The Trauma-Man® simulator (Simulab, USA) was announced by the American College of Surgeons as a legitimate alternative to the advanced trauma life support (ATLS) animal surgical skill station. The aim of this study was to evaluate chest drain insertion training using the simulator. Twenty-four experienced physicians and 42 ATLS course participants performed chest drain insertion using the simulator. Additionally, the ATLS course trainees performed the task in the animal skills laboratory. Following training they all completed a subjective questionnaire. Experts rated the various steps required for chest drain insertion similar to the human equivalent, with median scores of 4 or 5 (scale of 1–6) for all steps and recommended the use of the simulator for the training of novice doctors in performing the procedure (score 5.5 ± 0.8, median 6 in a scale of 1–6). Experts recommended that the area allotted for chest drain insertion in the simulator will be modified in the cephalad direction to correspond with the guidelines of chest drains insertion. ATLS course participants found the simulator superior to the animal model only in teaching anatomical landmarks, whereas the animal model was found to be superior in teaching tissue dissection and chest drain fixation. The Trauma-Man® simulator is an efficient training tool for the chest drain insertion. Minor changes are recommended for the enhancement of the simulators' realism.

Due to the increase in the incidence of osteoporosis with age and the high biochemical load on the proximal femur, the pertrochanteric femur fracture is the typical fracture of the elderly. The number of different fracture types and the characteristic features of this patient population places high demands on any universally applicable implant. The rotational instability of the head–neck fragment in the case of a trochanter minor defect, in particular, is a significant factor in the care of pertrochanteric femur factures. The object of this study was to show that the gliding nail constitutes a universal implant for the care of proximal femur fractures with constantly maintained stability under load. Between March 1996 and April 2001, 501 patients with per- and subtrochanteric fractures and an average age of 76 were included in the study. All osteosyntheses were carried out using the gliding nail which has an I-beam cross-section profile blade. 73.2% were treated operatively for closed isolated per- or subtrochanteric femur fractures. All patients were restored to full weight-bearing postoperatively. The combined overall early and late complication rate following gliding nail synthesis was only 5.4%. Neither blade cut-out nor head–neck rotation was observed following gliding nail osteosynthesis. Three-month mortality rose from 2.4% in patients with no complications to 90% in patients with four complications. 92.1% of patients were independently mobile at the time of the follow-up examination. With its low complication rate and the ever-present possibility of full weight bearing, the gliding nail fulfills all the requirements of a modern implant for the treatment of proximal femur fractures. In our opinion, its most advantageous features are the high moment of resistance of the I-beam cross-section profile blade which ensures the possibility of gliding, the minimalized risk of proximal cut-out due to the large surface area with two planes of support in the bone, and its secure rotational stability in terms of both nail and bone. The impaction of the blade, which requires no reaming with its resulting loss of bone substance, is responsible for the excellent bone–implant interface.

The value of cranial computerized tomography (CT) scan as a method of predicting traumatic brain injury (TBI) in patients with minor head trauma (MHT) is controversial. We aimed to assess the effectiveness of cranial CT by retrospectively studying head-injured patients presenting to the accident and emergency (AE King Khalid University Hospital, Riyadh, Saudi Arabia. To determine the frequency of utilization, yield for TBI, incidence of missed injuries, and to assess the effectiveness of cranial CT for patients with MHT. These retrospective medical records and imaging survey were conducted for 600 consecutive patients. Included in this review were patients above 12 years who sustained acute MHT, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale (GCS) score of 13 or greater. During the year 2004, and over a 10-month period, 600 patients attended the A&E department with MHT. Only 130 patients (21.7%) fulfilled the indication criteria of the Canadian CT Head Rule, and were referred for cranial CT scan. CT scans demonstrated evidence of intracranial injuries in 24 patients (18.5%), 19 of them admitted for observation, and only two patients (1.5%) required craniotomy for evacuation of extradural hematoma. Brain CT was normal in 100 patients (77%), showing incidental findings unrelated to head injury in five patients, and one scan could not be interpreted due to poor quality. No one died as a consequence of MHT, and no one reported again to A&E of the discharged group, without CT scan. There have been several studies examining the indications for CT scan imaging in MHT. Canadian CT Head Rule can accurately identify patients who have no need for head CT imaging, however, if applied to the wrong patients or used incorrectly, it may lead to unnecessary referrals for CT. If successfully validated, this simple decision rule may lead to a more standardized approach to the A&E investigation and management of patients with MHT, this would potentially reduce costs, and so should be considered for application by all A&E, neurosurgery, and radiology departments.

Reconstruction of the three-point dynamic suspension of the fibula in the fibular groove of the tibia. Elimination of pain and functional disturbances. Prevention of posttraumatic osteoarthritis. Chronic symptomatic insufficiency of the distal tibiofibular syndesmosis with widening of the mortise. Poor skin and soft tissue conditions. Advanced osteoarthritis of ankle. Reconstruction of the three most important ligaments of the distal syndesmosis complex: the anterior and posterior as well as the interosseous tibiofibular ligaments, with a halved, distally pedicled tendon of the peroneus longus tendon. Ten tenodeses (eight women, two men, average age 40 years) were done between January 1998 and December 1999. The syndesmosis insufficiency persisted after surgical treatment of eight pronation-eversion and two -abduction fractures. Average duration of follow-up 11.4 months. Using the Karlsson score, the subjective and functional assessment of all patients reached 88 out of 100 points. One patient reached only 70 points on account of a preoperatively present dysesthesia in the territory of the tibial nerve giving rise to persistent pain.

The objective of this retrospective study over a 5-year period was to assess the success rate of airway management by residents. Criteria of successful airway management were both the adherence to a standardized protocol of pre-hospital airway management and successful endotracheal intubation (ETI) in rescue missions. The minimal level of training time required for residents rotating in the pre-hospital emergency team was either 1 year in our university department of anesthesiology, or 3 years of internal medicine including 20 ETIs under supervision in the operating room. According to a strict protocol detailing indications and drugs to be administered, residents performed rapidsequence intubation (RSI) except in cases of cardiopulmonary arrests where ETI was performed without drugs. Adherence to the protocol of airway management was evaluated according to data provided by the residents. Successful endotracheal tube placement was confirmed only in transported patients with a combination of clinical signs, infrared capnography, and a chest X-ray on hospital admission. A total of 13,537 rescue missions were reviewed. The protocol adherence was 96.1%. ETI was attempted in 753 patients, and successful placement was confirmed in 98.2%. Pre-hospital airway management (protocol adherence and proper endotracheal tube placement) was successful overall in 94.3% of rescue missions. Our results support the efficacy of a pre-hospital emergency rescue system reinforced by residents.

Clearing the cervical spine in polytrauma patients still presents a challenge for the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and lifethreatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or performed by clinicians. The aim of this study was to assess the safety and efficacy of the diagnostic algorithm at this trauma center and to propose a possible consensus of the optimal method for clearing the cervical spine in polytrauma patients. This study retrospectively analyzed the clinical records of all polytrauma patients with cervical spine injuries (n = 118) who were admitted to this level-I trauma center between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of a single lateral view or a three-view cervical spine series. Further radiological examinations (functional flexion/extension views, oblique views, CT-scan, MRI) were performed by clinical suspicion of an injury or when indicated by the standard radiographs. Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries: In six cases skeletal injuries were missed because only a lateral view of the cervical spine was performed during primary trauma evaluation and in one case because a three-view cervical spine series did not show the extent of the injury. In four cases discoligamentous injuries were missed despite complete sets of standard radiographs and a CT-scan, but missing functional flexion/ extension views. For assessment of the cervical spine in poly-trauma patients we recommend a three-view trauma series as minimum to clear the cervical spine and the more liberal use of CT-scan as standard diagnostic tool in a specific subset of patients with clinically suspected cervical spine injuries and significant trauma history. In those patients also, passive functional flexion/ extension views should be considered as obligate in later stages of diagnostic algorithm.

Background: A central component to the statistical analysis of trauma care is the probability of survival model, which predicts outcome of the trauma event taking into account various anatomical and physiological factors. One of the key input information to the survival model is the injury score which forms the cornerstone of trauma epidemiology. There are many scoring systems currently in use, and the Injury Severity Score (ISS) as the anatomical component of the injury in the probability of survival model is a widely used one. This paper examines the possibility of representing the anatomical component of the trauma using different injury severity scoring methods described in the literature. Material and methods: The dataset used consists of 75,371 cases from the Trauma Audit and Research Network (TARN). TARN regroups 110 hospitals in the UK and it is the largest European trauma registry. Various limitations of ISS have been described in the literature and an investigation into other scoring methods, which could be calculated from the available data, was proposed. Using the available database, the alternative injury scoring methods can be calculated and their use within a Trauma score and Injury Severity Score (TRISS) probability of survival model

To analyze the role of multidetector CT (MDCT) in the management of abdominal highenergy trauma patients using CT classification of organ injury. During the past 2 years, 451 patients with abdominal trauma were examined by MSCT. Most were victims of RTA, 400 men and 51 women, between 18 and 80 years old (mean age 38 years). In 78 patients injury to abdominal organs was diagnosed by MDCT. MDCT (GE Light Speed) was performed using 2.5 mm collimation and 7.5 mm table movement with dynamic IV injection of iohexol 350 mg iodine/ml. A workstation was used for 2D and 3D reconstructions. We detected 24 patients with liver rupture. The spleen was ruptured in 20 cases, kidneys in 14 cases; urinary bladder rupture occurred in 4 cases and urethral rupture in 1 case. In 19 patients, more than one organ injuries were observed. In only 23 patients (30% of all injured with grades 3–4), surgery was an imperative treatment, but the majority of victims with abdominal injuries, grades 1–2, were treated conservatively. MDCT plays a crucial role in the management of patients with abdominal trauma. A team approach (traumatologist, surgeon and radiologist) is mandatory in high-energy trauma.

The delayed presentation of traumatic diaphragmatic hernia is associated with high morbidity and mortality. Acute colobronchial fistula complicating delayed presentation of traumatic diaphragmatic hernia is previously unreported. A 52-year-old woman presented with a 4-day history of dyspnoea, feculent sputum and chest and abdominal pain 3 months after a road traffic accident. The diagnosis of Chilaiditi's syndrome, diaphragmatic hernia and colobronchial fistula was confirmed with computed tomography (CT) and treated by chest drain, primary hernia repair and right hemicolectomy. Spontaneous decompression through the bronchus had prevented tension fecopneumathorax. The diagnosis of diaphragmatic hernia is difficult but delay is associated with increased mortality. Symptoms include dyspnoea, chest and abdominal pain, with decreased respiratory sounds and visceral sounds in the thorax. Abdominal visceral structures or gas on CXR, CT or contrast studies will confirm the diagnosis. The initial operative approach is laparotomy but thoracotomy must be considered as abdominal viscera may be adherent to thoracic structures.