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Aims: Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate., Methods: We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed., Results: The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups., Conclusion: Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Study Design: This report documents a case of delayed hypopharyngeal and esophageal perforation after anterior spinal fusion and reviews relevant literature., Objectives: Presentation of an alternative solution of primary repair and reinforcement of a delayed esophageal and hypopharyngeal perforation after anterior spinal fusion., Summary of Background Data: Anterior plating is generally used for stabilization after cervical spine trauma. Esophageal and hypopharyngeal perforation is a rare but potentially life-threatening complication due to mediastinitis with consecutive septic shock and multiorgan failure., Methods: Our patient was operated on after cervical trauma caused by car accident. The neurologic condition did not improve in the postoperative period. About 4 months later, the patient had increasing dysphagia as well as episodes of odynophagia. Flexible esophagoscopy showed a perforation of a part of the plate from the hypopharynx down to the proximal esophagus. Primary repair reinforced by a pedicled pectoralis major flap was done without complications., Results: Postoperative fluoroscopy as well as endoscopy showed no signs of perforation. Swallowing was possible without any further episodes of dysphagia or odynophagia. Neck movement was unconfined., Conclusions: Primary repair reinforced by pedicled pectoralis major flap has been shown to be an alternative in case of combined hypopharyngeal and esophageal perforation due to orthopedic spine stabilization. Advantage of the pectoralis major muscle flap is no functional loss of neck movement.

This paper reports on the sonographic localisation of a metallic foreign body in the upper arm region and its topographic anatomic position as well as the sonographic diagnosis of an AV fistula due to a lesion of the brachial blood vessels. Ultrasonography is the method of choice for the evaluation and diagnosis of foreign body injuries and possible subsequent complications.

Ultrasonography with high-frequency transducers nowadays plays an important role in diagnosing post-traumatic complaints of the elbow and hand tissue in children as well as in adults. We see it as an addition to clinical examination, standard X-ray, and other radiological methods. As a noninvasive procedure we can investigate post-traumatic changes and postoperative pain, detect foreign bodies, and also use it for postoperative metal removal. The possibility of imaging cartilage structures with ultrasound also enables us to diagnose post-traumatic injuries in children's elbows such as supracondylar fractures, epiphysiolyses, and fractures of the epicondyles.

Recurrent traumatic anterior shoulder instability following surgical repair may be associated with implant failure and an array of capsulolabral pathology including separation of the labrum (Bankart lesion), humeral avulsion of the glenohumeral ligaments (HAGL lesion), and capsular rupture. We detail a previously unreported case of a HAGL lesion occurring in a shoulder with an intact arthrosopic Bankart repair following an additional traumatic event. Anatomic repair of this subsequent injury resulted in an excellent outcome. The patient returned to his high-demand ski racing activities without any shoulder limitation.

Ultrasound examinations of the sciatic nerve were performed using high-resolution transducers (7.5, 10 to 20 MHz) both in anatomical specimens and in healthy volunteers. The ultrasonographic anatomy (sono-anatomy) of the nerve, its course along the thigh and its echogenicity in comparison with muscles, tendons and adipose tissue were investigated in 10 isolated muscle/nerve preparations. In addition, the influence of the angle of the applied transducer on the various different tissues was evaluated. In the clinical part of the study, the sciatic nerve was identified ultrasonographically in both thighs of 50 sex-matched healthy volunteers aged between 2 and 76 years. The normal sciatic nerve presents as a tubular echogenic structure with parallel linear internal echoes in the longitudinal section, and as a punctiform moderately echoic structure in cross-section, with the perineurium producing bright boundary echoes. Varying the insonating angle of the transducer reduced echogenicity, but to a smaller degree than in muscles and tendons. Unequivocal identified of the sciatic nerve from the level of the gluteal fold to its bifurcation in the distal thigh was possible in all but one case. We conclude that the course of the sciatic nerve along the thigh can be reliably identified and imaged with high-resolution ultrasound.

We present a case of a 65-year-old patient with a surgically treated distal radius fracture. At 5-month follow-up, conventional radiography revealed breakage of the plate and a screw displaced into the volar soft tissue. Preoperative ultrasonography including dynamic assessment of the tendons showed the screw intratendinously as a hyperechogenic structure with repetitive echoes. This unusual localization was proven by surgery. Dynamic ultrasonography played an important diagnostic role in the localization of the loosened and displaced osteosynthetic material.

Purpose of the Study: The aim of the study is to show the value and reliability of ultrasound examination in detecting free intraabdominal air after blunt abdominal trauma., Methods: The experimental part of this study includes the evaluation of the sonographic morphology of air within liquid and solid tissues. Subsequently air was injected into the abdominal cavities of 10 cadavers and sonography utilized for localization and assessment of the minimal detectable air volume. The clinical part of the study reports on the sonographic detection of hollow viscus perforation in 10 patients, who were admitted to our institution because of acute abdominal problems., Results: Sonography is a reliable method for the diagnosis of free intraabdominal air. Best position for ultrasound examination of the abdomen is supine with the thorax slightly elevated (10-20 degrees). The optimal probe position is in the right paramedian epigastric area in the longitudinal direction. In all the 10 patients we were able to diagnose pneumoperitoneum preoperatively by ultrasound assessment.

Denervation surgery has been a mainstay of our management of chronic pain in the wrist. If there is useful movement at the wrist we prefer denervation to arthrodesis. We have reviewed 22 patients at a mean of 50 months after such denervation surgery at the wrist. This was the only treatment in 16 patients; the other six also had other treatments. Pain was reduced in 16 patients, and 17 were satisfied or improved. None of the patients wished to have a supplementary arthrodesis. We stress the importance of preoperative blockade tests and of a very detailed knowledge of the local anatomy.

Sonographic studies were performed on cadaveric bones placed in a water bath, using 7.5-MHz linear-array transducers and 3.5-MHz sector transducers. Depending on its size, the defect was revealed as an interruption of the cortical reflection of echo or a dorsal band of echoes confined to the region of the fracture. It was interesting to note that fractures and bony defects are not visualized when the transducer is placed parallel to the fracture line or the zone of bony impaction. A further remarkable aspect was the numerous artefacts adjacent to each other at several fracture margins. It may be concluded that in an experimental setting and under standardized conditions, high-resolution transducers permit the examiner to detect cortical discontinuities of 1 mm or more.

In recent years, ultrasonic assessment of the locomotory system has become established both as a screening method in patients with chronic disorders and for evaluating acute injuries. Thanks to technical improvements to the equipment (use of high-frequency probes up to 20 MHz), ever smaller structures can be visualized. Ultrasonography can be carried out immediately following the clinical- and possibly radiological-assessment, by one and the same investigator, and requires little extra time. A bilateral examination in particular permits good evaluation of the extent of an injury and, with appropriate experience and good-quality equipment, an accurate assessment of the anatomical topography. Ultrasonography should now be used as the primary imaging method in the diagnosis of injuries to the following parts of the locomotory system, thus helping to minimize the number of expensive, and more invasive, diagnostic procedures: muscles and tendons, peri-articular soft tissue (in particular shoulder, knee and elbow joints), detection of intra-articular effusions, collections of fluid and, where applicable, ultrasonically guided puncture. In numerous other problems, too (postoperative complications, foreign bodies, fractures, osteomyelitis, soft tissue inflammation, etc.), ultrasound can deliver the first information. In this way, expensive diagnostic techniques can be reserved for special cases only, thus reducing costs. Furthermore, used as an adjunctive method, ultrasonography can reduce the number of diagnostic and follow-up X-rays in the case of injuries to the AC joint, shoulder dislocations, Hill-Sachs lesions, fractures in children, and for the detection of foreign bodies, again reducing radiation exposure and overall costs.

Method: In an experimental study on ten isolated human cadaver tendons, the ultrasound anatomy and the reproducibility of artefacts was determined using 10- and 13-MHz probes. With these in vitro data, the form and diameter of a non-injured tendon were documented in a series of 30 patients between 3 and 60 years old. In a second series of 32 patients with acute, traumatic ruptures of the Achilles tendon and 40 patients with chronic disorders, we distinguished the pathological anatomy., Results: Injuries to a tendon with chronic disorders, reruptures and complications in the postoperative period after tendon repair can be made more difficult by calcification, scars, oedema, haematoma and suture materials. It is necessary to check the changing ultrasound patterns owing to an haematoma or oedema with tendon carpulence, the missing linear signals in a fresh rupture and the different signals after operative or nonoperative treatment., Conclusion: Using high-frequency probes with 10 or more MHz, it is possible to examine even the insertion area of the tendon or the pathology of a subachilleal bursa by tilting the probe. The dynamic examination and the comparison with the contralateral side in two planes should be included in a standardized examination procedure and are of great importance in some cases of fresh tendon ruptures. Knowledge of the physical principles and the possibility of misleading artefacts is crucial.

In an experimental study, the US pattern of foreign materials such as are often found in wounds, was investigated. The exploration was carried out with the aid of high-resolution, mechanical US probes (10-12 MHz) used to examine foreign bodies placed in a gelatine bath and in the shoulder of a pig. The study showed that all foreign bodies that measured at least 1-2 mm in diameter were reliably detected. The intensity of the interface echoes was identical with all the materials employed, irrespective of the nature of the surface. However, the artefacts caused by the foreign bodies used revealed considerable differences. Complete acoustic shadow, acoustic attenuation, reverberation echoes and even "comet-tail" artefacts were observed. In clinical practice, familiarity with the artefacts that may be expected during sonographic exploration and localization of foreign bodies in wounds would seem to make good sense.

Heterotopic ossification is a non-neoplastic deposit of bone within soft tissue (myositis ossificans). The most common localized form is post-traumatic myositis ossificans. The ultrasonographic appearance of heterotopic ossification is characterized by highly echogenic areas with attenuation or complete disappearance of the acoustic signal distal to these areas. The size and extent of para-articular ossifications can also be evaluated, and the choice of the surgical approach is facilitated and damage to soft tissue minimized by the ultrasonographic examination.

In a first experimental study we investigated the visualisation of metal implants in reference to dimension, shape, material (titanium, steel, biodegradable screws) and surface structures and an eventual change of the echo pattern in correlation to the surrounding structures, the vicinity to bone and the change of the sound angle. For this purpose ultrasound investigation was performed in artificial and cadaver bones and in cadaver limbs after implantation of screws, plates, K-wires and cerclage wires. We found that metal implants of a certain dimension can be localised by typical artefacts (resonance artefact, comet tile artefact). In the following clinical study we investigated the value of ultrasound in finding and localisation of implants after osteosynthesis. In patients with 25 locking femur nailing, 30 locking tibia nailing, 30 osteosynthesis done by screws and plating, metal was easily localised by typical artefacts. Ultrasound examination gave the possibility to define the number of screws, the localisation to surrounding tissue, loosening of screws and eventual as sociated inflammatory tissue swelling (bursitis, tendovaginitis).

The aim of the present study was to establish the typical ultrasound (US) patterns of metal implants used for internal fracture fixation, and consequently to use US for the identification and localisation of such implants. We investigated both the visualization of the implants in term of size and shape, material (titanium, steel, biodegradable screws) and surface structures, and possible changes in the echo pattern in relationship to surrounding structures (muscles, body fluid), proximity to bone, and changes in the angle of insonation. For this purpose ultrasonography was performed on artificial and isolated cadaver bones in a water bath, as well as on cadaver limbs following prior implantation of screws, plates, K-wires and cerclage wires. We found that, from a certain size upwards, metal implants can be easily localised on the basis of typical artefacts (resonance artefact, comet-tail artefact). US is thus most suitable for localisation of metal implants. The spatial and anatomical relationship to bony structures, joints, tendons, muscles and blood vessels can be determined with a high degree of accuracy.