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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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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).


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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).


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.


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 %.


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.


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.


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.


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.


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.


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’.


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!


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.


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.


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.


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.


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.


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.


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.


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.


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,


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.


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.


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.


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.


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.


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


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.


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.


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.


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,


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.


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.


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.


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.


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.


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.


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.


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.


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.


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)


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.


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.


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

http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/commonfiles/open.htm

http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/commonfiles/open.htm

http://www.bapras.org.uk

http://www.bapras.org.uk

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.


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.


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.


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.


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.


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 %.


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


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


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


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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

http://whqlibdoc.who.int/publications/2002/9241562323.pdf

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.


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.


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.


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.


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.


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.


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.


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.


O107

INTRAMEDULLARY OSTEOSYNTHESIS OF AND ANKLEFRACTURES WITH A STRAIGHT LOCKED NAIL: XS NAIL

W. Friedl

Orthopedic,trauma and Hand Surgery, Klinikum Aschaffenburg,


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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

http://dx.doi.org/10.1016/j.injury.2011.04.010

http://dx.doi.org/10.1097/TA.0b013e31821852ed



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.


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.


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.


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).


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.


O142

FLOPPY POSITIONING OF THE PATIENT FORTREATMENT OF COMPLEX ACETABULAR FRACTURES

L. Buchler, J.D. Bastian, K.A. Siebenrock, M.B.J. Keel



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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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,


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.


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.


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.


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.


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.


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.


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.


O163

SYSTEMIC INFLAMMATORY RESPONSE AND ORGANDYSFUNCTION FOLLOWING HAEMORRHAGIC SHOCKAND PULMONARY VERSUS SYSTEMIC IL-10ADMINISTRATION

R. Pfeifer1, P. Lichte2, H. Schreiber1, H. Pape2, P. Kobbe2


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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,


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).


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.


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.


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.


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


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.


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.


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.


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

http://www.traumamaps.org

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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


Abstract S73

123

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.


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.


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.


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.


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.


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.


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


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



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.


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.


PS019

POSTERIOR INSTRUMENTATION ANDMONOSEGMENTAL SPONDYLODESIS IN COMBINATIONWITH CEMENT AUGMENTATION FOR THE TREATMENTOF THORACOLUMBAR BURST FRACTURES

S. Hoppe, M.B.J. Keel, L.M. Benneker



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.


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).


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.


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.


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.


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.


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.


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.


PS027

METHODS OF ABDOMINAL CLOSURE: BOGOTA BAGVERSUS VACUUM-ASSISTED CLOSURE



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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


Abstract S105

123

PS106


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.


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.


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.


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.


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,


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.


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.


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).


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.


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.


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.


PS117


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.


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


PS132


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).


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


Abstract S119

123

PS151

MALROTATION AFTER LOCKED TIBIALINTRAMEDULLARY NAILING

F. Say, A.M. Bulbul



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.


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.


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).


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.


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.


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 treatment of complex blunt liver injuries. Curr Probl Surg.

2001;38:1–60.


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.


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.


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.


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.


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.


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).


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.


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.


PS166

TREATMENT OF BREAST GANGRENE: A RARECONDITION



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.


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).


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.


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.


PS170

NONOPERATIVE MANAGEMENT OF SPLENIC TRAUMAIN POLYTRAUMA SETTING

M. Beuran1, I. Negoi1, S. Paun1, A. Runcanu1, B. Gaspar1, M. Vartic2


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.


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.


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.


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.


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.


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.


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.


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.


S128 Abstract

123

PS179

AN ALTERNATIVE TREATMENT METHOD FORTREATING DISTAL TIBIAL INTRAARTICULARFRACTURES: HYBRID EXTERNAL FIXATOR

F. Say, A.M. Bulbul



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.


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.


PS181

MINIMALLY INVASIVE SCAPHOID OSTEOSYNTHESIS:STILL NEED FOR A CAST?

J. Ciernik, M. Reska, J. Konecny, M. Kabela



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.


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.


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.


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.


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.


PS186

EXTERNAL FIXATOR IN TREATMENT OF COMMINUTEDINTRAARTICULAR FRACTURE AT THE FIRSTMETACARPAL BASE

J. Konecny, L. Veverkova, M. Reska, J. Ciernik



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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


P003

TRAUMATIC DIAPHRAGMATIC INJURY: A MARKER OFSERIOUS INJURY CHALLENGING TRAUMA SURGEONS

M. Pol, A. Gupta, S. Kumar, B. Mishra, S. Sagar, M. Singhal



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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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: [email protected].

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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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

€.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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


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.


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.


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.


P073

AN UNUSUAL MAXILLOFACIAL INJURY

J. Thareja, S. Sagar, M. Singhal, M. Pol, A. Gupta, S. Kumar



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.


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.


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.


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.


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.


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.


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.


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.


P081


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).


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.


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.


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.


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.


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.


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.


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.


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.


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.


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

http://www.ahrq.gov/qual/vtepresentation/maynardtranscr.htm

http://www.ahrq.gov/qual/vtepresentation/maynardtranscr.htm

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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


Abstract S171

123

P115


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.


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.


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.


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.


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.


P121


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


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.


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


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.


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


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.


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.


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.


Abstract S185

123

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.


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.


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.


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.


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.


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.


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).


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.


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.


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.


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.


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.


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.


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.


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

http://www.eur-lex.europa.eu

http://www.eur-lex.europa.eu

(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.


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


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.


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.


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.


Abstract S191

123

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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


P196

NONOPERATIVE MANAGEMENT OF HEPATIC TRAUMAIN POLYTRAUMA SETTING

M. Beuran1, I. Negoi1, S. Paun1, A. Runcanu1, B. Gaspar1, M. Vartic2


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.


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.


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.


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.


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.


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.


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)’’.


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.


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.


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.


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.


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.


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.


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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