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

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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

Pediatric trauma in the Netherlands: incidence, mechanism of injury, and in-hospital mortality

BackgroundIn the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care.MethodsA retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009-2018, concerning all children (0-16 years) hospitalized due to injury in the Netherlands.ResultsThe annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0-5 years (89.2%). Severe injury (injury severity score >= 16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%).ConclusionsDomestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.Trauma Surger

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

Maturation of trauma systems in Europe

PurposeTo provide an overview of trauma system maturation in Europe.MethodsMaturation was assessed using a self-evaluation survey on prehospital care, facility-based trauma care, education/training, and quality assurance (scoring range 3-9 for each topic), and key infrastructure elements (scoring range 7-14) that was sent to 117 surgeons involved in trauma, orthopedics, and emergency surgery, from 24 European countries. Average scores per topic were summed to create a total score on a scale from 19 to 50 per country. Scores were compared between countries and between geographical regions, and correlations between scores on different sections were assessed.ResultsThe response rate was 95%. On the scale ranging from 19 to 50, the mean (SD, range) European trauma system maturity score was 38.5 (5.6, 28.2-48.0). Prehospital care had the highest mean score of 8.2 (0.5, 6.9-9.0); quality assurance scored the lowest 5.9 (1.7, 3.2-8.5). Facility-based trauma care was valued 6.9 (1.4, 4.1-9.0), education and training 7.0 (1.2, 5.2-9.0), and key infrastructure elements 10.3 (1.6, 7.6-13.5). All aspects of trauma care maturation were strongly correlated (r > 0.6) except prehospital care. End scores of Northern countries scored significantly better than Southern countries (p = 0.03).ConclusionThe level of development of trauma care systems in Europe varies greatly. Substantial improvements in trauma systems in several European countries are still to be made, especially regarding quality assurance and key infrastructure elements, such as implementation of a lead agency to oversee the trauma system, and funding for growth, innovation and research.Trauma Surger

Does clavicular shortening after nonoperative treatment of midshaft fractures affect shoulder function? A systematic review

Trauma Surger

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