (5) Weights lift (2). Only 5
patients 5/238 complained for neurological signs at the time of injury.
The other patients classified in the minor grades I and II according
QTF classification. No patient complained for neurological signs after
6 months from the injury. Only 3 patients 3/238 remain with neck
pain, vertigo, tinnitus, and tenderness, but with no physical signs
[grade I] 1 year posttraumatic.
S106 Abstract
123
Conclusion: Our study shows that there is a significant risk of
whiplash type injuries in sports, especially indoor soccer 5 9 5. But
serious injuries with neurologic sequelae and WAD remain very
infrequent, and most of these injuries have minor severity.
References: 1. Hynes LM, Dickey JP. Is there a relationship between
whiplash-associated disorders and concussion in hockey? A pre-
liminary study. Brain Inj. 2006;20(2):179–88. 2.Kochhar T, Back DL,
Mann B, Skinner J. Risk of cervical injuries in mixed martial arts. Br
J Sports Med. 2005;39(7):444–7.
Disclosure: No significant relationships.
PS110
ARTHROSCOPIC MENISCUS REPAIR IN LOCALANESTHESIA
K. Strus1, V. Senekovic2, M. Veselko2
1Traumatology, University Medical Centre Ljubljana, Ljubljana,
Slovenia, 2Department of Traumatology, University Medical Centre
Ljubljana, Ljubljana, Slovenia
Introduction: The meniscus repair using bioabsorbable arrows or
arrows in combination with sutures represents an easy task for a
skilled surgeon and it can be performed in local anesthesia.
Materials and methods: From February 2001 to February 2005 70
patients with torn meniscuses were treated at the University Medical
Centre, Ljubljana. We divided them in a group treated with arrows
and a group treated with combination of arrows and sutures. We
treated 52 medial meniscuses and 18 lateral meniscuses. In the first
group torn meniscus was fixated with minimum 1 and maximum 5
arrows. In the second group torn meniscus was fixated with minimum
1 arrow and 1 suture and maximum 3 arrows and 3 sutures.
Results: At least 22 months after the arthroscopic fixation of the torn
meniscus in local anesthesia clinical evaluation was made. In the first
group postoperative Lysholm score was 89, in the second 86. Average
deficit of flexion was 5�.
Conclusion: We can confirm that the meniscus fixation with bioab-
sorbable arrows or in combination with sutures is technically easy and
fast procedure. It can be performed with good results in local
anesthesia.
Disclosure: No significant relationships.
PS111
FRACTURES UNDER TENSION IN SPORTS INJURIES. NEWPOSSIBILITIES IN PRIMARY WEIGHT BEARINGCAPACITY AND FUNCTION RESATURATION WITH THEXS NAIL IN PATELLA AND OLECRANON FRACTURES
W. Friedl
Orthopedic,Trauma and Hand Surgery, Klinikum Aschaffenburg,
Aschaffenburg, Germany
Introduction: Typical fractures under tension are the patella and
olecranon. For these fractures the tension belt osteosynthesis is the
mainly used procedure. Because of the tendon insertions loosening of
the TB is common.
Materials and methods: To improve stabilisation a new device was
developed : the XS (4.5 mm diameter) and the XXS nail (3.5 mm)
which is locked with threatened wires and a set screw allows
fracture compression inside the nail independent from the soft tis-
sues around.
Results: the experimental results show in all XS nail group no gap
after alternating load of 250 and 500 N. In the tension belt groups in
all tested patellae visible gaps of 1–3 mm occurred. In the period may
1999 to March 2002 49 patella fractures where treated with the XS
nail. In no case fracture dislocation or non-union occurred. 89.7 %
had good and very good functional results. From may 2000 to March
2002 79 patients with olecranon fracture where treated with the XS
nail and evaluated according to the Murphy score. 64.5 % where
more than 2 part fractures. 71.7 % showed a very good, 22.6 a good
and only 5.7 % satisfactory result. In 2 part fractures all patients
showed good and very good results.
Conclusion: The results show a high stability of the XS nail Osteo-
synthesis. Due to the intraosseous position of the nail also soft tissue
problems are avoided and if there are soft tissue problems present
their management is much easier because of the lack of metal implant
between skin and bone surface.
Disclosure: No significant relationships.
PS112
BLUNT SPLENIC INJURIES IN RELATION WITH SKI ANDSURF
B. Paquette, J. Abba, F.X. Ageron, C. Broux, M. Rodiere, C. Arvieux
Chirurgie Viscerale, CHU GRENOBLE, GRENOBLE, France
Introduction: Traumatic spleen lesions are frequent in ski or snow-
board. Their high incidence correlated to its potential gravity and cost
encourage the development of prevention measures Their treatment
has been thoroughly evaluated and is increasingly based on non
operative management (NOM), with or without SAE, leading to
improved results in term of spleen salvage rate (SSR). The aim of our
study was to evaluate the local practice management guideline.
Materials and methods: Epidemiology, choice of initial manage-
ment, severity of spleen trauma evaluated by Moore’s classification,
associated lesions, early in-hospital follow up, global therapeutic
strategy and final outcome were analyzed for patients presenting
spleen lesions in relation with skiing or snowboarding from 2004 to
2011.
Results: 41 were skiers and 21 were snowboarders. Mean age in
SB group was lower (p = 0.04). Most of patients were males. The
mechanism was a collision in one-third of cases. Half of the
patients presented associated lesions, with IgSII and ISS scores
higher in the SK group. Skiers’ admission in ICU was statistically
more frequent than snowboarders (p = 0.01). Eleven splenecto-
mies have been performed for a global SSR of 82.26 %. Post-
operative complications concerned 20 % of the patients, and were
mainly represented by thrombosis and pleural effusions. One
patient died.
Conclusion: Spleen lesions are frequent and severe, affecting young
males Snowboarders are more likely to present isolated spleen lesions
whereas skiers present multiple associated lesions. NOM has a high
success rate due to increased use of SAE. Prevention measures in the
slopes have to be maintained and developed.
Disclosure: No significant relationships.
Abstract S107
123
PS113
A NEW REAMER FOR INTRAMEDULLARY NAILS:PRESSURE ANALYSIS IN COMPARISON WITHCOMMONLY USED REAMER
Y. Arlettaz1, C. Bonjour2, P. Fehlbaum3
1Orthopaedics and Trauma, Hopital du Valais, Sion, Switzerland,2Chirmat Sarl, Monthey, Switzerland, 3SwissMIM SA, Bassecourt,
Switzerland
Introduction: Reamed, locked nails provide a stable fixation of
fracture of the long bones and a high rate of consolidation. Intra-
medullary nailing could lead to pulmonary complications with
development of fat embolism syndrome and acute respiratory distress
syndrome. Pressure generated during reaming is determined by
design, sizes and shape quality of the reamers We report results of
pressure measurement of a new reamer in comparison with well
known currently used reamers.
Materials and methods: The method consist in introduction of the
reamer in a tube containing a mixture of petroleum jelly and paraffin
as described by Sarasin and Vannet (1). We took also in consideration
the diameter of the stem: 8 and 7 mm in diameter mounted each time
with 10.5 mm, 12 mm and 14 mm reamer head diameter.
Results: The results are comparable with the best reamers currently
used (BixCut Stryker) with a 8 mm stem. But, the results are better
when the reamer heads are mounted on the 7 mm stem. This is true
for all the reamer head diameter.
Conclusion: Not only the design of the reamer head is important but
also the stem diameter.The shape quality is also an important factor to
improve the intramedullary pressure. Therefore, we are thinking
about the industrialization process permitting to give on the market a
cost effective single use reamer.
References: Sarasin SM, Vannet NB. A comparison of pressures
created by various commonly uses intramedullary reamers. Internet J
Orthopedic Surg. 2007;7(2).
Disclosure: No significant relationships.
PS114
HIP FRACTURE MORTALITY: IS IT AFFECTED WITHANAESTHESIA TECHNIQUES?
E. Ayhan1, S. Karaca2, H. Kesmezacar3, O. Uysal4
1Orthopaedics and Traumatology, Sariyer Ismail Akgun Public
Hospital, Istanbul, Turkey, 2Anesthesiology and Reanimation,
Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey,3Orthopaedics and Traumatology, Istanbul Bilim University Medical
Faculty, Istanbul, Turkey, 4Biostatistics and Medical Informatics,
Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
Introduction: We hypothesized that combined peripheral nerve block
(CPNB) technique might reduce postoperative mortality in hip frac-
ture patients with the advantage of preserved cardiovascular stability.
Materials and methods: We retrospectively analyzed 257 hip frac-
ture patients for mortality rates and affecting factors according to
general anesthesia (GA), neuraxial block (NB), and CPNB tech-
niques. Patients’ gender, age at admission, trauma date, ASA status,
delay in surgery, follow-up period, and Barthel Activities of Daily
Living Index were determined.
Results: There were no differences between three anesthesia groups
regarding to sex, follow-up, delay in surgery, and Barthel score. NB
patients were significantly younger and CPNB patients’ ASA status
were significantly worse than other groups. Mortality was lower for
regional group (NB + CPNB) than GA group. Mortality was
increased with age, delay in surgery, ASA, and decreased with CPNB
choice, however, was not correlated with NB choice.
Conclusion: Since the patients’ age and ASA status cannot be
changed, they must be operated immediately. We recommend CPNB
technique in high risk patients to operate them earlier.
Reference: Kesmezacar H, Ayhan E, Unlu MC, Seker A, Karaca S.
Predictors of mortality in elderly patients with an intertrochanteric or
a femoral neck fracture. J Trauma. 2010;68(1):153–8.
Disclosure: No significant relationships.
PS115
MUSCLE PERFUSION DETECTED BY CONTRASTENHANCED ULTRASOUND: A POTENTIAL DIAGNOSTICIN ACUTE COMPARTMENT SYNDROME?
R.M. Sellei1, A. Wahling1, S. Jeromin2, F. Schmidt2, P. Kobbe1,M. Knobe1, P. Lichte1, H. Pape1
1Department of Orthopaedic Trauma, University of Aachen, Medical
Center, Aachen, Germany, 2Chair of Medical Engineering,
Helmholtz-Institute, Aachen, Germany
Introduction: The early assessment of the muscle perfusion in sus-
picion of an acute compartment syndrome (ACS) continues to be
challenging. The use of contrast enhancement in ultrasound may help
to determine the collapse of the muscle perfusion indicating
fasciotomy.
Materials and methods: We simulated a decrease of muscle perfu-
sion in volunteers. The perfusion of the anterior tibial muscle was
determined in recumbent (control) and contralateral lithotomy posi-
tion with additional thigh cuff. Contrast enhanced ultrasound (CEUS)
was used to measure and calculate the perfusion curve of each
specimen and limb. The contrast agent (2.5 ml) was applied by an
intravenous bolus and visualized by a contrast-featured unit. The
muscle perfusion of the anterior tibial compartment was determined
(Time to Peak, Wash in Slope, AUC). All results were calculated and
the Wilcoxon test was used to determine potential differences.
Results: Eight healthy volunteers (age 21–37 years, 7 male and one
female) were included. No undesirable side effects occured. The time
to peak (TTP) of the perfusion curve as from the bolus resulted in the
control group in an average of 46.9 s (SD ± 9.2) and in the simulated
ACS group of 64.9 s (SD ± 4.7). These values resulted in a statisti-
cally significant difference (p = 0.0078). The other values also
resulted in significant disparity.
Conclusion: We tested a safe method to determine the muscle per-
fusion. The results show a potential use of this technique to prove the
local micro-vascular status. This may help to detect the ‘‘point of no
return’’ resulting in muscle necrosis and to reduce the time to delayed
fasciotomy.
Disclosure: No significant relationships.
S108 Abstract
123
NEUROTRAUMA AND OTHERS
PS116
HYPODENSE AREA WITHIN EPIDURAL HEMATOMA INTHE BRAIN CT SCAN; PREDICTION OF ACTIVEBLEEDING AND ACCURACY OF SWIRL SIGN IN HEADTRAUMA
P. Moharamzadeh
Emergency Department, Tabriz University of Medical Sciences,
7645453, Iran
Introduction: One of the most important factors in management of
head trauma patients is the existence of the hypodense area in the
epidural hematoma in the primary brain CT scan(SWIRL sign).This
finding can be the sign of active bleeding and developing the
hematoma.
Materials and methods: Forty-nine patients entered the study and
divided into two groups. Group A was those with epidural hematoma
who had immediate craniotomy and group B was those who were kept
under close observation without surgery.
Results: Forty-nine patients were included in this study. Among the
patients, transferred to the OR for emergent craniotomy(Group A)and
all of them had positive swirl sign in their brain CT scan. Of these
patients 90 % had obvious active bleeding artery within the hema-
toma during craniotomy. Patients that did not transferred to the OR
underwent close observation (Group B). In group B all the patients
with positive swirl sign had increasing size of hematoma in their
second brain CT scan.
Conclusion: In the CT of the patients with head trauma, hypodense
area in the epidural hematoma (SWIRL sign) is a serious caution of
developing bleeding and existence of an active site of bleeding in the
hematoma.
Disclosure: No significant relationships.
PS117
This abstract has been withdrawn.
PS118
CLINICAL OUTCOME AFTER CUBITAL TUNNELDECOMPRESSION
F. Saedi, S. Grant, M. Mohamed, N. Hyder
Trauma and Orthopaedics, Leighton Hospital, 4QJ, UK
Introduction: Cubital tunnel syndrome is the second most common
compression neuropathy in the upper limb. The clinical manifesta-
tions may include pain, paraesthesia and/or motor dysfunction.
Surgical management options include in situ decompression, anterior
transposition or medial epicondylectomy.
Materials and methods: Study period was between March 2004–
December 2009. Data was collected by case note review and a patient
outcome scale was carried out by telephone and postal questionnaire.
Exclusions criteria included (1) trauma, (2) preceding or concurrent
surgery and (3) proximal pathology.
Results: Ninety-seven patients underwent the procedure within the
study period. Eighty patients underwent primary decompression.
Seventeen patients were excluded. The average age was 55 years.
Sixty-six patients had unilateral decompression and fourteen had
staged bilateral. Average duration of symptoms prior to surgery was
13.2 months. According to the McGowan scale of severity of symp-
toms, 10 patients had grade I (12.5 %), 57 patients grade II (71.25 %),
7 patients grade III (8.75 %) and 6 patients (7.5 %) could not be
graded due to insufficient information in the note. Complications
included scar dysesthesia in 11 cases (13.7 %), wound infection in 2
(2.5 %) and 1 (1.25 %) wound dehiscence. Fifty-six (70 %) patients
completed the outcome scale measure. Eighty-three percent of patient
symptoms reported to have been cured or improved, thirteen percent
reported no improvement and four percent reported symptom
deterioration.
Conclusion: In situ decompression is an effective treatment for pri-
mary cubital tunnel syndrome. The main aim of the procedure is to
stop the progression of symptoms and not to provide complete
resolution.
Disclosure: No significant relationships.
PS119
DELAY IN TRANSPORT AND SEVERE BRAIN INJURY
M. Marcikic1, B. Hreckovski2, J. Samardzic2, M. Jurjevic3,I. Mirkovic3
1Neurosurgery, General Hospital, Slavonski Brod, Croatia, 2Surgery,
General Hospital, Slavonski Brod, Croatia, 3Anaesthesiology, General
Hospital, Slavonski Brod, Croatia
Introduction: Severe traumatic brain injury is the most frequent
cause of young adult fatalities all over the worlds. The deformation of
the brain at the moment of impact, leads to primary brain injury.
Secondary brain injury may be due to surgical mass lesions and brain
swelling causing elevated intracranial pressure. More than 4 h delay
in evacuation of surgical mass lesions has been demonstrated to have
an additional impact on outcome. We studied two groups of patients
with the goal to investigate an influence of transport time delay on
neurosurgical outcome.
Materials and methods: The study population was comprised of 37
patients with severe brain injury who were admitted to neurosurgical
division of General Hospital Slavonski Brod and operated on in
7 years period. Patients were divided in two groups based on trans-
portation delay: A patients transported from the town and surrounding
area, B patients transported from distant cities. We used Chi-square
test for statistical analysis.
Results: Analyzing median time, patients mostly came to neurosur-
gical unit in the 90 min (group A) and 180 min (group B) after an
accident.
Conclusion: We found out that time required for transport didn’t play
an important role in treatment outcome after brain injury. Critical
time is 4 h as it is published in literature. Age is the only solid fact
which affects the result if all prerequisites have been made for
transport, welfare and other measures.
References: 1. Reed AR, Walsh DG. S Afr Med J 2002;92. 2. Seelig
JM, Becker DP, et al. N Engl J Med. 1981;304.
Abstract S109
123
Disclosure: No significant relationships.
PS120
FOLLOW-UP INDICATORS RELATING TO THESTRENGTH AND DIRECTION OF A CRASH, PERTAININGTO EXTERNAL HEAD INJURIES
Y. Sakamoto, N. Kutsukata
Emergency Medicine, Saga University Hospital, Saga/Japan
Introduction: External injuries are very important external injuries
that are critical in many cases of external injury, such as traffic
accidents, accidental falls, and violent incidents. In contract, it is not
necessarily easy to verify the force and input direction, etc., of a force
that is actually applied to the head in a critical case of external head
injury. Although there have been experiments on external head injury
models using cadavers and animals previously, they were studies of
brain contusion, etc., which can be checked macroscopically. Micro
level inspections have not been studied so far. In contrast, because
brain damage that is difficult to capture using images, such as diffuse
brain damage, is becoming important from a clinical perspective,
micro level verification is important.
Materials and methods: Using pigs that weight 50–70 kg, the
heads were stabilized while under general anesthesia, then the
calvaria of skulls were removed, and force was applied to the brain
parenchyma by an impactor that was developed by engineers.
Similar experiments were performed a total of 4 times in 2 cases
with the dura mater and 2 cases without the dura mater, such that
the impact after removal was applied with an impulsive force of
3.3–7.2 m/s. After the experiments, the pigs were euthanized and
the degree of deformation of the nuclei of the brain cells were
examined, along with their aspect ratios, after staining using an
enzyme antibody technique for neurofilaments, with the aim of
observing the degree of damage to the brain parenchyma, and
performing hematoxylin-eosin staining to stain the nuclei.
Results: Because the aspect ratios of brain cells are horizontally long
for stronger impulsive forces, their abnormalities were observed in the
deeper regions. In addition, stronger deformation of cells was
observed in cases without the dura mater. Furthermore, the same
applies to neurofilament damage, abnormalities being observed in
deeper lesions in cases without the dura mater.
Conclusion: The micro evaluation of brain parenchyma in cases of
mortality due to external injuries is believed to allow extremely
beneficial information to be obtained in the search for causes.
Disclosure: No significant relationships.
PS121
DAMAGE CONTROL ORTHOPAEDICS VS EARLY TOTALCARE: TREATMENT STRATEGY FOR OPEN LONG BONEFRACTURES WITH HEAD INJURIES
H. Minehara1, M. Uchino2, T. Matsuura1, S. Konno3, T. Suzuki3,K. Souma3, M. Takaso1
1Orthopaedic and Trauma Surgery, Kitasato University School
of Medicine, Sagamihara, Japan, 2Orthopaedic Surgery, Machida
Municipal Hospital, Machida, Japan, 3Kitasato University School
of Medicine, Sagamihara, Japan
Introduction: It is often chaotic in the emergency room when the
patient with open long bone fracture also has head injury. A speedy
appropriate decision is mandatory. Basically for the patients with
GCS more than 9, early total care (ETC.) is selected if hemody-
namically stable. For the patients with GCS less than 8, damage
control orthopaedics (DCO) is performed in our facility. However,
there are exceptional cases with suddenly altered treatment plan for
acute deterioration. Clinical courses were reviewed and efficacy of
our treatment strategy was evaluated.
Materials and methods: Registry data and charts of the patients
admitted to our facility from March 2002–March 2010 were reviewed
retrospectively. Open long bone fractures with head injuries: 23 cases,
24 limbs/male: 14 cases, female: 9 cases age at the time of injury:
15–76 years old (average: 46) GCS, treatment methods, ICP moni-
toring, involvement of craniotomy, complications were investigated
and our treatment strategy was evaluated.
Results: \GCS more than 9: 11 cases[ETC.: 8 cases/local DCO: 3
cases \GCS less than 8: 12 cases [ETC.: 3 cases with GCS 7
*GustiloI, ICP \20, ope. time \1.5 h DCO: 9 cases ICP: 13 cases/
craniotomy: 7 cases. No orthopaedic complications Sudden deterio-
ration noted in 1 patient: GCS14 to 3/Nailing with free flap was
changed to craniotomy, EF and acute shortening with skin closure.
Conclusion: During the clinical course, always be ready to change
from ETC. to DCO whenever you notice the sign of deterioration. Our
treatment strategy was adequate without complications.
References: Pape HC, et al.: J Trauma. 2003;55(1):7–13. 2. Bone LB,
et al. Clin Orthop Relat Res. 2004;422:11–6.
Disclosure: No significant relationships.
PS122
AN 11-YEAR REVIEW OF CRANIO-MAXILLOFACIALINJURIES IN A SWISS UNIVERSITY HOSPITAL
A. Businger1, J.C. Krebs1, S. Heinz2, B. Schaller3, H. Zimmermann4,A.K. Exadaktylos4
1Department of Emergency Medicine, Inselspital, Bern University
Hospital, Bern, Switzerland, 2STATWORX, Frankfurt am Main,
Germany, 3Department of Craniomaxillofacial, Skull Base, Facial
Plastic, and Reconstructive Surgery, Inselspital, Bern, Switzerland,4Department for Emergency Medicine, Inselspital, Bern, Switzerland
Introduction: The incidence of injuries caused by interpersonal
violence is comparatively low in Switzerland, but recent research has
indicated an increase in the severity of head injuries. This investi-
gation aimed to assess whether the injury patterns of neurocranial and
maxillofacial (CMF) injuries caused by interpersonal violence have
changed over the past 11 years.
Materials and methods: The records of 1585 patients who had
referred to the adult surgical emergency department (ED) with
neurocranial or maxillofacial injury caused by interpersonal violence
between January 1, 2000, and December 31, 2010, were retrospec-
tively analysed for demographic data, type and location of injury,
instrument used, and drug consumption. Data were analysed for each
year and by comparison of the years 2000–2004 to 2005–2010.
Results: Patients’ median age at the time of admission was 26 years
(range 12–82), and 1473 of 1585 (92.9 %) were males. Referrals
increased from an annual average of 119.6 in 2000–2004 to 164.5 in
2005-2010 (+37.5 %). Severe neurocranial injuries doubled from an
annual average of 4.2 in 2000–2004 to 8.5 in 2005–2010 (+102 %).
Maxillofacial injuries seen in the ED increased from an average of
163.6 per year in 2000–2004 to 247.8 in 2005–2010 (+51.5 %).
S110 Abstract
123
Conclusion: CMF injuries affect mostly young people, impose great
costs on society and have a large impact on quality of life. An
increase in number and severity of head injuries was found, but
research in other Swiss cities is necessary for nationally applicable
conclusions to be made. Preventive measures need to be intensified in
order to curtail the increase of interpersonal violence-related injuries.
Reference: Exadaktylos AK, Hauselmann S, Zimmermann H. Are
times getting tougher? A six year survey of urban violence related
injuries in a Swiss university hospital. Swiss Med Wkly.
2007;137:525–30.
Disclosure: No significant relationships.
PS123
TRAUMATIC SUPERIOR ORBITAL FISSURE SYNDROME:REPORT OF TWO CASES
I. Kalaitsidou, I. Barlas, A. Anastasiou, I. Tilaveridis, G. Venetis
Oral and Maxillofacial Surgery, Aristotle University of Thessaloniki,
Thessaloniki, Greece
Introduction: Superior orbital fissure syndrome (SOFS) is a rare
complication of facial trauma characterized by ophthalmoplegia,
ptosis and proptosis of the eye, dilation of the pupil and hypoesthesia
in the first division of trigeminal nerve. The purpose of this study is to
present two cases of post-traumatic superior orbital fissure syndrome.
Materials and methods: We retrospectively studied two cases of
patients, male and female, victims of fall from height and traffic
accident, respectively, with skull and facial fractures. Diagnosis of
SOFS was made by clinical presentation, radiographic imaging and
formal ophthalmology evaluation.
Results: Both patients underwent early open reduction and internal
fixation of facial fractures. The clinical features of the syndrome were
significantly improved by the administration of corticosteroids.
Conclusion: SOFS is an uncommon finding associated with cranio-
facial trauma. The neurological manifestations of the syndrome are
caused by palsies of III, IV, V, and VI cranial nerves. If the nerves are
severely damaged, the prognosis of the syndrome is poor. Gradual,
automatic, partial recovery of motor and sensory function of the
nerves was reported in many cases of traumatic SOFS. The treatment
is guided by the cause. Surgical decompression is recommended when
there is evidence of compression of the orbital fissure. In cases with
no narrowing of the fissure, steroid administration improves the
manifestations.
Disclosure: No significant relationships.
PS124
WOODEN FOREIGN BODY MASQUERADINGAS A DEPRESSED SKULL FRACTURE
E.S. Concannon, A. Hogan, K. Barry
General Surgery (Mr Kevin Barry Service, F.a.c.s.), Mayo General
Hospital, Castlebar, Ireland
Introduction: A 78 year old male patient was brought by ambulance
to the Emergency Department after falling down a wooden staircase
at home. On arrival, his Glasgow Coma Scale was 15/15, his pupils
were equal and reactive to light and he was alert and orientated. The
patient denied loss of consciousness but complained of a severe
occipital headache without nausea, vomiting or visual disturbance. On
examination an actively bleeding 5 cm transverse laceration was
noted at the patient’s occipital area. A palpable, hard prominence
extended longitudinally from the occipital area to the vertex, taken to
represent a depressed skull fracture. CT Brain imaging outruled skull
fracture or intracranial abnormality. Surgical exploration of the scalp
laceration under local anaesthetic revealed a large 2 cm 9 30 cm
piece of timber which dissected along a longitudinal subcutaneous
tract from the occiput to the vertex.
Only when ‘lung window’ settings were used to view the CT images
retrospectively could this large wooden foreign body be visualised
radiologically.
Materials and methods: Case report (illustrated by excellent pho-
tographic images and CT Brain stills) + Literature Review using
Medline search engine.
Results: Not applicable.
Conclusion: Our case and literature review illustrates the importance
of CT ‘lung window’ views and ultrasonography as techniques that
aid visualisation of radiolucent foreign bodies (e.g.: chopsticks/hair
accessories) in penetrating and non-penetrating head injury, which
pose a risk of infection if surgical extraction is incomplete.
Reference: Syed ON, Mack WJ, Feldstein NA, Anderson RC.
Radiolucent hair accessories causing depressed skull fracture fol-
lowing blunt cranial trauma. J Neurosurg Pediatr. 2008;2(6):424–6.
Disclosure: No significant relationships.
PS125
MORBIDITY, IMAGE DIAGNOSIS AND TREATMENTFOR TBI IN CURITIBA: BRAZIL
F.G. Blauth, M.M. Rodrigues, A.K. Calixto, A.D. Oliveira,L.C.V. Bahten
Ccbs, PUCPR, Curitiba, Brazil
Introduction: Injury in children is a major cause of morbidity and
mortality it also presents an economic burden to society world-wide.
It is most of the time avoidable and it can have different implications,
varying from simple repercussions to systemic involvement and
death.
Materials and methods: The data was collected trough medical
registers at the service of medical archives in Curitiba, Brazil. The
population analyzed were children from 0 to 12 victims of trauma,
hospitalized at the Hospital Universitario Cajuru, in the period from
April 2009 to April 2011. Epi-Info and Excel were used for data
analysis.
Results: A total of 731 registers were analyzed. TBI occurred at 142
children (19.29 %). The three most frequent responsible mechanisms
for it were: ‘‘fall from a different level’’ with 60 (42.55 %), ‘‘running
over’’ with 25 (17.75 %) and ‘‘fall from the same level’’ with 20
(14.18 %). For TBI treatment, two conducts prevailed: ‘‘conservative
measures’’ with 122 (86.52 %) and ‘‘surgical treatment’’ with 15
(10.64 %). All of the children were submitted to some kind of image
diagnosis, the most frequent one was CT with 134 (95.04 %) followed
by radiography with 131 (92.91 %). The average of internment
caused by TBI was 3,42 days.
Conclusion: TBI had an important incidence, it was usually caused
by falls, has a simple treatment and few days of hospitalization.
However, it had an elevated cost because of the use of imaging
diagnosis.
Disclosure: No significant relationships.
Abstract S111
123
PS126
NEUROLOGICAL DISORDERS IN SPORTS TRAUMA
J.A.S. Da Silva1, J.P.S. Gandara1, G.H. Cainelli1, L.B. Salim2,C.M. De Oliveira2, L.A.L. Da Silva2, E. Achar1, A.C. Piccolo3,M.A.F. Ribeiro Jr1
1Surgery, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil,2Surgery, Universidade Cidade de Sao Paulo, 03071000, Brazil,3Neurology, Universidade Cidade de Sao Paulo, 03071000, Brazil
Introduction: Concussion is a trauma that leads to changes in mental
status in contact sports. Monitoring and care of athletes who suffered
concussions, are extremely important to be able to make an early
treatment for brain lesions and neurological deficits.
Materials and methods: We performed a critical review of the
literature where a survey was made in the database EBSCO,
MEDLINE and SciELO where selected articles about concussion in
sports.
Results: For Grade 1 the athlete does not lose consciousness and
suffers only momentary confusion or change in mental status. The
symptoms resolve in less than 15 min after the concussion. Grade 2
injuries the athlete does not lose consciousness but exhibits signs or
symptoms of concussion and loss of concentration, mental status
changes lasting more than 15 min. It should examine the athlete on
the site, should be performed a complete neurological examination to
clear the athlete to return to their activities 1 week after being
asymptomatic. For Grade 3 lesions where the athlete loses con-
sciousness for any length of time the athlete must be transferred to
realize head CT or MRI.
Conclusion: Concussion is a trauma that leads to changes in mental
status that may or may not lead to loss of consciousness, one of the
main symptoms is loss of consciousness, it is important to make the
observation of the athlete and the evolution of this after a trauma, in
order to determine possible neurological changes associated with
concussion.
Reference: Practice parameter: The management of concussion in
sports (summary statement) Neurology 1997;48:581–5.
Disclosure: No significant relationships.
PS127
CRANIOENCEPHALIC LESIONS IN MOTORSPORTS
J.A.S. Da Silva1, J.P.S. Gandara1, G.H. Cainelli1, A.C. Piccolo2,E. Achar1, M.A.F. Ribeiro Jr1
1Surgery, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil,2Neurology, Universidade Cidade de Sao Paulo, 03071000, Brazil
Introduction: Traffic accidents are a common cause of mortality
related to trauma, being identified as the most frequent cause of death
in individuals between 1 and 34 years old. The skull brain injuries in
car accidents, is defined as a injury that leads to anatomical lesions
and functional impairment involving the skull and encephalic tissue.
Materials and methods: Review of literature using the databases
PubMed/Medline, Lilacs and Ebsco. We selected articles which
contain aspects relevant to the objectives and data on cranioence-
phalic injuries in motorsports.
Results: The head injury in victims of traffic accidents is the most
frequently isolated lesions found in severe and fatal cases and one that
brings more sequels, disabilities and handicap. The brain contusions
increase in size in 12–24 h may be evident 1 day after injury, sub-
dural and epidural hematomas are present in cases of severe head
trauma, and may cause increased intracranial pressure resulting in
death of brain tissue.
Conclusion: Head injury remains a serious safety concern in motor
sports and the greatest cause of death. The differentiation between
these lesions and the potential for serious life-threatening it is critical
to define the beginning of treatment and immediate release or
admission to hospital. Sports-related head injuries are Also of great
concern because repeated mild head injury has become an important
health issue with potential long-term disability.
Reference: Weaver CS, et al. An analysis of maximum vehicle G
forces and brain injury in motorsports crashes. Med Sci Sports Exerc.
2006;38(2):246–9.
Disclosure: No significant relationships.
PS128
SEVERE TRAUMATIC BRAIN INJURY: TRAUMA’SGOLDEN HOUR
T.N. Santos1, H.M. Fernandes1, A.L.C. Silva1, V. Castro1, S.M. Silva2,M. Oliveira1, C. Dias2
1Surgery Department, Alto Ave Hospital Center, Guimaraes,
Portugal, 2Neurocritical Unit, Hospital Sao Joao, Porto, Portugal
Introduction: Traumatic Brain Injuries (TBI) are the most common
type of traumatic injury admitted to emergency departments. Most
patients are likely to die before reaching a hospital, whereas brain
injuries account for 90 % of trauma-related deaths.
Materials and methods: The authors present the case study of patient
a severe TBI (resulting from a blow to the head).
Results: A 37 year old male patient, who sustained a severe TBI was
assisted by an EMS unit on the scene, 10 min after having sustained
injury. The patient was hypotensive, tachycardic and presented an
injury to the left frontoparietal region of the skull with a calvarial
fracture and loss of brain tissue. The patient arrived at the emergency
room (20 min after injury). The surgical correction of a depressed
skull fracture was performed on the patient via a frontal craniotomy
incision. The patient was then taken to the Neurocritical Intensive-
Care Unit (NICU). Postoperative complications were registered, with
intracranial hypertension, cerebrospinal fluid leakage and brain her-
niation, which was corrected surgically 12 days after the first surgery.
The patient was discharged from the neurotrauma ICU on postoper-
ative day 25, presenting speech and behavior impairment but no
further neurological changes.
Conclusion: Approximately 363 per million inhabitants sustain a
moderate to severe TBI and from those more than one-third requires
brain rehabilitation. Learning how to recognize the severe traumatic
brain injuries, establishing basic life support measures, the rapid
access to specialized treatment and the existence of neurocritical
intensive care units can make the difference.
Disclosure: No significant relationships.
S112 Abstract
123
PS129
MULTIPLE MICRO RIDDLED INJURY: A NEW ETIOLOGYOF ACUTE EXTREMITY COMPARTMENT SYNDROME
A.C. Ezanno1, A. Lamy1, C. De Serre De Saint Roman1, S. Rigal2,P. Sockeel1, J.F. Gonzalez1
1Surgery, HIA Legouest, METZ cedex 3/France, 2Surgery,
HIA PERCY, Clamart Cedex/France
Introduction: Many etiologies have already been described for acute
extremity compartment syndrome (ECS). The authors here report an
original cause of ECS with a series of ECS caused by multiple mi-
crofragment injury during a massive influx of war injuries patients.
Materials and methods: Prospective study of 10 ECS by multiple
micro riddled injury in 5 patients treated by the French medico-sur-
gical team. The diagnostic was considered present when one or more
signs and symptoms were described. Fasciotomy was immediately
performed after the diagnostic, using large incisions. Air evacuation
flight from the theater of operation to France was performed after.
Patients were reevaluated after 2 years.
Results: At reevaluation, all patients had kept their limb and full
function, without any sepsis. In only 2 cases, a skin graft was nec-
essary. There was a neurological complication in one case. All
patients returned to their former job. They all declared having an
esthetical discomfort due to the scar.
Conclusion: This work is the first to present a series of ECS by
multiple micro riddled. The physiopathology is the same as usual.
Since it only affected soft tissues, the compartments with the most
projectiles (more than 10) were the ones with ECS. The decision of
performing a surgical fasciotomy was made on clinical arguments.
Because of the large influx of wounded, the difficulties of proper
clinical surveillance of the wounded, and the necessity of an long
aerial evacuation, the indication of a fasciotomy must be large and
made as soon as the diagnostic is mentioned.
Disclosure: No significant relationships.
PS130
MULTILOC NAILING: FIRST EXPERIENCE IN 50 CASES
S. Nijs, P. Caeckebeeke
Traumatology, University Hospitals Leuven, Leuven/Belgium
Introduction: Proximal humerus fractures remain a major problem in
the elderly population their incidence is increasing and failures of
osteosynthesis or major complications have been reported in up to
25 % of cases. Arthroplasty remains a poor alternative as functional
outcome is poor to moderate on average and complication rates are
not lower than for osteosynthesis. Multiloc is a new implant com-
bining the advantages of intramedullary nailing to a high number of
fixation points we typically now from angular stable plating. Fur-
thermore new technologies as screw in screw fixation and an
ascending cal car screw have been implemented in the system.
Materials and methods: We describe the functional and radiographic
outcome in a series of 50 consecutive patients at 6 months after
surgery. Mean age is over 70 year, and 2, 3 and 4 fragment of frac-
tures, as well as delayed unions or failed osteosynthesis after the use
of other implant have been included.
Results: Functional outcome after 6 months will be described. Pre-
liminary analysis of the series demonstrate a functional outcome
(constant score and ASES index) which is favorable to historical
series using angular stable plates or X-mas tree nails. Radiographic
outcome is described focussing on failures of osteosynthesis, healing
and loss of reduction. Three months analysis only showed 3 failures
of osteosynthesis, which is much lower than expected based upon the
experience in angular stable plating. At the congress 6 month results
will be available and described for the entire series of 50 consecutive
cases.
Conclusion: Preliminary 3 months analysis demonstrate favorable
outcome. At the congress a conclusion based upon 6 months analysis
will be available.
Disclosure: The main author is part of the developing team of the
implant discussed. He received financial reimbursements for his work
in the development team and for teaching activities related to the
product discussed.
PS131
TISSUE ENGINEERED NASAL CARTILAGE FOR THEREGENERATION OF ARTICULAR CARTILAGE IN THEKNEE AFTER TRAUMATIC INJURY: A PHASE 1 CLINICALTRIAL
M. Mumme1, A. Barbero2, S. Miot2, A. Wixmerten2, F. Wolf2,S. Feliciano2, F. Saxer1, I. Fulco3, M. Haug3, D.J. Schaefer3,M. Steinwachs4, U. Studler5, M. Arnold6, V. Valderrabano7,T. Schwamborn8, I. Martin2, M. Jakob1
1Traumatology, University Hospital Basel, Basel, Switzerland,2Institute for Surgical Research and Hospital Management, University
Hospital Basel, Basel, Switzerland, 3Plastic Surgery, University
Hospital Basel, Basel, Switzerland, 4Orthopaedic Surgery, Schulthess
Klinik, Zurich, Switzerland, 5Radiology, University Hospital Base,
Basel, Switzerland, 6Orthopaedic Surgery, Bruderholz Hospital,
Bruderholz, Switzerland, 7Orthopaedic Surgery, University Hospital
Base, Basel, Switzerland, 8Orthopaedic Surgery, CrossKlinik, Basel,
Switzerland
Introduction: Articular cartilage injuries are a prime target for
regenerative techniques, as spontaneous healing is poor and untreated
defects predispose to osteoarthritis. A three-dimensional in vitro
engineered cartilage tissue graft based on autologous nasal chondro-
cytes, recently validated in different pre-clinical models, could
overcome drawbacks of established therapies. The purpose of this
phase-1 study is to demonstrate safety and feasibility of the procedure.
Materials and methods: Ten patients below 55 years with an iso-
lated full-thickness cartilage lesion of up to 8 cm2 due to traumatic
injury on the femoral condyle of the knee will be enrolled in the trial.
Tissue engineered cartilage grafts will be based on autologous nasal
chondrocytes combined with a collagen type I/III membrane (Chon-
dro-Gide�, Geistlich). A nasal septum cartilage biopsy will be
harvested in an out-patient procedure and processed in a GMP-facility
to isolate nasal chondrocytes. After 4 weeks of culture with autolo-
gous serum in the framework of an established quality management
system, the resulting three-dimensional cartilaginous tissues will be
implanted into the defect. Patients will be followed up clinically
according to the ICRS evaluation package and radiologically with
High Resolution MRI, dGEMRIC and T2-mapping for the evaluation
of the repair tissue.
Results: The study was recently approved by the local ethical com-
mission. The application package was submitted to Swissmedic and
Abstract S113
123
approval is pending. We expect to include the first patient at the
beginning of 2012.
Conclusion: If successful, this study will open a new approach in
biolocial cartilage regeneration with engineered tissue and nasal
chondrocytes as cell source.
Reference: Acknowledgments: Deutsche Arthrose-Hilfe for financial
support.
Disclosure: No significant relationships.
PS132
This abstract has been withdrawn.
PS133
COMPARATIVE EVALUATION OF SURGICAL OUTCOMEIN UNSTABLE INTER TROCHANTERIC FRACTURES INELDERLY PATIENTS TREATED BY DHS ANDARTHROPLASTY
E. Ghayem Hassankhani1, A.R. Hutkani1, G. Ghayem Hassankhani2
1Orthopeadic, Mashad University of Medical Sciences, Mashad, Iran,2Mashad Medical School, Mashad University of Medical Sciences,
Mashad, Iran
Introduction: Unstable intertrochanteric fractures are a major source of
mortality, morbidity and functional impairment in the elderly. The pur-
pose of this study was to compare the results of arthroplasty, with those of
internal fixation by DHS for elderly unstable intertrochanteric fractures .
Materials and methods: Forty elderly patients (25 females and 15
males) with an unstable intertrochanteric fracture were randomized
into two treatment groups between January 2007 and December 2010.
The twenty patients in Group A were treated with arthroplasty and the
twenty patients in Group B were treated with DHS.
Results: There were no significant differences between two groups in
operative time, general complications, hospital stay and functional
outcomes. arthroplasty had lower mortality and implant failure rate,
shorter time to weight-bearing but had more blood loss and more
hospital costs compared with DHS.
Conclusion: Arthroplasty is an alternative treatment in elderly
patients with unstable intertrochanteric fractures and provides good
clinical outcomes with stable, pain-free, mobile joint and lower
complication and mortality rate as seen in our study.
References: 1. Sancheti KH. Primary hemiarthroplasty for unstable
intertrochanteric fractures in the elderly. Indian JO. 2010;44(4). 2. Flo-
rian G. Trochanteric fractures in the elderly. Arch OTS 2007;127(10).
Disclosure: No significant relationships.
PS134
TEXT-MESSAGE REMINDERS TO INCREASEATTENDANCES AT ORTHOPAEDIC OUTPATIENTCLINICS
R.G. Kavanagh1, O. Flannery2, P.J. Kenny2
1Orthopaedic Surgery, Connolly Hospital, 15/Ireland, 2, Connolly
Hospital, 15, Ireland
Introduction: We aimed to assess the impact of a text-message
reminder service on the attendance rates at the orthopaedic outpatient
department in a large Irish teaching hospital. We also assessed the
cost-effectiveness of such a strategy.
Materials and methods: We obtained data from the HIPE
department of the hospital regarding outpatient attendances and
DNA rates from 6 month periods before and after the introduction
of the text-message reminder system. We also obtained information
from the governmental finance department regarding costing of
OPD services.
Results: We found that overall and return outpatient attendance rates
were increased after the introduction of the text-message reminder
service and this was statistically significant (p \ 0.0001). The overall
attendance rate increased by 2.8 %, while the return attendance rate
increased by 5.6 %. This strategy was also found to be cost effective
given that the overall saving was calculated to be approximately
€28760 and the cost of providing the service over the 6 months of the
study was estimated at €240.
Conclusion: In the current economic climate, the introduction of
strategies that reduce the cost of delivering healthcare is important.
Our study shows that a simple text-message reminder service sig-
nificantly increases OPD attendance rates and that this strategy is cost
effective and would result in the saving of millions of euro if similar
results could be achieved nationally.
Disclosure: No significant relationships.
PS135
MANAGEMENT OF NONUNIONS WITH ALLOGRAFTCELLULAR MATRIX CONTAINING VIABLEMESENCHYMAL STEM CELLS
A. Startzman, S. Martinez, B.J. Cross
Orthopedics, Broward General Medical Center, Nova Southeastern
University, Fort Lauderdale, FL, USA
Introduction: Management of nonunions is a challenging task with
variable outcomes that are not always positive. A common tech-
nique for surgical management of nonunions involves the use of
autograft materials, however, complications can occur. We propose
the use of a novel allograft cellular matrix containing viable
mesenchymal stem cells for treatment of nonunions to replace
autograft.
Materials and methods: Retrospective case study that took place at
Broward General Medical Center between 9/2009 and 5/2010. We
compared the rate, time of union, and complications using a novel
allograft to published data on autografts. Outcomes were based on
callus formation and fracture closure radiographically, decreased pain
and increased stability functionally.
Results: Based on radiograph average time to callus formation:
5.85 weeks, average time to union: 16.4 weeks. Union success was
90 %, there were no malunions. One patient had complications due to
infection and noncompliance. Two patients required additional sur-
gery, one for infection and one for a failing proximal screw. At healed
fracture site three patients reported no pain and six reported minimal
pain. Nonunion locations: 7 tibia/fibula, 2 femur, and 1 humerus.
There were 7 males and 3 females included in this study.
Conclusion: The results of our study suggest that this novel allograft
is comparable to published standards for autogenous bone graft.
Additionally this allograft has fewer complications, decreased pain,
and shorter time to union than compared to published autograft
studies.
S114 Abstract
123
References: 1. J Orthop Trauma. 2002;16:287–96. 2. Clin Orthop
Relat Res. 2003;411:245–54. 3. JBJS Am. 1999;81:1217–28. 4. JBJS
Am. 1976;58:653–7. 5. JBJS Br. 2009;91:522–9.
Rockwood and Greens Fractures in Adults, 2010, Ch25.
Disclosure: No significant relationships.
SKELETAL TRAUMA
PS136
REFRACTURE INCIDENCE FOLLOWINGINTRAMEDULLARY IMPLANT REMOVAL IN CHILDREN’SLOWER ARM FRACTURES
S. Kocuvan1, J. Robida2
1Department of Traumatology, General and Teaching Hospital Celje,
Celje, Slovenia, 2General and Teaching Hospital Celje, Celje,
Slovenia
Introduction: The method of intramedullary fixation has been a
proven and widely used technique in children’s lower arm fracture
stabilisation since the early 80s, and has likewise been generally
accepted and used since 1995 in the General and teaching hospital
Celje. Originally the method postulated the removal of intramedullary
implants 8–12 weeks after stabilisation, but recent literature has
advocated a longer fixation period due to a higher incidence of re-
fractures, in some cases even up to 1 year. The higher refracture
incidence in implant removal after 12 weeks led us to extend treat-
ment and remove intramedullary implants after 5 months. The
following paper will substantiate the reason for this decision and
demonstrate the outcomes of such prolonged treatment.
Materials and methods: Case study with follow up.
Results: Extending treatment and removing intramedullary implants
after 5 months decreases the rate of refracture incidence.
Conclusion: Similarly to others around the world the surgeons at the
general and teaching hospital Celje have also come to the conclusion
that prolonged fixation significantly reduces refracture incidence; yet,
considering the current refracture incidence a further prolongation of
treatment may be warranted.
Disclosure: No significant relationships.
PS137
COMPARATIVE STUDY OF POSTERIOR, ANTERIOR ANDLATERAL APPROACH TO THE TREATMENT OFGARTLAND TYPE III PEDIATRIC SUPRACONDYLARHUMERUS FRACTURES
M.F. Catma, B. Tunc, F. Bozkurt, M. Altay
Orthopaedics and Traumatology, Ankara Diskapi Yildirim Beyazit
Training and Research Hospital, Ankara, Turkey
Introduction: As a retrospective examination, this study aims at
evaluating the influence of the incision methods on the outcome of the
surgical treatment performed between 2005 and 2010 on 120 patients
with Gartland Type III supracondylar humerus fractures.
Materials and methods: The study consisted of 120 patients diag-
nosed at emergency clinic between March 2005 and February 2010
with Gartland Type III supracondylar humerus fractures. The patients
were grouped in regards of the surgical approaches performed. The
first group included 35 patients treated with lateral approach, the
second group consisted of 45 patients treated with posterior approach.
40 patients in the third group were operated by applying anterior
approach. The cases were evaluated according to Flynn’s criteria.
Results: Among 120 patients, the number of girls was 38 (32 %) and
that of boys was 82 (68 %). Average age was 6.9 ± 3.5. Of all the
cases, 52 had a fracture of the left (43 %) and 68 of the right (58 %)
extremity. As regards of the functional factor, excellent results were
achieved in 95 % of the patients approached by anterior incision,
57 % by lateral incision, 44 % by posterior incision. 46 % of the
patients treated with lateral approach, 82 % with posterior approach
and 87 % with anterior approach gave excellent results in view of the
cosmetic factor.
Conclusion: It was observed that compared with the other approa-
ches, anterior approach to displaced supracondylar humerus fractures
put out far better results considering functional and cosmetic factors.
Reference: Davis RT, Gorczyca JT, Pugh K. Supracondylar humerus
fractures in children. Comparison of operative treatment methods.
Clin Orthop Relat Res 2000;49–55.
Disclosure: No significant relationships.
PS138
SPORTS INJURIES. 11 YEARS OF EXPERIENCEIN A TERTIARY HOSPITAL
N. Zambudio-Carroll1, J.D. Turino-Luque2, A. Mansilla-Rosello3,J. Jorge Cerrudo2, I. Segura Jimenez3, A. Paz Yanez2,J.A. Ferron-Orihuela3
1Cirugıa General, Hospital Virgen de las Nieves, Granada, Spain,2Servicio De Cirugıa General Y Aparato Digestivo, Hospital
Universitario Virgen de las Nieves, Granada, Spain, 3Cirugıa General,
Hospital Universitario Virgen de las Nieves, Granada, Spain
Introduction: Depending on the sport involved, a variety of injuries
can often result that require attention to the patient in an emergency
room setting. This study analyzes the impact of a specific sport and
how it might lead to the damage of certain organs and tissues.
Materials and methods: Trauma patients studied retrospectively
over a period of 11 years, separating those injuries caused by sports
from those caused by cars and motorcycles. We used SPSS 17.0 for
statistical analysis.
Results: Sports injuries accounted for a total of 51 (11.2 %) of the
patients while 404 (88.8 %) were due to traffic accidents. The most
common sports injuries were cycling (51 %), horse riding (17.9 %)
and skiing (17.9 %). In traffic accidents, the percentage of head and
thorax injuries was higher in comparison to sports injuries: (25.4 vs.
11.7 %, p = 0.006 and 57.4 vs. 29.4 %, p \ 0.001, respectively).
There were no differences in abdominal injuries (78.9 vs. 66.6 %,
p = 0.072). No differences in hepatic lesions were found when ana-
lyzing solid intraabdominal organs (26.5 vs. 23.5 %, p = 0.7) but
differences were found in splenic lesions (41.1 vs. 23.5 %, p = 0.02).
Statistically significant differences existed for pancreatic (7.8 vs.
1.2 %, p = 0.0078) and renal lesions (45.1 vs. 19.3 %, p \ 0.001),
with both occurring more frequently in sports injuries. There were
significant differences in overall mortality rates for traffic accidents
(18.9 vs. 1.9 %, p = 0.006).
Conclusion: Pancreatic and renal injuries are more frequent and
statistically significant in sports-related accidents when compared to
traffic accidents. There are no significant differences in liver injury
Abstract S115
123
among the two groups. Head and trunk injuries predominate in traffic
accidents.
Disclosure: No significant relationships.
PS139
DOES FULL REDUCTION OF CALCANEAL POSTERIORFACET FRACTURES IMPROVE QUALITY OF LIFE?
F. Say, A.M. Bulbul
Orthopaedics and Traumatology, Samsun Training and Research
Hospital, Samsun, Turkey
Introduction: This study aimed to investigate the impact on daily life
of the post-operative status of the posterior facet of calcaneal fractures
which had undergone open reduction and plate fixation.
Materials and methods: 18 patients were evaluated; mean age
26 years (18–34). All fractures were Type four by the Sanders clas-
sification system. The fracture reduction was performed with grafting
and osteosynthesis was performed with the aid of a calcaneal plate.
All fractures occurred from falls from height. All fractures were
closed.
Results: The post-operative Bohler angle measured 15–20� in 16
patients, and less than 10� in 2 patients. All patients were evaluated
again at the end of 1 year. According to the American Foot & Ankle
Score, the 2 cases with a radiological Bohler angle of less than 10�were poor clinical outcomes, and the other cases were determined as
moderate and good. There were no problems with wound and skin. At
the end of 1 year early arthritic changes were seen radiographically in
the cases of Bohler angle less than 10� and no arthritic changes were
seen radiographically in the other cases.
Conclusion: It has been established that early arthrosis results from
calcaneal fractures where the posterior facet is not reduced fully. This
results in the patient’s quality of life being seriously restricted. Thus,
it can be concluded that posterior facet reduction is very important for
the patient’s quality of life.
Reference: Swanson SA, Clare MP, Sanders RW. Management of
intra-articular fractures of the calcaneus. Foot Ankle Clin.
2008;13(4):659–78.
Disclosure: No significant relationships.
PS140
METAPHYSEO-DIAPHYSEAL JUNCTION FRACTURE OFDISTAL HUMERUS IN CHILDREN
N.R. Gopinathan, R.K. Sen, V.G. Goni, V.K. Viswanathan,S.B. K
Orthopaedics, PGIMER, Chandigarh, India
Introduction: Fracture at the metaphyseal-diaphyseal junction of
distal humerus is an uncommon injury in children and has been
recently isolated from supracondylar and distal humeral fractures.
This is second report of this kind where we review our experience
about this injury.
Materials and methods: A retrospective review of medical records
and radiographs of pediatric-elbow fractures revealed 6 metaphyseal-
diaphyseal junction fractures (supra-supracondylar fractures) of distal
humerus and 182 supracondylar fractures of humerus that were
treated in our institute over a period of 5 years. Clinical data
regarding patient’s age, neurovascular status of the affected limb,
mechanism of injury, mode of treatment and ultimate clinical out-
come were collected for both these fractures and a comparison was
made.
Results: Oblique (2 patients), comminuted (3 patients) and transverse
types (1 patient) of fracture patterns were identified at distal humeral
metaphyseal-diaphyseal junction: The oblique and comminuted
fractures were managed conservatively; where as the only transverse
fracture was treated surgically with Kirschner-wires. Assessment by
Flynn criteria after 1-year of injury revealed better functional out-
come in metaphyseal-diaphyseal junction fractures than the
supracondylar fractures.
Conclusion: Though transverse fractures are unstable and may
require surgical fixation; oblique and comminuted fractures can be
managed conservatively. The overall outcome of metaphyseal-
diaphyseal junction fracture is better than the common supracondylar
fractures in children.
Reference: Fayssoux RS, Stancovist L, Domzalski ME, Guille JT.
Fractures of the distal humeral metaphyseal-diaphyseal junction in
children. J Pediatr Orthop. 2008;28:142–146.
Disclosure: No significant relationships.
PS141
MULTIPLE DIAPHYSEAL FRACTURES OF THE HUMERUS:TREATMENT WITH THE ILIZAROV APPARATUS
I. Lalic1, V. Kecojevic1, S. Tomic2, M. Lukic3, B. Vukajlovic4
1Orthopaedics, KCV, Novi Sad, Serbia, 2Department of Physical
Medicine, Institute of Oncology Sremska Kamenica, Novi Sad,
Serbia, 3Clinic for Anesthesiology and Reanimatology, KCV, Novi
Sad, Serbia, 4University of Novi Sad, Medical Faculty of Novi Sad,
Novi Sad, Serbia
Introduction: Treatment techniques of multiple fractures of humeral
diaphysis are largely determined by the general position of the
institution where the patient is treated as the personal experience of
the surgeon.
Materials and methods: During the period from 2005 to 2011, 30
patients with various types of humeral fractures, were treated in our
clinic. From that amount, 24 patients (80 %) had closed fractures
(7 segmental and 17 multiple) while 6 patients (20 %) had open
fractures. 20 patients (56 %) were males and 10 (44 %) females.
The youngest patient was 18 and the oldest 62 years old (average
age was 40). Average wearing time of the apparatus was 3 months
(2-4).
Results: We obtained complete recovery in 25 patients (83 %),
extended recovery in 3 patients (10 %), pseudarthrosis in two patients
(7 %). Further complications were noted: in 6 pin-site infections,
which have been successfully treated with antibiotics and frequent
bandaging, 4 transient radial nerve lesions, 4 transient outage of
sensitive functions of ulnar nerve and one iatrogenic pseudoaneurysm
of brachial artery. To present our functional results we used Stewart-
Hundley scale and based on it we had 20 excellent, 8 good and two
bad results.
Conclusion: Our results have shown that the treatment of multiple
fractures of the humeral diaphysis, including segmental and open
fractures, using the transosseous osteosynthesis with the Ilizarov
apparatus, is the sovereign method or the method of choice.
S116 Abstract
123
Reference: Ilizarov GA. The principles of Ilizarov method. Bull Hosp
Joint Dis Orthop Inst. 1988;48(1):1–11.
Disclosure: No significant relationships.
PS142
COMBINED OSTEOSYNTHESIS IN MULTIFRAGMENTALCOMPOUND FRACTURES OF PROXIMAL TIBIAL BONE
S. Sakhvadze1, K. Sirbiladze1, V. Kakhnidze1, S. Sakhvadze2
1Department of Traumatology and Orthopedy, Acad. N. Kipshidze
Central University Clinic, Tbilisi, Georgia, 2Tbilisi State Medical
University, Tbilisi, Georgia
Introduction: Challenges in treatment of multifragmental compound
fractures of proximal tibia is provided by high fluctuation of fracture
and the lack of soft tissue cover in this region. Osteosynthesis with
lateral plate only usually can not provide stable fixation and the
balance of varus stress on leaning on the limb, while bilateral plate
osteosynthesis frequently leads to complicated healing of medial zone
wound.
Materials and methods: 15 patients (mean age 42.3 years) with
multifragmental fractures of proximal tibia were subjected to com-
bined osteosynthesis during the period of 2002–2010. The technique
implied the combined use of plate on lateral side and close fixation
with fixator externa on the medial. Limb movement was gradually
applied from second day after the operation, and the patient was
allowed to lean partially (10–15 %) on the limb from 14th day.
Fixator externa was removed after 2–2.5 months.
Results: Complete consolidation of fractures was achieved in all
cases in 3–4 months period, without any deformation or limb short-
ening. Stable fixation and early applying of movement provided the
prevention of genual contraction.
Conclusion: Combined use of internal and external osteosynthesis in
multifragmental fractures of proximal tibia refers to less invasive
method of treatment, which provides the stable fixation of fragments
reduces the risk of complications postoperatively and allows early
rehabilitation for patients.
Disclosure: No significant relationships.
PS143
PLATE FIXATION VERSUS INTRAMEDULLARY FIXATIONFOR DISLOCATED MID-SHAFT CLAVICLE FRACTURES
R.M. Houwert1, F.G. Wijdicks1, C.N. Steins Bisschop2,E.J.J.M. Verleisdonk1, M.C. Kruyt3
1Surgery, Diakonessenhuis Utrecht, Utrecht, Netherlands, 2Health
Sciences, Julius Center for Health Sciences and Primary Care,
Utrecht, Netherlands, 3Orthopaedics, UMC Utrecht, Utrecht,
Netherlands
Introduction: The optimal surgical approach for dislocated midshaft
clavicular fracture remains controversial. The objective of this sys-
tematic review is to compare functional outcome and complications
after plate fixation and intramedullary fixation for dislocated midshaft
clavicular fractures.
Materials and methods: Studies that compared plate fixation with
intramedullary fixation in patients with fresh unilateral dislocated
midshaft clavicular fractures were included. Dislocation or displace-
ment had to be mentioned in the inclusion criteria of the study for
inclusion in this review. The modified version of the Cochrane Bone,
Joint and Muscle Trauma Group’s former quality assessment tool was
used. Furthermore, the included studies were scored according to the
GRADE approach to assess the quality. Included studies were sum-
marised in a data-extraction form. Because of the different study-
designs and characteristics data were summarized separately per
study.
Results: A computer aided search of Medline and Embase was car-
ried out on January 11th 2011. Every study that was published in
English, German, French or Dutch language was considered for
inclusion. A total of 4 studies could be included of which 2 compared
intramedullary fixation versus plate fixation, and 2 compared intra-
medullary fixation and plate fixation versus conservative treatment for
dislocated midshaft clavicular fractures.
Conclusion: High quality evidence from one study and low quality
evidence from three studies showed no difference in functional out-
come and complications after plate fixation or intramedullary fixation
for dislocated midshaft clavicular fractures.
Disclosure: No significant relationships.
PS144
THE VASCULAR IMPAIRMENTS AT SUPRACONDYLARFRACTURES OF THE HUMERUS AT CHILDREN
V.F. Kuksov
Traumatology, Second Clinical City Hospital, Samara/Russian
Federation
Introduction: To the main hard complication at supracondylar
fractures of the humerus with displacement of the fragments at chil-
dren are concerning impairments of the brachial artery.
Materials and methods: During last 15 years under our observation
were gone treatment 870 children with supracondylar fractures of the
humerus with fragments displacement, among them at 9 young
patients (7 boys, 2 girls at the age of 6–8 years old) was clear clinic
picture of compression of the brachial artery (pulse absence at
peripheral artery, X-ray—displacement of the peripheral fragment to
back, at ulna side and inter rotation). In urgent order were laying
vertical skeleton extension on Balkan frame (Kirchner’s wire was
provided though proximal metaphysic of ulna and strengthened at
staple), were used max weight 4.0 kg. The constant control was under
pulsation at peripheral artery! At absence of pulsation during 40 min
were moving to urgent surgical operation—revision of ulna fossa.
Operative access was external lateral. We were working with close
community with vascular surgeon. At 2 patients were providing
intraoperatively arteriography. At all 9 patients were fond the full
compression and thrombosis of the brachial artery.
Results: At all 9 patients were examined long-term results of the
treatment from 2 till 10 years after trauma. X-ray-anatomic indices at
all observed are excellent. All are going into sports.
Conclusion: Applied by us the medical algorithm to children with
hard complications—compression and thrombosis of the brachial
artery—is adequate, the evidence of it is excellent anatomic-func-
tional indices and favorable prognosis.
Disclosure: No significant relationships.
Abstract S117
123
PS145
RESULTS AFTER ANATOMICAL GRAFT-RECONSTRUCTION FOR REVERSED HILL-SACHSLESIONS IN PATIENTS WITH LOCKED DORSALSHOULDER LUXATION: A CASE SERIES OF THREEPATIENTS
M. Gloyer, A. Villiger, R. Stieger
Surgery, GZO Spital Wetzikon, Wetzikon, Switzerland
Introduction: An impact fracture of the anterior humeral head
(reverse Hill-Sachs lesion) associated with posterior glenohumeral
dislocation is rare. Different methods exist to restore the impression
fractures e.g., (transhumeral bone grafting, bone allo- or autograft,
osteocartilagineous allograft or, in very large defects, prosthetic
replacement). We present a case series and results of three patients
treated with bone allo- or autograft.
Materials and methods: Case 1: 63 years male with 3 days old
dorsal shoulder luxation after epileptic seizure. After open shoulder
reposition the reversed Hill-Sachs lesion was filled with allograft. The
motion results after 3 months were satisfying. Constant score: 100.
Case 2: 77 years male with dorsal luxation fracture after traffic injury.
After primary reposition the patient suffered from recurred relax-
ations. Osteosynthesis of the humeral head and the reversed Hill–
Sachs lesion was performed. In contrast to case I and III, an autolo-
gous bone graft from pelvis was used. Range of motion after
2 months was bilaterally equal. Final control after 42 months showed
a satisfied patient with no limitations of daily life. Constant score:
100. Case 3: 61 years female with dorsal shoulder luxation, reversed
Hill–Sachs lesion and multiple fracture of the minor tuberculum
epilepsia associated seizure. Open reduction was necessary. The
reversed Hill–Sachs lesion was filled with an allogen bone graft and
fragments of the minor tuberculum. Final examination after
20 months showed a satisfied patient with no limitations of daily life.
However, a control CT scan revealed a subtotal resorption of the
graft. Constant score: 89 (lower weight in abduction).
Results: After a mean follow-up of 22 months, all patients were
satisfied and free of redislocations. Constant shoulder score and
control CT scans were performed in all patients and showed graft
incorporation in two and graft-failure in one patient.
Conclusion: Treatment of posterior locked shoulder dislocation with
moderate and large reverse Hill-Sachs lesions using allo- or autograft
is feasible an led to favourable postoperative results.
Disclosure: No significant relationships.
PS146
THE USE OF ARTHROSCOPIC ‘‘ALLIGATOR’’ FORCEPSFOR THE REMOVAL OF EXCESS CEMENT INUNICOMPARTMENTAL KNEE ARTHROPLASTY
P. Sturch, D. Marsland, I. Barlow
Orthopaedics, Dorset County Hospital, Dorchester, UK
Introduction: During minimally invasive cemented unicompart-
mental knee arthroplasty (UKA), the removal of excess cement from
the posterior aspect of the joint following insertion of the prosthesis
may be technically difficult due to limited surgical exposure.
Retained cement following UKA is a well recognised complication
which may require further surgery as consequence of loose body
formation or impingement. We report the use of arthroscopic for-
ceps for he easy and effective removal of excess cement following
implant insertion.
Materials and methods: This illustrated case report details the use of
arthroscopic forceps for the removal of excess cement.
Results: The use of the arthroscopic Alligator grasping forceps
(Acufex, UK) facilitates easy access and retrieval of cement following
component insertion.
Conclusion: The senior author has used this simple technique suc-
cessfully in 200 UKAs. Arthroscopic instruments can be useful during
minimal access open surgery.
Disclosure: No significant relationships.
PS147
OPERATIVE FIXATION OF RIB FRACTURES:A DESCRIPTION OF A MODERN APPROACH TOREDUCTION AND FIXATION OF RIB FRACTURES
N. D’Souza1, A. Kamocka2, E. Black3
1General Surgery, Wycombe Hospital, High Wycombe, UK, 2London
Deanery, London, UK, 3Thoracic Surgery, Oxford Heart Centre,
Oxford, UK
Introduction: The value of internal fixation of multiple rib fractures
in improving outcomes is debated. Current practice is to manage most
thoracic cage trauma non-operatively. When it comes to surgical
management, a variety of techniques and prostheses are available but
there is no clear evidence base for an optimal method. We have
evaluated our experience of open reduction and internal fixation of rib
fractures using different prostheses and compared it with current
evidence in the literature.
Materials and methods: Retrospective case series review of sur-
gical management of rib fractures in one thoracic surgeon’s
experience.
Results: Over the 4 year period, 14 patients (13 male, 1 female; mean
age 49.7) underwent surgical rib fixation (5 with non-specific plate
and screws/sutures, 9 with rib-specific prostheses). Indications for
surgery included pain (64 %), worsening respiratory failure (27 %),
and lung injury (9 %). 100 % of DC plates and screws had to be
removed at variable timing due to pain and/or implant dislocation.
There was only one case of screw dislocation in rib-specific pros-
thesis. Our literature search reveals 2 randomised controlled trials
(RCTs) that show evidence of benefits in early operative stabilisation
of rib fractures in flail chest. We also evaluated other non-RCTs,
which also favour surgical intervention.
Conclusion: Current evidence from RCTs shows benefits in early
operative stabilisation of rib fractures in flail chest. We show evi-
dence in our series that the preferred surgical management of these
injuries should we with rib-specific prostheses.
Reference: 1. Tanaka, et al. Surgical stabilization or internal pneu-
matic stabilization? A prospective randomized study of management
of severe flail chest patients. 2. Granetzny, et al. Surgical versus
conservative treatment of flail chest.
Disclosure: No significant relationships.
S118 Abstract
123
PS148
HYALURONIC ACID IN INTRAARTICULAR FRACTURESAND SECONDARY ARTHROSIS
D. Todhe
Orthopedic Department, University Hospital Center ‘‘Mother
Teresa’’, Tirane, Albania
Introduction: The intraarticular use of Hyaluronic Acid is not new.
We have search statistically proofs of the clinical improvement in
tibial plateau fractures using Hyalart injections after internal osteo-
synthesis in 56 patients, in a 3 years follow up study. We like to see
whether or not the intraarticular administration of hyaluronic acid can
improve functional parameters, such as isokinetic muscle strength or
total work and clinical test results in patients with tibia plateau
fracture.
Materials and methods: In 56 patients operated in our clinics for a
tibial plateau fracture and an internal synthesis was performed. The
fractures were classified according to Schatzker’s. The patients were
divided in two groups, composed of different types of fractures but
the same type of synthesis differing from the use of Hyaluronic acid
(Hyalart). We used four Hyaluronic acid intraarticular injections
every week in 27 patients. The results in the two groups were esti-
mated according to the Iowa Knee Score and than statistically
elaborated.
Results: We conclude that the clinical improvement in the group
where Hyaluronic acid was used, was statistically sensible. No
complications were seen.
Conclusion: We could suggest the use of intraarticular injection
Hyaluronic acid after tibial plateau fracture in order to improve the
clinical relevance of the outcome in this fractures.
No complications were reported during or after the treatment with a
mean of 3 years follow up.
References: 1. Chen-Ti W, et al. Therapeutic effects of hyaluronic
acid on osteoarthritis of the knee. JBJS Am. 2004;86:538–45. 2.
Altman RD. Intraarticular sod. hyal. in the treat. of patients with
osteo.
Disclosure: No significant relationships.
PS149
VALGUS INTERTROCANTERIC OSTEOTOMY FOR VARUSMALUNION AFTER AN INTRACAPSULAR FRACTURE.A CASE REPORT
J. Quintana1, M. Porras-Moreno2, V. Rodriguez- Vega3,A. Jorge Mora1, I. Aunon1, C. Resines Erasun1
1Hospital Doce de Octubre, Madrid, Spain, 2Hospital Doce de
Octubre, Madrid, Spain, 3Servicio Traumatologia Y Ortopedia,
Hospital Doce de Octubre, Madrid, Spain
Introduction: Intracapsular hip fractures in young active patients is a
surgical emergency. If treatment of the injuries is delayed, there is a
high risk of avascular necrosis of the femoral head and nonunion.
Therefore, it is mandatory a reduction of the fracture, open or closed,
and internal fixation at an early stage. Despite these measures, the
aforementioned complications are not uncommon. It is unusual,
however, a consolidation in an anomalous position, with femoral
neck-shaft angle alteration after treatment of the injuries.
Materials and methods: We present the case of one patient with
varus malunion after an intracapsular fracture and his treatment.
Results: Varus malunion is an infrequent complication that can fol-
low the treatment of intracapsular fractures.
Conclusion: Valgus intertrochanteric osteotomy is an effective
treatment for these deformities. However, it s a great challenge for
surgeons and that is why, nowadays, the total hip arthroplasty has
replaced this technique.
Reference: Valgus osteotomy of the Proximal Femur with Sliding
Hip screw for femoral Neck Nonunions Intertrocanteric osteotomy for
nonunion of femoral neck. Treatment of femoral neck nonunions with
sliding compression screw.
Disclosure: No significant relationships.
PS150
PREFERENCES OF THE BLOCKING INTERMEDULLARYOSTEOSYNTHESIS AT DIAPHYSIS FRACTURES OF THETIBIA AT YOUNG SPORTSMEN
V.F. Kuksov
Traumatology, Second Clinical City Hospital, Samara/Russian
Federation
Introduction: To the hard injuries of the support-moving system at
young sportsmen are concerning diaphysis fractures of the tibia with
fragments displacement.
Materials and methods: During last 5 years under our observation
was the control group at the quantity of 17 young sportsmen with
closed diaphysis fractures of the tibia with fragments displacement.
The age of the patients was 13-15 years old. Sport specialization of
the children was: Alpine skiing—12, football—5. The adequate
treatment (creation of the fragments stability) is operative. Perma-
nently were taking into consideration: the age of the young sportsman
(not younger than 13 years old), features of bone growth and growth
zones, localization and fracture character, sport specialization of the
child. BIOS were provided to all 17 patients. The closed reposition
the fragments of the tibia were provided at 10 patients, open com-
parison of the fragments—at 7 patients. On operation table X-ray
control were provided.
Results: The far distant outcomes of the treatment were examined at
all 17 patients at the period from 2 years till 5 years after trauma. At
all observed patients were true union at the fracture area; were
occurred the full reconstruction bone structure (return to norm);
accelerated synostosis zone of the proximal epiphysis of the tibia.
Conclusion: Preferences of BIOS at diaphysis fractures of the tibia
with fragments displacement at young sportsmen are not doubt. It is
high effectiveness and stability, optimal short terms returning trau-
matized children into sport trainings. Still at children BIOS must be
provided always on strict evidence.
Disclosure: No significant relationships.
Abstract S119
123
PS151
MALROTATION AFTER LOCKED TIBIALINTRAMEDULLARY NAILING
F. Say, A.M. Bulbul
Orthopaedics and Traumatology, Samsun Training and Research
Hospital, Samsun, Turkey
Introduction: Malrotation after reamed tibial intramedullary nail is a
serious complication which may lead to joint arthrosis in the long-
term and malrotation is also a cosmetic problem. This study aimed to
determine the extent of tibial malrotation after reamed locked tibial
intramedullary nailing as measured by computerized tomography.
Materials and methods: 26 patients with tibial shaft fractures and
treated with reamed locked intramedullary nail were evaluated. The
same nail system, surgical approach and postoperative protocols were
used for all patients. Radiological assessment, involving CT images
of both tibiae, was used to quantify accurately the degree of tibial
rotation based on a standard technique similar to those previously
described in literature. Malrotation was defined as rotational defor-
mity greater than 10 degrees.
Results: Malrotation ranged from 19 degrees of external rotation to
14 degrees of internal rotation (mean rotational difference 4.7
degrees). In eight patients malrotation was internal, in eighteen
external. Five of the 26 tibia (19 %) were malrotated greater than 10�.
Conclusion: Tibial malrotation can be prevented with careful surgical
evaluation. Malrotation is best identified by clinical inspection and
best quantified by CT scan.
Reference: Jakob R, Haertel M, Stussi E. Tibial torsion calculated by
computerised tomography and compared to other methods of mea-
surement. J Bone Joint Surg Br. 1980;62B:238–42.
Disclosure: No significant relationships.
PS152
BIOMECHANICAL INVESTIGATION OF DIFFERENTEXTERNAL FIXATION FRAMES IN REGARD OF PINSCONFIGURATION
M.M. Mitkovic
Trauma, Orthopaedic and Traumatology clinic, Nis, Serbia
Introduction: The aim of this study was to compare stabilities of
external fixators with parallel pins and with other different
configurations.
Materials and methods: Three different types of external fixation
frames have been tested using bending and axial loading tests. Dates
have been statistically analysed.
Results: The most balanced AP and lateral stability was observed in
cases of 90 degrees of convergent orientation of pins while AP sta-
bility in cases of parallel pins was list balanced showing up to 5 times
less stability then in lateral direction.
Conclusion: Convergent orientation of pins gives the most 3D bal-
anced stability of external fixator.
Disclosure: No significant relationships.
PS153
SYSTEMATIC REVIEW OF THE COMPLICATIONSOF PLATE FIXATION OF CLAVICLE FRACTURES
F.G. Wijdicks1, O.A.J. Van Der Meijden2, E.J.J.M. Verleisdonk1,P.J. Millet3, R.M. Houwert1
1Surgery, Diakonessenhuis Utrecht, Utrecht, Netherlands, 2Research,
Steadman Philippon Research Institute, Vail, CO, CO, USA,3Orthopaedics, Steadman Clinic, Vail, CO, USA
Introduction: The number of displaced midshaft clavicle fractures
treated surgically is increasing and plate fixation is often the treatment
modality of choice. The study quality and scientific levels of evidence
at which possible complications of this treatment are presented vary
greatly in literature. The purpose of this systematic review is to assess
the prevalence of complications concerning plate fixation of dislo-
cated midshaft clavicle fractures.
Materials and methods: A computer based search was carried out
using EMBASE and PUBMED/MEDLINE. Studies included for
review reported complications after plate fixation alone or in com-
parison to either treatment with intramedullary pin fixation and/or
nonoperative treatment. Two quality assessment tools were used to
assess the methodological quality of the studies. Included studies
were ranked according to their levels of evidence.
Results: After study selection and reading of the full texts, 11 studies
were eligible for final quality assessment. Nonunion and malunion
rates were less than 10 % in all analysed studies but one. The vast
majority of complications seem to be implant related, with irritation
or failure of the plate being consistently reported on in almost every
study, on average ranging from 9 to 64 %.
Conclusion: The quantity of relevant high evidence studies is low.
With low nonunion and malunion rates plate fixation can be a safe
treatment option for acute dislocated midshaft clavicle fractures, but
complications related to the implant material requiring a second
operation are frequent. Future prospective trials are needed to analyse
the influence of various plate types and plate position on implant
related complications.
Disclosure: This work was not supported directly by an outside
funding or grant. However, Dr. Millett is a consultant and receives
payments from Arthrex and has stock options in Game Ready. In
addition, Dr. Van der Meijden’s research position was supported by
Arthrex.
PS154
MANDIBULAR BONE TRAUMATIC CYST: A CASE REPORT
T.E. De Almeida1, G.H. Cainelli1, J.P.S. Gandara2, J.A.S. Da Silva1,H. Pippa3, E. Achar1, M.A.F. Ribeiro Jr1
1Surgery, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil,2Surgery, Universidade Cidade de Sao Paulo, Guarulhos-SP, Brazil,3Surgery, Universidade Cidade de Sao Paulo, 03071000, Brazil
Introduction: The traumatic bone cyst is a non neoplastic lesion that
has no capsule epithelial lining, featuring not just a cyst classic. It is
S120 Abstract
123
believed that the lesion originates due to intraosseous hemorrhage
with subsequent liquefaction of the clot leading to the formation of a
cavity pathology. The incidence of traumatic bone cyst is 1 % of the
maxillo-mandibular cysts, mainly affecting the region of the sym-
physis and mandibular body. The highest prevalence is in the second
decade of life, is rare in adults. Because it is asymptomatic and is
diagnosed, usually on routine imaging.
Materials and methods: Was carried out a review of the literature
using the databases SciELO, PubMed and EBSCO, and was used
articles of relevance in the treatment of traumatic bone cyst.
Results: There are several treatment modalities including resection,
curettage, bone grafting, corticosteroid injection and, more recently,
autologous bone marrow injection. Finally we conclude that traumatic
bone cysts can regress spontaneously and in most cases surgery is the
most suitable due to a low-risk procedure and a speedy resolution.
Conclusion: Because it is asymptomatic and it is diagnosed usually
on routine imaging. Regarding treatment, there are several approa-
ches: resection, curettage, bone grafting, corticosteroid injection and,
more recently, autologous bone marrow injection. Surgical treatment
has proved to be a simple procedure with a prognosis over the long
term, extremely favorable.
Reference: Xanthinaki AA, et al. Traumatic bone cyst of the man-
dible of possible iatrogenic origin: case report and brief review of the
literature. Head Face Med. 2006;v.2(40).
Disclosure: No significant relationships.
PS155
MID-TERM RESULTS OF SURGICAL TREATMENT OFSANDERS TYPE II AND TYPE III FRACTURES
B. Tunc, M.F. Catma, K. Hazanay, M. Altay
Orthopaedics and Traumatology, Ankara Diskapi Yildirim Beyazit
Training and Research Hospital, Ankara, Turkey
Introduction: This study addressed the retrospective evaluation of
the diagnosis and the results of surgical treatment of patients with
intraarticular calcaneal fractures (IACF).
Materials and methods: 80 calcaneal fractures on 72 patients who
were operated between May 2006 and April 2010 were evaluated. 62
fractures were caused by falling from height, 6 caused by pedestrian
crashes and 4 caused by articular sprain. Among the patients included
in this study, 60 were men and 12 were women. Their average age
was 42 (16–71). Patients were pre- and post-operatively controlled
with radiographs at which Bohler’s and Gissane’s angles were mea-
sured. Functions and pain of foot were assessed with AOFAS scoring.
Open reduction with lateral extensil locked plate approach and
internal fixation with screws were performed on all patients on the 7th
day.
Results: Average follow-up period was 28 months. Any problem
associated with bone healing was not identified. Superficial necrosis
at the edges of the incisions was observed at 14 patients (19.4 %). No
cases of infection was detected on follow-up. Reflex sympathetic
dystrophy developed at 13 fractures (18 %). 64 of 72 feet (88.8 %)
had a correction of Bohler’s angle within the normal limits and 58 of
70 feet (82.8 %) had a correction of Gissane’s angle within the nor-
mal limits. Mean AOFAS score was found to be 81.
Conclusion: Correct timing, proper technique and appropriate reha-
bilitation at especially Sanders type II and type III fractures enable
surgical treatment to give satisfactory results.
References: Crosby LA, Fitzgibbons TC. ORIF of type 2 intra-
articular calcaneal fractures. Foot Ankle. 1996;17:253–8.
Disclosure: No significant relationships.
EMERGENCY SURGERY III
PS156
SUCCESSFUL DAMAGE CONTROL SURGERY IN GRADE VLIVER INJURY
D. Soldatenkova1, A. Rudzats2, S. Stabina1, G. Pupelis1
1General And Emergency Surgery, Riga East Clinical University
Hospital ‘‘Gailezers’’, Riga, Latvia, 2Emergency And General
Surgery, Riga East Hospital Gailezers, Riga, Latvia
Introduction: Liver damage is one of the most common causes of
death in severe abdominal injury. The reported postoperative mor-
tality in grade V liver injuries ranges from 67 to 80 %.
Materials and methods: Case report.
Results: The 35-year-old man was brought to the emergency
department after blunt compression trauma of the chest and abdomen
in hemorrhagic shock, GCS—12, ISS—50, ASA—V E. Suspected
traumatic brain injury mandated CT scan which revealed grade V
liver injury and grade III splenic injury. During laparotomy damage
control was provided by perihepatic packing. Additionally splenec-
tomy was done. All surgical procedure lasted 1 h and by the time of
completion 1,700 ml of blood had been re-transfused. Due to recov-
ery of the gastrointestinal transit and moderate systemic inflammatory
reaction we removed packing on postoperative day 8 when second
surgical intervention was performed which revealed that all fragments
were tightly fixed, no signs of bleeding or bile flow were observed.
All pads were removed leaving one subhepatic drain. Fever gradually
subsided, output of circa 700 ml of sero-bilious peritoneal fluid was
observed 1 month. On day 24 after first operation CT scan revealed
10.4 9 10.8 9 7.2 cm hematoma in liver’s VI segment, which was
managed conservatively. Patient was discharge on day 39 after
admission. After 92 days from injury formation of 6.5 9 7.2 cm
connective tissue area in liver was detected by ultrasound.
Conclusion: Perihepatic packing and damage control surgery can be
lifesaving in patients with grade IV–V liver injury.
Disclosure: No significant relationships.
PS157
THE IMPORTANCE OF LIVER ENZYMES IN HEPATICTRAUMA
L.B. Salim1, G.H. Cainelli2, J.P.S. Gandara3, J.A.S. Da Silva2,C.M. De Oliveira1, L.A.L. Da Silva1, H. Pippa1, J.V.P. Huayllas1,E. Achar2, M.A.F. Ribeiro Jr2
1Surgery, Universidade Cidade de Sao Paulo, 03071000, Brazil,2Surgery, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil,3Surgery, Universidade Cidade de Sao Paulo, Guarulhos-SP, Brazil
Introduction: The liver injury occurs when there is an open or closed
abdominal trauma, affecting the liver. This entity is well defined in
medical emergencies, and is commonly diagnosed by imaging
examinations of the abdomen by CT and MRI and through laboratory
tests that show changes in liver enzymes. The most common etiology
Abstract S121
123
revolves around closed abdominal trauma secondary to injuries,
multiple trauma affecting mainly individuals.
Materials and methods: We performed a critical review of literature
which were used to obtain information the following databases:
PubMed/Medline, Lilacs and Ebsco. Of all the publications were
selected articles which contain relevant issues on the cumulative
effect of a railing and the role of mediators in the presence of hepatic
trauma.
Results: Liver damage leads to increased release of transaminases in
proportion to liver damage suffered. Thus, a predictive factor in
determining the degree of severity of the patient.
Conclusion: Liver lacerations are common in patients with multiple
trauma. The present results suggest that the trauma victim with
multiple injuries. It is suggested that liver enzymes may prove to be a
useful diagnostic tool Elevated liver enzymes have been shown to aid
in the diagnosis of liver injury using liver enzymes to predict the need
for CT scanning could result in time, cost and safety benefits patients
with liver injury.
Reference: Carrillo E, Wohltmann C, Richardson J, et al. Evolution
in the treat- ment of complex blunt liver injuries. Curr Probl Surg.
2001;38:1–60.
Disclosure: No significant relationships.
PS158
A MOTHER WITH A BROKEN HEART: PECTUSEXCAVATUM IN BLUNT CHEST TRAUMA
E. Liodakis1, E. Liodaki2, M. Ettinger3, C. Krettek4, M. Petri3,M. Jagodzinski3
1Medical School of Hanover, Hannover, Germany, 2Plastic Surgery,
University Schleswig–Holstein, Lubeck, Germany, 3Hannover
Medical School, Hannover, Germany, 4Trauma Department,
Hannover Medical School, Hannover, Germany
Introduction: Patients with cardiac rupture following blunt thoracic
trauma rarely survive and most die at the scene or in the emergency
room before the cardiac lesions are disclosed. The most common
feature of blunt traumatic cardiac rupture is cardiac tamponade.
However, the Beck’s triad has no sufficient sensitivity and specificity
in cases of multiple systemic traumas.
Pectus excavatum accounts for 90 % of congenital chest wall defor-
mities and refers to the posterior depression of the sternum and
adjacent costal cartilages. The depressed sternum compresses often
the right atrium as well as the right ventricle. Rationally the incidence
of cardiac ruptures should be higher in patients with pectus
excavatum.
Materials and methods: We report a case of blunt cardiac trauma in
a young mother with pectus excavatum while sitting in the front seat
and holding her 2-year-old boy in her arms during a car accident. The
mother was awake and alert within the first 2 h after trauma and then
haemodynamically collapsed. The child did not sustain any severe
injuries. Intraoperatively a combined 1 cm left atrium and right
ventricle laceration was found.
Results: Reporting this case we would like to suggest new treatment
regimes in order to increase survival rates in the group of patients
with pectus excavatum as these patients have an increased risk for
cardiac ruptures after blunt chest trauma due to the squeezing of the
heart between sternum and spine.
Conclusion: Therefore, patients with pectus excavatum and blunt
chest trauma should be admitted to a Level I Trauma Center.
Disclosure: No significant relationships.
PS159
THORACOABDOMINAL PENETRATING WOUNDTREATED BY THORACOSCOPY: A CASE REPORT
S.V. Starling1, E.A. Junior2, P.P. Furtado2, W.J. Dos Santos2,F.L. Pereira2
1Trauma Surgery, Hospital Joao XXIII_ FHEMIG, Belo Horizonte/
Brazil, 2Cirurgia Geral, Hospital Regional Antonio Dias, Patos de
Minas/Brazil
Introduction: The following account refers to the thoracoabdominal
stab wound injury addressed in by video-thoracoscopy. Thoracoab-
dominal impalement injuries are relatively uncommon and only a few
cases have been reported in the literature. Thoracoabdominal trauma
is defined to the chest area located between the fourth intercostal
space anteriorly, sixth laterally and eight posteriorly, and inferiorly
delimited by the costal margin. Written informed consent was
obtained from the patient for publication of this case report.
Materials and methods: SSC, admitted on 09 of April 2011 with
stab wound dorsal thoracic injury—sixth right space, presenting
dyspnea and abdominal painless. Chest radiography evidenced right
hemopneumothorax. Submitted immediate thoracostomy with drain-
age of 400 ml of blood. Evolved with drain obstruction and the need
for new thoracostomy. Tomography showed a retained residual
hemothorax and subcapsular hepatic injury in segment VII/VIII and
the absence of blood in the peritoneal cavity.
Results: Performed exploratory thoracoscopy on the fifth day after the
initial drainage, with confirmation of retained residual hemothorax,
clotted hepatic injury and 4 cm lesion in the right hemidiaphragm. The
hemothorax was evacuated and the phrenic injury sutured. Presented
satisfactory evolution.
Conclusion: Thoracoscopy has been diagnosing and treating diffi-
cult injuries, besides being minimally invasive. The approach in the
thoracoabdominal trauma should be quickly and always consider the
possibility of concomitant diaphragmatic and abdominal injuries.
The use of chest drains is secure in the initial care, but should raise
the need to realize spend other diagnostic and therapeutic methods,
such video-thoracoscopy, to excluded simultaneous abdominal
trauma.
Reference: Bagheri R, et al. The role of thoracoscopy for the
diagnosis of hidden diaphragmatic injuries in penetrating thoracoab-
dominal trauma. Interact Cardiovasc Thoracic Surg. 2009;9:195–8.
Disclosure: No significant relationships.
PS160
DAMAGE CONTROL SURGERY APPROACH IN A GRADEIV HEPATIC INJURY: CASE OF SUCCESS INA INEXPERIENCED HOSPITAL
N. Fernandes1, I. Subotin1, M. Reis1, L. Silva1, P.M. Ramos2,C. Caldeira1, E. Parodi1, F. Jasmins1, A. Teixeira1
1General Surgery, Hospital Dr. Nelio Mendonca, Funchal, Funchal,
Portugal, 2Cirurgia Geral, Hospital Dr. Nelio Mendonca, 089,
Portugal
Introduction: The authors report their approach in a grade IV hepatic
injury. The only hospital in Funchal, Madeira Island, serves about 260
000 people and have all medical valences. Complex liver injuries do
S122 Abstract
123
not occur very often, as so, they are not experienced in day-to-day
managements. Authors report a 41-year old male who suffered a fall
about 7 meters, which resulted in a blunt thoraco-abdominal injury.
FAST: haemoperitoneum. CT Scan: bilateral pleural effusion and
grade IV liver injury. Patient underwent laparotomy and damage
control surgery. At 72 h, when they removed the liver packing,
atypical liver resection was needed. By 8th day, during review of the
laparostomy, there was a high output biliary fistula secondary to
laceration of a branch of the right hepatic duct. They proceeded to
close the abdomen after treating the bile leak. The patient was dis-
charged from ICU at day 10 (APACHE II—8 and SAPS II—34).
Transferred to the Surgical Intermediate Care Unit; right pleural
drainage was necessary. Discharged by 29th day.
Materials and methods: Clinical records and photos taken during
successive surgical approaches.
Results: The approach has proved feasible, safe and effective.
Probably it’s the result of the frequency of trauma courses extended to
the whole team of General Surgery.
Conclusion: Damage control surgery with initial therapeutic packing
in blunt hepatic trauma is a valuable option for the inexperienced
surgeon.
References: 1. Feliciano M. Damage control and alternative wound
closures in abdominal trauma, 4th edn. New Jersey: McGraw-Hill;
2000. 2. Ivantury RR, Nallathambi M. Liver packing for uncontrolled
hemorrhage: a reappraisal. J Trauma. 1986.
Disclosure: No significant relationships.
PS161
A RARE ADULT PRESENTATION OF A MASSIVECONGENITAL DIAPHRAGMATIC HERNIA
L.J. Cook1, D. Debnath2, R. Tabbakh1, R. Daoud1, I. Karat1,I. Laidlaw1
1Frimley Park Hospital, Frimley, UK, 2General Surgery, Frimley Park
Hospital, Frimley, UK
Introduction: Congenital massive diaphragmatic hernias presenting
in adulthood is rare.
Materials and methods: A 20-year-old nulliparous healthy woman
presented with acute shortness of breath and chest pain of few hours’
duration. She denied any bowel symptoms. There was no history of
trauma. Chest examination revealed absent air entry and presence of
bowel sound on left side. Abdominal examination was unremarkable.
A CT scan confirmed ‘a massive left central diaphragmatic hernia
with most of abdominal contents being herniated into the thoracic
cavity with mediastinal shift to the right. The spleen was completely
malrotated with features of infarction. The left lung was collapsed and
right lung volume was reduced’. Absence of history of trauma and
hypoplastic pulmonary changes suggested the diagnosis of ‘congen-
ital’ diaphragmatic hernia.
Results: She subsequently developed further chest pain and a gas-
troscopy detected blood in the stomach, suggesting ischaemia. She
underwent emergency laparotomy, which entailed partial gastrec-
tomy, reduction of spleen as well as small and large bowel loops
(90 % of bowel was noted to be in the left hemithorax). The hernial
defect was repaired with suture and laparostomy was performed. She
was awaiting further surgery.
Conclusion: Severe congenital central diaphragmatic hernia pre-
senting in adulthood, and affecting a non-pregnant woman, has not
been reported. Furthermore she did not have any bowel symptoms. A
high index of suspicion is necessary when bowel sounds replace
breath sounds in an adult, even if there is no history of trauma. Once
diagnosed, an urgent and carefully planned surgery should be
undertaken to avoid the risk of bowel ischaemia and laparostomy.
Disclosure: No significant relationships.
PS162
PRACTICE ELEMENTS FOR THE PREVENTION OF DEEPVENOUS THROMBOSIS
G. Orosan1, C. Iorga2, C. Puscu1, A. Manta1, P.A. Radu2,M. Bratucu2, D. Garofil1, S. Stoian1, V.D.E. Strambu2, F. Popa2
1General Surgery, carol davila hospital, bucharest/Romania, 2General
Surgery, University of Medicine ‘‘Carol Davial’’ Bucharest,
Bucharest/Romania
Introduction: The risk of deep vein thrombosis (DVT) is present in
all forms of major surgery.Patients undergoing major surgery of the
colon and rectum are at particulary high risk for DVT and its
potentially life-threatening complication of pulmonary embolism
(PE).
Materials and methods: A study of more than 632 patients who
underwent surgical interventions for colorectal malignancy between
2006 and 2010, were divided in three groups depending on risk fac-
tors. First group—patients in the moderate-risk to high-risk categories
for VTE undergoing abdominal surgery should receive prophylaxis
with unfractionated or low-molecular- weight heparin. Patients in
second group with high risk factors should receive LMWH, and the
third, patients with very high risk of bleeding, mechanical prophylaxis
should be instituted as early as possible and continued until phar-
macologic prophylaxis should be initiated.
Results: Although a very frequent disease in the postoperative period,
and a common cause of sudden death, prophylaxis of DVT remains
underused.
Conclusion: There is a multitude of methods for the prophylaxis from
which we must choose the most efficient and safest preventive
method.
Disclosure: No significant relationships.
PS163
NEGATIVE PROGNOSTICS FACTORS IN PANCREATICTRAUMA
B. Gaspar1, S. Paun2, R. Ganescu2, I. Negoi2, M. Beuran2, I. Lica2
1General Surgery, Clinical Emergency Hospital of Bucharest,
Bucharest, Romania, 2Clinical Emergency Hospital of Bucharest,
Bucharest, Romania
Introduction: Pancreatic trauma is on 8 th place between intraab-
dominal organ injuries (after small intestine, spleen, colon, rect,
stomach, kidney and adrenal gland) and represents 3.5 % among
death from trauma patients.
Materials and methods: In past 10 years in Emergency Hospital
Bucharest were admitted 950 trauma patients, 76 of them having
different grades of pancreatic trauma from a simple contusion to a
complete destruction. Although the precise diagnostics was made
intraoperative, the CT scan was performed in about 80 % of the cases
at the admittance.
Abstract S123
123
Results: In past 10 years in Emergency Hospital Bucharest were
admitted 950 trauma patients, 76 of them having different grades of
pancreatic trauma from a simple contusion to a complete destruc-
tion. Although the precise diagnostics was made intraoperative, the
CT scan was performed in about 80 % of the cases at the
admittance.
Conclusion: Pancreatic lesion alone, regardless the grade, it is very
rare and may be complicated postoperative with a negative prog-
nosis. Associated lesions can concur to a prolonged and difficult
evolution.
Reference: Paun S, Beuran M, Negoi I, Runcanu A, Gaspar B.
Trauma-epidemiology: where are we today? Chirurgia (Bucur).
2011;106(4):439–43 (Review. Romanian).
Disclosure: No significant relationships.
PS164
SPONTANEOUS RUPTURE OF THE SPLEEN IN NONDIAGNOSED HODGKIN’S LYMPHOMA: A CASE REPORT
C. Mauricio Alvarado, J. Lopez Perez, F. Oliva Mompean
General Surgery, Hospital Universitario Virgen Macarena, Seville,
Spain
Introduction: Spontaneous rupture of the spleen (SRS) is a relative
rare entity, moreover in the context of Hodgkin’s disease.
Materials and methods: We describe one case which presents as an
acute abdominal symptoms and we made a bibliographic review in
the most popular database.
Results: Case: A 22-year-old man with no medical history pre-
sented with severe abdominal pain and abdominal distention. In the
emergency room presented hipovolemic shock and emergent
exploratory laparotomy and splenectomy was done. The anatomo-
pathological diagnosis was spleen with multifocal infiltration by
Hodgkin’s lymphoma with mixed cellularity Stage III B. Discus-
sion: The SRS is a rare entity in a Hodgkin’s disease. In 1966
Knoblich described 3 cases of SRS in Hodgkin disease in which
the rupture of the spleen caused death. The most common cause of
SRS is neoplasia in which the most common neoplasia is leukemia.
In the literature has been descibed at least 10 cases of SRS in
Hodgkin’s lymphoma. Some anatomopathological studies demon-
strate 3 possible alternatives to explain its mechanism. Although
the gold standard treatment of SRS is a total splenectomy a non-
surgical treatment is possible in 15 % of cases in non oncological
patients, but in oncological patients is recommended a total
splenectomy.
Conclusion: It is not demonstrated anatomopatologically the mech-
anism of spontaneous splenic rupture in Hodgkin’s disease but some
authors suggest that the major alteration is splenic capsule distention.
References: 1. British J Surg. 2009;96:1114–21. 2. ClinOncol
1982;8:69–71. 3. Am J Emergency Med. 2008;26:733.4. Mich Med.
1966;65:105–110. 5. Clin Oncol. 1982;8:69–71. 6. Ann Emerg Med.
1991;20:424–5. 6. South Med J. 1983;76:247–9. 7. Amyloid.
2009;16:47–53. 8. Ann Chir. 2003;128:303–9. 9. Sci Int. 2001;119:
149–54. 10. Med Corps. 1991;137:50–1. 9. Chest. 2005;128:1884–6.
11. JR Coll Surg Edinb. 1985;30:326–7.
Disclosure: No significant relationships.
PS165
SUBCUTANEOUS EMPHYSEMA IN THE ANTERIOR COLIAREA, IN A CHILD WITH BLUNT CHEST TRAUMA
A.S. Dogjani1, G.S. Zikaj2, M.D. Kerci1, B.E. Hasanaj1, A.M. Lila1
1Surgery, Military Universitary Central Hospital; National Trauma
Center, Tirana, Albania, 2Surgery, Universitary Hospital Center,
Tirana, Albania
Introduction: Blunt injuries to the chest are not rare but if present,
are usually associated with either a direct impact the neck or accel-
eration–deceleration injuries.
Materials and methods: A 12-year-old boy fell from bicycle and
sustained blunt injury to his chest. He was brought to the hospital (6 h
later) with difficulty in breathing and inability to speak. There was a
large bruise and subcutaneous hematoma on the neck and extensive
subcutaneous emphysema over the neck and chest and decreased air
entry.
Results: Radiographs revealed a right-sided pneumothorax, pneu-
momediastinum and tracheal deviation. An intercostal drain was
inserted.
Conclusion: The trauma surgeon prepared to perform a surgical
airway if required. This not only facilitates diagnosis but also safe
intubation.
Reference: Mattoux KL, Feliciano DV, Moore EE. Injury to the
esophagous, trachea and bronchus. Trauma. 4th ed. 2000.
Disclosure: No significant relationships.
PS166
TREATMENT OF BREAST GANGRENE: A RARECONDITION
E. Ozkurt, I.S. Sarıcı, H.T. Yanar, C. Ertekin, R. Guloglu, M.K. Gunay
General Surgery, Istanbul University Istanbul Faculty of Medicine,
Fatih, Turkey
Introduction: Gangrene of the breast, although rare, has been
reported following anticoagulant treatment, trauma, and infection.
Antibiotics and debridement are used for management.
Materials and methods: A retrospective study of 12 patients who
had breast gangrene over a period of 10 years (January 2000–2010)
were analyzed.
Results: All the patients in the study group were female. Six (50 %)
patients presented with breast gangrene on the right breast whereas
six (50 %) had on left breast. Four (25 %) had breast abscess after
teeth bite followed by gangrene that 3 were lactating female and 1
was non-lactating; eight(75 %) had iatrogenic trauma by needle
aspiration of erythematous area of breast under septic conditions and
had diabetes mellitus. 7 debridmans, 3 local excisions and 2 mas-
tectomies performed to 12 patients. Broad spectrum antibiotic used
for all the patients. Three patients had grafting to cover the raw area
after local excision.
S124 Abstract
123
Conclusion: Breast gangrene occurs rarely. Etiology is variable and
multifactorial. Teeth bite while lactation and the iatrogenic trauma by
needle aspiration of breast abscess under unsterilised conditions could
be causative. Uncontrolled diabetes can be one more causative factor
for the breast gangrene. Treatment is antibiotics and debridement.
References: Breast G. World J Emergency Surg. 2011;6:29.
Disclosure: No significant relationships.
PS167
MULTIPLE HEPATIC HYDATIDOSIS: CASE REPORT
C. Iorga1, C. Puscu2, A. Manta2, S. Stoian2, P.A. Radu2, M. Bratucu1,D. Garofil2, M. Dumitras3, G. Orosan1, V.D.E. Strambu1, F. Popa1
1General Surgery, University of Medicine ‘‘Carol Davial’’ Bucharest,
Bucharest, Romania, 2General Surgery, Carol Davila Hospital,
Bucharest, Romania, 3General Surgery, Spitalul Clinic ‘‘Carol
Davila’’, Bucuresti, Romania
Introduction: We presented the case of a 52 year old patient that
came to consult for non-specific digestive symptoms (diffuse
abdominal pain, loss of appetite). Ultrasound raises the suspicion of
multiple hepatic hydatidosis (4 hydatid cysts) diagnosis confirmed by
abdominal computed tomography.
Materials and methods: Hepatic hydatid cyst is found in 60–70 %
cases of echinococcosis in the world, especially in rural areas in
relation with professions such as: pastors, shepherds, butchers.
Results: Clinical diagnosis is difficult to establish in debut stages
(longly asymptomatic), in tumoral stages depending on the size of
cysts and compression on adjacent organs.
Diagnosis is established corroborating serological data and medical
imaging.
Conclusion: In this patient’s case we preferred combination of
medical and surgical treatment, as follows: 1 week preoperative
medical treatment, surgery (Lagrot cystectomy practiced for 3 hepatic
cysts), medical treatment for 3 months postoperatively and pro-
grammed surgery (for the 4th hydatid cyst).
The particularity of the case consisted of multiple liver hydatidosis (4
hydatid cysts with size between 6 and 10 cm) and location of the 4th
cyst (in segm IV, in contact with suprahepatic veins and the aorta).
Disclosure: No significant relationships.
PS168
TRAUMA PATIENTS WITH SOLID ORGAN INJURY:RESULTS FROM A BORDER TOWN HOSPITAL IN TURKEY
A.C. Dural1, C. Ercetin2, T. Tezcaner3, M. Kirnap3, N.F. Sayit4,E. Kabul Gurbulak5, B. Gurbulak6
1General Surgery, Igdir Government Hospital, Igdir, Turkey, 2General
Surgery, Tuzluca Government Hospital, Igdir, Turkey, 3General
Surgery, Baskent University, Ankara, Turkey, 4General Surgery,
Nizip Government Hospital, Gaziantep, Turkey, 5General Surgery,
Sisli Etfal Research and Education Hospital, Istanbul, Turkey,6General Surgery, Arnavutkoy Government Hospital, Istanbul,
Turkey
Introduction: We aimed to categorize retrospectively trauma patients
by using an anatomical (Injury Severity Score; ISS) and a
physiological (Revised Trauma Score; RTS) scoring system in our
center which is established in a depressed area, east border of Turkey.
Materials and methods: Twenty-five patients (19 male and 6 female)
with solid organ injuries who had Abbreviated Injury Scale (AIS) 3
and higher and undergone life saving surgery between September
2010 to September 2011 were evaluated retrospectively. Patients’
demographics, mechanism of injury, vital parameters, injury severity,
and outcomes were collected.
Results: Average age was 32.4 (19–64). The most frequently mech-
anism was traffic accident (n = 12). Patients with blunt abdominal
trauma were 14; with penetrating trauma were 11 patients. According
to the injured organ the distribution of the patients was: liver: 14
(56 %); spleen: 6; both solid organs: 2; solid organs accompanying
bowels (small/large): 3. Eleven patients needed thoracic intervention
(two thoracotomy, nine tube drainage). The mean ISS was
23.6 ± 19.9. The mean initial RTS was 6.7 ± 1.8. ISS was higher
than 60 in four patients, in parallel with the mean RTS was signifi-
cantly lower (3.1 ± 1.8) (p \ 0.05). The mortality of this subgroup
was 100 %. General multitrauma proportion was 7 (28 %) with
57.1 % mortality, although this four patients had polytrauma
involving three cavities.
Conclusion: Evaluation of polytrauma patient’s status by using
scoring system is very useful for selection of patient’s management,
prophylaxis and intercept early complications. However, the occur-
rence of accompanying severe injuries in multitrauma is a major
cause of death in patients operated for thoracoabdominal injury.
Disclosure: No significant relationships.
PS169
FOCUSED ASSESSMENT WITH SONOGRAPHY INTRAUMA (FAST): EXPERIENCE OF A TERTIARYHOSPITAL IN SOUTH-EAST ASIA
E. Wong1, A. Ngo2
1Emergency Medicine, Singapore General Hospital, 169608,
Singapore, 2Jurong General Hospital, 159964, Singapore
Introduction: This study aims to: (1) Compare the sensitivity and
specificity of FAST as used by our local emergency physicians and
surgeons compared with those from other studies. (2) Compare the
use of ultrasound versus CT abdomen/pelvis (CTAP) in the detection
of intraabdominal bleeding. 3 Determine if any false negative ultra-
sound studies were associated with significant morbidity e.g.
unexpected laparotomy.
Materials and methods: A 1 year retrospective study of patients
enrolled in the trauma registry presenting to the ED, SGH in 2009.
Results: There were 285 patients of which 243 (85.3 %) were men.
The mean age was 38.2 years. Mechanisms of trauma include MVAs
(183 patients, 64.2 %), falls (66 patients, 23.1 %), penetrating
wounds (15 patients, 5.3 %), assaults (4 patients, 1.4 %) and others
(17 patients, 6 %). There were 276 patients with FAST done, of
which 133 also had CTAP done. 9 patients did not have FAST. 143
patients had only FAST done. Comparing FAST with CTAP, the
sensitivity was 0.355, specificity was 0.921, PPV was 0.55 and NPV
was 0.823. Comparing FAST with need for abdominal surgery, the Sn
was 0.857, SP was 0.922, PPV was 0.222 and NPV was 0.996. There
was one patient with a negative FAST who had abdominal surgery.
He had a perforated appendicitis.
Conclusion: FAST has high NPV for abnormal CTAP results and
need for surgery. In hemodynamically stable patients with negative
FAST, there is no need for CTAP.
Abstract S125
123
References: 1. Lucciarini P. Surgery. 1993;114(3):506. 2. Healey.
J Trauma. 1996;40(6):875. 3. McKenney. J Trauma. 1996;40(4):607.
4. Glaser. Arch Surg. 1994;129(7):743. 5. Porter. Ann Emerg Med.
1997;29(3):323.
Disclosure: No significant relationships.
PS170
NONOPERATIVE MANAGEMENT OF SPLENIC TRAUMAIN POLYTRAUMA SETTING
M. Beuran1, I. Negoi1, S. Paun1, A. Runcanu1, B. Gaspar1, M. Vartic2
1General Surgery, Emergency Hospital of Bucharest, Bucharest,
Romania, 2Emergency Hospital of Bucharest, Bucharest, Romania
Introduction: Despite nonoperative management has proven to be of
tremendous benefit in splenic injuries, the trauma surgeon faces
many challenges in the setting of polytrauma patients with splenic
lesions.
Materials and methods: Prospective observational study in a level I
trauma center. Inclusion criteria: (1) Injury Severity Score C17; (2)
splenic trauma revealed by imagistic or surgical exploration; (3)
highest intra-abdominal value for splenic Abbreviated Injury Scale
(AIS). There were 3 groups: successful nonoperative management
(SNOM), failed nonoperative management (FNOM) and operative
management (OM).
Results: There were 95 polytrauma patients. According to Organ
Injury Scale (OIS) there were 14 (14.7 %) grade I, 42 (44.2 %) grade
II, 23 (24.2 %) grade III, 15 (15.8 %) grade IV and 1 (1.1 %) grade V
splenic injuries. 55 patients (57.9 %) were successful nonoperatively
managed, 29 (30.5 %) OM and in 11 (11.6 %) cases there were a
failed nonoperative management. There was a medium correlation
between splenic OIS, AIS and nonoperative management (Spear-
man’s rho = 0.453, p = 0.001). There were no differences regarding
early mortality and in-hospital stay between the three groups (pA-
NOVA = 0.741, p = 0.647).
Conclusion: Polytrauma patients represent a more complex puzzle.
Nonoperative management of splenic lesions in such conditions is
feasible but demand for a dedicated and an experienced trauma team.
Disclosure: No significant relationships.
PS171
THE IMPACT OF SOLID ORGAN INJURIES ON THEOUTCOME OF CHILDREN WITH BLUNT MULTIPLETRAUMA
O. Ben-Ishay1, H. Bahouth2, Z. Peled1, Y. Kluger1, L. Hayari3,M. Arkovitz3
1Department of Surgery, Rambam Health Care Campus, Haifa, Israel,2Department of Surgery, Acute Care Service, Rambam Health Care
Campus, Haifa, Israel, 3Department of Pediatric Surgery, Meyer’s
Children Hospital, Haifa, Israel
Introduction: Blunt solid organs injuries in children bear significant
morbidity and even mortality. The purpose of the current study is to
examine the impact of solid organ injuries on outcome of children
with blunt multiple trauma.
Materials and methods: A retrospective review of all children (0-
18 years) admitted with blunt trauma to the Rambam Health Care
Campus in Haifa, Israel, from January 2006 through December 2009.
Children who suffered spleen or liver injuries were identified and
further scrutinized. Patients were divided in two groups, group I
included patients with either spleen or liver isolated injuries, and
group II included spleen and/or liver injuries with other associated
injuries. The primary end points of this study were: mortality, liver or
spleen related morbidity, and failure of non-operative management.
Results: 111 children met the inclusion criteria. There were 36
children in group I and 75 in group II. Both groups were similar with
respect to liver or spleen injury grade. ISS, need for ICU, LOS in the
ICU (p \ 0.001 for all) and need for blood transfusion were signifi-
cantly higher in group II. However, spleen or liver associated
mortality, related complications and failure of non-operative man-
agement was not significantly different between the two groups.
Conclusion: We conclude that in children with multiple injuries and
associated solid organ injury the overall mortality and complication
rate is not influenced by the solid organ injury itself. Non-operative
management for solid organ injuries may still be successfully prac-
ticed in children who suffer multiple trauma.
Disclosure: No significant relationships.
PS172
SPLENIC ARTERY EMBOLIZATION IN THE PEDIATRICPOPULATION: AN 8 YEAR EXPERIENCE FROM A MAJORSCANDINAVIAN TRAUMA CENTER
J. Skattum1, C. Gaarder1, P.A. Naess2
1Traumatology, Oslo University Hospital OUS, Ullevaal HF, Oslo,
Norway, 2Department of Traumatology, Oslo University Hospital,
Ulleval, OSLO, Norway
Introduction: Background: Non-operative management (NOM) is
the treatment of choice for blunt splenic injuries in the pediatric
population, with reported success rates exceeding 90 %. Splenic
artery embolization (SAE) was added to our institutional treatment
protocol for splenic injury in 2002. We wanted to review indications
for SAE and the clinical outcome of splenic injury management in
children admitted between August 1,2002 to July 31, 2010.
Materials and methods: Methods: Patients aged \17 years with
splenic injury were identified in the institutional trauma and medical
code registries. Patient charts and computer tomographic (CT) scans
were reviewed.
Results: Results: Of the 72 children with splenic injury included
during the 8 year study period, 66 patients (92 %) were treated non-
operatively and six underwent operative management. Severe splenic
injury (OIS grade 3 - 5) was diagnosed in 67 patients (93 %). SAE
was performed in 22 of the NOM patients. Indications for SAE
included—bleeding (n = 8), pseudoaneurysms (n = 2), contrast
extravasation (n = 2), high OIS injury grade (n = 8) and prophy-
lactic due to specific disease (n = 2). NOM was successful in all but
one case (98 %). Two SAE procedure specific complications were
registered, but resolved without significant sequelae.
Conclusion: Conclusion: After SAE was added to the institutional
treatment protocol, 22 of 66 NOM pediatric patients underwent NOM.
NOM was successful in 98 % of attempts, and a 90 % splenic pres-
ervation rate was achieved.
Disclosure: No significant relationships.
S126 Abstract
123
PS173
IMPLEMENTATION OF THE TRAUMA REGISTRY TARN�
IN A SWISS TERTIARY EMERGENCY DEPARTMENT
A.K. Exadaktylos, D. Srivastava, H. Zimmermann
Emergency Medicine, Inselspital, University Hospital Bern, Bern,
Switzerland
Introduction: Comparison of trauma centres by using a standardized
registry helps to reveal systemic and methodical issues and simplifies
the quality management in an emergency department.
Materials and methods: Analysis of epidemiology of adult major
trauma patients of a Swiss tertiary trauma centre from 2009 to 2010
using the trauma registry TARN� (Trauma Audit Research Network),
the first international trauma registry implemented in Switzerland.
Results: 458 patients were entered into the database. Median age was
50.5 years (IQR = 32.2–67.7 years) and median ISS 14 (IQR =
9–20). 71.0 % (n = 325) were male. 34.5 % (n = 158) of patients
had been admitted from June to August. Peak hours were from 1200
and 2200 hours (59.6 %, n = 273) and from 2400 to 0200 hours
(12.0 %, n = 55). Most injuries (29.0 %, n = 133) were due to road
traffic collisions, followed by falls 2 m (19.7 %, n = 90) and sports
injuries (11.4 %, n = 52). 75.1 % (n = 344) received a CT scan.
Median time to CT scan was 30 min. (IQR = 20–55 min.). 1.1 %
(n = 5) arrived under CPR. Overall, 3.7 % (n = 17) of patients died
within 30 days of admission. 13 (76.5 %) patients died from severe
cerebral injury, 2 from abdominal trauma, 1 from bilateral limb
amputation at hip and 1 from suffocation.
Conclusion: The main cause of death at our tertiary trauma centre is
severe head injury. Most injuries are due to road traffic collisions or
falls and occur during the summer months at day time. Although our
trauma unit is among the fastest in patient management, the atten-
dance of senior staff is nearly 100 % and our facilities are among the
most modern available, the probability of survival is ranked as
average. Therefore, time seems only one factor in successful patient
management and more research towards identification of factors
influencing mortality after trauma should be undertaken.
Disclosure: No significant relationships.
PS174
CAN HANDHELD MICROPOWER IMPULSE RADARTECHNOLOGY BE USED TO DETECTPNEUMOTHORACES? FIRST EXPERIENCEFROM A EUROPEAN TRAUMA CENTER
C.E. Albers1, P. Haefeli1, M. De Moya2, H. Zimmermann1,A.K. Exadaktylos1
1Department for Emergency Medicine, Bern University Hospital,
Bern/Switzerland, 2Division of Trauma, Emergency Surgery, Surgical
Critical Care, Massachusetts General Hospital, Harvard University,
Boston, MA, USA
Introduction: Pneumothoraces (PTX) are common in emergency
medicine. Rapid and save identification reduces morbidity and mor-
tality. A new handheld, battery-powered device, the Pneumoscan
(CE561036, PneumoSonics Inc.), using micropower impulse radar
technology (MIR) has been introduced to rapidly and reliably detect
PTX. However, this technology has not yet been tested in trauma
patients. This is the first study to report on emergency room perfor-
mance of this new device.
Materials and methods: This was a retrospective study in a Level I
trauma center. All patients with thoracic trauma undergoing CXR and
CT were eligible. Pneumoscan readings were performed shortly
before CXR and CT. The patients had eight lung fields tested. The
qualitative MIR results were blinded and stored on the device. We
compared the results of the MIR to those of clinical examination,
CXR and CT.
Results: Of the 50 patients enrolled in the study, seven presented with
PTX diagnosed by CT, six of which were detected by Pneumoscan
leading to an overall sensitivity of 85.7 %. Only two of seven PTX
were found during clinical examination and on CXR (sensitivity
28.6 %). Of the remaining 43 patients without PTX, one false-posi-
tive PTX was found by Pneumoscan resulting in a specificity of
97.7 %.
Conclusion: MIR is an easy to use handheld technology that effec-
tively screens patients with PTX. MIR may be used for rapid,
repeatable, and on-going surveillance of trauma patients.
Disclosure: Our unit received financial support and one device by
PneumoSonics Inc. towards a department based general trauma
research grant. The company was not granted any intellectual prop-
erties nor any rights to influence data selection, evaluation, or
discussion.
PS175
ABDOMINAL MYXOFIBROSARCOMA, ACUTE & LETHALPRESENTATION: A CASE REPORT
C. Mauricio Alvarado, E. Domınguez Adame-Lanuza,A. Cano Matıas, R. Perez Huertas, A. Villa Dıaz, F. Oliva Mompean
General Surgery, Hospital Universitario Virgen Macarena, Seville/
Spain
Introduction: Myxofibrosarcoma (MFS) predominantly occurs in the
lower and upper limbs of elderly people. Intraabdominal MFS is not
common even less with an acute and lethal presentation.
Materials and methods: We describe one case and we made a bib-
liographic review.
Results: Case: A 34-year-old man presented with severe abdominal
pain, and hipovolemic (erase hipovolemic) shock. Radiological
examination reveled an image suggesting marked dilatation of the
gastric lumen. An emergent exploratory laparotomy was done and we
fund a mass (24 cm 9 15 cm) with a cystic cavity attached to sigmoid
colon. A resection of the colic segment and Hartman procedure was
done. The anatomopathologic study reveled infiltration of the colon
by sarcoma, type dedifferentiated liposarcoma, subtype Myxofibro-
sarcoma grade 2 with a cystic pattern. Discussion: MFS was first
proposed in 1977. Occurs in older adults and the most common
locations of are, the limb and limb girdle followed by the head and
neck. Retroperitoneum and mediastinum are rare locations. Metasta-
ses are more common in higher-grade tumors, large tumors ([10 cm),
and deep-seated neoplasms. Acute presentation of MFS is exceptional
because normally it produces unspecific symptoms where it grows.
The gold standard in treatment is surgical resection with free margin
of tumor, when it is no possible, chemotherapy and radiotherapy is
considered.
Conclusion: Not all the gastric or intestinal lumen dilation in a
radiography image is synonym of intestinal dilatation. Undiagnosed
intraabdominal cancer is a challenge in the emergency room.
Abstract S127
123
References: 1. Am J Surg Pathol. 1996;20(4):391–405. 2. Ophthal
Plast Reconstr Surg. 2010;26(2):129–31. 3. Am J Surg Pathol
1996;20(4):391–405. 4. Cancer J Clin. 2006;56;282–91. 5. Chin Med
J. 2009;122(1):51–3.
Disclosure: No significant relationships.
SKELETAL TRAUMA/HAND AND OTHERS
PS176
OCCULT FRACTURES IN THE CARPAL REGION:INCIDENTAL FINDINGS ON BONE SCINTIGRAPHY
S. Zoakman, R. Van Leerdam, F. Beerens, S. Rhemrev
Traumatology, Medisch Centrum Haaglanden, Den Haag,
Netherlands
Introduction: At our institution we use routine bone scintigraphy in
patients with suspected scaphoid fracture and normal or suspicious
radiographs, to confirm or exclude the presence of this type fracture.
We noticed that bone scintigraphy often detected fractures of distal
radius and other carpal bones withe there was only a clinical suspicion
of a scaphoid fracture.
Materials and methods: We retrospectively included 445 consecu-
tive patients with a suspected scaphoid fracture who underwent
routine bone scintigraphy. None of the radiographs showed evidence
of a fracture. We analyzed the type and number of other fractures
incidentally found on bone scintigraphy.
Results: On average, bone scintigraphy was done in 4 days (1–9).
The outcome of bone scintigraphy: 80 (18.0 %) a scaphoid fracture,
145 (32.6 %) another fracture in the carpal region, 208 (46.7 %)
normal and the diagnosis of 12 (2.7 %) was unclear.
Conclusion: In the present study, we demonstrated that in patients
with a suspected scaphoid fracture and negative radiographs, bone
scintigraphy detected in many cases (64.4 %) other fractures in the
carpal region other than the scaphoid. This suggests that radiographs
not only miss scaphoid but also many other carpal and distal radius
fractures. Solutions should be found to solve this problem and
probably routine advanced imaging techniques should be used in a
routine manner.
Disclosure: No significant relationships.
PS177
THERAPY OF FINGERTIP INJURIES:THE SEMI-OCCLUSIVE DRESSING AS ANALTERNATIVE OPTION TO LOCAL SKIN FLAPS
S. Quadlbauer, C. Pezzei, J. Jurkowitsch, T. Beer, H. Hertz,M. Leixnering
Traumatology, European Handtrauma Center Lorenz-Bohler Hospital
Vienna, Vienna, Austria
Introduction: Fingertip injuries are very common in emergency
departments and the reconstruction is a central aim of their man-
agement. Purpose of this study was to find out, if the semi-occlusive
dressing is able to replace local skin flaps and to expand the indica-
tions for a treatment of fingertip injuries.
Materials and methods: Fingertip injuries threatened with semi-
occlusive dressing, were retrospective analysed. In all cases the
injured fingers were only cleaned, debrided and covered with an
occlusive dressing. The bone was not shorted even if it was up the
wound level. The primarily occlusive dressing was left as long as
possible. The fingertip injuries were classified according to Allen.
Treatment time and the period of disability was recorded. A Semmes–
Weinstein test was performed to document the sensitive outcome.
Results: 77 Patients were treated with a semi-occlusive dressing. The
mean treatment duration was 21 ± 10 days and the mean period of
disability 30 days. Amputation level: 49 % Allen 1, 33 % Allen 2,
13 % Allen 3 and 5 % Allen 4. All patients developed a satisfactory
tissue cover and the sensibility was normal. There were no compli-
cations. No secondary skin flaps were necessary.
Conclusion: The semi-occlusive dressing is an easy, cheap and save
therapy, with no complications, for all kind of fingertip injuries, even
if bone is exposed on the wound level. It leads to an excellent result in
function, sensibility and carry capacity.
References: 1. Richter M. Fingertip injuries. Will semiocclusive
dressings replace VY-advancement flaps? Obere Extremitat. 2. Quell
M. Treatment of fingertip defect injuries with a semi-occlusive
dressing. Handchir Mikrochir Plast Chir.
Disclosure: No significant relationships.
PS178
INTRAOPERATIVE C-ARM CT IMAGING IN VOLARPLATE OSTEOSYNTHESIS OF DISTAL RADIUSFRACTURES
I. Mehling1, P. Rittstieg2, L.P. Muller3, R. Kuchle2, P.M. Rommens2
1Universitatsmedizin Mainz, Klinik fur Unfallchirurgie, Mainz,
Germany, 2Klinik fur Unfallchirurgie, Mainz, Germany, 3Klinik fur
Orthopadie und Unfallchirurgie, Koln, Germany
Introduction: Two-dimensional X-ray examination during surgery
provides limited information in complex distal radius fractures.
Therefore, an image intensifier with 3D options was developed. The
purpose of this prospective study was to analyse the intraoperative
convenience and benefit of C-arm CT imaging in volar plate osteo-
synthesis of distal radius fractures.
Materials and methods: During a one-year period an intraoperative
CT imaging with the ARCADIS Orbic 3D of distal radius fractures
was performed in 51 cases. A standard volar angular stable plate was
used for ORIF of the distal radius fractures. The operation was
accomplished by an additional intraoperative 3D scan and malposi-
tioned screws were corrected during the same procedure. In addition
the duration of the scan and the radiation exposure dose was
measured.
Results: The performance of the scan and the analysis of the CT-
dataset together took 6.7 ± 1.8 min on average. In 31.3 % of the
surgeries a malpositioning of screws, overseen in the standard 2D-
fluoroscopy, was detected using the intraoperative CT-imaging. In
those cases a correction was done immediately. On average the radi-
ation exposure dose was increased by 3.2 cGycm2 ± 0.6 cGycm2.
Conclusion: Firstly C-arm CT imaging is an useful complement to
the standard 2D-fluoroscopy. It can be easily integrated in the normal
course of surgery. Secondly the 3D imaging revealed malpositioned
screw placement for an immediate correction. In our point of view, in
complex distal radius fractures there is a value for the CT imaging in
improving the outcome of volar plate osteosyntheses.
Disclosure: No significant relationships.
S128 Abstract
123
PS179
AN ALTERNATIVE TREATMENT METHOD FORTREATING DISTAL TIBIAL INTRAARTICULARFRACTURES: HYBRID EXTERNAL FIXATOR
F. Say, A.M. Bulbul
Orthopaedics and Traumatology, Samsun Training and Research
Hospital, Samsun, Turkey
Introduction: This study aimed to determine the clinical results of
patients treated with hybrid external fixator by minimal invasive
methods.
Materials and methods: 42 patients were evaluated. A lateral mal-
leolar internal fixation was performed first then distal tibial reduction
was performed by external joystick method with two schanz screws.
The hybrid external fixator was applied with the aid of fluoroscopy.
After 4 months external fixator was removed. All fractures were AO
43C type. All the fractures were the result of high energy trauma. 22
fractures were closed and 20 fractures were open. Mean operation
time was 45 (30–70) min. The follow-up period was 21.4
(12–44) months.
Results: Union was achieved in all patients. Mean union time was 17
(12–32) weeks. The mean lateral distal tibia angle measured 89
degrees (84–92). There were no cases with joint line stepping after
union. All patients dorsiflexion angle measured 15�. No patients had
restricted movement with plantar flexion. There were no problems
with wounds. Patients functional status was scored with the American
Foot & Ankle Score. 26 patients scored good, 14 patients scored
excellent, and 2 patients scored average.
Conclusion: Long operation time and patient postoperative discom-
fort are always a problem with distal tibial fractures. Our study
showed that a hybrid external fixator applied with minimal invasive
methods has the main advantages of shorter operation time, no
problems with skin and wound and good functional status.
References: Babis GC, Kontovazenitis P, Evangelopoulos DS,
Tsailas P, Nikolopoulos K, Soucacos PN. Distal tibial fractures
treated with hybrid external fixation Injury 2010;41(3):253–8.
Disclosure: No significant relationships.
PS180
EFFECT OF BALL JOINT LOCATION IN EXTERNALFIXATOR ON WRIST MOTION IN DISTAL RADIUSFRACTURES
S.H. Moon, S. Lee, B.S. Seo, D.K. Ahn
Orthopaedic Surgery, Seoul Sacred Heart General Hospital, Seoul,
Korea
Introduction: The effects of ball joint location from axis of rotation
on postoperative wrist motion in dynamic external fixator for dis-
placed intra-articular fractures in distal radius were evaluated.
Materials and methods: 33 patients who had dynamic external fix-
ative surgery after closed reduction within acceptable range and could
be followed at least 1 year were reviewed. They were divided into
two groups according to distance (5, 10 mm) of ball joint center from
axis of wrist rotation which located in proximal cortex of capitate.
These groups were compared by clinical results which were evaluated
by range of motion of wrist (flexion, extension, radial deviation, ulnar
deviation, pronation, supination) and pain evaluation system. They
were also divided into two groups according to direction of ball joint
migration (proximal, distal) and evaluated by the same methods.
Results: No difference in range of motion and pain was observed
between distance 0 mm-5 mm group and [5 mm group (p [ 0.05).
Distance 0 mm-10 mm group showed statistically significant more
range of motion in extension, supination and pronation than[10 mm
group (p \ 0.05). However, there was no significant difference in
flexion, radial deviation, ulnar deviation and pain (p [ 0.05). Also no
difference in range of motion and pain was observed between prox-
imal migration group and distal group (p [ 0.05).
Conclusion: In retrospective analysis of dynamic external fixator,
range of wrist motion should be preserved by decrease of changes of
ball joint location within 10 mm from center of rotation.
Reference: Cha JR, Ku JH, Cho HL, et al. J Korean Fracture Soc.
2005;18:304–10.
Disclosure: No significant relationships.
PS181
MINIMALLY INVASIVE SCAPHOID OSTEOSYNTHESIS:STILL NEED FOR A CAST?
J. Ciernik, M. Reska, J. Konecny, M. Kabela
1st Department of Surgery, 1st Department of Surgery, St. Anne‘s
University Hospital, Faculty of Medicine, Masaryk University, Brno,
Brno, Czech Republic
Introduction: Conservative treatment of scaphoid fractures requires
longterm cast fixation, which limits patients daily routine and may
become a substantial socio-economic problem. Authors propose more
aggressive approach minimalizing indications for conservative
treatment.
Materials and methods: First-year results of prospective study
comparing functional outcomes of scaphoid fracture treatment. All
patients with diagnosed scaphoid fracture regardless classification,
were proposed mininvasive osteosynthesis and were informed about
risk and benefits. Patient with serious cardiopulmonary comorbidities
were excluded.
Results: Since November 2010 till August 2011 42 scaphoid fractures
were diagnosed at 41 patients (1 bilateral). We carried out 31 min-
invasive osteosynthesis. Operative approach so far shows better
functional results as well as higher level of patient satisfaction. No
surgery related complication were recorded. Average surgery time
was 39 min. Restoration to satisfactory movement range averaged at
five and half weeks from injury comparing to 12 weeks in conser-
vatively treated group.
Conclusion: Minimally invasive osteosynthesis of scaphoid fractures
presents by the first results save and very well tolerated method of
treatment.
Reference: DraA P., MaAˆ
ak P., AŒiA�maATM I.: ResekAnı ar-
throplastika distalnı Aasti Alunkove kosti u pacientA¯
s pakloubem
skafoidea a symptomatickou arthrozou. Sbornık abstrakt. Sjezd
spoleAnosti chirurgie ruky, Senec, 11/2006, s.13.
Disclosure: No significant relationships.
Abstract S129
123
PS182
HAND AND WRIST FRACTURES IN POLYTRAUMATIZEDPATIENTS
R. Matteotti1, B. Panero2, A. Gallo2, D. Ciclamini2, R. Panarese2,B. Battiston2
1Orthopedics and Traumatology, CTO Turin, Turin, Italy,2Traumatology, CTO, Turin, Italy
Introduction: Hand and wrist fractures are relatively common in
polytraumatized patient. Life-threatening injuries take priority in
multi-injured patients, hand and wrist injuries have to be recognized
and appropriately treated. If missed, these lesions result in limb
function loss with severe disability. Aim of this study was to examine
the clinical outcome in polytraumatized patient who sustained a hand
or wrist lesion.
Materials and methods: 56 polytraumatized patients (ISS[15) with
associated injuries to hand or wrist were considered. All patient were
treated following principles and methods of ATLS and Damage
Control Orthopaedics. Type and timing of treatment, relationship with
life-saving procedures, and late secondary procedures were analyzed.
Results: 56 patients: 34 (60.7 %) were treated in day 0 after trauma,
22 (39.3 %) after 4 days to minimize the surgical ‘‘2nd hit’’. 8 (14 %)
needed a 2nd surgical intervention due to the complexity of lesions or
bad outcome. In most cases external fixation was used, eventually in
association with K-wires. rarely plate and screws was used.
Conclusion: No evidence-based guidelines or recommendation exist
in literature for treatment of these kind of lesions in multi-injured
patients. Treatment must respect ATLS guidelines and DCO princi-
ples, preserving in order life, limb and tissues and restoring function.
References: 1. Schaedel–Hoepfnerm, Siebert. Operative strategies for
hand injuries in multiple trauma. A systematic review of the literature.
Unfallchir 2005;10:850–857. 2. Green D. Green’s Operative Hand
Surgery. Livingstone: Churchill; 2005.
Disclosure: No significant relationships.
PS183
THE CHANGING OF THE TREATMENT FOR DISTALRADIUS FRACTURES
M. Uchino
Department of Orthopaedic Surgery, Machida Municipal Hospital,
Machida City, Japan
Introduction: Here is presented the clinical results in the three kinds
of the treatments for distal radius fractures which are MIPO, the
locking plate projecting beyond the watershed line and under the
watershed line.
Materials and methods: There were 48 fractures between 2002 and
2010. We divided 3 groups which were MIPO is Group M, the
locking plate beyond the watershed line is Group B, and under the
watershed line is Group U. We evaluated time for range of motion,
union rate, union period, complication, outcome (Cooney).
Results: Time for range of motion was started on the first postoper-
ative day in three groups. Union rate was 100 %. The average of
union periods was 9.3 weeks in Group M, 10.0 weeks in Group B and
9.9 weeks in Group U. One FPL rupture and one CRPS were occured
in Group B. The outcome was excellent in three groups.
Conclusion: Three groups are the established treatment because of
good functional results. When we considering these problems which
are the removal after MIPO and FPL disturbance after using the
locking plate beyond the watershed line, we should use the plate
under the watershed line.
References: 1.Orbay JL, et al. Clin Orthop Relat Res. 2006;
445,58–67. 2.Cooney WP, et al. Clin Orthop Relat Res. 1987;214:
136–47.
Disclosure: No significant relationships.
PS184
INCIDENCE, IMAGE DIAGNOSIS AND OTHER ASPECTSOF HAND INJURIES IN CURITIBA CITY: BRAZIL
M.M. Rodrigues, F.G. Blauth, A.K. Calixto, A.D. Oliveira,L.C.V. Bahten
Ccbs, PUCPR, Curitiba, Brazil
Introduction: The hand is essential to nearly all economic, leisure
and daily performance. It is identified as an important component of
human anatomy. Its unique function and structure disables the doctors
to reproduce its structures with the same perfection, thus increasing
the importance of prevention for hand injuries.
Materials and methods: The data was collected trough medical
registers at the service of medical archives in Curitiba, Brazil. The
population analyzed were children from 0 to 12 victims of trauma,
hospitalized at the Hospital Universitario Cajuru, in the period from
April 2009 to April 2011. Epi-Info and Excel were used for data
analysis.
Results: A total of 731 registers were analyzed. From the total
sample, 42 (5.7 %) of children suffered some kind of hand injury. The
average hospitalization time was 2.71 days. Male children were the
most affected ones, with 24 accidents (57 %). Of the 42 children who
suffered hand injury, 38 (90 %) needed X-rays. The most common
types of trauma were: ‘‘blunt or cutting wounds’’ 14 (33.33 %),
‘‘exposed fracture’’ 11 (26.19 %) and ‘‘closed fractures’’ 9 (21.43 %).
The treatments that prevailed were: ‘‘surgical reduction’’ 16
(38.10 %) followed by ‘‘repair of the lesion’’ 15 (35.71 %).
Conclusion: Hand injuries was generally caused by blunt or cutting
wounds, generated low morbidity and short period of admission.
References: 1. Mattar Junior R. Lesoes traumaticas da mao. Rev Bras
Ortop. 2001;36(10):359–66. 2. Aparecida Mendes de BEM, et al.
Health consequences of behaviours: injury as a model. 1992;90:
789–807.
Disclosure: No significant relationships.
PS185
LATE RESULTS OF TENDON TRANSPOSITION TORESTORE HAND FUNCTION
A. Renner1, L. Egri1, J. Rupnik1, A.R. Szentirmai2
1Hand- and Microsurgery, Trauma Centre, Budapest, Hungary,2Trauma Centre, Budapest, Hungary
Introduction: Tendon transfers are usually secondary procedures.
We performed diverse procedures after nerve injuries, tendon
S130 Abstract
123
ruptures, spastic hand, ischamic contractures and congenital
malformations.
Materials and methods: We evaluate the results of tendon transfers
of 175 patients between 01.01.1999. and 31.12.2009. Nerve injuries
53 (n. radialis 14; n. medianus 18; n. ulnaris 14; combined n.
medianus n. ulnaris 7), tendon ruptures 66 (flexor 19; extensor 47),
tendon defects 16, iscamic contracture 6, spastic hand 6, PCP 12,
congenital malformations 16 cases. The effectiveness of the transfer
was assessed objectively by measuring pinch grip, precision grip,
ROM. The subjective patient’s evaluation was based on the ADL
questionnaire.
Results: After 3 years 121 patients, after 5 years 110 patients, after
10 years 97 patients returned for follow-up examination. According
to the objective and subjective evaluation we report 40 excellent, 65
good, 13 satisfactory, and 3 poor results.
Conclusion: The chose of the surgical technique is individual. The
results depend on the technical carry out, ont he patient cooperation,
and on the regular physiotherapy.
Disclosure: No significant relationships.
PS186
EXTERNAL FIXATOR IN TREATMENT OF COMMINUTEDINTRAARTICULAR FRACTURE AT THE FIRSTMETACARPAL BASE
J. Konecny, L. Veverkova, M. Reska, J. Ciernik
1st Department of Surgery, 1st Department of Surgery, St. Anne‘s
University Hospital, Faculty of Medicine, Masaryk University, Brno,
Brno/Czech Republic
Introduction: Intraarticular fractures of the base of the thumb usually
require open reduction and internal fixation to maintain the articular
surface and prevent arthritis as well as to give stability to the base of
the thumb. In case of comminuted intraarticular fractures the treat-
ment is usually more difficult. If internal fixations are not possible,
distraction techniques such as banjo casting or bridging external
fixators are good alternatives.
Materials and methods: We describe special case of polytrauma-
tized patient—23 years old woman with injury of the chest, liver
contusions, dislocated fractures of lower limb and dislocated com-
minutive fracture of first metacarpal base. In this case we used
intermetacarpal external fixation.
Results: We applied intermetacarpal external fixation in acute phase
of treatment. The conversion to internal fixation was planed. Good
position of fragments on control X-rays and another injuries requiring
interventions made us let this external fixation like definitive solution.
The external fixation was removed after 2 months. We documented
check-up 9 months after injury when the patient was without troubles,
on X-ray the bone was completely healed and thumb function was
excellent.
Conclusion: The most common treatment of intraarticular fracture of
first metacarpal base using internal fixation has high risk of joint
stiffness and restriction of thumb motion. Bridging external fixator
limits motion of wrist. In our experience intermetacarpal external
fixation could be good alternative to this method.
Reference: Berger RA, Weiss AC. Hand surgery, 1st Edition. Lip-
pincot: Williams Wilkins;2004.
Disclosure: No significant relationships.
PS187
RUPTURE OF EXTENSOR HALLUCIS LONGUS TENDONDURING SPORT ACTIVITY
I. Frangez, R. Beden, K. Strus
Traumatology, University Clinical centre Ljubljana, Ljubljana,
Slovenia
Introduction: Extensor hallucis longus (EHL) tendon injuries are
uncommon. Usually they occur during work and are accompanying
lacerocontusious wounds. Closed traumatic ruptures are even less
common and they usually occur during sport activity. Missed injury
can lead to tendon retraction, scarring and flexor contracture of the
toe.
Materials and methods: The literature considering this injury is
scarce. In acute rupture of tendon the first line treatment is end to end
suture with nonresorbtive suture. In delayed therapy this is often
impossible because of the retraction and scaring of tendon. Refix-
ation, transposition or reconstruction with free graft can be used.
Results: Case: An overlooked traumatic tendon rupture of a 23-year-
old athlete that appeared during running. After the removal of a
walking below-knee cast (after 4 weeks) for treating a fracture of
fourth metatarsal bone, the patient noticed he can not extend the toe
on his left foot. Flector contracture of the hallux was also present. He
was sent to our clinic for further treatment. There was an overlooked
injury of extensor hallucis longus tendon at first examination. Ultra-
sound showed lesion of the tendon at the site of insertion on the distal
phalange of the toe. We decided for refixation of EHL on its anatomic
place with anchor sutures 3,5 mm and performed arthrodesis. A
walking below-knee cast for 4 weeks, then physiotherapy and
8 weeks after operation he was able to walk and run.
Conclusion: Reconstruction of overlooked ruptures of the extensor
hallucis longus tendon is demanding because of the scaring and the
retraction of the tendon.
References: 1.Geoghegan JM, et al. Hip extension strength following
harmstring tendon harvest for ACL reconstruction. Knee. 2007;
14(5):352–6. 2. Park HG, et al. Autogenous graft repair using semi-
tendinous tendon for a chronic multifocal rupture of extensor
hallucis longus tendon: a case report. Foot Ankle Int. 2003;24(6):
506–8.
Disclosure: No significant relationships.
PS188
WHITE MARBLE AS SCAFFOLD FOR BONEREGENERATION: COMPARATIVE STUDY IN RATS
T. Shadmanov1, R. Hodjaev2, B. Magrupov3
1Traumatology, Republican Research Center of Emergency Medicine,
Tashkent, Uzbekistan, 2Children Traumatology, Republican Science
Center of Traumatology and Orthopedy, Tashkent, Uzbekistan,3Pathology, Republican Research Center of Emergency Medicine,
Tashkent, Uzbekistan
Introduction: The idea of using white marble for bone tissue
replacement a was born through knowledge about bone chemical
compound and researches devoted to using in orthopedic practice a
natural heterograft—a sea coral. A white marble implant is easily
Abstract S131
123
available and it shared close resemblance of bony mineral and made it
a good alternative as bone graft.
Materials and methods: Sixty male Wistar rats were used. All rats
were operated to create a 2.5 mm defect in right femur. The cavities
were filled with: white marble powder (WM); calcium carbonate
powder (CC) and autogenous blood clot (control). The animals were
euthanized 7, 14, 30, 60, 90 days after surgery. All the rats were
assessed clinically, radiologically and sacrified for histology
evaluation.
Results: In Wistar rat femoral bone defects white marble presented a
better osteoconductive capacity when compared to calcium carbonate;
white marble and calcium carbonate powder were completely re-
sorbed after 90 days; control cavities did not completely heal until
90 days after surgery, while there is a complete calcification in WM
and CC groups.
Conclusion: This study has shown that the white marble can be used
as a graft to a small cortical bone defect. The white marble provides
an excellent scaffold for osteoconduction. The white marble implants
presented a better osteoconductive capacity, compared to calcium
carbonate.
Disclosure: No significant relationships.
PS189
LATE RADIOGRAPHIC FOLLOW UP OFUNCOMPLICATED DISTAL RADIUS FRACTURES, IS ITJUSTIFIED? CLINICAL OUTCOME AND FINANCIALIMPLICATIONS
N. Eastley, Z. Khan
Trauma and Orthopaedics, Kettering General Hospital, Kettering/
United Kingdom
Introduction: Fractures of the distal radius constitute 18 % of all
human fractures. Inaccurate reduction can lead to secondary
osteoarthritis. Early follow up imaging is consequently paramount
to recognise displacement and facilitate reduction. Developing
callus eventually makes reduction impractical. This potentially
makes follow up radiographs in the absence of clinical compli-
cations obsolete. We aimed to highlight several objective
parameters dependant on radiographs taken more than 2 weeks post
injury in uncomplicated distal radius fractures. Our outcome mea-
sures were visible clinical deformity, range of movement and grip
strength.
Materials and methods: Cases between May 2009 and September
2010 were reviewed. Devised criteria regulated case selection. Data
was collected from local radiological software and clinical notes.
Fractures were classified as undisplaced or displaced, and placed in
long term and short term follow up groups dependant on their
radiographic follow up. T-tests looked for significant differences
between these groups.
Results: 66 cases were included; 45 displaced fractures (22 short-
term; 23 long-term) and 21 undisplaced (5 short-term; 16 long-term.)
No cases reported visible clinical deformity. There was no significant
difference between grip strengths or range of movements of the short-
term and long-term groups in the undisplaced or displaced fractures.
No cases required intervention for late displacement.
Conclusion: Although complications may justify delayed imaging,
results suggest radiographs late in the follow up of uncomplicated
distal radius fractures have no impact on our outcome measures.
Financial regulation within the NHS means any potential benefits
from the removal of these unnecessary radiographs should be
recognised. Established radiological follow up regimes need to be
devised.
Disclosure: No significant relationships.
PS190
ARTHROSCOPIC TREATMENT OF THE ANKLEIMPINGEMENT SYNDROME AFTER INVERSION INJURY
I. Frangez1, V. Senekovic2, M. Veselko2
1Traumatology, University Clinical Centre Ljubljana, Ljubljana,
Slovenia, 2Traumatology, University Medical Centre Ljubljana,
Ljubljana, Slovenia
Introduction: Inversion injuries of the ankle are common and most
are managed adequately by functional treatment. A significant num-
ber will, however, remain symptomatic (pain, elicted by full range of
motion because of the mechanical impingement in the joint). This
condition is often difficult to diagnose because the physical signs and
investigations are non specific. The patient may note some mild
swelling when comparing this ankle to the contralateral ankle. There
may be a feeling of instability. Physical examination reveals localized
palpable tenderness at the ankle joint. Pain is often elicited by passive
forceful dorsiflexion of the ankle. The cardinal physical sign is the
Molloy–Bendal impingement test. Definitive diagnosis is made only
with arthroscopy, which is diagnostic and therapeutic.
Materials and methods: From June 2010 to June 2011 we have
performed operative arthroscopy in 27 patients with impingement
syndrome of the ankle under local anesthesia. The following arthro-
scopic procedures were carried out: synovectomy, removal of
osteophytes, loose bodies, cicatrices, removal of meniscoid lesions
and drilling of the chondral defects.
Results: The results were evaluated by Martin’s scale. At the follow
up results were excellent in 22/27 patients (81.5 %), good in 3/27
patients (11.1 %) and fair in 2/27 patients (7.4 %). Two patients had
mild complication—transient hiposensibility of the branches of the
superficial peroneal nerve.
Conclusion: In all cases the arthroscopy confirmed the suspected
diagnosis of impingement syndrome and the procedure was in all
cases continued into operative arthroscopy. Considering our experi-
ences we believe that in impingement syndrome the operative
arthroscopic procedure is indicated.
Disclosure: No significant relationships.
PS191
A NOVEL APPROACH TO WRIST REDUCTION - A CROSSTRUST ANALYSIS AND THE POTENTIAL HEALTHECONOMICS
R. Karthigan1, M.R. Ricks2, A. Mohan2, N. Ellahee2, J. Hendry2,K. Stevens3
1Trauma and Orthopaedic, Epsom and St Helier Hospital, London,
UK, 2Trauma and Orthopaedics, Epsom and St Helier Hosptial,
London, UK, 3Accident and Emergency, Epsom and St Helier
Hospital, London, UK
Introduction: Distal radius fractures commonly require a reduction
by a team of skilled Accident and Emergency practitioners. The
S132 Abstract
123
fracture is reduced to correct the deformity and potentially prevent the
need for an operation. By using three people to reduce a fracture this
can be time consuming and expensive. We have designed a reduction
aid and technique for reducing distal radius fractures with the use of a
specialised frame. This frame is set up on a hospital bed and provides
counter traction and support.
Materials and methods: It is a retrospective study looking at a
2 year period with one site using the reduction aid and a two person
technique and the standard 3 person reduction technique being used at
another site. We have analysed the pre-reduction and post reduction
radiographs of the wrist fractures. Assessment of the radio-ulnar
height, radial height and volar tilt were made.
Results: There were 38 patients involved in both the STH and EGH
populations. For the reduction aid technique 4 patients went onto have
an operation compared with the 3 person technique of 15 patients.
This results in 34 patients being managed conservatively for the
reduction aid technique and 23 for the 3 person technique.
Conclusion: A reduction aid technique in the hands of a skilled
operator achieves a better reduction with less patients going on to
require an operation. The machine is easily constructible and highly
effective and with less staff involved there is a potential cost saving.
Disclosure: No significant relationships.
PS192
ENDOSCOPIC TECHNIQUE FOR BONE GRAFTING ATDOCKING SITE DURING BONE TRANSPORT. REPORT OFFOUR CASES
F. Sala, E. Marinoni, F. Castelli, M. Othman, D. Capitani
Orthopaedic Trauma Team, Niguarda Hospital, Milano, Italy
Introduction: Docking site non union often occurs in distraction
osteogenesis procedures in the treatment of traumatic bone loss of the
tibia. Revision surgery at the docking site non union is complicated
also by the in situ hardware. A mini-invasive and tissues sparing
technique is needed to perform the docking site revision and the bone
grafting.
Materials and methods: An endoscopic approach in four tibial cases
were performed during docking site revision. Non union occurred
following compound tibial fractures treated by circular external
fixation. All were complicated by severe skin damage. Two little
skin incisions were created in order to reach the docking site with
an usual arthroscopic instrumentation. Low pressure-low flow sal-
ine irrigation was obtained by mean of MFS arthroscopic pump. A
30� arthroscope and a motorized 5 mm. shaver/abrader were used.
Fibrous tissue was removed, the bone ends abraded and the bone
canal cleaned. Bone graft was obtained from the iliac crest in three
cases and in other case from the ipsilateral medial femoral condyle
using osteochondral transfer instrumentation (Makar Inst.). No
tourniquet was used on the limb. At the end a realignment and
acute compression was performed.
Results: The procedure was possible with good direct vision of the
site, small surgical approach and no complications like bleeding or
compartimental syndrome. It took 60 min in mean time for operative
procedure.
Conclusion: The endoscopic approach provided minimal incision,
accurate debridement, precise bone grafting, minimal vascular injury
to the surrounding tissues, fewer complication, minimal hospital stay,
less expensive procedure obtaining rapid bone union.
Disclosure: No significant relationships.
PS193
PREDICTORS OF RETURN AFTER CAST REMOVAL INPATIENTS WITH A NONOPERATIVELY TREATED DISTALRADIUS FRACTURE
W.E. Bruinsma, A.G.J. Bot, D. Ring
Orthopaedic Hand and Upper Extremity Service, Massachusetts
General Hospital, Boston, MA, USA
Introduction: Patients with a nonoperatively treated fracture of the
distal radius are often scheduled for a follow-up appointment after
cast removal to assess function and outcome. Our experience is that,
once the cast is off, many patients do not return. The purpose of this
study was to determine which variables significantly influence return
for a scheduled visit after cast removal.
Materials and methods: Thirty-seven patients (27 men and 10
women) with an average age of 49 years (range 19–82) had a distal
radius fracture immobilized in a cast. During the visit at which the
cast was removed, arm-specific disability, misinterpretation of noci-
ception, and symptoms of depression were measured using validated
questionnaires. Bivariate and multivariable analysis of the predictors
of returning for another scheduled visit after cast removal and of arm
specific disability was performed.
Results: Eleven of 37 patients did not attend the final scheduled office
visit. The only predictor of a return visit was older age.
Conclusion: The only predictor in return to follow-up was older age.
Disclosure: Dr. Ring Study Grants Skeletal Dynamics (pending)
Consultant Wright Medical Skeletal Dynamics Biomet Honoraria AO
North America AO International Royalties Received Wright Medical
Royalties Contracted Biomet Skeletal Dynamics. Stock Options
Illuminos.
PS194
THE EXTENDED FLEXOR CARPI RADIALIS APPROACHFOR PARTIALLY HEALED MAL-ALIGNED FRACTURESOF THE DISTAL RADIUS
M. Wijffels1, J. Orbay2, I. Indriago2, D. Ring1
1Orthopaedic Hand and Upper Extremity Service, Massachusetts
General Hospital, Boston, MA, USA, 2Miami Hand Center, Miami,
FL, USA
Introduction: Objectives: to describe the extended flexor carpi
radialis (FCR) approach for correction of partially healed mal-
unions of distal radius fractures and evaluate its safety and
effectiveness.
Materials and methods: 35 patients underwent the extended FCR
approach for correction of malaligned, partially healed, distal radius
fractures and were evaluated after a minimum of 12 months of fol-
low-up. Special attention was paid to function, radiologic
improvement in malalignment and complications.
Results: Postoperative functional outcome was good. Significant
improvement in alignment was found comparing pre- and postoper-
ative situation without the cost of complications.
Conclusion: The extended FCR approach is a useful reduction
technique in nascent malunions of the distal radius leading to good
radiographic and clinical results with no major complications.
Abstract S133
123
Disclosure: Dr. Ring: Royalties Received: Wright Medical Royalties
Contracted: Biomet, Skeletal Dynamics Stock Options: Illuminos,
Mimedex.
PS195
LONG TERM RESULTS AFTER TRAUMATIC ANTERIORSHOULDER DISLOCATION IN ADOLESCENTS:A POSTTRAUMATIC ANALYSIS
R.C. Ostermann, M. Gregori, M. Hofbauer, P. Platzer, C. Fialka
Trauma Surgery, Medical University of Vienna, Vienna, Austria
Introduction: Traumatic anterior shoulder dislocations in adoles-
cence are associated with a high rate of recurrent instability. Recent
studies have demonstrated improved results and reduction in recurrent
instability in patients treated with surgical stabilization.
Materials and methods: We retrospectively evaluated the natural
history of traumatic anterior shoulder dislocations in adolescents. 11
patients, who were between 12 and 18 years of age at the time of
injury, were available for clinical follow up with a mean follow up
time of 11.5 years. During clinical follow up the patients subsequent
history, a clinical examination, an individual relative Constant score,
an UCLA shoulder score and a Rowe score was obtained. In addition,
a telephone interview was conducted with 12 further patients, who
were not available for clinical follow up.
Results: A recurrence rate of 100 % was noted. The average number
of recurrences was 7.3. Clinical examination revealed an average
Constant score of 93.5, an average UCLA shoulder score of 32 and an
average Rowe score of 88 in patients who had undergone shoulder
stabilization surgery. In patients treated nonoperatively, an average
Constant score of 80.8, an average UCLA shoulder score of 22.4 and
an average Rowe score of 54 was noted. In patients treated nonop-
eratively, only one was able to participate in sports without any
restrictions whereas 53 % of the patients treated operatively reported
no restrictions during sports.
Conclusion: A high rate of recurrence can be expected for adoles-
cents who sustained a traumatic anterior shoulder dislocation. Thus,
to prevent further damage to intraarticular structures caused by
recurrent dislocations, an early shoulder stabilization surgery should
at least be considered in these young patients.
Disclosure: No significant relationships.
POSTERS
DIAPHRAGM AND OESOPHAGEAL INJURIES
P001
MANAGEMENT OF ACUTE COMPLICATEDPARAESOPHAGEAL HERNIAS
L. Alvarez Llano, J. De Tomas Palacios, Y. Mohamed Al-Lal,T. Sanchez Rodriguez, F. Turegano Fuentes
Cirugıa General Ii, Hospital Gregorio Maranon, Madrid/Spain
Introduction: Management of paraesophageal hernia (PEH) in the
elderly is controversial. Most authors agree that symptomatic
hernias should be operated on, but the problem arises with
asymptomatic or mildly symptomatic ones. Neither the prevalence
nor the complication rate of the hernias is well known. Several
decades ago, experts advocated that all PEH should be operated on,
due to the high mortality of emergency procedures in aged
patients. Nowadays, laparoscopy and anesthetic management of the
elderly have improved the outcome of surgical procedures among
this population. However, the complication rate of emergency
operations is still high when compared to non-emergency
procedures.
Materials and methods: We present our preliminary results of a
prospective study on the emergency surgical repair of PEH’s in the
elderly. Cases were collected from the Department of emergency
surgery in our hospital (HGUGM).
Results: During the first 12 months of the study we have operated 5
patients with acute complicated PHE. The average age was 85 years
and all patients were initially treated by laparoscopy. One patient had
to be converted to an open procedure (20 %). There were two gastric
necrosis requiring resection, and one death. Four patients (80 %) had
postoperative complications. The onset of symptoms before operation
was of 68.8 h on average, and postoperative hospital stay was
14.6 days.
Conclusion: Morbidity and mortality of emergency PEH repair are
still very high. We have observed some delay in the diagnosis of the
complication and the decision to proceed to surgery. Conservative
management of mildly symptomatic PEH’s could impair the prog-
nosis of elderly patients.
Disclosure: No significant relationships.
P002
DIAGNOSTICAL AND SURGICAL MISTAKES DURINGDIAPHRAGM INJURY
Z. Chkhaidze1, A. Chatterjee2, N. Lominadze1, T. Gvenetadze3
1Department of Emergency Surgery And Critical Medicine, Tbilisi
State University, Tbilisi, Georgia, 2Anatomy, Tbilisi State Medical
University, Tbilisi, Georgia, 3Tbilisi State University, Tbilisi, Georgia
Introduction: Circulatory shock is a common result of the simulta-
neous damage of thorax and abdominal cavity. In case of thoracic
cavity damages of its multiple organs are usually observed. In the
cases of abdominal muscle rigidity and symptoms of peritonitis,
injury of diaphragm can be a conclusive diagnosis.
Materials and methods: One of the most complex aspects of poly
trauma surgery is, on time diagnosis and treatment of diaphragm
damage. By literature findings such cases are observed in 0.5–5.0 %
of all complex trauma cases. In about 50 % of patients with such
lesion it is accompanied with damage of 3–5 anatomical regions.
Diagnosis in more than 50 % of patients that was not done on time.
Diagnostical mistakes can be discovered during additional manipu-
lation or during autopsy. Diagnostical and tactical mistakes during
diaphragmal injuries are commonly the cause of: (1) The lack of
alertness and competency of doctors and medical staffs. (2) Less
evidence of clinical symptoms during acute traumatic illness. (3) Low
contrast of X-ray diagnostical methods.
Results: Most common complications are herniation of abdominal
organs through the diaphragm into the pleural cavity and subsequent
causation of cardiorespiratory symptoms.
Conclusion: (1) During multiple traumas diaphragm injury rate is
very high. (2) During acute stage of traumatical illness in 36.6 % of
patients with diaphragm injury dislocation of abdominal organs into
S134 Abstract
123
pleural cavity occurs. 4. Most informative diagnostical methods
during diaphragmal injuries are laparoscopy and thoracoscopy.
References: 1. Sotnichenko B, Salienko S. Sotnichenko dr. Diag-
nostika lechenie travmaticheskix ushchemlennix diafragmalnix grij.
2. Brandt ML, Raghu TG. Diagnosis of hemidiafragmatic rupture by
liver scintigraphy.
Disclosure: No significant relationships.
P003
TRAUMATIC DIAPHRAGMATIC INJURY: A MARKER OFSERIOUS INJURY CHALLENGING TRAUMA SURGEONS
M. Pol, A. Gupta, S. Kumar, B. Mishra, S. Sagar, M. Singhal
Trauma Surgery, Jpn Apex Trauma Center, All India Institute of
Medical Sciences, Delhi, India
Introduction: Introduction: Traumatic diaphragmatic injuries (TDI)
is occult marker of serious injury and are often association with other
visceral injuries causing substantial morbidity and mortality. Aim: To
study prevalence, identify the predictors of mortality and study the
accuracy of investigations.
Materials and methods: Retrospective analysis of TDI from January
2007 through October 2011. Ed records, operative details, and
autopsy reports were reviewed to determine characteristics of injury,
treatment and outcome. Statistical analyses were performed using the
SPSS ver.15 software.
Results: TDI was identified in 64 individuals. 32 cases underwent
surgery, in 7 cases preoperative diagnosis was made. 32/37 nonsur-
vivors were brought dead to the hospital. Mean age was 26.22 among
survivors and 37.04 among nonsurvivors, the mean injury severity
scores (ISS) was 19.33 in survivors and 42.11 among nonsurvivors.
Bilateral sides of diaphragmatic injury were noted in 12 cases.
Pearson Chi square test suggested that increased ISS (p value
\0.000001), increased NISS (p value \0.000001), increasing age (p
value of 0.022) and bilateral TDI (p = 0.006) are the predictors of the
mortality. The prevalence of TDI was 2.35 %, and CT scan did not
replace intraoperative diagnosis of TDI in our study.
Conclusion: TDI is a marker of serious injury challenging trauma
surgeons. Those with increased ISS, increased NISS, increasing age
and bilateral involvement of diaphragm are at the greatest risk of
mortality. Intraoperative visualization of diaphragm is the most reli-
able way of diagnosing TDI.
References: 1. Reid J. Diaphragmatic hernia. Edin Med Surg.
1840;53:104–7. 2. Scharff JR, Naunheim KS. Traumatic diaphrag-
matic injuries. Thorac Surg Clin. 2007;17:81–5.
Disclosure: No significant relationships.
GERIATRIC TRAUMA
P004
BILATERAL TOTAL KNEE ARTHROPLASTY INA PATIENT WITH NEUROPATHIC (CHARCOT)JOINTS-MID TERM RESULTS
K.I. Papagiannakos, G. Protopapadakis, P. Papagiannopoulos,P. Kalantzis, P. Boudouris, E. Nikas, I. Akrivos
2nd Orthopaedic, ‘‘Evangelismos’’ Hospital, Athens, Greece
Introduction: Neuropathic arthropathy (Charcot joint) is a progres-
sive degenerative disease of the joint characterized by development of
bone destruction related to alteration of afferent proprioceptive fibers
and subsequent loss of joint sensation.
Materials and methods: A 57 year old male was presented for
painless swelling of his right knee without having any history of
trauma. His medical history revealed IDDM I for the last 20 years.
Soft tissue swelling, knee subluxation, complete absence of pain,
abnormal mobility and severe instability where revealed. He was
operated on August 2008 and a TKA of the right knee was performed.
6 months later the patient presented the same symptoms on his con-
tralateral knee and was operated.
Results: More than 2 years after surgery bilateral knee joint function
is preserved in excellent condition without instability and pain.
Conclusion: TKA may be offered to those patients with end stage
neuropathic arthropathy. Our opinion is that TKA is preferable to
arthrodesis or amputation.
References: 1. Parvizi J, et al. TKA for neuropathic (Charcot) joints.
CORR. 2003;(416):145–50. 2. Fullerton BD, Browngohl LA. TKA in
a patient with bilateral Charcot knees. Arch Phys Med Rl.
1997;78(7):780–2.
Disclosure: No significant relationships.
P005
PAMMA AUGMENTED DHS IN TROCHANTERICFRACTURES: A SIMPLE & EFFECTIVE TECHNIQUE
R. Gupta
Department of Orthopaedics, PGIMS, Rohtak, Rohtak/India
Introduction: Polymethylmethacrylate (PMMA) augmentation has
been advocated to improve fixation stability in osteoporotic tro-
chanteric fractures [1, 2]. However, most of the techniques described
in literature involve possible complications like cement penetration
into the fracture area or joint and loss of sliding collapse. We present
a simple and effective technique of cement augmentation of DHS in
osteoporotic trochanteric fractures without any risk of above men-
tioned complications.
Materials and methods: The prospective study included 64 patients
(AO type 31A2—44 patients and 31A3—20 patients) with an average
age of 72 years, of which 60 were available for final follow up. After
achieving reduction, appropriate guide wires were passed followed by
triple reaming and tapping. Long barrel of a custom made gun
designed by the authors was inserted as far as possible into the hole in
femoral head over the guide wire and approximately 4–5 ml of
cement was injected from the deepest part of the head to outwards up
to base of femoral head. Cement gun was then quickly removed and
compression screw and barrel plate of DHS were inserted followed by
guide wire removal and fixation of plate to the shaft of femur. All
patients were allowed partial weight-bearing ambulation on second or
third postoperative day followed by full weight bearing, depending
upon the tolerance of the patient.
Results: All patients had radiological union at an average of
13.8 weeks. With a minimum follow-up of 24 months, there was
no incidence of varus collapse, superior screw cutout or thermal
necrosis in any of the patients. Most of the patients were able to
regain their pre fracture mobility status with a mean hip pain score
of 8.6.
Conclusion: Cement augmentation of DHS using our technique
appears to be a simple and effective method of preventing
Abstract S135
123
osteoporosis related complications of fracture fixation in trochanteric
fractures without any apparent limitations or side effects.
References: 1. Lee PC, et al. DHS for unstable intertrochanteric
fractures in elderly patients—encouraging results with a cement
augmentation technique. J Trauma. 2010;68(4):954–64. 2. Dall’Oca
C, et al. Cement augmentation of intertrochanteric fractures stabilised
with intramedullary nailing. Injury. 2010;41(11):1150–5.
Disclosure: No significant relationships.
P006
ANGLE STABLE VERSUS CONVENTIONAL DISTAL TIBIANAIL LOCKING SCREWS – A BIOMECHANICAL STUDYON FATIGUE PERFORMANCE
M. Lenz1, B. Gueorguiev2, R.G. Richards2, T. Muckley3,G.O. Hofmann3, M. Windolf2, D. Hontzsch4
1Biomedical Services, AO Research Institute Davos, Davos Platz,
Switzerland, 2AO Research Institute Davos, Davos Platz, Switzerland,3Trauma, Hand And Reconstructive Surgery, Friedrich-Schiller-
University, Jena, Germany, 4Medical Technology Development, BG
Trauma Hospital, Tubingen, Germany
Introduction: Distal interlocking screw failure of intramedullary
tibia nails mainly occurs, if high implant stress could not be reduced
by other means, so in delayed fracture consolidation or early full
weight bearing. Due to the need of a reliable fixation, we investigated
the long-term performance of angular-stable locking screws compared
to conventional locking screws for distal locking of intramedullary
tibia nails.
Materials and methods: The cut distal third of human surrogate
tibia bones was overreamed and a 10 mm diameter intramedullary
tibia nail was locked distally in the mediolateral plane with either
two angular-stable locking screws or two conventional locking
screws. Six specimens per group were mechanically tested under
quasi-static and cyclic axial loading with constantly increasing
load.
Results: Stiffness values of angular stable locking screw constructs
were significantly higher (7,809 N/mm ± 647, mean ± SD) com-
pared to conventional locking screw constructs (6,614 N/mm ± 859,
p = 0.025). The longer fatigue life of angular stable locking screw
constructs is expressed in a significantly higher number of cycles to
failure (187,200 ± 18,100) compared to conventional locking con-
structs (128,700 ± 7000, p = 0.004).
Conclusion: If the nail acts as load carrier and an improved stability
during fracture healing is needed, fatigue performance of locking
screws can be ameliorated by the use of angular stable locking screws.
References: 1. Horn J, et al. Injury. 2009;40:767–71. 2. Gueorguiev
B, et al. J Orthop Trauma. 2011;25(6):340–6. 3. Gueorguiev B, et al.
J Trauma. 2011;70(2):358–65.
Disclosure: The authors are not compensated and there are no other
institutional subsidies, corporate affiliations, or funding sources
supporting this work unless clearly documented and disclosed.
Implants were kindly donated by Synthes GmbH, Solothurn,
Switzerland.
P007
NON-SYNCOPAL FALLS IN THE BATHROOM:UNDERESTIMATED MODE OF INJURY
H. Abdelrahman, R. Alajaj, A. El-Menyar, A. Almadani, A. Shunni,H. Al Thani, R. Latifi
Trauma Surgery, Hamad General Hospital, Foha, Qatar
Introduction: Few data are available on the injury patterns of non-
syncopal falls at bathroom particularly in young age. Elderly people
are well-known vulnerable group. The study aimed to describe the
incidence and patterns of injury associated with non-syncopal falls at
bathroom in young and old age.
Materials and methods: Data were collected retrospectively from
the registry of the section of trauma surgery at Hamad General
Hospital from Jan 2008 to July 2011. Patients with history of non-
syncopal falls at bathroom requiring admission were divided into 2
groups (\60 and C60 years). Data including gender, injuries, length
of stay, ISS, risk factors and outcomes were analyzed and compared.
Results: A total of 102 consecutive patients were identified (mean
age of 51 ± 18 years, average weight 80 kg). thirty-eight percent of
cases were C60 years. Female: male ratio was 1:6 in young age and
1:1 in elderly. Five patients were alcoholic; all were in the young age
group. Average ISS was comparable in the 2 groups. Head injury was
3 times higher in young age (17 vs. 5 %), whereas lower extremities
injuries were 2 times higher in old age (57 vs. 34 %, P = 0.16 for
each). There was also non-significant higher incidence of chest injury
in young age group. Hospital length stay was longer in elderly (12.7
vs. 7.7 days, P = 0.3). There were 3 deaths (5 %); all were in the old
age group.
Conclusion: Regardless of age, Bathroom related falls are important
mode of injury with considerable impact on and morbidity and
mortality and needs special attention for primary prevention.
Disclosure: No significant relationships.
P008
THE GAMMA3 TROCHANTERIC NAIL: A PROSPECTIVEEVALUATION OF 70 CONSECUTIVE PATIENTS WITHTROCHANTERIC FRACTURES OF THE FEMUR (4MONTHS RESULTS)
E. Wilde1, H. Kemper1, G. Zech1, G. Heinrichs1, A. Paech1,A.P. Schulz2
1Trauma and Orthopedics Department, University Hospital Luebeck,
Luebeck, Germany, 2Traumatology, University Hospital Luebeck,
Luebeck, Germany
Introduction: A prospective clinical evaluation was initiated to
analyze complications and clinical results of the Gamma3 nail. A
consecutive series of 70 cases will be examined over a period of
2 years. Actually we present the preliminary results of the 4 months
follow-up.
S136 Abstract
123
Materials and methods: An external monitored prospective con-
secutive single armed cohort study was conducted at a University
hospital in Germany. We included all patients [50 years with a
proximal femoral fracture requiring treatment with a Gamma3 nail.
Assessed were the Merle dAubigne-, Zuckerman-, Parker Mobility-
and Sahlgrenska Score and Radiographs. We included 70 patients in a
12 months period (71 % female) with an average age of 78 years and
a BMI of 24.2 kg/m2. 6 patients died before 4 months follow-up
(8.6 %), 1 lost of follow-up. The study was funded by the
manufacturer.
Results: Index procedure was performed in all cases without tech-
nical problems. In 5 cases superficial wound healing disorder occured.
Non-surgical complications were found in 5 patients (3 cardiac, 1
DVT, 1 lung embolism). Re-operation was performed in 4 cases (3
cut-out, 1 subnail fracture). At 4 months the Parker Mobility Score
was 6.3 (7.2 pre-OP), Merle d’Aubigne 8.3 (11.3 pre-OP) and
Zuckerman Score was 27.3 points. Analgesia was taken from 21 % of
the patients. Sahlgrenska Score was 6.2 at day 7.
Conclusion: Treatment of proximal femoral fractures with Gamma3
Nail is safe and the mortality rate seems to decrease—as also found in
the literature—in the last years. The results indicate that rehabilitation
is still not finished during a 4 month period.
Reference: Westacott D, Bould M. Outcome in 36 elderly patients
treated with the Gamma3 Long Nail for unstable proximal femoral
fracture. Acta orthopaedica Belgica. 2011;77(1):68–72.
Disclosure: No significant relationships.
P009
THE ASSOCIATION BETWEEN GENDER AND MORTALITYFOR TRAUMA CARE IN JAPAN
T. Fujita, Y. Uchida, T. Sakamoto
Teikyo University Hospital, Trauma and Resuscitation Center,
Tokyo, Japan
Introduction: There have been many publications about the advan-
tage for survival of females. However, there has not been such a
report for trauma care in Japan. We hypothesized that females are at
lower risk for mortality than males after trauma.
Materials and methods: This study used the data in the Japan
Trauma Data Bank 2004–2009 for 22316 patients without data defi-
cits for their Injury Severity Score (ISS), Revised Trauma Score
(RTS), age and crude survival. The population was divided into two
gender groups. The female group included 6887 patients. The male
group included 15429 patients. The Mann–Whitney U test was
applied for the statistical analysis of the two groups. Multivariate
logistic regression model was applied to adjust age, ISS, RTS and
male ratio.
Results: The mean age with a 95 % confidence interval (female vs.
male) was 54.9 (54.3–55.5) versus 46.1 (45.7–46.4) (p = 0.000). The
mean ISS was 15.6 (15.3–15.8) versus 16.4 (16.2–16.6) (p = 0.000).
The mean RTS was 7.27 (7.24–7.30) versus 7.24 (7.22–7.26)
(p = 0.001).The mean TRISS-Ps was 0.889 (0.884–0.894) versus
0.895 (0.892–0.898) (p = 0.000). The crude Survival rate was 0.911
(0.904–0.917) versus 0.908 (0.903–0.912) (p = 0.485). The anatom-
ical and physiological severity were significantly different, however,
the crude survival was not statistically different between the two
groups. Adjusted odds ratio for survival was 1.246(95 % CI:
1.088–1.426, p = 0.001).
Conclusion: Multivariate logistic regression model demonstrated a
positive value for the improving outcome in a female gender. This is
the first study about the gender analysis for trauma using the JTDB.
Reference: O’Keefe GE, Hunt JL, Purdue GF. An evaluation of risk
factors for mortality after burn trauma and the identification of gen-
der-dependent differences in outcomes. JACS. 2001;192(2):153–60.
Disclosure: No significant relationships.
P010
PERI-IMPLANT BONE QUALITY ASSESSMENT IN THEPROXIMAL HUMERUS
D. Schiuma1, M. Plecko2, M. Kloub3, S. Rothstock4, M. Windolf4,B. Gueorguiev-Ruegg5
1Preclinical Testing, AO Research Institute, Davos Platz, Switzerland,2Unfallkrankenhaus Graz der AUVA, Graz, Austria, 3Hospital Ceske
Budejovice, Ceske Budejovice/Czech Republic, 4Biomedical
Research Services, AO Research Institute Davos, Davos Platz,
Switzerland, 5Biomedical Services, AO Research Institute, Davos
Platz, Switzerland
Introduction: Insufficient primary stability is still reported for
proximal humerus fractures in elderly patients [1]. Fixation stability
could be improved by aiming locking screws at bone regions with
better quality. A novel method [2] was used in this study to investi-
gate the bone regions engaged by the locking screws of a Proximal
Humeral Nail (MultiLoc PHN, Synthes GmbH), which provides a
new option to insert secondary locking screws through the screw
heads of the primary screws.
Materials and methods: The distal locking part of the PHN was
fixed to six human cadaveric humeri. The nails were then removed
and the bones scanned at 82 lm isotropic resolution using HR-pQCT
(XtremeCT, Scanco Medical). Bone volume fraction (BV/TV) and
apparent BMD were evaluated at the locations where the proximal
locking screws would have been positioned after complete
instrumentation.
Results: Higher bone properties were found at the secondary locking
screw paths. The investigated bone parameters were found to be
significantly different between the screw paths. In particular, a sig-
nificant difference was found between the most proximal secondary
locking screw and all primary locking screws (BV/TV, p B 0.02;
apparent BMD, p B 0.02).
Conclusion: The secondary locking screws were found to aim at bone
volumes with better properties in the posteromedial part of the
humeral head, confirming that they can be used to increase osteo-
synthesis stability in bone with poor quality.
References: 1. Sudkamp N, et al. J Bone Joint Surg Am. 2009. 2.
Schiuma D, et al. Med Eng Phys. 2011.
Disclosure: The authors are not compensated and there are no other
institutional subsidies and corporate affiliations supporting this work.
Partial contribution cost was received from Synthes GmbH (Soloth-
urn, Switzerland) in support of this work.
Abstract S137
123
P011
THE USE OF THE GAMMA3 NAIL IN GERIATRICTROCHANTERIC AND SUBTROCHANTERIC FRACTURES:A PROSPECTIVE CLINICAL TRIAL
B. Bucking, J. Struewer, T. Muller, S. Ruchholtz
Department of Trauma, Hand and Reconstructive Surgery, University
Hospital Giessen and Marburg GmbH, Location Marburg, Marburg,
Germany
Introduction: Treatment of trochanteric fractures is associated with
high rates of complications and long term results are still poor.
Objective of the present study was to evaluate the results of fixation of
geriatric trochanteric fractures by using the Gamma3 nail.
Materials and methods: In our study patients 60 years or older with
pertrochanteric and subtrochanteric femoral fractures were included.
All patients with polytrauma or pathological fractures were excluded.
Data concerning age, gender, and fracture type, concerning surgeon
(resident vs. consultant), time of operation and perioperative com-
plications were recorded. Complications, Barthel Index, the IADL
and the EQ-5-D measurements were collected at 6 and 12 month.
Results: 90 patients (69 female, 21 male) were prospectively inclu-
ded. Patients mean age was 81 years and mean ASA score was 3.
Cutting/suture time was 53 min (range 19–180 min). Hospital mor-
tality was 4 % and over all 22 % at 12 months follow up. 8 local
complications occurred. 42 % of the patients were operated by resi-
dents in training with similar results to consultant operations. The
Incidence of relevant systemic complications was 5 %. The Barthel
Index (82–71), IADL (4.5–4.3) and EQ-5-D (0.75–0.66) values are
decreasing during the follow up period of 12 month.
Conclusion: The results showed a relatively low complication rate by
using the Gamma3 nail even if nailing was performed by residents in
training. Probably high mortality, the decline in function and the
quality of life could be attributed by pre-existing conditions like
physical status. Though further studies comparing different current
devices are necessary.
Disclosure: No significant relationships.
P012
THE SPECTRUM OF ALCOHOL AND DRUG ABUSEIN ELDERLY TRAUMA PATIENTS
A.P. Ekeh, M. Walusimbi, R. Woods, M. Mccarthy
Surgery, Wright State University, Dayton, OH, USA
Introduction: Alcohol and drug abuse are recognized to be signifi-
cantly prevalent in trauma patients. The prevalence of substance
abuse in elderly trauma patients has, however, received minimal
attention. We sought to identify the spectrum of this issue by exam-
ining the positive alcohol and drug toxicology screens in patients
[65 years admitted to a Level I Trauma Center.
Materials and methods: All patients [65 years admitted over a
60-month period were identified. Demographic data, blood alcohol
content (BAC) and urine drug screens (UDS) at admission were
obtained by chart review. Patients identified were compared with
those \65 years admitted during the same time period. Statistical
analysis was performed using Fischer’s exact test.
Results: In 5 year period, 4139 patients over 65 years were admitted
and 1305 (31.5 %) underwent BAC or UDS screening. Positive BAC
present in 10.7 % and positive UDS in 48.5 %. Mean BAC level in
those tested was 163 g/dL. Comparing with individuals \65 years, a
positive BAC was found in 10.7 % of patients [65 years versus
44.4 % in those less than 65 years. This was statistically significant.
(p \ 0.0001). The UDS was positive in 48.5 % of individuals
[65 years compared with 74.5 % of individuals \65 years
(p \ 0.0001) Marijuana and cocaine use was statistically significantly
less in the elderly population. (p \ 0.0001 in both cases).
Conclusion: Alcohol and drug abuse are an issue in patients
[65 years although not as pervasive a problem as in younger popu-
lations. Admission toxicology screens are important to help identify
geriatric individuals who may require intervention.
Disclosure: No significant relationships.
P013
THE ANTERIOR TRANSARTICULAR C1-2 STABILISATIONIN ATLANTO-AXIAL INSTABILITIES: A CONSIDERATEPROCEDURE IN ELDER PATIENTS
C. Josten1, J.S. Jarvers1, S. Glasmacher1, A. Franck1, J. Adermann1,U. Spiegl2, C. Schmidt1
1Department of Traumatology, Plastic- and Reconstructive Surgery,
Spine Center, University of Leipzig, Leipzig, Germany, 2Department
of Trauma and Reconstructive Surgery, Spine Center, University of
Leipzig, Leipzig, Germany
Introduction: In case of atlantoaxial instabilities the therapy remains
controversal. In spite of a high primary instability it holds risks to
injure the A. vertebralis as well as neurological structures. Further-
more the posterior approach of the upper part of the cervical spine
requires a huge and traumatic preparation of the soft tissue. However,
the anterior transarticular C1/2 fusion (ATF) is less traumatic and
offers almost the same strength of the stabilisation.
Materials and methods: Since the 01/2007 48 multimorbid patients
with atlanto-axial instabilities of different entities were treated via the
ATF, were regular examined radiologically (X-ray/CT) and the pro-
cedure critically judged.
Results: C1–2 fusions were performed in 48 patients (35f, 13 m;
average 80.4 years). Main symptoms was pain radiating in the upper
cervical spine and the occiput. The average operation-time took
64.5 min. No introperative complications occured, one revision had to
be done because of p.o. bleeding, one because of screw dislocation.
Postoperative x-ray and CT control of the upper cervical spine
showed 81/96 (85.3 %) screws in correct position. 8 (8.4 %) screws
were too long, 3 (3.2 %) screws were placed too anterior and 4
(4.1 %) too medial. 41 additional positionated dens-screws were in
correct position. A correct entry point and right insertion of the angle
in the coronar and sagittal view. A low intraoperative blood loss, a
non traumatic access as well as an immediate pain decrease have to be
valued positively for this procedure.
Conclusion: The gentle procedure of the ATF requires- despite of the
huge experience in anterior surgery of dens fractures—a learning
curve, because of the more proximate insertion point, the flat insertion
angle and the closeness of the A. vertebralis. If these aspects are going
to be noticed, failed screw positioning and excessive length as well as
injuries of the A. vertebralis can be avoided.
Disclosure: No significant relationships.
S138 Abstract
123
P014
MANAGEMENT OF PERIPROSTHETIC FRACTURESFOLLOWING IPSILATERAL KNEE AND HIPENDOPROSTHESIS
J. Kottstorfer, R. Schuster, R. Ostermann, G. Oberleitner, R. Schmidt,S. Eipeldauer, P. Platzer
Department Of Trauma Surgery, General Hospital Vienna, Wien,
Austria
Introduction: Interprosthetic femoral fractures following ipsilateral
hip and knee arthroplasty are a rare but serious complication in
clinical practice. Adequate management of these injuries might be a
challenging problem. However, literature provides only few data
regarding the treatment and outcome of interprosthetic femoral frac-
tures. Purpose of the study was to analyse our experience in the
management of interprosthetic femoral fractures.
Materials and methods: We reviewed the clinical and radiographic
records of 23 consecutive patients averaging 79.2 years. For classi-
fication, fractures were divided into three types, depending on the
fracture site and the adjacency to the prostheses. All patients under-
went operative stabilization, either by lateral plate fixation (n = 19),
by revision arthroplasty using a long-stem (n = 2), or by plate fixa-
tion and hip shaft replacement (n = 2).
Results: 16 patients returned to their pre-injury activity level and
were satisfied with their clinical outcome. In 6 patients we saw a
relevant decrease of hip or knee function and severe limitations in gait
and activities of daily living. One patient died related to surgery.
Successful fracture healing within 6 months was achieved 86 %.
Failures of reduction or fixation occurred in 18 %. Re-operation (due
to non-union) was necessary in one patient.
Conclusion: We had a satisfactory outcome following individualized
treatment of interprosthetic femoral fractures following ipsilateral hip
and knee joint replacement. We had promising functional result and
high rate of bony fusion. Regarding the complexity and challenges in
many of these cases, interprosthetic fractures require an adequate
analysis of the fracture aetiology and a suitable transfer into the best
possible treatment concept.
Disclosure: No significant relationships.
P015
EXPERIENCE WITH THE TARGON FN SYSTEM FORFEMORAL NECK FRACTURES
X. Bucher1, M. Bachmann2, M. Clauss1, T. Ilchmann1
1Traumatologie und Orthopadie, Kantonsspital Liestal, Liestal/
Switzerland, 2Traumatologie und Orthopadie, Spital Region
Oberaargau, Langenthal/Switzerland
Introduction: The Targon FN system (Aesculap Orthopaedics) is a
device to fix femoral neck fractures providing a telescoping mecha-
nism with angular and rotational stability. As it was launched in 2007,
there are only few data.
Materials and methods: 35 patients (23 females, 12 males) with an
average age of 74 years (41–95 years) and femoral neck fracture were
operated between 2008 and 2009 with the Targon FN system. We
analysed the re-operation rates, the reasons for re-operation and
measured the telescoping of the screws on the digital x-rays within
3 month and one year respectively.
Results: 6 (17 %) patients were re-operated, 4 with a total hip
arthroplasty, one endoprothesis and one dynamic hip screw. The
reasons for re-operation were insufficient reduction in 2 patients, poor
screw positioning in one patient and too many drill hole attempts in
another patient. In spite of good reduction and screw positioning, one
patient had an avascular osteonecrosis and one had a secondary dis-
location. In the average the screws did telescope 3.9 mm within
3 months and 4.1 mm (0–19 mm) within 1 year.
Conclusion: The screws of the Targon FN system did telescope in a
sufficient way. The study might show a lower re-operation rate with
the Targon FN system compared to other internal fixation systems for
femoral neck fractures, due to the missing metal removal following
screw cut-outs and lateral irritation. Nevertheless correct reduction
and good positioning of the screw apex in the femoral head are
mandatory to get a maximum outcome.
Disclosure: No significant relationships.
P016
RISK FACTORS FOR CLINICAL OUTCOME OF PROXIMALHUMERAL FRACTURES
F. Domaszewski, M. Gregori, H. Binder, C. Fialka
Traumatology, Medical University Vienna, Vienna/Austria
Introduction: Proximal humeral fractures represent the third most
frequent fracture in the elderly population. It is still not known
which risk factors predict a negative therapeutic outcome inde-
pendent of operative or non-operative treatment. The aim of this
study was the investigation of therapy-independent risk factors,
which lead to a negative therapeutic outcome of proximal humeral
fractures.
Materials and methods: Over a period of 12 months, 188 consecu-
tive patients(66 men, average 65 years) with proximal humeral
fractures were included in a prospective study design, independent of
fracture type and non-operative or operative treatment. After the
patients’ affirmation a standardised questionnaire was used to collect
epidemiological data. Plain X-ray and the Individual Relative Con-
stant Score(CS) were performed 3 and 6 month after trauma. A
negative therapeutic outcome was defined as Individual Relative
Constant Score \70.
Results: 142 patients completed the 6-month follow up, 64
patients(45 %, 24male, average 70 years) showed poor therapeutic
outcome with an CS \70 %, with Body Mass Index [25 (38/64
patients), menopause (37/64) and intake of b-blocker (28/64) as most
frequent risk factors. 78 patients (55 %, 23 male, average 60 years)
with good clinical outcome and an CS [70 % had menopause (49/
78), Body Mass Index [25 (43/78) and intake of proton pump
inhibitors (23/78) as most frequent risk factors. The comparison of
both groups showed higher incidence of intake of b-block-
er(18.2 %),chronic alcoholism (14.4 %) and intake of proton pump
inhibitors (14.3 %) in the CS \70 % group.
Conclusion: The prevalence of the described risk factors is a prog-
nostic factor for poor clinical outcome. Patients with intake of b-
blocker, proton pump inhibitors and chronic alcoholism are likely to
have a poor therapeutic outcome, independent of fracture type or
treatment modality.
Disclosure: No significant relationships.
Abstract S139
123
P017
LOW REVISION RATE IN THE TREATMENT OFINTERTROCHANTERIC FEMUR FRACTURES WITH PFN A
R. Hartel1, A. Platz2, U. Can1
1Division of Trauma Surgery, City Hospital Triemli, Zurich/
Switzerland, 2Division of Trauma Surgery, City Hospital Triemli,
Zurich/Switzerland
Introduction: Since 2006 we treat patients with intertrochanteric
femoral fractures with the new PFN-A. Although 50.7 % of inter-
ventions are done by residents, our quality control study shows a
significant reduction in complication-, especially revision rate do to
the new design of PFN-A.
Materials and methods: All patients with proximal femur fractures
are collected in a consecutive data base. The clinical information
system is used for analysis of surgical report, discharging-report and
the x-rays. Revision surgeries and other postoperative complications
are listed.
Results: From 2006 to 2009, 345 PFN-A patients (262 w, 83 m)
median age 84 years and length of stay of 14.9 days showed a
cumulative complication rate of 51.9 %, urinary tract infection
(36.2 %), pneumonia 10.2 %, haematoma 2.6 % and wound infection
1.7 %. 20 patients needed revision surgery (5.8 %), whereof 8 spiral
blade changes and 5 hip replacements. The postoperative mortality
was 4.6, 35 % of patients underwent a rehabilitation program, 35 %
were placed in a nursing home and 25 % went home.
Conclusion: The use of PFN-A in intertrochanteric femoral fractures
in a teaching hospital is a save and effective procedure and shows a
low implant related complication rate. Change from PFN to PFN-A
reduces the rate of revision surgery (12.2 % in a study 2008 to 5.8 %
in this study). A low complication rate is not only a benefit for our
patients, but also an important economic factor, especially with DRG
coming up in 2012.
Reference: Penzkofer J, et al. Ergebnisse bei der Versorgung per- und
subtrochanterer Femurfrakturen. Ein retrospektiver Vergleich zwis-
chen PFN und PFN-A. Unfallchirurg 2009;112:699–705.
Disclosure: No significant relationships.
P018
TREATMENT OF THE DISPLACED FEMORAL NECKFRACTURES: INDICATIONS AND LIMITS OFOSTEOSYNTHESIS
I. Floris, Z. Vendegh, J. Baktai, B. Gloviczky, P. Balazs
Iii. Department for Locomotor System, Peterfy Street Hospital and
Center of Traumatology, Budapest, Hungary
Introduction: The aim of our study was to determine the most ade-
quate surgical procedure for displaced, Garden type III–IV femoral
neck fractures: which patients should undergo an osteosynthesis or
primary arthroplasty, with the least prospect of complications?
Materials and methods: We analyzed 489 femoral neck fractures
treated by percutaneous osteosynthesis. We also compared the results
of displaced fractures treated with primary arthroplasty versus sec-
ondary arthroplasty performed due to the failure of primary
osteosynthesis.
Results: The rate of redisplacement in the Garden type III group was
7.6 %, and in the Garden type IV group, it was 25.5 %, mainly in the
case of subcapital fractures. Also, walking ability was examined
4 months after injury. In the ASA score II–III group, most of the
patients were able to walk with or without walking aids, but in the
case of ASA score IV, most of them were immobile or died during the
hospital or posthospital phase. In cases of femoral neck fractures
treated with primary arthroplasty, the complication rate is lower than
after secondary arthroplasty due to failure of the primary
osteosynthesis.
Conclusion: We recommend osteosynthesis in the case of Garden
type III femoral neck fractures and, in turn, arthroplasty with respect
to the high rate of early redisplacement in the case of Garden type IV
fractures, especially in the case of subcapital fractures. For patients
confined to a bed and in poor general condition (ASA score IV), the
first choice treatment option is the minimally invasive percutaneous
osteosynthesis.
Reference: Manninger. Internal fixation of femoral neck fractures.
Berlin: Springer; 2007.
Disclosure: No significant relationships.
P019
LOCKING COMPRESSION PLATE FIXATION FORSUPRACONDYLAR PERIPROSTHETIC FRACTURE OF THEDISTAL FEMUR AFTER TOTAL KNEE ARTHROPLASTY
C. Michelitsch
Orthopedic and Trauma Surgery, Kantonal Hospital of Graubuenden,
Chur, Switzerland
Introduction: Conventional plating of femur fractures associated
with a total knee arthroplasty was often associated with secondary
instability. New locked plate devices improve fixation especially in
osteoporotic bone and can be inserted minimally invasive. We present
a continuous series of distal femoral fractures after knee arthroplasty
treated with a locked plate designed for the distal femur.
Materials and methods: From June 2004 to April 2011 seventeen
patients with eighteen femur fractures above a well-fixed TKA were
treated with a locked plate (LCP-DF, Synthesa) in a MIPO-technique.
No initial bone graft was used. Rehabilitation protocol consisted in
immediate mobilisation with partial weight bearing whenever
possible.
Results: Six patients were lost of follow-up. Eleven patients with
twelve fractures (1 male, 10 females, average age 71.8 (range 58–85)
years) were available for follow-up at an average of 7.5 months.
According to the Rorabeck classification, there were eleven Type II
and one Type I fractures. Eleven of the twelve fractures healed. One
developed an aseptic delayed union due to fixation loss distally. Re-
osteosynthesis with distal cement augmentation, bone grafting and
additional medial plate was successful. There was no change in
alignment in any other patient. No infectious complication was
reported and all knee prosthesis remained stable at follow-up.
Conclusion: Fixation of periprosthetic supracondylar femur fractures
with a locked plate is an efficient method with high stability for
immediate mobilisation even in osteoporotic bone. MIPO-techniques
are optimal for preservation of the vascularity of the fracture zone.
Despite the rather rigid construct, a high rate of primary bone healing
can be expected.
Disclosure: No significant relationships.
S140 Abstract
123
P020
LCP DISTAL HUMERUS PLATE, USEFULL OR JUSTANOTHER PLAYTHING?
U. Can1, M. Rancan2, A. Platz2
1Division of Trauma Surgery, City Hospital Triemli, Zurich/
Switzerland, 2Division of Trauma Surgery, City Hospital Triemli,
Zurich/Switzerland
Introduction: In the last decade fractures of the distal part of the
humerus show a substantial increase in number and incidence espe-
cially in elderly women with osteoporotic bone. With anatomically
preshaped angular stable implants it is possible to restore anatomy
and function even in very distal and comminuted fractures. We
present our experience.
Materials and methods: All patients with distal humerus fractures
treated from 2006 to 2011 in our hospital are retrospectively analysed.
Patient report, X-rays and follow up data are collected.
Results: 53 patients, 42 women and 11 men with a mean age of
68 years were treated with a distal humerus fracture. 10 patients were
treated non operatively. In 14 cases, 11 w/3 m, we used the new LCP
Distal Humerus Plate (Synthes) because of fracture pattern, osteo-
porosis and age. Mean age in this subgroup was 70 years. Mean
operating time 137 min. According to the AO-Classification we found
7 type A-, 2 type B- and 5 type C-fractures. 13 (of 14) fractures healed
uneventful with mean ROM Flex/Ex 130/15/0.
Conclusion: The shape of the new LCP Distal Humerus Plate allows
anatomic restoration in very distal, comminuted or osteoporotic
fractures. In these selected cases it is reasonable to use anatomically
preshaped implants although costs are higher but still less than for
joint replacement. Postoperative function is excellent due to anatomic
reduction.
Reference: Greiner S, et al. Outcome after open reduction and
angular stable internal Fixation for supra-intercondylar fractures:
preliminary results with the LCP distal humerus system. Arch Orthop
Trauma Surg. 2008;128:723–9.
Disclosure: No significant relationships.
P021
BIPOLAR OR UNIPOLAR HEMIARTHROPLASTY AFTERFEMORAL NECK FRACTURES: SELECTION CRITERIABASED ON MORTALITY
E. Ayhan1, H. Kesmezacar2, M.C. Unlu3, N. Kir3
1Orthopaedics and Traumatology, Sariyer Ismail Akgun Public
Hospital, Istanbul, Turkey, 2Orthopaedics and Traumatology, Istanbul
Bilim University Medical Faculty, Istanbul, Turkey, 3Orthopaedics
and Traumatology, Istanbul University, Cerrahpasa Medical Faculty,
Istanbul, Turkey
Introduction: We hypothesized to construct selection criteria for
unipolar or bipolar prosthesis based on factors affecting mortality
after femoral neck fracture.
Materials and methods: To reveal factors affecting mortality,
patients were grouped as alive and dead. Gender, age, delay in sur-
gery, and American Society of Anesthesiologists’ (ASA) score were
obtained from patients’ folders. Patients were classified as unipolar
and bipolar prosthesis groups. In alive patients Barthel Daily Living,
Harris Hip, and acetabular erosion scores were calculated and bipolar
head movement analyzed with radiographs at last follow-up.
Results: One-year mortality was 31.94 %. Male gender, increased
age, high ASA, and delay in surgery were related with increased
mortality. There were 81 patients in unipolar and 63 patients in
bipolar prosthesis groups. Twenty patients from both groups admitted
for last follow-up. There were no differences between groups
regarding gender, age, ASA score, delay in surgery, mortality and
Barthel, Harris, acetabulum scores. Bipolar head movement was
preserved for 33.3 % of patients. These were inactive patients with
low Barthel and Harris scores.
Conclusion: Although bipolar head movement preserved for inactive
patients, this has no advantage for hardly walking patients. Consid-
ering 1/3 of patients die in postoperative first year, expensive bipolar
prosthesis must be used selectively. In our study; men, aged C79,
ASA score C3 had increased mortality risk. We think there is no way
to use bipolar prosthesis with these patient characters.
Reference: Ong BC, Maurer SG, Aharonoff GB, et al. Unipolar
versus bipolar hemiarthroplasty: functional outcome after femoral
neck fracture at a minimum of thirty-six months follow-up. J Orthop
Trauma. 2002;16(5):317–22.
Disclosure: No significant relationships.
P022
EXTERNAL FIXATOR FOR PERTROCHANTERICFRACTURES IN SEVERELY ILL ELDERLY PATIENTS
T. Kozak1, R. Hart2
1Ortopedicko - Traumatologicke Oddelenı, Nemocnice Znojmo,
Znojmo/Czech Republic, 2Yyyyy, Nemocnice Znojmo, Znojmo/
Czech Republic
Introduction: There is an effort to provide as minimally invasive
treatment of fractures of the proximal femur as possible in consid-
eration of increasing incidence in elderly polymorbid patients. One
possibility of such a treatment is the external fixator. Orthofix per-
trochanteric external fixator (ex-fix) has been used since 2006 to treat
type 31 A1, A2, A3, B1, and B2 fractures. The aim of the prospective
study was to evaluate the benefits of this way of treatment.
Materials and methods: The ex-fix was used in 18 cases for the
treatment of the pertrochanteric hip fracture so far. Indication for this
external osteosynthesis was severe polymorbidity in all cases where
other type of operative management was not possible. These patients
were 74 years old at average. The duration of the fixation was
75.5 days at average (range 56–112 days). Local care for the ex-fix
was done 5 times a day postoperatively. There was none transfusion
needed.
Results: Duration of the surgical procedure was 32 min at average
(range, 25 - 42 min) with minimal blood loss. All fractures healed.
We observed a pin-track infection in 2 cases (it resolved spontane-
ously after pin removal). Other complications as release of the ex-fix
or neurovascular injury were not observed.
Conclusion: The advantages of ex-fix is its minimal invasivity,
reduction of the blood loss and the possibility of the early mobilisa-
tion of the patients despite of other treatment necessities. The
disadvantage is the higher risk of pin infection which must be mini-
mized by nursing care.
Reference: tomas.kozak@nemzn.cz.
Abstract S141
123
P023
OSTEOSYNTHESIS WITH PLATE IN MULTIFRAGMENTALMETAPHYSEAL FRACTURES OF FEMORAL BONE
S. Sakhvadze1, K. Sirbiladze1, V. Kakhnidze1, S. Sakhvadze2
1Department of Traumatology and Orthopedy, Acad. N. Kipshidze
Central University Clinic, Tbilisi/Georgia, 2, Tbilisi State Medical
University, Tbilisi/Georgia
Introduction: Multifragmental metaphyseal fracture of femoral bone
mostly evolves as a result of influence of highly traumatic agent and
represents a significant problem with respect to stabilization as well as
fracture consolidation.
Materials and methods: Osteosynthesis with plate was performed on
84 patients with metaphyseal and meta-diaphysial fractures of fem-
oral bone, in the period of 2000–2009. Proximal metaphyseal fracture
was presented in 49 patients and distal metaphyseal fracture—in 35,
respectively. In proximal metaphyseal fracture, 1300 angle plate (11),
950 angle plate (15) and DHS (23) were used for fixation, and in distal
metaphyseal fracture—95� angle plate (24) and condylar plate (11)
were applied. In 5 cases with severe osteoporosis we used combined
osteosynthesis method with both plate and cement.
Results: Complete healing (consolidation) in 4.5–6.5 months period
was achieved in 79 cases. The fracture failed to consolidate in 5 cases.
The latter involved 2 cases of 130� angle plate breakage, and 2 cases
of dislocation.
Conclusion: Osteosynthesis with plate in multifragmental metaphy-
seal fractures of femoral bone still appears to be an effectual and
favourable method of choice, particularly when applying the indirect
closed reposition and less invasive operation technique.
Disclosure: No significant relationships.
P024
PERTROCHANTERIC FRACTURES TREATED WITH PC.C.P
E. Grosso1, R. Matteotti2, M.P. Tarello1, L. Rollero1, R. Sisto1,B. Battiston1
1Traumatology, cto, Turin/Italy, 2Orthopedics and Traumatology,
CTO Turin, Turin/Italy
Introduction: Hip fracture surgery in elderly patient is associated
with high post-operative mortality and poor functional results: the
excess mortality is 20 % in the first year; of those patients who sur-
vive, only 50 % recover their previous ability to walk. Selection of a
correct type of implant for fracture fixation is a very interesting
challenge. A minimally invasive fixation device may potentially
improve patient’s outcome.
Materials and methods: We considered 545 patients with pertro-
chanteric fracture(AO type 31 A1 and 31 A2)treated in 7 years in our
Department with PCCP. Mean age: 80.7. Female: 73 %. We collected
the following data: pre-injury and post-operative general health
condition with the Parker’s mobility score HB pre and post operative,
number of transfused blood units, mortality,surgical and clinical
complications.
Results: Mortality : 20 % (31 % in the males, 16 % in females). The
mortality has been bigger in the patients with more than 80 years and
in patients with a pre-injury low functional status. Mean number of
transfused blood units: 0.85. Few complications.
Conclusion: In patients whose general condition is frequently com-
promised by severe concomitant medical or surgical conditions,
primary objectives in proximal femural fractures are that there should
be minimal operative trauma and blood loss and that walking ability
should be, if possible, maintained. Our results agree with data in
literature as to the clinical outcomes of pertrochanteric fractures so
the PCCP can be considered a good option in the surgical treatment.
References: 1. Gotfried Y. Percutaneous compression plating for
intertrochanteric hip fractures: treatment rationale. Orthopaedics.
2002;25:647–52. 2. Peyser et al. Percutaneous compression plating
versus CHS for the treatment of intertrochanteric hip fractures. Injury.
2005;36:1343–9.
Disclosure: No significant relationships.
P025
A RETROSPECTIVE COHORT STUDY TO DETERMINEWHETHER COMMON HEAD INJURY SYMPTOMS DIFFERBETWEEN ELDER PATIENTS AND NON ELDER PATIENTS
A. Wigelsworth1, J. Batchelor1, M. Wigelsworth2
1Emergency Department, Trafford General Hospital, Manchester,
UK, 2Health Sciences, Manchester University, Manchester, UK
Introduction: The aim of the current study was to determine if there
was a difference in the frequency of occurrence of symptoms fol-
lowing a minor head injury (defined as GCS 13–15 for this study) in
elder patients compare to non elder patients.
Materials and methods: A retrospective review was undertaken of the
clinical notesofall patientswhounderwent ahead CTfor traumatic brain
injury at Trafford General Hospital during the period January 2009–
December 2010. The CT findings and clinical correlates were collated.
Chi Square analysis was performed on the clinical correlates comparing
the elder group (age 60 years and greater) with the non elder group.
Results: 218 patients with a GCS 13-15 were identified. 128 patients
were less than 60 years and 90 patients were greater than 60 years.
The CT abnormality rate in the two groups was 10 % in the under 60
and 19 % in the 60 and over group. Patients less than 60 years were
statistically less likely to report vomiting (X2 (1) = 13.827, p \ 0.01)
and headache (X2 (1) = 8.111, p = 0.004) following a minor head
injury compared to those greater than 59 years. However, there was
no statistically significant difference in the reporting of amnesia or
loss of consciousness between the two groups.
Conclusion: The results of this small pilot cohort study suggest that
vomiting is a qualitative clinical features of elder patients with minor
head injury compared to non elder patients which should be taken into
consideration for future head injury guideline development.
Disclosure: No significant relationships.
P026
OUTCOMES OF MINIMALLY INVASIVE PLATEOSTEOSYNTHESIS THROUGH THE ANTEROLATERALACROMINAL APPROACH USING LOCKING PLATES FORDISPLACED PROXIMAL HUMERAL FRACTURES
T. Matsumura
Orthopaedics, Jichi Medical University, Shimotsuke-shi, Tochigi-ken/
Japan.
S142 Abstract
123
Introduction: The treatment for the fractures of proximal humerus
has been still problematic and challenging for orthopaedic surgeon.
The various surgical options have been performed for the unstable
fractures for proximal humerus but optimal implant and technique do
not determined. We present the results of minimally invasive plate
osteosynthesis (MIPO) of displaced proximal humeral fractures using
locking plates.
Materials and methods: Between April 2006 and July 2009, 37
consecutive patients with an acute displaced fractures of the proximal
humerus were treated with the insertion of locking plates. Of the 37
patients who underwent treatment, two were lost follow-up and two of
whom had died. The remaining 33 patients (6 men and 27 women)
were reviewed retrospectively. 17 fractures were AO 11-A3, 11 were
B2, 1 was B3, 2 were C2, and 2 were C3. Their mean age at the time
of fracture was 64.7 years (16 to 86) and the mean follow-up was
21.7 months (12–48).
Results: All fractures healed. Mean final constant score was 79.6
points (range 54–100). Two patients developed avascular necrosis of
the humeral head. Two patients showed considerable loss of fixation.
There were no cases of hardware failure or infection.
Conclusion: Minimally invasive plate osteosynthesis through the
anterolateral acromial approach using locking plates yield satisfactory
results for displaced proximal humeral fractures. This surgical pro-
cedure may decrease complication rates and allow for quicker return
to function.
Reference: Gardner MJ, et al. Vascular implication of minimally
invasive plating of proximal humerus fractures. J Orthop Trauma.
2006;20:602–7.
Disclosure: No significant relationships.
P027
SURGICAL TREATMENT OF ACETABULAR FRACTURESIN ELDERLY PATIENTS OVER 65 YEARS
N. Shiota1, T. Sato1, M. Yoshida2
1Orthopaedic Surgery, Okayama Medical Center, Okayama, Japan,2Okayama Medical Center, Okayama, Japan
Introduction: Acetabular fracture is intra-articular fracture, requiring
anatomical reconstruction of the articular surface. Not only there are
many complications, it is difficult to reposition the fracture. Espe-
cially in the elderly due to osteoporosis, deterioration of general
condition due to trauma, often there are a lot of medical histories,
difficult to treat. We examined in 10 cases of acetabular fractures in
elderly people over 65 years treated from April 2007.
Materials and methods: The mean age is 74.8 years (67-84), 7 men
and 3 women cases. Injuries caused by falls 2 patients, 2 patients
drop, 4 cases of traffic accidents, industrial accidents were 2 cases.
Fracture type was considered using Judet & Letournel classification, 1
case posterior wall, 1 anterior wall, 1 anterior column, 1 T-shaped, 3
anterior column + posterior hemi-transverse and 3 both column. One
case used anterior small incision, 6 cases ilioinguinal approach, 1 case
Kocher–Langenbeck approach, two cases combined approach were
performed. Operation time and blood loss for the operation, postop-
erative CT evaluation about the fracture reduction, walking ability
after surgery (free gait, walking using a cane or crutch, wheelchair,
bedridden) and perioperative complications were investigated.
Results: The mean operative time 189.9 min (55–302), mean blood
loss 1008.7 ml (100–3063), respectively. One case had 2–4 mm step
off, 9 cases 0–2 mm. Walking ability, three patients had recovered the
previous level before the injury, 5 cases decreased by one level, two
patients had a decrease in two levels. Perioperative complications
were observed in 1 case of infection, 1 case of intraoperative bleeding
secured by gauze packing, 3 cases of venous thromboembolism and 3
cases of perioperative delirium.
Conclusion: Fracture reduction was almost good in this study, but
one case was remained step off showed marginal impaction and
comminution of the fracture site before the surgery. Primary THA
should have been considered in marginal impaction cases of elderly
patients. Elderly are less reserve capacity of coagulation and intra-
operative bleeding, thus we need to restrict on intraoperative
bleeding and perform less invasive surgery. The final walking ability
has been affected by delays in rehabilitation due to perioperative
delirium and complications. Early intervention is needed aggressive
treatment.
Disclosure: No significant relationships.
P028
ACUTE MAJOR TRAUMA IN THE ELDERLY PATIENT
G. Parra Sanchez1, V. Guimera Garcıa2, V. Rodriguez Vega3,P. Caba4
1Cirugıa Ortopedica Y Traumatologıa, HU 12 de Octubre, Madrid,
Spain, 2Orthopaedic Surgery and Traumatology, Hospital
Universitario 12 de Octubre., Madrid, Spain, 3Orthopedics, Hospital
12 de Octubre, Madrid, Spain, 4Traumatology and Orthopedic
Surgery, Hospital 12 de Octubre, Madrid, Spain
Introduction: Multiple trauma in the elderly is increasing with the
aging population. Elderly patients experience significantly higher
mortality rates and complications after major trauma due to an
ample array of factors including diminished physiological reserve
and multiple medical comorbidities which challenge the attending
physician. This article reviews various aspects of geriatric trauma,
including injury mechanisms, physiologic differences in elderly
patients, and their prehospital and emergency department evalua-
tion. Specific organ injuries and associated mortality are also
discussed.
Materials and methods: We retrospectively review 147 patients
aged over 65 years admitted to our trauma center between 2003 and
2008, analysing factors such as age, mortality, cause of mortality,
hospital stay, as well as time spent in ICU and nature of the injuries,
accounting their MAIS for each region and AO classification of all
fractures.
Results: There were 92 male and 55 female. The mean age was
75.88 years (66–96) and the mean ISS was 15.57 (9–59). The mean
hospital stay was 688.60 days (24–6112). The mean mortality rate
was 22.44, 31 % of these secondary to head injury and 25 % sec-
ondary to MODS and only 9.3 % due to exsanguination.
Conclusion: We find data in our study similar to other series higher,
in any case, to the series presented for younger patients, which can be
justified due to a higher physiologic reserve and less baseline
pathology in the latter group. It is remarkable the small number of
avoidable deaths secondary to exsanguination.
Reference: Soles GL, Tornetta P, 3rd. Multiple trauma in the elderly:
new management perspectives. J Orthop Trauma. 2011;25(Suppl
2):S61–5.
Disclosure: No significant relationships.
Abstract S143
123
HAND TRAUMA AND EMERGENCY
P029
OUTCOMES OF INTRAMEDULLARY FIXATION ANDPLATE FIXATION FOR HUMERAL SHAFT FRACTURE
T. Matsuura1, M. Uchino2, H. Minehara1, T. Suzuki3, M. Toyama1,H. Sekiguchi1, M. Takaso1
1Orthopaedic Surgery, Kitasato University School of Medicine,
Sagamihara, Japan, 2Orthopaedic Surgery, Machida Municipal
Hospital, Machida, Japan, 3Emergency Medicine and Critical Care,
Kitasato University School of Medicine, Sagamihara, Japan
Introduction: There are various surgical treatments for humeral shaft
fracture but no consensus has been reached as to which is best. We
compared postoperative outcomes between intramedullary fixation
and plate fixation for humeral shaft fracture.
Materials and methods: This study involved 15 patients with 15
fresh humeral shaft fractures. There were 9 men and 6 women. Ages
at the time of fracture ranged from 18 to 63 years, with a mean age of
34 years. Follow-up periods ranged from 6 to 41 months with a mean
of 1 year 8 months. As to surgical procedures, intramedullary fixation
was performed in 10 patients, plate fixation in 5. Outcomes of these
patients were assessed and compared in terms of bone union time,
results of Hunter’s assessment of upper limb function at the end of
follow-up and postoperative complications.
Results: The mean bone union time was 33 weeks for intramedullary
fixation and 22 weeks for plate fixation. Non-union was observed in 1
patient undergoing intramedullary fixation. Bone union was achieved
in all patients undergoing plate fixation. According to Hunter’s
assessment, grade IV or above was observed in 6 patients undergoing
intramedullary fracture fixation (60 %) and in 5 undergoing plate
fixation (100 %). Postoperative radial nerve palsy was detected in 2
patients undergoing intramedullary fixation, but in none receiving
plate fixation.
Conclusion: In this study, all patients undergoing plate fixation
achieved bone union and good upper limb function, with no radial
nerve palsy. Based on this study, plate fixation is advocated as the first
choice for managing humeral shaft fractures.
Disclosure: No significant relationships.
P030
THE ANATOMICAL COURSE OF THE ULNAR NERVE INPRONATION AND SUPINATION WITH RESPECT TOINTRAMEDULLARY LOCKED NAILING
T.E. Nowak, T. Andres, S.G. Mattyasovszky, K.J. Burkhart,I. Mehling, D. Klitscher, L.P. Muller, P.M. Rommens
Center for Muskuloskeletal Surgery, Johannes Gutenberg University
Mainz, Mainz, Germany
Introduction: Intramedullary locked nailing of the lower arm gains
importance as various intramedullary implants appeared recently on
the market. Detailed knowledge of the anatomic characteristics of the
ulnar nerve especially during forearm rotation may help to prevent
injury performing surgical procedures like distal interlocking.
Materials and methods: 30 fresh cadaver arms and wrists were
dissected to determine the anatomical course of the ulnar nerve in
the forearm during rotation in relation to the ulnar bone. The
distance between bone and nerve was measured in supination and
in pronation starting at the tip of the olecranon and running distally
in steps of 3 cm. A statistical analysis using the t-test was
performed.
Results: The distance between ulnar bone and ulnar nerve in the
middiaphysis and the distal third of the lower arm is in supination
significantly larger than in pronation.
Conclusion: Therefore we recommend supination for the surgical
procedures like distal locking of an intramedullary ulna nail.
Disclosure: No significant relationships.
P031
INCOMPLETE NON VIABLE AMPUTATION OF THE UPPERARM AFTER GUNSHOT. REVASCULARIZATION–REIMPLANTATION OF THE BRACHIAL PLEXUS. A CASEREPORT FROM A GENERAL HOSPITAL
A. Manimanaki1, M. Gionis2, Z. Kokkalis3, G. Poulios4,V. Petroulakis5
1Orthopaedic, General Hospital of Chania, Chania, Greece, 2Vascular
Surgion, Chania, Greece, 3A’orthopedic Clinic, Attikon University
Hospital., Athens, Greece, 4Orthopaedic, General Hospital of Chania,
Chania, Greece, 5Orthopaedic, General Hospital of Chania, Chania,
Greece
Introduction: Gunshot trauma is a frequent situation in which a
doctor of a hospital of Crete must affront. Trauma may concern
isolated lesions (vascular, myoskeletal, peripheral nerves), or in the
vast majority of cases a combination of all above. Early diagnosis and
urgent treatment are the basis of viability and acceptable post-op.
function of wounded member. This is a case report of upper arm
combinated lesions after gunshot injury.
Materials and methods: A 35 year old suicidal male, was trans-
ferred in E.R. having a vast lesion of left Axillary region and
emithorax, with complete damage of the neurovascular bundle,
comminuted humeral fracture and skin loss of the whole area. Left
hemothorax was also present. Bone lesion was fixed by an intra-
medullary Nancy nail, and revascularization was obtained with the
use of autologous vein grafts. Brachial plexus damage was fixed
secondary using autologous grafts. A chest tube was inserted
immediately in E.R.
Results: The patient was discharged 20 days after primary surgery.
Surral grafts reimplantation concerning musculocutaneous and med-
ian nerves took place 5 months later. No complications were reported
in both cases. Until now the member is viable and partially functional.
Conclusion: Combinated vascular and orthopedic lesions consists
one of the most challenging problems in trauma, since irreversible
handicap may reach up to 20–50 % of cases. Urgent treatment with
respect to ATLS principles is of major importance to affront these
life-threatening lesions.
S144 Abstract
123
P032
DETERMINANTS OF GRIP STRENGTH IN HEALTHYSUBJECTS COMPARED TO PATIENTS RECOVERINGFROM A DISTAL RADIUS FRACTURE
A.G.J. Bot, M.A.M. Mulders, S. Fostvedt, D. Ring
Orthopaedic Hand and Upper Extremity Service, Massachusetts
General Hospital, Boston/MA/United States of America
Introduction: Grip strength is influenced primarily by BMI, sex, and
age. Grip is also partly voluntary and correlates with symptoms of
depression. This study examined whether psychological factors
influence grip more in the setting of injury than in healthy volunteers.
Materials and methods: One hundred patients were compared; 50
healthy and 50 injured patients (6 weeks after nonoperatively treated
distal radius fracture). Grip strength was measured as the mean of
three attempts and patients completed questionnaires for arm specific
disability (Disabilities of the Arm, Shoulder and Hand: DASH),
depression (CES-D), pain anxiety (PASS), pain catastrophizing (Pain
Catastrophizing Scale, PCS) and negative pain thoughts (Negative
Pain Thoughts Questionnaire, NPTQ).
Results: Mean grip strength in the injured group was 54 percent of
the uninjured side, and pain anxiety was the only predictor of grip
strength accounting for 8.5 % of the variability in grip strength. The
best predictor of grip strength in the healthy group was BMI,
explaining 22 % of the variation in grip strength.
Conclusion: Grip strength relates most strongly to BMI in healthy
volunteers and to pain anxiety in patients recovering from a distal
radius fracture. In other words physical make-up is key when you’re
healthy, but less important than anxiety in response to pain in the
context of recovery. Although the limited amount of variability in
grip that can be accounted for in these models demonstrate the
complexity of influences on grip strength, differences among recov-
ering and healthy patients demonstrate the role of voluntary or
subjective factors, particularly when patients are in pain and feeling
vulnerable.
Disclosure: A. Bot Conflict with: None for the current study, but
received funds by: Dutch Research Funds: VSB Fonds and Prins
Bernhard CultuurFonds (Banning-de Jong) both non-orthopaedic
general funds. Travelgrant Anna Fonds, the Netherlands, W. Bruisma:
None Declare.
P033
ROLE OF MRI IN THE DIAGNOSIS OF TRAUMATIC WRISTPAIN
M. Al-Najjim, A. Mustafa, S. Morapudi, M. Waseem
Trauma and Orthopaedics, Macclesfield General Hospital, 3BL/UK
Introduction: The wrist is the most common injured region of the
upper extremities and fracture of carpal bones account for about 15 %
of wrist injury. (1) It presents with pain, disability and has both social
and financial consequences. Early diagnosis is essential for definitive
management plan and avoid unnecessary immobilisation. The aim of
the study is to evaluate the role of MRI in the early diagnosis of acute
wrist pain not diagnosed by the conventional imaging following
recent trauma.
Materials and methods: Consecutive data was collected retrospec-
tively between January 2007 to December 2008 for patients who had
MRI scan for acute wrist pain following recent trauma. All patients
who had MRI scan for traumatic wrist pain due to unconfirmed
diagnosis were included in the study. Patient with chronic wrist pain
and had no history of trauma were excluded from the study.
Results: 126 patients were identified. There were 76 male and 50
female. The mean age 39.5(10-79), Mean time for the scan was
12.5 days (0-32). Positive MRI finding in 60 (47.6 %) patients. 39
patients had different bone pathologies which include 14 scaphoid
fractures, 13 carpal fractures other than scaphiod. 8 distal radius
fractures, 3 metacarpal fractures and 1 scaphiod cyst. 21 patients had
soft tissue injuries which include 8 Triangular fibrocartilage com-
plex(TFCC) injuries, 6 scapho-lunate disruption, 5 tensynovitis and 2
gangilion.
Conclusion: Study demonstrates that patients with painful wrist can
have wide range of diagnoses. Inaccurate diagnosis has social and
financial implications. MRI has superior role in diagnosis of wrist
pathology and has got 100 % sensitivity and specificity in diagnosis
of Scaphoid fracture.(2) It helps in early accurate diagnosis and also
able to pick up associated injury or pathology.(3) It does not require
any special positioning of painful wrist and there is no exposure to
ionising radiation.
References: 1. American College of radiology. Appropriateness cri-
teria. Acute hand and wrist trauma. 2005. 2. Khalid M, Jummani ZR,
Kanagaraj K, et al. Role of MRI in the diagnosis of clinically sus-
pected scaphoid fracture: analysis of 611 consecutive cases and
literature review. Emerg Med J. 2010;27:266–9. 3. Robinson P. MR
imaging of the wrist. Curr Orthop. 2005;19:196–208.
Disclosure: No significant relationships.
P034
NEW ASPECTS IN THE DIAGNOSIS OF POSTTRAUMATICALGODYSTROPHY OF THE HAND WITH 3-PHASE BONESCINTIGRAPHY IN CORRELATION WITH VENOUSBLOOD GAS ANALYSIS
E. Scola
Klinik fur Unfall- und Wiederherstellungschirurgie, Dietrich
Bonhoeffer Klinikum, Neubrandenburg/Germany
Introduction: In the posttraumatic dystrophy (CRPS I) the diagnostic
findings by 3-phase scintigraphy are well known. The target of this
presentation is to proof the a-v shunts by scintigraphy and venous
blood gas analysis and to develop specific therapy.
Materials and methods: Between July 2006 and October 2011 28
patients underwent 8–14 weeks after distal radius fracture and clinical
symptoms of dystrophy a 3-phase bone scintigraphy. Furthermore a
blood gas analysis of the cubital vein was performed on both sides in
order to detect differences in oxygen concentration. All patients were
treated with NSAIDs, antioxidants, neurotropic and rheological drugs.
Additionally intensive physiotherapy including manual lymph drain-
age and ergotherapy was performed. The inpatient treatment lasted
3 weeks.
Results: In the perfusion phase increased blood circulation could be
demonstrated. In contrast the venous blood gas analysis from the V.
cubitalis of the affected arm showed an increased oxygen content
(20–45 mmHg higher values). The final results of the blood gas
analysis showed a significant improvement of oxygen utilization in
tissue (difference to the non affected side 0–8 mmHg). The correlated
clinical symptoms of the dystrophy decreased and the hand function
was normal at the end of treatment.
Abstract S145
123
Conclusion: A posttraumatic dystrophy after distal radius fracture
presents typical signs of arterio-venous shunts with scintigraphic
proven increased blood circulation (no real hyperemia!) and
decreased oxygen utilization. The therapeutic approach is based on
early diagnosis and improvement of microcirculation with rheological
medication. The venous blood gas analysis is a direct parameter for
treatment success.
Disclosure: No significant relationships.
P035
HAND AND WRIST FRACTURES IN POLYTRAUMATIZEDPATIENTS
T. Vlahovic1, M. Malovic1, T. Beker2, I. Krpan1
1Hand Surgery Department, University Hospital of Traumatology,
Zagreb, Croatia, 2, University Hospital of Traumatology, Zagreb,
Croatia
Introduction: Hand and wrist fractures in polytraumatized patients
are easily overlooked injury. Incidence of hand and wrist fractures in
polytraumatized patients are between 20 and 60 % by literature, and
overlooked injury is up to 20 %.
Materials and methods: In University hospital of traumatology in
Zagreb in period between 2006 and 2010 we treated 275 patients in
intensive care unit, and 74 (26.9 %) had hand and wrist fractures. 39
(52.71 %) had wrist fractures, 22 (29.72 %) had metacarpal fractures
and 13 (17.56 %) had fractures of carpal bones.
Results: After admission to hospital 53 (71.26 %) of hand and wrist
fractures are diagnosed, another 14 (18.91 %) were diagnosed in first
24 h and 7 (9.45 %) are diagnosed in period form 2 to 28 days. .
Conclusion: Hand and wrist fractures in polytraumatized patients are
often and easily overlooked injuries. Those injuries are not life
threatening but can produce significant disability when they are
overlooked. Only with timely diagnosed and treated hand and wrist
fractures in polytraumatized patients we will have satisfactory results.
Disclosure: No significant relationships.
P036
SURGICAL TREATMENT OF DISTAL HUMERALFRACTURE BY EXTERNAL FIXATION
H. Tsibidakis, L. Lovisetti, A. Biffi, M. Camagni, F. Guerreschi,M. Catagni
Department of Orthopaedic Surgery and Traumatology and Ilizarov
Unit, A. Manzoni Hospital, Lecco, Italy, Lecco, Italy
Introduction: Evidence of surgical treatment by external fixation in
case of supracondylar and supraintracondylar humerus fractures.
Materials and methods: From January 2002 to December 2009, 15
patients (8 males and 7 females, mean age 61.1 years-range. 36–82)
with distal humerus fracture, were treated surgically. 10 fractures
were supraintracondylar and 5 supracondylar. A high-energy trauma
with open fracture was the cause in 3 cases, while for the remain 12
was a consequence of a low energy trauma. All patients received
surgical treatment with a posterior approach after olecranon oste-
otomy and exploration of the ulnar nerve, osteosynthesis was
performed using lag screws and k- wires and in order to obtain
ligamentotaxis, an external fixator spanning the elbow was applied.
Clinical evaluation was performed using the Mayo Elbow Score and
VAS. Clinical and radiographic control after 1, 2, 3, 6 months and
1 year were performed, with a mean follow-up time of 14.5 months
(range 9–21).
Results: excellent results was observed in 46.6 % (7 elbows), good in
33.3 % (5 elbows), modest in 13.4 % (2 elbows) and low in 6.7 % (1
elbow) associated with a satisfactory reduction of pain (mean VAS
improvement: 5.2). The mean healing time was 64.9 days (range:
46–90) with mean ROM in flexion was 112.4� (range 95�–130�) and
16.3� in extension (range 0�–25�) degrees. No cases of infection were
observed.
Conclusion: external fixator, used in treatment of distal humerus
fractures, provides an anatomic reduction, stability of the elbow,
excellent functional results, with a good clinical outcome, and could
be a valid option of surgical treatment.
Disclosure: No significant relationships.
P037
THE DIFFERENCE OF FUNCTIONAL RESULTS OFARTICULAR DISPLACEMENT WHO OPERATED FORCOMMUNITED RADIAL HEAD FRACTURES
S. Yılmaz, A. Deveci, A. Fırat, K.O. Unal, M. Akkaya, M. Bozkurt
Orthopaedics and Traumatology, Ankara Etlik Ihtisas Educational
and Research Hospital, Ankara, Turkey
Introduction: Radial head fractures are the most seen fractures in
adult elbow. There is no consensus on the treatment of comminuted
radial head fractures. These are accompanied with serious ligamen-
tous and osteochondral injuries. Radial head excision is chosen on
selected patients to prevent elbow instability. Fixation of comminuted
radial head fractures is difficult and for function it is important to fix
the fragments nearly normal.
Materials and methods: We operate 13 patients which is classified
as Mason type 3 radial head fracture. Their average age was 38.3
(18–52). The average follow up time was 9 month (6–17). All of the
patients had an open reduction. Their function was evaluated with
Broberg and Morrey score system.
Results: All of the patients’ fractures were united. There was 1 mm
step of on 3 patient, 2 mm step of on 1 patient. 3 patients were
functionally excellent, 9 patients were good and 1 patient was fair. All
of the patients which had a step of on the radial head were func-
tionally good.
Conclusion: The comminuted fracture of radial head treatment is
difficult. We found the fixation of the fragments either with dis-
placement on the articular surface has no effect on function. But there
is no data on long term results of the effect of articular displacement
on the radial head.
Reference: Pappas N, et al. Fractures in brief: radial head fractures.
J Clin Orthop Relat Res. 2010;468(3):914–6.
Disclosure: No significant relationships.
S146 Abstract
123
IMPLANT REMOVAL
P038
LOCKED INTRAMEDULLARY (IM) NAILS &COMPRESSION PLATES IN HUMERAL DIAPHYSEALFRACTURES TREATMENT
A.V. Kalashnikov1, S.V. Kovalenko2, V.M. Maiko3, V.G. Lutsyshyn3,P.V. Nikitin4
1Traumatology and Orthopaedics for Adults, the Institute of Trauma
and Ortopaedics, Kiev, Ukraine, 2Traumatology, Vinnitsya Clinical
Emergency Hospital, Vinnitsya, Ukraine, 3Vinnytsia Regional
Hospital, Vinnitsya, Ukraine, 4Kiev Sport Traumatology Centre,
Kiev, Ukraine
Introduction: Humeral shaft fractures make approximately 3 % of all
fractures, and represent 20 % of all humeral fractures. The humerus
fractures treatment problem is ambiguous and controversial. The
present research is aimed at comparison of clinical efficiency, shown
by locked intramedullary (IM) nails and compression plates for
humeral diaphyseal fractures treatment.
Materials and methods: We have analysed the results of treatment
of 129 patients, suffering from humeral shaft fractures; divided them
into 2 groups, standardized according to their age, sex and types of
fractures: 52 patients underwent locked intramedullary nailing, 77
patients underwent osteosynthesis with compression plates. Besides,
we have analysed the data of theoretical and biomechanical modeling
at different humerus fractures’ levels.
Results: Biomechanical modeling has shown that critical size bone
fragments for IM distal nailing is over 6 sm for a proximal bone
fragment and over 7 sm for a distal one. All patients have been fol-
lowed up for a minimum of 12 months. The comparison has shown
the significant increase in positive results of treatment (p \ 0.05) after
IM nailing, compared to the results of group, treated by compression
plates. IM nailing provides 94.23 % of positive results of treatment.
Conclusion: Intramedullary nailing provides reasonably predictable
method for achieving fracture stabilization and ultimate healing for
patients, suffering from humeral shaft fractures.
Disclosure: No significant relationships.
MINIMAL INVASIVE VS CONVENTIONAL
SURGERY UNNECESSARY SURGERY
P039
NPWT: NEGATIVE PRESSURE WOUND THERAPY ATA COMPLICATED MULTIPLE EXTREMITY INJURIES
M. Reska, J. Ciernik, J. Konecny, L. Veverkova, M. Kaspar,M. Kabela, I. Capov
1st Department of Surgery, St. Anne’s University Hospital, Brno,
Czech Republic
Introduction: Authors present case report of polytraumatized patient
after a car accident, transferred to Urgent Admission of our hospital
with liver laceration, pulmonary contusion and multiple fractures
dominated by left upper and lower extremity trauma with vast lac-
eration of the soft tissues and open fractures of left distal humerus,
olecranon and distal tibia.
Materials and methods: Basic examination at the Urgent Admission,
FAST ultrasonography, stabilization with vacuum splints. Hemody-
namically stable—CT scan. From CT scan to the operating theatre for
definitive wound revision and fracture stabilization. Periferal liver
laceration left for conservative treatment. At the beginning of the
anesthesia muted sounds of left hemithorax—chest drain. Afterwards
hemodynamically stable. Debridement of the soft tissues left upper
extremity, reconstruction and stabilization of the distal humerus and
proximal ulna, reconstruction of soft tissues. Left forearm osteosyn-
thesis. Preoperative ultrasound of the abdomen—stationary findings,
patient hemodynamically stable. Debridement left lower shank
and foot. External fixation. Antibiotics preoperatively. Tetanus
vaccination.
Results: Following primary care local ischemia of the left foot soft
tissues. Necrectomy, large soft tissue defect. Successfully applied
V.A.C negative pressure system. Cleaning of the wound bed and
granulation tissue. Definitive treatment with cooperation with plastic
surgeon. Opened fracture of the left elbow healed without compli-
cations. Patient proceeds with rehabilitation, X rays showing good
bone healing process.
Conclusion: NPWT uniformly draws wounds closed by helping to
remove interstitial fluid, which contains inflammatory and potentially
infectious exudate that could impair healing. Patient stays mobile
during the therapy. Cost effective TNP 1.788 €/classic therapy 2.467
€.
Disclosure: No significant relationships.
P040
COMBINED TREATMENT CLOSED FRACTURES OF TIBIABY THE USE OF EXTERNAL FIXATION SYSTEM AND PTBWALKING BRACE
N.M. Markovic, A.D. Stamenkovic, V. Rankovic, N. Mikic,Z. Vukmirovic, Z.P. Bokun, I. Djulic, M.Z. Ivanovic
Orthopedic, KBC Zvezdara, Belgrade/Serbia
Introduction: Fractures of tibia are the most frequently in orthopedic
praxis (40 %).Primary goal of treatment is retaining function of
injured extremities. In the treatment we used unilateral external fix-
ator with dynamisation. In certain cases (21.2 %) we used PTB
walking brace until the healing of the fracture.
Materials and methods: Follow-up period from 2008 to 2011. with
isolated closed fracture of tibia. The total number of patients is 33 (22
male, 11 female).We used AO classification (42 A1–A3, 42 B1–B3,
42 C1).All patients were treated operatively by using external fixator
with repositioning control by fluoroscopy. In 10 cases (33.3 %) we
used minimal incision. Average time of surgery is 3 days. We used
unilateral Ex Fix 2 + 2 pins, convergent-oriented. Average time of
healing was 18–22 weeks. After 4 weeks we used dynamisation of Ex
Fix. Becuse of delayed healing and loosening around the pins, put off
ex fix and placed PTB brace until healing finishes. Average time of
healing was extended for 4.8 weeks. We had 7 cases(2 male, 5
female-21.2 %).
Results: In this method of treatment using PTB walking brace was
connected for loosening of the pins, so we used the same in 7 cases
until final healing.
Conclusion: Our experience confirm success rate of treatment closed
fracture of tibia with Ex Fix with possibility of continuing treatment
with walking brace where it was necessary.
Disclosure: No significant relationships.
Abstract S147
123
P041
CONSERVATIVE MANAGEMENT OF A GRADE IV RENALINJURY WITH ONGOING BLEEDING: CASE REPORT
T.W.A. Koedam1, H.R. Tromp1, G.F. Giannakopoulos2
1Trauma Surgery, VU University Medical Center, Amsterdam,
Netherlands, 2Trauma Surgery, VU University Medical Centre,
Amsterdam, Netherlands
Introduction: Management of (poly)trauma patients has seen a
drastic shift in the past decades. From aggressive to a more non-
operative treatment. Renal trauma management is no exception.
Materials and methods: In this case we present an 18-year-old man
hit in his left flank by a car, driving his scooter at 40 km/h without
helmet, sustaining major renal injury.
Results: Initial assessment showed a hemodynamically stable patient
with painful abdomen in the left upper quadrant without stiffness or
rebound tenderness, a painful chest and some minor injuries in the
face. Additional radiological diagnostics showed no injuries. FAST
of the abdomen gave suspicion of parenchymal injuries of the left
kidney without collateral injuries or free fluid. Urine sediment and
blood samples showed macroscopic haematuria and a normal
hemoglobin level, respectively. Three hours later the ultrasound was
repeated, showing a thicker parenchyma. A CT scan with contrast
followed, a parenchyma laceration through the cortex and medulla
with a large contained haematoma, urinoma and active bleeding was
seen (Grade 4 on the AAST). The patient was hospitalized and
conservatively treated, including checking vital functions, monitor-
ing Hb-levels, bed rest with a catheter and adequate fluid intake.
Changes of the patient’s condition would indicate the need for an
alternative treatment like PTAE or laparotomy. Later he developed a
fever without focus, treated with antibiotics it lasted for 5 days.
Eleven days after admission the bleeding stopped visible on the CT
scan and in the urine sediment no haematuria was visible. After
13 days he was discharged. A last CT scan with contrast 2 months
later showed a dissolved haematoma without ureter dilatation or
extravasation.
Conclusion: Nowadays trauma surgeons are more inclined to use
PTAE to control ongoing bleeding. Positive results are found in the
literature for this type of intervention. This patient, however, makes
us wonder if it is really necessary to use PTAE as a management to
control renal IV parenchyma bleeders. Prospective research including
hemodynamically stable patients without concomitant (extra- and
intra-)abdominal injuries is therefore necessary.
Disclosure: No significant relationships.
P042
COMBINED PERCUTANEOUS INTERNAL AND EXTERNALFIXATION FOR TREATMENT TIBIAL PLATEAUFRACTURES
D.S. Mladenovic1, P.M. Stojiljkovic2, M.D. Mladenovic2, I. Micic2,S. Karalejic2, M.B. Mitkovic2
1Orthopeadics, Clinical Center of Nis, Nis/Serbia,2Clinic of Orthopaedic Surgery, Nis, Serbia
Introduction: Introduction Complex tibial plateau fractures represent
a challenge. The aim of this study is to review the results of a surgical
technique consisting of closed reduction and combined percutaneous
internal and external fixation.
Materials and methods: Materials and methods: During the period
between 2007 and 2010 were treated 32 type C2 and C3 tibial plateau
fractures. 28 (87 %) fractures were closed and 4 (13 %) were open.
The age ranged from 22 a€‘‘82 years. Trough a small skin incision
over the anteromedial aspect of the tibial shaft, a small hole was
made. A blunt tipped curved 3 mm Kirschner wire is inserted through
the hole up to the articular fragments, which are elevated under image
intesifler control. 1 or 2 Kirschner wires are inserted to stabilize the
reduced fragments and 1 or 2 cannulated screws are introduced over
them. After reduction of the articular fracture, an external fixator type
Mitkovic is applied. The external fixator was removed between 113
and 16 weeks.
Results: Clinical results were evaluated according to the Knee
Society clinical score. 30 fractures healed. Average healing time was
14 weeks (11–19).In 2 (6.5 %) patient a non union occured. In 2
(6.5 %) patient a varus knee deformity occured. Mean knee range of
motion was 100 (7o a€‘‘11o) and mean Knee Society clinical score
was 88.21 (65 %)results were scored as excellent, 7 (21 %),good 2
(7 %) and 2 (7 %) poor.
Conclusion: Closed reduction and combined percutaneous internal
and external fixation enables careful management of the soft tissue
injury. Good reduction of the joint can be obtained. Knee rehabili-
tation starts immediately. These factors were responsible for the
optimal clinical long term results.
Disclosure: No significant relationships.
P043
ARTHROSCOPICALLY ASSISTED OSTEOSYNTHESIS OFCALCANEAL FRACTURES
L. Kopp, P. Obruba
Traumacentre, Masaryk Hospital, Ustı nad Labem, Czech Republic
Introduction: To assess clinical and radiological results in a group of
patients with calcaneal fracture, treated by means of minimally
invasive, arthroscopically assisted osteosynthesis.
Materials and methods: In period from January 2005 to September
2011, we have treated surgically 213 patients with 242 calcaneal
fractures. For prospective follow-up, we have included 30 patients
with 32 fractures, treated by arthroscopically assisted osteosynthesis.
In all consecutively included patients, there were recorded basic data,
fracture classification (Sanders), time to surgery, quality of reduction,
Bohler’s angle, soft tissue complications, functional score (Rowe) and
time of follow-up. This type of surgery was also performed in
smokers, diabetic and dialysed patients.
Results: Nine men were heavy smokers, four patients were
addicted to alcohol. Fracture types according to Sanders classifi-
cation: 18 type IIa, 10 type IIb, two type IIIab and one IIIac and
IIIbc, respectively. There were neither postoperative soft-tissue
complications nor deep infection in this group of patients. Fracture
reduction was assessed as excellent in 29 fractures, good in 2
fractures and bad in one fracture. Mean improvement of Bohler’s
angle 28.2�. Bony healing was achieved in all patients. Mean
follow-up was 15.5 months. Final functional score (Rowe) was
excellent in 22 patients, good in 5 patients and sufficient in 5
patients. Mean score was 86 points.
Conclusion: Final assessment show similar results in terms of frac-
ture reduction and functional results, when compared to open
techniques. Achieved full bony healing and absence of soft tissue
S148 Abstract
123
complications could present a good alternative for patients not suit-
able for ORIF.
Disclosure: No significant relationships.
P044
EXTERNAL FIXATION AS A TOOL FOR FRACTUREREDUCTION BEFORE DEFINITIVE INTERNAL FIXATION
M.B. Mitkovic1, P.M. Stojiljkovic2, S. Milenkovic2, I. Micic1,D.S. Mladenovic1, M.M. Mitkovic1
1Trauma, Orthopaedic and Traumatology Clinic, Nis/Serbia,2Orthopaedic and Traumatology Clinic, Nis/Serbia
Introduction: In this paper, we present possibility of using of already
applied external fixation device as accurate reduction device before
internal fixation of the femur.
Materials and methods: Using concept of damage control in 18
patients with femur fractures we have used external fixation as tem-
porarily method. Pins of external devices were applied from anterior
side in proximal femur and from medial side in distal femur or from
anterior side in tibia (if knee bridging frame used). Before second
operation (internal fixation), if fracture alignment is not acceptable,
we have used already applied high mobile external fixation device as
a tool for accurate gradual reduction. Once, desirable fracture
reduction achieved, it is shown that internal fixation is very simple
using lateral approach.
Results: Transforming of external into internal fixation was short—
average operation time was 37 min (23–58). Mean fluoroscopy time
was 6 s (2–18). Intraoperative blood loose was 80 ml (40–200).
Conclusion: High mobile external fixator is suitable for reduction of
fracture before definitive internal fixation.
Disclosure: No significant relationships.
P045
INTRAMEDULLARY FIXATION OF FOREARMFRACTURES
T. Braunsteiner
Dept Trauma Surgery, Medical University of Vienna, Vienna, Austria
Introduction: The forearm is a functional anatomic construct, which
requires in case of fracture proper reduction and fixation to maintain
anatomic structure and function. The long bones of the forearm are,
similarly to other long bones, ideal for intramedullary fixation. The
surgical principles typically accepted and used in children, can be
carried out satisfactorily in adults, too.
Materials and methods: In 112 patients intramedullary fixation of
the radius and/or ulna was carried out. We used self-locking implant
to the radius and proximally interlocking, distally self-locking nail in
the ulna. The implant design ensures distention of the interosseous
membrane, thereof resulting proper fragment rotation and rotational
stability after implantation. Indications are recent fractures (24 radius,
40 ulna, 32 both bones), non-unions (2 radius, 7 ulna), re-fractures
after plating (6 pat.), osteotomy (1 ulna) of both bones except the
distal 5 cm s. The radius is accessed through the styloid process, the
ulna through the olecranon. The is used for fragment manipulation
and reduction. The shape of the implant tip makes pushing of the
implant and beading of the particular fragments easier. Post-operative
management is in co-operative patients without further fixation,
otherwise orthosis with elbow hinge is used for 4-6 weeks.
Results: Bony healing with periostal callus was achieved in all but
one case of ulna fracture (bone grafting and renailing). In 2 cases
bridging callus developed. All treated non-unions and refractures
healed. Merle d’Aubigne: excellent/good 101 satisfactory 8 unsatis-
factory 3.
Conclusion: Intramedullary nailing of forearm fractures with sofis-
ticated implants is a serious counterpart to plate osteosynthesis.
Disclosure: No significant relationships.
P046
CLINICAL AND RADIOLOGICAL OUTCOME OF THEDIRECT ANTERIOR APPROACH IN HEMIARTHROPLASTYFOR DISPLACED FEMORAL NECK FRACTURES
K. Schneider1, L. Audige2, S. Kuehnel1, N. Helmy1
1Orthopedics and Traumatology, Burgerspital Solothurn, Solothurn,
Switzerland, 2AO Clinical Investigation and Documentation,
Dubendorf, Switzerland
Introduction: Hip replacement is the most common treatment for
displaced femoral neck fractures in the elderly, and minimally inva-
sive surgery is popularised in the field of orthopedic surgery. The
present study evaluated the outcome of monopolar hemiarthroplasty
by the direct anterior approach over a postoperative period up to
2.5 years.
Materials and methods: A total of 86 patients with displaced fem-
oral neck fractures were included (mean age of 86.5 years). Surviving
patients were reviewed 3 months (retrospectively) and 1–2.5 years
(prospectively) after surgery. The 3-month mortality was 30 %, the
1-year mortality 36 %.
Results: For all stems, implant positioning concerning stem align-
ment, leg length and restoration of femoral offset was
radiographically correct. Acetabular protrusion was observed in 55 %
of the patients 1–2.5 years postoperatively. Subsidence and intraop-
erative periprosthetic fractures occurred in 3 patients (3 %) each. All
revision stems for postoperative periprosthetic fractures could be
implanted using the initial surgical technique without extension of the
previous approach.
The mean Harris Hip Score increased from 81 points (range 35-100)
at the 3-month follow-up to 85 points (range 33–100) at the 1- to 2.5-
year follow-up.
Conclusion: According to these findings, hip replacement for dis-
placed femoral neck fractures can be performed safely and effectively
through the direct anterior approach with good functional outcome
and high patient satisfaction.
Disclosure: No significant relationships.
P047
LESS INVASIVE CLAVICULAR PLATE OSTEOSYNTHESIS
F. Carlier1, S. Troussel2
1Orthopedic, Grand Hopital de Charleroi, Charleroi, Belgium,2Orthopedics, Grand Hopital de Charleroi, Charleroi, Belgium
Abstract S149
123
Introduction: We describe a new technique of clavicular plating with
the patient positioned supine and the incision made vertically. The
plate used are the anatomic antero-superior LCP and the lateral LCP
clavicular plate from Synthes.
Materials and methods: From July 2009 to June 2011 we prospec-
tively operated 23 clavicular shaft fractures and 2 clavicular
pseudarthrosis. The patient is positioned supine on a shoulder or
radiolucent table. The C-arm is above, coming from the head in line
with the table. The incision is made vertically, in front of the fracture.
The subcutaneous tissue and the platysma are opened to access the
fracture. Reduction is done by direct manipulation of the fragment. A
rasp is used to create a subcutaneous pouch over the rest of the
diaphysis. The plate is inserted in a comings and goings way. The
plate is chosen in correspondence to radius of curvature and the length
of the bone. The plate is not modeled to fit the bone. The screw
fixation is done by one cortical and 2 LCP on each side of the fracture.
One stitch incision is necessary for farthest screw from the fracture.
The wound is closed with cosmetic dermic running suture.
Results: Every wound healed without any problem in very cosmestic
scar. All fractures consolidated, even the pseudarthrosis without
grafting.
Conclusion: Perpendicular limited incision gives good access for
fracture treatment, preserve the soft tissues and the periosteal vas-
cularisation of the clavicula. This approach decrease the risk of
wound dehiscence, infection and the scar is easily hidden even under
a bra.
Disclosure: No significant relationships.
P048
IS MINIMAL OSTEOPLATE SYNTHESIS RELIABLE ANDAPPLICABLE AT ALL LEVELS OF HUMERAL SHAFTFRACTURES? CLINICAL AND CADAVERIC STUDYOUTCOMES
G. Huri1, O.S. Bicer1, A. Mirioglu1, H. Ozturk2, I. Tan1
1Orthopedics and Traumatology, Cukurova University, Adana,
Turkey, 2Anatomy, Mersin Universitesi Tıp Fakultesi, Mersin, Turkey
Introduction: The purpose of the study was to evaluate the appli-
cability, reliability an clinical and functional results of minimal
invasive plating osteosynthesis (MIPO) technique in humerus shaft
fractures.
Materials and methods: Cadaveric study: The applicability and
reliability of straight plate application in three different parts of
humerus shaft (1/3 distal, 1/3 middle, 1/3 proksimal) were assessed in
fresh cadaver. Distance between plate and radial/musculocutaneous
nerve was measured. Other soft tissue structures which may disturb
advancing the plate submuscularly during procedure. Clinical study:
This part of the study included 10 patients with humeral shaft frac-
tures. All of the patients were treated with the same technique and by
the same surgeons. 4.5 mm straight locked plate and screws were
placed submuscularly. After bone union was achieved, the patients
were evaluated with UCLA shoulder score and Mayo elbow score.
Results: The average union time was 11.2 months (6–14 months).
One patient who had radial nerve paralysis at early period after
operation, spontaneously showed complete recovery. According to
UCLA shoulder scoring, 8 patients revealed excellent results and 2
patients resulted in good results. 7 excellent results ([90) and 3 good
results (85) was found with Mayo elbow score.
Conclusion: Cadaveric study demonstrated that, use of MIPO tech-
nique is more applicable and reliable in midshaft level fractures of
humerus than distal and proximal. In clinical study we concluded that
MIPO is effective and functional technique, there was no significant
difference in functional results between distal, middle and proximal
fractures treated with MIPO technique.
Disclosure: No significant relationships.
P049
RESULTS OF PERCUTANEOUS FIXATION OF PELVICRING DISRUPTIONS
O. Farouk, M. Badran, K. Elgafary
Orthopaedic Department, Assiut University Hospitals, Assiut, Egypt
Introduction: Surgical exposures of the pelvis are usually extensive
with soft tissue dissections, blood loss, and possible healing problems.
Minimal invasive fixation (MIF) may reduce these hazards. The aim
of this study is to report results of percutaneous fixation of pelvic ring
disruptions.
Materials and methods: This prospective study included 32 patients
with pelvic ring disruptions that were treated by MIF methods.
Closed reduction techniques were done in 26 patients, and mini-
incision to manipulate the fracture was needed in 6. Patients were
sorted into 3 groups: (1) Ipsilateral fracture acetabulum and sacroiliac
dislocation: 6 patients (19 %), treated by percutaneous lag screw
fixation. (2) Type C-pelvic injury associated with intestinal, lower
urinary injury, or perineal tear: 14 patients (44 %), treated by ilio-
sacral lag screws combined with percutaneous single-pin supra-
acetabular external fixator. (3) Acetabular fractures: 12 patients
(37 %), treated by percutaneous lag screw fixation.
Radiological assessment was done according to Matta and functional
assessment according to Majeed’ score.
Results: Follow up ranged from 18 to 32 months. Excellent reduction
was achieved in 21 patients (66 %), good in 8 (25 %) and fair in three
(9 %). Fracture healing was achieved in all patients. Re-displacement
was not reported. Functional recovery was remarkably fast and
functional result was excellent in 19 patients (60 %), good in 12
(37 %), and fair in one (3 %).
Conclusion: MIF of pelvic ring disruptions provides excellent to
good radiological and functional results. Whenever possible, MIF is
preferred to open reduction with extensive surgical dissections.
However, these techniques are demanding and image dependent
which need specialized pelvic trauma team.
Disclosure: No significant relationships.
P050
THE USE OF HYBRID MONOLATERAL EXTERNALFIXATION FOR THE TREATMENT OF COMPLEXPROXIMAL TIBIA FRACTURES
I.M. Kostic, M.M. Mitkovic, S.B. Karaleic, M.B. Mitkovic
Clinic of Orthopaedic and Traumatology, Clinical Center Nis, Serbia,
Nis, Serbia
Introduction: This study evaluated the use of the hybrid monolateral
external fixation for the treatment of complex proximal tibia fractures.
Fractures were classified as high energy based on the mechanism of
S150 Abstract
123
injury (motor vehicle accident, motorcycle crash, fall from a signifi-
cant height, etc.) radiographic findings of comminution, and
significant fracture displacement with associated soft tissue injuries
(open injuries, severe blood filled skin blistering).
Materials and methods: Forty-three patients with high-energy
Schatzker V and VI tibial plateau fracture with severe soft tissue
injury precluding formal open reduction were enrolled into the study.
There were 25 Schatzker-V and 18 Schatzker-VI injuries. There were
14 cases of compartment syndrome. The indication for this method of
treatment was Schatzker V and VI tibial plateau fractures with
associated severe soft tissue injury of Gustilo and Anderson grade 2
and 3. The 37 patients were available for the follow-up.
Results: The results, bony union, range of motion, and associated
complications of the treatment were assessed. All fractures united
within an average time of 14 weeks. Neither loss of reduction nor
surgical site wound breakdown/osteomyelitis was noted. Eight
patients developed superficial pin track infection and one septic
arthritis of the knee joint.
Conclusion: During our research, the best results were achieved by
using minimally invasive surgical techniques including hybrid
external fixation, in which the possibility for iatrogenic lesions and
infection is reduced to a minimum. At the same time, it allows for
rapid physiotherapy without postoperative immobilization.
References: 1. Watson JT. High-energy fractures of the tibial plateau.
Orthop Clin North Am. 1994;25:723–52. 2. Anglen JO, Healey WV.
Tibial plateau fractures. Orthopedics. 1988;11:1527–34.
Disclosure: No significant relationships.
P051
EXTERNAL FIXATION IN PELVIC FRACTURES: CAN ITBECOME A DEFINITIVE MINIMAL INVASIVE SURGERY?
O. Lupescu1, M. Nagea2, C. Patru1, G.I. Popescu2, D. Lupescu3
1Orthopedics And Trauma Clinic, Clinical Emergency Hospital
Bucharest, Bucharest, Romania, 2Orthopedic And Trauma Clinic,
Clinical Emergency Hospital Bucharest, Bucharest, Romania,3General Medicine, University of Medicine and Pharmacy, Bucharest,
Romania
Introduction: Due to the complexity of the pelvic fractures, many
therapeutic methods and implants have been described. One of them,
widely used, is external fixation, especially in polytrauma patients.
The authors analyze the opportunities to use ex-fix in pelvic fractures,
and evaluate the results.
Materials and methods: The authors analyse 27 cases admitted
between 01.01.2006 and 01.08.2011 for pelvic fractures, with external
fixation as the first therapeutic choice. The criteria were: the posi-
tioning of the frames, the indications, the reduction achieved,
evaluated by both X-ray and CT scan, in order to completely evaluate
the vertical and rotational displacement of the fractures, and the
complications.
Results: The indication for external fixation was correct in 24 of the
27 cases, following a complete CT evaluation. In 19 cases, ex-fix
reduced the difference of length to less than 2.5 cm. Rotational dis-
placement was over-corrected in 3 cases and incompletely corrected
in 13 cases. Due to various reasons, external fixation was the defin-
itive method of stabilization in 7 cases. The complications were
represented by accidental penetration of iliac crest, superficial sepsis
and implant failure.
Conclusion: Indicated in unstable pelvic fractures when delayed
ORIF, ex-fix can be considered a minimally invasive surgery, but
rarely a definitive fixation. Due to the limited possibility of reduction,
it has to be followed by internal fixation.
References: 1. Giannoudis PV. Surgical priorities in damage control
in polytrauma. J Bone Joint Surg. 2003;85(B):478–83. 2. Giannoudis
PV, Pape HC. Damage control orthopaedics in unstable pelvic ring
injuries. Injury. 2004;35:671–7.
Disclosure: No significant relationships.
P052
ANTERIOR APPROACH HIP ARTHROPLASTY: WHAT ARETHE BENEFITS IN THE MANAGEMENT OF FEMORALNECK FRACTURES?
T.M. Aguiar1, P. Amaral2, L. Tavares2, J. Raposo2, A. Rebelo2,C. Simoes2
1Orthopaedic Surgery, Hospital do Divino Espirito Santo, Ponta
Delgada, Portugal, 2Hospital do Divino Espirito Santo, Ponta
Delgada, Portugal
Introduction: The use of a direct anterior approach (Heuter) for hip
replacement has gained popularity over the last decade. Recent
studies have shown that the benefits of this technique applied to
femoral neck fractures in the elderly patient are: supine position, early
mobilization (minimize the risks of decubitus complications), low
dislocation rate (no precautions required), accurately restore leg
length and offset (decreased risk of falls), low narcotic requirements
and low infection rate.
Materials and methods: Retrospective study conducted between
February 2010 and October 2011.
Epidemiological data: age, gender, comorbidities, mean length of skin
incision, time of surgery, length of hospital stay, blood work changes,
and intra and postoperative complications. Imaging evaluation was
performed (AP and cross-table lateral). Harris Hip Score (HHS) was
used. Statistical treatment-SPSSv17.0.
Results: Were operated 25 patients with a femoral neck fractures.
Mean age 81.4 years, 90.5 % female.
100 % of comorbidities. Mean length of skin incision 10.1 cm (8–13).
Surgical time averaged of 100.2 min (72–142) and duration of hos-
pital stay of 5.7 days (4–7). Mean postoperative hemoglobin decrease
of 1.6 g/dl (1.1–2.7). Complications: none. Imaging evaluation:
Gardner type III and IV; no other signs of instability or loosening of
the components. Averaged HHS-86 points.
Conclusion: A method that preserves all muscles and limits muscle
damage during a procedure is the least invasive approach. This
technique meets this definition.
The learning curve is demanding, especially when preparing the
femur.
In our opinion anterior approach hip arthroplasty benefit the elderly,
traumatized patient more than any cohort. However, long-term fol-
low-up is needed to confirm these preliminary results.
Disclosure: No significant relationships.
Abstract S151
123
P053
SYSTEMATIC REVIEW OF COMPLICATIONS OFINTRAMEDULLARY FIXATION OF DISPLACEDMIDSHAFT CLAVICLE FRACTURES; WHAT CANWE LEARN?
F.G. Wijdicks1, R.M. Houwert1, P.J. Millet2, E.J.J.M. Verleisdonk1,O.A.J. Van Der Meijden3
1Surgery, Diakonessenhuis Utrecht, Utrecht, Netherlands,2Orthopaedics, Steadman Clinic, Vail, CO, USA, 3Research,
Steadman Philippon Research Institute, Vail, CO, CO, USA
Introduction: The number of displaced midshaft clavicle fractures
treated surgically is increasing and open reduction and intramedullary
fixation is an upcoming surgical treatment option. The study quality
and scientific levels of evidence at which possible complications of
this treatment are presented vary greatly in literature.
Materials and methods: Systematic computer based searches using
online databases EMBASE and PUBMED/MEDLINE were carried
out. Studies included for review reported complications after intra-
medullary fixation alone or in comparison to either treatment with
plate fixation and/or nonoperative treatment. The Level of Evidence
rating and Quality Assessment Tool were used to assess the meth-
odological quality of the studies. Included studies were ranked
according to their levels of evidence.
Results: A total of six articles were eligible for inclusion and final
quality assessment after study selection and reading of the full texts, 3
studies were graded the highest Level of Evidence. Major compli-
cations like bone-healing problems and deep infections requiring
implant removal were reported no higher than 7 %. Reported rates for
minor complications, such as wound infection and implant irritation
which could be resolved without further surgery, were as high as
31 %.
Conclusion: The noted rates for major complications requiring
additional surgery were low, but implant related problems that also
require additional surgery may present with high prevalence. Due to
routine implant removal, treatment with intramedullary fixation often
requires an additional surgery.
Disclosure: This work was not supported directly by an outside
funding or grant. However, Dr. Millett is a consultant and receives
payments from Arthrex and has stockoptions in Game Ready. In
addition, Dr. Van der Meijden’s research position was supported by
Arthrex.
P054
THE RELATIONSHIP BETWEEN TRAUMA MECHANISM,FRACTURE TYPE AND TREATMENT OF MIDSHAFTCLAVICULAR FRACTURES
S.A. Stegeman1, C.W.J. Roeloffs1, J. Van Den Bremer2, P. Krijnen1,I. Schipper1
1Trauma Surgery, Leiden University Medical Centre, Leiden,
Netherlands, 2Trauma Surgery, Rijnland Hospital Leiderdorp,
Leiderdorp, Netherlands
Introduction: The debate on whether midshaft clavicular fractures
should preferably be treated operatively or non-operatively still
continues. Several patient related factors, such as trauma mechanism,
fracture type, age and gender, may influence this treatment decision.
A retrospective study was performed to investigate the relation
between trauma mechanism and fracture type, and between fracture
type and choice of primary treatment.
Materials and methods: Data on trauma mechanism and treatment of
232 adult patients who presented with a midshaft clavicular fracture
in two hospitals in the Netherlands during the years 2006–2009, were
collected. The extent of clavicular shortening, dislocation, and frac-
ture type were scored on the primary X-ray.
Results: Traffic accidents are the main cause of midshaft clavicular
fractures. Comminuted fractures are more common in the elderly.
After correction for age, no relation was found between trauma
mechanism and fracture type. Extensive shortening ([20 mm) was
identified as the main clinical indication for primary surgery, whereas
dislocation and fracture classification seemed less relevant. Primary
surgery of operated midshaft clavicular fractures increased from 5 to
44 % during the study period. This could not be explained by an
increase of more complex fractures, nor by age- or trauma mechanism
related factors.
Conclusion: Compared to the factor trauma mechanism, age is more
indicative for the risk of sustaining a comminuted fracture. The
choice for primary surgery is primarily determined by the amount of
shortening of the clavicle, rather than by overall dislocation or frac-
ture type. The choice of treatment is, over the years, increasingly
influenced by the patient’s and surgeon’s preferences.
Disclosure: No significant relationships.
NEUROTRAUMA
P055
CEREBRAL STATE INDEX AND GLASGOW COMA SCOREAS A PREDICTOR OF IN-HOSPITAL MORTALITY INPATIENTS WITH TRAUMA BRAIN INJURY
M. Mahdian, M.R. Fazel, E. Fakharian, H. Akbari
Trauma Research Center, Kashan University of Medical Sciences,
Kashan, Iran
Introduction: Cerebral State Index (CSI) derived from electroen-
cephalogram (EEG) and usually uses for monitoring of level of
consciousness during anesthesia. Present study was designed to
investigate the accuracy of GCS and CSI as a predictor of in- hospital
mortality in patients with trauma brain injury (TBI).
Materials and methods: In 60 TBI patients who did not require
sedative medication and admitted in our institute’s neurosurgery ICU
during 2010, GCS and CSI were measured once a day for the first
10 days of hospitalization. Correlation between two variables was
calculated by Pearson’s index. The ROC curve was plotted for each
index and the best cut of point was determined. Sensitivity and
specificity of GCS and CSI was calculated.
Results: A significant correlation was found between GCS and CSI at
the time of admission (r = 0.647; p \ 0.001). A significant linear
correlation is noted between GCS and CSI in the data sets for all days
of hospitalization (p \ 0.05). Scatter plot of GCS and CSI showed an
exponential shape between two variables (correlation coefficient of
relationship between logarithm of GCS and CSI was r = 0.977;
p \ 0.001). Gamma agreement coefficient was 0.79 for two indices.
Sensitivity and Specificity of GCS (cut of point = 4) for prediction of
in-hospital mortality were 95.3 and 82.4 %, respectively. These val-
ues for CSI (cut of point = 64) were 88.1 and 65 %, respectively.
S152 Abstract
123
Conclusion: In patients with trauma brain injury, significant corre-
lation exists between GCS and CSI and GCS has a higher accuracy
for in-hospital mortality prediction than CSI.
Disclosure: No significant relationships.
P056
DETERMINANTS OF LONG TERM OUTCOME INMULTIPLY INJURED PATIENTS WITH SPINALFRACTURES
C. Bley1, S. Darwiche2, C. Garving1, J.L. Steel2, N. Sittaro3, H. Pape1
1Department Of Orthopaedic Trauma, University of Aachen Medical
Center, Aachen, Germany, 2University of Pittsburgh Medical Center,
Pittsburgh, USA, 3Hannover Life RE-Insurance, Hannover, Germany
Introduction: Sparse data is available on the outcome of spine
trauma in polytrauma-patients. We evaluated clinical and functional
outcomes and specifically assessed the effect of fracture level and
initial neurologic deficit on long term outcome.
Materials and methods: Multiple trauma patients with spinal frac-
tures were classified according to fracture location: cervical, thoracic,
lumbar; single or multiple spinal fractures, and presence of paraple-
gia. Outcome was evaluated through both general (SF-12 and
HASPOC scores, limp, use of special aids, use of medications) and
spine-specific parameters (local pain, neurological symptoms, modi-
fied Frankel grade-ASIA impairment scale).
Results: Fifty-two patients were included. The mean follow-up was
16 years (range = 10–23 years), mean ISS was 27.1. Comparison of
groups showed significant differences in ISS and initial spinal injury
severity, with paraplegia group having a significantly higher score
(ISS, p = 0.04; MAIS(spine), p = 0.02). There was no difference in
outcome between patients who had minimal neurologic deficit after
isolated cervical, thoracic or lumbar spine fractures. Patients with
multiple level spine trauma had a worse long-term outcome when
compared with those who had a single-level fracture (SF-12-pcs,
p = 0.02; HASPOC, p = 0.001; use of special aids, p = 0.001; use
of pain medication, p = 0.05). Patients with initial paraplegia had, as
expected, the worst outcome in terms of both general and spine-
specific outcomes.
Conclusion: Neurologic deficit caused by a spine fracture is a major
determinant of poor clinical outcome. Also, patients with multiple
level spinal fractures had more problems in the long term when
compared with isolated spine fractures. No differences in outcome
were observed when comparing different fracture levels.
Disclosure: No significant relationships.
P057
AS A DEVELOPMENTS’ PARAMETER:PEDIATRIC HEADTRAUMA CHARACTERISTICS IN SOUTH-EASTERNANATOLIA, TURKEY: A COMPARATIVE APPROACH FOR12 YEARS RESULTS
S. Kemaloglu, O. Derin, S. Ercan, K. Kamasak, A. Ceviz
Neurosurgery, Dicle University Medical Faculty, Diyarbakir/Turkey
Introduction: Purpose of this study was to determine the demo-
graphic and epidemiological 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 of injury, triage time and models.
The outcomes for each patient were retrieved and analyzed, and the
chi–square test was used in the statistical analyses.
Materials and methods: The pediatric head injured patients were
investigated for two periods; The first period covered patients covered
patients admitted 1993 during which time an influx of people from
rural to urban areas occured. In the second period influx of people
declined and social instability was reduced.
Results: The most causes of injuries were road traffic accidents,
followed by falls and bullet wounds. While the leading cause of head
injury for the two time periods was road traffic accidents, firearm
injuries for the first period and falls for the second period were second
most frequency causes of injury.
Conclusion: We believed that pediatric health characteristics are
development parameters of the populations. We suggest that demo-
graphic and epidemiologic factors may affect the characteristics of
pediatric head injury in a region based population even in a short
period of time.
Disclosure: No significant relationships.
P058
TEMPORAL GUNSHOT INJURIES: ABOUT 3 DIFFERENTCASES
J.L. Alves1, N. Duarte1, B. Costa1, R. Velasco1, M. Bento2, A. Lopes1
1Neurosurgery, Centro Hospitalar de Coimbra, Coimbra, Portugal,2Maxilo Facial Surgery, Centro Hospitalar de Coimbra, Coimbra,
Portugal
Introduction: An infrequent presentation, penetrating temporal bone
trauma by gunshot injury has a tremendous potential impact in
mortality and morbidity. As one of the most complex anatomical
regions, multiple clinical and radiological presentations are expected,
implying different management strategies and outcomes. The authors
report on three patients with this type of injury, particularities and
management.
Materials and methods: The authors report on 3 cases of temporal
gunshot injuries. Their clinical pictures and imaging are depicted, and
the different management strategies are described, including the
multidisciplinary context, emergent surgical procedures and
outcomes.
Results: All patients with temporal gunshot injury. All of them
required collaboration between Neurosurgery, Neurointensivists and
others (ENT, Maxillo-facial surgeons, Opthalmology).
Patient 1—Surgery for large right hematoma and intracranial metallic
fragments. Good functional outcome on long term, moderate neuro-
logical deficits Patient 2—Transcranial route of projectile and
multiple injuries. Surgery for intracranial bullet and hematoma and
relief of intracranial pressure. Death in 10 days Patient 3—Temporal
gunshot injury and bullet lodged in left orbit, no neurological deficits,
minor opthalmologic deficits, failed surgery to extract the bullet.
Good functional outcome.
Conclusion: An interdisciplinary approach, including Neurosurgery,
Maxilla-facial Surgery, ENT, Opthalmology and Neurointensivism—
able to deal with different medical and surgical issues, is mandatory,
in order to minimize the effects and long term deficits imposed by this
potentially devastating injury.
Abstract S153
123
References: 1. Katzen T, et al. Craniofacial and skull base trauma.
J Trauma. 2003. 2. Nosan NK, et al.: Current perspective on temporal
bone trauma. Otolaryngol Head Neck Surg. 1997;117.
Disclosure: No significant relationships.
P059
SPINE INJURIES IN PEDIATRIC POLYTRAUMATIZEDPATIENTS: CHARACTERISTICS AND EXPERIENCE FROMA LEVEL I TRAUMA CENTER OVER TWO DECADES
M. Hofbauer, M. Winnisch, L.L. Hochtl, R. Ostermann, A. Silke
Department of Trauma Surgery, Medical University Vienna, Vienna/
Austria
Introduction: Spine injuries are very rare in pediatric patients. The
aim of this study was to determine the characteristics of multiply
injured children and spine injuries in different pediatric development
ages.
Materials and methods: A retrospective review of all pediatric
patients with polytrauma and injury to the spine was conducted from
January 1992 to December 2010. Patients were stratified into 4
developmental age groups: infants (0–4), young children (5–9),
preadolescents (10–14), and adolescents (15–17). Demographics,
patterns of spine injuries, associated injuries, treatment and outcome
were analyzed.
Results: 28 children met the inclusion criteria. The mean age was
12.9 years (range, 1.3–17.7 years), there were 18 males and 10
females. Younger children (0–9) sustained more injuries to the upper
spine region, whereas injuries to the lumbar region were only seen in
elderly patients. Nine (32 %) patients received surgically treatment,
15 (54 %) were treated conservatively.
Conclusion: The age-related anatomy and physiology predispose
younger children to upper spine injuries in contrast to lower spine
injuries seen in the adolescents. Predictors of mortality include
pathological pupillary light reflex, high ISS- and AIS-scores and a
low GCS-score at admission. Thoracic injuries were the most com-
mon associated injuries followed by TBI.
Reference: Platzer P, Jaindl M, Thalhammer G, et al. Cervical spine
injuries in pediatric patients. J Trauma. 2007;62:389–96.
Disclosure: No significant relationships.
SILS AND LAPAROSCOPY IN
ABDOMINAL TRAUMA AND EMERGENCY
P060
ABDOMINAL COMPARTMENT SYNDROME IN TRAUMA
M. Pandurovic1, P. Gregoric2, B. Karadzic3, K. Doklestic3, D.Radenkovic2, D. Bajec2
1Anesthesia, Clinical Centre of Serbia, Belgrade, Serbia, 2Clinical
Center of Serbia and Faculty of Medicine University of Belgrade,
Belgrade, Serbia, 3Clinical Center of Serbia, Belgrade, Serbia
Introduction: Intra-abdominal hypertension (IAH) and abdominal
compartment syndrome (ACS) are increasingly recognised to be a
contributing cause of organ dysfunction and mortality in critically ill
patients.
Materials and methods: This syndrome is most commonly observed
in the setting of severe abdominal trauma. ACS affects mainly the
respiratory, cardiovascular, renal, gastrointestinal and central nervous
system.
Results: According to the etiological classification causes of ACS can
be divided into intra-abdominal and extra-abdominal ones. Trauma
patients usually have the combination of multiple factors: massive
fluid resuscitation, coagulopathy, surgical intervention and shock.
Other factors associated with trauma patients are: retroperitoneal
haemorrhage and overlooked abdominal injuries.
Conclusion: Non-invasive techniques efficiently eliminate conse-
quences of IAH grade I and II, while abdominal decompression is the
«gold standard» for fully developed ACS.
References: Sugrue M (2005) ACS. Curr Opin Crit Care. 11:333–8.
Disclosure: No significant relationships.
P061
A CASE OF GASTRIC NECROSIS AFTER TWO YEARSLAPAROSCOPIC GASTRIC BENDING
N. Romano1, G. Basili2, D. Pietrasanta3, O. Goletti3
1General Surgery, ‘‘F.Lotti’’ Hospital Pontedera (Pisa), Tuscany,
Italy, 2General Surgery, ‘‘F.Lotti’’ Hospital Pontedera (Pisa),
Pontedera (Pisa), Italy, 3General Surgery, ‘‘F.Lotti’’ Hospital
Pontedera (Pisa), Pontedera, Italy
Introduction: The worldwide obesity has more than doubled since
1980. The LAGB represent one of more performed procedure to treat
the morbid obesity (1). We describe a case of gastric necrosis two
years after LAGB positioning.
Materials and methods: A 58 years old female patient reached to
our observation for abdominal pain, syncope and hypovolemic
shock signs. Past medical history documented a previously deep
venous thrombosis in treatment with oral anticoagulant (Warfa-
rin). At the admission the patient presented signs of abdominal
peritonitis and hypovolemic shock, with leucocytosis and ane-
mia. An abdominal CT-scan was performed that evidenced a
complete anterior gastric wall necrosis and a spleen laceration.
The patient was submitted to gastrectomy, splenectomy. The
patient was submitted to a scheduled second and third look and
after 13 days the patient underwent to jejunum-esophageal
anastomosis.
Results: The patient was discharged after 30 days.
Conclusion: The risk of band slippage of the LAGB was decrease
with the introduction of pars flaccid approach (3). However, this
complications can occur any time from the band placement.
References: 1. Eid I. Complications associated with LAGB for
morbid obesity: a surgeon’s guide. Can J Surg. 2. Zinzindohue F.
LAGB: a minimally invasive surgical treatment for morbid obesity.
Ann. Surg.
Disclosure: No significant relationships.
S154 Abstract
123
P062
SMALL INTESTINUM INJURIES
S.D. Sekulic1, A.S. Sekulic-Frkovic2, A.S. Sekulic3, J.S. Vasic4
1Surgical Clinic, C.H.C Pristina-Gracanica, Gracanica, Serbia,2Pediatric Clinic, C.H.C Pristina, Gracanica, Serbia, 3C.H.C Pristina,
Gracanica, Serbia, 4Surgical Clinic, C.H.C Pristina, Gracanica, Serbia
Introduction: Small intestinum injuries appears in about 30 % of
abdominal injuries. They are mostly penetrating (80 %) or blunt
trauma (20 %).
Materials and methods: Work is 15 years period study of operated
patients due to abdominal injuries at Surgical clinic, C.H.C Pristina –
Gracanica. We established the diagnosis based on anamnesis, clinical
inspection or available radiological method.
Results: Out of 736 (9.1 %) of abdomen injuries, we had 249
(33.6 %) injuries of small intestinum. Males were 203 (81.5 %) and
females 46 (18.5 %).Isolated injuries of small bowel appeared at 82
or (32.9 %). Penetrating injuries of small intestinum are found at 209
(83.9 %), and injuries caused by blunt force at 40 (16.1 %).
According to scale for organ injuries, penetrating injuries were at III
and IV level and blunt injuries at I, II and V level. Penetrating injuries
operated within first 6 h, and with blunt injuries during 24 h. At
penetrating multiple injuries of intestinum resection with T–T anas-
tomosis was performed at 90.1 % of patients. At blunt injuries with
single perforation we performed a suture. Complications occured at
47 (18.8 %) out of which: enteral fistula at 3 (1.2–6.3 %), infection of
wound at 20 (8.03–42.6 %) of cases. We had death outcome at 6
(2.4–12.8 %) of cases.
Conclusion: It’s essential to make quick differentiation of injury and
cause of injury. Resection with T–T anastomosis is method of choice
at multiple perforations of intestinum. Death outcome depends on
injury.
References: 1. Moorre EE, Cogbil TH, Malangoni MA, et al. Organ
injury scale II duodenum, smallbowel, colon and rectum. J Trauma.
1990;30:1427. 2. Sekulic S. Abdominalna hirurgija-pitanja i odgo-
vori. Dijam press, Novi Sad 2007.
Disclosure: No significant relationships.
P063
PENETRATING ABDOMINAL TRAUMA: UNCOMMONASSAULT IN A LITTLE VILLAGE IN ARAGON (SPAIN)
G.I. Perez-Navarro, I. Molinos-Arruebo, V.M. Borrego-Estella,P.A. Cano-Jimenez, G.C. Inaraja-Perez, J.J. Aguaviva-Bascunana,L. Gracia-Cortes, X. Vila-Amengual, A.P. Eced-Martinez,D. Judez-Legaristi, J.M. Remartinez-Fernandez, S. Laglera-Trebol
Anestesia Y Reanimacion, Universitary Miguel Servet Hospital,
Zaragoza, Spain
Introduction: Abdomen is the 3rd most commonly injured region of
the body, involving 10–20 % of all injured civilians who undergo
surgical intervention, in Spain usually due to traffic accidents.
Penetrating wounds in the literature represent 25 % of all urban
traumas which include gunshot and stab wounds. These injuries are
potentially life threatening and often warrant laparotomy or laparos-
copy exploration due to the association of hemorrhagic shock and
visceral injury.
Materials and methods: Male, 32 yo, NKDA. PMH: Apenddecto-
my. Suffers assault at 3 a.m. Presents stab wounds in the upper limbs,
back, right buttock and abdomen. On admission to the bay was very
anxious. A: airway was intact. B: bilateral breath sounds. C:2 negative
radial pulses. Supraumbilical omentum and infraumbilical small
bowel evisceration. No suspected hollow viscus injury at the moment.
No vertebral steps off or tenderness. Besides, stab wound in lower
back and right buttock. D:GCS12.BP:74/44, HR120 bpm, RR25 rpm,
O293 %. Patient was intubated in the bay and transferred to the OR,
where surgeons performed xifo-pubic incision founding 2 l of
hemoperitoneum. Small bowel resection was performed due to hollow
viscus injury. Retroperitoneum was clear. Patient was transfused 5
PRBC and 300 ml FFP. In SICU, pyrexia with good response to
antibiotics.
Results: Patients with abdominal stab wounds presenting with peri-
tonitis, shock, and evisceration require immediate surgery.
Conclusion: Penetrating abdominal injuries have been traditionally
managed by routine laparotomy, but years ago, new understanding of
trajectories has allowed to shift towards non-operative management in
a selected few patients.
References: 1. Vizuete Gallango F.J. Nure Investigacion 2006;21. 2.
Muhammad U Butt et al. Scand J Trauma. 2009;17:19. 3. Tantry PT,
et al. Joacp 2011;27:272–4. 4. Da Silva M, et al. World J Surg.
2009;33:215–9.
Disclosure: No significant relationships.
P064
TORSION AND INFARCTION OF THE GREATEROMENTUM SIMULATING ACUTE CHOLECYSTITIS.TREATMENT BY LAPAROSCOPY
S.G. Koulas1, N. Zikos2, G. Pappas-Gogos2, S. Bikos3
1Department of Surgery, General Hospital of Ioannina, Ioannina,
Greece, 2Surgery, Filiates General Hospital, Filiates, Greece,3Surgery, General Hospital of Ioannina, Ioannina, Greece
Introduction: Torsion of the omentum is an uncommon cause of
acute abdomen, that usually affects adults, in their fourth and fifth
decade of life.
Materials and methods: Aim of this study is to present 4 cases with
this unusual entity, that often resemble acute cholecystitis, and usu-
ally the diagnosis is made at the time of exploratory laparotomy or
diagnostic laparoscopy. Method - Cases description: All patients (3
female-1 male) were admitted in the Hospital with a chronic history
of non specific abdominal pain, mainly in the aria of right upper
quadrant. At the time of admission, all patients presented with fever,
vomitus and exacerbation of the pain while standing. Mild leucocy-
tosis and increase of CRP, accompanied symptomatology. All patients
underwent abdominal U/s which revealed the presence of mass in the
right abdomen, beneath the rectus abdominal fascia, lying besides the
normal free-stone gallbladder. In one case an enlarging mass
6 9 5.5 cm of dimension was surrounding the spleen.
Results: Appendectomy was performed in one patient, laparoscopi-
cally. Two patients underwent diagnosed laparoscopy and excision of
the mass was performed. In one patient, a large cystic mass originated
from the greater omentum surrounding the spleen, was resected
laparoscopically.
Conclusion: Symptoms, laboratory findings and imaging evaluation
of torsion and infarction of omentum, are non specific. Differential
diagnosis includes acute cholecystitis and other entities. Laparoscopic
Abstract S155
123
approach, seems to be an effective and save procedure for diagnosis
and treatment of the disease.
Reference: Sanchez J, et al.: Torsion of the greater omentum: treat-
ment by laparoscopy. Surg Lap Endosc Perc Tech. 2002;12:443–5.
Disclosure: No significant relationships.
P065
A PROSPECTIVE SINGLE INSTITUTION EXPERIENCEON BLUNT HEPATIC TRAUMA
A.F.Z. Barragat De Andrade1, F.B. Caetano2, J.F. Castro2,S.V. Starling1, D.A.F. Drumond1
1General and Trauma Surgery, Hospital Joao XXIII - FHEMIG, Belo
Horizonte, Brazil, 2General and Trauma Surgery, Hospital Joao
XXIII, Belo Horizonte, Brazil
Introduction: Our objective is to report and evaluate prospectively
our experience on the non-operative management of blunt hepatic
trauma.
Materials and methods: From June 2009 to April 2011, 108 unse-
lected blunt hepatic trauma patients were followed up prospectively.
The patients were divided in two groups: non-operative management
(NOM) and operative management (OM). The patients selected for
NOM were haemodynamically stable with no peritonitis signs and the
other patients were selected for the OM group. NOM failure was
defined as the need of laparotomy for the patient who was initially
selected for NOM. The data were analysed by the software EPI INFO
3.5.1.
Results: 96 patients were stable enough to undergo a CT scan and the
liver injuries found were 11 grade I, 30 grade II, 37 grade III, 18 grade
IV. For NOM 85 patients were selected and most of them had liver
injuries grading II and III (ISS mean 17.35). In the NOM there where
2 (2.3 %) failures due to intra-abdominal associated injuries and 4
(5 %) deaths due to brain injury. In the OM, most of the 23 patients
had grade IV liver injury (ISS mean 22.86). The patients underwent
surgery for non-responsive hypotension in 19 cases and associated
injuries in 4 cases. There were 10 deaths in this group.
Conclusion: The success rate in NOM was 97 %. The ISS was
greater in the OM.
References: 1. Kozar AK, et al. Risk factors for hepatic morbidity
following nonoperative management. Arch Surg. 2006;141:451–9. 2.
Velmahos GC et al. High success with NOM of blunt hepatic trauma.
Arch Surg. 2003;138:475–81.
Disclosure: No significant relationships.
P066
PRELIMINARY EXPERIENCE WITH DIAGNOSTIC ANDTHERAPEUTIC LAPAROSCOPY IN SELECTED TRAUMAPATIENTS
Y. Mohamed Al-Lal, L. Alvarez Llano, C. Camarero Mulas,T. Sanchez Rodriguez, A. Fabregues Olea, M.D. Perez Dıaz,F. Turegano Fuentes
Cirugıa General Ii, Hospital Gregorio Maranon, Madrid, Spain
Introduction: The role of laparoscopy (LP) in abdominal trauma is
controversial. Concerns remain regarding missed injuries and safety.
Materials and methods: Observational retrospective study over a
period of 14 years (March 1997–May 2011) at our center. Laparos-
copy was performed in 37 patients out of 1440 included in our severe
trauma registry. We analyzed incidence, mechanism of injury,
severity scores, operative findings, conversion rates, morbidity and
mortality.
Results: We included 33 men and 4 women, with an average age of
34 years (range 16–81). The mechanism of injury was a stab wound
in 24 cases (64.8 %), and blunt trauma from MVA in 13 (35.2 %). All
patients but one were hemodynamically stable on admission (SBP
[90 mmHg). The average ISS and NISS were of 11.4 (±8) and 13.6
(±10), respectively. Therapeutic laparoscopic surgery was done in 18
patients. 6 patients had a negative laparoscopy, and in 9 the lapa-
roscopy was diagnostic but not therapeutic. There was conversion to
open surgery in 4 cases, and 2 reoperation for a missed injury. The
average LOS was of 10 days (range 1–46 days). Patients with asso-
ciated orthopedic and maxillofacial injuries had a prolonged LOS.
The only complications were 2 pneumonias, and there were no deaths.
Conclusion: In our limited experience laparoscopy has proven fea-
sible and safe in selected trauma patients. The conversion rate, missed
injuries rate, and morbidity were low, with no mortality. We believe
there is a potential for increasing use of both diagnostic and thera-
peutic laparoscopy in selected trauma patients.
Disclosure: No significant relationships.
P067
AN UNUSUAL COLORECTAL FOREIGN BODY: A CASEREPORT
B. Buckus, G. Varanauskas, J. Stanaitis, A. Stasinskas
Department of General Surgery, Vilnius University Emergency Care
Hospital, Vilnius, Lithuania
Introduction: Foreign bodies of the colorectal region are not
uncommon finding in the emergency department but it is difficult to
encounter it‘s true amounts in the population, because patients come
into the hospital after their own attempts of extraction failure. The
variety of foreign bodies inserted to the distal colon is enormous and
ingenious methods have been described for the extraction of these
foreign bodies.
Materials and methods: We present a case of a 29-year old male
patient with a difficult colorectal foreign body of moisture-cure
semirigid polyurethane foam insulation which expands roughly two
times in size during curing.
Results: When manual transanal extraction in the emergency
department failed, the patient was admitted directly to the operating
room for retrieval of the foreign body under general anesthesia. When
manual and instrumental transanal extraction in the operating room
failed, the lower midline laparotomy was performed and the foreign
body was successfully removed transanally from the colorectal region
without a colotomy. The postoperative course was uneventful. The
patient had his first bowel movement on day 2. He was discharged
within 6 days of the operation.
Conclusion: Regardless of the foreign body inserted in the colorectal
region the simplest method for it’s extraction has to be chosen. The
main goal is to preserve the integrity of the intestine during the
procedure. The colon has been not damaged during the extraction of
this difficult foreign body in our department and the patient had good
postoperative results.
Disclosure: No significant relationships.
S156 Abstract
123
P068
BLADDER INJURIES AFTER EXTERNAL TRAUMA:20 YEARS EXPERIENCE REPORT
B.M. Pereira1, L.O. Reis2, G.P. Fraga3
1Division Of Trauma Surgery, UNIVERSITY of CAMPINAS,
Campinas, Brazil, 2Of Urology, University of Campinas, Campinas,
Brazil, 3Surgery, University of Campinas, Campinas, Brazil
Introduction: About 10 % of all injuries seen in the emergency room
involve the genitourinary system to some extent. Here, the authors
report 20 years of experience on bladder injuries after external
trauma.
Materials and methods: Bladder injury AAST-OIS higher than II
(American Association for the Surgery of Trauma Organ Injury
Scaling) from 1990 to 2009 were reviewed. Gender, age, mechanism
of injury, systolic blood pressure (SBP), Revised Trauma Score
(RTS), associated injuries, Injury Severity Score (ISS), complications,
Trauma Injury Severity Score (TRISS), and the length of stay (LOS)
were analyzed.
Results: Among 2575 patients experiencing trauma laparotomy, 111
presented AAST-OIS higher than II bladder ruptures, being 83.8 %
males. Blunt mechanism accounted for 50.5 %; motor vehicle crashes
(MVC) represented 47.3 % followed by pedestrians hit by a car.
Gunshot wounds represented 87.3 % of penetrating mechanism. The
mortality rate was 10.8 %. Pelvic fracture, SBP lower than 90 mmHg,
RTS lower than 7.84, and ISS higher than 25 were highly associated
with a grim prognosis and death.
Conclusion: Patients sustaining an isolated bladder injury are
uncommon, Even though, it is still an interesting subject leading to
considerable morbidity and mortality. RTS lower than 7.84 and ISS
above 25 are associated with high mortality rates in bladder-injured
patients.
References: 1. Karim TM, et al. Bladder injuries frequently missed in
polytrauma. J Urol. 2010. 2. Reis LO, et al. Arteriovesical fistula as a
complication of a GSW to the pelvis. Int J Urol. 2007.
Disclosure: No significant relationships.
P069
EMERGENCY SURGERY IN PATIENTS WITHINFLAMMATORY BOWEL DISEASE: EXPERIENCEIN 32 CASES
I.S. Sarıcı, E. Ozkurt, H.T. Yanar, C. Ertekin, R. Guloglu, M.K. Gunay
General Surgery, Istanbul University Istanbul Faculty of Medicine,
Fatih, Turkey
Introduction: The emergency surgical treatment of inflammatory
bowel diseases is closely related to the classification of patients
according to their symptoms and clinical conditions, as well as pos-
sible surgical options.
Materials and methods: We retrospectively evaluate the outcome of
32 patients who were diagnosed as inflammatory bowel disease and
underwent emergency surgery from January 2000 to December 2010
in our hospital. Twelve patients who were diagnosed as ulcerative
colitis (UC), underwent total colectomy or total procto-colectomy
with ileostomy; the remaining 20 patients had been diagnosed as
Crohn’s disease (CD) and treated with ileo-colic resection, colon
resection or segmental ileal resection.
Results: Patients with UC’s operative indications were toxic mega-
colon in 7 patients, uncontrolled severe bleeding in 4 patients and
perforation in 1 patient. In CD, patients were operated for mostly
because of complications such as perforation with fistula (11
patients), intestinal obstructions (6 patients) and acute abdomen (3
patients). Thirteen ileo-colic resections, 4 jejuno-ileal resections and 3
colon resections were performed to the patients.
Conclusion: Even though recent treatments in inflammatory bowel
disease is medical treatment with or without elective surgery, in some
emergent cases surgery is the only treatment that effects the survival
of the patients.
Reference: Surgical management of inflammatory bowel disease.
Arch Dis Child. 2007.
Surgery for inflammatory bowel disease. World J Gastroenterol 2008.
Disclosure: No significant relationships.
P070
SURGERY FOR PERFORATED COLORECTAL CANCERS:SINGLE INSTITUTION’S EXPERIENCE OVER 10 YEARS
I.S. Sarıcı, E. Ozkurt, H.T. Yanar, C. Ertekin, R. Guloglu, M.K. Gunay
General Surgery, Istanbul University Istanbul Faculty of Medicine,
Fatih, Turkey
Introduction: Perforated colorectal malignancy is associated with
high rates of mortality and morbidity. This study aimed to review the
relationship between mortality and morbidity rates related with ASA
scores and severity of peritonitis.
Materials and methods: A retrospective review was performed to all
patients who had been operated for perforated colorectal cancer from
June 1999 to May 2009. The severity of abdominal sepsis was graded
by using the Mannheim peritonitis index (MPI).
Results: A total of 92 patients, with median age of 62 years (range:
33–89 years), formed the study group. Seventy patients (76.1 %) had
severe peritoneal contamination (MPI [25). Among patients, 60
(65.2 %) had an American Society of Anesthesiologists (ASA) score
C3. The most common sites of perforation was sigmoid colon in 51
patients (55.4 %) and caecum in 26 patients (28.3 %). Hartmann’s
procedure and right hemicolectomy were performed in 59.8 and
28.3 % of the patients. The in-hospital mortality rate in our series was
33.7 %. The criterias predicting worse perioperative complications
were American Society of Anesthesiologists (ASA) score C3 and MPI
[25.
Conclusion: Surgery for colonic perforation is associated with high
morbidity and mortality rates. This rates are related with high ASA
scores and severity of peritonitis.
References: Surgery for perforated colorectal malignancy in an Asian
population: an institution’s experience over 5 years Int J Colorectal
Dis. 2010.
Management of obstructive and perforated colorectal cancer. Anti-
cancer Ther. 2010.
Disclosure: No significant relationships.
Abstract S157
123
P071
PNEUMORETROPERITONEUM AND SUBCUTANEOUSEMPHYSEMA AFTER COLONIC JATROGENICPERFORATION: A CASE REPORT AND LITERATUREREVIEW
G. Cocorullo G. Carollo M.A. Di Maggio T. Fontana G. Gulotta
University of Palermo, Italy
Introduction: Colonoscopic perforation is widely recognized as one
of the most serious complications following lower gastrointestinal
endoscopies. Although it is a rare complication it is associated with a
high rate of morbidity and mortality. The incidence could be as low as
0.016 % of all diagnostic colonoscopy procedures and may be seen in
up to 5 % of therapeutic colonoscopies. The most frequently affected
site is the colon rectum-sigmoid (62–64 %), 50 % for mechanical
causes, 34.6 % for bariatric causes and only 11.5 % for jatrogenic
causes. Diagnosis and early treatment are critical to prognosis.
Materials and methods: We report one case of jatrogenic perforation
of an 81-year-old male patient with moderately active ulcerative
colitis (UC) and follow-up. 19 h after the exam, the patient com-
plained of abdominal symptoms, fever and subcutaneous emphysema.
After 20 h the full body CT scan demonstrated free air in the abdo-
men and in the retroperitoneum, subcutaneous emphysema and
pneumomediastinum. Then, the patient underwent an explorative
laparoscopy that showed a lot of intra-abdominal exudative material
and pneumoperitoneum effects of a cecal perforation. We proceeded
to a laparoscopic right hemicolectomy and antiperistaltic L–L ileo-
colic anastomosis. The patient channeled on the III post-operation-
day (POD) and he was discharged on the VI POD in good clinical
condition.
Conclusion: Laparoscopic surgery is safe and effective, in case of
emergency, for the treatment of iatrogenic bowel perforations.
However, in the literature there are no guidelines. The therapeutic
choice depends on: site, size of the perforation, clinical data and
surgeon’s skill and experience in the laparoscopic approach.
Disclosure: No significant relationships.
SPORT INJURIES
P072
MASSIVE RECURRENT EXOSTOSIS OF THE SHOULDER(MULTIPLE HEREDITARY EXOSTOSES)
K.I. Papagiannakos, G. Protopapadakis, P. Kalantzis,P. Papagiannopoulos, I. Akrivos
2nd Orthopaedic, ‘‘Evangelismos’’ Hospital, Athens, Greece
Introduction: Multiple hereditary exostoses (MHE) occurs in 1 out
of 50,000 people and are typically inherited as an autosomal dominant
trait. The male to female ratio is approximately 3:1. The lesions
involve 70 % distal femur and proximal tibia and 50 % proximal
humerus. Clinical problems arise from pressure of exostosis on sur-
rounding soft tissues and vessels and rarely on nerves. Recurrence of
the lesions should be highly suspicious for the possibility of malig-
nant degeneration (1–2 % for age above 21 years).
Materials and methods: We present a case of a 46 years old man
suffering from MHE, who was operated on his right shoulder 20 years
ago. He developed a recurrent lesion on the same shoulder resulting in
mechanical dysfunction which caused pain and severe restriction of
range of movement. The lesion extended from humeral head to the
glenoid invading the whole subacromial space and resulting in per-
manent subluxation of the humeral head.The lesion was recected
through a deltopectoral approach.
Results: The patient had an uncomplicated post operative rehabili-
tation period. Three years after the operation his painless ROM is
1608 flexion, 908 abduction and internal rotation up to L1.
Conclusion: Although surgical resection of massive recurrent exos-
toses may be technically demanding, it is recommended in cases of
severe mechanical dysfunction of the joint.
Disclosure: No significant relationships.
P073
AN UNUSUAL MAXILLOFACIAL INJURY
J. Thareja, S. Sagar, M. Singhal, M. Pol, A. Gupta, S. Kumar
Trauma Surgery, Jpn Apex Trauma Center, All India Institute of
Medical Sciences, Delhi, India
Introduction: Maxillofacial Injury are increasing in life of a Com-
mon man following road traffic injury (RTI) and injuries can vary
from simple injuries to life threatening event. We report an unusual
maxillofacial injury from our institution, New Delhi. Patient alleged
history of RTI with a glass cut injury. The victim was travelling in a
three wheeler holding a high thickness glass. With a sudden jerk, the
glass broke and the victim had a massive glass cut injury over the
face. There was an unusual isolated maxillofacial injury involving
loss of soft tissue from forehead, nose, upper lip and lower lip. Lower
anterior tooth were avulsed.
Materials and methods: 28 year male sustained glass cut injury on
face and presented to our emergency department. Tracheostomy was
done in view of threatened airway and after completion of ATLS
protocol, patient was shifted to operating room. After doing the
haemorrhage control, forehead rotational flap was planned to cover
the soft tissue loss of nasal component. Graft was harvested from Left
thigh to cover over the raw area on forehead and midface.
Results: Patient’s life is saved with good cosmetic cover over on the
face.
Conclusion: Unusual maxillofacial injuries can present as lifethre-
tening events, timely intervention can save the life of the individual
and also provide good cosmetic look in the same operative setting.
References: 1. Hallock GG. Nasal degloving injuries. Ann Plastic
Surg. 1984;12:537–41. 2. Gentile VG, Mohr RM, Houle JG. Midfa-
cial degloving for an unusual foreign body. Am J Otolaryngol.
1996;17:67–70.
Disclosure: No significant relationships.
P074
ACL SINGLE BUNDLE RECONSTRUCTION:COMPLICATIONS AND SOLUTIONS
T. Randl
Traumatology, University Medical Centre Ljubljana, Ljubljana,
Slovenia
S158 Abstract
123
Introduction: Arthroscopic anterior cruciate ligament (ACL) repair
should be minimally invasive procedure nowadays. Our aim is to
improve stability of the knee and prevent additional meniscal injury
or early arthrosis. Unfortunately there is a high risk of errors and
iatrogenic injuries.
Materials and methods: I analysed 50 ACL single bundle recon-
structions with quadriceps tendon. I searched for events which
importantly affected the course of operations or endangered the
final outcome. I also sought surgical actions which overcome
complications.
Results: I found 20 different complications in only 50 operations.
Most frequently complications appeared during transplant harvesting
and transplant fixations in femoral or tibial tunnels. Every single
complication demanded improvisation and non-routine proceeding
during operation. Surgeons found solution for each of 20 complica-
tions. All 50 operations were successfully accomplished. No further
operations were needed.
Conclusion: ACL reconstruction is a procedure which requires
cooperation among all members in the operating team. Many com-
plications can be avoided if the procedure is standardised.
Disclosure: No significant relationships.
P075
THE TREATMENT OF ACETABULAR FRACTURECOMPLICATIONS IN A COMBINATION OF POST-TRAUMATIC HIP JOINT OSTEOARTHRITIS ANDFEMORAL FRACTURE FOR POLYTRAUMA PATIENT
A. Vikmanis
Traumatology, RAKUS, Riga, Latvia
Introduction: Pelvic bone fractures are related to a high energy
injury. In the case of acetabular fractures, as the most frequent
complication is the hip joint post-traumatic osteoarthritis.
Materials and methods: A 28-year old female. Road traffic accident.
Diagnosis : polytrauma. Brain contusion. Bilateral pulmonary con-
tusion. Splenic rupture. Liver rupture. Comminuted and open distal
metaphyseal fractures of the left forearm and left upper arm. Open
diaphyseal left femoral fracture. Fracture of the left side pelvic bone
both columns. Extensive torn wound with a soft tissue defect in the
gluteal area.
The femoral bone was fixed with an intramedullar locking nail.The
pelvic bones were fixed with a plate using the illiolinguinal approach.
After the operation the hip joint ostearthritis rapidly progressed. In-
tramedullar nail was evacuated in 12 months to prepare the patient for
the left hip joint arthroplasty. In a result of a repeated injury the
patient underwent a refracture of the left femur. In a format of council
a decision was made to perform a hip joint plastic with autograft and
total arthroplasty and to simultaneously carry out femoral fracture
fixation with a revision femoral component.
Results: After arthroplasty equal leg length was achieved and the
motion extent in the left hip joint was renewed.
Conclusion: In case those were large wounds in the gluteal areas, an
alternative is modified Stoppa approach, because it is possible to
visualise and to reduce and fix both columns.
Reference: Matta JM. Indications for anterior fixation of pelvic
fractures. Clin Orthop. 1996;88–96.
Disclosure: No significant relationships.
P076
PANTON-VALENTINE LEUKOCIDIN METHICILLINSENSITIVE STAPHYLOCOCCUS AUREUS (PVL-MSSA)INDUCED OSTEOMYELITIS: A CASE REPORT
A. Vasireddy1, K. Turnbull2, M. Phillips2
1Trauma & Orthopaedics, King’s College Hospital, London, UK,2King’s College Hospital, London, UK
Introduction: Panton–Valentine leukocidin (PVL) is a cytotoxin, first
described in 1932, that can destroy white blood cells and can cause
extensive tissue necrosis and severe infection. The Health Protection
Agency have issued guidance on the diagnosis and management of
PVL-associated infections in the UK. Some staph. aureus (both
MRSA and MSSA) organisms carry genes coding for PVL. Com-
monly caused infections include necrotizing skin infections, cellulitis
and/or tissue necrosis. Young children and young adults are generally
affected.
Materials and methods: We present the case of a 21-year-old
Afro-Caribbean woman presenting to our hospital with a three-day
history of severe abdominal symptoms. Extensive investigations
did not identify any early initial infection. However, symptoms
then progressed to involve right leg pain. A subsequent MRI
illustrated signs of multicompartmental pyomyositis and osteomy-
elitis in the distal femur with concurrent elevated inflammatory
markers.
Results: Treatment involved initial sequestrectomy and washout
with tissue samples, which demonstrated the presence of PVL-
MSSA. Focused intravenous poly-antimicrobial therapy was initiated
and a further wound debridement was completed. The leg wound
was then managed with a Vacuum-Assisted Closure (VAC) Device.
With prolonged oral antimicrobial treatment and the use of a VAC,
the patient’s condition continued to improve and the infection
resolved.
Conclusion: This report highlights the importance of suspecting PVL
infection early in the clinical course. In addition, early aggressive
surgical treatment with prolonged antimicrobial therapy is important
in controlling this potentially lethal infection.
References: Penn–Barwell, JG et al. PVL Staphylococcus aureus
osteomyelitis complicating septic arthritis in a UK soldier serving in
Iraq. JP Army Med Corps. 2009;155(3):208–09.
Disclosure: No significant relationships.
P077
A SEVERE DEGLOVING INJURY OF THE LOWER LEGAND THE FOOT WITH TARSAL FRACTUREDISLOCATIONS SUCCESSFULLY TREATED WITH THEUSE OF VACUUM ASSISTED CLOSURE AND A SMALLSPLIT-THICKNESS SKIN GRAFT
H. Fujimaki1, H. Minehara1, T. Suzuki2, T. Matsuura1, R. Shintani1,K. Souma2, M. Takaso1
1Orthopaedic and Trauma Surgery, Kitasato University School of
Medicine, Sagamihara, Japan, 2Kitasato University School of
Medicine, Sagamihara, Japan
Introduction: Vacuum-assisted closure (VACTM) has been reported
as a method for securing skin grafts in degloving injury. This report
Abstract S159
123
describes the salvation of soft tissues by replacing the whole degloved
skin as a full-thickness skin graft and securing it using the VACTM.
Materials and methods: Case report A 62 year-old-female was run-
over by a forklift. She sustained medial malleolus fracture of her right
ankle and a severe degloving injury to her right lower leg and foot
with 90� rotational fracture dislocation of talus and calcaneus. There
was a laceration across the posterior aspect of the lower leg and the
entire heel was degloved. Dislocations were reduced following thor-
ough debridement and irrigations. The skin was reapplied as a full-
thickness graft with partial defatting and sutured in place after
external fixation. VACTM was then applied at a pressure of
125 mmHg to cover whole degloved tissues and exchanged every
third day.
Results: After 10 days tarsi were stabilised with K-wires and mal-
leolus was fixed with one cannulated screw. On day20, unhealed areas
were only 10 % and grafted with a STSG. After 4 months she was
able to commence full weight bearing and walk without major
complications.
Conclusion: Severe degloved skin was successfully treated by
VACTM with a reapplication of the skin and a single STSG. It pro-
vides a constant conforming pressure, allowing secure contact with
the bed and potentially increasing the take by reducing seroma and
haematoma formation.
References: 1. DeFranzo AJ, et al. Plast Reconstr Surg.
1999;104:2145–8. 2. Josty IC, et al. Br J Plast Surg. 2001;54:363–5.
Disclosure: No significant relationships.
P078
FRACTURES OF THE LATERAL PROCESS OF THE TALUS
T. Waki1, T. Niikura1, A. Sakurai2, S.Y. Lee1, K. Oe2, T. Koga1,Y. Dougaki1, E. Okumachi1, R. Kuroda1, M. Kurosaka1
1Orthopaedic Surgery, Kobe University Graduate School of Medicine,
Kobe, Japan, 2Awaji Hp, Awaji, Japan
Introduction: Fracture of the lateral process of the talus is a rela-
tively rare trauma. This fracture is called as ‘‘snowboarder’s
fracture’’. The incidence of this fracture was reported as 0.86 % in all
ankle injuries. This fracture is often misinterpreted as a severe ankle
sprain.
Materials and methods: We experienced four patients with a uni-
lateral fracture of the lateral process of the talus. The diagnosis was
established immediately in all but one patient. One was diagnosed
1 week after the injury. The mean age of the patients was 46.5 years
(range 30–65). All patients were male. The mean period of follow-up
was 3.1 years (range 3–108 months). Two patients were stepped on
by cow, one was stepped on by ‘‘Mikoshi’’ (Japanese traditional
vehicle) and one was injured in MVA.
Results: All patients were treated with open reduction and internal
fixation. Three patients were treated with screw and Kirshner wire
fixation and one patients treated with screw fixation. AO small screw
was used in three patients and Acutrack mini screw (ACUMED) was
used in one patient. All patients obtained bone union. However one
complained dull pain of the lateral ankle the pain disappeared after
the hardware removal. All patients returned to work and had no
symptom.
Conclusion: When a patient complains of the pain of the lateral ankle
after a trauma, it is important to consider the fractures of the lateral
process of the talus as one of the differential diagnoses.
Disclosure: No significant relationships.
P079
ADULT PROXIMAL HUMERUS LOCKING PLATE FOR THETREATMENT OF PAEDIATRIC SEGMENTALSUBTROCHANTERIC FEMORAL FRACTURE:A CASE REPORT
A. Vasireddy, R. Varma
Trauma & Orthopaedics, King’s College Hospital, London, UK
Introduction: Segmental subtrochanteric femoral fractures are rare
injuries and have to date not been reported in the literature.
Materials and methods: We present the case of a 10-year-old boy
who sustained this injury after being struck by a car travelling at an
intermediate speed. The patient also sustained a contralateral open
tibial fracture.
Results: Due to the two severe lower limb injuries, early surgical
intervention was undertaken. The tibial fracture was treated with
flexible intramedullary nailing. The segmental subtrochanteric prox-
imal femoral fracture was treated with an adult proximal humerus
locking plate (PHILOS-Synthes).
Conclusion: A modified MIPO technique was utilised and submus-
cular plating was completed and bone grafting was not undertaken.
Uneventful healing was possible. No short- or midterm complications
occurred. Although other implants can certainly be used (e.g. paedi-
atric dynamic hip screw) or others adapted to a use different than that
of its original design, the present case suggests that adult proximal
humerus locking plates may be a safe option for proximal pediatric
femur fixation.
References: Cortes LE, et al. Adult proximal humerus locking plate
for the treatment of a paediatric subtrochanteric femoral nonunion: a
case report. J Orthop Trauma. 2011;25(7):e63–76.
Disclosure: No significant relationships.
P080
TIBIAL PLATEAU FRACTURES TREATED WITH THEILIZAROV APPARATUS
I. Lalic1, V. Kecojevic1, S. Tomic2, M. Lukic3, B. Vukajlovic4
1Orthopaedics, KCV, Novi Sad, Serbia, 2Department of Physical
Medicine, Institute of Oncology Sremska Kamenica, Novi Sad,
Serbia, 3Clinic for Anesthesiology and Reanimatology, KCV, Novi
Sad, Serbia, 4University of Novi Sad, Medical Faculty of Novi Sad,
Novi Sad, Serbia
Introduction: We restricted our work on treatment of open and
closed tibial plateau fractures, of different gradings and classifica-
tions, with the Ilizarov apparatus, considering it as a valid method of
choice in the treatment of these fractures.
Materials and methods: In our clinic, from the period of 2006 to
2011, 28 patients with tibial plateau fractures were treated using the
Ilizarov apparatus. 20 were males and 8 females. Open fractures,
using the Anderson–Gustillo classification, type I—one, type II—two
and type III three patients. Closed fractures, according to Schatzker
classification, type II—six, type V—two and type VI nine patients.
For fracture types II and III we performed lifting of the depressed
plateau using the elevator and metaphyseal bone graft. Average
wearing time of the apparatus was 3 (2.5–3.5) months.
S160 Abstract
123
Results: Complete reconstruction of the tibia plateau was achieved in
24 treated patients with good results. In five patients we had an
infection around the pins of the device which was taken care of with
antibiotics based on smear findings. In three cases we had common
fibular nerve lesions, (Schatzker V and VI), of transitory nature,
which restituted after 6 months, verified with EMNG.
Conclusion: Our experience shows, that using the Ilizarov method
benefits with good reconstruction of the tibial plateau, avoidance of
major operative incisions, blood loss and minimal risk of infection.
References: Ilizarov GA. The tension and stress effect on the genesis
and growth of tissues: part II. Clin Orthop Relat Res. 1989;239:
263–85.
Disclosure: No significant relationships.
P081
This abstract has been withdrawn.
P082
PREVENTION OF IATROGENIC RADIAL NERVE PALSY INTHE TREATMENT OF HUMERAL SHAFT FRACTURES: ANANATOMICAL STUDY WITH RADIOLOGICAL GUIDANCE
B. Van Der Ende1, H.P. Theeuwes2, J. Potters1, A.J.H. Kerver3,J.H. Bessems4, G. Kleinrensink1
1Neuroscience-Anatomy, Erasmus Medical Centre, Rotterdam,
Netherlands, 2Surgery, Maastricht University Medical Center,
Maastricht, Netherlands, 3Surgery, St. Franciscus Gasthuis,
Rotterdam, Netherlands, 4Orthopaedics, Erasmus Medical Centre,
Rotterdam, Netherlands
Introduction: An important complication in humeral shaft fracture
treatment is iatrogenic radial nerve palsy. This study uses radiological
guidance to measure the course of the radial nerve in the distal upper
arm in relation to the medial epicondyle to determine a safe zone for
placing the distal locking screws.
Materials and methods: Ten embalmed arms were used to identify
and mark the distal radial nerve in the upper arm: marking A was
placed at the point where the radial nerve enters the anterior com-
partment; marking B where the radial nerve bends from lateral to
anterior; marking C was placed at the bifurcation of the nerve.
Standard radiographs were made and measured.
Results: The mean distances between the medial epicondyle and the
markers at point A, B and C are, respectively: 113 mm (SD 25.4,
range 67–152 mm), 68 mm(SD 17.7, range 44–100 mm) and
25.5 mm(SD 7.8, range 13–38). For lateral radiographs these mean
distances are, respectively, 139 mm (SD 23.9, range 106–177),
94.5 mm(SD 18.6, range 64–122) and 48 mm(SD 9.2, range 35–61).
Conclusion: Based on our findings we advice distal screw fixation by
blunt dissection instead of blind fixation. In case of blind fixation a
relative safe zone should be determined preoperative by radiographic
imaging to reduce the risk of nerve damage. The lateral locking
screws should be placed more proximal than 177 mm from the medial
epicondyle or more distal than 64 mm and the anterior locking screw
should be placed more proximal than 100 mm from the medial
epicondyle.
References: 1. Shao YC, et al. J Bone Joint Surg Br. 2005;87(12):
1647–52(Review). 2. Noger M, et al. Injury. 2007;38(8):954–7. 3.
Zhang J, et al. ANZ J Surg. 2011;81(4):227–36 (Review).
Disclosure: No significant relationships.
P083
SURGICAL VERSUS CONSERVATIVE TREATMENT OFDISPLACED INTRA-ARTICULAR GLENOID FRACTURES
F.F. Adam1, H.H. Refae2
1Orthopaedic Surgery & Traumatology, Assiut University Hospital,
Assiut, Egypt, 2Orthopaedics, South Valley University Hospital,
Qena, Egypt
Introduction: Displaced intra-articular glenoid fractures are 1 % of
all fractures that cause significant disability unless properly managed.
Materials and methods: Between 1994 and 2006, 20 patients with
displaced intra-articular glenoid fractures were treated and prospec-
tively followed for a minimum of 2 years. Indications for surgery
included displacement 310 mm, angulation 340�, articular step-off35 mm, articular involvement 3� glenoid cavity. Open reduction and
internal fixation was performed in 15 patients after stabilization of
their general condition. Five patients who refused surgery and were
conservatively managed during the same time period constituted a
control group.
Results: According to Denis scale of pain and work status, 14
patients of the surgical group reported no or minimal pain (P1–P2),
while 1 has moderate pain with occasional medication (P3). In the
conservative group, only 1 patient had no pain (P1), 1 had mod-
erate pain (P3), and 3 reported severe pain with frequent
medication (P4). Normal range of motion was regained in all
surgically treated patients within 3 months postoperatively and
within 6 months in 2 out of the conservative group, while per-
manent limitation of movement was observed in 3 of the
conservative group. Ten manual workers of the surgical group
returned to their previous work (W1–2) and five (33.3 %) returned
to a modified work (W3), whereas none of the conservatively
treated patients resumed their previous work (W3–4), three of them
were completely disabled (W5). No major surgical complication
was observed.
Conclusion: Surgical treatment of displaced intraarticular glenoid
fractures usually results in better outcome than conservative
management.
P084
INTRACAPSULAR HIP FRACTURES IN HIGH ENERGYTRAUMA
V. Rodriguez Vega1, P. Caba2, G. Parra Sanchez1, L. Garcıa Lamas3,J. Quintana4, B. Bravo Gimenez3, A. Jorge Mora2, C. Resines Erasun2
1Orthopedics, Hospital 12 de Octubre, Madrid, Spain, 2Orthopaedic
Surgery and Traumatology, Hospital Universitario 12 de Octubre.,
Madrid, Spain, 3Hospital 12 de Octubre, Madrid, Spain, 4Hospital 12
de Octubre, Madrid, Spain
Introduction: Intracapsular hip fractures in polytrauma have both
diagnostic and treatment problems. IC fractures are frequently missed
in polytrauma patients with possible severe complications. We review
the epidemiology, associated injuries and clinical outcome of a group
of polytrauma patients with IC fractures.
Abstract S161
123
Materials and methods: Retrospective analysis of a prospectively
recorded trauma database of patients admitted at our hospital between
2004 and 2008. We analyzed the clinical outcomes in terms of sys-
temic complications, mortality measured and avascular necrosis.
Inclusion criteria: Age over 18, ISS over 15 and intracapsular hip
fracture.
Results: 17 patients met the inclusion criteria. Mean: age 39, ISS 26
and NISS 31. Most patients were treated by contemporary DCO
methods by external fixation or minimally invasive fixation of the hip.
In 14 cases (82 %) we found also femoral fractures; 8 of these
patients had unilateral fractures (6 ipsilateral and 2 contralateral) and
6 patients had bilateral femoral fractures. 10 patients were treated by
screw fixation, 2 with cephalomedular implants, 4 with dynamic hip
screw and one case was treated with a recon nail. 2 patients developed
avascular necrosis.
Conclusion: We found a high association between IC fractures and
ipsilateral femoral fracture (35 %) and bilateral femoral fracture
(35 %) In severe polytrauma patients, 7 % of the patient with femur
fracture had IC fracture. Early treatment in the first 24 h after the
trauma reduces complications. Surgeons must be aware of the pres-
ence of IC fracture in polytrauma with high ISS and femur fracture,
specially in road traffic accidents and high falls.
Disclosure: No significant relationships.
P085
TREATMENT OF HUMERAL SHAFT FRACTURES BYMEANS OF INTRAMEDULLARY BUNDLENAILING
P. Obruba, L. Kopp
Traumacentre, Masaryk Hospital, Ustı nad Labem, Czech Republic
Introduction: To inform of our experiences in treatment of humeral
shaft fractures using elastic bundle nailing and to assess the relevancy
of indication of this method.
Materials and methods: In period from 1/2001 to 12/2009, 184
patients with diaphyseal humeral fracture underwent surgery in our
department. 147 patient were treated using bundle nailing. 118
patients were followed-up in prospective manner for at least
12 months. Study was assessing epidemiological data and results of
treatment. Surgery was performed in accordance with original tech-
nique of prof. Hackethal using K-wires.
Results: There was observed neither deep infection, iatrogenic frac-
ture nor compartment syndrome. Two patients had superficial wound
healing problems, two had temporary radial palsy, 13 had irritation of
soft tissues by synthetic material. Mild ROM limitation in elbow was
seen in 8 cases, ROM limitation in shoulder was 239 mild, 8 times
severe. Full bony healing after 6 months was achieved in 95 % of
patients. Six patients developed pseudarthrosis, which was causes
either by wrong indication (severe comminution) or wrong surgical
technique (insufficient number of implants). 12 % of patients had an
axial dislocation of 5–10�, 2 % of 13 degrees. Full satisfaction with
result was seen in 78 % of patients after 6 months and in 88 % of
patients after 12 months.
Conclusion: Hackethal’s technique of osteosynthesis by means of
intramedullary elastic bundle nailing does allow us to treat these
fractures simply and safely. Results are comparable to modern
methods, which are more expensive. This method could be a first
choice for transverse and short oblique fractures of humeral shaft.
Disclosure: No significant relationships.
P086
SURGICAL VERSUS NON-OPERATIVE TREATMENT OFHADLEY TYPE IIA ODONTOID FRACTURES
P. Platzer1, J. Kottstorfer1, I. Vielgut2, R. Ostermann1, R. Schuster1,S. Eipeldauer1, G. Pajenda1
1Department of Trauma Surgery, General Hospital Vienna, Wien,
Austria, 2General Hospital Vienna, Wien, Austria
Introduction: Type II odontoid fractures with additional anterior or
posterior chip fragments account for less than 10 % of all odontoid
fractures. Hadley et al. were the first to describe these fractures as
type IIA. To analyze the outcome of patients following surgical or
non-operative treatment of Hadley type IIA odontoid fractures,
regarding bony fusion, cervical spine motion and complications.
Materials and methods: We analysed the clinical and radiographic
records of 46 patients with an average age of 64 years at the time of
injury. 25 patients underwent surgical stabilization by anterior screw
fixation, whereas 21 patients were treated non-operatively by halo
fixation.
Results: 37 patients (84 %) returned to their pre-injury activity level
and were satisfied with their treatment. Using the Cervical Spine
Outcomes Questionnaire we had an overall outcome score of 21.8.
Radiographic results revealed bony fusion in 35 of 44 patients (80 %).
Comparing between the study groups, we had a non-union rate of
13 % in patients following anterior screw fixation and a significantly
higher rate of 30 % in patients treated by halo immobilisation. Fail-
ures of reduction or fixation occurred in 12 patients (27 %), with a
significantly higher failure rate after halo immobilisation.
Conclusion: Type II odontoid fractures with an additional chip
fragment at the fracture site are inherently unstable and impede proper
reduction and realignment. These fractures, commonly described as
Hadley type IIA fractures, have a significantly increased risk for
secondary loss of reduction and bony non-union, particularly fol-
lowing non-operative management. When diagnosing this fracture
subtype, early surgery should be considered to avoid further
complications.
Disclosure: No significant relationships.
P087
DISTRACTION OSTEOGENESIS IN SEGMENTAL BONEDEFECTS OF THE LOWER LIMB
D. Aloj1, R. Matteotti2, D. Testa1, D. Santoro1, E. Petruccelli1,M. Giovanni1
1Traumatology, cto, Turin/Italy, 2Orthopedics and Traumatology,
CTO Turin, Turin/Italy
Introduction: To evaluate the results of segmental bone transport
using circular external fixator (EF) in patients with tibia of femur
bone defects.
Materials and methods: This descriptive study was carried out at the
CTO Turin (Italy) from July 2002 to December 2010 with 152
patients with tibial and femural segmental bone defects. Circular EF
technique was employed. Results were evaluated using Paley score.
Results: Out of 152 patients 117 were male and 35 were female with
a middle age of 39 yy (15–68). 117 bone defects were of the tibia and
35 were of the femur. Average length of bone transport was 61 mm
S162 Abstract
123
(20–170 mm). Average duration was 64.3 days and time with EF was
38.9 weeks. Only 3 required later amputation. 94 patient required
further surgical treatment including surgical debridement of docking
point, EF reset or biological addition. Paley score shown 135 excel-
lent or good results 12 fair results and 2 poor results.
Conclusion: Distraction osteogenesis with circular EF is considered
useful for serious post-traumatic bone defects of both tibia and femur.
Long term analysis of function demonstrate Good and durable recover
of function 1, 2. Further improvement have to be achieved improve
healing time using distraction osteogenesis with circular EF method
combined with: multiple osteotomy; fibula-pro-tibia transport (per-
cutaneous or microvascular) biological additions(OP-1, PrP, stromal
cells)monitoring the neoangiogenesis with contrastographic ultra-
sound technique.
References: Kesemenli C, et al. Treatment of traumatic bone defects
by bone transport. Acta Orthop Belg. 2001;67(4):380–6.
Disclosure: No significant relationships.
P088
SURGICALLY TREATED WOUND COMPLICATIONSAFTER OPERATIVE TREATMENT OF CALCANEUSFRACTURES ARE COMMON
K. Mustonen1, L. Maki-Lohiluoma2, E. Tukiainen2, M. Paavola2,M. Kirjavainen2
1Trauma Unit, Helsinki University Central Hospital, HUS, Finland,2HUCH, HUS, Finland
Introduction: The purpose of this study was to analyse the occur-
rence of wound complications requiring surgical management after
the operative treatment of calcaneus fractures, and to analyse possible
risk factors leading to wound complications. The type of operations
due to problems in wound healing was assessed.
Materials and methods: In Helsinki University Central Hospital, 101
patients were surgically treated for calcaneus fractures between
1.1.2006-31.12.2010. All documents related to treatment were eval-
uated retrospectively.
Results: The average age of patients was 42 years. A total of 22 out
of 101 patients (22 %) had problems in wound healing requiring
surgical treatment. Four patients needed free skin graft and 15 addi-
tional soft tissue reconstructions: two local fasciocutaneous flaps, one
pedicular fasciocutaneous flap, five pedicular muscle flaps and seven
free flaps. In 14 patients vacuum assistant closure therapy was used.
Ten out of 16 patients with open fracture and 14/37 smoker had
wound problems needing surgical treatment. The rate for complica-
tions among patients with suicide attempt and with inexperienced
surgeons was 5/9 and 12/28. Univariate and multivariate analyzes
between risk factors and complications will be presented.
Conclusion: Following surgical treatment of calcaneus fracture,
substantial numbers of the patients needed further operative treat-
ment. Smoking, suicide attempt, open fracture and inexperienced
surgeon were related to wound complications. Our results are in
accordance to earlier studies where the incidence of wound compli-
cations after operative treatment of calcaneus fracture has varied from
0 to 25 % and comminuted fracture, smoking, diabetes and open
fracture has been found to be risk factors for wound complications.
Disclosure: No significant relationships.
P089
CAN USAGE OF HEAD AND NECK SUPPORT SYSTEM(HANS) LEAD TO FRACTURES OF THORACOLUMBARSPINE? ANALYSIS OF INJURY PATTERNS IN RALLYDRIVERS IN CZECH REPUBLIC
P. Obruba1, J. Avenarius1, L. Kopp1, P. Pilat2, M. Svec3,P. Cernohorsky4
1Traumacentre, Masaryk Hospital, Ustı nad Labem, Czech Republic,2Department of Orthopaedics, Masaryk Hospital, Ustı nad Labem,
Czech Republic, 3Faculty of Biology, University of Jan Evangelist
Purkyne, Ustı nad Labem, Czech Republic, 4Association of Rally
Drivers of Czech Republic, Ustı nad Labem, Czech Republic
Introduction: Since 2008 the HANS system (Hand and Neck Sup-
port) was introduced in rally races. Since then there also emerged
fractures of thoracolumbar spine during accidents. This coincidence
led to hypothesis of causal relationship with usage of HANS system.
Purpose of our study was to admit or reject this hypothesis.
Materials and methods: From 1/2008 to 6/2010, all drivers who
suffered fracture of thoracolumbar spine were identified. From 8
injured, 5 made available their medical documentation (with CT and
X-rays and video of accident) for further evaluation. Assessing the
video and interviews with drivers, mechanism of injury was identified
and used for physical modeling of the forces acting on driver’s spine
in time of injury. The situation with and without using the HANS
system was simulated.
Results: All fractures were of AO A1.1 type, caused by axial over-
load. This overload arises in falls from height combined with frontal
impact. Without using HANS the inertia and breaking force are equal.
With HANS the acting point of forces and breaking force do shift and
there emerges a vertical force acting in axis of thoracolumbar spine.
This force can reach according to different models 4500 to 14600 N
(equals load of 450–1,460 kg).
Conclusion: Fractures of thoracolumbar spine in sport drivers are
caused either by axial overload or by fall of car even from smaller
heights in situation, when spine loses it’s elasticity due to fixation in
protective system and simultaneous action of vertical force. This
could be caused by incorrect usage of HANS.
Disclosure: No significant relationships.
P090
VENOUS THROMBOEMBOLISM (VTE) RISKASSESSMENT: A PROSPECTIVE AUDIT
C.U. Menakaya, M. Shah, R. Malhotra, H. Ingoe, T. Boddice,A. Mohsen
Trauma and Orthopaedic Department, Hull and East Yorkshire NHS
Trust, 2JZ, UK
Introduction: Over 25,000 patients die yearly in the UK secondary to
hospital acquired VTE. This lead to the 2006 Department of Health
initiative of implementing VTE risk assessments to all patients
admitted into a hospital in the UK. The goal of this initiative was to
Abstract S163
123
curb the huge financial cost (£ 640 million/year) plus reduce VTE
associated morbidities and mortalities. The National Institute of
Clinical Excellence (NICE January 2010) developed guidelines in
order to standardise effective assessment process. This audit aimed to
assess primarily adherence to NICE guidelines and secondarily to
identify weak areas with regards to risk assessment and address these
as a matter of urgency.
Materials and methods: Prospective data collection using a VTE
risk assessment monitoring tool (10-question scale) to assess all VTE
risk assessments done over a 1 month period in Trauma and Ortho-
paedics (N40), Plastics (N25) and Neurosurgery (N30).
Results: Trauma and orthopaedics and Neurosurgery had an overall
score of 0 % while plastics scored 42 %. Majority of doctors did not
adhere to prescription guidelines. There were poor results in 24-h
reassessment rule or 5th day blood check. There was poor supply of
prescribersa€TM information with regards to General Medical Council
guideline in both Trauma and Orthopaedics and Neurosurgery (60 and
42 %).
Conclusion: There is urgent need for VTE risk assessment culture
change among junior doctors bearing in mind the huge financial costs
and complications associated with VTEs. GMC prescribing guidelines
need to be adhered to.
References: Venous thromboembolism (VTE) prevention in the
hospital. Transcript of presentation. June 2010. Agency for Health-
care Research and Quality, Rockville, MD. http://www.ahrq.gov/
qual/vtepresentation/maynardtranscr.htm NICE Clinical Guidance 82:
Venous Thromboembolism: reducing the risk Dr Roopen Arya
Kinga€TMs College Hospital London. VTE Risk Assessment
powerpoint.
Disclosure: No significant relationships.
P091
THIRTEEN TO 35-YEAR FOLLOW UP AFTER OPENREDUCTION AND INTERNAL FIXATION OF TIBIALCONDYLAR FRACTURE
G. Mattiassich1, E. Foltin1, A. Schneiderbauer1, M. Van Griensven2,G. Scheurecker3, A. Kroepfl1, M. Fischmeister1
1UKH Linz Trauma Center, UKH Linz Trauma Center, Linz, Austria,2Ludwig Boltzmann Institute for Experimental and Clinical
Traumatology, Vienna, Austria, 3Institut fur CT- und MRT-
Diagnostik am Schillerpark, Linz, Austria
Introduction: A fork-shaped plate designed by Streli was used to
stabilise tibial condylar fractures during the years 1979–1998. In the
years 1985 and 1999 follow up examinations were performed. These
patients were reevaluated.
Materials and methods: Participants of two former studies in 1985
and 1999, treated with ORIF and fork-shaped plate for tibial condylar
fracture were included in the study. Clinical records were analyzed,
X-ray and MRI examinations were performed. The Knee injury and
Osteoarthritis Outcome Score (KOOS) was the main clinical outcome
parameter. The local Ethics Committee approved the study.
Results: Twentysix patients were available for the second follow up
examination after 21.4 years (range 13–35). Arthroscopy was per-
formed in 4 patients after healing of the fracture. Total knee
arthroplasty was needed in 1 case. Two patients had an extension lag
of more than 10�. Five had a flexion deficit of more than 20 degrees.
The average pain-score (KOOS) was 79.5 ± 25.8. For comparison
with the first follow-up examination subjective pains were dichoto-
mized as (1) not severe and (2) severe: 55 and 15 % remained in class
(1) and (2), respectively. About 15 % deteriorated from (1) to (2),
whereas another 15 % described pain as ameliorated from (2) to (1).
Radiologically the percentage of grade III an IV osteoarthritis
increased from 15 to 30 %.
Conclusion: It is to be concluded that the objective results after tibial
condylar fracture deteriorate in the long run, but there is not neces-
sarily an increase in subjective complaints.
Disclosure: No significant relationships.
P092
TREATMENT OF UPPER TIBIAL METAPHYSEAL ANDTIBIAL PLATEAU FRACTURES USING HYBRIDEXTERNAL FIXATORS
K.I. Papagiannakos1, P. Kakavas1, I. Akrivos1, K.J. Doudoulakis2,A.A. Priftis2, G. Protopapadakis3, P. Kalantzis1, P.Papagiannopoulos1
12nd Orthopaedic, ‘‘Evangelismos’’ Hospital, Athens, Greece,2Orthopaedic, ‘‘Evangellismos’’ Hospital, Athens, Greece, 32nd
Orthopaedic, ‘‘Evangelismos’’ Hospital, Athens, Greece
Introduction: The aim of this study is to evaluate the outcomes after
stabilisation of proximal tibial an tibial plateau fractures using a
hybrid ring external fixator.
Materials and methods: Between 1996 and 2010, 25 patients (26
fractures) with proximal tibial fractures were treated with hybrid ex-
fix. 14 were men and 11 women. The average age was 42.8 years
(18–88). A road traffic accident was the cause for 18 patients and a
fall from height for the remaining 7.
Results: Follow up ranged from 1 to 14 years. One fracture had to be
converted to IM nail due to non-union. The remaining fractures
healed at an average time to union of 3.4 months. Superficial pin tract
infection complicated the treatment in 7 patients. One peroneal nerve
palsy needed exploration. Early osteoarthritic changes were seen in 2
patients. One patient developed varus malalignment (*15�).
Conclusion: Hybrid ex-fix is a good method for treating upper met-
aphyseal and tibial plateau fractures, even Schatzker V and VI. It
allows corrections and conversion to different fixation methods if
needed, and is versatile in its application.
Disclosure: No significant relationships.
P093
HOW TO EVALUATE THE QUALITY OF FRACTUREREDUCTION AND FIXATION OF THE CALCANEUS INCLINICAL PRACTICE? AN INTERNATIONAL DELPHICONSENSUS
M.S.H. Beerekamp1, J.S.K. Luitse1, M. Maas2, D.T. Ubbink3,N.W.L. Schep1, J.C. Goslings1
1Trauma Unit, Department of Surgery, Academic Medical Center,
Amsterdam, Netherlands, 2Radiology, Academic Medical Center,
Amsterdam, Netherlands, 3Department of Quality & Process
Innovations, Academic Medical Center, Amsterdam, Netherlands
Introduction: The radiological evaluation of the quality of fracture
reduction and fixation of the calcaneus is based on the surgeons and/
or radiologists frame of reference. A generally accepted scoring
S164 Abstract
123
protocol is currently not available. The aim of this study was to obtain
consensus regarding criteria for the radiological evaluation of calca-
neus fractures.
Materials and methods: A Delphi study was conducted, consisting
of an online questionnaire, focusing on the interpretation of X-rays
and CT-scans after reduction and fixation of calcaneus fractures. A
sample of 10 radiologists and 44 trauma or orthopaedic surgeons, all
experts in calcaneus fractures, from the USA and Europe were invited
to respond. Questions addressed imaging technique, aspects of the
anatomy and fracture reduction and fixation. Agreement was
expressed as the percentage of respondents with similar answers.
Consensus was defined as an agreement of at least 80 %.
Results: In three Delphi rounds, 16, 18, and 13 specialists responded,
respectively. Agreement was reached for 22 of the 38 (58 %) imaging
techniques, 19 of the 21 (90 %) aspects of the anatomy and 11 of the
16 (69 %) items for the fracture reduction and 8 of 9 items (89 %) for
fracture fixation. In addition, agreement was reached on how (not) to
evaluate evaluation criteria.
Conclusion: In this clinically based consensus measurements do not
take a prominent place, in contrast with previous scoring systems.
However, more aspects were considered important than in the tradi-
tional scoring systems. This consensus can be used as an educational
tool, but also to create more uniformity in the radiological evaluation
of the calcaneus in clinical practice.
Disclosure: No significant relationships.
P094
REFIXATION FOR SIMPLE AND COMPLEX FRACTURESOF THE TIBIAL INTERCONDYLAR EMINENCE USING THETIGHTROPETM SYSTEM
R. Glaab1, W. Siekmann2, C. Ryf3, M. Loibl4
1Traumatologie, Kantonsspital Aarau, Aarau, Switzerland, 2Klinik
Fleetinsel, Hamburg, Germany, 3Spital Davos, Davos, Switzerland,4Universitatsklinikum Regensburg, Regensburg, Germany
Introduction: Despite numerous techniques described fixing these
rather rare tibial eminence fractures is challenging. Screw fixation has
its biomechanical limitations while suture fixation often lacks
strength. Correct reduction is considered crucial for good results. The
limitation for this technique is seen in multifragmentary fractures
(Zaricznyj IV) and.
Materials and methods: The TightRopeTM (Arthrex Inc, Naples,
FL.) System is well established in ankle and acromioclavicular
reconstructive surgery. It consists of two buttons, connected with a
high tensile strength suture in a block and tackle principle. We treated
six patients with isolated avulsions (ACL and PCL, Meyer-McKe-
ever/Zaricznyj II and III) arthroscopically and four patients with
combined fractures of the tibial plateau (AO 41 B3, Moore II) in open
techniques.
Results: All patients had an uneventful recovery. Simple fractures
have been to full weight bearing after 6 weeks and have back into
their preoperative level of sports and activities of daily living at
6 month. So far we had no postoperative complication or implant
removal.
Conclusion: Our technique is easily replicable, needs no extra portals
or new tools and shows convincing biomechanics. The result is very
stable and allows for early functional mobilisation.
References: 1. Meyers MH, McKeever FM. Fracture of the interc-
ondylar eminence of the tibia. JBJS, 1959. 2. Zaricznyj B. Avulsion
fracture of the tibial eminence: treatment by open reduction and
pinning. JBJS, 1977.
Disclosure: No significant relationships.
P095
CLASSIFICATION OF PROXIMAL ULNA FRACTURES:A NEW POINT OF VIEW
F. Bakal, S. Nijs
Traumatology, University Hospitals Leuven, Leuven/Belgium
Introduction: Proximal ulna fractures are relatively common and not
related to a specific age group. Multiple classification systems have
been described to illustrate the severity of the fractures and the cor-
related surgical treatment as an ideal necessity. However, its use in
the clinical-therapeutic setting is controversial since there is no
classification universally accepted.
Materials and methods: In our study we performed a radiographic
analysis of 101 cases, all surgically treated between 2004 and 2010 in
our department of Traumatology, to devise a new classification sys-
tem for proximal ulna fractures. Our underlying principle is to
illustrate the fracture patterns at first. This will lead to understand the
necessary characteristics of the osteosynthesis implants as a treatment
to each fracture type.
Results: It takes into account 3 major categories which are based on
the etiologic mechanism of the fractures: avulsion fractures (category
A; 50 patients), impaction fractures (category B; 30 patients) and bow
fractures (category C; 17 patients). Four patients were excluded due to
pathological or other than proximal ulna fractures. Furthermore, the
majority of the studied cases is younger than 65 years old (60
patients) and more than a third is older than 65 years (37 patients).
Conclusion: This emphasizes the need for a classification with
clinical-therapeutic significance.
Disclosure: No significant relationships.
P096
IS ARTIFICIAL LIGAMENT RECONSTRUCTION IS ANEFFECTIVE OPTION IN MANAGING PATIENTS WITHMULTIPLE LIGAMENT INSTABILITY FOLLOWING KNEEDISLOCATION?
S. Lakkol1, R. Patel1, A. Lakdawala2, R. Varma2
1Trauma & Orthopaedics, Kings College Hospital, London/United
Kingdom, 2Trauma & Orthopaedics, King’s College Hospital,
London/United Kingdom
Introduction: Management of multiligament instability following
knee dislocation can be challenging. Multiple ligament reconstruction
and rehabilitation is one of accepted surgical option. It is debated
whether to reconstruct ACL, PCL & PLC as a single procedure or as
staged procedure. The graft options include autologous grafts from
non injured site, allograft or artificial grafts.
The aim of the study is to assess the efficacy of total artificial liga-
ment reconstruction in knee dislocations.
Materials and methods: This is a retrospective study conducted at
level trauma center in London. Patients with multiple ligament
instability following knee dislocation and who underwent early
Abstract S165
123
reconstruction using Ligament Augmentation & Reconstruction
System (LARS) were included in the study. No autologous graft was
used. Patients’ quality of life was assessed using SF36. Their activity
was recorded using Tegner activity score and knee function was
assessed clinically and with Lysholm scores.
Results: There were 12 patients. They were assessed at minimum of
1 year following the procedure. The average age was 33 years. All
patients were back to full time work at the time of final follow-up. All
had good range of movement. Only three patients had grade I laxity
on anterior drawer test and one patient had slight laxity of PCL.
Conclusion: The benefits of LARS ligament reconstruction include
early enhanced recovery due to absence of graft site pain on the contra
lateral leg and reduced risk of disease transmission as would be with
allograft. This review shows that LARS ligament reconstruction for
multiple ligament instability following knee dislocation is an effective
alternative option.
Disclosure: No significant relationships.
P097
FRACTURE PATTERNS IN THE FRACTURE UNIT, ROYALVICTORIA HOSPITAL: EXPERIENCE OVER THE PAST 11YEARS
K.W. Chan, S. Mcdonald, D. Kealey
Trauma and Orthopaedic Surgery, Royal Victoria Hospital, Belfast,
UK
Introduction: Royal Victoria Hospital is a major trauma centre
serving the greater Belfast population of 646,000 for management of
general fractures and also acts as tertiary referral centre for spinal
trauma/fractures, pelvic fracture, limb reconstruction and major
polytrauma for the whole Northern Ireland population of 1.79 million.
Materials and methods: The fracture outcome unit collected and
stored the data of 35,538 patients being admitted to the fracture unit
from year 2000 to 2010. Demographic of the fracture patterns were
identified and analysed for the purpose of this study.
Results: We believe that the data available to us were the biggest
available for analysis of fracture patterns in Northern Ireland. Female
made up 53 % of patients admitted to our unit. The highest number of
patients admitted to this unit was in the age range of 80–89 years old.
Mean admission was 3,231 patients per year and half of the workload
of this unit was for fragility fracture (patient aged more than 65 years
old). 10,529 hip fractures were treated over the past 11 years, con-
tributing to 30 % of the workload of our unit. Spinal fractures and
tumour contributed to 11 % of the workload, followed by tibia/fibula
(9.7 %), ankle (9.4 %) and polytrauma (9.0 %).
Conclusion: Treatment of fragility fracture will remain significant
and challenging with the ageing population in this region.
Disclosure: No significant relationships.
P098
ACUTE FRACTURE CARE BY EXTERNAL FIXATION INPATIENTS WITH OPEN PHYSEAL PLATE
F. Sala, M. Othman, F. Castelli, D. Capitani
Orthopaedic Trauma Team, Niguarda Hospital, Milano, Italy
Introduction: The accepted treatment for unstable displaced long
bone fractures in adult is primary closed reduction and intramedullary
nailing or plating. However, this method poses a problem when
treating young adolescents whose epiphyseal plates have not yet
closed. We used the external fixation as a definitive method of
treatment for these patients.
Materials and methods: 18 patients with displaced unstable humeral
(1), tibial (9), and femoral (8) fractures (age 4 to 14 years) of which 2
were open (Gustilo II-III), were treated by this method from 2003 to
2009. All patients were allowed to weight bear from the first post-
operative week. Physiotherapy was started immediately after
operation and continued until normal knee and ankle function was
regained. Dynamization was done in all cases 2 weeks before removal
of frame.
Results: A good or excellent alignment with full ROM in the ankle
and knee joint was obtained in all patients. There were no cases of
delayed or non union. No cases of contractures or nerve injuries were
reported. Superficial pin tract infection was seen in 5 patients, treated
by antibiotics and local care. No case of osteomyelitis or deep
infection occurred. Length of fixation was 8-20 weeks (mean-
12 weeks).
Conclusion: This method permits fixation without danger of injury to
the epiphysis in growing adolescents. The stability of the fixator
allows early weight bearing and leaves the adjacent joints mobile. The
healing time is relatively shorter than in other methods of the treat-
ment and the complications rate was low in the presented series.
Disclosure: No significant relationships.
P099
ARE CLASSIFICATION METHODS SUFFICIENT FOR TIBIAPLAFOND FRACTURES? DO WE NEED ANY OTHER?
C. Copuroglu1, B. Yilmaz2, M. Ozcan1, M. Ciftdemir1, K. Saridogan1
1Orthopadics and Traumatology, Trakya University, Edirne, Turkey,2Besni Government Hospital, Adiyaman, Turkey
Introduction: To evaluate the availability and effectiveness of the
classification methods used in tibia plafond fractures.
Materials and methods: X-rays and computed tomogra-
phy(CT)sections of 54 tibia plafond fractures were retrospectively
evaluated.AO classification, Schatzker and Moore classification
methods were used.Ten experienced orthopaedic surgeons evaluated
the data 2 times in a one month interval.In the first evaluation, only
X-rays were given to the observers and need for CT for evaluation
was asked. One month later, same X-rays and CT sections of the
fractures were given to the observers.The results were examined for
sufficiency and for coherence, as an intra-interobserver study.
Results: In the first examination, 74.6 % of the observers needed CT
sections for a reliable evaluation. By using X-rays and CT, observers
could classify 96.4 % of the fractures with AO, 94.7 % with
Schatzker and 78.8 % with Moore classification. By using only
X-rays interobserver coherence was 67.9 % in AO, 68.5 % in
Schatzker, 58.3 % in Moore. When CT is added to X-rays, interob-
server coherence was 77.2 % in AO, 82.9 % in Schatzker, 69 % in
Moore. By only X-rays, intraobserver coherence was 9.26 % in AO,
6.48 % in Schatzker and 16.6 % in Moore. When CT is added in-
traobserver coherence was 6.48 % in AO, 2.77 % in Schatzker,
15.7 % in Moore.
Conclusion: The most detailed AO classification is the most available
classification while simplest Moore is the least. Moore classification
is the most coherent. Coherence decreases when CT is added to
S166 Abstract
123
X-rays. These results show that observers can classify fractures better
by using more detailed classification methods but detailed classifi-
cation methods are difficult to use. Detailed but available
classification method is needed and when these situations are taken
into consideration, Schatzker seems to be the most available method,
in these classification methods.
Disclosure: No significant relationships.
P100
OUTCOME AFTER PATELLA FRACTURE
S. Wurm1, P. Augat2, V. Buhren1
1Trauma Surgery, BG-Unfallklinik Murnau, Murnau/Germany,2Institute for Biomechanics, BG-Unfallklinik Murnau, Murnau/
Germany
Introduction: About 0.5–1.5 % of all skeletal injuries are patella
fractures. Although the patella is a small bone, the rate of compli-
cations is high: Almost half of the patients have residual pain and one-
third reduced function.
Materials and methods: Therefore, we retrospectively analysed the
operative treatment and the outcome of patients suffering from a
patella fracture.
Results: Between 1/2009 and 8/2011 43 patients (49.5 ± 18.7 years)
with a patella fracture were treated operatively in the Trauma Center
Murnau. 21 patients (48 ± 19.4 years) were treated with tension band
wiring, 12 patients (50.3 ± 17.9 years) with screw fixation and 10
patients (51.5 ± 17.6 years) with a special patella plate. After tension
band wiring one-third of the patients had a good outcome without
problems, but 43 % suffered from pain and 28.6 % had a reduced
function. Furthermore, we saw one delayed union and one failure of
the osteosynthesis. Screw fixation produced a better outcome: 50 %
had no problems, one-third suffered from a reduced function and
17 % had still pain. The best results were seen after plate osteosyn-
thesis: Only 10 % had a limitation in high flexion and residual pain. A
failure of the osteosynthesis or delayed union was not found.
Conclusion: In conclusion, there is relatively high complication rate
after patella fracture, especially when using tension band wiring. The
plate osteosynthesis seems to be a good alternative in the treatment of
patella fractures reducing considerably the complication rate.
Disclosure: No significant relationships.
P101
IS OLECRANON OSTEOTOMY A MUST, IN THE SURGICALTREATMENT OF DISTAL HUMERUS PARTIALINTRA-ARTICULAR FRACTURES?
C. Copuroglu1, B. Yilmaz2, M. Ciftdemir1, M. Ozcan1, K. Saridogan1
1Orthopadics and Traumatology, Trakya University, Edirne, Turkey,2Besni Government Hospital, Adiyaman, Turkey
Introduction: The need for olecranon osteotomy in the humerus
distal end partial intra-articular fractured patients and the effects of
the osteotomy on clinical results were evaluated.
Materials and methods: Forty-one humerus distal end AO type B
fractured patients, between 2006 and 2010, were retrospectively
evaluated. Two study groups were formed as olecranon osteotomy
applied(Group 1) and non olecranon osteotomy applied (by paratri-
cipital approach)(Group 2). Surgical time, complications and healing
periods were compared. Functional results were evaluated with the
Mayo elbow performance score and Quick-DASH score.
Results: Group 1 had 22 patients (16 men, 6 women) and Group 2
had 19 patients (11 men, 8 women).Time between fracture and
operation was 4.3 days (1–14 days), mean follow-up time was
19.4 months (12–36 months). Surgical time for Group 1 was
133 min, and 171 min for Group 2.No severe complications were
seen. Radiological healing times were similar in both groups. In group
1, mean total range of motion was 89.6� and 93.2� in group 2. Mean
Mayo elbow performance score was 85.4, in group 1 and 90.2, in
group 2. Mean Quick DASH score was 6.46 (2.27–13.63) in group 1
and 5.97 (2.27–11.36) in group 2.
Conclusion: In the olecranon osteotomy group, surgical time was a
little bit longer but healing time and complication rate was similar for
both groups. Olecranon osteotomy group had better mean range of
motion and functional scores. As a result, for the humerus distal end
partial intra-articular fractures, while applying open reduction-inter-
nal fixation with plates, olecranon osteotomy is not a must, unless
there is difficulty in providing articular congruency.
Disclosure: No significant relationships.
THE ACUTE CARE SURGEON
P102
MODIFIED TECHNIQUE FOR DELAYED PRIMARYCLOSURE OF FASCIOTOMY WOUNDS
D. Jurisic, B. Hreckovski, V. Pitlovic, D. Rosko, J. Jankovic, J. Mihic
Surgery, General Hospital, Slavonski Brod/Croatia
Introduction: While pathophysiology and management of compart-
ment syndrome is well documented in the literature, fasciotomy
wounds are still a difficult reconstructive challenge to the surgeon.
Materials and methods: Management of the fasciotomy wounds
postoperatively has consisted traditionally of split-thickness skin
grafting, healing by secondary intention and delayed primary closure.
The keystone of delayed primary closure relies on the visco-elastic
properties of the skin and the stretching potential of the soft tissues.
Results: Our technique for delayed primary closure of the fasciotomy
wounds combines the subcuticular suture technique with the VAC
system.
Conclusion: The technique presented is simple, allows for earlier
rehabilitation and is useful even in patients with very thin and fragile
skin which are poor candidates for treatment with dermatotraction.
Disclosure: No significant relationships.
P103
A MAJOR HEMORRHAGE PROTOCOL IMPROVES THEDELIVERY OF BLOOD COMPONENT THERAPY ANDREDUCES WASTE AS PART OF DAMAGE CONTROLRESUSCITATION OF TRAUMA PATIENTS
S. Khan1, S. Allard2, R. Davenport1, A. Weaver3, I. Raza1, K. Brohi1
1Trauma Science, Trauma Academic Unit, Queen Marys and
University of London, London, UK, 2Haematology And Transfusion
Abstract S167
123
Medicine, Barts and The London NHS Trust & NHSBT, London, UK,3Emergency Medicine and Pre Hospitalm Care, Barts and The
London NHS Trust, London, UK
Introduction: Major hemorrhage protocols (MHP) are required as
part of damage control resuscitation regimens in modern trauma care.
The primary objectives of this study was to ascertain whether a MHP
improved blood product administration and reduced waste compared
to traditional Massive Transfusion Protocols (MTP) (1).
Materials and methods: Datasets on adult trauma admissions 1 year
prior and 1 year post implementation of a MHP at a Level 1 trauma
centre were obtained from the trauma registry. Demographic and
clinical data were collected prospectively including mechanism of
injury, physiological observations, ICU admission and length of stay.
The volume of blood components (packed red blood cells, platelets,
cryoprecipitate and fresh frozen plasma) issued, transfused, returned
to stock and wasted within the first 24 h was gathered retrospectively.
Results: Over the 2 year study period 2986 patient records were
available for analysis. 40 patients required a 10+ units of packed red
blood cells in the MTP group vs 56 patients post MHP implementa-
tion. The administration of blood component therapy improved
significantly post MHP implementation. FFP:PRBC transfusion
improved from 1:2.7 to 1:2 (p \ 0.01) and CRYO:PRBC improved
from 1:10 to 1:6.5 (p \ 0.01). Platelet transfusion improved from
72 % to 87 % (p \ 0.01) and there was also a significant reduction in
the waste of platelets from 14 to 2 % (p \ 0.001). Outcomes had
improved:.Median hospital length of stay was reduced from 54 to
26 days (p \ 0.05).
Conclusion: Implementation of a MHP results in improved delivery
of blood components and a reduction in the waste of blood products
compared to the older model of MTP. In combination with educa-
tional programs MHP can significantly improve blood product
administration and patient outcomes in trauma hemorrhage.
References: Stanworth SJ, Morris TP, Gaarder C, et al. Reappraising
the concept of massive transfusion in trauma. Crit Care. 2010;14(6):
R239.
Disclosure: No significant relationships.
P104
ARE WE MEETING THE EXPECTATIONS OF OURORTHOPAEDIC TRAUMA PATIENTS? A TWO YEAREXPERIENCE AT LEEDS GENERAL INFIRMARY, UK
S. Jain, S. Harrison, J. Rushbrook
Trauma & Orthopaedic Surgery, Leeds General Infirmary, Leeds/
United Kingdom
Introduction: The British Orthopaedic Association (BOA) developed
guidelines setting out the expectations of trauma patients in 20071.
This highlighted numerous issues relevant to our patient group. Our
study was conducted at Leeds General Infirmary which is one of the
largest trauma centres in the UK. Our aim was to learn from Patient
Reported Outcome Measures (PROMs) in order to provide the best
possible care.
Materials and methods: Key objectives within the BOA guidelines
were highlighted and rewritten into a questionnaire. Forty patients
were asked how much they agreed with each statement. Question-
naires were completed within a day of operative management.
Patients were excluded if they were lacking in mental capacity. This
study was initially carried out in 2009 and again in 2011 following
structural changes to our department.
Results: Adequate administration of analgesia, obtaining informed
consent, being promptly admitted, the understanding of delays in
surgery and the opportunity to meet with an anaesthetist were areas
that improved. The opportunity to meet with the surgeon pre-opera-
tively and being informed of delays remained areas in which we
performed well. However, patients felt that they were less promptly
assessed on arrival to the emergency department.
Conclusion: Changes implemented since 2009 include the develop-
ment of an orthopaedic trauma ward, the addition of trauma
managers, dedicated ‘‘hip fracture’’ operating lists, the use of hip
fracture pathways and the development of a multi-specialty assess-
ment area. This study has shown great progress within our
department. However, improvements are necessary to improve patient
satisfaction.
References: Expectations of Trauma Orthopaedic Patients, British
Orthopaedic Association, 2007.
Disclosure: No significant relationships.
P105
HOMOLATERAL DISLOCATION OF THETARSOMETATARSAL JOINT COMPLEX-CASE REPORT
M.Z. Ivanovic, A.D. Stamenkovic, N.M. Markovic, Z. Vukmirovic,V. Rankovic
Department for Traumatology and Orthopedic Surgery,
KBC ‘‘Zvezdara’’, Belgrade, Serbia
Introduction: We present 44-years-old women, very obese and
poorly movable. Mechanism of injury was indirect loading which
produced significant disruption of the whole complex of Lanfranc’s
joint.
Materials and methods: Patient has fallen on the same level.
Orthopedic clinical examination revealed pain over the tarsometa-
tarsal joint complex and presence of medial plantar ecchymosis.
Passive dorsiflexion and plantar flexion of individual metatarsal heads
were elicited pain at the proximal articulations. X-ray evaluation
finded a total homolateral incongruity without fractures of the base of
the second metatarsal bone (type A—Myerson’s classification).With
the patient under general anesthetic we started immediate open
reduction and internal fixation. We restored and fixation the medial
column. The lateral column required no fixation. For fixation used
3.5 mm screws. The foot is immobilized in a non-weight-bearing,
plantigrade short cast for 4 weeks.Partial weight bearing allowed after
4 weeks, full weight bearing started after 6 weeks. Screws are
removed at 6 months after surgery .
Results: After 1 year follow-up patient is without pain and presence
of posttraumatic arthrosis.
Conclusion: The best resultants depends only on ability of early
operation, anatomic reduction of the joint complex and the restoration
of the arch.
Disclosure: No significant relationships.
S168 Abstract
123
P106
CENTROLOBULAR HEPATIC NECROSIS FOLLOWINGELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY
A. Karentzos1, S.G. Koulas1, G. Pappas-Gogos2, N. Zikos2,N. Katsamakis2
1Surgery, General Hospital of Ioannina, Ioannina, Greece, 2Surgery,
Filiates General Hospital, Filiates, Greece
Introduction: Acute liver failure is an uncommon condition in which
the rapid deterioration of liver function results in coagulopathy,
alteration in the mental status and a very high mortality.
Materials and methods: A 72 year old woman was operated for
laparoscopic cholecystectomy. Her medical history included heavy
smoking and hypertension. On the next day, typical laparoscopic
cholecystectomy was performed and a Jackson-Pratt drain was
inserted in the pouch of Morrison.
Results: The drain was removed on the is POD On the 2nd POD
abdominal U/s was performed and an amount of free fluid was
detected. On the 3rd POD the patient underwent exploratory lapa-
rotomy through a right Kocher incision. Chyloperitoneum was
detected and common bile duct exploration was performed. Biliary
stones residues were detected and removed and a T-tube was intro-
duced in the CBD. On the same night she presented suddenly with
hypotension (BP: 80/60 mmHg) which was treated with rapid infu-
sion of intravenous fluids and correction of electrolytic imbalance and
the patient quickly regained haemodynamic stability. She was given
analgesics (3 g of paracetamol) in the last 24 h. The next morning the
patient was initially lethargic and finally in a state of stupor. Resus-
citation efforts were immediately initiated. Lab tests findings included
low hematocrit, low platelets number, hypoglycaemia, profoundly
elevated liver function enzymes. No pathological findings were
detected on abdominal U/S and T-tube cholangiography demonstrated
the patency of the biliary tree. The patient was finally intubated and
transferred to the ICU of the University Hospital of Ioannina where
she died after 24 h due to hyperpyrexia and centrilobular hepatic
necrosis.
Conclusion: A positive correlation between the amount of covalent
binding and the severity of centrilobular necrosis was obtained after
various drug treatments and with several different halogenated ben-
zene derivatives of varying hepatotoxicity. These results suggest that
covalent binding of toxic metabolites may be an important mecha-
nism in the pathogenesis of tissue lesions elicited by a variety of
foreign compounds.
Disclosure: No significant relationships.
P107
UNEXPECTED LEFT VENTRICLE INJURY AFTER FALLOVER GLASS TABLE. LESSONS LEARNT
Y. Caballero, C. Rosas Bermudez, M. Braithwaite, J. Ceballos,F. Rodrıguez, D. Fernandez, V. Nunez
General Surgery Department, Hospital Universitario Insular de Las
Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
Introduction: Severe trauma often hide surprising injuries that
require fast-decision making abilities that can only be gained through
experience and training. Penetrating injuries to the abdomen not only
requires careful inspection of the cavity but also of the neighbouring
structures.
Introduction: Severe trauma often hide surprising injuries that
require fast-decision making abilities that can only be gained through
experience and training. Penetrating injuries to the abdomen not only
requires careful inspection of the cavity but also of the neighbouring
structures.
Materials and methods: A 53 year old male was brought after
falling from a height of 1.7 m onto a glass table. On arrival to the
hospital ATLS was initiated. Primary survey at the hospital revealed a
tender acute abdomen with a penetrating injury in the superoexternal
portion of the left gluteus. An ECO FAST showed intraabdominal
free fluid and alteration in the echo-structure of the spleen. With the
suspicion of a splenic rupture, the patient was taken to theatre.
Midline laparotomy was performed revealing 300 cc of haemoperi-
toneum, an intact spleen, complete laceration of both transverse and
descending colon, a 25 9 4 cm triangular shaped glass fragment and
a penetrating injury on the left diaphragm with jet bleeding directly
from the left ventricle. A ‘‘clamshell’’ bilateral thoracotomy incision
was then performed in order to expose and control the injured thoracic
structures. The patient suffered a cardiac arrest, requiring internal
cardiac massage, supraceliac aortic clampage, blood transfusion and
drug support. After successful resuscitation and stabilisation, the left
ventricle was repaired. The injury to the left diaphragm was sutured,
the glass fragment was removed and a Hartmann’s procedure was
performed.
Results: After surgery, patient required ICU support and was dis-
charged home 18 days later after favourable recovery. The patient had
a wound infection and a transient ischaemia of the stoma due to
oedema. 8 months later, reconstruction of the colonic transit and
abdominal wall plastia were performed.
Conclusion: Trauma due to penetrating injuries can have unsuspected
tracts and lesions that can add further complexities to the surgical
treatment. Surgical treatment must not be delayed in the pursuit of a
clearer diagnosis.
Disclosure: No significant relationships.
P108
TRAUMA SURGERY IN PATIENTS RECEIVINGANTICOAGULANT THERAPY: IS IT SAFE?
M. Anastasiu, R. Popescu, N. Micu, R. Dedu, A. Ivan
Emergency and General Surgery, Emergency County Hospital,
Buzau, Romania
Introduction: Perioperative management of trauma patients receiv-
ing anticoagulant therapy who have major bleeding or need to
undergo emergency surgery is a complex medical problem.
Materials and methods: A 36 month retrospective study was per-
formed on trauma patients admitted in our hospital and who received
therapeutic anticoagulation using warfarin and fractionated heparin.
Data collected included demographics, traumatic injuries findings and
surgical procedures required, comorbid diseases, indication and type
of anticoagulation, complications rate resulting from anticoagulation
and the management of life-threatening bleeding. All statistical
analyses were performed using SPSS for Windows and categorical
variables are compared using Chi-square or Fischer Test.
Results: From the 2240 trauma patients admitted in our hospital, we
identified 92 anticoagulated patients (4 %) who underwent surgical
procedures. Fifty-eight patients (63 %) had different comorbid dis-
eases (hypertension, DVT, atrial fibrillation and cerebral ischaemic
Abstract S169
123
attack). For 55 patients (60 %) it was necessary a ‘‘bridging therapy’’
protocol but in major life-threatening haemorrhage (9 patients) the
anticoagulant treatment was fully stopped and Prothrombin complex
concentrate infusion is performed. We identified 22 complications
(24 %) related to anticoagulant therapy that required emergent blood
transfusion and haemostatic therapy. Nine patients died and 7 of them
had a major complication of anticoagulation. The bivariate analysis
certified current pulmonary embolism, chronic obstructed pulmonary
disease, chronic liver disease and lower initial platelet count associ-
ated with complications.
Conclusion: The management of hemorrhage in the anticoagulated
patient is complex and is based on balancing the risks and benefits of
each intervention.
Reference: Tchachil J. Management of surgical patients receiving
anticoagulants. Br J Surg. 2008;1437–48.
Disclosure: No significant relationships.
P109
RUPTURE OF ECTOPIC PREGNANCY FOLLOWING ANABORTION FOR INTRAUTERINE GESTATION: A RARECAUSE OF ACUTE ABDOMEN
I. Lintzeris1, X. Agrogianni2, P. Prigouris3, L. Iosifidis3, S. Prigouris3
1Surgery, General Hospital of Tripolis, Tripolis, Greece, 2Medicine
School, University of Athens, Athens, Greece, 3General Hospital of
Athens ‘‘Evangelismos’’, Athens, Greece
Introduction: The coexistence of both an ectopic and an intrauterine
pregnancy consists of a rare but possible clinical entity. We report a
case of acute abdomen caused by the rupture of an extrauterine
gestation following an abortion for a coexistent intrauterine one.
Materials and methods: A 27 year old female patient came to
emergency complaining of abdominal pain, nausea, vomiting. She
had undergone an abortion 7 days ago. Clinical and laboratory
examination revealed signs of acute abdomen and haemorrhage.
Because of her constant worsening clinical state, an exploratory
laparotomy was performed that indicated a bleeding mass in the right
salpinx. Therefore, both the salpinx and appendix were resected.
Results: The histological examination of the surgical specimen
established the diagnosis of a parallel extrauterine pregnancy which
was originally misdiagnosed.
Conclusion: Clinicians should always be aware of the fact that an
intrauterine pregnancy complicated by an ectopic one is unusual and
perhaps life-threatening but not an impossible entity especially now-
adays with the extended use of assisted reproductive technologies.
References: 1. Bugatto F. Heterotopic triplets: tubal ectopic and twin
intrauterine pregnancy. Arch Gynecol Obstet. 2010;282(6):601–6. 2.
Nikolic B. Intrauterine and bilateral tubal ectopic pregnancies. Aust
NZ J Obstet Gynaecol. 2004;44(3):260–1.
Disclosure: No significant relationships.
P110
THE COMPARTMENT SYNDROME OF THE THIGH:ANALYSIS OF 40 PROSPECTIVELY COLLECTED CASES
R. Schmidt1, W. Machold2
1Trauma Surgery, Medical University of Vienna, Vienna/Austria,2Medical University of Vienna, Vienna, Austria
Introduction: Although the compartment syndrome of the thigh
(CST) occurs rarely, it plays a significant role in emergency surgery
because of its high morbidity and mortality. The importance of
diagnosis and treatment is often noted, but in the literature only ret-
rospective studies with small sample sizes (n \ 30) are given. The
purpose of this study was to analyse 40 prospectively collected cases
presented to our department since 1995.
Materials and methods: From 1995 until 2010 data of 39 patients
(40 cases) with a diagnosis of a CST, that were treated at the
department of trauma surgery, Medical University of Vienna, was
collected. Additional information was added from the patient’s charts.
Statistical analysis was done with Microsoft Excel�.
Results: The average age was 36.5 a (11a–87a). Men were more
affected than women (36/3). One patient suffered from a bilateral
CST. In 4 patients an additional CS of the lower leg was found.
Causes of injury varied: stroke (n = 11), trivial fall (n = 4), etc. 16
patients had an accompanying femoral fracture. In 18 cases mea-
surement of the compartment pressure was done (av. 57 mmHg). All
others had conclusive clinical symptoms. 3 cases were treated con-
servatively with unsatisfying results. Most of the patients were
operated with a lateral incision and from the second operation, wound
closure with Epigard� and restraining vessel loops was done. Sec-
ondary the fascia and the skin were sutured in most cases.
Conclusion: The early fasciotomy of all the affected compartments,
the gradual wound reduction and the suture of fascia and skin is
recommended.
Disclosure: No significant relationships.
P111
IMMUNOPHENOTYPING OF POST-TRAUMATICNEUTROPHILS ON A ROUTINE HEMATOLOGYANALYSER
M. Heeres1, K.M. Groeneveld2, L. Koenderman3, L. Leenen2
1General Surgery/Trauma Surgery, University Medical Centre
Utrecht, Utrecht, Netherlands, 2General Surgery/Trauma Surgery,
University Medical Center Utrecht, Utrecht, Netherlands,3Respiratory Medicine, University Medical Centre Utrecht, Utrecht,
Netherlands
Introduction: Flowcytometric markers have been proposed as useful
predictors for the occurrence of post-traumatic inflammatory com-
plications. However, currently the need for a dedicated laboratory and
the labour-intensive analytical procedures, make these markers less
suitable for clinical practice. We tested an approach to overcome
these limitations.
Materials and methods: Neutrophils of healthy donors were incu-
bated with antibodies commonly used in trauma research: MAC-1
(CD11b/CD18), L-selectin (CD62L), FccRIII (CD16) and FccRII
(CD32) in active form. Flow cytometric analysis was performed both
on a FACSCalibur, a standard flow cytometer, and on a Cell-Dyn
Sapphire, a routine hematology analyser.
Results: There was a high level of agreement between the two flow
cytometers, with 77 % for FccRIII, 99 % for active FccRII, 93 % for
L-selectin and 99 % for MAC-1.
Conclusion: Analysis of neutrophil phenotypes on a Cell-Dyn Sap-
phire leads to the same conclusion compared to a standard flow
cytometer. The markedly reduced time necessary for analysis and
reduced labour intensity constitute a step forward in implementation
of this type of analysis in clinical diagnostics in trauma research.
Disclosure: No significant relationships.
S170 Abstract
123
P112
DOUBLE LOCKING PLATE FIXATION OF DENIS II/IIITYPE SACRAL FRACTURES IN UNSTABLE PELVICC-TYPE FRACTURES: RESULTS OF 28 CASES
Y.P. Acklin, M. Germann, C. Sommer
Department of Surgery, Kantonsspital Graubunden, Chur,
Switzerland
Introduction: In vertical unstable AO C-type fractures with associ-
ated Denis type II/III fractures of the sacrum, dorsal pelvic ring
fixation is crucial and several operative methods exist. We describe a
method with dorsal double plating technique.
Materials and methods: From 2001 to 2011, 119 unstable pelvic
ring fractures were treated operatively in our institution. 28 AO
C-type fractures with associated Denis type II or III type fractures
meet the inclusion criteria and were managed using our dorsal double
plate osteosynthesis technique. For osteosynthesis, a posterior median
approach was used, allowing anatomic reduction of the sacral fracture
under visual control. For fixation, two parallel locked compression
plates (LCP 3.5) were used, placing the most lateral screws either
sacral or sacro-iliacal.
Results: 28 patients sustained a vertical unstable pelvic ring injury.
24 patients had unilateral and four patients bilateral sacral fractures.
Associated with the injury, eight patients showed a lumbo-sacral
plexus lesion. In the perioperative period, four infections were
observed which were treated successfully without longterm sequelae.
No iatrogenic nerval injury was observed. Long term follow-up was
available in 19 patients. All fractures united within the follow-up
period.
Conclusion: Dorsal double locking plate fixation of the sacrum by
open approach and direct reduction is a successful and save alterna-
tive to percutaneous iliosacral screw fixation in pelvic C-type
fractures. The risk of iatrogenic nerve injury seems to be low even in
Denis II type fractures. The open approach enables a good quality of
reduction especially in severely displaced fractures, which increases
the postoperative stability even using small 3.5 mm implants.
Disclosure: No significant relationships.
P113
REDUCED MORTALITY IN PATIENTS WITH FULMINANTCLOSTRIDIUM DIFFICILE COLITIS DUE TO A NEWMANAGEMENT PROTOCOL
G.M. Van Der Wilden1, G.C. Velmahos1, N.S. Harris2,W. O’Donnell3, B.T. Thompson3, K. Finn3, E. Bajwa3,H.B. Alam1, M.A. De Moya1, P.J. Fagenholz1
1Surgery, Division of Trauma, Emergency Surgery and Surgical
Critical Care, Massachusetts General Hospital, Boston, USA,2Emergency Medicine, Massachusetts General Hospital, Boston,
USA, 3Internal Medicine, Massachusetts General Hospital, Boston,
USA
Introduction: Fulminant Clostridium Difficile Colitis (FCDC) will
develop in 3–8 % of all patients infected with C. difficile. Mortality
rates range from 12 to 80 %. We hypothesized that a standard pro-
tocol for surgical consultation in CDC would result in earlier surgical
consultation, earlier identification of patients who could benefit from
surgical therapy, and reduced mortality.
Materials and methods: Consensus criteria for surgical consultation
in CDC patients were developed. Compliance with the referral pro-
tocol was evaluated by chart review of all inpatient C. difficile cases.
Results: In a 10-month period, 369 patients developed CDC. 147
patients matched the referral criteria, of which 86 had surgical con-
sultation (compliance with protocol 53 %). 28 patients developed
FCDC, of whom 7 (25 %) died. In FCDC patients the mean time
interval between meeting criteria and surgical consultation was 6.3
(7.5) hours. None of the CDC patients with a single referral criterion
on presentation subsequently developed FCDC. The guidelines were
amended to recommend surgical consultation when 2 or more criteria
were met. Compliance increased to 63 % and the mean time interval
to surgical consultation decreased to 4.7 (4.3) h. Although compliance
with the established protocol was not universal, all patients with
FCDC were promptly identified.
Conclusion: A management protocol with established criteria for
surgical referral in cases of CDC is feasible and reduced mortality by
29 % compared to historical controls.
Reference: Sailhamer EA, Carson K, Velmahos GC. Fulminant
Clostridium difficile colitis: patterns of care and predictors of mor-
tality. Arch Surg. 2009;144(5):433–9.
Disclosure: No significant relationships.
P114
THE RELENTLESS PURSUIT OF THE SURGICAL MD: BUTAT WHAT PRICE?
T.V. Masilonyane-Jones, D. Baschera, R. Zellweger
Orthopaedic Surgery, Royal Perth Hospital, Perth, WA, Australia
Introduction: Surgery is unquestionably among the most demanding
and competitive medical fields. However, the rumour also persists
that surgeons are the more simple minded physicians within the guild.
Our aim was to find out what characterises the surgically minded
medical student.
Materials and methods: In February 2010 we established and online
survey using the open source tool Limsurvey (Version 1.85 RC3).
This was made available to all medical students in countries where
English and German were official languages. Students who identified
surgery as a potential career choice were analysed separately from the
body of survey responses.
Results: Between February and June 2010 we received 2907
responses from 10 different countries. 2,351 answered the key ques-
tion identifying the discipline they would prefer to pursue after
graduation. The 385 (16.4 %) who favoured surgery were on average
six months younger (p = 0.023), more likely to be male (p = 0.01)
and over 20 % were single. Interestingly, the decision to study
medicine amongst the surgical cohort was most likely driven by
perceived high social standing and potential financial reward. These
students were prepared to work more hours per week both during and
after medical school. Conversely, a worrying trend was identified
where the surgical minded student demonstrated higher rates of
alcohol, nicotine and illicit drug consumption.
Conclusion: Medical students who wanted to become surgeons in our
survey appeared more goal orientated and prepared to work longer
hours. Conversely, they were worryingly less health conscious
regarding substance intake.
Disclosure: No significant relationships.
Abstract S171
123
P115
This abstract has been withdrawn.
P116
BILATERAL TIBIA SHAFT FRACTURES IN THEMULTIPLY INJURED PATIENT: A RISK FACTOR FORRESPIRATORY COMPLICATIONS AND MORTALITY?
C.D. Weber, P. Lichte, P. Kobbe, H. Pape
Department of Orthopaedic Trauma, University of Aachen Medical
Center, Aachen, Germany
Introduction: Long bone fractures represent a substantial proportion
in the injury pattern of the multiply injured patient. In patients with
bilateral long bone fractures a high-energy mechanism of injury with
a great degree of kinetic energy is often causal. Several authors
reported an increased risk for associated injuries, systemic compli-
cations and death after bilateral femur fractures. The aim of our study
was to analyse whether patients sustaining bilateral fractures of the
tibial shaft are at increased risk for pulmonary morbidity and
mortality.
Materials and methods: The German Trauma Registry from
1993-2005 was used to perform a retrospective analysis. Individuals
with unilateral (UTF) or bilateral tibia shaft fracture (BTF) and age
[16 years were included. Endpoints were defined as pulmonary
organ failure (POF), multiple organ failure (MOF), sepsis and death.
Univariate data analysis using PASW 18 was performed to compare
demographic data (age, sex, ISS, NISS, AIS). Logistic regression
analysis were performed to determine factors statistically associated
with pulmonary organ failure and mortality.
Results: We identified 2081 patients, including 1862 with UTF and
219 with BTF. The mean ISS was comparable (25.95 vs. 26.21,
p = 0.975). The BTF-Group revealed a significant higher incidence
of POF (34.9 vs. 23.3 %, p = 0.001) and mortality (22.83 vs. 17.3 %,
p = 0.031), but not of MOF and sepsis. Logistic regression analysis
identified BTF as independet risk factor for POF (p \ 0.001, OR
2.1465) and death (p = 0.009, OR 1.848).
Conclusion: We identified BTF as independent risk factor for POF
and even mortality. The ISS underestimates the higher mortality
associated with BTF.
Disclosure: No significant relationships.
P117
PELVIC RING AND/OR ACETABULAR FRACTURERELATED BLEEDING IN LOW-AND HIGH-ENERGYINJURIES
P. Astrom1, T. Soderlund2, L. Handolin2
1Orthopaedics and Traumatology, Helsinki University Hospital,
Helsinki, Finland, 2Helsinki University Hospital, Helsinki, Finland
Introduction: To evaluate the incidence of bleeding related to high-
and low-energy pelvic ring and acetabulum fractures.
Materials and methods: We identified all pelvic and acetabular
fractures treated in Helsinki University Central Hospital between
1.1.2000 and 31.12.2008. Patients were identified from several in-
hospital registries and presence of pelvic/acetabular fracture was
confirmed from X-rays and/or CT-scans. The fractures were classified
by the TILE fracture classification and by the Letournel-classification.
The collected data consisted of patient characteristics, the mechanism
of injury, injury energy, hemodynamic status, blood transfusions,
number of diagnosed injuries, the diagnosis themselves, mortality and
the cause of death.
Results: 1301 patients of which 1168 patients had pelvic ring and/or
acetabular fracture. 827 high-energy pelvic ring and acetabular frac-
tures and 341 low-energy pelvic ring and acetabular fractures. 49 %
of our pelvic fractures were classified as Tile-B. 27 % Tile-A and
24 % Tile-C. The bleeding-rate grew apparently towards the Tile-C
group, bleeding-rate over 60 % (Tile-A 26.5 % and Tile-B 41 %).
The reason(s) for hemodynamic instability were also reviewed ret-
rospectively from the medical records. 343 (29.4 %)
hemodynamically unstable patients, 311 patients received more that 3
units of packed red blood cells within the first 24 h. Half of the Tile-A
fractures arose from low-energy trauma, in the Tile-C group the same
number was only 0.5 %.
Conclusion: Pelvic fracture related bleeding is rare in the low-energy
pelvic ring fractures, but in low-energy acetabular fractures it is more
common. Our study support the findings in earlier studies in which the
more unstable fractures have a higher risk for markable bleeding and
higher mortality-rate.
Disclosure: No significant relationships.
P118
PERIHEPATIC PACKING AND ARTERIOGRAPHY IN THEOPERATING ROOM AS A DAMAGE CONTROL STRATEGYFOR SEVERE HEPATIC INJURIES
T. Mastropietro, S. Manfroni, C. Cataldi, D. Antonellis
Emergency Surgery, ACO San Camillo, Rome/Italy
Introduction: Uncontrolled bleeding is among the most important
cause of death for polytraumatic patients. The rapid management of
the bleeding is one of the most important challenge in the early phase
of the trauma care. For the management of severe hepatic injuries (IV
and V grade), the literature recommends the combined treatment
packing and arteriography followed by arterial embolization.
Materials and methods: During the year 2009, 22 patients with
hepatic trauma underwent surgery, 8 packing and arteriography per-
formed in the operating room. In the patients underwent to damage
control surgery like perihepatic packing, the arteriography was per-
formed in the operating room, with an important reduction of the time
to access to the procedure.
Results: Of the total 8 patients, 7 male 1 female, only 1 died. The
complications have been: 1 necrosis of the hepatic segments and
consequently necrosectomy, 1 perihepatic abscess treated by percu-
taneous drainage and 1 biliary stasis treated by nose biliary drain.
Conclusion: The management of hepatic trauma has to consider:
haemodynamic of the patient, extension of the hepatic lesion, pres-
ence of the other traumatic lesions. The arteriography, followed by
embolization, is a valid technique to control the bleeding hepatic
lesion showed by CT and to complete the damage control surgery, but
it has to be performed early, within 3 h from the hospital admission,
after 3 h the mortality increases. The arteriography performed in the
operating room, after perihepatic packing, allows a reduction of the
time to access to the vascular procedure and a reduction in the time
interval to control bleeding.
Disclosure: No significant relationships.
S172 Abstract
123
P119
TREATMENT OF PEDIATRIC SPLENIC INJURY INA DUTCH LEVEL ONE TRAUMA CENTER: A TWELVEYEAR EXPERIENCE
M. Teuben1, L. Leenen2
1Surgery, University Medical Centre Utrecht, Utrecht, Netherlands,2University Medical Centre Utrecht, Utrecht, Netherlands
Introduction: The treatment of blunt splenic injury in children has
been evolving. Nowadays, nonoperative management (NOM) is the
treatment of choice in hemodynamically stable children. The present
study was conducted to analyse the results of selective NOM for blunt
splenic injury in children.
Materials and methods: All patients (\18) admitted over a 12-year
period were selected from our prospectively composed trauma data-
base. Patient demographics, AIS-spleen, ISS, GCS, hemodynamics,
management and outcome were assessed.
Patients were categorized by type of treatment. Group I consisted of
patients treated by NOM and Group II included patients treated by
operative therapy. Outcome measures included hospitalization time,
ICU-stay, complications and mortality.
Results: A total of 62 patients with a median (IQR) age of 12(8-16)
were identified. The median ISS was 16 (12–29). Failure of NOM
occurred in three patients and one patient was successfully treated by
angio-embolization. Ten splenectomies and three spleen saving pro-
cedures were performed. Patients treated by early laparotomy had
significantly higher grades (IQR) of splenic injury (grade 3 (2–4)) as
compared with patients from group I (grade 4 (4–5)). The median
(IQR) hospital-LOS did not significantly differ between groups and
was 9 (6–18) days in group I and 12 (5–21) in group II. The number of
complications was significantly higher in group II (p = 0.018). One
patient from group II died due to multi organ failure.
Conclusion: Our findings show that children with splenic injury can
be treated safely by selective NOM, with no splenic injury related
deaths. Angio-embolization is used as a adjunct to NOM and can
successfully prevent the need for surgical intervention.
Disclosure: No significant relationships.
P120
A COMPARISON OF THE PLASMA PROTEOME OFPATIENTS WITH APPENDICITIS, MESENTERIALISCHEMIA AND SECONDARY PERITONITIS
B.C. Enholm1, R. Soliymani2, P. Vikatmaa3, M. Karjalainen2,M. Baumann2, A. Leppaniemi1
1The Department of Abdominal Surgery, Helsinki University Central
Hospital, Helsinki, Finland, 2Protein Chemistry Unit, Helsinki
University, Helsinki, Finland, 3Vascular Surgery, Helsinki University
Central Hospital, Helsinki, Finland
Introduction: The plasma proteome of patients with severe appen-
dicitis, secondary peritonitis or mesenterial ischemia were analysed
by LC MS/MS.
Materials and methods: Analysed samples at this point include four
with uncomplicated appendicitis, three with diverticular perforation
and one with confirmed mesenterial ischemia. Plasma samples were
subjected to depletion of the seven most common plasmaproteins,
trypsin-digested and analysed by LC MS/MS consisting of nano-ac-
quity UPLC coupled to a Synapt G2 HDMS mass spectrometer
(Waters, UK). ProteinLynxGlobalServer (PLGS) version 2.4v soft-
ware was used for the processing of raw data and protein database
searching. The results were interpreted in terms of PLGS Mowse
score readouts.
Results: All samples had higher levels of C-reactive protein (CRP)
and serum amyloid A (SAA) as compared to controls. There were
thirteen protein hits in the peritonitis and mesenterial ischemia group
with an over three-fold Mowse score increase as compared to con-
trols. Peptides detected specifically in peritonitis samples included
Light chain of factor I (Score 495.94 vs. 0) and Leucine rich alpha 2
glycoprotein (Score 595.45 vs. 108.06). In contrast, the mesenterial
ischemia sample displayed a divergent proteome that included ele-
vated levels of Complement component 4 binding protein (Score
760.21 vs. 0) and low levels of Apo-E (Score 300.11 vs. 22539.8),
findings that were described previously in patients with critical limb
ischemia (Martin M et al., Ahnstrom J et al.).
Conclusion: Patients with an acute abdomen display diverging
proteomic profiles with a potential for improved diagnostics.
References: 1. Martin M, et al. Complement J Vasc Surg.
2009;50(1):100–6. 2. Ahnstrom J, et al. Clin Biochem. 2010;43(6):
599–603.
Disclosure: No significant relationships.
P121
This abstract has been withdrawn.
P122
INJURY PROFILES RELATED TO MORTALITY INPATIENTS WITH A LOW ISS: A CASE-MIX ISSUE?
P. Joosse, N.L. Schep, J.C. Goslings
Trauma Unit, Department of Surgery, Academic Medical Center,
Amsterdam/Netherlands
Introduction: Outcome prediction models are widely used to eval-
uate trauma care. External benchmarking provides individual
institutions with a tool to compare survival with a reference dataset.
However, these models do have limitations. In this study the
hypothesis was tested whether specific injuries are associated with
increased mortality and whether differences in case-mix of these
injuries influence outcome comparison.
Materials and methods: A retrospective study was conducted in a
Dutch trauma region. Injury profiles, based on injuries most fre-
quently endured by unexpected death, were determined. The
association between these injury profiles and mortality was studied in
patients with a low Injury Severity Score (ISS) by logistic regression.
The standardized survival of our population (Ws statistic) was com-
pared to North-American and British reference databases, with and
without patients suffering from previously defined injury profiles.
Results: In total 14,811 patients were included. Hip fractures, minor
pelvic fractures, femur fractures and minor thoracic injuries were
significantly associated with mortality corrected for age, sex and
physiologic derangement in patients with a low injury severity. Odds
ratios ranged from 2.42 to 2.92. The Ws statistic for comparison with
North-American databases significantly improved after exclusion of
patients with these injuries. The Ws statistic for comparison with a
British reference database remained unchanged.
Abstract S173
123
Conclusion: Hip fractures, minor pelvic fractures, femur fractures,
and minor thoracic wall injuries are associated with increased mor-
tality. Comparative outcome analysis of a population with a reference
database that differs in case-mix with respect to these injuries should
be interpreted cautiously.
Disclosure: No significant relationships.
P123
INTRAMEDULLARY NAILING AS A METHOD OFTREATMENT OF OPEN FRACTURES OF THE FEMORALSHAFT IN CHILDREN
R. Tomaszewski, J. Kler, K. Pethe, A. Gap
Pediatric Orthopedic and Traumatology, GCZD, Katowice, Poland
Introduction: Immediate intramedullary nailing of open fractures of
femur in children remains controversial due to increased rate of
infection. This study presents results of intramedullary nailing of open
femoral shaft fractures.
Materials and methods: From the 1st Jan 2001 to the 1 th Jan 2009
among 166 treated fractures of femoral shaft 19 were open in 18
patients. The mean age of patients was 12,5 years (5-16,5). Using the
Gustilo-Anderson classification there were type I in 12 patients, II in
3, IIIA-2, IIIB-1, IIIC-1.
Results: The mean follow up was 56 month (14–102). In 17 patients
bone consolidation was obtained 3 month post-op. 1 patients with
deep infection presented bone consolidation 4.5 month post-op. That
1 case required change of manner procedure and intramedullary nail
has been substituted with external fixation.
Conclusion: In children with polytrauma, multiple fractures, head
injures and other conditions which necessitate intensive nursing care,
intramedullary nailing of opens femoral shaft fractures(type I, II, IIIA,
IIIB) gives satisfactory results and should be preferred.
Reference: Hosalkar H. Intramedullary nailing of pediatric femoral
shaft fracture. J Am Orthop Surg. 2011;19(8):472–81.
Disclosure: No significant relationships.
P124
COMPLICATIONS IN THE EXTENDED LATERALAPPROACH FOR CALCANEAL FRACTURES DO NOTINFLUENCE LONG-TERM OUTCOME
R.D. Groot1, A. Frima1, T. Schepers2, W. Roerdink1
1Surgery, Deventer Hospital, Deventer/Netherlands, 2Surgery-
traumatology, Erasmus MC, University Medical Center, Rotterdam,
Netherlands
Introduction: Open reduction and internal fixation (ORIF) of intra-
articular calcaneal fractures through an extended lateral approach is
frequently accompanied by a high complication rate. However, ORIF
currently provides the best long-term clinical results. The aim of this
study was twofold: (1) to evaluate both long-term clinical and
radiological results of a consecutive series treated by ORIF and (2) to
determine the influence of short-term complications on long-term
clinical outcome.
Materials and methods: Patients with a displaced intra-articular
calcaneal fracture, treated in a level-2 trauma centre between 1995 to
2008 were evaluated for the study. The long-term functional outcome
and radiographic results were determined. Short- and long-term
complications were documented.
Results: A total of 86 displaced intra-articular calcaneal fractures
were operated in the study-period. Fifty-seven patients matched the
inclusion criteria wherefrom 39 patients agreed to participate in this
study (68 %). Median follow-up was 6.5 years (range 2-16 years).
Based on the AOFAS hindfoot score, 74 % of the patients had a good
to excellent long-term clinical result. Radiological results were sat-
isfying with a median post-operative Bohler angle of 26 degrees and
25� at follow up. Complications occurred in 34 % of all patients;
mainly wound healing problems were noted. Short-term complica-
tions did not influence long-term clinical results (p [ 0.05). Anatomic
reconstruction of the calcaneus was associated with improved long-
term clinical results.
Conclusion: Despite the high complication rate following ORIF of a
calcaneal fracture, complications do not affect long term clinical
outcome. Surgical treatment should focus on restoring the anatomy.
Disclosure: No significant relationships.
P125
RADIOGRAPHIC CHARACTERISTICS AND PATTERNS OFDISPLACEMENT OF LATERAL COMPRESSION TYPEPELVIC FRACTURES
M.J. Weaver, W.E. Bruinsma, E. Toney, E.E. Dafford, M.S. Vrahas
Orthopaedic Trauma Service, Brigham and Women’s Hospital,
Boston, MA, USA
Introduction: Lateral compression (LC) type pelvic fractures are the
most common type of pelvic fracture. Current classification systems
provide little information regarding the stability of these injuries—
particularly those that involve a sacral fracture [1]. The purpose of
this study is to better define the injury characteristics and displace-
ment patterns seen in LC type pelvic fractures. A better understanding
of LC fracture patterns may assist us in our ability to predict fracture
stability and to guide treatment.
Materials and methods: A retrospective study was performed of 318
LC type pelvic fractures. Displacement of the anterior pelvic ring was
identified and measured on plain radiographs and posterior dis-
placement was identified by computer tomography.
Results: Lateral compression fractures including a sacral fracture
represented 87 % of injuries. Posterior fracture patterns varied, with
51 % of having a anterior incomplete fracture, 17 % having a com-
plete simple fracture, 15 % having a complete comminuted fracture
and 13 % having a crescent fracture. Thirty-three percent of fractures
were displaced at presentation. The presence of bilateral rami fracture
(p = 0.001), a comminuted sacral fracture (p \ 0.001), or a crescent
fracture (p = 0.007) indicated an increased incidence of initial
displacement.
Conclusion: Lateral compression type pelvic fractures (in particular
those classified as LC1) represent a heterogeneous group of injuries
with a wide range of associated fracture patterns. Fracture patterns
with more complex sacral fractures, crescent fractures and bilateral
pubic rami fractures tend to have higher degrees of initial
displacement.
Reference: Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring
disruptions: effective classification system and treatment protocols.
J Trauma. 1990;30:848–56.
Disclosure: No significant relationships.
S174 Abstract
123
P126
ISCHEMIC COLITIS: A STANDARDIZED SURGICALTREATMENT
D. Moszkowicz, C. Tresallet, G. Godiris-Petit, S. Noullet,H. Salepcioglu, S. Li Sun Fui, F. Menegaux
General Surgery, Hopital Pitie-Salpetriere, Paris, France
Introduction: The surgical management of ischemic colitis (IC) is
not consensual. Our aim was to assess the indications, extent and
results of standardized surgery in all cases of post-operative (POIC)
and spontaneous (SIC) IC.
Materials and methods: Demographic data, extent of surgery,
mortality, rates and delay of continuity restoration (CR) were pro-
spectively collected in 191 patients with pathology-proven IC: 119
POIC (62 %), including 100 aortic reconstructions and 72 SIC
(38 %). Nonoperative management was limited to endoscopic type 1,
and type 2 without MOF. Patients with type 3 or type 2 with MOF
underwent emergency surgery for resection of the ischemic colon
without anastomosis. The extent of resection was based on endo-
scopic and intraoperative evaluations.
Results: POIC patients were younger than SIC (68 vs 71 yo,
p = 0,01), and more often males (100 M/19F), contrary to CIS
(36 M/36F, p \ 0,001). Seventeen patients were managed exclusively
medically, 10 SIC (14 %) and 7 POIC (6 %), without death. The 174
others (62 SCI/112 POIC) were operated: 96 total (37 SIC/59 POIC),
68 left (17 SIC/51 POIC) and 10 right colectomies (8 SIC/2 POIC)
(p = 0,02). After a median delay of 7 days (0-57) for SIC and
11 days (0-152) for POIC (NS), postoperative mortality was: 47 %
(n = 34) for SIC vs 42 % (n = 50) for POIC (NS). Among 81 sur-
vivors, CR rate was 25 % (7/28) for SIC vs 38 % (20/53) for POIC
(NS), within 7,9 months (0,2 - 35,0).
Conclusion: When indicated, standardized aggressive surgery with
extended colectomy, especially for SIC, based on endoscopic evalu-
ation, allows comparable survival and CR rates in every case of IC.
Disclosure: No significant relationships.
P127
LOWER GASTROINTESTINAL PERFORATION, AGE ANDTHE LENGTH OF HOSPITAL STAY CONTRIBUTE TO THEMORTALITY IN ACUTE CARE SURGERY
K. Yo1, T. Kanai2, T. Hanaoka1, Y. Suzuki1, S. Matsui2, S. Takada1,Y. Kobayashi2, Y. Hari2, N. Fujimura2, H. Kuroda2, S. Imai2,T. Akatsu2, T. Nagase2, M. Nakagawa2
1Emergency Medicine, Hiratsuka City Hospital, Hiratsuka/Japan,2Surgery, Hiratsuka City Hospital, Hiratsuka/Japan
Introduction: Recent advances such as established surgical treatment
strategies for trauma and surgical critical ill patients contribute to
decrease the mortality in acute care surgery. However, the predictors
of outcome and have not well studied. The aim of this study was to
elucidate the predictor of outcome and its impact on mortality in acute
care surgery.
Materials and methods: A single-center retrospective observational
study. Based on the record of the operating room, 532 patients who
were performed emergency surgery were enrolled in this study. After
excluding 45 patients (20 semi-elective surgery, 25 s surgery), the
487 patients were eligible for this study. To identify multivariate
predictors of the mortality, age, gender, operating time, length of
hospital stay, and diseases were entered in a logistic regression model
and the analysis was conducted by the backward elimination method.
Results: Of the eligible patients, 16 (3.3 %) were died and all of these
were elderly ([=65 y/o). The results of the multivariate analysis
identified that lower gastrointestinal perforation patients, age and the
length of hospital stay were independent predictors of outcome (odds
ratio: 11.655 (95 % CI: 3.487 to 38.958), 1.081 (1.019 to 1.146),
1.016 (1.004 to 1.029), respectively).
Conclusion: Lower gastrointestinal perforation was the most impor-
tant predictor of overall mortality among acute care surgery patients.
Elderly had higher mortality than non-elderly patients.
Disclosure: No significant relationships.
P128
TREATMENT OPTIONS FOR UPPER GASTROINTESTINALBLEEDING OF NON-VARICEAL ETIOLOGY INEMERGENCY - 10 YEARS OF EXPERIENCE
V.D.E. Strambu, P.A. Radu, M. Bratucu, C. Iorga, S. Stoian,D. Garofil, C. Puscu, A. Manta, G. Orosan
General Surgery, Carol Davila Hospital, Bucharest, Romania
Introduction: Introduction With high prevalence and mortality,
upper gastrointestinal bleeding remains one of the largest, most fre-
quent and important medical and surgical emergencies, in terms of
diagnosis, treatment and, not at least in terms of cost economic.
Materials and methods: We analyzed a total of 343 patients hos-
pitalized with the diagnosis of digestive hemorrhage in our clinic in
recent years.
Results: The upper gastrointestinal bleeding is 5 times more frequent
than the lower. 50 % are non-cirrhotic patients and gastric and duo-
denal ulcer is responsible for over half of all cases of active bleeding
in these patients. Although the last two decades the diagnostic and
treatment techniques have improved, two major parameters remained
almost unchanged: mortality has remained stable at values of 10 to
14 % rebleeding has decreased by only two percentage points (from
22 to 20 %). Maintaining unchanged is a consequence of these two
parameters: 1. increase average lifespan by placing upper gastroin-
testinal bleeding peak incidence over 55 years, 2. associated disease
or aggravated pre-existing hemorrhagic episode 3. Age increase
consumption of aspirin and other non steroidal anti-inflammatory
drugs (NSAIDs) or modern classic, 4. Infection with Helicobacterpylori (Hp). Infection in ulcer Hp cofactor is known as bleeding and
perforation risk, 5. synergistic action of NSAID use and HP infection,
both the precipitating factors of upper gastrointestinal bleedings.
Conclusion: Conclusions: Approximately 80 % of upper gastroin-
testinal bleeding stops spontaneously. The main clinical factors
adversely influencing the evolution of non-variceal upper gastroin-
testinal bleedings: age [60 years, severe comorbidities,
hemodynamic instability at admission, the red color of nasogastric
aspirate, or need for transfusion [5 U, continued or recurrent bleed-
ing, need for surgery in emergency. Consumption of NSAIDs
increases the risk of upper gastrointestinal bleedings regardless of
etiology.
Disclosure: No significant relationships.
Abstract S175
123
P129
CONSERVATIVE MANAGEMENT OF SPLENIC TRAUMAASSOCIATED WITH 26 % PSEUDO ANEURYSMS: THEROYAL ADELAIDE EXPERIENCE
P.C. Bautz
Trauma Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
Introduction: The spleen is one of the most commonly injured
abdominal organs in both blunt and penetrating trauma. Conservative
management of splenic trauma has created new phenomenon of
delayed pseudoaneurism formation. Increasingly, angio-embolisation
is being utilised for both penetrating and blunt trauma. This study
reviews the RAH splenic injury protocol efficacy.
Materials and methods: CT scans of a cohort of 24 trauma patients
admitted under the trauma unit at the Royal Adelaide Hospital
(RAH). Initial CT was compared with post embolisation films at
1 week and 3 months to determine the incidence of splenic haema-
toma, pseudo aneurysm formation, and functional splenic tissue.
Results: Lacerations of all grades in 87 % initial scans. Contrast
blushes in 25 %. Peri-splenic haematomas in 75 %. Pseudoaneurysm
in 4 %. In one week follow-up films post angio-embolisation: Lac-
erations 86 %, Contrast blushes 5 %, haematomas 27 % and
pseudoaneurysm in 22 %. At 3 months functional splenic tissue
72 %, pseudoaneurysm 0 %. At 1 week postembolisation CT angi-
ography 70 % patients had [50 % functional splenic tissue,
increasing to 80 % at 3 months. No delayed splenic ruptures seen.
One splenic infection requiring laparoscopic necrosectomy. Signifi-
cant postembolisation pain and pyrexia in 25 %.
Conclusion: Angio-embolisation of traumatic splenic lesions at RAH
safely controls bleeding and effectively manages pseudo-aneurysms.
Benefit of splenic CT angiography 7–10 days post injury in diag-
nosing pseudo-aneurysms is shown, identifying 26 % pseudo-
aneurysms. Three month post embolisation CT determines remaining
splenic tissue, with 70 % normosplenic. RAH splenic injury protocol
is safe, and effective.
References: Improved success in nonoperative management of blunt
splenic injuries: embolization of splenic artery pseudoaneurysms. The
Journal of Trauma 1998;44:1008–15.
Disclosure: No significant relationships.
P130
BLUNT HEPATIC TRAUMA: LIVER MORPHOLOGYINFLUENCE BASED ON A SERIES OF 83 CONSECUTIVEPATIENTS EXPLORED BY MDCT
S. Coze1, J. Soussan1, C. Prost1, P. Arnoux2, C. Brunet2, M. Panuel1,K. Chaumoitre1
1Radiology, Aix-Marseille Univ, North Hospital, APHM, Marseille,
France, 2Laboratoire de Biomecanique Appliquee Umr 24, Aix-
Marseille Univ, Marseille, France
Introduction: MDCT (multidetector computed tomography) imaging
represents the core of the management in liver trauma. Liver anatomy
could have a significant incidence on loading distribution.
Materials and methods: We analyzed the data of 83 consecutive
patients (mean age 32 years), with blunt hepatic injuries between
2005 and 2010. All the patients were explored by a 64 rows MDCT
with dual-phase CT. Ventropetal liver (VL) corresponded to a larger
axial diameter, and dorsopetal liver (DL) corresponded to a larger
vertical diameter (hepatic arrow).
Results: We found no difference in trauma circumstances or severity
between both groups. Considering demographics data, patients in the
DL group were significantly older than those in the other one
(respectively, 47 and 38 years, p \ 0.001). On MDCT, there was no
difference between groups on AAST classification, presence of an
active bleeding, number of segments involved. A significant differ-
ence was found in the distribution with more injuries in the DL group
lateral segments (respectively, 70 vs. 32 %, p = 0.002). This differ-
ence between groups was not associated with a difference in
management (surgery rate, embolization) or in follow up.
Conclusion: Variations in morphology of the liver affect the distri-
bution of liver injury during blunt trauma. This concept allows a
better understanding of the mechanical phenomena involved in
trauma. This concept has, however, no impact on clinical assessment
or on the management of patients.
Disclosure: No significant relationships.
P131
IN-PATIENT MANAGEMENT OF DRUG MULES IN ONEINSTITUTION
C.M. Caruana, M. Cassar
General Surgery, Mater Dei Hospital, Msida, Malta
Introduction: Body packers or drug mules are persons who swallow
or stuff drug packets rectally or vaginally for the purpose of smug-
gling drugs across borders. In this study we examine retrospectively
all the body packers who were admitted to our hospital to establish
trends in presentation and management that would direct us in the
future management of these patients.
Materials and methods: We retrospectively examined the medical
records as well as the records on iSOFT, PACS and ECS software
systems of all patients admitted for observation due to presumed
gastrointestinal body packing between November 2007 and July 2010
with particular emphasis on clinical and radiological findings, treat-
ment modalities and outcomes.
Results: 27 patients with a mean age of 32 years were admitted to
Mater Dei Hospital. The type of packaging was unknown in all
patients while the content was not known in 85 % of the cases. Few
patients had minor findings on examination while the majority were
unremarkable. On plain radiography of the abdomen, capsules were
visible in 74 % of patients. 19 (70 %) patients were prescribed lax-
atives either in combination or singly. None required surgical
intervention and only 11 % patients had minor complaints during
their stay. The mean length of stay was 2.13 days. 3 patients (11 %)
were discharged after passage of stools failed to reveal the presence of
drug packets. 21 patients (78 %) were discharged following check XR
and/or passage of stool with no capsules.
Conclusion: All patients were treated conservatively with a satis-
factory outcome. Following this retrospective review a management
protocol has been designed.
Disclosure: No significant relationships.
S176 Abstract
123
P132
SPLENIC DECAPSULATION AFTER GASTROSCOPY
I. Fuchs1, R. Schrittwieser1, J. Tauss2, F.M. Kovar3
1Department General Surgery, LKH Bruck, Mur, Bruck, Mur,
Austria, 2Inst. F. Diagmostic & Interventional Radiology, LKH
Bruck, Mur, Bruck, Mur, Austria, 3Trauma Surgery, Medical
University Vienna, Vienna, Austria
Introduction: Sanguineous splenic complications in elective treat-
ment procedures remain a potentially life threatening complication in
patients of all ages.
Materials and methods: One of the diagnostic procedures to find the
reason for the epigastric pain, a gastroscopy, can retrospectively be
held responsible for the decapsulation of the spleen.
Results: During grand rounds 1 h after gastroscopy the patient
complains about increased abdominal pain with pressure pain but no
signs of peritonitis. Immediately a laboratory control and a CT scan
was performed. Laboratory results showed a blood count decrease and
in the images of the CT scan a massive bleeding in the free abdominal
cavity was observed. The intraabdominal finding where a decapsu-
lation of the spleen from the cranial to the caudal pole without
parenchymal lesions. A suspicious adhesion between the stomach and
the spleen with a very short spleno-gastric ligament and a torn short
gastric artery have been observed, but no other adhesions. The artery
as a bleeding source was treated and post surgery the patient was
cardio respiratory stable at all times.
Conclusion: The fact of adverse outcomes, even if they are very rare,
should increase our awareness in patients with abdominal pain after
endoscopic procedures to prevent unnecessary life threatening
complications.
Reference: Pamela EsAvez-Boullosa, Pedro A Alonso-Aguirre, Ig-
nacio Couto-WArner et al. Splenic rupture following a diagnostic
upper endoscopy. World J Gastrointest Endosc. 2010;2(6):235–6.
Disclosure: No significant relationships.
P133
EFFECTS OF ACCIDENTAL HYPOTHERMIAON POSTTRAUMATIC COMPLICATIONSAND OUTCOME IN MULTIPLE TRAUMA PATIENTS
P. Mommsen1, H. Andruszkow2, C. Zeckey2, M. Frink2, C. Macke2,C. Krettek2, F. Hildebrand2
1Trauma Department, Hannover Medical School, Hannover,
Germany, 2Trauma Department, Hannover Medical School,
Hannover, Germany
Introduction: Accidental hypothermia as an independent prognostic
factor in multiple trauma is controversially discussed. The aim of the
present study was to evaluate the incidence of accidental hypothermia
in multiple trauma patients and its effects on the development of
posttraumatic complications and mortality.
Materials and methods: Inclusion criteria for patients in this retro-
spective study (2005–2009) were ISS C16, age C16 years, admission
to our Level I trauma centre within 6 h after trauma. Accidental
hypothermia was defined as body temperature less than 35 �C mea-
sured within 2 h after admission, but always before first surgical
procedure in the operation theatre. The association between acci-
dental hypothermia and the development of posttraumatic
complications as well as mortality was investigated. Statistical anal-
ysis was performed with v2-test, Student’s t test, ANOVA and logistic
regression.
Results: 310 patients were enrolled. Mean age was 41.9 ± 17.5
years, the mean injury severity score was 29.7 ± 10.2. The overall
incidence of accidental hypothermia was 36.8 %. No association was
shown between accidental hypothermia and the development of
posttraumatic complications. Overall, 8.7 % died during the post-
traumatic course. Despite an increased mortality rate in hypothermic
patients, hypothermia failed to be an independent risk factor for
mortality in multivariate analysis.
Conclusion: Accidental hypothermia is very common in multiply
injured patients. However, it could be assumed that the increase of
mortality in hypothermic patients is primarily caused by the injury
severity and does not reflect an independent adverse effect of hypo-
thermia. Furthermore, hypothermia was not shown to be an
independent risk factor for posttraumatic complications.
Disclosure: No significant relationships.
P134
SIX YEARS RESULTS OF PROXIMAL HUMERALFRACTURES TREATED OPERATIVE WITH AN ANGELSTABLE IMPLANT (LPHP, FA. SYNTHES)
J. Theopold, P. Hepp, B. Marquaß, C. Josten
Chirurgische Klinik I, Universitat Leipzig, Leipzig, Germany
Introduction: Are there any findings in clinical outcome after six
years follow up? Is there a higher rate of Omarthrosis?
Materials and methods: A non-randomised prospective study (12/
2001 through 12/2004). 79 Patients were surgically treated with the
LPHP. A postoperative clinical examination was carried out after 3
and 12 months after the surgery, and an additional one after
74 months (min 63, max 98). Until today 31 of the initially included
patients have been re-examined.
Results: 9 of 31 re-examined patients presented with a 2-segment
fracture, 16 presented with a 3-segment fracture and 6 with a 4-part
fracture according to Neer classification. The average Constant Score
3 months after surgery was 63 points (±9.56) and 75 points (±7.2)
after 12 months. Re-examinations at an average of 74 months after
surgery showed a Constant Score of 74 points (±8). This shows a
significant difference (p 0.01) only between the findings 3 months and
12 months postoperatively. 10 (32.2 %) patients had surgery for
material removal and arthrolysis. 22 (71 %) patients did not show any
radiologically visible signs of secondary/posttraumatic Omarthrosis/
necrosis. 5 (16.1 %) patients developed Omarthrosis and 4 (12.9 %)
developed a radiologically manifested AVN. Patients without Om-
arthrosis showed better clinical results (p = 3 M = 0,023,
12 M = 0.061, 74 M = 0.007). Statistically there was no difference
between patients with AVN and patients without Omarthrosis
(p = 3 M = 0,811, 12 M = 0,864, 74 M = 0,560).
Conclusion: The biggest increase in clinical results is found during
the first 12 months after surgery. In the medium term the rate of
posttraumatic necrosis is 12.9 %. There is no difference between
AVN and omarthrosis.
Disclosure: No significant relationships.
Abstract S177
123
P135
ARE SELF INFLICTED STAB WOUND INJURIES LESSSEVERE THAN THOSE INFLICTED BY OTHERS?A REVIEW OF STAB WOUND INJURIES AT A TERTIARYTRAUMA CENTER IN SINGAPORE
J.J. Leow, L. Teo, P. Lingam, J. Cheng, M.T. Chiu
Department of General Surgery, Tan Tock Seng Hospital, Singapore,
Singapore
Introduction: Due to strict laws against armed violence in Singapore,
we do not witness large numbers of stab injuries. Despite the rela-
tively small numbers, we hypothesize that self-inflicted stab wound
injuries are less severe than those inflicted by others, owing to an
individual’s inherent ‘‘self-preserving’’ internal mechanism, while
those with malicious intent can inflict significant injury if desired.
Materials and methods: Tan Tock Seng Hospital is the busiest
trauma and acute care hospital in Singapore. We reviewed all pene-
trating injuries between 2005 to 2010 and identified all stab wound
injuries, classifying them into 2 groups: self inflicted (SI) and inflicted
by others (IO).
Results: Between 1 January 2005 and 31 December 2010, there were
a total of 149 stab wound injuries. Of these, 24 (16.1 %) were self-
inflicted and 125 (83.89 %) inflicted by others. The median ages for
the SI and IO groups were 35.5 ± 22 and 30 ± 20 with a male
predominance in both groups of 62.5 % and 93.6 % respectively. The
median Injury Severity Scores for the SI and IO group were 9 ± 7.5
and 10 ± 9, respectively; this difference was statistically significant
(p = 0.0263). In both groups, most required an operation (83.3 vs.
85.6 %). The average hospital length of stay was 4 days in both
groups. In the SI group, 87.5 % (n = 21) were reviewed by a psy-
chiatrist inpatient.
Conclusion: Our retrospective review study confirms our hypothesis
that self-inflicted stab wound injuries are less severe than those
inflicted by others. This can help guide trauma services in the man-
agement of stab wound injuries.
Disclosure: No significant relationships.
P136
TRAUMA-RELATED SEPTIC COMPLICATIONS AREDIFFERENTIATED BY AGE AND GENDER
H. Redl1, S. Drechsler1, K. Weixelbaumer2, M. Jafarmadar2,M. Van Griensven2, S. Bahrami2, M.F. Osuchowski2
1Experimental and Clinical Traumatology, Ludwig Boltzmann
Institute, Vienna, Austria, 2Ludwig Boltzmann Institute for
Experimental and Clinical Traumatology, Vienna, Austria
Introduction: Secondary sepsis is frequent in trauma patients of all
ages. In a 2-hit model we studied the period between trauma/haem-
orrhage (TH) and sepsis (CLP) for age/gender related differences in
cytokine response and organ function.
Materials and methods: 3 and 15 month (mo) old females (F) and
males (M) underwent femur fracture followed by sublethal haemor-
rhage (TH). 48 h later mice underwent CLP (50–80 % mortality).
Survival was followed for 14 days. Blood was drawn daily starting
with TH (-48 h) up to day 5 post-CLP to assess circulating KC, MIP-
1a, TNF-a, MCP-1, IFN-c, IL-1b, 5, 6, 10 and urea, ALT, AST,
glucose and LDH.
Results: 14-day survival was higher in F compared to M independent
of age. Outcome separation based on cytokines was strongest in
mature 15moM at 0 h prior to CLP. Cytokine release post-TH was
stronger in 3moF compared to 3moM (p \ 0.05). TH induced
increase of urea, ALT and AST in 3MoM that died post-CLP (DIE)
was higher compared to those that survived (SUR) (p \ 0.05). Post-
CLP cytokines were increased in DIE animals independent of age/
gender at 6 h and 24 h (p \ 0.05). All DIE mice displayed higher
urea, ALT, AST and LDH values post-CLP (up to 8-fold at 72 h),
while glucose was decreased at 72 h compared to SUR.
Conclusion: Our data suggests that age and gender affect immune
responses after TH, but these changes did not demonstrate a clear
association to the gender-specific survival differences found after
secondary polymicrobial sepsis.
Disclosure: No significant relationships.
P137
THE OPEN ABDOMEN WHAT DO I DO NOW?
J.M. Saxe
Surgery, Wright State University, Dayton, OH, USA
Introduction: The open abdomen remains a significant operative
problem facing the general surgeon. These repairs are complicated,
often involving large areas surface areas with loss of abdominal
domain, and latent bacterial invasion into the wound. A variety of
repair modalities have been advocated for the repair of such hernias.
The objective of this study was to evaluate biologic material repairs
done at a community based level one Trauma center.
Materials and methods: We performed a retrospective case study of
1227 hernia repairs performed over 4 years at a level 1 trauma center.
Data collected included age, sex, height, weight, BMI, smoking his-
tory, medical history including hypertension and diabetes, surgical
history, type of hernia, defect size, repair mesh size, surgical method,
mesh brand, mesh material, infections, and reoccurrences. Infections
were evaluated based on notes from the initial admission and follow
up visits shortly after.
Results: There were 27 patients with open abdominal wounds after
injury. Primary repair was accomplished in 25.9 %, synthetic material
repairs were used in 25.9 %, and biologic repairs in 37.0 %. Synthetic
material included polypropylene (11.1 %), PTFE (11.1 %), polygl-
actin (3.7 %). Biologic repairs included human collagen (14.8 %),
porcine dermis (7.4 %), bovine dermis (14.8 %). Hernias reoccurred
in polyglactin (100 %), bovine (25 %). Synthetic repair had a 33.3 %
infection rate while primary repairs were found to be infected in
14.3 % of repairs. Biologics had a 30 % infection rate, bovine (50 %),
human (25 %), and primary repairs (14.3 %).
Conclusion: A Primary repair if possible appears to be the superior
repair. Despite high infection rates biologic material remain to
superior synthetics.
Disclosure: No significant relationships.
S178 Abstract
123
P138
DAMAGE CONTROL FOR CERVICAL HEAMORRAGEIN WAR SURGERY
J. Jarry1, V. Nguyen1, N. Biance2, M. Imperato1, F. Rongieras3,P. Michel1
1Visceral Surgery, HIA Desgenettes, Lyon, France, 2Visceral Surgery,
HIA Robert Picque, Bordeaux, France, 3Orthopedic Surgery, HIA
Desgenettes, Lyon, France
Introduction: Damage control (DC) represents a major advance in
modern trauma surgery. This concept was initially developed to treat
exsanguinating abdominal injuries and then successfully extended to
orthopaedic, gynaecologic and thoracic surgery. However, there have
been no articles concerning DC in cases of cervical haemorrhage.
Materials and methods: Two different cases of cervical haemor-
rhaging were treated by French military surgeons. The first case was
due to iatrogenic vascular injuries following elective thyroidectomy
in Chad, Africa. The second was the result of a penetrating neck
injury suffered by a soldier in Afghanistan. Both haemorrhages were
controlled by cervical packing and the patients were transferred to an
ICU for a secondary resuscitation.
Results: Treating cervical injuries in wartime offers difficult chal-
lenges. Namely, the multitude of vital structures, especially vascular,
concentrated in the neck means several may be affected at once.
Furthermore, surgeons often work in isolated facilities and must
rapidly transport the wounded out of the theatre of operations. Their
primary objective is to stop the haemorrhaging and they do not
necessarily have time to perform all cervical repairs. Thus, DC is
extremely pertinent when operating in wartime conditions.
Conclusion: Based on the two cases described herein, we find DC to
be very useful in treating cervical haemorrhage wounds in war sur-
gery. Moreover, this application of DC would also be beneficial in
civilian practice.
References: 1. Thompson EC. Penetrating neck trauma: an overview
of management. J Oral Maxillofac Surg. 2002. 2. Charles JF. Delayed
evaluation of combat-related penetrating neck trauma. J Vasc Surg
2006.
Disclosure: No significant relationships.
P139
SURGICAL TREATMENT OF STRICTURES IN CROHN’SDISEASE
V.D.E. Strambu1, P.A. Radu1, M. Bratucu1, C. Iorga2, D. Garofil1,S. Stoian1, C. Puscu1, A. Manta1
1General Surgery, Carol Davila Hospital, Bucharest, Romania,2General Surgery, University of Medicine ‘‘Carol Davial’’ Bucharest,
Bucharest, Romania
Introduction: Crohn’s Disease is a pan enteric transmural inflam-
matory disorder of the GI tract that cannot be cured by medical/
surgical treatment.
Materials and methods: We analysed 34 patients admitted in our
department in the last 15 years. Indications for surgery: Complica-
tions: perforation, abscess, fistula, obstruction, bleeding, toxic
megacolon. Extra-colonic manifestations (exceptions: sclerosing
cholangitis, ankylosing spondylitis). Intractable symptoms with
failure to respond to prolonged medical treatment. Severe side effects
or complications of chronic medical treatment. (steroids induce early
closure of epiphyseal plate and osteoporosis - both irreversible).
Results: Pre-op considerations: Most patients are operated on elec-
tively or semielectively allowing for: optimization of hemodynamic,
hematological and nutritional status. (2 weeks of preoperative treat-
ment reduce surgical complications in patients with greater than 10 %
weight loss). Complete small/large bowel investigation: small bowel-
radiographic contrast study, large bowel colonoscopy, CT—may
contribute valuable information in selected cases (abscess), candi-
dates for ostomy should be familiarized with the new condition and
related devices.
Conclusion: Clinically asymptomatic strictures (found on radio-
graphic small bowel studies) are usually not an indication for surgery.
Asymptomatic strictures discovered incidentally during surgery
should be treated. Most patients with acute bowel obstruction due to
an acutely inflamed segment respond to medical therapy. Short
fibrotic large bowel strictures may be treated with endoscopic balloon
dilatation. Malignancy should always be ruled out surgical
procedures.
Disclosure: No significant relationships.
THE EMERGENCY ROOM
P140
OUR EXPERIENCE IN MULTITRAUMA CASES WITHPELVIC FRACTURE
G. Dalkılıc, A. Cevik, H. Ekinci, N. Bildik, T. Yucel
2nd General Surgical Clinic, Dr. Lutfi Kırdar Kartal Research and
Training Hospital, Istanbul, Turkey
Introduction: Recently depending on the increasing number of traffic
accidents obvious abdominal and pelvic trauma is increasing in our
country. In this study, it was aimed to research the demographic
features and accompanying injuries of pelvis trauma cases in our
clinic retrospectively.
Materials and methods: Between the years of 2008-2011 in terms of
sex, age, type of trauma, accompanying injury, mortality and mor-
bidity rate. A total of 125 cases of pelvic fracture consisting of 28
female and 97 male having mean age of 38 (18 ± 1.42) were inclu-
ded. Traumatic injuries were occured by traffic accidents in 68.2 % of
the cases and by falling 31.8 %. In 32.4 % of cases, only pelvic
fracture were determined.
Results: Pelvic wrap was applied to 12 cases (9.6 %), also skeleton
traction was applied in 8 cases (6.4 %) with deplased fracture. Our
mortality rate was 1.6 % (2 cases). One of them from cranial injury,
the other from liver injury. Our major morbidity was pulmonary
infection in 8 cases (6.4 %) and paralitic ileus in 10 cases (8 %).
Conclusion: As a result, pelvic trauma requires additional close
surgical and medical attention in order to decrease morbidity and
mortality. Hemorrhage due to pelvic fracture remains a major cause
of morbidity and mortality in the trauma patient.
References: 1. Cullinane DC, et al. Eastern Association for the
Surgery of Trauma in Pelvic Fracture. J Trauma. 2011;71(6):
1850–68. 2. Bailey JR, Stinner DJ, et al. Combat-related pelvis
fractures in nonsurvivors. J Trauma. 2011;71(1 Suppl):S58–61.
Disclosure: No significant relationships.
Abstract S179
123
P141
A RETROSPECTIVE TRIAL ON THE CORRELATIONBETWEEN COMPREHENSIVE CLASSIFICATION ANDLONG TERM OUTCOME FOLLOWING ACETABULARFRACTURES
V.K. Viswanathan1, N.R. Gopinathan2, R.K. Sen2, V.G. Goni3
1Orthopedics, PGIMER, Chandigarh, Chandigarh, India,2Orthopaedics, PGIMER, Chandigarh, India, 3Orthopaedics,
PGIMER, Chandigarh, India
Introduction: A multitude of acetabular classification systems have
been proposed to emphasise upon the differences in the fracture
patterns, ideal management to be followed, possible complications
encountered and long-term prognosis and outcome anticipated. The
present literature, however, offers little information regarding the
correlation of the long term outcome and results with specific fracture
patterns as defined by the comprehensive classification. The present
study has, hence been planned to analyse the role of this classification
in the prognostication of these injuries.
Materials and methods: The study was a retrospective analysis of
patients treated at Postgraduate Institute of Medical Education and
Research (PGIMER), Chandigarh, India. A total of 220 patients
treated operatively for fracture acetabulum over a period of 9 years
(from January 2000 to December 2009) were selected for the study.
Only 145 of the selected 220 patients turned up and out of them only
119 patients had adequate records. The selected 119 patients were
clinically examined and investigated for current status of their
involved hip joint. The quality of reduction achieved at the end of
active intervention was graded as described by Matta et al. The hip
was evaluated using the score developed by Merle D’ Aubigne and
Postel (modified by Matta).
Results: Though the results were numerically better in type A pattern
of injury in comparison with type B and type C fractures, the results
were not statistically significant. The proportion of patients with type
A fractures who had an excellent outcome was 46.3 % (25 patients),
as against an excellent outcome of 25 % in type B patients (8 patients)
and no patients in type C injury.
Conclusion: Although, the comprehensive classification has been
devised to categorise the acetabular fractures in a more systematic
way, our study failed to indicate any specific advantage of this clas-
sification over the findings suggested by the Letournel and Judet
system. There were no specific statistically significant differences
between the fracture patterns described, except for an increased inc-
idence of neurological injury and avascular necrosis in type A1 and
A2 fractures.
Disclosure: No significant relationships.
P142
A CASE OF ACUTE ISOLATED DISLOCATION OF THEDISTAL RADIOULNAR JOINT: ULNA VOLAR
A. Frischknecht, S. Fleischmann, H. Buchel, G.A. Melcher
Surgery, Hospital Uster, Uster, Switzerland
Introduction: Isolated ulna volar dislocation of the distal radioulnar
joint is a rare entity of injury and accurate diagnosis is easily missed
upon initial presentation [1, 2].
Materials and methods: A 43-year-old right hand dominant manual
labourer presented with an injury of his left forearm. On examination
a fully supinated forearm with a dorso-ulnar dimple were noticed.
Pronation was not possible, wrist flexion/extension was normal.
Conventional radiographs taken in two planes studies suggested an
ulna volar dislocation without concomitant fractures. Diagnosis was
confirmed by computerized tomography. Successful closed reduction
was performed followed by retention in an above elbow cast for
6 weeks. Follow-up at 3 months showed full functional recovery.
Results: This case highlights the importance of early diagnosis and
treatment of this injury as poor outcome and need for surgical
intervention are well described with delayed diagnosis [1]. Thorough
examination with notification of subtle signs and a true lateral
radiograph can lead to correct diagnosis. Where true lateral views can
not be obtained CT scan is recommended [2]. Closed reduction of
simple acute volar dislocations is well established and usually stable
with immobilisation in an above elbow cast required for 6 weeks [1].
In accordance to cases reported in the literature this management was
successful resulting in favourable outcome [1].
Conclusion: Acute dislocation of the distal radioulnar joint can easily
be missed. However awareness of this injury with a high index of
suspicion triggers right diagnosis and prompt treatment with early
functional recovery in the majority of cases.
References: 1. Dameron. Traumatic dislocation of DRUG. Clin
Orthop Related Res. 1972;83:55–63. 2. Kumar. Missed isolated volar
dislocation of DRUG. J Emerg Med. 1999;17(5);873–5.
Disclosure: No significant relationships.
P143
THE EFFECT OF CHITOSAN ON COLONIC ANASTOMOSISHEALING
B. Citgez1, A.N. Cengiz1, I. Akgun1, M. Uludag1, G. Yetkin1, N. Balat2,O. Ozcan3, N. Polat4, O. Karatepe5, A. Akcakaya1
1Second General Surgery, Sisli Etfal Training and Education
Hospital, Istanbul, Turkey, 2First Department of Obstetrics And
Gynecology, Sisli Etfal Training and Education Hospital, Istanbul,
Turkey, 3Department of Biochemistry And Clinical Biochemistry,
GATA Haydarpasa Training Hospital,, Istanbul, Turkey, 4Pathology,
Sisli Etfal Training and Research Hospital, Istanbul, Turkey,5Department Of General Surgery, Bezmialem Vakif University,
Istanbul, Turkey
Introduction: Leakage from colonic anastomosis is a major com-
plication causing increased mortality and morbidity. The aim of this
study is to investigate whether chitosan application over colonic
anastomosis line, provide reinforcement, and subsequently improve
anastomotic healing.
Materials and methods: Forty-eight Wistar Albino female rats were
used for this study. Rats were randomly divided into four groups, 12
rats in each: The control groups (1 and 3) received no further treat-
ment. The experimental groups (2 and 4) received chitosan
application over the colonic anastomosis. After sacrifying rats at the
end of the experiment (either on day 3 or on day 7, depending on the
group), colonic bursting pressure, and hydroxyproline level and his-
topathologic characteristics of the perianastomotic tissue were
examined.
Results: At 3 days, chitosan and control groups had similar values for
histopathologically. On day 7, chitosan group had significantly higher
mean score of collagenization (p \ 0.05) and a significantly higher
bursting pressure (p \ 0.05).
S180 Abstract
123
Conclusion: Our study emphasizes the positive effect of chitosan in
the process of collagenation in anastomosis healing.
Disclosure: No significant relationships.
P144
AMYAND’S HERNIA-A VERMIFORM APPENDIXPRESENTING IN AN INGUINAL HERNIA: A CASE REPORT
B. Citgez, I. Akgun, M. Uludag, G. Yetkin, F. Ferhatoglu, A. Akcakaya
Second General Surgery, Sisli Etfal Training and Education Hospital,
Istanbul/Turkey
Introduction: Amyand hernia is rare condition and has been
described as the presence of appendix vermiformis in an inguinal
hernia sac. The incidence of Amyand hernia is approximately 1 % of
types inguinal hernia. Appendix in the hernia sac can be found as
normal, inflamed, perforated or incarcerated.
Materials and methods: A 58-year-old man presented with inguinal
hernia was admitted to our department for an elective hernia repair.
Results: A 58-year-old man presented with inguinal hernia was
admitted to our department for an elective hernia repair. We found the
appendix vermiformis in the hernia sac, during a standard hernia
repair. An appendicectomy was not performed because of no edema
or inflammation was observed. Patient applied Lichtenstein procedure
was discharged on second day postoperatively.
Conclusion: Treatment approaches for Amyand’s hernia vary
according to the state of appendix in the hernia sac and presence of
additional pathology. If the appendix in the sac is inflamed or per-
forated, the most accepted procedure is to perform apendectomy and
hernia repair through the same incision. Apendectomy is controversial
for patients without evidence of appendicitis because of infection risk.
We do not routinely perform prophylactic appendectomy in such
patients. We thought that a patient tailored approach is more
acceptable.
Disclosure: No significant relationships.
P145
INTRATHORACIC MALPOSITION OF A NASOGASTRICFEEDING TUBE THROUGH TRANSBRONCHIAL ANDLUNG PERFORATION
M. Malota, W. Woehrl, R. Kopp
General Surgery, Krankenhaus Munchen Harlaching, Munchen,
Germany
Introduction: Feeding tubes are used frequently in the intensive care
unit to provide enteral nutrition. Malpositioning is the most common
complication with a rate of 1.3 %. Most of the malpositions so far
described in the literature are located in the gastroesophageal system,
the pleural cavity, the peritoneal cavity or the mediastinum through
gastric or esophageal perforation. Furthermore even intravascular and
intracranial misplacement have been reported.
Materials and methods: We report a case of a malpositioning of a
nasogastric feeding tube, which was first located intrabronchially and
then perforated through the right lower lobe into the thoracic cavity
causing a pyothorax and a severe mediastenitis.
Results: Initially the patient was at the internal ward treated for his
congestive heart failure after a cardiac arrest, when he was commited
to our emergency department with a SIRS and an acute dyspnoea due
to a right sided pneumonia with atelectasis of the right lung and
increasing pleural effusion. The insertion of a chest tube revealed
mucous, pus and suspicion of nutritive fluid. Following bronchoscopy
and CT scan, the malposition of a nasogastric feeding tube with
transbronchial and pulmonal perforation in the right pleural cavity
was diagnosed. We performed a thoracotomy with a partial decorti-
cation and an atypical pulmonary wedge resection of the right lower
lobe. After a 2 weeks stay at our ICU, we were able to discharge the
patient in a good condition for rehabilitation.
Conclusion: Malpositioning of a nasogastric feeding tube with
transbronchial perforation has to be considered in intensive care
patients suffering from dyspnoea, sepsis, pneumonia and pleural
empyema.
Disclosure: No significant relationships.
P146
INFLUENCE OF INDUCED HYPOTHERMIA ON LIVERAND KIDNEY INFLAMMATION IN A SWINE MULTIPLETRAUMA MODEL
M. Frohlich1, R. Pfeifer1, P. Raeven2, I. Witte3, J. Mohr4,M. Weuster5, P. Mommsen6, M. Van Griensven2, F. Hildebrand6,S. Flohe3, S. Ruchholtz7, A. Seekamp5, H.-. Pape1
1Orthopaedic Trauma Surgery, University Clinic Aachen, RWTH
Aachen University, Aachen, Germany, 2Ludwig Boltzmann Institut
for Experimental an Clinical Traumatology, Wien, Austria,3Department of Trauma and Handsurgery, University Hospital
Dusseldorf, Dusseldorf, Germany, 4Department of Trauma, Hand and
Reconstructive Surgery, University Hospital Giessen and Marburg
GmbH, Marburg, Germany, 5Traumatology, University Hospital Kiel,
Kiel, Germany, 6Trauma Department, Hannover Medical School,
Hannover, Germany, 7Department of Trauma, Hand and
Reconstructive Surgery, University Hospital Giessen and Marburg
GmbH, Location Marburg, Marburg, Germany
Introduction: Mild therapeutic hypothermia following trauma has
been introduced in several studies in order to reduce the post-trau-
matic inflammation and organ injury. In this study, we analysed the
organ protective effect of induced hypothermia (34A �C) on typical
shock organs such as liver and kidney.
Materials and methods: Four groups each of ten pigs were analysed.
After anaesthesia the pigs received a blunt thoracic trauma followed
by a laparotomy and liver laceration. Controlled haemorrhagic shock
was carried out from the right femoral artery up to a maximum of
45 % of total blood volume. The mean arterial blood pressure of
30 mmHg A ± 5 mmHg was maintained for 1.5 h. One hour after
reperfusion and stabilization either normothermia was hold or hypo-
thermia targeting 34A �C was induced and maintained for 1.5 h. The
pigs were observed for further 10 h. Blood samples were taken every
2 h. At the end of the experiment 15.5 h after shock, liver and kidney
Abstract S181
123
were removed and analysed with regard to cytokine expression by
real-time polymerase chain reaction.
Results: Hypothermia did not alter the expression of IL-6 and IL-8 in
kidney. In contrast, we measured a significant lower expression of IL-
8 in the hypothermic trauma group. Moreover, marked reduction of
IL-6 expression was also observed in this group. Serum ALT Levels,
as marker for liver injury, were lower in animals with hypothermia.
Conclusion: In summary, we conclude that mild therapeutic hypo-
thermia is able to regulate the post-traumatic inflammatory response
and reduce liver inflammation in severe shock.
References: 1. Chomczynski P, Sacchi N. Single-step method of
RNA isolation by acid guanidinium thiocyanate–phenol–chloroform
extraction. Anal Biochem. 1987;162:156. 2. Schmittgen TD, Livak
KJ. Analyzing real-time PCR data by the comparative C(T) method.
Nat Protoc 2008;3:1101. 2. Tisherman S. Hypothermia and injury.
Curr Opin Crit Care. 2004;10:512–9. 3. Hildebrand F, Pape HC. Die
Bedeutung der Zytokine in der posttraumatischen EntzA�ndungs-
reaktion, Unfallchirurg 2005;108:793–803. 4. Kobbe. Bedeutung der
Hypothermie in der Traumatologie, Unfallchirurg 2009;112:1055–61.
Disclosure: No significant relationships.
P147
AFTERCARE AND FOLLOW-UP TREATMENT OF 13YOUNG NORTH-AFRICAN WAR VICTIMS
M. Weuster1, S. Oestern2, J. Finn2
1Trauma Surgery, University, Kiel, Germany, 2Trauma Surgery,
University Medical Center Schleswig–Holstein, Kiel, Germany
Introduction: The north-african liberation in first half of 2011 has
aroused huge interest and attention in Europe. Now medical sup-
port as post-operative aftertreatment was enabled by a Department
of Trauma surgery in a German University Hospital. This duty
assumed a new kind of arrangement concerning the entire staff and
logistics.
Materials and methods: Post-operative treatment of 13 young male
patients after civil war from North-Africa, Lybia.
Results: The transfer of 13 young male patients was operated by
specialized flying medical units from North-African airports at night.
3 patients were intended for intensive care units other 10 patients
were able to be transferred to normal ward. Welcoming procedure
was conducted through the emergency room staff with 2 nurses, 2
surgeons and 1 Arabian interpreter. Prior conditions were isolated
wards as each patient was potentially contaminated with unknown
microbiology species. Photo documentation, taking medical history,
changing old dressings, applying tetanol shots and defining further
procedures were the first steps. Further treatment was conducted by
one medical division. Getting to know foreign osteosynthesis further
diagnostics such as x-rays, computer-tomography and laboratory
studies were needed. Conducting information from their history and
new attained information during diagnostics led to preparing opera-
tive steps together with plastic and visceral surgeons. The patients
ethnical background had to be considered.
Conclusion: Managing 13 patients as post-operative and secondary
treatment after having survived civil war asks for special logistics and
new kind of thinking in trauma surgery. The operative treatment
assumes a complex and multi-specialist planning within different
surgery departments.
Disclosure: No significant relationships.
P148
THE BALISTIC IMPORTANCE IN GUNSHOT WOUNDS,A GLOBAL PERSPECTIVE
J.P.S. Gandara1, J.A.S. Da Silva1, G.H. Cainelli1, C.M. De Oliveira2,E. Achar1, M.A.F. Ribeiro Jr1, C.F. Collares3
1Surgery, Universidade Cidade de Sao Paulo, Sao Paulo/Brazil,2Surgery, Universidade Cidade de Sao Paulo, 03071000/Brazil,3Pharmacology, Universidade Cidade de Sao Paulo, 03071000/Brazil
Introduction: According to the Global Peace Index the incidence of
violent crime has increased each year, a comparison between the
countries has shown that the incidence of gunshot wounds is higher in
third world countries. Victims of firearms injury require a rapid
diagnosis and definitive treatment, it is important to understand the
ballistics and the direct and indirect actions from firearms injury, in
order to determine the severity of their damage and the impact of such
lesions.
Materials and methods: Literature review using the databases
PubMed/Medline, Lilacs and Ebsco. which were selected articles on a
global perspective of firearms injury and the balistic importance for
diagnosis and treatment.
Results: Injuries caused by firearms cause and primary and secondary
effects. The primary effects have a direct action that is cause by the
impact of the projectile against the body’s tissues injuring them and
causing two types of lesions, permanent cavity and temporary cavity.
The distance that the shot is madea€‹a€‹, the injured structures and
final disposal of the projectile is of great importance to determine the
severity of injuries.
Conclusion: We conclude that there is no consensus on the optimal
time for surgery, but available data indicate higher rates of infection
in patients operated on later and there is a higher incidence of disease
in patients operated soon. The only indication for emergency surgery
when there is progressive neurological damage.
Reference: Michael S, et al. Civilian and military trauma: does
civilian training prepare surgeons for the battlefield. Am Surg.
2011;77:19–21.
Disclosure: No significant relationships.
P149
ELECTRONIC SURVEILLANCE AND PERSONALFEEDBACK INCREASE HAND HYGIENE COMPLIANCEAND QUALITY AMONG HEALTH CARE PROVIDERS
E. Brauner, O. Ben-Ishay, H. Gilshtein, Y. Kluger
General Surgery, Rambam Health Care Campus, Haifa, Israel
Introduction: Health care associated infection is a pandemic result-
ing in high morbidity and death that can be reduced by simple hand
hygiene. Poor hand hygiene compliance among health care providers
arises from the difficulty and inconsistency of its monitoring as well
as poor adherence to recommended practices. New tools for tracking
healthcare provider—patient interaction are necessary for imple-
menting hand effective hygiene protocols. In a busy surgical ward,
monitoring staff compliance is of utmost importance yet fraught with
multiple logistic and ethic problems.
S182 Abstract
123
Materials and methods: We evaluated the effectiveness of an
electronic system on hand hygiene compliance and its quality among
health care providers, and assessed the impact of systematic and
personal feedback on compliance and quality of hand hygiene exe-
cution. Health care providers wore wristband sensors. Other sensors
were placed in strategic locations. A total of 408,272 valid events of
hand hygiene were recorded prospectively. The quality of hand
washing was assessed by the time spent washing or rubbing hands.
Results: During the study period, mean compliance increased from
9.5 % (SE ± 9 %) to 34 % (SE ± 26 %) (p \ 0.005), and the time
spent on hand washing increased significantly. Cessation of personal
feedback resulted in decreased compliance and time spent on hand
washing.
Conclusion: A new technology system facilitates hand hygiene
compliance and quality monitoring; this system is a reliable tool for
interventional studies and protocols for hospital infection control. The
quality of hand hygiene was recorded for the first time. Such quality
control can add value for compliance monitoring regarding the WHO
recommendations.
Disclosure: No significant relationships.
P150
This abstract was moved to ‘‘Sport injuries/Spine’’.
P151
NEAR-INFRARED SPECTROSCOPY (NIRS) TO MONITORPERIPHERAL TISSUE OXYGENATION IN AN AIRPLANE-BASED AND A HELICOPTER-BASED EMERGENCYMEDICAL SERVICE: A SAFETY AND FEASIBILITY STUDY
P. Schober, L.A. Schwarte
Dept. of Anesthesiology & Trauma Center Amsterdam, VUMC
University Medical Center, Amsterdam, Netherlands
Introduction: During air-transportation of critical patients traditional
monitoring of circulation/oxygenation performs suboptimal: Regard-
ing physiology, traditional parameters of circulation/oxygenation
respond relatively late in the sequence of deterioration. Regarding
technology, systemic monitoring techniques of circulation/oxygena-
tion (e.g., pulse oxymetry) tend to fail in critical patients, and during
air-transports additional artifact sources become relevant, e.g., cabin
vibrations. NIRS-based monitoring of peripheral tissue SperiO2-
saturation (e.g., forearm muscle, SperiO2-saturation) is suggested to
sensitively track perfusion/oxygenation, and in case of the Nonin/
Equanox-7600 to be particularly artifact resistant. However, to
our knowledge, no data are available on the impact of a airplane/
helicopter environment on NIRS-based SperiO2-saturation-
measurements.
Materials and methods: Two airborne emergency medical services
(AEMS) were selected for this safety and feasibility study: An air-
plane-based inter-island AEMS (Dutch Caribbean) and a helicopter-
AEMS (Amsterdam, Netherlands). In initial safety studies, we tested
effects of the Nonin/Eqanox-7600 on avionics of respective airplanes/
helicopter. In the subsequent feasibility study, subjects were placed
into the patient compartment of the airplane/helicopter with Nonin/
Eqanox-7600 probes attached to the subject’s forearm. SperiO2-sat-
uration data covering starts-flights-landings and transport to/from
aircraft were recorded for analysis.
Results: Concerning flight safety, airplane/helicopter avionics were
apparently not disturbed by the Nonin/Equanox-7600. Subsequent
implementation of NIRS in the airplane/helicopter allowed SperiO2-
measurements in all subjects studied. No apparent, systemic distur-
bances of subject’s NIRS-based SperiO2-measurements occurred in
airplane/helicopter.
Conclusion: In both airborne EMS services studied, we were able to
demonstrate safety and feasibility of NIRS-based SperiO2-measure-
ments. Thus, NIRS-based SperiO2-measurement could become a
valuable addition in airborne EMS. Further studies will have to
demonstrate that NIRS-monitoring improves therapy and ultimately
outcome in patients transported by airplane/helicopter.
Disclosure: No significant relationships.
P152
CHANGES OF COAGULATION FACTOR PATTERNS INTHE EARLY COURSE AFTER MULTIPLE INJURY ANDTHE ROLE OF CLINICAL PARAMETERS
M. Burggraf, B. Hussmann, J. Keitel, M.D. Kauther, S. Lendemans
Department of Traumatology, University Hospital Essen, Essen,
Germany
Introduction: Coagulopathy is frequently seen after multiple injury.
Affected patients are at high risk for death due to uncontrolled
haemorrhage. Hence, little is known about underlying changes to the
coagulation system. Therefore, the purpose of our study was to elu-
cidate potential alterations of clotting factor activity in the early post
injury phase and to evaluate correlations of possible changes with
routinely acquired clinical parameters.
Materials and methods: Patients admitted directly from the scene of
accident were included. Ten healthy volunteers served as control
group. Besides routine tests of coagulation, activities of clotting
factors were measured.
Results: Study group consists of 64 patients (mean age 46 years;
mean ISS 25 points). We found significantly reduced activity of
factors II (87 %*), V (83 %*), VII (94 %*) and X (91 %*) as well as
serum calcium levels (2,11 mmol/l*); *p \ 0,0001. In contrast,
activity of factor VIII (198 %*) is significantly increased. The
remaining factors and fibrinogen show a tendency towards reduced
activity or levels. Further analysis revealed a moderate correlation of
initial haemoglobin level with reduced activity of factors II (0,51*), V
(0,54*), X (0,64*) and serum calcium (0,67*). No relevant correlation
was found regarding ISS, serum lactate, blood pressure, temperature
and volume therapy.
Conclusion: Present study describes the changes of coagulation
factors in the initial course after severe injury. As supposed by other
authors, we demonstrate a widespread reduction of clotting factor
activity. Furthermore, we found a clear increase of factor VIII
activity. Initial haemoglobin was found to correlate with reduced
clotting factor activity, whereas other clinical parameters didn’t show
significant relationship.
Disclosure: No significant relationships.
Abstract S183
123
P153
ADMISSION THROMBIN ACTIVATABLE FIBRINOLYSISINHIBITOR (TAFI) LEVELS ARE SIGNIFICANTLYDECREASED IN TRAUMA PATIENTS DEVELOPINGINFLAMMATORY COMPLICATIONS
T. Lustenberger, B. Relja, B. Puttkammer, I. Marzi
Department of Trauma, Hand and Reconstructive Surgery, Goethe
University Hospital, Frankfurt, Germany
Introduction: Thrombin activatable fibrinolysis inhibitor (TAFI) has
been recognized as a potent inhibitor of fibrinolysis in the coagulation
system. However, recent experimental evidence indicates that TAFI
may additionally play a pivotal role in the regulation of inflammation
by inactivation of inflammatory mediators. Nevertheless, clinical
evaluation of the role of TAFI in the inflammatory course following
major trauma is lacking.
Materials and methods: This was a retrospective analysis of pro-
spectively collected data in 24 severely injured (ISS C16) trauma
patients. The study cohort was divided into controls (no inflammatory
complications) and patients developing inflammatory complications
(pneumonia, sepsis) at any time of their hospital course. Admission
levels of TAFI and activated TAFI (TAFIa) were measured using
ELISA and were compared between the groups.
Results: Of the 24 patients included, 16 developed an inflammatory
complication (pneumonia, n = 10; sepsis, n = 6) and 8 patients did
not develop an inflammatory complication (control group) in their
further hospital course. Patients with inflammatory complications had
significantly decreased TAFI levels on admission to the hospital
(112.8 ± 35.8 vs. 160.6 ± 42.6 lg/mL; p = 0.011; Mann–Withney
Test) and demonstrated a trend towards decreased TAFIa levels on
hospital admission (5.4 ± 3.6 vs. 3.2 ± 3.1 lg/mL; p = 0.153) as
compared to the control group. No statistical significant differences
were found for TAFI and TAFIa levels on admission comparing
patients developing pneumonia vs. sepsis.
Conclusion: Admission TAFI levels were significantly decreased in
trauma patients developing major inflammatory complications in their
hospital course. Further prospective evaluation of the anti-inflam-
matory properties of TAFI following injury is warranted.
Disclosure: No significant relationships.
P154
BENEFITS OF HELICOPTER EMERGENCY MEDICALSERVICE COMPARED TO GROUND EMERGENCYMEDICAL SERVICE IN TRAUMA PATIENTS
H. Andruszkow1, R. Lefering2, M. Frink1, C. Zeckey1, P. Mommsen1,C. Krettek1, F. Hildebrand1
1Trauma Department, Hannover Medical School, Hannover,
Germany, 2University Witten, Herdecke, Koln, Germany
Introduction: Helicopter emergency medical service (HEMS) is
established in prehospital trauma care and treatment of traumatized
patients in Germany. Improved rescue times as well as increased
covered area are discussed as specific advantages of HEMS. In con-
trast, the availability of HEMS is associated with increased costs and
depends on the weather, time of day and controlled visual flight rules.
To date, clear references regarding benefits of HEMS are still
missing.
Materials and methods: Traumatized patients (ISS [9) primarily
treated by HEMS or ground emergency medical service (GEMS)
between 2007 and 2009 were analyzed using the Trauma Registry of
the German Trauma Society. Only patients treated in German hos-
pitals with complete data referring the transportation mode were
included.
Results: 13470 traumatized patients were included in the present
study. 62.8 % (8453) were rescued by GEMS and 37.2 % (5017) by
HEMS. Patients treated by HEMS were more seriously injured (ISS
26.0 vs. 23.5, p \ 0.001) emphasizing on chest and abdominal inju-
ries. The extent of medical treatment on scene is more extensive in
HEMS (p \ 0.001) resulting in a prolonged rescue time (39.4 min.
vs. 28.9 min., p \ 0.001). During clinical course, HEMS patients
developed MODS more frequently (33.3 vs. 24.9 %, p \ 0.001)
resulting in an increased period of ICU treatment and in-patient time
(p \ 0.001). The Standard Mortality Ratio was decreased in HEMS
compared to GEMS referring to the prognosis of TRISS (0.676 vs.
0.832, p = 0.0004) and RISC score (0.796 vs. 0.872, p = 0.076).
Conclusion: Although HEMS patients were more seriously injured
and developed significantly more MODS, these patients seem to have
a survival benefit compared to GEMS.
Disclosure: No significant relationships.
P155
NEW INJURY SEVERITY SCORE: A MORE RELIABLEASSESSMENT TOOL IN PREDICTING MORBIDITY ANDMORTALITY IN MUSCULOSKELETAL INJURIESCOMPARED TO INJURY SEVERITY SCORE
N.R. Gopinathan1, V.G. Goni2, V.K. Viswanathan1, S.B. K1
1Orthopaedics, PGIMER, Chandigarh/India, 2Orthopaedics,
PGIMER, Chandigarh, India
Introduction: The Injury Severity Score (ISS) sums the severity
score for the three most severe injuries, but it only considers one
injury per body region. Therefore, ISS underscores the severity in
trauma victims with multiple injuries confined to one body region.
Osler et al., introduced in 1997, a modification of the ISS, the New
Severity Injury Score (NISS). The NISS sums the severity score for
the three most severe injuries, regardless of body region. Values of
NISS higher than the ISS indicate multiple injuries in at least one
body region. Osler claimed that NISS predicted short-term mortality
significantly better than did the ISS.
Materials and methods: So it was considered worthwhile to look for
the differences in outcome analysis in isolated musculoskeletal
trauma using both ISS and NISS. A total of 1000 patients were
included in the study. patients were selected based on the inclusion
criteria, mainly multiple skeletal injuries involving extremities. Data
were collected in a proforma and injury Scoring carried out. Also
other necessary details including mortality and morbidity profile
noted down.
Results: Appropriate statistical analysis were made and NISS was
found to outperform ISS in predicting mortality and morbidity in
patients with multiple skeletal injuries than ISS.
Conclusion: From our study it can be concluded that NISS is more
predictive of overall mortality and morbidity profile in patients with
multiple extremity skeletal injuries than conventional ISS.
Reference: Baker et al. The Injury Severity Score. J Trauma.
1974;14:187–96.
S184 Abstract
123
Disclosure: No significant relationships.
P156
IS A 5 % UNDERTRIAGE RATE ACCEPTABLE IN-HOSPITAL? INCREASED MORTALITY FOR UNTRIAGEDPATIENTS IN A MATURE TRAUMA CENTER WITH ANAGGRESSIVE TRAUMA ACTIVATION SYSTEM
A.T. Rogers1, F.B. Rogers1, M. Krasne1, E.H. Bradburn2, J. Lee1,D. Wu1, C.W. Schwab3, M.A. Horst4
1Trauma, Lancaster General Hospital, Lancaster, PA, USA, 2Hershey
Medical Center, Hershey, PA, USA, 3Department of Surgery,
University of Pennsylvania, Philadelphia, PA, USA, 4Research
Institute, Lancaster General Hospital, Lancaster, PA, USA
Introduction: The American College of Surgeons (ACS) has deter-
mined that a 5 % undertriage (UT; defined ISS [15 and no trauma
activation) is an acceptable rate for transfer to a non-trauma center.
We sought to determine if this same level of undertriage is acceptable
within a mature Level II trauma center Emergency Department as a
measure of the adequacy of its multi-tiered trauma activation system.
Materials and methods: Our trauma activation system encompasses
anatomic, physiologic and mechanism of injury criteria. All UT
patients for 2000–2010 were compared to properly triaged patients
(T). Variables examined were mortality, ED length of stay (LOS,
hospital LOS, complications and Coumadin use.)
Results: Of 17168 patients 1156 (6.7 %) were UT. In comparison,
UT had 3-fold mortality increase [5.9 vs. 16.1 %, p \ 0.001,
OR = 3.07 (2.42–3.89)] and 2-fold in complications (4.6 vs. 8.8 %,
p \ 0.001, OR = 1.99 (1.60–2.47)]. ED-LOS in minutes was strati-
fied into four categories. In all categories, comparisons between T and
UT reached statistical significance (p \ 0.005): 0–100 (28.5 vs.
15.4 %), 100–200 (41.4 vs. 29.3 %), 200–300 (18 vs. 30.4 %), and
300+ (12.2 vs. 24.9 %), respectively. Additionally, UT were more
likely to have longer ED-LOS ([200 min). Regarding hospital-LOS,
81.3 % of T were discharged by day 5, compared to 63.8 % of UT
(p \ 0.001). UT had longer hospital-LOS. Patients with hospital-LOS
6–10 days (23.9 vs. 11.7 %, p \ 0.001) and C11 days (12.3 vs.
7.1 %, p \ 0.001) were more likely to be UT. UT were nearly 4-times
more likely on warfarin [4.9 vs. 15.6 %, p \ 0.001, OR = 3.61
(3.04–4.30)].
Conclusion: Similar to ACS out of hospital guidelines, UT in-hos-
pital is associated with significant delay in care, morbidity, and
mortality. In-hospital multi-tiered triage guidelines should be tailored
to minimize the potential for UT.
Disclosure: No significant relationships.
P157
LEUKOTRIENE B4: SIGNIFICANT CORRELATIONBETWEEN PERIPHERAL PLASMACYTOID CELLS ANDLTB4 FOLLOWING MULTIPLE TRAUMA
B. Auner, E. Geiger, B. Relja, D. Henrich, I. Marzi
Department of Trauma, Hand and Reconstructive Surgery, Goethe-
University Frankfurt, Frankfurt, Germany
Introduction: Dendritic cells (DC) are professional antigen-present-
ing cells bridging innate and adaptive immunity. A variety of cells
and their mediators, such as cytokines and leukotrienes, regulate the
interaction between these two systems. Since genes encoding for
5-lipoxygenase and the corresponding LTB4-receptor were found
highly upregulated in DC after multiple trauma and all subtypes of
DC are able to produce LTB4, aim of this study was to compare
LTB4 and subtypes of DC measured in peripheral blood from mul-
tiply traumatized patients.
Materials and methods: This prospective study included 40 multiple
trauma patients (mean ISS 32.3 points). Blood samples were taken
directly on admission in the emergency room (d0) and for the fol-
lowing five days (d1- d5). Plasma LTB4 levels were measured using
ELISA, the percentages of myeloid DC (MDC1, MDC2) and plas-
macytoid DC (PDC) were determined by flow cytometry. Statistics:
Spearman’s rank correlation.
Results: LTB4 measured at each time point (d0–d5) showed a strong
inverse correlation to PDC on day 2 and 3 and to DC on day 3 and a
positive correlation to the MDC:PDC-ratio on day 2 after trauma.
Further correlation was found, for example between LTB4 on day 1, 3
and 4 and PDC on day 0 or between LTB4 on day 1, 2, 4 and 5 and
DC on day 2. In contrast to this no significant correlation between
LTB4 and MDC-subset was found.
Conclusion: LTB4 may have an important role in the regulation of
the posttraumatic immune response through the modulation of DC.
Disclosure: No significant relationships.
P158
EPIDEMIOLOGY OF IN-HOSPITAL TRAUMA DEATHS
R. Lefering1, T. Paffrath2, T. Coates3, F. Lecky3
1Institute for Research in Operative Medicine (ifom), University
Witten, Herdecke, Cologne, Germany, 2Department for Trauma
Surgery, Cologne Merheim Medical Center, Cologne, Germany,3Trauma Audit and Research Network, Salford, UK
Introduction: About half of all trauma-related deaths occur after
hospital admission. The present study investigates the time of death,
and thereby contributes to the discussion about factors considered as
cause of death.
Materials and methods: Data from two large European trauma
registries (TraumaRegister of DGU, TR-DGU, and the Trauma Audit
and Research Network, TARN) were analyzed in parallel. All hospital
deaths with ISS [ 9 documented between 2000 and 2010 were con-
sidered. Patients were categorized in 5 subgroups according to time to
death (0–6 h; 7–24 h; day 1–6; day 7–30; beyond day 30). Surviving
patients from the same time period served as a control group.
Results: In total, 6,685 and 6,867 non-survivors were included from
TR-DGU and TARN, respectively. Hospital mortality rate was
between 15 and 17 %. About half of all deaths occurred within the
first 24 h after admission (TR-DGU: 58 %; TARN: 51 %). The ear-
liest subgroup of trauma deaths showed the highest mean ISS and
highest rate of mass transfusions. Severe head injury rate was highest
in the subgroup of day 1–6. Late deaths are associated with higher age
and more complications (sepsis, multiple organ failure).
Conclusion: Time to death after severe trauma does not follow a
trimodal distribution but shows a constantly decreasing incidence.
Reference: The paper is submitted to Europ J Trauma Emerg Surg.
Disclosure: No significant relationships.
Abstract S185
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P159
IMPLEMENTATION OF AN EVIDENCE BASEDDIAGNOSTIC PROTOCOL IN THE EVALUATION OFBLUNT HIGH-ENERGY TRAUMA PATIENTS
R. Van Vugt1, D. Kool2, S. Lubeek2, H. Dekker2, M. Brink2, J. Deunk2,M. Edwards2
1Surgery, Rijnstate Hospital, Arnhem, Netherlands, 2Radboud
University Nijmegen Medical Centre, Nijmegen, Netherlands
Introduction: Currently computed tomography (CT) is rapidly
implemented in the evaluation of trauma patients. In anticipation of a
large international multicenter trial, this study’s aim was to evaluate
the clinical feasibility of a new diagnostic protocol, used for the
primary radiological evaluation in adult blunt high-energy trauma
patients, especially for the use of CT.
Materials and methods: An evidence-based flowchart was created
with criteria based on trauma mechanism, physical examination and
laboratory analyses to indicate appropriateness of conventional radi-
ography (CR), sonography and CT of head, C-spine and trunk. To
evaluate this protocol, we prospectively included 81 consecutive
patients. Collected data included protocol adherence and number and
type of performed CR and CT scans. We also determined time needed
to perform radiologic investigations, adverse events in the CT room
and clinically relevant missed injuries after one-month clinical fol-
low-up.
Results: There was 99 % adherence to the protocol concerning CT.
Seventy-nine patients (98 %) received one or more CT scans: 72
(89 %) had thoracoabdominal, 78 (96 %) C-spine and 54 (67 %) had
cranial CT. In thirty patients one or more CT scans of body regions
could be omitted. In 38 % CR was wrongly omitted or performed
incorrectly at a variance with the protocol. No major adverse events
occurred in the CT room and no clinically relevant injuries were
missed.
Conclusion: We introduced a diagnostic protocol that seems feasible
and safe for the evaluation of adult blunt high-energy trauma patients.
Implementation of this protocol has the potential to reduce unneces-
sary radiological investigations, especially CT scans.
Disclosure: No significant relationships.
P160
THE DISTRIBUTION OF TRAUMA DEATHS IN A MATURELEVEL I TRAUMA CENTRE IN THE NETHERLANDS
A.C. Gunning1, K.W.W. Lansink2, L. Leenen2
1Surgery, University Medical Center Utrecht, Utrecht, The
Netherlands, 2General Surgery, Trauma Surgery, University Medical
Center Utrecht, Utrecht, The Netherlands
Introduction: The implementation of regionalised trauma care and
centres in the Netherlands influences the distribution of trauma deaths
[1]. After these implementations the mortality significantly decreased
in our trauma centre and region. We hypothesized that further mat-
uration of the trauma system and centre have a influence on the
distribution of trauma deaths.
Materials and methods: We performed a prospective database study
and included and analysed all trauma-related deaths, prior to dis-
charge from our hospital, between January 1999 and December 2010.
Results: A total of 720 trauma deaths were included, 94.7 % was
caused by blunt trauma. Mean ISS was 28.7; 87.8 % had an ISS C16
and 73.6 % C25. Most common causes of death were CNS injury
(59.9 %) and exsanguination (12.9 %). 44 % of the patients died
B24 h. One peak was observed in the first hour after which a rapid
decline; 7.6 % died B1 h, predominantly caused by exsanguination
(52.7 %). Through the years a decline occured in the patients who
died in the first hour after arrival, 11.5–7.6 % (p = 0.022). Further-
more, we observed a decrease in deaths due to exsanguination through
the years (p = 0.035).
Conclusion: The distribution of trauma deaths changed after further
maturation of the trauma system and trauma centre. We observed a
decrease in patients dying due to exsanguination. Furthermore,
patients were less likely to die in the first hour after arrival. These
results suggest improved prehospital and in-hospital trauma care.
Reference: 1. Knegt et al .Applicability of the trimodal distribution of
trauma deaths in a level I trauma centre in the Netherlands with a
population of mainly blunt trauma.Injury.2008.
Disclosure: No significant relationships.
P161
DIAGNOSTIC ACCURACY AND REPRODUCIBILITYOF THE OTTAWA KNEE RULE (OKR) VERSUS THEPITTSBURGH DECISION RULE (PDR)
T.C. Cheung1, R.J. Derksen2, Y. Tank2, W.E. Tuinebreijer2,R.S. Breederveld2
1Emergency Department, Red Cross Hospital, Beverwijk, The
Netherlands, 2Red Cross Hospital, Beverwijk, The Netherlands
Introduction: Radiographs of injured knees are commonly ordered,
even though fractures are found in only 6 percent. The Ottawa Knee
Rule (OKR) and Pittsburgh Decision Rule (PDR) were both devel-
oped for the selective use of radiographs in knee trauma. Application
of the rules may lead to a more efficient evaluation of knee injuries
and a reduction in health care costs without an increase in missed
fractures. The aim of this study was to evaluate the diagnostic
accuracy and interobserver agreement of the OKR versus the PDR.
Materials and methods: In a prospective study, all single knee
injuries presented in the ED from October 2008 to July 2009 who met
the inclusion criteria were assessed by two residents (emergency
medicine resident and surgical resident), using the OKR and PDR. In
all patients, radiography was performed as the gold standard. Pooled
sensitivity and specificity were compared using Chi square statistics
and interobserver agreement was calculated by using kappa statistics.
Results: Ninety injuries were assessed. Seven injuries concerned
fractures (7.8 %). For the OKR, the pooled sensitivity and specificity
were 86 and 27 % respectively. The PDR had a pooled sensitivity and
specificity of 86 and 51 %. The PDR was significantly (p = 0.002)
more specific. The kappa for the OKR and PDR were 0.51 and 0.71.
Conclusion: The PDR was found to be more specific than the OKR,
with equal sensitivity. Interobserver agreement was moderate for the
OKR and substantial for the PDR.
Disclosure: No significant relationships.
S186 Abstract
123
P162
EFFECTS OF PREHOSPITAL FLUID VOLUMES INHYPOTENSIVE TRAUMA PATIENTS: A RETROSPECTIVECOHORT STUDY OF 941 PATIENTS
L.M. Geeraedts Jr1, L.A. Pothof2, E.S. De Lange-De Klerk1,E. Caldwell3, S. D’Amours3
1Trauma Surgery, VU University Medical Center, Amsterdam, The
Netherlands, 2Ziekenhuis De Gelderse Vallei, Ede, The Netherlands,3Liverpool Hospital, Sydney, Australia
Introduction: Hemorrhage accounts for 30–40 % of trauma mortal-
ity. Fluid replacement may worsen bleeding due to hemodilution, and
increased arterial blood pressure may accelerate the rate of bleeding
and promote cloth disruption. We studied the effects of prehospital
fluid volumes upon arrival in emergency department (ED) in trauma
patients that were hypotensive at the scene.
Materials and methods: Retrospective cohort study in an urban level
1 trauma centre. Trauma patients with a systolic blood pressure [0
and B90 mmHg at the scene were included. Logistic regression
models were used to investigate associations between total prehos-
pital fluid volumes and, respectively, clinical shock in ED (Shock
Index C1), blood transfusion in ED and mortality at 24 h while
adjusting for relevant confounders.
Results: 941 patients were enrolled. Prehospital fluid volumes are
independently associated with mitigation of shock upon arrival in ED:
OR for 0.5–B1 L: 0.609 (p = 0.031) and OR for 1–B2 L: 0.541
(p = 0.021) but also with an independent, increased need for blood
transfusion in ED: OR for 1–B2L: 3.274 (p \ 0.0001) and OR for
[2L: 9.923 (p \ 0.0001). No association with mortality at 24 h was
found.
Conclusion: Increased prehospital fluid volumes are independently
associated with mitigation of clinical shock upon arrival in ED
but at the cost of an increased need for blood transfusion in ED.
No significant association with mortality at 24 h was noted.
Fluid volume resuscitation in the prehospital phase must be tailored
(or titrated) to the specific situation in each hypotensive trauma
patient. Prospective trials in patient(sub)groups are warranted.
Disclosure: No significant relationships.
P163
TRAUMATIC DEATHS IN HOSPITAL: ANALYSIS OFPREVENTABILITY AND LESSONS LEARNED
S. Vahaaho1, T. Soderlund2, L. Handolin2, I. Tulikoura2, M. Niemela3,J. Reitala2
1Operative, HUCH, Jorvi Hospital, Espoo, Finland, 2Operative,
HUCH Toolo hospital, Helsinki, Finland, 3Neurosurgery, HUCH,
Helsinki, Finland
Introduction: The aim of the present study was to characterize
traumatic deaths occurring in the hospital and to assess retrospec-
tively the quality of given care by evaluating whether any of the
deaths could be identified as potentially preventable.
Materials and methods: All consecutive deaths of trauma patients
between January 1st 2004 and December 31th 2008 in the Toolo
Hospital Trauma Centre were retrospectively reviewed. The inclusion
criterion was death of a trauma patient occurring in the hospital.
Patients aged [65 years with an isolated proximal femoral fracture
were excluded as were burn patients, patients with isolated limb
fractures (except of femoral and tibial shaft fractures which were
included) and isolated traumatic brain injuries.
Results: A total of 131 patients fulfilled the inclusion criteria. The
records of 3 patients could not be recovered, so 128 patients were
included. The autopsy reports were obtained for 103 of these cases
(80.4 %). The majority of the patients were male and the median age
was 58 (range 1–95). Blunt trauma was the most common type of
injury. 12.5 % of the deaths were considered potentially preventable.
The most common injury mechanisms were a fall from a higher level
(31 %), a fall from the level of the patient (21 %) and motor vehicle
accident (17 %). Of the injuries that were not diagnosed before
autopsy, most common were liver lacerations, rib fractures, pul-
monary contusions, sternum fractures and blunt cardiac injuries.
Conclusion: In our study population 12.5 % of cases were considered
potentially preventable. Traumaresuscitation was inadequate in 7.8 %
of cases.
Disclosure: No significant relationships.
P164
COMPLIANCE OF THE FIELD TRIAGE PROTOCOL INHIGH ENERGY TRAUMA PATIENTS
J.V. Laarhoven1, K.W.W. Lansink2, L. Leenen2
1Surgery, UMC Utrecht, Utrecht, The Netherlands, 2General Surgery,
The Trauma Surgery, University Medical Center Utrecht, Utrecht,
The Netherlands
Introduction: The objective of this study is to analyse the compli-
ance and outcome of the in 2008 updated nationwide
ambulanceprotocol LPA 7.1 on field triage of trauma patients and
level hospital of destination.
Materials and methods: This is a retrospective analysis created from
databases of the Regional Ambulance Facility Utrecht (RAVU) and
the trauma network of all hospitals in this trauma region. All con-
secutive highest emergency ambulance deployments for
traumapatients in the period of 01/06/2008 until 31/05/2011 are
included. Compliance to the LPA was the primary endpoint. Triage
criteria, hospital of destination, transport time, RTS, ISS, H-LOS,
ICU-LOS, hospital transfers and mortality were subtracted from the
databases.
Results: Of all patients 58.5 % was transported to the level I trauma
centre, 39.8 % to a level-II and 1.7 % to a level-III hospital. Of
polytraumatised patients (ISS C16) 93.3 % (n = 154) was trans-
ported to level-I, 6.66 % to level-II and none to level-III hospitals.
The median ISS at level-I, -II and -III, was respectively 5.00 (range
0–75), 4.80 (range 0–24) and 3.61 (range 0–13) with a mortality of
3.8, 0.3 and 0 %. The median H-LOS (days) was 6.21, 1.13 and 3.05.
The mean age was 31.2, 34.5 and 35.4 years.
Conclusion: There’s a good compliance of the current LPA protocol,
the great majority of all polytraumatised patients are directly trans-
ported to the TC. There’s a higher ISS, H-LOS and lower mean age at
the level I TC with a low mortality rate.
Disclosure: No significant relationships.
Abstract S187
123
P165
A COMPARATIVE STUDY ON THE LONG TERMOUTCOME IN LATE PRESENTING CASES OF PIPKIN’SFRACTURE AND ISOLATED POSTERIOR HIPDISLOCATIONS
N.R. Gopinathan1, V.K. Viswanathan2, R.K. Sen1, V.G. Goni3,S.B. Kanthakumar4
1Orthopaedics, PGIMER, Chandigarh, India, 2Orthopaedics,
PGIMER, Chandigarh, Chandigarh, India, 3Orthopaedics, PGIMER,
Chandigarh, India, 4Orthopaedics, PGIMER, Chandigarh, India
Introduction: To evaluate the long-term outcome (clinical, radio-
logical, SF-36 scores) in patients with Pipkin’s fractures with late
presentation and compare outcome scores between patients with
fracture-dislocations and isolated posterior hip dislocations.
Materials and methods: The study included a total of 70 patients
with posterior hip dislocation received at the emergency of our hos-
pital between Jan 1998 to Dec 2003: 46 patients had isolated
dislocations while 24 patients had femoral head fractures in addition
to dislocated hips. The fracture-dislocation patients were grouped on
the basis of Pipkin’s classification and managed appropriately. The
patients were followed-up regularly in the out-patient department and
necessary clinical and radiological evaluations done.
Results: According to the clinical scoring by Merle D’Aubigne
scores, excellent results were obtained in 32.61 % of hip dislocations
and only 8.33 % of Pipkin’s fracture. Matta’s radiological outcome
scoring showed 69.57 % normal results in isolated hip dislocations as
against 45.83 % in Pipkin’s fracture. The physical component score
(of SF-36) was more than 90 in 39.13 % of simple dislocations and
only 16.67 % of fracture-dislocations.
Conclusion: We were able to observe much poorer outcome in the
femur head fracture dislocations than isolated dislocations. In those
posterior hip dislocations with early reductions also, we could observe
such excellent results. However, we could not observe significantly
poorer results while comparing hip dislocations that were reduced
beyond 12 h (mean reduction interval of 5.4 days) and Pipkin’s type
II injury that were managed through closed reductions followed by
internal fixation (mean reduction interval of 23.8 h).
Disclosure: No significant relationships.
P166
ACUTE PANCREATITIS AND ACUTE RENAL FAILURE:DOES THE RISK INCREASE BY RADIO CONTRASTUSAGE?
M. Akkas1, N.M. Aksu1, C. Akman1, E. Akpınar2, M.M. Ozmen1
1Emergency, Hacettepe University School of Medicine, 06200,
Turkey; 2Radiology, Hacettepe University School of Medicine,
06200, Turkey
Introduction: Acute Renal Failure (ARF) is a common complication
of Acute Pancreatitis (AP) and closely associated with the duration of
hospital stay, mortality and the cost. Contrast Induced Nephropathy
(CIN) is one of the most prevalent causes of hospital- acquired ARF.
Aim: To evaluate whether radio contrast agent exposure is a risk
factor of ARF in patients with AP.
Materials and methods: The records of 160 patients that had been
admitted to the Hacettepe University Faculty of Medicine Adult
Emergency Department with AP and had been exposed to radio
contrast agent following admission are analyzed retrospectively.
Results: The mean age of the patients with AP (87 male) was 57
(21–90) years. A total of 22 cases (13.7 %); with and without
recovery in 13 (8.1 %) and 9 (5.6 %) cases respectively, developed
ARF. Six of ARF cases without recovery (66.6 %) resulted in mor-
tality and 77 % of these cases were accompanied with Multiple Organ
Failure (MOF). Age, BUN, diabetes mellitus, chronic kidney disease,
MOF, Ranson (I and II), APACHE II and Balthazar computed
tomography severity index score were found to be associated with
ARF development.
Conclusion: Despite the difficulties in ruling out the other causes and
determining the exact prevalence of CIN; the prevalence is associated
with radio contrast agent exposure, comorbidities, advanced age and
high APACHE II and Ranson scores. The only well-accepted pro-
phylactic measure for CIN is hydration. Therefore, unnecessary radio
contrast agent exposure of dehydrated patients without fluid
replacement should be avoided.
Disclosure: No significant relationships.
P167
DOES THE PATIENT KNOW BETTER THAN THESURGEON?
S. Tsitsilonis1, A. Springer1, T. Lindner2, J. Koch2, T. Marnitz3,N.P. Haas1, F. Wichlas2
1Center for Musculoskeletal Surgery, Charite University Medicine,
Berlin, Germany, 2Emergency Department, Trauma Wing, Charite
University Medicine, Berlin, Germany, 3Department of Radiology,
Charite University Medicine, Berlin, Germany
Introduction: The aim of the present study was to evaluate the
sensitivity and specificity of the patient opinion, the history of injury
and the clinical examination in the diagnosis of extremity fractures.
Materials and methods: We evaluated prospectively 436 ED
patients (59.2 % men) with an extremity trauma. The patients were
asked, whether they believed that they had a fracture. The doctor was
asked to express his belief after obtaining the history of the injury and
after clinical examination. Radiological examination served as
control.
Results: An extremity fracture was present in 134 patients (30.7 %),
in 302 (69.3 %) no; 79 upper extremity fractures, 55 lower-extremity.
Sixty-seven patients with fracture could detect it (50 % sensitivity of
patient opinion). Of the 302 patients without a fracture, 224 were able
to detect that (74.8 % specificity). After injury history the doctors
were able to diagnose 89 fractures. After clinical examination 106
cases were correctly diagnosed (12.6 % increase in recognition). The
history of injury had a sensibility of 66.4 % and a specificity of
85.2 % in fracture detection. The sensibility of the combination of
history and clinical examination was 79.1 %, the specificity 87.5 %.
Conclusion: The estimation of the existence of a fracture cannot rely
on the patient. The surgeon through the combination of history and
clinical examination is more successful. In 80 % of the cases a
fracture can be diagnosed without radiographs, in 90 % a fracture can
be ruled out. This can be of importance in improving the triage sys-
tem, according to the ‘‘treat the right patient at the right time’’
principle.
Disclosure: No significant relationships.
S188 Abstract
123
P168
PROBLEMS IN PREVENTABLE TRAUMA DEATH CASESOCCURRED MAINLY IN THE EMERGENCY ROOM INCHIBA PREFECTURE HOSPITALS IN JAPAN IN 2009
T. Motomura, K. Mashiko
Emergency and Critical Care Medicine, Chiba Hokusoh Hospital,
Nippon Medical School, Inzai, Chiba Prefecture, Japan
Introduction: In 2009, 4,914 people died in traffic accidents in
Japan. An evaluation of such deaths may improve emergency
medicine, and here we aimed to reveal the rate of, and problems
associated with, preventable trauma death (PTD) following traffic
accidents.
Materials and methods: We investigated details of the traffic acci-
dents and emergency activities involving 196 fatalities from traffic
accidents by conducting a questionnaire survey of the fire depart-
ments and hospitals in Chiba prefecture. For 87 such cases with vital
signs when emergency medical teams made contact, we considered
the time taken until different pre-hospital activities commenced, type
of injury, injury severity score (ISS), revised trauma score (RTS), and
probability of survival (Ps). During peer review, the cases were
classified as suspected PTD or PTD and problems in the cases were
identified.
Results: Time from the accident to first doctor contact was
44.3 ± 20.8 min. Mean ISS was 19.0 ± 11.2 and mean RTS was
3.514 ± 2.784 at first doctor contact. The review revealed 18.4 % of
the traffic accident fatalities that year were classified as suspected
PTD or PTD. Of the problems identified, 49 % concerned initial
evaluation and care undertaken in the emergency room (assessment
for shock 14 %, strategy for/priority for treatment 14 %, delay in
IVR/surgery 14 %, delayed diagnosis/injury missed 7 %).
Conclusion: It is important to improve education in trauma evalua-
tion and care, as well as functioning of the doctor delivery and trauma
center systems. The evaluation of quality of emergency activities
undertaken in this peer review should be continued over the long
term.
Disclosure: No significant relationships.
P169
MONITORING OF MIDDLE LATENCY AUDITORYEVOKED POTENTIALS INDEX DURING GENERALANESTHESIA FOR COMATOSE PATIENTS AT THEEMERGENCY DEPARTMENT
J. Tsurukiri1, Y. Ikeda2, S. Ohta3, J. Haraoka1
1Neurosurgery, Tokyo Medical University Hospital, Shinjuku-ku,
Tokyo, Japan, 2Neurosurgery, Tokyo Medical University Hachioji
Medical Center, Hachiouji, Japan, 3Emergency and Ccm, Tokyo
Medical University Hospital, Shinjuku-ku, Tokyo, Japan
Introduction: Non-invasive monitoring that can indicate cerebral
function for comatose patients at the emergency department (ED)
remains unknown. In an operative setting, middle latency auditory
evoked potentials provide (MLAEP) a good discrimination of con-
sciousness during general anesthesia [1]. We assessed the hypothesis
that MLAEP index (MLAEPi) can predict the cerebral function for
comatose patients at the ED.
Materials and methods: This study included 20 healthy volunteers
and 20 comatose patients who were Glasgow Coma Scale \8 and
received oral intubation after induction of general anesthesia. MLA-
EPi was measured using an aepEX monitor (Audiomex, Glasgow,
UK) at rest in the volunteers, and was measured in the comatose
patients from arrival at the ED until ICU admission.
Results: MLAEPi in comatose patients was significantly lower than
that of volunteers (54 ± 17 vs. 89 ± 10, p \ 0.01, Mann–Whitney
test). Twenty comatose patients included 12 cerebral vascular dis-
eases, 2 hypoxia, 2 epilepsy, 2 heat stroke, and 2 toxicosis. Following
premedication (19; midazolam and 1; diazepam), the MLAEPi soon
decreased to 30 ± 10, which was significantly lower than initial
MLAEPi (p \ 0.05, Repeated measures ANOVA), and was main-
tained during performing intubation and other procedures at the ED.
Conclusion: The MLAEPi is represented by simple numerical values
for the evaluation of altered level of consciousness in comatose
patients at the ED. Alternatively, MLAEPi may help emergency
medical teams as a clinical predictor of cerebral function during
general anesthesia in an emergency setting.
Reference: 1. Doi M, et al. Prediction of responses to various stimuli
during sedation: a comparison of three EEG variables. Intensive Care
Med. 2005;31:41–7.
Disclosure: No significant relationships.
P170
MAJOR TRAUMA AND URBAN CYCLISTS
J. Manson1, S. Cooper2, A. West2, E. Foster3, N. Tai2
1Trauma Sciences, Barts and The London School of Medicine &
Dentistry, London, UK, 2Trauma Clinical Academic Unit, The Royal
London Hospital, London, UK, 3Hems, The Royal London Hospital,
London, UK
Introduction: Cyclists are vulnerable road users. Reducing the
number of cyclist deaths on the road is a high priority within Europe.
National statistics detail the number of reported collisions between
cyclists and other motor vehicles. Little is known about the injuries
which cyclists sustain during a collision.
Materials and methods: The aim of this study was to characterise
the physiological status and injury profile of cyclists admitted to our
urban major trauma centre. A retrospective analysis of our trauma
registry database was conducted. All cyclist casualties admitted
between 2004–2009 were included. The physiological parameters
examined were admission systolic blood pressure, pre-hospital GCS
and admission base deficit.
Results: 265 cyclists required full trauma team activation. 82 %
were injured during a collision with a motor vehicle. Cars(C) and
heavy goods vehicles(HGV) accounted for the majority (C:
n = 142, HGV: n = 52). Cyclists who collided with an HGV had
higher injury severity scores, lower SBP and higher base deficit
indicating that haemorrhagic shock is a key feature in these casu-
alties. Car casualties had more severe head injuries, HGV more
severe pelvic injuries.
Conclusion: Injury profile in cyclists varied with the vehicle
involved. Haemorrhagic shock was a key feature of HGV casualties.
Survival was dependent on the ability to achieve timely surgical
haemorrhage control. Awareness of injury profile may aid emergency
management.
References: 1. Andrei S Morgan, Helen B Dale, William E LEe, Phil
J Edwards. Deaths of cyclists in london: trends from 1992–2006.
BMC Public Health. 2010;10:699. 2. European Road Safety Action
Abstract S189
123
Programme. Halving the number of road accident victims in the
European Union by 2010: a shared responsibility. 2003. http://www.
eur-lex.europa.eu.
Disclosure: No significant relationships.
P171
PROCEDURAL SEDATION AND ANALGESIAIN A REGIONAL HOSPITAL EMERGENCY DEPARTMENTIN SWITZERLAND
M. Marco, D.S. Vincent
Urgences, HNE, Neuchatel, Switzerland
Introduction: To examine the efficacy and safety of procedural
sedation and analgesia by non-anaesthesiologists at the Emergency
Department of a Swiss regional hospital.
Materials and methods: We conducted a longitudinal observational
study on all the adult patients who underwent a procedural sedation in
the ED during 17 months, filling during the procedure an apposite
chart for safety and effectiveness measures.
Results: We enrolled 176 consecutive patients (mean age
53.3 years) with anaesthesia risk score ASA I 38 %, ASA II 49 %,
ASA III 13 %, reflecting the comorbidities of a general, unselected
population. We reached deep sedation in 89 % of cases (Ramsay
score 5–6). We performed mainly traumatology procedures: reduc-
tion of fracture (47.5 %), of luxation (32 %), the need of prolonged
sedation and analgesia in case of severe polytrauma (3 %). Other
reasons (15.5 %): agitation, minor surgery, analgesia for severe
burning, cardioversion, urgent gastroscopy. Medications used: Pro-
pofol and/or Ketamine ± opioid analgesics and/or Midazolam. In
82 % of cases we used Propofol alone (mean total dose of 1.72 mg/
kg) and Ketamine in 11 % of cases (mean total dose of 1.75 mg/kg).
In 7 % of cases a combination of Propofol (mean dose of 1.12 mg/
kg) and Ketamine (mean dose of 1.29 mg/kg). No major adverse
events were observed. As minor adverse events we registered apnea
needing short mask ventilation (6.2 % of cases) and a significant
hypo-tension ([20 mmHg) with spontaneous resolution (1.1 %of
cases).
Conclusion: Procedural sedation and analgesia is safe in the envi-
ronment of the ED when performed by non-anaesthesiologist doctors
if strict conditions of safety and appropriate education of the care-
givers are respected.
Disclosure: No significant relationships.
P172
THE EFFECT OF SEVERE INJURY ON QUALITY OF LIFEAND THE INCIDENCE OF PSYCHOPATHOLOGY. A PILOTSTUDY
C.C.H.M. Van Delft-Schreurs Msc1, J. Van Bergen Bsc2,P. Van De Sande Msc2, M. De Jongh1, M.H.J. Verhofstad1,J. De Vries2
1Traumacentre Brabant, St. Elisabeth Hospital, Tilburg, The
Netherlands, 2Medical Psychology, St. Elisabeth Hospital, Tilburg,
The Netherlands
Introduction: Severe trauma often results in physical limitations. The
objective of this study is to investigate the relation between severity
and type of injury, physical limitations, quality of life (QoL) and
psychopathology in severely injured patients.
Materials and methods: Patients of 18 years or older with an ISS
above 15 were included. Accident and patient characteristics, QoL
and appearance of psychopathology were obtained from traumareg-
istry, medical records and questionnaires. Several questionnaires were
used to determine psychopathology. The HADS was used to identify
anxiousness or depression, the SVL to determine posttraumatic stress
disorder and CFQ to determine cognitive functioning. The WHO-
QOL-Bref was used to determine QoL and the SMFA to determine
physical limitations.
Results: Participation rate was 61.1 % (n = 173). The median ISS
was 21 and mean age 44 (±19.3). Most common injury was brain
injury (60.7 %). Participators did not differ significantly from non-
responders, except for sex. 52 Patients suffered from psychopathol-
ogy. ISS was not associated with QoL or psychopathology. Presence
of brain injury significantly affected social aspects of QoL negatively,
but did not significantly increase psychopathology. Patients with more
physical limitations had a significant lower QoL and suffered more
often from psychopathology (p \ 0.001). QoL was significantly
decreased compared with the general Dutch population. Patients with
Psychopathology had a lower QoL (p \ 0.001). QoL for patients
without psychopathology was not impaired comparing to Dutch
general population.
Conclusion: Quality of life of is impaired in severly injured patients.
This is not related to ISS. It seems to depend more on psychological
elements than on physical limitations.
Disclosure: No significant relationships.
P173
RETRIEVABLE INFERIOR VENA CAVA FILTER USE INMAJOR TRAUMA
A. Vasireddy1, M. Phillips1, D. Lewis2
1Trauma and Orthopaedics, King’s College Hospital, London, UK,2Radiology, King’s College Hospital, London, UK
Introduction: The aim of this review is to highlight and develop
guidelines for the use of retrievable inferior vena cava (IVC) filters in
Major Trauma patients.
Materials and methods: An electronic literature search of the Eng-
lish language was performed of PubMed, Medline, EMBASE and the
Cochrane Library. Studies that were eligible for review included
original research studies that evaluated the use of IVC filters in Major
Trauma patients.
Results: The pooled studies included a number of small prospective
studies and larger retrospective studies. Many articles highlighted the
beneficial use of IVC filters in patients who had contraindications to
conventional DVT prophylaxis. However, problems with IVC filters
were also noted, which included the complications of insertion in
addition to a risk of thrombus forming under the filter. In all studies,
there was a very large loss to follow-up that led to many patients
never having their retrievable filter removed.
Conclusion: Retrievable IVC filters represent an option when man-
aging major trauma patients who have contraindications to
conventional anticoagulation. Guidelines for the use of IVC filters in
Major Trauma patients have been formulated within this review
article, with the Eastern Association for the Surgery of Trauma
S190 Abstract
123
(EAST) guidelines (developed in 2002) providing the necessary
template.
References: Eastern Association for the Surgery of Trauma. Man-
agement of venous thromboembolism in trauma patients. Trauma
practice guideline. J Trauma. 2002;53(1):142–64.
Disclosure: No significant relationships.
P174
USE OF FLEXION–EXTENSION CERVICAL SPINERADIOGRAPHY IN A LEVEL-1 TRAUMA CENTER
J.C. Sierink1, E. De Jong1, L.F. Beenen2, W.P. Vandertop3,J.C. Goslings1
1Trauma Unit Department of Surgery, Academic Medical Center,
Amsterdam, The Netherlands, 2Radiology, Academic Medical Center,
Amsterdam, The Netherlands, 3Neurosurgery, Academic Medical
Center, Amsterdam, The Netherlands
Introduction: Cervical spine injuries occur in 2–6 % of blunt trauma
patients. Accurate, rapid and safe diagnostic procedures may prevent
neurological impairment. Our aim was to assess the value of flexion–
extension (F/E) radiography in the evaluation of the cervical spine in
blunt trauma patients and to compare its effectiveness with CT and
MRI.
Materials and methods: All trauma patients who underwent F/E
radiographs and CT or MRI of the cervical spine from June 1999 to
September 2010 were identified (n = 379). Patients with incomplete
documentation of their medical records (n = 70), referred patients
(n = 67) and patients in whom the traumatic event happened[3 days
before moment of presentation (n = 78) were excluded.
Results: Hundred and sixty-four consecutive patients were analysed.
Mean age was 43 years, 61 % was male and median Glasgow Coma
Score at arrival was 15 (range 3–15). Ninety-six of the patients
(59 %) were involved in motor vehicle collisions. In only 22 patients
F/E views were obtained during primary diagnostic workup. Twelve
out of 22 patients had true-negative F/E radiographs. In 1 patient F/E
was false-negative for a stable fracture. In 4 patients stable fractures,
apparent on CT as well, were seen. In 3 patients subluxations were
suspected on F/E views, but MRI was negative. In 2 patients F/E
views were inconclusive.
Conclusion: F/E views of the cervical spine are infrequently used in
the acute evaluation of blunt trauma patients in our trauma center. F/E
radiographs seem to add little to the diagnostic value of CT and MRI
and its use in the acute trauma care setting is questionable.
Disclosure: No significant relationships.
P175
IS THE INJURY MECHANISM INDICATION TO PERFORMACUTE WHOLE BODY COMPUTED TOMOGRAPHY (CT)IN TRIAGE POSITIVE TRAUMA PATIENT?
M. Krticka1, V. Beres2, V. Nekuda2, D. Ira1, M. Masek2, J. Svancara3,A. Stouracova4
1Department of Trauma Surgery, University Hospital, Brno, Czech
Republic, 2Department of Trauma Surgery, University Hospital Brno,
Brno, Czech Republic, 3Institute of Biostatistics and Analyses,
Masaryk University, Brno, Czech Republic, 4Department of
Radiology, University Hospital Brno, Brno, Czech Republic
Introduction: Injuries represent a major cause of mortality in people
younger than 45 years. Triage positive patients should be primarily
transported to the trauma center. Whole Body CT is currently used
routinely in the diagnostics of serious injuries. Speed of CT
examination, specificity and sensitivity to the trauma of paren-
chymal organs are advantages of this examination. On the other
hand, whole body CT is hampered by high radiation burden and
other complications.
Materials and methods: Authors provide evaluation of 480 triage
positive patients who were examined with Whole Body CT in 2009 at
University Hospital Brno. Indication for examination included history
of high-energy trauma. Authors with the help of statistical methods
(Odds ratio, ML Chi square, Logistic regression, ROC analysis)
evaluate a set of patients in the relationship between injury mecha-
nism and findings on Whole Body CT (results classified by
Abbreviated Injury Scale, AIS). Correct indication for Whole-Body
CT was defined as finding trauma in thorax (AIS C3) and abdomen
(AIS C2).
Results: Authors did not find statistically significant relationship
between indication for whole body CT and injury mechanism as the
sole indicator.
Conclusion: Injury mechanism (high energy trauma) should not be
automatic indication for performance of Whole Body CT. Radiation
dose associated with Whole Body CT is not negligible.
References: 10 articles were used for this publication.
Disclosure: No significant relationships.
P176
TIMING OF WHOLE-BODY COMPUTED TOMOGRAPHY(WB-CT)
R. Lefering1, S. Huber-Wagner2
1Institute for Research in Operative Medicine (ifom), University
Witten, Herdecke, Cologne, Germany, 2Klinukum rechts der Isar,
Munich, Germany
Introduction: WB-CT has shown to reduce mortality (Huber-Wagner
2009, Lancet) but there is still a discussion about the best timing.
Materials and methods: Data from the TraumaRegister of the Ger-
man Society for Trauma Surgery (2002–2007; n = 14,858) were
analyzed. All patients were classified as ‘WB-CT first’, ‘WB-CT
later’, or ‘no WBCT’. In addition, also hospitals were classified
accordingly, based on their preferred strategy. Observed mortality
was compared with the average prognosis based on the Revised Injury
Severity Classification (RISC) score. The relation is expressed as
standardized mortality ratio (SMR).
Results: Only a minority of patients were classified as ‘WB-CT first’
(10 %). Their outcome (SMR 0.75) was comparable with that of
patients in the ‘WB-CT later’ subgroup (SMR 0.77) but clearly better
than those without WB-CT (SMR 0.90). Similar results are found on a
hospital basis (SMR 0.76, 0.82, 0.90, respectively). However, in
‘WB-CT first’ hospitals even patients without a WB-CT had a very
good outcome (SMR 0.80).
Conclusion: The effect of initial vs delayed WB-CT seems to be
marginal, but treatment algorithms and organisational aspects seem to
be more important.
Disclosure: No significant relationships.
Abstract S191
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P177
ACUTE RESUSCITATION RESEARCH FOR POST-TRAUMATIC HEMORRHAGIC SHOCK: AREPROSPECTIVE RANDOMIZED TRIALS DOOMED?
H.R. Champion1, J.B. Holcomb2, R.B. Weiskopf3, C.E. Wade2
1Surgery, Uniformed Services University, Annapolis, MD, USA,2Surgery, University of Texas Health Sciences Center, Houston, TX,
USA, 3Surgery, University of California, San Francisco, CA, USA
Introduction: No institution sees sufficient patients to power acute
resuscitative research of treatment of shock following trauma. Multi-
institutional efforts are required compounding the complexity of
implementing research in acute care setting. Premature closure of
large, prospective, randomized acute resuscitation clinical trauma
trials highlights the frustrating inability to marshal data that could
change therapy for post-traumatic hemorrhagic shock. The objective
of this study was to identify why clinical research has failed. We
hypothesized these studies failed because of shortcomings in planning
and/or execution and from unintended regulatory consequences.
Materials and methods: Fifteen major clinical trauma trials of
hemorrhagic shock resuscitation therapy over the past 25 years were
reviewed.
Results: Issues include consistency of clinical practice, availability of
blood products, data acquisition/management, informed consent,
study design/implementation particularly case definition and analytic
approaches, and mortality and other endpoints. Poor accrual rates
commonly result in outcome-related futility and inconsequential
findings. Limiting factors also include use of surrogate patient pop-
ulations, selection and survival bias.
Conclusion: Retrospective data are mounting that cast doubt on
current resuscitation strategies and thus emphasize the potential value
of improved blood product/fluid ratios. Inability to conduct explor-
atory Phase I/II studies has impeded Phase III study development,
leading to failure to meet primary endpoints. Academic trauma
societies must work with the FDA to develop reasonable endpoints for
these challenging studies that are achievable within the current
understanding of epidemiology of traumatic death, emergency con-
sent regulations, and civilian/military clinical environments.
Disclosure: No significant relationships.
P178
THE MANAGEMENT OF BITE WOUNDS IN CHILDREN:A RETROSPECTIVE ANALYSIS AT A LEVEL I TRAUMACENTRE
M. Jaindl1, J. Grunauer2, P. Platzer2, G. Endler3, C. Thallinger4,F.M. Kovar1, S. Hajdu1
1Dep. Trauma Surgery, Meidcal University Vienna, Vienna, Austria,2Dep of Traumatology, Medical University Vienna, Vienna, Austria,3Dep of Laboratory Medicine, Wilheminenspital, Vienna, Austria,4Dep of Internal Medicine I, Med University Vienna, Vienna, Austria
Introduction: Animal bite wounds are a significant problem, which
caused several preventable child deaths in clinical practice in the past.
The majority of bite wounds is caused by dogs and cats, but also
humans have to be considered to lead to those extreme complicated
diagnosis in the paediatric patient population. Early estimation of
infection risk, adequate antibiotic therapy and if indicated surgical
treatment, are cornerstones of successful cure of bite wounds. How-
ever, antibiotic prophylaxis and wound management are discussed
controversial in the current literature. In our study we retrospectively
investigated the bite source, infection risk and treatment options of
paediatric bite wounds.
Materials and methods: 1,749 paediatric trauma patients were
analysed over a period of 19 years in this retrospective study at a
Level I Trauma Center, Department of Trauma Surgery, Medical
University of Vienna, Austria. Data for this study were obtained from
our electronic patient records and follow up visits. In our data base all
paediatric patients triaged to our major urban trauma centre have been
entered retrospectively.
Results: During the 19 year study period, 1,749 paediatric trauma
patients met the inclusion criteria. The mean age was 7.2 years
(range 1.9–17.2), 969 (55.4 %) were males and 780 (44.6 %) were
females. In our study population a total of 1311 dog-bites (75 %),
174 cat-bites (9.9 %), 140 rodent-bites (8 %), 88 human-bites
(5 %) and 36 other-bites (2.1 %) have been observed. A total of 62
wounds (3.5 %) have been infected at onsite, whereas secondary
infection occurred in 151 cases (8.6 %). Surgical intervention was
done in 39 wounds (2.2 %).
Conclusion: In this study population we showed a correlation
between gender and bite wounds. Antibiotic therapy and surgical
intervention has been necessary in only a small number of cases. In
our opinion this might suggest that early admittance to the emergency
room and close follow up and wound control could be taken as an
indirect predictor for uncomplicated wound healing. Our findings
need to be proven in further prospective clinical trials.
Disclosure: No significant relationships.
P179
THROMBOCYTES IN BURN PATIENTS
R.S. Breederveld, H. Montagne, R. Marck
Surgery, Red Cross Hospital, Beverwijk, The Netherlands
Introduction: Thrombocytopenia is a common finding in trauma and
critical ill patients, and associated worse outcome. The objective of
this retrospective study was to investigate the course of thrombocytes
in a large population burn patients, and the influences of various
factors on this course.
Materials and methods: Patients we included 244 patients with
burns admitted to the Burn Centre, from January 2005 to January
2011. Thrombocyte counts were obtained up until 50 days after the
burn injury. Data collected included patient demographics (age, sex,
date of admission), burn size and depth, relevant laboratory values,
sepsis, mortality, medicines and operative interventions.
Results: A clear pattern of thrombocyte counts after burn injury was
demonstrated, with a nadir at day 3 post-burn followed by a top at day
15 and a persistent thrombocytosis until the end of the study period.
Increasing age and TBSA, mortality and sepsis were associated with
significantly decreased counts.
Conclusion: To our knowledge this is the largest population in whom
platelet counts were analyzed after burn injury. Although the general
pattern is an important finding, additional research is necessary to
explore the causality of influencing factors on the thrombocyte counts
as well as the function and quality of the post burn thrombocytes.
Disclosure: No significant relationships.
S192 Abstract
123
P180
HITTS AFTER A SEVERE PELVIC TRAUMA TREATEDWITH A LONG TERM ARGATROBAN THERAPY: A CASEREPORT
R. Mazzani1, A. Rocci2, R. Dalla Valle3, E. Picetti1, M. Mergoni1,A. Volpi1
11st Anesthesia and Intensive Care, Azienda Ospedaliero
Universitaria di Parma, Parma, Italy, 2Internal Medicine, Azienda
Ospedaliero Universitaria di Parma, Parma, Italy, 3Emergency
Surgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
Introduction: Heparin induced thrombocytopenia (HIT) is a rare but
serious immune mediated complication of treatment with LMWH, which
can cause potentially fatal thromboembolism. The treatment is based on
LMWH discontinuation and starting a direct thrombin inhibitor.
Materials and methods: A 61 year old man was the victim of an
accident with an agricultural machine. The patient reported a severe
pelvic fracture with hemodynamic instability.He was subjected to
early angiography followed by a retroperitoneal packing. In the fol-
lowing days the patient developed a compartimental syndrome treated
with a lower limb fasciotomy.
Results: After eight days from the trauma and four from the begin-
ning of LMWH prophylaxis the patient presented a drop in the
platelets count (21.000/mm3) and multiple thrombosys (common
femoral vein extended to the sapheno-femoral cross, the popliteal vein
and both tibial veins, thrombosis of the subclavian, axillary and arm
peripheral veins on one side).The diagnosis of HITT was made on
clinical and laboratory criteria with a positivity for anti-PF4/heparin
antibodies. We started argatroban (a direct thrombin inhibitor) at
2 mcg/kg/min and monitoring of aPTT levels. We have continued this
treatment for 38 days, starting Sintrom only after a surgical stabil-
ization of the patient.
Conclusion: In literature we found only 2 weeks therapy with this
drug, but we can say that in our experience argatroban therapy for a
long period was safe for the patient permitting surgical interventions
without bleeding adverse events.
References: 1. Bloemen A, et al. Incidence and diagnosis of heparin-
induced thrombocytopenia in patients with traumatic injurues treated
with unfractioned or LMWH: a literature review. 2. Shaikh N. Hep-
arin-induced thrombocytopenia. J Emerg Trauma Shock.
2011;4:97–102. 3. Lewis BE, et al. Argatroban anticoagulant therapy
in patients with heparin-induced thrombocytopenia. Circulation.
2001;103:1838–43.
Disclosure: No significant relationships.
P181
SEQUENTIAL APPROACH OF COMBINED PELVIC ANDACETABULAR FRACTURES: FUNCTIONAL OUTCOMESAND COMPLICATIONS
B. Bravo Gimenez, J.L. Leon Baltasar, D. Blanco Dıaz,L. Garcıa Lamas, A.A. Jorge Mora, M. Aroca Peinado,P. Caba, C. Resines Erasun
Traumatology and Orthopedic Surgery, Hospital 12 de Octubre,
Madrid, Spain
Introduction: Treatment of combined pelvic and acetabular fractures
is a surgical challenge. We report a case series of 24 patients
describing fracture pattern and evaluating functional outcomes and
complications after surgery using a sequential approach.
Materials and methods: Inclusion criteria: high energy trauma
associated to disruption of the pelvic ring, including both pelvic and
acetabular fractures. Retrospective review of 24 patients for the
Hospital Database between 2000–2010. The analysis included demo-
graphic data, injury mechanism, fracture classification (AO-OTA),
surgical approach and physical and radiological examination. Com-
plications were recorded and functional outcomes were evaluated by a
modified Majeed scale and the Short Form questionnaire (SF-36).
Results: 17.4 % of polytrauma patients had complex pelvic injuries.
24 patients met the inclusion criteria. The average age was 32 years.
Mechanism: falls from height in 13, traffic accidents in 11. Six
patients were treated by external fixation. Eleven with ilioinguinal
approach and percutaneous fixation of the posterior ring. One patient
needed a combined approach and another patient a Kocher–Langen-
beck. Five cases were treated by percutaneous methods. Complication
rate was low (one infection and one intraoperative bleeding). Con-
gruent reduction was achieved in 80 % of cases.
Conclusion: Most patients with pelvic ring and acetabulum fractures
can be treated in supine with a combination of anterior approaches
and percutaneous techniques with a low complication rate. There is a
strong correlation between the treatment sequence and the accuracy of
reduction and long-term clinical outcomes.
References: 1. Porter SE, et al. Acetabular fracture patterns and their
associated injuries. J Orthop Trauma. 2. Cano-Luis P, et al. Fracturas
del anillo pelvico asociadas a fracturas acetabulares. Revista Espanola
de traumatologıa.
Disclosure: No significant relationships.
P182
COMMON MISTAKES IN INITIAL TREATMENT OFMULTIPLE INJURED PATIENTS
B. Buhanec, S. Mihaljevic
Traumatology, Splosna Bolnisnica Celje, Celje, Slovenia
Introduction: Basic condition for reducing preventable death in
multiple injured patients is appropriate organisation of trauma service.
Identification and analysis of mistakes can significantly reduce the
number of preventable deaths.
Materials and methods: Data of 441 polytraumatized patients were
prospectively collected in GH Celje since 1992. Out of them 142
randomly selected were analysed routinely in that period according to
the list of 24 possible errors. They were grouped into resuscitation
phase errors, initial surgery stage errors, intensive care errors and
strategic decision-making mistakes. Data of 177 polytraumatized
patients included in Traumaregistry DGU in years 2006–2009 were
prospectively collected in General Hospital. All of them were ana-
lysed routinely in that period according to the list of possible errors.
Results: In 142 analysed polytrauma patient 153 mistakes were found
(average 1,1). 60 % of them were found in resuscitation phase, 12 %
in initial surgery phase, 17 % in ICU phase, and 11 % of mistakes
were classified as strategic decision-making mistakes. In 177 patients
included in Traumaregistry DGU 192 mistakes were found (aver-
age1.1). 75 patients were treated without noticed errors, in 45 we
identified more than one error. Groups of errors were compared to
historical period and discussed further in presentation.
Conclusion: Strict use of protocols essentially increases possibility of
survival of polytraumatized patients. The process of continuous iden-
tification and analysis of mistakes in using algorithms is crucial for
Abstract S193
123
quality improvement; it improves the outcome of patient care and
reduces the number of preventable deaths. According to that data
protocols should and can be customized to reduce the number of errors.
Disclosure: No significant relationships.
P183
AN EVALUATION OF UNNECESSARY USE OF COMPUTEDTOMOGRAPHY FOR EMERGENCY ORTHOPEDICTRAUMA PATIENTS
A. Kaya1, A. Imerci2, U. Canbek3, G. Adam4, M. Bozoglan5
1Orthopaedics and Traumatology, Izmir Tepecik Education and
Research Hospital, Izmir, Turkey, 2Orthopedics and Traumatology,
Erzurum Palandoken State Hospital, Turkey, Erzurum, Turkey,3Department of Orthopaedics and Traumatology, Izmir Karsıyaka
State Hospital, Izmir, Turkey, 4Department of Radiology, Izmir
Kemalpasa State Hospital, Izmir, Turkey, 5Orthopaedics and
Traumatology, Mardin Derik State Hospital, Mardin, Turkey
Introduction: While the need for a computed tomography (CT) fol-
lowing the plain radiography on orthopedic patients arriving at the
emergency room is of great importance for the diagnosis and treatment
of certain patients, it is regarded as unnecessary for some others. The
purpose of the present study is to evaluate and note the possible cancer
risk caused by the application of CT evaluated as negative among both
child and adult emergency orthopedic trauma patients, as well as the
unnecessary financial burden it brings on the state budged.
Materials and methods: The number of patients examined in the
adult and child ERs of our hospital in 2010 is 183.552 and 171.450
respectively. The records for the application of CT on child (aged
0–14) and adult (aged 14+ age) patients visiting the emergency
trauma section over 1 year were analyzed.
Results: Of all patients, 145 of the CTs (80.1 %) in child group and
1.108 CTs (74.7 %) in adult group were found to be negative. Per-
centage of the negative CTs in children were found to be significantly
higher than that of adults (p \ 0.001). Percentage of negative CTs in
spine locations in both child and adult group were significantly higher
when compared that of pelvic and extremity locations.
Conclusion: Consequently, although CT has significant diagnostic
medical benefits, it has a great risk of causing cancer with relation to
received radiation.
References: DaAYlar B, et al. Superfluous computed tomography
utilization for the evaluation of the pelvis and spinal column in an
orthopedic ER.
Disclosure: No significant relationships.
P184
MORTALITY ANALYSIS OF A SEVERE TRAUMAPATIENTS PROSPECTIVE REGISTRY AT A LEVEL 2BTRAUMA CENTER IN SPAIN
I. Martınez-Casas1, J. Sancho Insenser1, A. Villasboas Vargas2,E. Membrilla Fernandez1, M.J. Pons Fragero1, J. Guzman Ahumada1,L. Grande Posa1
1General and Digestive Surgery, Hospital Universitari del Mar,
Barcelona, Spain, 2Intensive Care Unit, Hospital del Mar, Barcelona,
Spain
Introduction: A Trauma and Acute Care Surgery Unit was developed
at our center in 2008. The study aim was to know risk factors asso-
ciated with mortality in an intermediate category University Hospital
to be compared with standards.
Materials and methods: Descriptive analysis of a prospective data-
base selecting ISS [ 15 cases. Mortality was main variable. By
means of bivariate and multivariate analysis we compared variables
related to the accident, patient characteristics and Trauma Team
performance.
Results: From 2008 to 2011, 168 severe trauma patients were
attended (n: 817; 20.5 %). Mainly males, aged 44 ± 19 and mean ISS
29 ± 17. Mainly motor-vehicle accidents, 84.5 % blunt trauma.
Anatomical injury distribution was 67 % head, 55 % thorax, 48 %
abdomen. Only 19 % needed instrumented reanimation and mean
trauma bay time was 44 min. 39 % needed transfusion, 46 % surgery
and 52 % ICU admission. Mean hospital stay was 14 ± 17 days.
Mortality was 20.2 %, mainly due to severe head injury 41 %. One-
third of deaths occurred within the first 24 h, but half of them were
‘‘dead on arrival’’ patients. Mortality was significantly associated with
age (p = 0.003), suicide attempts (p = 0.01), roll-over mechanism
(p = 0.02), physiologic criteria on arrival (p = 0.001), lower GCS
(p \ 0.001), lower SBP, need for instrumented reanimation
(p = 0.005), transfusion (p = 0.02), initial haemoglobin, platelets
and prothrombin levels (p \ 0.001). Multivariate analysis showed
age, ISS, presence of physiologic triage criteria and prothrombin time
to be independent factors associated with mortality.
Conclusion: Analysis of our series showed results similar to those in
other European Trauma Centers. Mortality was independently asso-
ciated with age, physiologic status on arrival, injury severity score
and coagulopathy.
Disclosure: No significant relationships.
P185
UNSTABLE CLOSED TIBIA FRACTURES AND EXTERNALFIXATION
M.D. Mladenovic, D.S. Mladenovic, I. Micic, S. Karalejic,P.M. Stojiljkovic, S. Stamenic
Orthopeadics, Clinical Center of Nis, Nis, Serbia
Introduction: The aim of this work is to show the result of our work
on the treatment of the unstable closed fractures of the diaphysea of
the tibia by the use of the method of external fixation.
Materials and methods: 62 patients have been analysed with
unstable closed fractures of the diaphysea of the tibia witch have been
treated in the period of six years by the use of the method of external
fixation. In the analyzed group 42 (68 %) were male and 20 (32 %)
were female. In 51 cases in the treatment of the unstable closed
fractures of the diaphysea of the tibia closed method of external
fixation has been used while in 11 cases open method of external
fixation has been used.
Results: In the analyzed group fractures in all patients healed. No
case of postoperative osteitis has appeared. External fixator to prove
the possibility that while managing the system we can come to our
aim-correction deformity.
Conclusion: External fixation is method of choice in the treatment of
the unstable closed fractures of the tibia diaphysis with marked
damaged soft tissues caused by big trauma and with comminution and
bigger dislocation bone fragments.
Disclosure: No significant relationships.
S194 Abstract
123
THORACIC DAMAGE CONTROL
P186
SURGICAL TREATMENT OF CLOSED FEMORAL SHAFTFRACTURES IN PATIENTS WITH LUNG CONTUSION
I. Bisbinas, D. Georgiannos, V. Lampridis, T. Michail,I. Theodoroudis, M. Savvidis, G. Gouvas
Orthopaedic, 424 General Military Hospital, Thessaloniki, Greece
Introduction: Aim of this study is to evaluate the need of delayed
intramedullary nailing of isolated closed femoral shaft fractures in
patients with lung contusion after high energy injuries to avoid
complications of pulmonary or fat embolism.
Materials and methods: During 2007–2009, 15 patients were
referred to our department after high energy road traffic accidents.
They sustained 17 closed femoral shaft fractures with no other
musculoskeletal injuries but lung contusions. 6 patients were treated
with skeletal traction of the injured extremity and the rest 9 patients
(11 femoral fractures) were treated with external fixation after epi-
dural anaesthesia. All 15 patients received definitive treatment with
intramedullary nailing 10–12 days after the initial injury.
Results: No major complications were reported but one case of fat
embolism with mild symptoms. The patient recovered uneventfully.
Mean time in hospital 18 days (15–22 d). Mean time of follow-up
1 year. All fractures were healed with no complications of delayed
union or non-union.
Conclusion: Delayed intramedullary nailing of closed femoral shaft
fractures in patients with lung contusion at the safe ‘‘window’’ of
10–12 days after injury, reduces significantly the hazard of the
disastrous complications of pulmonary or fat embolism.
Disclosure: No significant relationships.
P187
RESUSCITATIVE THORACOTOMY FOR TRAUMA:54 MONTH REVIEW AT THE ROYAL ADELAIDEHOSPITAL
P.C. Bautz
Trauma Surgery and Trauma Dept, Royal Adelaide Hospital,
Adelaide, SA, Australia
Introduction: A review of resuscitative trauma thoracotomies (RT)
by 2 trauma surgeons at the RAH. Prior to the appointment of trauma
surgeons, RT were not performed at this level 1 Trauma Centre. RAH
is Primary Trauma Centre in South Australia, receiving 75 % of
trauma.
Materials and methods: All patients with thoracic penetrating
wounds, or blunt chest bleeding presenting with severe haemodynamic
collapse, polytrauma hypovolaemic collapse underwent resuscitative
thoracotomy, as part of a Emergency Resuscitative Thoracotomy
(ERT) protocol: ERT activated when systolic \70 mm Hg with
maximal resuscitation, and ERT performed when BP\60 mmHg.
Results: 18 patients; 10 penetrating, 8 blunt traumas. 17 RT per-
formed in the emergency room, 1 in ICU. All RT were successful,
100 % ER RT reached the operating theatre. 8/14 survived (44.4 %).
4/8 (50 %) blunt thoracotomies survived, 4/10 (40 %) penetrating
ERT survival. 1 (0.07 %) air embolus with CVA.
Conclusion: Resuscitative thoracotomies are highly effective if per-
formed early for appropriate indications. A trauma surgical response
time of \7 min contributed to successful ERT. A survival of 40 %
achieved for blunt and penetrating trauma.
Disclosure: No significant relationships.
P188
RIGHT THORACOABDOMINAL GUNSHOT INJURIES: ISNON-OPERATIVE MANAGEMENT POSSIBLE?
S.V. Starling1, D.A.F. Drumond2, B.L. Rodrigues2, M.P.R. Martins2,A.F.Z. Barragat De Andrade3, M.S.A. Silva2
1Trauma Surgery, Hospital Joao XXIII_ FHEMIG, Belo Horizonte,
Brazil, 2Trauma Surgery, Hospital Joao XXIII, FHEMIG, Belo
Horizonte, Brazil, 3General and Trauma Surgery, Hospital Joao
XXIII, FHEMIG, Belo Horizonte, Brazil
Introduction: The management of abdominal gunshot wounds
(GSW) continues to be mandatory laparotomy. The number of non-
therapeutic laparotomy varies 5.3–27 %. Several studies had proposed
the non-operative management (NOM) of right thoracoabdominal
(RTA) gunshot injuries.
Materials and methods: From Jan 05–Dec 10 110 patients were
selected. Criteria for inclusion was GSW to the RTA, haemodynamic
stability and no signs of peritonitis. The patients necessarily underwent
CT to diagnose liver and/or renal injuries, and to exclude hollow
viscus injury. The patients who fitted the inclusion criteria were
admitted to a special ward and treated as indicated in our protocol. The
data collected were analysed by the software EPI INFO 3.5.1.
Results: Of the 110 patients included in our study, the mean age was
21 years, of whom 94.5 % were male, 61 % had thoracoabdominal
injuries and 39 % had exclusively abdominal injuries. The trauma
scores were RTS 7.7, ISS 14.9 and TRISS 97 %. Of the 110 patients,
105 (95.5 %) had liver injury, 67 (61 %) had diaphragm and lung
injury, 29 (26.3 %) had renal injury. Complications were present in 6
(5.4 %) patients. The NOM failure happened in 3 (2.7 %) patients.
The mean hospital stay was 6 days. There was 1 death due to asso-
ciated gunshot brain injury.
Conclusion: NOM of the penetrating RTA injuries must be seen with
caution. It is safe only in selected cases by well-defined protocols and
when performed in places that have adequate infrastructure.
References: Renz BM, Feliciano DV. Gunshot wounds to the right
thoracoabdomen: a prospective study of nonoperative management.
J Trauma. 1994;37:737–44.
Disclosure: No significant relationships.
P189
EFFECT OF KINETIC THERAPY ON POSTTRAUMATICOUTCOME IN POLYTRAUMA PATIENTS WITH SEVERECHEST TRAUMA
C. Zeckey, P. Mommsen, K. Wendt, H. Andruszkow, M. Frink,C. Krettek, F. Hildebrand
Trauma Department, Hannover Medical School, Hannover, Germany
Introduction: Chest trauma represents an undependend risk factor for
posttraumatic complications after polytrauma. Kinetic therapy (KT) is
Abstract S195
123
a relevant treatment option in order to restore pulmonary function in
these patients. Literature reports improved oxygenations in a heter-
ogenous polytrauma cohort suffering from ARDS. The purpose of this
study was to investigate the effect of kinetic therapy compared to lung
protective ventilation in a homogenous multiple trauma cohort.
Materials and methods: A retrospective analysis (2001–2009) of
primary treated polytrauma patients (age [16 years, ISS C16) with
severe chest trauma (AISChest C3) was performed. Patients receiving
either kinetic (KT) or lung protective ventilation strategy (LP) were
compared. Patients with TBI (AISHead [2)were excluded. Chest
trauma was classified according to the AISChest, pulmonary contusion
score (PCS), Wagner-Score and Thoracic trauma severity score
(TTS). Analysed were mortality, posttraumatic complications (ARDS,
ALI, sepsis, MODS) and various clinical parameters. A multivariate
regression analysis was performed.
Results: 283 patients were included (group KT n = 160; group LP
n = 123). No differences were found for AISChest order age. An
increased ISS was found in group KT. There were significantly
increased values of the PCS, Wagner-Score and TTS in group KT; the
incidence posttraumatic complications and mortality were increased
compared to group LP (p \ 0.05). Multivariate logistic regression
analysed the TTS and transfusion requirement as independent pre-
dictors for mortality.
Conclusion: Logistic regression analysis revealed a comparable
survival in patients suffering from more severe chest trauma using
kinetic therapy, indicating a protective effect of this treatment option.
To identify high-risk patients, the analysed chest trauma scores seem
to be more reliable than the AISChest.
Disclosure: No significant relationships.
P190
EXTRA-CORPOREAL MEMBRANE OXYGENATION(ECMO) AS LAST RESOURCE IN SEVERE CHESTTRAUMA: CASE REPORT
V. Tomajer1, A.A. Beneduce1, P. Bisagni1, R. Faccincani2,E. Ortolano2, C. Leggieri2, M. Scandroglio2, F. Pappalardo2,A. Zangrillo2, M. Carlucci1
1Emergency and General Surgery, San Raffaele, Milano, Italy,2Emergencies, IRCCS San Raffaele, Milano, Italy
Introduction: Thoracic lesions are the second cause of morbidity and
mortality in trauma patients after head injuries. ECMO is a supportive
care intervention for both artificial blood oxygenation and extra-
corporeal blood pump in case of cardiac failure. We present a suc-
cessful use of ECMO in a very severe blunt chest trauma.
Materials and methods: A 17 years old boy arrived to our Emer-
gency Department following a motor vehicle crash. On admission the
patient was tachypnoic, major cough. A chest X-ray showed a severe
right lung contusion. Abdominal E-FAST and pelvic X-ray were
normal. Moreover he presented left limbs and facial multiple frac-
tures. Definitive airway was placed and blood drained from the
tracheal tube. A CT scan showed bilateral extensive pulmonary
contusion with lacerations and pneumothorax with no active bleeding
source. Despite aggressive conventional ventilatory and circulatory
support, ARDS and right ventricle failure rapidly progressed. We
instituted ECMO: it lasted 7 days, veno-arterial (VA)-ECMO for
2 days and veno-venous (VV)-ECMO for others 5. During the time of
ECMO support, a tracheostomy was performed; the patient developed
renal failure and infection of the open femur fracture, both success-
fully treated.
Results: Overall ICU length of stay was 35 days. Orthopedic left arm
and leg fractures stabilization was performed. He spontaneously
breathed after 28 days and then was transferred to orthopedic reha-
bilitation centre.
Conclusion: Morbidity and mortality of blunt chest trauma can be
reduced by applying ECMO, a complex, risky and expensive support,
but life-saving.
References: Cordell-Smith JA et al. Traumatic lung injury treated by
extracorporeal membrane oxygenation (ECMO) Injury. 2006.
Disclosure: No significant relationships.
P191
ROTATIONAL BED THERAPY AFTER PULMONARYCONTUSIONS: A NATIONWIDE ONLINE-SURVEY ONCURRENT CONCEPTS OF CARE IN GERMANY
H. Wyen1, S. Wutzler1, M. Maegele2, R. Lefering3, C. Nau1,D. Seidel3, I. Marzi4
1Department of Trauma, Hand and Reconstructive Surgery,
University Hospital of the J.W. Goethe-University, Frankfurt,
Germany, 2Department of Trauma and Orthopedic Surgery,
University of Witten, Herdecke, Cologne-Merheim Medical Centre
(CMMC), Cologne, Germany, 3Institute for Research in Operative
Medicine (ifom), University Witten, Herdecke, Cologne, Germany,4Department of Trauma, Hand and Reconstructive Surgery,
University Hospital of the J.W. Goethe University, Frankfurt,
Germany
Introduction: Although blunt chest injuries are among the most life
threating injuries in adult multiple trauma patients, its therapy has not
been standardized yet. The benefit of continuous lateral rotational bed
therapy (CLRT) in pulmonary contusions is contended. Therefore we
want to assess the current treatment concepts in German trauma
centers (TC) regarding this entity.
Materials and methods: We submitted a 32-item online-question-
naire to 155 hospitals participating in the nationwide TraumaNetwork
to assess current treatment concepts regarding this entity with par-
ticular focus on the use of CLRT. Overall, 21 level I, 53 level II and
81 level III trauma centres were contacted.
Results: The response rate was 35.5 % (55/155) and responses were
received from 10 level I (47.6 %), 17 level II (32.1 %) and 24
(29.6 %) level III TC. 63.6 % of the responders were able to
perform CLRT. This rate decreased from more than 80 % in Level
I to 50 % in Level III TC. Although 42.9 % of the participants
reported on the existence of standardized treatment protocols,
57.1 % failed to report a SOP for CLRT. The annual mean number
of patients per center treated via CLRT was 15 (0-130). Treatment
modalities (PEEP, CLRT-duration) showed great variability. 75 %
of the centers declared an urgent need for further clinical research
in this field.
Conclusion: There is a wide range of different CLRT treatment
strategies performed for lung contusions in German TC. We conclude
that a high-quality randomized-controlled trial is warranted to criti-
cally assess the role of CLRT in this entity.
Disclosure: No significant relationships.
S196 Abstract
123
UNNECESSARY SURGERY
P192
TRAUMA AND CHARCOT FOOT SYNDROME. REPORT OFAN INTERESTING CASE
I. Lintzeris1, X. Agrogianni 2A. Fortis3, E. Siabou3, A. Lintzeri4,V. Ponirakos1
1Surgery, General Hospital of Tripolis, Tripolis, Greece, 2Medicine
School, University of Athens, Athens, Greece, 3Orthopedics, General
Hospital of Tripolis, Tripolis, Greece, 4, General Hospital of Athens
‘‘polycliniki’’, Athens, Greece
Introduction: The Charcot Foot syndrome is a serious and potentially
limb-threatening lower-extremity complication of diabetes that is
frequently triggered by a trivial injury.
Materials and methods: A 65 year old woman, suffering from
Diabetes Mellitus type 2, was admitted to hospital because of a
seriously infected wound on her right foot, as a result of a trivial
injury 1 week ago. The foot was red, warm, edematous and sensitive.
A fistula rising from the traumatic area of the midfoot to the second
toe, was discharging pus. Laboratory testing revealed elevated
infection indexes and glucose serum levels. MRI and bone scan
confirmed infection of soft tissues and osteomyelitis. Cultures from
the affected tissues indicated an E.Coli development. The patient was
treated for a 3 month period time because of additional P. aeuro-ginosa and A. baumanii development until she was cured. However,
after a month free of symptoms, she came back with a painless, red,
warm and swollen right foot.
Results: This time, the clinical history, course, manifestations com-
bined with an absolute normal laboratory testing result, regular
glucose levels of serum and a pathological new bone scan established
the diagnosis of Charcot foot. The patient was successfully treated
avoiding a limb-threatening procedure.
Conclusion: The Charcot osteoarthropathy can result in significant
deformity, ulceration and limb loss. However, clinical suspicion and
early diagnosis help avoiding major complications and a subsequent
amputation.
References: 1. Rogers LC. The Charcot foot in diabetes. J Am Pe-
diatr. Med Assoc. 2011;101(5); 437–46. 2. Gouveri E. Charcot
osteoarthropathy in diabetes. World J Diabetes. 2011;2(5):59–65.
Disclosure: No significant relationships.
P193
CONSERVATIVE TREATMENT OF IMPLANT FAILURE OFSURGICALLY TREATED HUMERUS DIAPHYSISFRACTURE: A CASE REPORT
A. Ersen1, A. Guvendiren2, B.O. Yazıcı2
1Ortopaedics and Traumatology, Kızıltepe Devlet Hastanesi, Mardin,
Turkey, 2Orthopaedics and Traumatology, Kızıltepe Devlat
Hastanesi, Mardin, Turkey
Introduction: Implant failures and loss of the reduction are the main
complications of open reduction and internal fixation with plate and
screws. If those complications occur revision surgery is the standard
treatment [1, 2]. We would like to present a case where implant
failure and loss of reduction of humerus diaphyseal fracture is treated
with close reduction and Sarmiento bracing [3].
Materials and methods: 28 years old male was diagnosed with
closed humerus diaphyseal fracture without neuromuscular injury due
to traffic accident.He was treated with open reduction and internal
fixation with plate and screws. Postoperative period was uneventful.
After 3 months he was presented to outpatient clinic with severe pain
after minor trauma. Implant failure with screw breakage and loss of
reduction with angulation were obvious on plane x rays. Instead of
revision surgery it was treated with closed reduction and Sarmiento
bracing.
Results: After 3 months of the closed manipulation solid union
without any angulation was achieved. The patient has full elbow and
shoulder ROM. He still have broken screws and an unnecessary plate
but has no complains because of them.
Conclusion: Although orthopedic implant industry forces surgeons
more to operate humerus diaphyseal fracture some basic principles of
the fracture treatment do not change. Humerus diaphyseal fracture
treatment and even revisions can be done conservatively successfully
[3].
References: 1. Abalo Open reduction and internal fixation of humeral
non-unions: Acta Orthop Belg. 2.Paris Fractures of the shaft of the
humerus Reparatrice Appar Mot. 3. Sarmiento Acad Orthop Surg.
Functional fracture bracing.
Disclosure: No significant relationships.
P194
ROLE OF PERITONEAL-SERUM LACTATE RATIO AFTERABDOMINAL SURGERY AND RISK OF RELAPAROTOMY
R. Bini1, G. Ferrari2, F. Apra2, R. Leli1
1General and Emergency Surgery Dept, S. Giovanni Bosco Hospital,
ASLTO2, Torino, Italy, 2Emergency Medicine, SG Bosco Hospital,
Torini, Italy
Introduction: The aim of this study is to evaluate the role of peri-
toneal-serum lactate ratio for the assessment of the risk for
relaparotomy after elective and emergency surgery.
Materials and methods: This prospective observational included 66
of 682 patients that were admitted to our surgical ward after operation
between June 2010 to December 2010. 29 need relaparotomy (rela-
parotomy group) while 37 don’t (no relaparotomy group). We
measured serum lactate and lactate in the fluid collected from
abdominal drains of those patients in the post operative period.
Results in the re-operation and no-re operation groups were evaluated
with two-tailed Chi-square test, unpaired Student’s t-test or Fisher’s
exact tests, when appropriate. Comparisons of median values were
made using the Mann–Whitney test. The receiver operating charac-
teristic curve (ROC) was employed to determine the best threshold
value of serum-peritoneal lactate ratio to differentiate patients who
need urgent relaparotomy from patients who didn’t.
Results: We observed that a peritoneal-serum lactate ratio [4.5
(AUC = 0.865; CI 95 % = 0.773–0.957) could discriminate between
patients who needed relaparotomy with a sensibility of 91.3 % and a
specificity of 81 %, a negative predictive value of 94.4 % and a
positive likelihood ratio of 4.79.
Conclusion: Post operative intra-abdominal sepsis due to surgical
complications is associated with high mortality rates. Early diagnosis
of complications is crucial to improve outcome.This study supports
the hypothesis that the peritoneal-serum lactate ratio could be a cheap,
Abstract S197
123
non invasive and useful tool to identify the patient who needed rel-
aparotomy both in elective and in emergency settings.
Reference: DeLaurier. Am J Surg. 1994.
Disclosure: No significant relationships.
P195
SUCCESSFUL NON-OPERATIVE MANAGEMENT OF THEMOST SEVERE BLUNT LIVER INJURIES:A MULTICENTER STUDY OF THE RESEARCHCONSORTIUM OF NEW ENGLAND CENTERS FORTRAUMA (RECONNECT)
G.M. Van Der Wilden1, G.C. Velmahos2, M.A. De Moya2, H.B. Alam2,T. Emhoff3, S. Brancato4, C. Adams4, G. Georgakis5, L. Jacobs5,R. Gross6, S. Agarwal7, P. Burke7, A. Maung8, D. Johnson8,R. Winchell9, J. Gates10, W. Cholewczynski11, M. Rosenblatt12
1Surgery, Division of Trauma, Emergency Surgery and Surgical
Critical Care, Massachusetts General Hospital and Harvard Medical
School, Boston, USA, 2Surgery, Division of Trauma, Emergency
Surgery and Surgical Critical Care, Massachusetts General Hospital,
Boston, USA, 3Trauma Surgery, University of Massachusetts
Memorial Hospital, Worchester, MA, USA, 4Trauma Surgery, Rhode
Island Hospital and Brown University, Providence, RI, USA, 5Trauma
Surgery, Hartford Hospital, University of Connecticut School of
Medicine, Hartford, CT, USA, 6Trauma Surgery, Baystate Medical
Center, Springfield, MA, USA, 7Trauma Surgery, Boston Medical
Center and Boston University, Boston, MA, USA, 8Trauma Surgery,
Yale New Haven Hospital and Yale Medical School, New Haven, CT,
USA, 9Trauma Surgery, Maine Medical Center, Portland, ME, USA,10Trauma Surgery, Brigham and Women’s Hospital and Harvard
Medical School, Boston, MA, USA, 11Trauma Surgery, Bridgeport
hospital, Bridgeport, CT, USA, 12Trauma Surgery, Lahey Clinic,
Burlington, MA, USA
Introduction: This multi-center study is determining rate and pre-
dictors of failure of non-operative management (NOM) in patients
with grade IV and V Blunt Liver Injury (BLI). Our hypothesis is that
such high-grade BLI can be safely managed by NOM.
Materials and methods: This is a retrospective case series, including
393 patients with a grade IV or V BLI, admitted January 1, 2000, and
January 31, 2010. Main outcome was failure of NOM (f-NOM),
defined as the need for a delayed operation.
Results: An immediate operation was performed in 131 patients
(33 %), typically because of hemodynamic instability. NOM was
offered in 262 patients, and failed in 23 patients (9 %) but only in 17
(6 %) because of the liver (ongoing bleeding in 7, biliary peritonitis in
10). Two independent predictors of f-NOM were identified: SBP on
admission\100 mmHg and other abdominal organ injury. With both
factors present f-NOM happened in 23 % of the patients; with both
factors absent in 4 %. The mortality rate was similar between s-NOM
(5 %) and f-NOM patients (9 %, p = 0.52). Of the patients with
s-NOM, liver-specific complications developed in 10 % and were
managed definitively without major sequelae.
Conclusion: NOM can be offered safely even in the most severe BLI.
Only 6 % of NOM patients required a delayed operation because of
liver-related issues and typically not for ongoing bleeding. Nearly
67 % of BLI patients were discharged without a laparotomy.
References: 1. Piper GL, Peitzman AB. Current management of
hepatic trauma. Surg Clin North Am. 2010;90:775–85. 2. Velmahos
GC, Toutouzas KG, Radin R, Chan L, Demetriades D.
Disclosure: No significant relationships.
P196
NONOPERATIVE MANAGEMENT OF HEPATIC TRAUMAIN POLYTRAUMA SETTING
M. Beuran1, I. Negoi1, S. Paun1, A. Runcanu1, B. Gaspar1, M. Vartic2
1General Surgery, Emergency Hospital of Bucharest, Bucharest,
Romania, 2Emergency Hospital of Bucharest, Bucharest, Romania
Introduction: Even though nonoperative management of hepatic
trauma is the standard of care for haemodynamic stable patients, there
are many controversies regarding hepatic lesions in polytrauma
patients.
Materials and methods: Prospective observational study in a level I
trauma center. Inclusion criteria: (1) Injury Severity Score C 17; (2)
hepatic trauma revealed by imagistic or surgical exploration; (3) the
highest intra-abdominal value for liver Abbreviated Injury Scale
(AIS). There were 3 groups: successfull nonoperative management
(SNOM), failed nonoperative management (FNOM) and operative
management (OM).
Results: There were 38 polytrauma patients: 10 (25 %) grade I, 12
(32.1 %) grade II, 11 (28.6 %) grade III and 5 (14.3 %) grade IV liver
injuries, according to Organ Injury Scale (OIS). 19 (50 %) had a
successfull nonoperative management, 18 (47.4 %) a OM and 1
(2.6 %) a FNOM. There was no correlation between the liver OIS,
AIS and therapeutic approach (Spearman’s rho = -0,204, p = 0,298
and Spearman’s rho = -0,068, p = 0,733). We have found no dif-
ferences regarding in-hospital stay and mortality for operative or
nonoperative approach in liver trauma (p = 0,357, p = 0,490).
Conclusion: Nonoperative management of liver injuries is feasible
and safe in polytrauma patients.
Disclosure: No significant relationships.
P197
INITIAL RADIOLOGICAL ASSESSMENT IN A COHORT OF1,124 LEVEL-1 TRAUMA PATIENTS
G.F. Giannakopoulos1, T.P. Saltzherr2, L.F. Beenen3, G. Streekstra3,J.B. Reitsma4, F.W. Bloemers1, J.C. Goslings2, F.C. Bakker1, *. ReactStudy Group1
1Trauma Surgery, VU University Medical Centre, Amsterdam, The
Netherlands, 2Trauma Unit Department of Surgery, Academic
Medical Center, Amsterdam, The Netherlands, 3Radiology, Academic
Medical Center, Amsterdam, The Netherlands, 4Epidemiology and
Statistics, Academic Medical Center, Amsterdam, The Netherlands
Introduction: To assess the amount and findings of radiological
examinations during the initial assessment and to determine the
radiation doses to which these patients are exposed to.
Materials and methods: We analyzed the 1,124 patients included in
the randomized REACT trial. All radiological examinations during
primary and secondary survey were assessed. The examination results
were categorized as positive findings ((suspicion for) traumatic
injury)), negative findings and incomplete/invaluable results. The
effective doses for the examinations were calculated separately for
each patient.
Results: 803 patients were male (71 %), median age was 38 years
and 1.079 patients sustained blunt trauma (96 %). During initial
assessment, almost 3.900 x-rays were performed for the total
S198 Abstract
123
population of which 25.4 % showed positive findings. FAST of the
abdomen was performed in 989 patients, founding injury in 10.6 %.
Additional CT-scan examination was performed 1.890 times for 813
patients of which approximately 43.4 % revealed positive findings.
Hemodynamically and neurologically stable patients showed signifi-
cantly more negative findings than unstable patients. The mean
radiation doses for the total population was 8.46 mSv (±7.7) and for
polytraumatized patients (ISS C16) 14.3 mSv (±9.5).
Conclusion: Radiological diagnostics during initial assessment show
a high rate of overuse in our trauma system. The radiation doses to
which trauma patients are exposed to is considerable and in many
cases unnecessary. Considering that the majority of the injured
patients who are admitted are hemodynamically stable and alert,
selective diagnostics is feasible without increasing the missed injury
rate.
Disclosure: No significant relationships.
VASCULAR INJURIES
P198
POPLITEAL ARTERY INJURY ASSOCIATED WITH BLUNTTRAUMA TO THE KNEE WITHOUT FRACTURE ORDISLOCATION: CASE REPORT
A. Imerci1, K. Ozaksar2, Y. Gurbuz2, T.S. Sugun2, A. Savran3
1Orthopedics and Traumatology, Erzurum Palandoken State Hospital,
Turkey, Erzurum, Turkey, 2Department of Orthopedics, Hand,
Microsurgery, Orthopedics and Traumatology (EMOT)
Hospital,Izmir, Turkey, Izmir, Turkey, 3Orthopaedics and
Traumatology, Tepecik Education and Research Hospital, Izmir,
Turkey
Introduction: Popliteal artery injuries are frequently seen with
fractures, dislocations or penetrating injuries. Having concern about
artery injury or early recognition of possible artery injury is very
important for salvage of extremity. In our paper; we are presenting a
popliteal injury case of which happened after blunt trauma to the knee
without fracture, dislocation or penetrating injury. The importance of
detailed vascularly examination of blunt traumatized patient wanted
to be emphasized.
Materials and methods: 38 years old miner has had a crushing left
knee injury while working. It was 18 h before he had attended to our
emergency. Due to having no laceration and growing pain he attended
5 h after the accident to a periphery hospital. Fogarty catheter has
been used to make an embolectomy but it was evident that total
occludation found by angiography and catheter could not passed
through thrombus.
Results: All ligamentous examinations were normal. Angiograpy
showed that popliteal artery was totally occluded. Subtle knee dis-
location was excluded. Intraoperative assessment of popliteal artery
was made and 3 cm intimal injury found. Above knee amputation was
performed.
Conclusion: In this very rare case report we hoped to emphasize that
after blunt trauma to the knee it is important to make an accurate
examination and differential diagnosis. Also we hoped that surgeons
would be more aware about artery injuries are not occurs with
penetrating or fracture/dislocation injuries to the knee, it can occur
with blunt trauma.
References: Gable DR. Blunt popliteal artery injury: is physical
examination enough for evaluation? J Trauma. 1997;43:541–5.
Disclosure: No significant relationships.
P199
LESION OF A. AND V. FEMORALIS IN PATIENT WITHBILATERAL SUBTROCHANTERIC FRACTURE- A CASEREPORT
S. Zagorac1, A. Lesic2, I. Milosevic2, M. Bumbasirevic2
1Emergency Center, Clinic of Orthopaedic Surgery and
Traumatology, Belgrade, Serbia, 2Clinic of Orthopaedic Surgery and
Traumatology, Belgrade, Serbia
Introduction: An arterial disruption in a closed fracture is rare. It has
been reported in only 0.3 % of long bone fractures.
Materials and methods: We report about 46-years old male patient,
who has falled from the roof of his house, from the height of about
8 m. He was addmited in the Emergency Center in Belgrad with
consciousness in alert condition, heart rate was 102/min, blood pre-
sure was 100/65. At the physical examination we noticed pathological
deformities of proximal part of the both femur with pathological
movements. Pedal pulses at the both legs were very weak.Despite
blood transfusion there was no improvement of his hemodynamic
stability. The CT of proximal parts of femur and right femoral arte-
riography had been performed. The patient underwent the bilateral
pelvi-femoral external fixation. At the right side, after carefully
exploration, vascular surgeons have founded a 7 cm long lesions of
femoral artery and vein and end to end anastomosis with autograft had
been performed.
Results: When nerve and vascular injuries are associated with a
traumatic fractured limb, the tendency is to attribute the nerve and
vascular injuries to the fractured bone fragments. In our case it seems
as if the initial trauma causing the fracture may be responsible for the
vascular injuries. The use of external fixation has been shown to allow
associated injuries to the nerves, arteries and soft tissues to be treated
adequately while maintaining skeletal stability.
Conclusion: Trauma can involve the vessels and the nerves of the
extremities either directly from the initial injury or secondarily from
the fragments.
Disclosure: No significant relationships.
P200
BLUNT TRAUMA OF POPLITEAL ARTERY WITHSECONDARY OBLITERATION: CASE REPORT ANDDISCUSSION OF PATHOPHYSIOLOGY
E. Scola
Klinik Fur Unfall-Und Wiederherstellungschirugie, Dietrich
Bonhoeffer Klinikum, Neubrandenburg, Germany
Abstract S199
123
Introduction: In blunt arterial trauma a secondary obliteration of
the lumen is often overlooked with a high risk for amputation of the
limb.
Materials and methods: A 26 years old biker suffered a high
speed traffic accident with injury of knee ligaments on the right
side. Primary peripheral pulses were palpable without any signs of
ischemia. On ICU in the following day the right foot got pale
and pulseless, the angiography showed a complete stop in the first
popliteal segment.
Results: Despite of urgent surgery the lower leg could not bee saved
by severe damage of soft tissues and additional fractures and an above
knee amputation was necessary.
Conclusion: In blunt arterial trauma the obliteration of the lumen is
caused by an interaction of platelets and collagen fibers—not by an
intimal flap. Therefore the stop of bloodflow occures sometimes slow
and lasts hours. Attention must be payed for peripheral circulation
even in high enregy trauma for more than 24 h.
References: Scola E. Stumpfe Artrienverletzungen, Biomechanik und
Pathophysiologie. Hefte zur Unfallheilkunde 224, Springer 1992.
Disclosure: No significant relationships.
P201
MASSIVE ORAL AND NASAL BLEEDING FROMTRAUMATIC INJURIES OF THE INTERNAL CAROTIDARTERY
Y. Mohamed Al-Lal1, L. Alvarez Llano2, T. Sanchez Rodriguez2,C. Camarero Mulas2, M.D. Perez Dıaz2, M. Sanz Sanchez2,F. Turegano Fuentes2
1General Surgery Ii, Hospital Gregorio Maranon, Madrid, Spain,2Cirugıa General Ii, Hospital Gregorio Maranon, Madrid, Spain
Introduction: The optimal management of traumatic injuries of the
internal carotid artery (ICA) has not been standardized and today it is
still controversial.
Materials and methods: Observational retrospective study over a
period of 13 years. Nine patients were assessed, out of 1.435 patients
included in our severe trauma registry. We analyzed the incidence,
mechanism of injury, severity scores, clinical presentation, diagnostic
methods, treatment, length of hospital stay (LOS), morbidity and
mortality.
Results: We included 7 men and 2 women, with an average age of
32.11 years (range 13–66). The mechanism of injury was penetrat-
ing in 2 cases and blunt in 7 (77.8 %). The average RTS, ISS, and
NISS were of 8.5 (±2.2), 32.7 (±7.8), and 39.9 (±8.2), respectively.
The most frequent clinical manifestations were neurologic deficits,
massive epistaxis and oral bleeding. All patients underwent cervical
and cranial CT, and 5 cerebral arteriographies were performed.
Only 2 patients underwent surgery. 2 endovascular carotid embo-
lizations, and 2 endovascular stent placements were performed.
Mortality was of 66.7 % (6 patients). The average LOS for
surviving patients was of 34.7 days (±7.6). Complications included
a postoperative pneumonia and an epistaxis in a patient with
endovascular stent that required a new angiography and coil
embolization.
Conclusion: Traumatic injuries of the ICA are uncommon and carry a
high mortality. Massive oral and nasal bleeding is a common mani-
festation. Endovascular stent placement or embolization are useful
tools in selected patients. The most common cause of death is
bleeding and associated neurological damage.
Disclosure: No significant relationships.
P202
TRAUMATIC AVULSION OF THE LEFT SUPRAHEPATICVEIN–CASE REPORT AND REVIEW
A.P. Gomes1, M.D. Sousa1, A.R. Tomas1, R.C. Abreu1, S. Gomes2,C. Carmona2, N.B. Pignatelli1, A. Pedro2, E. Pedro2, V.M. Nunes1
1Cirurgia B, Hospital Prof. Dr. Fernando Fonseca, E.P.E., Amadora,
Portugal, 2Anestesiologia, Hospital Prof. Dr. Fernando Fonseca,
E.P.E., Amadora, Portugal
Introduction: Vascular lesions from abdominal trauma, namely
lesions of the suprahepatic vena cava (SHVC) and suprahepatic veins
(SHV), have a reported 100 % mortality due to uncontrolled bleeding.
Materials and methods: Case report and systematic review in
‘‘PubMed’’ on 24th September 2011. Keywords: ‘‘traumatic AND
hepatic vein lesion (Review OR Case Reports)’’. 20 papers selected.
Results: 31 year old male admitted to the Emergency Room (ER) due
to motorcycle accident. At admission: no respiratory distress, blood
pressure 115/76 mmHg, heart rate 88, GCS = 15, positive for
abdominal pain and tenderness. Haemoglobin 10.6 g/dl. CT showed
right pneumothorax, possible injury of the spleen and left kidney with
haemoperitoneum. Sudden onset of haemodynamic instability led to
urgent laparotomy. An avulsion of the left SHV was found, with
active bleeding and serious haemodynamic deterioration despite
massive blood transfusion. Esternotomy and phrenotomy were per-
formed and vascular reconstruction with cava-SHV anastomosis was
done. Patient was transferred from ICU on day 10 and discharged on
day 12. Systematic review highlights high mortality. When anatomic
vein reconstruction is unfeasible, atriocaval shunt should be per-
formed in order to have a bloodless field for vascular repair.
Recommendations for definite treatment in centers with a multidis-
ciplinary approach and available ICU are also highlighted.
Conclusion: Although surgical approach was challenging, requiring
skilled and experienced surgeons, the success in this particular
patient, rather than associated with the surgical technique itself, was
mainly due to an efficient multidisciplinary approach, involving
radiology, surgery and anesthesiology in the ER.
Reference: PubMed on 24/09/2011 ‘‘Traumatic AND hepatic vein
lesion (Review OR Case Reports)’’.
Disclosure: No significant relationships.
P203
VERTEBRAL ARTERY INJURY FOLLOWING FLEXION–EXTENSION INJURY TO THE NECK
T. Ehrenfreund, T. Zigman, D. Rajacic, I. Dobric, T. Antoljak,S. Davila
Department of Surgery, University Hospital Centar Zagreb, Zagreb,
Croatia
Introduction: The possibility of a vertebral artery injury should be
kept in mind when examining patients with cervical spine trauma.
Most traumatic vertebral artery injuries are limited to an intimal
dissection and are usually clinically occult. Rarely, transection of the
vertebral artery can be seen following cervical trauma in patients that
have cervical spine fractures and/or dislocations and may cause fatal
ischemic damage to the brain stem and cerebellum.
Materials and methods: We report a case of trombosys/transection
of both vertebral arteries in polytrauma due to flexion–extension
S200 Abstract
123
injury to the neck, without the presence of cervical fracture or dis-
location, resulting in brain stem infarction with fatal outcome.
Disclosure: No significant relationships.
P204
MUSCULAR CRUSHING: CAN IT BE CONSIDEREDA THROMBOTIC STATUS?
O. Lupescu1, M. Nagea2, C. Patru3, G.I. Popescu2, D. Lupescu4,D. Sucoveschi2
1Orthopedics and Trauma, Clinical Emergency Hospital Bucharest,
Bucharest, Romania, 2Orthopedic And Trauma Clinic, Clinical
Emergency Hospital Bucharest, Bucharest, Romania, 3Orthopedics
And Trauma Clinic, Clinical Emergency Hospital Bucharest,
Bucharest, Romania, 4General Medicine, University of Medicine and
Pharmacy, Bucharest, Romania
Introduction: Muscular crushing influence not only the vitality of the
injured limb, but also the life of the patient. One of the mechanisms
activated by crushing is thrombosis, affecting from microcirculation
to medium or great vessels. The authors of this prospective study
evaluate (clinical and using Doppler-ultrasound) the status of the
arterial and venous axes of the crushed limbs.
Materials and methods: This study evaluates 70 patients operated in
our Hospital between 1.01.2005–1.01.2009 for muscular crushing,
associated with femoral fractures (20 cases), tibial fractures (30
cases), compartment syndrome (20 cases). Fasciotomy was performed
in all cases in order to excise the necrotic muscle. All the patients
received LMWH therapy. LDH and CK values were monitorised.
Clinical and ultrasound examinations were performed 1, 2, 6, 12, 24
and 48 months after trauma.
Results: Acute peripheral ischaemia (API) was associated with initial
crushing in 12 cases (5 cases-arterial thrombosis) and in other 2 cases,
API appeared more than 16 h after initial crushing and required
surgery. Recurrent API was clinically diagnosed in 3 of these 12 cases
within the first week after trauma; late post-traumatic arterial
incomplete occlusion by thrombotic material appeared in 8 cases. In
14 cases, crushing was followed by venous thrombosis of: femoral
veins (3 cases), tibial veins (9 cases), peroneal veins 2 cases).
Conclusion: Crushing produces metabolic and vascular imbalances,
some of them activating thrombosis, which can affect the injued limb
long time after crushing, which can be considered to be a ‘thrombotic
disorder’.
References: Malinoski DJ, Slater MS. Crush injury and rhabdomy-
olysis. Crit Care Clin. 2004;20:171–92.
Disclosure: No significant relationships.
P205
PSEUDOANEURYSM AFTER TRAUMATIC LIVER INJURY.IS CT FOLLOW-UP WARRANTED?
L. Oesterballe, L.B. Svendsen, A. Wettergren, J. Hillingsoe
Department of Surgery, Rigshospitalet, Copenhagen, Denmark
Introduction: Hepatic pseudoaneurysm (HPA) is an unusual but
potentially a severe complication after traumatic liver injury. As it
may rupture and cause massive haemorrhage it should be taken
seriously. The risk of a HPA is one of the reasons why some trauma
centres do follow-up radiology of hepatic trauma. However, limited
studies exist, focusing on the incidence of post-trauma HPA. The aim
of this work is to investigate wether the follow-up scan is warranted
or if it is safe to discharge a patient with no symptoms.
Materials and methods: A retrospective study of non-operatively
treated patients with sustained liver injury due to trauma from
1999–2010. Patient demographics, liver injury severity score (AAST),
hemodynamic status, blood transfusions, liver biochemical parame-
ters and initial and follow-up CTs were obtained.
Results: Between 1999–2010, 206 patients were treated conserva-
tively for traumatic liver injury. 156 patients were followed up by CT,
of which 5 (3.2 %) patients were suspicious of HPA. The diagnosis
was confirmed by angiography.They were all treated successfully
with angiographic embolization and discharged without further
complications from the liver injury.
Conclusion: In order to avoid potentially life-threatening haemor-
rhage from a post traumatic pseudoaneurysm in the liver, it seems
appropriate to do follow-up CT as part of the conservative manage-
ment of traumatic liver injuries. Apparently the AAST grade of injury
can not be used to rule out minor traumas (grade 1–3).
References: 1. Bardes. Trauma. 2008; Safavi. Pediatr Surg. 2011. 2.
Inogushi, Surg Today. 2001. 3. Demetriades. Br J Surg 2003. 4.
Stylianos, Ped Surg. 2002. 4. Stylianos. Ped Surg. 2000. 5. Norman,
HPB. 2009; 6. Parks. Trauma. 2011.
Disclosure: No significant relationships.
P206
THE USE OF MODIFIED MANGLED EXTREMITYSEVERITY SCORE (MESS) SCALE FOR LIMB SALVAGEPROGNOSIS IN CIVILIAN TRAUMA
I. Samokhvalov, A. Pronchenko, V. Reva
War Surgery Department, Kirov Military Medical Academy, Saint-
Petersburg, Russian Federation
Introduction: The aim of our study was to evaluate prognostic value
of the modified MESS scale based on analysis of combat extremity
injuries - « VPH-MESS » (VPH–Voenno-Polevaja Hirurgija, ‘‘War
Surgery’’ in Russian).
Materials and methods: A retrospective analysis of severe extremity
injuries in 24 patients admitted to our Level 1 trauma center from
2001 to 2011 was performed. The main inclusion criterion was the
presence of major arterial injuries accompanied by bone fractures.
The main characteristics of VPH-MESS are following: the assessment
of ischemia degree according to V.Kornilov’s classification, the
exception of a mild extremity ischemia; a shift of age limit deter-
mining prognosis up to 50 years. With the score 7 and more, the
amputation was carried out.
Results: The average age of the patients was 44.4 ± 3.6 years. Upper
and lower extremities were injured in 6 and 10 patients, respectively;
two extremities or more were injured in 8 patients. All patients were
delivered into two groups similar in trauma severity. In the 1st group
(VPH-MESS \7) (n = 13) only one patient underwent the amputa-
tion though the score was 5. Extremity was saved in the other patients.
All patients of the 2nd group (VPH-MESS C7) (n = 11) had
extremities amputated. In this group complications occurred threefold
more often, compared to the 1st group (45.4 and 15.4 %, respectively)
(p = 0.11). The mortality rate differed considerably: in the 1st group
7.7 %, in the 2nd group 63.6 % (p \ 0.05).
Abstract S201
123
Conclusion: This modified VPH-MESS scale allowed us to arrive at a
correct decision regarding amputation or extremity salvage in 95.8 %
of cases of severe trauma (23 of 24 injured).
References: Johansen K, Daines M, Howey T, Helfet D, Hansen ST
Jr. Objective criteria accurately predict amputation following lower
extremity trauma. J Trauma. 1990;30(5):568–73.
Disclosure: No significant relationships.
P207
COMBAT VASCULAR INJURY WITH ASSOCIATED LONGBONE FRACTURE
I. Samokhvalov, A. Pronchenko, V. Reva
War Surgery Department, Kirov Military Medical Academy, Saint-
Petersburg, Russian Federation
Introduction: The objective of the study was to analyse management
and outcomes of combat vascular injuries associated with bone
fractures.
Materials and methods: A retrospective analysis has been made,
which comprised 78 patients with severe extremity injuries, admitted
to advanced trauma management (ATM) and definitive surgery (DS)
levels of care during first (1994–1996) and second (1999–2002)
armed conflicts in the North Caucasus.
Results: All patients were males, whose average age was 23 years.
There were 41 % of isolated extremity injuries, 59 % of multiple
injuries. The signs of uncompensated ischemia were noted in
34.4 % of patients, irreversible ischemia—in 13.0 % of patients.
Bone fractures of lower and upper extremities were noted in 46.2
and 41.0 % of cases, respectively. Fractures of two and more bones
occurred in 12.8 % cases. The main vascular operation used at
ATM level was vessel ligation (64.7 %). Temporary shunting was
performed in 7 patients: with brachial (3), common femoral (2), and
superficial femoral artery (2) injury. After evacuation these patients
underwent a definitive blood flow restoration using autologous vein
grafting. In 10 cases of irreversible ischemia extremity amputation
was done. External fixation using the unilateral or Ilizarov frame at
ATM level was carried out in 13.2 % of patients. Internal fracture
fixation was performed at DS level in only 6 % of cases. The
amputation rate was 14.1 %. The mortality rate decreased from
13.9 % in the first North Caucasus conflict to 5.7 % in the second
one.
Conclusion: The use of temporary shunting and external fixation of
bone fractures allow to decrease amputation and mortality rate.
Disclosure: No significant relationships.
P208
DVT SURVEILLANCE: IS IT COST EFFECTIVE
A.K. Malhotra, S.R. Goldberg, N. Martin, M. Levy, C.T. Borchers,M. Aboutanos, R. Ivatury
Surgery, Virginia Commonwealth University, Richmond, VA, USA
Introduction: Deep Venous Thrombosis (DVT) and pulmonary
embolism (PE) are prevalent in trauma patients. The role and cost-
effectiveness of survielance is not established. The current study
evaluates the role of survielance and its costeffectiveness.
Materials and methods: A list of all trauma patients admitted to the
ICU from 2001–07 was obtained from the trauma registry. Patients
admitted during 2001–03 were in the pre-surveillance period (PSP),
while patients admitted from 2004–07 were in the surveilance period.
In the PSP, diagnostic duplex examinations of the Lower extremity
were performed on clinical suspicion of DVT, while patients in the SP
underwent twice weekly duplex examination of the lower extremity
irrespective of symptoms. The rates of DVT and PE were derived and
compared. Also, the cost of the examinations were calculated and the
cost-effectiveness os the surveillance program was evaluated.
Results: During the study period, a total of 4,234 trauma patients
were admitted to the ICU of which 1,422 were in PSP and the
remaining 2,812 were in SP. THe rates of DVT were significantly
higher [18/1,422 (1.3 %) vs. 78/2,812 (2.8 %), p \ 0.05] and rates of
PE significantly lower [22/1,422 (1.5 %) vs 21/2,812 (0.7 %),
p \ 0.05] during SP as compared to PSP. Assuming a PE fatality rate
of 5–10 %, the cost was US$ 419,000–838,000 per life saved, US$
17,000–34,000 per year of life saved and US$ 23,000–46,000 per
DALY saved.
Conclusion: A DVT surveillance program in the ICU increases the
rate of DVT detection, and decreases the rate of PE. It is cost effective
when compared to other accepted life saving therapies.
Disclosure: No significant relationships.
S202 Abstract
123
INDEX OF AUTHORS
Aaberge I. O036
Abba J. PS112
Abbas A. K. O010
Abbas I. M. P162
Abbasi H.R. PS039
Abdelrahman H. P007
Aboutanos M. P208
Abreu R.C. P202
Abujayyab Z. P162
Achar E. P148, PS076, PS086, PS126, PS127, PS154, PS157
Acklin Y.P. O105, P112
Adam F.F. O124, P083
Adam G. P183, PS068
Adams C. P195
Adermann J. O110, P013
Agarwal S. P195
Ageron F.X. PS112
Agostinelli A. O045
Agrogianni X. P109, P192, PS092
Aguaviva-Bascunana J.J. P063, PS018, PS095
Aguiar T.M. P052
Ahmadzai W. O081
Ahmed S. PS099
Ahn D.K. PS180
Ahrberg A. O048
Ajit Singh V. PS106
Akatsu T. P127
Akay S. PS034
Akbari H. P055
Akcakaya A. P143, P144, PS025
Akgun I. P143, P144, PS025
Akgul T. O016, PS067
Akkas M. P166
Akkaya M. P037
Akman C. P166
Akpınar E. P166
Akrami M.A. PS039
Akrivos I. P004, P072, P092
Aksoy M.S. O016
Aksu N.M. P166
Aktas A. O134
Aktas A. O027
Al Saied G. PS023
Al Thani H. P007
Al-Habboubi M. PS056, PS057
Al-Najjim M. O070, P033
Al-Shahrabani F. PS040
Alajaj R. P007
Alam H.B. P113, P195
Albers C.E. O146, PS174
Albrecht R. O097
Alexandris I. PS044
Alkwuaiti F. O010
Allard S. P103
Almadani A. P007
Almodovar Delgado J.A. O122
Almogy G. O019
Aloj D. P087
Altay M. PS137, PS155
Altermatt S. O035
Alvarez Llano L. P001, P066, P201, PS037, PS088
Alvarez-Martin M.J. PS026
Alvarez Martın M.J. PS084
Alves J.L. P058
Amaral P. P052
Ampollini L. O045
Amsler F. O031
Anastasiou A. PS123
Anastasiu M. P108, PS024
Andres T. P030
Andruszkow H. O043, O133, P133, P154, P189, PS005
Angst E. PS028
Ansaloni L. O032
Antinori A. O001
Antoljak T. P203
Antonellis D. O040, P118
Antoni A. O126
Apra F. P194
Arazo-Iglesias I. PS095
Arbak S. O025
Arigoni M. O067
Aris I. P121
Arkovitz M. PS171
Arlettaz Y. PS113
Arnold M. PS131
Arnoux P.-J. P130
Aroca Peinado M. P181
Arvieux C. PS112
Astrom P. P117
Athanasiou K. PS044
Attenberger C. O031
Audige L. P046
Auer R.T. V06
Aufdenblatten C. O035
Augat P. O104, P100, PS104
Auner B. P157
Aunon I. PS103, PS149
Aunon-Martin I. PS098
Avella J.M. PS029, PS084
Avenarius J. P089
Avis D. P014
Avram M. PS041
Ayhan E. P021, PS114
Babst R. O119
Bachmann M. P015
Badran M. O140, P049
Bahari H. PS106
Bahouth H. PS171
Bahrami S. O160, P136
Bahten L.C.V. PS125, PS184
Bahcivan M. PS055
Bajec D. P060, PS079, PS087
Bajwa E. P113
Bakal F. P095
Baker C.R. PS077
Bakkaloglu H. O119A
Bakker F.C. O018, O042, O057, P197
Baktai J. P018
Bala M. O019
Balalaa N. O010
Balat N. P143, PS025
Balazic M. O108
Baltov A. O015
Balazs P. P018
Baraza N. O138
Barbero A. PS131
Barlas I. PS123
Barlow I. PS146
Barmparas G. O056
Abstract S203
123
Barragat De Andrade A.F.Z. P065, P188, PS022
Barry K. PS074, PS124
Barth X. O150
Baschera D. P114
Basili G. P061, V04
Bastian J.D. O051, O142, PS017
Batchelor J. P025, PS099
Battaloglu E. PS016, PS072
Battiston B. P024, PS182
Baumann M. P120
Baumbach S.F. O126
Bautz P.C. O100, P129, P187
Beano Aragon A. O122
Bechensteen A.G. O036
Beden R. PS187
Beenen L. F. O034, O062, P174, P197
Beer T. PS177
Beerekamp M.S.H. O129, P093
Beerens F. PS176
Beeres F. O087, O091, O120
Behrendt D. P115
Beker T. P035
Ben-Ishay O. P149, PS171
Beneduce A.A. O004, P190
Benneker L.M. O111, P150, PS017, PS019
Benois A. PS007
Bento M. P058
Bentohami A. O129
Bentue-Olivan L. PS018
Bergmann J. O127
Bergonzi P. O017, V03
Berkman Z. O025
Bernards A. O076
Bertani A. O028, O083, O086, PS004
Bessems J.H. P082
Beuran M. P196, PS041, PS163, PS170, V05A, V09A
Biance N. P138
Biffi A. P036
Bihalskyy I. PS048
Bijlsma T.S. O103, O129
Bikos S. P064, PS096
Bildik N. P140
Bilsel K. PS075
Binder H. P016
Bini R. P194, PS033
Biondi G. V04
Bisagni P. O004, P190
Bisbinas I. P186, PS097
Biscardi A. O155
Bicer O.S. P048
Black E. PS147
Blanco Dıaz D. P181
Blauth F.G. PS125, PS184
Bley C. P056
Bloemers F.W. O018, O042, P197
Boddice T. P090
Boer C. O018
Boger A. O136
Bokun Z.P. P040
Bolandparvaz S. PS039
Bollen S.R. O109
Bonjour C. PS113
Bonk A. O121
Bonnet S. PS002, PS007
Boonen S. O135
Borchers C.T. P208
Borrego-Estella V.M. P063, PS018, PS095
Bot A.G.J. P032, PS193
Bouamra O. P150
Boudouris P. P004
Bourilhon N. PS035
Boyd R. P014
Bozkurt F. PS137
Bozkurt M. P037
Bozoglan M. P183
Bradburn E.H. P156.
Bradt N. PS005.
Braithwaite M. P107.
Branas C. V02.
Brancato S. P195.
Branco B.C. O056
Brannigan S. O114
Bratucu M. O008, P128, P139, PS162, PS167
Brauner E. P149
Braunsteiner T. P045
Bravo Gimenez B. P084, P181
Breederveld R.S. O071, P161, P179
Bremerich J. PS040
Brevart C. O028
Brianza S. PS102
Bricchi C. O045
Brilej D. O052
Brink M. P159
Brockamp T. O055
Brodmann Maeder M. O080
Brohi K. P103
Broux C. PS112
Bruesch M. O097
Bruinsma W.E. P125, PS193
Brunet C. P130
Brunetti S. O125
Brunner A. O119
Brusko A.T. O139
Bucher X. P015
Buckus B. P067
Buggenhagen H. O060
Bugiantella W. O005
Buhanec B. O052, P182
Bumbasirevic M. P199, PS012
Burggraf M. P152
Burke P. P195
Burkhart K.J. P030
Businger A. PS122
Bustorff-Silva J.M. PS003
Bustos Merlo A. PS029, PS084
Butti F. O168, V10
Beres V. P175
Buchel H. P142
Buchler L. O142
Bucking B. P011
Buhren V. O079, O104, P100
Bulbul A.M. PS 139, PS151, PS179
Caba P. P028, P084, P181, PS103
Caballero Y. P107
Cabrera A. PS009
Caeckebeeke P. PS130
Caetano F.B. P065
Cainelli G.H. P148, PS076, PS086, PS126, PS127, PS154, PS157
Calcagni M. O088
Caldeira C. PS160
Calderan T. O154
Caldwell E. P162
S204 Abstract
123
Calixto A.K. PS125, PS184
Calland J.F. O096
Camagni M. P036
Camarero Mulas C. P066, P201
Can U. P017, P020
Canbek U. P183, PS068
Candinas D. PS028
Candrian C. O067
Cano Matıas A. PS175
Cano-Jimenez P.A. P063, PS018
Cao P. O040
Capitani D. P098, PS192
Capov I. P039, PS083
Carda M. PS085
Carlier F. O172, P047
Carlucci M. O004, O017, P190, V03
Carmona C. P202
Carr B. V02
Carrasco M. PS029, PS073
Caruana C.M. P131
Casamassima A. O168, V10
Cassar M. P131
Castelli F. P098, PS192, V12
Castro J.F. P065, PS022
Castro V. PS054, PS128
Catagni M. P036
Cataldi C. O040, P118
Catena F. O032
Catma M.F. PS137, PS155
Cavazzoni E. O005
Ceballos J. P107
Celik S. PS055
Cengiz A.N. P143
Cennamo V. O032
Cernohorsky P. P089
Cevik A. P140
Cevik M. PS038
Ceviz A. O134, P057
Champion H.R. P177
Chan K.W. P097
Chatterjee A. P002
Chaumoitre K. P130
Chauvin F. O083, O086, PS004
Chen R.J. PS043, PS052, PS059
Cheng J. P135
Cheung T.C. P161
Chiotis A. PS036, PS078
Chiotoroiu A. PS041
Chiu M.T. P135
Chkhaidze Z. P002
Chmelova J. O115
Cholewczynski W. P195
Chong C.C.W. PS006
Chooklin S. PS048
Choren Duran M. O039
Christiaans H.M. O018
Christidis C. PS036
Christodoulopoulos C. PS101
Cibelli M.T. O017, V03
Cicha K. O171
Ciclamini D. PS182
Ciernik J. P039, PS083, PS181, PS186
Ciftdemir M. P099, P101
Cimerman M. O144
Citgez B. P143, P144, PS025
Cizmar I. O090, V07
Clancy M. P150
Clauss M. P015
Clifton R. O075
Climent Agustı M. O101, PS051
Coates T. P158
Coccolini F. O032
Colesnic V. O148
Collares C.F. P148
Concannon E.S. PS074, PS124
Conroy D. PS072
Cook L.J. PS077, PS161
Cooper S. P170
Copuroglu C. P099, P101
Cordier P.Y. O083, O086
Cordovana A. O003
Corral E. PS073
Coskun A. PS034
Costa B. P058
Coze S. P130
Cozza V. O001
Craciun M. O167
Croce M.A. O159
Cross B.J. PS135
Czerny M. O014
D’Amours S. P162
D’Souza N. PS147
Da Silva J.A.S. P148, PS076, PS086, PS126, PS127, PS154,
PS157
Da Silva L.A.L. PS126, PS157
Dabis H. O059
Dafford E.E. P125
Dalkılıc G. P140
Dall’Ara E. O126
Dalla Valle R. P180
Daoud R. PS161
Darwiche S. P056
Davenport R. P103
Davila S. P203
Dawood M. O140
De Almeida T.E. PS154
De Haan R.J. O034
De Jong E. P174
De Jongh M. O098, P172
De Lange-De Klerk E.S. O018
De Lange-De Klerk E.S. P162
De Liz N.A. PS032, PS091, PS093
De Matteis D. O045
De Moya M. PS174
De Moya M.A. P113, P195
De Oliveira C.M. P148, PS086, PS126, PS157
De Pasquale F. O040
De Reuver P.R. O103
De Serre De Saint Roman C. PS129
De Tomas Palacios J. P001
De Vries J. P172
De Zwart A. O087, O091, O120
Debnath D. PS077, PS161
Dedek T. O175
Dedu R. P108, PS024
Dekker H. P159
Del Mar C. O057
Del Re L. O003
Delgado Sanchez-Gracian C. O039
Demel J. PS069
Demetriades D. O056
Demirag M.K. PS055
Abstract S205
123
Den Hartog D. O044
Derin O. P057
Derksen R.J. P161
Deunk J. P159
Deveci A. P037
Di Giorgio A. O001
Di Grezia M. O001
Di Saverio S. O155
Dias C. PS128
Dijkgraaf M.G. O062
Dijkman, Van B.A. O129
Dikici F. O016
Dikmen G. O016
Dinescu G. O167
Disch A. O130
Djulic I. P040
Dobric I. P203
Dogaki Y. O147
Dogjani A.S. PS165
Doklestic K. P060, PS079, PS087
Doll D. PS053
Domaszewski F. O014, P016
Domınguez Adame-Lanuza E. PS175
Donini A. O005
Doornberg J.N. O066
Dorninger L. O093
Dos Santos W.J. PS159
Doudoulakis K.J. P092
Dougaki Y. P078
Doulami G. PS030
Drac P. V07
Drechsler S. P136
Drumond D.A.F. P065, P188, PS022
Duarte N. P058
Dulou R. O028
Dumfarth J. O014
Dumitras M. PS167
Dural A.C. PS168
Duverger V. PS002, PS007
Eastley N. PS189
Ebnother C. PS100
Eced-Martinez A.P. P063
Eckardt H. PS058
Ecker T.M. O177
Edwards M. P159
Egri L. PS185
Ehrenfreund T. P203
Ehrlich M. O014
Eipeldauer S. P014, P086
Ekeh A.P. P012
Eken T. O151
Ekici U. PS025
Ekinci H. P140
El-Menyar A. P007
Elgafary K. P049
Ellahee N. PS191
Elmadag N.M. PS075
Elsharkawy A.G. O073
Elwan H.O. O073
Emhoff T. P195
Emuce C. PS021
Enberg J. O058
Endler G. O162, P178
Enholm B.C. P120
Ercan S. O027, O030, O134, P057
Ercetin C. PS168
Erdil M. PS075
Erd}ohelyi B. V08
Erkan N. PS034
Ersen A. P193
Ertekin C. O002, O119A, P069, P070, PS027, PS166
Estebanez G. PS009
Ettinger M. PS158
Evliyaoglu O. O027, O134
Exadaktylos A.K. P150, PS122, PS173, PS174
Ezanno A.C. PS129
Fabian T.C. O159
Faccincani R. O017, P190, V03
Fagenholz P.J. P113
Fagevik-Olsen M. O041
Fakharian E. P055
Faroja M. O019
Farouk O. O140, P049
Fasoylas A. PS101
Fawi H.M.T. O075, PS108
Fazel M.R. P055
Fehlbaum P. PS113
Feichtinger G.A. O132
Fejer Z. O068
Feldman L. O099
Feliciano S. PS131
Fenton C. O070
Ferhatoglu F. P144
Fernandes H.M. PS054, PS128
Fernandes N. PS160
Fernandes N.C. O032A
Fernandez T. PS003
Fernandez D. P107
Ferrari G. P194
Ferrero A. O125
Ferrete Araujo A.M. O012
Ferron-Orihuela J.A. O164, PS026, PS029, PS073, PS084, PS138
Fialka C. O117, P016, PS195
Filippou F. PS036
Finn J. P147
Finn K. P113
Fischmeister M. P091
Flannery O. PS134
Fleischmann S. P142
Flikweert E. O137
Fliri L. O135, O136
Flohe S. P146
Floros T. PS047
Floris I. P018
Foco M. O001
Foltin E. P091
Forbes T.L. P139
Forman M. PS085
Fortis A. P192
Foster E. P170
Fostvedt S. P032
Foa R. O168, V10
Fraga A.M.A. PS003
Fraga G.P. O154, P068, PS003
Franceschini M.S. O005
Francese M. O003
Franck A. O110, P013
Franco Herrera R. PS037
Franco-Hernandez J.A. PS018
Frangez I. PS187, PS190
Frank M. O175
Franz T. O088
S206 Abstract
123
Franzon O. PS032, PS091, PS093
Friedl W. O089, O107, PS111
Frima A. P124
Frink M. O043, O133, P133, P154, P189, PS005
Frischknecht A. P142
Frohlich M. P146
Fu C.Y. PS043, PS052, PS059
Fuchs I. P132
Fujimaki H. P077
Fujimura N. P127
Fujita T. P009
Fulco I. PS131
Funovics M. O014
Furtado P.P. PS159
Fusetti C. O125
Fabregues Olea A. P066
Fırat A. P037
Gaarder C. O036, O151, O152, PS172
Gafoor A. O094
Gafton V. O148, O149
Gagauz I. O148, O149
Gallesio J.M.A. O058
Gallo A. PS182
Gandara J.P.S. P148, PS076, PS086, PS126, PS127, PS154, PS157
Ganescu R. PS163, V05A, V09A
Ganz R. O146
Gap A. P123
Garavaglia G. O125
Garcıa Lamas L. P084, P181
Garcıa Navarro A. PS084
Garofil D. O008, P128, P139, PS162, PS167
Garving C. P056
Gaspar B. P196, PS163, PS170
Gassmann S. P158
Gates J. P195
Geeraedts Jr L.M. O057, P162
Geiger E. P157
Geiser T. O079
Genebat Gonzalez M. O012
Georgakis G. P195
Georgiannos D. P186, PS097
Georgiou G. PS036, PS078
Germann M. P112
Gersons B.P.R. O156
Ghaffarpasand F. PS039
Ghandour A. PS108
Ghasoup A.S. PS031
Ghayem Hassankhani E. PS133
Ghayem Hassankhani G. PS133
Ghidirim G. O148, O149
Giannakopoulos G.F. O018, O042, O057, P041, P197
Gick S. O054
Gil Loza S. O164
Gil-Bona J. PS095
Gilshtein H. P149
Gionis M. P031
Giorgini E. O155
Giovanni M. P087
Giulii Capponi M. O032
Gkanas P. PS047
Glaab R. PS132
Glaser C. PS094
Glasmacher S. O110, P013
Gloor B. PS028
Gloviczky B. P018
Gloyer M. PS145
Gocmez C. O027, O030, O134
Godiris-Petit G. P126
Gokdemir M.T. PS038
Goldberg S.R. P208
Goldzak M. O178
Goletti O. P061, V04
Gomes A.P. P202
Gomes S. P202
Goni V.G. O161, P141, P155, P165, PS140
Gonzalez F. PS002
Gonzalez J.F. PS129
Goodwin M. PS010
Gopinathan N.R. O161, P141, P155, P165, PS065, PS140
Gorioux R. O086, PS004
Goslings J.C. O034, O062, O098, O129, O156, O174, P093, P122,
P174, P197
Goulart R.N. PS032, PS093
Gouvas G. P186, PS097
Gracia-Cortes L. P063
Grande Posa L. O101, P184, PS051
Granhed H.P. O041
Grant S. PS118
Graziosi L. O005
Greer S.E. O024
Greff G. PS004
Gregori M. P016, PS195
Gregoric P. P060, PS079, PS087
Greitbauer M. O014
Griffiths J. P014
Grimm M. O014
Groen R. O096
Groeneveld K.M. P111
Groot R.D. P124
Gross R. P195
Gross T. O031
Grosso E. P024
Groven S. O151, O152
Gruner L. O150
Grunauer J. P178
Grunfeld M. O102
Guenkel S. O097
Gueorguiev B. P006
Gueorguiev-Ruegg B. P010
Guerreschi F. P036
Gui D. O001
Guimera Garcıa V. P028, PS103
Guinaudeau F. PS050
Guloglu R. O002, O119A, P069, P070, PS027, PS166
Gunning A.C. P160
Gupta A. P003, P073, PS049
Gupta R. O024, P005
Gurbulak B. PS168
Gurghis R. O148
Guterbock T.G. O096
Guzman Ahumada J. P184, PS051
Gvenetadze T. P002
Gunay M.K. O002, O119A, P069, P070, PS027, PS166
Gurbuz Y. P198
Gurke L. PS094
Guvendiren A. P193
Haas N.P. O130, P167
Habermann B. PS109
Hacker H.-W. O035
Haefeli P. PS174
Hagemann O. PS053
Hajdu S. O014, O162, P178
Abstract S207
123
Haller S.A. PS094
Hanaoka T. P127
Hancock H. O159
Handolin L. P117, P163
Hantzis L. PS101
Haraoka J. P169
Hari Y. P127
Harris N.S. P113
Harrison S. P104
Hart R. P022
Hartmann A. PS015
Hasanaj B.E. PS165
Hasler R.M. P150
Haug M. PS131
Haverlag R. O064
Havlıcek K. PS085
Hayari L. PS171
Hazanay K. PS155
Heck S. O054
Hedberg M. O013
Heeres M. P111
Heier H.E. O036
Heinrichs G. P008
Heinz S. PS122
Heinz T. O162
Helmy H. O073
Helmy N. P046
Hendry J. PS191
Henning J.C. PS017
Henrich D. P157
Hepp P. P115, P134, P158
Heristanidu E. PS109
Herman S. O020
Hertz H. PS177
Hestnes M. O050
Heye S. PS064
Hildebrand F. O043, O133, P133, P146, P154, P189, PS005
Hillingsoe J. P205
Hilverdink E.F. O174
Hirano E.S. O154
Hodjaev R. PS188
Hoenemann C.W. PS053
Hofbauer M. O030A, P059, PS195
Hoffmann M. O029, P081
Hoffmann R. O121
Hoffmann S. O104
Hofmann A.T. O132
Hofmann G.O. P006
Hogan A. PS074, PS124
Hohlrieder M. O171
Holcomb J.B. P177
Holecek T. O175
Holena D.N. O058, O157
Holstein J.H. O112, O141
Homza M. V07
Hondo K. PS070
Hoppe S. PS019
Horst M.A. P156
Hosseinzadeh A. PS039
Hotz T. O123
Houwert R.M. P053, PS143, PS153
Hreckovski B. P102, PS066, PS119
Huang H.C. PS043
Huayllas J.V.P. PS157
Huber W. O093
Huber-Wagner S. P176
Huertas Pena F. O164
Hug U. O088
Hungerer S. O079
Huri G. P048
Hussein F. P121
Hussmann B. P152
Hutkani A.R. PS133
Huynh D. O069
Hyder N. PS118
Hartel R. P017
Harter L. O047, O049
Hassig G. O105
Hochtl L.L. O030A, P059
Hogel F.W. O104, PS104
Hontzsch D. P006
Idrees Z. O077
Ignatenco S. O149
Ikeda Y. P169
Ilchmann T. P015
Imai S. P127
Imerci A. P183, P198, PS068
Imperato M. P138, PS035, PS050
Inaba K. O056
Inaparthy P. O075
Inaraja-Perez G.C. P063, PS018, PS095
Indriago I. PS194
Ingoe H. P090
Inoue M. PS061
Iorga C. O008, P128, P139, PS162, PS167
Iosifidis L. P109
Ira D. O090, P175
Iselin L.D. O069
Ishigami K. O033
Ito Y. O116, PS060
Ivan A. P108, PS024
Ivanovic M.Z. P040, P105
Ivatury R. P208
Izaks G. O137
Jacobs L. P195
Jafarmadar M. O160, P136
Jagodzinski M. PS158
Jain S. P104
Jaindl M. P178
Jakob M. PS131
Jandali A. O088
Jankovic J. P102, PS066
Jaroslav S. O145
Jarry J. P138, PS035, PS050
Jarvers J.-.S. O110, P013
Jarvers J.-S. P115
Jasmins F. PS160
Jeromin S. PS115
Joeris A. O035
Johnson D. P195
Joosse P. O098, P122
Jorge Cerrudo J. PS138
Jorge Mora A. P084, PS149
Jorge Mora A.A. P181, PS103
Josten C. O048, O110, P013, P115, P134, P158
Judez-Legaristi D. P063
Jukema G.N. O076
Junior E.A. PS159
Jurisic D. P102, PS066
Jurjevic M. PS119
Jurkowitsch J. PS177
K S.B. P155, PS140
S208 Abstract
123
Kabela M. P039, PS181
Kabul Gurbulak E. PS168
Kafchitsas K. PS109
Kaipel M. O132
Kakavas P. P092
Kakhnidze V. P023, PS142
Kalaitsidou I. PS123
Kalantzis P. P004, P072, P092
Kalashnikov A.V. O139, P038
Kallitsoynaki E. PS101
Kamal A. O140
Kamasak K. O030, O134, P057
Kambouris A. PS036
Kaminskis A. PS081
Kamocka A. PS147
Kampouris A. PS078
Kanai T. P127
Kanazawa T. PS061
Kanthakumar S.B. O161, P165
Karaca S. PS114
Karadzic B. P060, PS079, PS087
Karaiskaki N. PS109
Karaleic S.B. P050
Karalejic S. P042, P185
Karamarkovic A. PS079, PS087
Karat I. PS161
Karatepe O. P143
Karentzos A. P106
Karjalainen M. P120
Karthigan R. O059, PS191
Kaspar M. P039
Katsagounos G. PS044
Katsamakis N. P106
Kauther M. D. P152
Kavanagh R. G. PS134
Kaya A. P183, PS068
Kaya B. O119A
Kaya H. PS038
Kazaka I. PS082
Kdolsky R. O030A
Kealey D. P097
Kebapci A. PS042
Kecojevic V. P080, PS141
Kedar A. O019
Keel M.B.J. O051, O142, PS017, PS019
Keijzers G.B. O057
Keil P. O095
Keitel J. P152
Kelsall N. PS010
Kemaloglu S. O025, O027, O030, O134, P057
Kemper H. P008
Kenny P.J. PS134
Kerci M.D. PS165
Kerver A.J.H. P082
Kesmezacar H. P021, PS114
Keceligil H.T. PS055
Khadem A. O160
Khan S. P103
Khan W. PS074
Khan Z. PS189
Khwaja K. O099, PS056, PS057
Kidane B. P139
Kiefer A.H. PS001
Kim Y.-J. O121
Kim-Fuchs C. PS028
Kinami Y. PS061, PS062
Kingma L. O120
Kir N. P021
Kirjavainen M. P088
Kirnap M. PS168
Kispert P. O024
Kitkani A. O167
Kleinrensink G.-J. P082
Kler J. P123
Klitscher D. P030
Kloen P. O066
Kloub M. P010
Kluger Y. P149, PS171
Knapp T. O109
Knobe M. PS115
Koami H. PS080
Kobayashi Y. P127
Kobbe P. O163, P116, PS115
Koch J. P167
Koci J. O175
Kocsis A. O068, O153
Kocuvan S. PS136
Kodonas F. PS036, PS078
Koedam T.W.A. P041
Koenderman L. P111
Koenig M. O097
Koga T. O147, P078
Koizumi M. O033
Kokkalis Z. P031
Kokoroskos N. PS030
Kolbakir F. PS055
Koller H. O095
Kollia M. PS047
Kolodzinskyi M.N. O018
Koltovich A. O082
Komadina R. O052
Komeno T. O033
Konecny J. P039, PS083, PS181, PS186
Konno S. PS121
Kool D. P159
Kopp L. P043, P085, P089
Kopp R. P145
Kornprat P. O037
Koshimune K. O116, PS060
Kosir R. O102
Kostic I.M. P050
Koulas S.G. P064, P106, PS096
Kovacic L. O131
Kovalenko S.V. P038
Kovar F.M. O162, P132, P178
Kozlov A. O160
Kozak T. P022
Kocis J. O115
Krasne M. P156
Kraus R. O067
Krause F. O106, O176, O177
Krebs J.C. PS122
Krestan C. O117
Krettek C. P133, P154, P189, PS005, PS158
Krijnen P. O032A, O091, O092, P054
Kristan A. O144
Kroepfl A. O093, P091
Krpan I. P035
Krticka M. O090, P175
Kruel N.T. PS032, PS091, PS093
Kruyt M.C. PS143
Kruger A.J. O050
Abstract S209
123
Kuehnel S.-P. P046
Kuhn S. O060
Kuksov V.F. PS144, PS150
Kumar L. PS065
Kumar S. P003, P073, PS049
Kurihara H. O168, V10
Kuroda H. P127
Kuroda R. O147, P078
Kurosaka M. O147, P078
Kurth A. PS109
Kushner A. O096
Kusy D. PS085
Kutsukata N. PS071, PS120
Kyamanywa P. O096
Kyriakidis A.V. PS044, PS101
Kadas I. O068
Kach K. O123
Kottstorfer J. P014, P086
Kuchle R. PS178
La Greca A. O001
La Scala G. O035
Laarhoven J.V. P164
Laglera-Trebol S. P063, PS018, PS095
Laidlaw I. PS161
Laidlaw I.J. PS077
Lakdawala A. P096
Lakkol S. P096
Lalic I. P080, PS141
Lam L. O056
Lambers K.T.A. O066
Lamdark T. PS105
Lammer J. O014
Lampridis V. P186, PS097
Lamy A. PS129
Lansink K.W.W. P160, P164
Lardinois D. PS040
Larentzakis A. PS030
Latifi R. P007
Laufer G. O014
Lazaridou E. PS047
Leal Ruiloba S. O039
Lecky F. P150, P158
Lee J. P156
Lee S. PS180
Lee S.Y. O147, P078
Lee U.J. PS045
Leenen L. O169, P111, P119, P160, P164
Lefering R. O055, P154, P158, P176, P191
Leggieri C. P190
Leimcke B. O048
Leixnering M. PS177
Leli R. P194, PS033
Lendemans S. P152
Lenz M. O136, P006
Leon Baltasar J.L. P181, PS098, PS103
Leow J.J. P135
Leppaniemi A. P120
Lesic A. P199, PS012
Levy M. P208
Lewis D. P173
Li Sun Fui S. P126
Lica I. PS163
Lichte P. O163, P116, PS115
Lila A.M. PS165
Lim G.H. PS006
Linchevskyy O. O113
Lindner T. P167
Lingam P. P135
Lintzeri A. P192
Lintzeris I. P109, P192, PS092
Liodaki E. PS158
Liodakis E. PS158
Liz N.A. PS032, PS091, PS093
Loibl M. PS132
Lokke R.J.V. O036
Lominadze N. P002
Lopes A. P058
Lossius H.M. O050
Lott C. O060
Loughenbury P. O109
Lovisetti L. P036
Lozano Gomez M. O039
Lubeek S. P159
Lucchina S. O125
Luitse J.S.K. O062, O156, P093
Lukic M. P080, PS141
Lunghi C. O003
Lupescu D. O078, P051, P204, PS063
Lupescu O. O078, P051, P204, PS063
Lustenberger T. P153
Lutsyshyn V.G. P038
Lutz N. O035
Lopez Perez J. PS164
Maas M. O129, P093
Macho D.B. O130
Machold W. P110
Macke C. P133
Madeja R. PS069
Maegele M. P191
Maegle M. O055
Magalini S.C. O001
Maggioli S. O155
Magnone S. O032
Magrupov B. PS188
Magyari Z. O068, O153
Mahdian M. P055
Maiko V.M. P038
Mair S. PS104
Makris K. PS101
Maleux G. PS064
Malhotra A.K. P208
Malhotra R. P090
Mallory M. O096
Malota M. P145
Malovic M. P035
Manfredi R. O032
Manfroni S. O040, P118
Manimanaki A. P031
Mansilla-Rosello A. O164, PS026, PS029, PS073, PS138
Manson J. P170
Mansoor A.A. PS031
Mansor A. PS106
Manta A. O008, P128, P139, PS162, PS167
Marcikic M. PS119
Marck R. P179
Marco M. P171
Mariani D. O168, V10
Marinoni E. PS192
Markovic D. PS079, PS087
Markovic N.M. P040, P105
Marlovits S. P162
Marnitz T. P167
S210 Abstract
123
Marquass B. P158
Marquaß B. P115, P134
Marsland D. PS146
Martens B. PS100
Martin I. PS131
Martin N. P208
Martinez S. PS135
Martinez-Nuez S. PS018
Martins M.P.R. P188
Marty A. O081
Martın Gil J. PS088
Martınez-Casas I. O101, P184, PS051
Marx W. O060
Marzi I. O055, O061, P153, P157, P191
Mashiko K. P168, PS071
Masilonyane-Jones T.V. P114
Massalis J. PS047
Mastropietro T. O040, P118
Mathieu L. O081, PS004
Matsui S. P127
Matsumura T. P026
Matsuura T. P029, P077, PS121
Matta J.M. O143
Matteotti R. P024, P087, PS182
Mattiassich G. O093, P091.
Mattyasovszky S.G. P030
Matzaroglou C. PS109
Maung A. P195
Mauricio Alvarado C. PS020, PS164, PS175
Mayrhofer-Stelzhammer M. O093
Mazzani R. O045, P180
Masek M. O090, P175
Mccarthy M. P012
Mcdonald S. P097.
Mchale A.P. O132
Mega M. PS090
Mehling I. P030, PS178
Melcher G.A. P142
Membrilla Fernandez E. O101, P184, PS051
Menakaya C.U. P090
Menegaux F. P126
Menenakos E. PS030
Mensch D.T. O103
Mergoni M. P180
Merlan V. O167
Metsemakers W.-J. PS064
Meylaerts S. O120
Micari J. PS033
Michail T. P186, PS097
Michel P. P138, PS035, PS050
Michelitsch C. P019
Micic I. P042, P044, P185
Micu N. P108, PS024
Mihajlovic J. PS012
Mihaylov V.I. O166
Mihic J. P102
Mikic N. P040
Milenkovic S. P044
Militz M. O072
Millet P.J. P053, PS153
Milosevic I. P199
Milou F. PS050
Minehara H. P029, P077, PS121
Minkov G. PS046
Miot S. PS131
Mirioglu A. P048
Mirkovic I. PS119
Mishra B. P003, PS049
Mitkovic M.B. P042, P044, P050
Mitkovic M.M. P044, P050, PS152
Mittlmeier T. O178
Mizobata Y. PS008
Mizuno S. O116
Mladenov N. O015
Mladenovic D.S. P042, P044, P185
Mladenovic M.D. P042, P185
Mohamed Al-Lal Y. P001, P066, P201, PS037, PS088
Mohamed M. PS118
Mohan A. PS191
Mohanty K. PS108
Moharamzadeh P. PS116
Mohr J. P146
Mohsen A. P090
Molinos-Arruebo I. P063, PS018, PS095
Mols A.M. PS094
Mommsen P. O043, P133, P146, P154, P189, PS005
Moniz C. O114
Monneuse O. O150
Montagne H. P179
Montan C.H. O013
Montcriol A. O028
Moon S.H. PS180
Moon Y.J. PS045
Morapudi S. P033
Mordecai S. P014
Moreno De La Santa Barajas P. O039, PS040
Morishita K. O158
Moszkowicz D. P126
Motomura T. P168
Mottier F. O083, O086, PS004
Mouthaan J. O156
Mpesikos I. PS044
Mueller T.S. O118
Mukans M. PS082
Mulders M.A.M. P032
Mumith A. PS010
Mumme M. PS131
Musavi M. PS039
Mustafa A. P033
Mustonen K.-M. P088
Mutafchiyski V.M. O166, V05
Munoz Sanchez M.A. O012
Maki-Lohiluoma L. P088
Marsmann S. O047, O049
Muckley T. P006
Muller L.P. P030, PS178
Muller T. O177, P011.
Naess P.A. O036, O151, O152, PS172
Nagase T. P127
Nagea M. O078, P051, P204, PS063
Nagele-Moser D. O037
Najib A. O081
Najibi S. O143
Nakagawa M. P127
Nakahara R. PS061, PS062
Naranjo Fernandez J.R. PS020
Nascimento B. O154
Natoudi M. PS030
Nau C. P191
Ndayizeye D. PS001
Negoi I. P196, PS041, PS163, PS170, V05A, V09A
Nekuda V. P175
Abstract S211
123
Nelissen R. O076
Nemec U. O117
Neunaber C. O133
Newham D. O127
Ngo A. PS169
Nguyen V. P138, PS050
Nicolau A.E. O167
Niemela M. P163
Niikura T. O147, P078
Nijs S. P095, PS064, PS130
Nikas E. P004
Nikitin P.V. P038
Nikolov S. PS046
Nishimoto T. PS071
Niwawest P. O009
Niyonkuru F. O096
Noda T. PS061, PS062
Noullet S. P126
Novel-Carbo L. PS018, PS095
Nowak T.E. P030
Ntaganda E. O096
Nunes V.M. P202
Nemeth A. O153
Nunez V. P107
O’Donnell W. P113
Oberleitner G. O117, P014
Obruba P. P043, P085, P089
Oe K. P078
Oesterballe L. P205
Oestern S. O133, P147
Ogawa K. PS061
Ohta S. P169
Okumachi E. O147, P078
Olaguibel Moret J. O122
Olff M. O156
Oliva Mompean F. PS020, PS164, PS175
Oliveira A. PS011
Oliveira A.D. PS125, PS184
Oliveira M. PS128
Olsson D. PS058
Olthof D.C. O034
Orbay J. PS194
Orlandi P. O045
Orosan G. O008, P128, PS162, PS167
Ortolano E. O004, P190
Orvieni V. O003
Osnes L.T. O036
Ostermann R. O030A, P014, P059, P086
Ostermann R.C. PS195
Osuchowski M.F. P136
Othman M. P098, PS192
Otoide M. O120
Otomo Y. O158, PS070
Ott T. O060
Ozaki T. PS061, PS062
Ozcan M. P099, P101
Ozcan O. P143, PS025
Ozeveren H. O025
Ozkan U. O030
Ozkurt E. O002, O119A, P069, P070, PS027, PS166
Ohlbauer M. O072
Ozaksar K. P198
Ozdemir G. PS067
Ozdemir M.F. PS089
Ozmen M.M. P166
Ozturk H. P048
Paavola M. P088
Padilla Morales V. O012
Paech A. O074, P008
Paffrath T. P158
Pafitanis G. PS096
Pai V. O038
Pajenda G. P086
Paltyshev I. O082
Panagiotopoulos D. PS109
Panagitodi E. PS044
Panarese R. PS182
Panchenko L.M. O139
Pandurovic M. P060, PS079, PS087
Panero B. PS182
Panfiorov S. O113
Panuel M. P130
Papadema E. PS047
Papadopoulos C. PS044
Papagiannakos K.I. P004, P072, P092
Papagiannopoulos P. P004, P072, P092.
Pape H. P146
Pape H.-C. O053, O084, O163, P056, P116, PS115
Pappa I. O021
Pappalardo F. P190
Pappas-Gogos G. P064, P106
Paquette B. PS112
Pardos N. PS095
Parfitt D. PS108
Pargger H. O031
Parodi E. PS160
Parra Sanchez G. P028, P084, PS103
Parry N.G. P139
Pascual J.L. O058, O157
Patel R. P096
Paternollo R. O003
Patru C. O078, P051, P204, PS063
Paulet-Gerber S. O165
Paun S. P196, PS163, PS170, V05A, V09A
Pavlishen Y.I. O139
Paydar S. PS039
Paz Yanez A. PS138
Pazooki D. O041
Pedro A. P202
Pedro E. P202
Peled Z. PS171
Pellek S. O046
Pennig D. O054
Penzenstadler C. O160
Pereira B.M. O154, P068
Pereira F.L. PS159
Perez-Navarro G.I. P063, PS018, PS095
Perisinakis I. PS044
Perren T. P094
Pethe K. P123
Petri G.J. O125
Petri M. PS005, PS158
Petroulakis V. P031
Petrov A. PS046
Petroze R.T. O096
Petruccelli E. P087
Pettit P. P014
Pezzei C. PS177
Pena De Buen N. PS095
Pena Gonzalez E. O039
Pfeifer R. O053, O084, O163, P146
Phillips A.M. O114
S212 Abstract
123
Phillips M. P076, P173
Piccolo A.C. PS126, PS127
Picetti E. P180
Pietrasanta D. P061, V04
Pignatelli N.B. P202
Pillay M. O091
Pilny J. O090
Pilat P. P089
Pinheiro L.F. PS011
Pipi V. PS101
Pippa H. PS154, PS157
Pisano M. O032
Pitlovic V. P102, PS066
Pizanis A. O112
Platz A. P017, P020, PS100, PS105
Platzer P. P014, P086, P178, PS195
Plecko M. P010
Pleva L. PS069
Pohlemann T. O112
Poiasina E. O032
Pol M. P003, P073, PS049
Polat N. P143, PS025
Pollock R. O127
Polo Otero M.D. O039
Ponirakos V. P192
Pons F. PS002, PS007
Pons Fragero M.J. P184, PS051
Pontikis I. PS092
Popa F. O008, PS162, PS167
Popescu G.I. O078, P051, P204, PS063
Popescu R. P108, PS024
Popp A. O111
Porras-Moreno M. PS149
Pothof L.A. P162
Potters J.-W. P082
Poulios G. P031
Prasad R. PS108
Pretell Mazzini J. PS098
Priftis A.A. P092
Prigouris P. P109
Prigouris S. P109
Probst C. O053, O084, PS005
Pronchenko A. P206, P207
Prost C. P130
Protopapadakis G. P004, P072, P092
Pupelis G. PS081, PS082, PS156
Puscu C. O008, P128, P139, PS162, PS167
Puttkammer B. P153
Puyana J.C. PS009
Puylaert J. O087
Pyrros D. O021
Perez Dıaz M.D. P066, P201, PS037, PS088
Perez Huertas R. PS175
Quadlbauer S. PS177
Quintana J. P084, PS149
Raaymakers E.L.F.B. O174
Rabiner R. O054
Rackham M. O069
Radcliffe G. O109
Radenkovic D. P060, PS079, PS087
Radu P.A. O008, P128, P139, PS162, PS167
Raeven P. P146
Rainho R. PS090
Rajacic D. P203
Ramaki A. O081
Ramasamy B. O069
Ramos P.M. PS013, PS014, PS160, V01
Rancan M. P020, PS100, PS105
Randl T. P074
Rankovic V. P040, P105
Raposo J. P052
Rasal-Miguel S. PS018
Raschke M.J. PS102
Raynaud L. PS007
Raza I. P103
Razek T. O099
React Study Group*. P197
Rebelo A. P052
Redl H. O132, O160, O171, P136
Refae H.H. O124, P083
Refai M. O140
Rehn M. O050
Reilly P.M. O157
Reis L.O. P068
Reis M. PS160
Reis M.C. PS003
Reitala J. P163
Reitsma J.B. P197
Rekha A. O038
Relja B. P153, P157
Remartinez-Fernandez J.M. P063
Renken F. O074
Renner A. PS185
Resch H. O119, PS015
Resines Erasun C. P084, P181, PS098, PS103, PS149
Reska M. P039, PS083, PS181, PS186
Reslinger V. PS007
Reva V. P206, P207
Reyes Dıaz M.L. PS020
Reynders P. O065
Rhemrev S. O087, O091, O120, PS176
Ribeiro Jr M.A.F. P148, PS076, PS086, PS126, PS127, PS154,
PS157
Richards R.G. O135, P006
Ricks M.R. O059, PS191
Rigal S. O081, PS129
Rillmann P. P094
Ring D. P032, PS193, PS194
Ringdal K.G. O050
Rittirsch D. O047, O049
Rittstieg P. PS178
Rivier P. O150
Rivkind A. O019
Robida J. PS136
Rocci A. P180
Rodiere M. PS112
Rodrigues B. L. P188
Rodrigues M.M. PS125, PS184
Rodriguez Vega V. P028, P084
Rodriguez-Vega V. PS098, PS149
Rodrıguez F. P107
Roeloffs C.W.J. P054
Roerdink W. P124
Rogers A.T.P156
Rogers F.B. P156
Rohacek M. PS117
Rojnoveanu G. O148, O149
Rollero L. P024
Romano N. P061, V04
Rommens P.M. O060, P030, PS178
Rongieras F. O028, O081, O083, O086, P138, PS004
Rosas Bermudez C. P107
Abstract S213
123
Rosen P. O058
Rosenblatt M. P195
Rosko D. P102, PS066
Rosso R. O067
Rossodivita A. O017, V03
Rothstock S. P010, PS102
Rubiano A.M. PS009
Ruchholtz S. P011, P146
Rudin M. O123
Rudzats A. PS156
Ruesseler M. O061
Runcanu A. P196, PS170
Rupnik J. PS185
Rushbrook J. P104
Russchen M.J. O062
Ryf C. P094, PS132
Røise O. O050
Røislien J. O050
Saad W.A. PS086
Sadieh O.G. PS031
Saedi F. PS118
Safi B. O010
Sagar S. P003, P073, PS049
Saglam Y. O016
Sagnak E. O074
Said T. O073
Saiga K. PS062
Saitoh D. O158
Sakamoto T. P009
Sakamoto Y. PS071, PS120
Sakhvadze S. P023, P023, PS142, PS142
Sakran I.F. O085
Sakurai A. P078
Sala F. P098, PS192
Saleh A. O010
Salepcioglu H. P126
Salim L.B. PS126, PS157
Saltzherr T.P. O062, P197
Samardzic J. PS119
Samokhvalov I. P206, P207
Sanchez A.I. PS009
Sanchez Canto A. O012
Sanchez Rodriguez T. P001, P066, P201, PS088
Sancho Insenser J. O101, P184, PS051
Sannicandro R. O017, V03
Santoro D. P087
Santos Costa C. PS054
Santos T.N. PS054, PS128
Sanz Sanchez M. P201, PS088
Sarani B. O058
Saridogan K. P099, P101
Sarıcı I.S. O119A, P069, P070
Sarıcı I.S. O002, PS027, PS166
Sato T. P027
Saudi-Moro S. PS018
Savage S.A. O159
Savran A. P198
Savvidis M. P186, PS097
Saxe J.M. P137
Saxer F. PS131
Say F. PS139, PS151, PS179
Sayit N.F. PS168
Scandroglio M. P190
Schaefer D.J. PS131
Schaller B. PS122
Scheerder M.J. O034
Schep N.L. P122
Schep N.W.L. O129, P093
Schepers T. P124
Scheurecker G. P091
Schibli S. O088
Schill A. O061
Schipper I. O032A, O087, O091, O092, O120, P054
Schiuma D. O111, P010
Schmid T. O176
Schmidt C. O110, P013
Schmidt F. PS115
Schmidt R. P014, P110
Schmidt-Horlohe K. O121
Schmolz W. O119
Schneider K. P046
Schneiderbauer A. P091
Schnuriger B. O056
Schober P. P151
Schoder M. O014
Schoenborn V. O047, O049
Schreiber H. O163
Schrittwieser R. P132
Schroter C. PS005
Schulz A.P. P008
Schuster R. P014, P086
Schwab C.W. O157, P156, V02
Schwamborn T. PS131
Schwarte L.A. P151
Schweizer W.P. O165
Schwieger K. O112, PS102
Schwyn R. O111
Schuepp M. O031
Schutzenberger S. O132
Scola E. P034, P200
Seekamp A. P146
Segeev S.K. V05
Segura Jimenez I. PS138
Seibert F.J. O095
Seidel D. P191
Seif T.M. O073
Seiler C. O165
Sekiguchi H. P029
Sekulic A.S. O170, P062
Sekulic S.D. O170, P062
Sekulic-Frkovic A.S. O170, P062
Seligson D. V06
Selimen D. PS021
Sellei R.M. PS115
Semiao M. PS090
Sen R.K. P141, P165, PS065, PS140
Senekovic V. O108, O131, PS110, PS190
Senohradski K. PS012
Seo B.S. PS180
Sermon A. O135
Shadmanov T. PS188
Shafi A.A. PS023
Shah M. P090
Shaunak S. O138
Shimamura Y. PS061, PS062
Shintani R. P077
Shiota N. P027
Shiraishi A. O158, PS070
Shoda E. O173
Shuen V. O094
Shunni A. P007
Siabou E. P192
S214 Abstract
123
Siddiqi M.A. O077
Siebenrock K.A. O051, O142, O146
Sieber R. P150
Siekmann W. PS132
Sierevelt I.N. O174
Sierink J.C. O062, P174
Sijbrandij M. O156
Silke A. O162, P059
Siller J. PS085
Silva A.L.C. PS054, PS128
Silva L. PS160
Silva M.S.A. P188
Silva S.M. PS128
Silveira L. PS090
Silverio G.S. PS032, PS091, PS093
Simmen H.P. O047, O049, O076, O097
Simon P. O178
Sims C.A. O058, O157
Simoes C. P052
Singh A.K. O127
Singhal M. P003, P073, PS049
Sinha J. O127
Sirbiladze K. P023, PS142
Sirin G. PS089
Sisto R. P024
Sittaro N.-A. O053, O084, P056
Skaga N.O. O050, O151, O152
Skattum J. O036, PS172
Slezak P. O132
Sluga B. O131
Smejkal K. O175
Sockeel P. PS129
Sogut O. PS038
Soldatenkova D. PS081, PS082, PS156
Soliymani R. P120
Sommer C. O105, O118, P112
Souma K. P077, PS121
Sousa M.D. P202
Soussan J. P130
Spada P.L. O001
Spengel K. O097
Spessot M. O017, V03
Spiegl U. O110, P013, P094
Springer A. P167
Spyrou S. PS096
Srivastava D. PS173
St.Louis E. PS056, PS057
Stabina S. PS081, PS156
Stamenic S. P185
Stamenkovic A.D. P040, P105
Stampfl J. O171
Stampfl P. O014
Stanaitis J. P067
Starling S.V. P065, P188, PS022, PS159
Startzman A. PS135
Stavrou P. O069
Stasinskas A. P067
Steel J.L. P056
Steen P.A. O050
Stegeman S.A. O032A, P054
Steins Bisschop C.N. PS143
Steinwachs M. PS131
Steppacher S.D. O146
Stergiopoulos S. O021
Stevens K. PS191
Stevens M. O137
Stieger R. PS145
Stoian S. O008, P128, P139, PS162, PS167
Stojiljkovic P.M. P042, P044, P185
Stouracova A. P175
Strambu V.D.E. O008, P128, P139, PS162, PS167
Streekstra G. P197
Struewer J. P011
Strus K. PS110, PS187
Stucki J. O136
Studler U. PS131
Stufkens S.A.S. O066
Sturch P. PS146
Subotin I. PS160
Sucoveschi D. O078, P204, PS063
Sudarshan M. PS056, PS057
Sugimoto M. O147
Surakarn E. O023
Suresh P. O094
Suzuki T. P029, P077, PS121
Suzuki Y. P127
Svancara J. P175
Svec M. P089
Svendsen L.B. P205
Szelle B.T. O064
Szentirmai A.R. PS185
Szita J. O068
Sa M.R. PS011
Sanchez Velazquez P. O101
Soderlund T. P117, P163
Sugun T.S. P198
Surer L. PS068
Tabbakh R. PS161
Tadayyon A. PS039
Tagliati M. O041
Taheri Akerdi A. PS039
Tai N. P170
Takada S. P127
Takamatsu J. PS008
Takaso M. P029, P077, PS121
Takigawa T. PS060
Takorov I.R. O166, V05
Talan H.C. O022
Talving P. O056
Tamm M. PS040
Tan X. PS056, PS57
Tan I. P048
Tank Y. P161
Tannast M. O143, O146
Tarancon M.E. PS095
Tarello M.P. P024
Tauss J. P132
Tavares L. P052
Taymaz T. PS042
Teixeira A. PS160
Teo L.-T. P135
Terashima T. O033
Testa D. P087
Teuben M. O169, P119
Teuschl A. O171
Tezcaner T. PS168
Thallinger C. P178
Thareja J. P073
Theeuwes H.P. P082
Theodorou D. PS030
Theodoroudis I. P186, PS097
Theopold J. P115, P134, P158
Abstract S215
123
Thiagarajah R. O094
Thompson B.T. P113
Tiemann A.H. O048
Tilaveridis I. PS123
Timmers M. O071, O076
Tintari S. O148, O149
Tiren D. O128, PS107
Titze T.L. O036
Toda K. O116
Todhe D. PS148
Toklu H.Z. O025
Tomagra S. O051
Tomajer V. O004, P190
Tomasch G. O037, V09
Tomaszewski R. P123
Tomazevic M. O144
Tomic S. P080, PS141
Tominaga S. PS071
Tomas A.R. P202
Toney E. P125
Toro-Nunez M. PS018
Torres Alcala T. O164, PS029
Toyama M. P029
Traxler H. O126
Treviranus G.R.S. O011
Trinidad C. O039
Trlica J. O175
Tromp H.R. O042, P041
Troussel S. O172, P047
Tresallet C. P126
Tsagaris I. PS044
Tsibidakis H. P036
Tsimogiannis E.C. PS096
Tsimpouris G. PS101
Tsitsilonis S. O130, P167
Tsuchiya A. O033
Tsuo H.C. PS043, PS052, PS059
Tsurukiri J. P169
Tsutsumi Y. O033
Tufo A. O001
Tugnoli G. O155
Tuinebreijer W.E. P161
Tukiainen E. P088
Tulikoura I. P163
Tunalı O. O016
Tunc B. PS137, PS155
Tuncay I. PS075
Tuncer N. PS075
Tung H.J. PS043, PS052, PS059
Turegano Fuentes F. P001, P066, P201, PS037, PS088
Turino-Luque J.D. O164, PS026, PS029, PS073, PS084, PS138
Turnbull K. P076
Tzachev N.N. O015
Ubbink D.T. P093
Uchida Y. P009
Uchino M. P029, PS121, PS183
Ueda Y. O116, PS060
Ueki H. O033
Uludag M. P143, P144, PS025
Ungria-Murillo J. PS095
Unlu M. C. P021
Upadhyay P. O138
Uranues S. O037, V09
Uysal O. PS114
Unal K.O. P037
Vaarun B. P121
Valderrabano V. PS131
Vallicelli C. O032
Vallinga J. O129
Van Bergen Bsc J. P172
Van De Sande Msc P. P172
Van Delden O. M. O034
Van Delft-Schreurs Msc C.C.H.M. O098, P172
Van Den Bekerom M. P. O103
Van Den Bekerom M.P.J. O066, O174
Van Den Bremer J. P054
Van Der Ende B. P082
Van Der Meijden O.A.J. P053, PS153
Van Der Vlies C. H. O034
Van Der Werken C. O063
Van Der Wilden G.M. P113, P195
Van Dijk C.N. O066, O174
Van Dissel J. O076
Van Griensven M. O132, O171, P091, P136, P146
Van Leerdam R. PS176
Van Lieshout E.M.M. O044
Van Noort A. O103
Van Riet P.A. O044
Van Valburg M.K. O092
Van Vugt R. P159
Van Waes O.J.F. O044
Vanderschot P. PS064
Vandertop W.P. P174
Varada E. PS078
Varanauskas G. P067
Varga E. V08
Varga Jr E. V08
Varma R. P079, P096
Vartic M. P196, PS041, PS170
Vartosu C. PS041
Vasic J.S. O170, P062
Vasilliu P. O021, V11
Vasireddy A. P076, P079, P173
Vatankhah P. O042
Velasco R. P058
Vellasamy A. P121
Velmahos G.C. P113, P195
Vendegh Z. P018
Venetis G. PS123
Verhofstad M.H.J. O063, O098, P172
Verhoof O.J.W. O103
Verleisdonk E.J.J.M. P053, PS143, PS153
Veselko M. O131, PS110, PS190
Veverkova L. P039, PS083, PS186
Vezyrgiannis I. PS101
Vidovic D. PS066
Vielgut I. P086
Vikatmaa P. P120
Vikmanis A. P075
Vila-Amengual X. P063
Vilchez Rabelo A. PS073
Villa Dıaz A. PS175
Villani S. O155
Villasboas Vargas A. P184
Villiger A. PS145
Vincent D.S. P171
Viswanathan V.K. P155, PS065, PS140
Viswanathan V.K. O161, P141, P165
Vladov N.N. O166, V05
Vlahovic T. P035
Vlaovic M. O052
Vlaykova T. PS046
S216 Abstract
123
Volpi A. O045, P180
Von Dercks N. P158
Von Wartburg U. O088
Vos D. I. O063, O128, PS107
Vossen F. O112
Vrahas M.S. P125
Vrakopoulou Z. PS030
Vroemen J. P.M. O128
Vukajlovic B. P080, PS141
Vukmirovic Z. P040, P105
Vahaaho S. P163
Vecsei V. O162
Wade C. E. P177
Wafaisade A. O055
Wagner O.F. O162
Wahlgren C.M. O013
Waki T. O147, P078
Walcher F. O055, O061
Walker R. PS010
Wallner B. O072
Walusimbi M. P012
Wanner G.A. O047, O049, O097
Wardak I. O081
Waseem M. P033
Weaver A. P103
Weaver M. J. P125
Weber C. D. P116
Weber M. O106, O176, O177
Wee C.P.J. PS006
Weiskopf R.B. P177
Weiter M.I. O114
Weixelbaumer K. P136
Wendsche P. O115
Wendt K. O137, P189
Weninger P. O126
Wenning A.S. PS028
Werner C.M.L. O047, O049, O097
West A. P170
Wettergren A. P205
Weuster M. P146, P147
Wichlas F. O130, P167
Wichmann C. PS100
Wigelsworth A. P025
Wigelsworth M. P025
Wijdicks F.-J.G. P053, PS143, PS153
Wijffels M. O092, PS194
Wilde E. P008
Wilde P. O121
Winchell R. P195
Windolf M. O135, O136, P006, P010, PS102
Winkelmann M. O043
Winnisch M. O030A, P059
Witte I. P146
Wixmerten A. PS131
Woehrl W. P145
Wolf F. PS131
Wolff C. V02
Wong E. PS169
Woo S.H. PS045
Woods R. P012
Wu D. P156
Wurm S. P100
Wuthisuthimethawee P. O009, O026
Wutzler S. O055, O061, P191
Wyen H. O055, O061, P191
Wahling A. PS115
Wahnert D. PS102
Yagata Y. O116, PS060
Yamakawa Y. PS061, PS062
Yanar H. T. O002, O119A, P069, P070, PS027, PS166
Yarollahi A. O041
Yazıcı B.O. P193
Yetkin G. P143, P144, PS025
Yildirim M. PS034
Yilmaz B. P099, P101
Yo K. P127
Yoshida M. P027
Yovtchev Y.P. PS046
Yuzawa K. O033
Yucel F. PS067
Yucel S.M. PS055
Yucel T. P140
Yılmaz S. P037
Zago M. O168, V10
Zago T. O154
Zagorac S. P199
Zaharopoulos A. PS101
Zambudio-Carroll N. O164, PS026, PS073, PS084, PS138
Zangrillo A. P190
Zarzaur, Jr. B.L. O159
Zech G. P008
Zeckey C. O043, P133, P154, P189, PS005
Zelig O. O019
Zelle B. A. O053, O084
Zellweger R. P114
Zhu R. P121
Ziagos T. PS092
Zifko A. O160
Zigman T. P203
Zigman Z. O144
Zikaj G.S. PS165
Zikos N. P064, P106
Zimmermann H. P150, PS122, PS173, PS174
Zimpfer D. O014
Zoakman S. PS176
Zografos G. PS030
Zosso C. O123
Zubenko A.G. O139
Zuccon W. O003
Zuidema W.P. O018
Zvak I. O175
Zysset P.K. O126
Abstract S217
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