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Background: Early recognition and management of trauma related coagulopathy improves the outcome. Trauma facilities should implement an algorithm to identify the bleeding trauma patient with coagulopathy., Objective: The scope of the paper is to identify the indicators of early coagulopathy and to optimize the indications for thromboelastometry and coagulation support., Design: Cohort study based on data from trauma registry., Setting: Data of 493 major trauma patients treated in GH Celje from 2006 to 2014 were included into The TraumaRegister DGU ® (TR-DGU)., Patients: Patients were selected for inclusion into TR-DGU according to the following criteria: polytraumatized patients with Injury severity score (ISS) ≥ 18, patients with injuries to single region with AIS 5, patients with major injuries to a single region and abnormal vital signs. All patients that were dead on arrival to hospital, patients presented to hospital >24 h after the injury, and head injuries that occurred with a low energy mechanism in patients on anticoagulation drugs were excluded., Measurements: Two groups were formed (with or without coagulopathy). Mortality, morbidity, length of mechanical ventilation, ICU and hospital stay were used as outcome and compared between the groups. A coagulopathy prediction model (CPM) was developed to identify the patients who were at high risk of coagulopathy., Results: Coagulopathy was present in 51 % of patients. Severe injuries to the torso and limbs, infusion of >1000 ml of fluids in the prehospital settings, and hypotension were included into CPM. If all three criteria were present, the sensitivity of the model to predict coagulopathy was 93 %. By adding the blood gas analysis (BE ≤ -5), the specificity increased to 81.7 %., Limitations: Shortcomings of our analysis are mainly related to the quality of data in the registry that may not be comparable to a clinical trial where data are collected specifically to address a given issue., Conclusions: The Criteria for activation of coagulation support treatment remain centre dependent. In our settings the CPM is the tool to select patients for ROTEM ® analysis. By adding data from blood gas analysis, treatment of coagulopathy is justifiable before complete test results are available.

Background: The aim was to describe an audit of hip fracture patient care and outcomes in a Slovenian healthcare setting prior to the implementation of the Geriatric Fracture Center (GFC) model of care., Methods: The Fragility Fracture Network (FFN) hip fracture audit database was used to collect data on hip fracture care in elderly patients. Epidemiological data were submitted as well as fracture type, prefracture residence and mobility prior to the fracture. The timeline of events and acute care data were also collected. Follow-up after 30 days included hip-related readmission, mobility, residence and life status., Results: Included were 495 patients with a mean age of 81 years of which 20% were preoperatively seen by a physician or geriatrician, 93.1% had surgical repair, 58.5% of them within 48 h of admission. The mortality rate in hospital was 5.4% and 10.1% at follow-up, 61.8% patients were able to return to prefracture residency and 23% could walk with minor assistance., Conclusion: This comprehensive and detailed audit report provides baseline data on case-mix, care and outcomes following hip fractures in Slovenia, in advance of planned quality improvement work in geriatric fracture care and provides a strong basis for the assessment of the impact of the GFC model of care.

Background: The objective of the study was to gather information about elderly major trauma patients admitted to one particular Slovenian trauma centre in Celje and examine this group of polytrauma patients, specifically with respect to mechanisms of injury, injury severity and distribution of injuries. Further on, to identify morbidity and mortality rates and compare these to the younger population and, finally, to determine the factors that have the most impact on treatment results., Methods: The study gathered and evaluated data of 532 patients included in the Trauma Register DGU® of the German Trauma Society (TR-DGU) during a 10-year period and two distinct groups of patients were established, separated on account of age as older or younger than 65 years. The differences between these two groups were analyzed with respect to demographics, comorbidities, preclinical management, injury patterns, relevant clinical and laboratory findings. Furthermore, differences between deceased and surviving elderly patients were also analyzed., Results: The majority of elderly patients suffered from a blunt mechanism of trauma (96.6%) and of these simple falls represented 47.9% within this injury mechanism. There were two body regions, which were most frequently represented, namely head and thorax injuries, accounting for 54.7% each. Complications were more frequent among the elderly, with sepsis being present in 29.9% and multiple organ failure (MOF) in 19.7% of cases. Cardiovascular failure was also high in both the elderly and young, accounting for 45.3% of the elderly and 31.3% of the younger population. The in-hospital mortality rate for the elderly group was 25.6% and was significantly higher compared to the younger counterparts (14.7%). Low fall mechanism of injury, coma and the new injury severity score (NISS) were statistically important factors for the mortality of seriously injured elderly patients during the acute phase of treatment., Conclusions: Despite advances in care, morbidity and mortality in elderly patients after major trauma remains considerably higher than in younger populations with head injuries accounting for the majority of fatalities. The elderly patient population in this study mostly suffered from blunt mechanisms of injury, with simple falls representing a high proportion of injury mechanisms. Generally, the injury severity scale (ISS) in the elderly is not statistically higher than with the younger population. Likewise, the distribution of injuries according to body regions is also similar; however, the elderly are more prone to complications (e. g. sepsis and MOF), which is likely due to a lower physiological reserves.

Objectives: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment., Design: Web-based reliability study., Setting: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey., Participants: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns., Main Outcome Measurements: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons., Results: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA., Conclusions: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

The usefulness of the Revised Injury Severity Classification (RISC) analysis was compared with that of the Trauma and Injury Severity Score (TRISS) for evaluating the quality of treatment of severely injured patients at the General Hospital Celje, Slovenia. Over a period of 2 years, data from a cohort of 155 patients treated at the General Hospital Celje were included in the Traumaregister Deutsche Gesellschaft für Unfallchirurgie. The structure of the patient group was compared with that in the registry, and TRISS and RISC analyses were performed. The M statistic (0.83) showed a good match of the distribution of probability of survival between groups. Evaluation of RISC (area under the curve [AUC] 0.94, Hosmer-Lemeshow test 3.5) demonstrated the efficacy of this method in the patient group. TRISS (AUC 0.89, Hosmer-Lemeshow test 21.1) was not a reliable instrument for analysis of treatment of major trauma patients. We believe that RISC should replace TRISS for evaluation of the treatment of major trauma patients.

Background: We report the long-term results of the surgical treatment of chronic rupture of the Achilles tendon using percutaneous suturing under local anesthesia., Patients and Methods: We operated on 22 patients with median age of 50 years (29-72) with chronic rupture of Achilles tendon between 1991 and 2005. The median time from injury to surgery was 7.1 weeks (4-40). We used percutaneous surgical technique similar to a technique described by Ma and Griffith (1977, Clin Orthop Relat Res 128:247-255) and Kosanović (1994, Arch Orthop Trauma Surgery 113:177-179). Eighteen (82%) patients attended the clinical review at a mean of 67 months (14-176). During follow up, patients were asked about pain, stiffness, weakness of the calf, footwear restrictions, occupation and level of activity before and after injury (Tegner score), influence of injury on ADL activities and satisfaction with treatment. The passive and active range of movement of the ankle and the power of isometric plantar flexion were measured, and the endurance test was performed. Functional assessment was performed using a Leppilahti clinical scoring scale and a modified Merkel score, Results: Complete healing of the tendon was achieved in 21 patients (95%). In 17 patients (77%) the postoperative course was complications free. There were no reruptures during the observation period. All were able to stand on the tiptoe of the injured leg. The operated leg had a mean of 87.5% of the isometric power compared with the uninjured leg (p = NS). On an average they could stand on toes and raise the heel 13 times on side with the ruptured tendon. The Leppilahti scoring scale revealed a result that was excellent for 11 patients (62%), good for 2 (11%), fair for 5 (28%) and no one had poor result. The average score was 83.3 (60-100). Eighty-three percent of patients stated that the result of surgery was very good and 11% rated it as good. Fourteen patients (78%) returned to same level of activity at median 7 months after surgery., Conclusions: Our series is one of the largest to be reported for the treatment of chronic rupture. Our technique offers a considerable advantage; it is minimal invasive, easy to perform with no associated harvesting morbidity and increased patient acceptance. We recommend this technique for the treatment of chronic rupture of Achilles tendon.

Lesions of the heart valve caused by blunt chest trauma is rare, but when it does occur it can significantly injure the patient. On the basis of autopsy studies, research shows that heart valves are injured in less than 5% of patients who have died due to impact thoracic trauma. Among the heart valves, the aortic valve is the most often lacerated, which has been proved by relevant autopsy and clinical studies. Aortic valve lesions can be the only injury, but it is possible that additional heart or large vessel injuries are also present (myocardial contusion, rupture of the atrial septum, aortic rupture, rupture of the left common carotid artery). The force that causes such an injury is often great and often causes injuries to other organs and organ systems. In a multiple trauma patient, it is very important to specifically look for heart-related injuries because it is possible that they may be overlooked or missed by the surgeon, because of other obvious injuries. We describe the case of a 41-year-old man with multiple trauma who was diagnosed with aortic valve insufficiency due to rupture of the left coronary cusp 6 weeks after a road accident. Valvuloplasty was performed. Seven years later the patient is free of symptoms and is in good physical condition. Echocardiography showed normal dimensions of the heart chambers, a normal thickness of the heart walls, and normal systolic and diastolic function of the left ventricle. Heart valves are morphologically normal, and only an unimportant aortic insufficiency was noticed by echocardiography.

The treatment of odontoid fractures remains controversial. The late results of 14 patients with Anderson D'Alonzo type II and III treated with halo jacket from 1995 to 1999 are presented. The fractures were reduced under image intensifier and stabilized by halo jacket. The immobilization period was 12 weeks. After 1 year, the fracture was roentgenologically consolidated in 12 out of 14 patients (85.7%), and all the patients were without neurological deficit. Nine patients (64.3%) were without subjective complaints, five had a reduced range of motion. Painful motion appeared in four patients (28.6%), and cervical stiffness was noted in five (35.7%). We recommend halo jacket for the treatment of most type II and III odontoid fractures which are unstable or displaced 6 mm and more, except for patients with tetraplegia. Fractures with minimal displacement and without neurological deficit were treated conservatively with rigid collars. In our institution, internal fixation was performed in selected cases. The presence of neurological deficit and the anatomic properties of the fracture site crucially influence the choice of treatment.

Background: Avulsion fractures of the anterior superior iliac spine are uncommon injuries. Most of them occur in adolescent athletes. Traditionally, they have been treated conservatively. We describe operative treatment of avulsion fractures that might shorten the period of rehabilitation., Methods and Results: Six patients with avulsion fractures of the anterior superior iliac spine were treated operatively by open reduction and osteosynthesis with two Kirschner wires and a wire loop. After 6 weeks, all of them had resumed their sports activities. No complications were recorded., Conclusions: Operative treatment of anterior superior iliac spine avulsions may reduce the time to full recovery. It should be considered for athletes requiring a short period of rehabilitation.