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In 2018 the first Dutch guideline on necrotizing soft tissue infections (NSTIs) was drafted. Its aim is to standardize the care of this disease in order to reduce variation, and thereby improve the quality of care. This guideline is a benchmark for all healthcare providers who deal with this devastating disease; it focuses on diagnostics, treatment options and organization of care. Given the low incidence, the complexity and the fulminant course of NSTIs, it is important to ensure continuous specialized care. Therefore it is recommended to make regional agreements about referral to specialized centres. Surgical exploration remains the gold standard for diagnosis. The empirical antibiotic regimen depends on if the onset of disease is community or nosocomial, and if its aetiology is a monomicrobial (type I) or a polymicrobial (type II). The guideline recommends that intravenous immunoglobulin (IVIg) therapy be started if gram staining reveals streptococci. IVIg must be discontinued if group-A streptococcus is excluded as a causative agent.

Fracture-related infection (FRI) is a serious complication after fracture care and can lead to severe morbidity with loss of quality of life, a significant increase in medical expenses and loss of participation in work and social life. Early recognition, adequate surgical debridement, deep uncontaminated tissue cultures with (if indicated) soft tissue reconstruction and fracture stabilization followed by antibiotic therapy are the cornerstones of the successful management of FRI. Recently, in 2018, the AO/EBJIS consensus definition for FRI was published and both national and international working groups are being assembled and provide guidelines and tools for the care of patients with FRI. This paper is a synopsis of the Dutch guideline on FRI (2018), illustrated by a clinical case, and is aiming to provide an overview of the current knowledge on diagnosis and treatment of this disease.

Background: Approximately one quarter of polytrauma patients has facial injuries, which usually lead to loss of form and function. Several specialties are involved in the acute and reconstructive phases of facial injuries, such as oral and maxillofacial surgery, otorhinolaryngology, plastic surgery, ophthalmology and dentistry., Case Description: A 25-year-old man with severe facial injuries was brought to the shock room after sustaining high-energy trauma. He had a panfacial fracture that required reconstruction. This was done with two surgeries, with an interval of 4 days. The patient recovered successfully after this., Conclusion: Because of the complexity of facial trauma, many factors are involved in acute care and treatment. It is therefore important to designate one coordinating specialty to guide this process. The oral and maxillofacial surgeon plays a vital role in this.

Necrotising soft tissue infections require early consultation of an experienced surgeon, regardless of what time of day they occur. Delays in diagnosis and treatment should not occur. Necrotectomy should be skin-sparing when possible. A low threshold for consultation with a tertiary referral center is recommended.

Necrotising soft-tissue infections occur in the soft tissue compartment consisting of the dermis, subcutaneous tissue, superficial fascia (fascia of Scarpa), deep fascia and muscle. Although this severe and acutely life-threatening infection has a low incidence, both GPs and specialists will see a necrotizing soft-tissue infection more than once during their career. The mortality related to necrotising soft-tissue infections has been halved during the past 15 years from nearly 40 to 20% due to adequate treatment. Laboratory examination and X-ray findings could be of added value, but the gold standard remains biopsy of the fascia and Gram staining. Treatment consists of prompt volume resuscitation in case of sepsis, administration of broad spectrum antibiotics and surgical debridement; this debridement should be as skin-sparing as possible. The use of hyperbaric oxygen therapy has remained a controversial issue, unless a patient has gas gangrene, caused by Clostridium species. A multidisciplinary treatment and admission to a tertiary intensive care unit are indispensable for the treatment of a septic patient with necrotizing soft-tissue infection.

Frostbite injuries rarely occur in healthy Dutch persons. However, as the number of people engaging in winter and outdoor activities and travelling to high altitudes increases, the risk of frostbite also increases. Frostbite is a cold-induced injury which results from two processes: freezing and microvascular occlusion. Adequate first aid, which focuses on the prevention of refreezing and mechanical injury, and rapid rewarming together with the administration of ibuprofen, are of the greatest importance for limiting eventual tissue damage. Iloprost infusion and possibly (r)tPA are indicated if a patient presents within 24 hours after the tissue has thawed and the injury is such that severe morbidity can be expected. If the patient presents after this time period, hyperbaric oxygen therapy may be considered; however, the evidence available on this type of treatment is limited.

We present three patients, a 55-year-old man, a 69-year-old woman and a 25-year-old man, with a seatbelt sign following a car accident. All 3 patients exhibited various injuries that may occur in the case of a blunt trauma, for example rib fractures. In one patient, however, symptoms of internal abdominal injury occurred several days after the accident. The presence of a seatbelt sign is associated with an increased risk of internal abdominal injury. We therefore advise a CT scan of the abdomen in patients who present with a seatbelt sign, even if abdominal ultrasound does not reveal signs of injury.

Objective: To assess the indications, complications and mortality associated with splenectomy in a large general hospital, and to evaluate adherence to guidelines for postoperative vaccination and prophylactic antibiotics., Design: Retrospective, descriptive., Method: Data were collected on 106 patients who underwent splenectomy between 1999 and 2004. Indications for surgery, complications, duration of hospitalisation, and vaccination status were investigated retrospectively. Patients were contacted by telephone for a structured interview regarding vaccination and antibiotic prophylaxis., Results: Of the 95 patients with sufficient data for analysis, 41 underwent elective surgery and 54 underwent non-elective surgery, including 37 who required splenectomy due to iatrogenic injury. Posteroperative complications arose in 45 patients, including 23 who developed serious complications. 10 patients died due to complications, including 7 who died within one month after the procedure. Vaccination coverage for the entire group was 58%., Conclusion: In this large general hospital, splenectomy was often performed due to iatrogenic injury and was associated with a relatively high complication rate. Adherence to guidelines on vaccination and prophylactic antibiotics could be improved.

In a 13-year-old girl sudden pain in the right hip after playing soccer was caused by anterior inferior iliac spine avulsion.

A 36-year-old man presented with acute abdominal pain due to occlusion of the superior mesenteric artery associated with intestinal rotation caused by an upper abdominal postoperative adhesion.

In a 73-year-old man with a non-tender palpable mass in the right part of the upper abdomen and soft stool a porcelain gallbladder was observed at radiological examination.