Treatment of unstable trochanteric fractures : the balance between man and material

Treatment of unstable trochanteric fractures poses a challenge to surgeons in many ways. Accepting this challenge requires understanding of those parameters that determine the outcome. In operative fracture care at least four elements influence the outcome of treatment: the patient, the fracture, the fixation device, and the surgeon. The degree of impact varies per specific element, as does the mutual relationship. The general physical state of the patient with a hip fracture is a parameter that is strongly related to fracture type and outcome, but cannot or only minimally be influenced by the surgeon: it is a relatively static parameter. The type of fracture that is sustained has similar static characteristics: it presents as a fixed value parameter that both directly and indirectly influences outcome, through its intrinsic stability and its tendency to redislocation. The flXation device that will be used for osteosynthesis depends on the patient, the fracture characteristics~ the way the fracture is classified, hospital logistics and the skills, experience and preference of the operating surgeon. Figure 1 s

Intraossale infusie

ABSTRACT Intraosseous (IO) infusion is a long existing method to obtain vascular access and has gained renewed interest over the last decade. IO infusion is an easy, safe, rapid and effective alternative method for vascular access in emergency clinical care and prehospital situations. The IO access can be used for administration of fluids, medication, analysis of electrolytes, blood type and blood gasses. The proximal tibia is the most common insertion location. New IO needles (F.A.S.T.1., Bone Injection-Gun and EZ-IO) have been developed over the last decade, to make insertion easier. Guidelines such as the ATLS and ERC are changing and currently recommend the use of IO needles in the emergency setting, in trauma and non-trauma situations, in both children and adults as alternative for peripheral vascular access. This will increase the use of the IO needles in de future. Awareness of indications, contra-indications and complications should therefore be enhanced

The follicle-stimulating hormone (FSH) threshold/window concept examined by different interventions with exogenous FSH during the follicular phase of the normal menstrual cycle: duration, rather than magnitude, of FSH increase affects follicle development

According to the threshold concept, FSH concentrations need to surpass a distinct level to stimulate ovarian follicle growth. The window concept stresses the significance of a limited duration of elevated FSH levels above the threshold for single dominant follicle selection. The aim of this study was to investigate effects on follicle growth of increased FSH levels, differing in duration and magnitude of elevation, durin

Low levels of follicle-stimulating hormone receptor-activation inhibitors in serum and follicular fluid from normal controls and anovulatory patients with or without polycystic ovary syndrome

In patients with normogonadotropic anovulation, either with or without polycystic ovary syndrome (PCOS), factors interfering with FSH action may be involved in arrested follicle development. The aim of this study is to assess whether factors inhibiting FSH receptor activation are elevated in serum or follicular fluid from anovulatory patients, as compared with regularly cycling women. For this purpose, a Chinese hamster ovary cell line, stably transfected with the human FSH receptor, has been applied. FSH-stimulated cAMP secretion in culture medium was measured in the presence of serum or follicular fluid. Chinese hamster ovary cells were stimulated with a fixed concentration of FSH (3 or 6 mIU/mL) to mimic FSH levels in serum or follicular fluid. Samples were added in concentrations ranging from 3-90% vol/vol to approach protein concentrations occurring in serum or follicular fluid. In the presence of 10% vol/vol serum from regularly cycling women (n = 8), FSH-stimulated cAMP production was inhibited to 42 +/- 2% (mean +/- SEM of 2 experiments, each performed in duplicate) of cAMP production in the absence of serum, whereas a similar cAMP level (up to 38 +/- 4% of the serum-free level) was observed at higher concentrations of serum (30-90% vol/vol). The inhibition of FSH-stimulated cAMP production in the presence of serum samples from normogonadotropic anovulatory patients, without (n = 13) or with (n = 16) PCOS, was similar to controls. Follicular fluid samples (n = 57) obtained during the follicular phase in 25 regularly cycling women and follicular fluid samples (n = 25) from 5 PCOS patients were tested in a slightly modified assay system. In the presence of 10 or 30% (vol/vol) follicular fluid, FSH-stimulated cAMP levels were decreased to 68 +/- 2% and 55 +/- 2% (mean +/- SEM of a single experiment in triplicate) of the cAMP levels in the absence of follicular fluid, respectively. There was no correlation between the degree of cAMP inhibition and follicle size, steroid content (androstenedione or estradiol concentrations), or menstrual cycle phase. Furthermore, no differences in inhibition were found, comparing PCOS follicles with size- and steroid content-matched follicles obtained during the normal follicular phase. It is concluded that inhibition of FSH receptor activation by proteins present in serum or follicular fluid is constant (60 and 40%, respectively) and independent from the developmental stage of the follicle, either during the normal follicular phase or in patients with normogonadotropic anovulation. Inhibition of FSH recepto

Percutaneous reduction and fixation of intraarticular calcaneal fractures

Objective: Percutaneous reduction by distraction and subsequent percutaneous screw fixation to restore calcaneal and posterior talocalcaneal facet anatomy. The aim of this technique is to improve functional outcome and to diminish the rate of secondary posttraumatic arthrosis compared to conservative treatment and, secondly, to reduce infectious complications compared to open reduction and internal fixation (ORIF). Indications: Sanders type II-IV displaced intraarticular calcaneal fractures. Contraindications: Isolated centrally depressed fragment. Contraindications: Patients who are expected to be noncompliant. Surgical Technique: Four distractors (Synthes™) are positioned, two on each side of the foot, between the tuberosity of the calcaneus and talus and between the tuberosity and cuboid. A distracting force is given over all four distractors. A blunt drifter is then introduced from the plantar side to unlock and push up any remaining depressed parts of the subtalar joint surface of the calcaneus. The reduction is fixated with two or three screws inserted percutaneously. Postoperative Management: Directly postoperatively, full active range of motion exercises of the ankle joint can start, with the foot elevated in the 1st postoperative week. Stitches are removed after 14 days. Implant removal is necessary in 50-60% of patients. Results: Between 1999 and 2004, 59 patients with 71 fractures were treated by percutaneous skeletal triangular distraction and percutaneous fixation. A total of 50 patients with 61 fractures and a minimum follow-up of 1 year were available for follow-up. According to the American Orthopaedic Foot and Ankle Society Hindfoot Score, 72% had a good to excellent result. A secondary subtalar arthrodesis was performed in five patients and planned in four (total 15%). Böhler's angle increased by about 20° postoperatively. Sagittal motion was 90% andsubtalar motion 70% compared to the healthy foot

Trauma Mechanisms and Injuries Associated with Go-Karting

Annually, approximately 600 patients seek medical attention after go-kart accidents in the Netherlands. A large variability in injury patterns can be encountered. Knowledge of the trauma mechanisms of go-kart accidents and insight into the associated injuries is limited and requires improvement. Such additional knowledge may lead to customized trauma protocols for patients with a high index of suspicion on go-kart injuries. Research into trauma mechanisms may also lead to implementation of improved or additional safety measures for go-karting, involving both the go-karts itself as well as prerequisites to the go-kart tracks and qualifications for the drivers. The main trauma mechanisms involved in go-kart accidents, and three cases to illustrate the variety of injuries are described in the current manuscript

Current methods of diagnosis and treatment of scaphoid fractures

Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs. The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings. Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid non-unions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis

Intraosseous devices: A randomized controlled trial comparing three intraosseous devices

Introduction. Access to the circulation is mandatory for adequate treatment in medical emergency situations. Intraosseous (IO) infusion is a safe, fast, and effective alternative for gaining access to the circulation, if intravenous access fails. In the last decade, the IO method gained renewed interest. New devices have been developed, such as the Bone Injection Gun (BIG) 15G/18G and the First Access for Shock and Trauma 1 (FAST1). Objective. To determine which IO needle is preferable for gaining IO access in patients requiring acute administration of fluids or medication in a prehospital setting. Methods. In this single-blind prospective randomized trial, the IO needles were added to the equipment of the helicopter emergency medical services (HEMS) system. The HEMS nurses received training in proper use of all needles. Children (113 years) were randomized to the Jamshidi 15G or the BIG 18G, and adults (≥ 14 years) were randomized to the Jamshidi 15G, the BIG 15G, or the FAST1. All patients requiring acute administration of fluids or medication, without successful insertion of an intravenous (IV) catheter, were included. The IO needles were compared in terms of insertion time, success rate, bone marrow aspiration, adverse events during placement, and user satisfaction. Results. Sixty-five adult and 22 pediatric patients were included. The treatment groups were similar with respect to age, gender, mortality, and trauma mechanism (p ≥ 0.05). The median insertion times ranged from 38 seconds for the Jamshidi 15G to 49 seconds for the BIG 15G and 62 seconds for the FAST1 (p 0.004). The devices did not differ with respect to success rates (adults overall 80 and children overall 86), complication rates, and user satisfaction. Conclusions. The Jamshidi 15G needle could be placed significantly faster than the FAST1. The devices had similar success rates, complication rates, and user-friendliness. Intraosseous devices provide a safe, simple, and fast method for gaining access to the circulation in emergency situations

Management of biliary complications following damage control surgery for liver trauma

Background: The liver is the most frequently injured solid intra-abdominal organ. The major cause of early death following severe liver trauma is exsanguination. Although perihepatic packing improves survival in severe liver trauma, this leaves parenchymal damage untreated, often resulting in post-traumatic biliary leakage and a subsequent rise in morbidity. The aim of this study was to analyze the incidence and treatment of biliary leakage following the operative management of liver trauma. Methods: Patients presenting between 2000 and 2009 to Erasmus University Medical Centre with traumatic liver injury were identified. Data from 125 patients were collected and analyzed. Sixty-eight (54 %) patients required operation. All consecutive patients with post-operative biliary complications were analyzed. Post-operative biliary complications were defined as biloma, biliary fistula, and bilhemia. Results: Ten (15 %) patients were diagnosed with post-operative biliary leakage following liver injury. Three patients with a biloma were treated with percutaneous drainage, without further intervention. Seven patients with significant biliary leakage were managed by endoscopic stenting of the common bile duct to decompress the internal biliary pressure. One patient had a relaparotomy and right hemihepatectomy to control biliary leakage and injury of the right hepatic duct. Conclusion: Biliary complications continue to occur frequently following damage control surgery for liver trauma. The majority of biliary complications can be managed without an operation. Endoscopic retrograde cholangiopancreatography (ERCP) and internal stenting represent a safe strategy to manage post-operative biliary leakage and bilhemia in patients following liver trauma. Minor biliary leakage should be managed by percutaneous drainage alone

Inventarisatiestudie naar de behoefte aan assistentie door het Mobiel Medisch Team in de avond en nacht

Samenvatting Inleiding: Tot 2005 kon men uitsluitend gedurende de dag een beroep doen op professionele aanvullende prehospitale hulpverlening. In 2005 ontstond een voor Nederland unieke situatie waarbij het Mobiel Medisch Team (MMT) ook ’s nacht paraat inzetbaar was. Het doel van deze studie was inzicht te krijgen in de kwantitatieve en kwalitatieve aspecten van grondgebonden MMT inzetten in de nacht, tussen 19.00 en 7.00 uur. Methode: In een beschrijvend cohortonderzoek werden alle patiënten waarvoor in 2005 tussen 19.00 en 7.00 uur MMT-assistentie werd gevraagd in de regio Zuid West Nederland geïncludeerd. Van de geïncludeerde patiënten werden prospectief (pre)hospitale data gedocumenteerd, en na 1 jaar geanalyseerd. Resultaten: Gedurende de studieperiode werd in de avond en nacht 235 keer om assistentie gevraagd, waarvan 69 aanvragen werden geannuleerd. Zevenenzestig procent van deze nachtelijke inzetten vond plaats op basis van de inzetcriteria die gebaseerd zijn op de aard van het ongeval, en 33% op basis van de toestand van de patiënt. Drieënzestig procent van de inzetten vond plaats tussen 19.00 uur en middernacht. De mediane Injury Severity Score was 10 (4-25) met een mortaliteit van 16 %. Drieëntwintig procent van de patiënten werd geïntubeerd. Conclusie: Deze studie laat zien dat er ook gedurende de avond en nacht aanzienlijke behoefte is aan gespecialiseerde medische hulp ter aanvulling op de ambulancezorg. De kwalitatieve behoefte aan zorg is vergelijkbaar met de zorgvraag overdag. Het handelen van het nachtelijk grondgebonden MMT was potentieel levensreddend. Extrapolatie van deze regionale resultaten levert een behoefteraming op van jaarlijks 505 daadwerkelijke MMT assistenties in heel Nederland tussen 19.00 uur en 7.00 uur