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The aim of this study was to identify, in (pre-) clinically obtained data, parameters predicting the outcome of patients with multiple trauma and severe head injury. Fifty-eight patients aged 27±10 years were investigated an average of 5.8 years after the accident. The Hanover Polytrauma Score was 34±11 points, the initially assessed Glasgow Coma Scale (GCS) was 6.2±3.2 points; and the duration of coma was 15.4±14.4 days. The primary length of stay in hospital averaged 33.4 days, including 22.9 days in the intensive care unit and 20.2 days of ventilation. For a further 223 days the patients were treated at the Neurologic Clinic of Hessisch Oldendorf. Besides different neurologic deficiency symptoms, the psychometric tests showed deficits in all areas. In particular, information processing speed, concentration, recent memory and learning performance were impaired. There was free mobility of all joints in 33% of the patients. Due to injury the elbow and ankle joint developed the worst restriction. Central paralysis and heterotopic ossification also caused a restriction in joint mobility. Half of the patients were confronted with different social changes. The rate of return to work was dependent on age. Some 42% of all patients had taken up their former profession, 5% were still in training or at college, 32% were retrained to other professions, 16% were unemployed and 5% were completely retired on pension. Age, injury severity, GCS, duration of coma and duration of weaning were suitable predictors in correlation- and regression analysis. The Glasgow Outcome Scale showed good recovery and moderate disability in 53%, severe disability in 33% and persistent vegetative state in 14% of the patients.

Mass casualty incidents (MCI) in this day and age represent a special challenge, which initially require on-site coordination and logistics and then a professional distribution of victims (triage) to surrounding hospitals. Technical, logistical and even specialist errors can impair this flow of events. It therefore seems advisable to make a detailed analysis of every MCI. In this article the railway incident from 9 February 2016 is analyzed taking the preclinical and clinical cirumstances into consideration and conclusions for future management are drawn. As a special entity it could be determined that fixed table units in passenger trains represent a particularly dangerous hazard and in many instances in this analysis led to characteristic abdominal and thoracic injuries.

Im Rahmen der Ellenbogenluxation kann es zu tief im Ellenbogengelenk verlaufenden Frakturen mit Abscherverletzungen der Gelenkflache von Capitulum und Trochlea und unterschiedlich ausgedehnter Beteiligung der Kondylen kommen, die haufig nicht nach den standardisierten Verfahren der AO klassifiziert und behandelt werden konnen. Die vorliegende Arbeit analysiert retrospektiv 30 Falle, um zusammen mit einer Literaturubersicht Empfehlungen fur die Diagnostik und das operative Vorgehen auszuarbeiten. Die praoperative Computertomographie ist in jedem Fall zu fordern – das wahre Ausmas des Traumas wird in der konventionellen Rontgendiagnostik meist unterbewertet. Die Schichtaufnahme ist Grundlage fur die Wahl des operativen Zugangs, um bei den meist kleinen Fragmenten das sichere Setzen der Implantate zu planen. Zudem hangt die Prognose der Ausheilung von der Grose der artikularen Fragmente ab. Bei der Implantatwahl haben sich kanulierte Kleinfragmentschrauben – uber die temporare Fixation mit den zugehorigen Kirschner-Drahten eingebracht – bewahrt. Das Outcome nach dem Morrey-Score zeigt trotz der in uber 90% mit verformenden Veranderungen ausheilenden Frakturen ein gutes Ergebnis (>75 Punkte).

Nach dem Traumaregister der Deutschen Gesellschaft fur Unfallchirurgie (DGU) haben Verletzungen im Bereich der Extremitaten zusammen mit den Beckenfrakturen einen wesentlichen Anteil im Verletzungsmuster aller dokumentierten schwerverletzten Patienten. Diese Ubersicht untersucht Art und Zeitdauer der klinischen Diagnostik und die Indikation fur notwendige Sofortmasnahmen wie z. B. die Notfallamputation im Schockraum. Klinische Studien wurden uber systematische Literatursuchen (Medline, Cochrane und Handsuchen) und Klassifikation nach Evidenzgute (Level 1–5 nach Oxforder Schema) zusammengetragen. Bei Eintreffen des Patienten ist nach Sicherung der Vitalfunktionen die systematische korperliche Untersuchung und die daraus resultierende radiologische Diagnostik die einzige evidenzbasierte Richtgrose bei der Erfassung von Extremitatenverletzungen. Alle anderen Aspekte sind lediglich auf empirische Grosen begrundet. Die Qualitat der Schockraumuntersuchung ist abhangig von der Erfahrung des unfallchirurgischen „Teams“. Leitlinien und Algorithmen konnen hierbei ein wichtiges Hilfsmittel darstellen.

The treatment of the scaphoid pseudarthrosis is up to now a special challenge. The operative treatment has to beware the integrity of the scaphoid bone and its ligamentous structures. Gold standard is the debridement of the pseudarthrosis and then implantation of a autograft from the iliac crest and compression screw. The operation is however very sophisticated, invasive and with high risk. The technique described here includes dowelling of the pseudarthrosis, implantation of a cylindric autograft without screw stabilisation. Preliminary results in 7 patients demonstrate a minimal-invasive technique with less risk and satisfying results up to now. Subsequent investigations with more patients are planned for the future.

Ziel der Untersuchung war es, durch (pra-) klinisch erhobene Daten pradiktive Aussagen uber die Spatresultate polytraumatisierter Patienten mit schwerem Schadel-Hirn-Trauma zu treffen. 58 Patienten im Alter von 27±10 Jahren wurden durchschnittlich 5,8 Jahre nach dem Unfall untersucht. Die Verletzungsschwere betrug nach dem Hannoverschen Polytraumaschlussel 34±11 Punkte, die initial erhobene Glasgow Coma Scale (GCS) lag bei 6,2±3,2 Punkten, die Komadauer belief sich auf 15,4±14,4 Tage. Die primare stationare Behandlung dauerte durchschnittlich 33,4 Tage, dabei entfielen 22,9 Tage auf die Intensivbehandlung und 20,2 Tage auf die Beatmung. Die Patienten wurden im Schnitt weitere 223 Tage in der Neurologischen Klinik Hessisch Oldendorf behandelt. Neben unterschiedlichen neurologischen Ausfallerscheinungen konnten psychometrische Tests in allen Bereichen Defizite aufzeigen, die insbesondere die Informationsverarbeitungsgeschwindigkeit, die Konzentrationsleistung und die Merkfahigkeit und Lernleistung betrafen. 33% der Patienten wiesen eine freie Beweglichkeit aller Gelenke auf, wobei verletzungsbedingt an Ellenbogen- und Sprunggelenk die schwersten Beeintrachtigungen beobachtet wurden. Weitere Ursachen stellten zentrale Lahmungen und heterotope Ossifikationen dar. Veranderungen im sozialen Umfeld wurden bei der Halfte der Patienten festgestellt. Die berufliche Reintegration war in starkem Mase altersabhangig, insgesamt kehrten 42% in ihren fruheren Beruf zuruck, 5% befanden sich in Ausbildung oder Studium, 32% wurden umgeschult, 16% waren arbeitslos und 5% vollberentet. In der Korrelations- und Regressionsanalyse konnten als geeignete Pradiktoren das Alter, die Verletzungsschweren der GCS sowie Koma- und Weaningdauer festgestellt werden. Nach schwerstem Schadel-Hirn-Trauma trugen, gemessen an der Glasgow Outcome Scale 53% der Patienten keine bzw. eine geringfugige Behinderung davon, eine teilweise in 33% und eine vollstandige Abhangigkeit in 14% der Falle.

Einleitung: Im Rahmen der Versorgung schwerstverletzter Patienten ruckt zunehmend die Frage des Qualitatsmanagements, der Behandlungsergebnisse und somit die Notwendigkeit der Erfassung der Rehabilitationsgute vor die Frage nach dem Uberleben des Patienten in den Mittelpunkt des Interesses. Bisherige Mesinstrumente basieren auf der Erfassung von Verletzungen einzelner Korperregionen. Scores, welche mehrere Organregionen beschreiben, wurden z. B. an Arthritispatienten entwickelt und erscheinen fur Traumapatienten wenig aussagekraftig. Deshalb wurde an unserer Klinik in Zusammenarbeit mit der AG Polytrauma der DGU ein neues Rehabilitationserfassungsinstrument entwickelt. Methodik: Eine Gliederung in 2 Teile ermoglicht sowohl die Erfassung des subjektiven als auch des objektiven Befundes des Patienten. Uber einen Auswertungsscore sind anschliesend Auswertungsberechnungen moglich. Ergebnisse: Diese Arbeit beschreibt die Entwicklung, den Aufbau sowie die quantitative Erfassung der Ergebnisse. Hierzu zahlt insbesondere die Moglichkeit einer regionenspezifischen Auswertung des Rehabilitationsergebnisses. Dieses standardisierte Rehabilitationserfassungsinstrument befast sich erstmals ausschlieslich mit dem sehr heterogenen Patientengut der Schwerstverletzten. Es ermoglicht mittels genauestens auf diese Patienten zugeschnittener Instrumente, diese nachzuuntersuchen und Rehabilitationsdefizite aufzudecken. Implementiert sind anerkannte Instrumente zur Beantwortung spezieller Fragen, um einen Vergleich der eigenen Ergebnisse mit denen anderer Scoresysteme zu ermoglichen. Schlusfolgerung: Unter Bezug auf die Datenbank des Deutschen Traumaregisters der DGU ist nun eine prospektive Erfassung und somit genaue Qualitatskontrolle des polytraumatisierten Patienten moglich.

OBJECTIVE The ventilation mode clearly influences the course of patients with multiple trauma on the ICU. Ventilation according the "open lung" approach rapidly opens up atelectatic lung regions. Generation of an adequate intrinsic PEEP enables to keep the lung open. We studied the consequences of the "open lung" approach on the lung function and monitored its side effects on patients with multiple trauma. METHODS 18 consecutive patients with multiple trauma and additional thoracic trauma were routinely ventilated according the "open lung" approach between May and November 1999. We were mainly interested in data of lung mechanics, oxygenation and ventilation. Side effects on other organ systems and consequence for the infection rate were monitored. RESULTS Ventilation according the "open lung" approach enables early sufficient oxygenation and ventilation of patients with severe multiple trauma and accompanying thoracic trauma. The ventilation mode helps to prevent baro-, volu- and atelectrauma and thus fulfils the requirements for a present-day ventilation mode. An immediate complete healing of the lung damages was not found. Nevertheless, as a trend the length of ventilation support seems short. Even extensive osteosynthesis at multiple fractures was possible without delay. Side effects of the high opening pressure on the lung or other organs as well as sequels of the high intrinsic PEEP on liver, kidney or intestine were not found. The infection rate was low, therapeutic doses of antibiotics were necessary only in less than half of the ICU-stay. CONCLUSION Ventilation according the "open lung" approach is a very effective and safe way to ventilate patients after severe multiple trauma with accompanying thoracic trauma.

Zusammenfassung Das komplexe Gelenktrauma ist definiert als Fraktur bzw. Luxation eines Gelenks mit ¶begleitendem schweren Weichteilschaden ¶(> zweitgradig) und/oder Serienverletzung und/oder Gefas- oder Nervenverletzung. Insbesondere beim Ellbogengelenk fuhrt dies haufig zu einer schwerwiegenden und manchmal dauernden Beeintrachtigung der oberen Extremitat. Es ist daher von besonderer Bedeutung, ein standardisiertes Behandlungskonzept zu beachten. Eine Analyse unseres Patientenkollektivs zeigte bei insgesamt 773 Frakturen des Ellbogengelenks im Zeitraum von 1981–1991 224 Komplexverletzungen (29%), davon 68% bei polytraumatisierten Patienten. Distaler Humerus und proximaler Unterarm waren annahernd gleichermasen beteiligt. Ein Sonderfall stellt der Floating elbow mit 6% dar. Die Halfte der Patienten hatte einen schweren Weichteilschaden, 82% davon offen. Neben einem Kompartmentsyndrom (23,8%) sahen wir in 63,5% der Falle eine Nerven- und in 25,4% eine Gefasverletzung. Bei der primaren operativen Therapie ist moglichst eine definitive Versorgung aller Verletzungen der oberen Extremitat anzustreben. Eine stabile Osteosynthese ermoglicht die rasche Mobilisierung, eine Transfixation des Gelenks ist nur in Ausnahmefallen gerechtfertigt. Im Bereich des distalen Humerus haben sich, wie am proximalen Unterarm, die Prinzipien der AO bewahrt. Fur eine adaquate Rekonstruktion des Gelenks sind haufig erweiterte operative Zugange angezeigt. Insbesondere bei der Versorgung der proximalen Ulna haben sich indirekte Repositionstechniken etabliert. Radiuskopfchen und Coronoid stellen wichtige dynamische Stabilisatoren dar. Bei der Weichteilversorgung sind meist nur lokal rekonstruktive Masnahmen erforderlich. Die Indikation zur Kompartmentspaltung des Unterarms sollte bei diesen Verletzungen groszugig gestellt werden. Die Diagnose und Therapie einer begleitenden Gefasverletzung sollten aufgrund der sonst resultierenden prolongierten Ischamiezeit rasch erfolgen. Bei Verzogerung ist ein intraluminaler Shunt indiziert. Bei den Nervenverletzungen ist eine initiale operative Versorgung nur im Einzelfall (bei scharfer Durchtrennung) angezeigt, ansonsten erfolgt eine sekundare Versorgung im Intervall nach 3 Monaten. Das Rehabilitationsergebnis wird durch die Art der initialen Behandlung stark beeinflust. Nur bei rascher Mobilisierung und intensiver krankengymnastischer Anleitung kann bei diesen schweren Verletzungen ein zufriedenstellendes Ergebnis erzielt werden. Eine geplante Arthrolyse spatestens nach 6 Monaten, ggf. mit Teilimplantatentfernung, kann dieses Ergebnis noch deutlich verbessern.

Extracorporal shock wave therapy (ESWT) has been postulated as an additional therapeutic option in nonunion after fracture treatment. We have reexamined patients with nonunions treated at our institution to evaluate the efficacy of the method. In a prospective nonrandomized study patients were investigated with a minimum duration of nonunion of 6 months. Following 2 cycles of ESWT with 2000 impulses/18 kV, the reevaluation was performed at 1, 3 and 6 months after treatment. A total of 27 pseudarthroses was reevaluated, in 11 one or more reosteosyntheses had been performed prior to ESWT. Following ESWT we found a success rate of 41 % (n = 11). The clinical evidence of subjective, clinical improvement was found in 5 of these patients within 1 month, in all of these patients within a period of 3 months. Radiologic evidence of improvement occurred in none of these patients within 1 month, in all of these patients within 6 months. ESWT appears to represent an additional treatment option in patients with longstanding nonunion. If no improvement occurs, the maximum delay of reosteosynthesis is three months.

Trotzdem wird in den letzten Jahren immer haufiger uber unnotige Einsatze und Fehlentscheidungen berichtet, so das auch hier eine Qualitatsanalyse gefordert wird [32]. Dieses Konzept wird unter dem Begriff „Medical Control” bereits seit Jahren in den Vereinigten Staaten erfolgreich praktiziert [23]. Zielgrosen um die Qualitat zu definieren und diese im Sinne der Qualitatssicherung einzusetzen, erfordert die Festschreibung von Standards [32]. Im Rahmen der Notfallmedizin sind Qualitatsstandards bereits von verschiedenen deutschen Organisationen (DGU, DIVI, DGNC, DGAI) zusammengestellt worden. Ein Bundeseinheitliches Notarztprotokoll konnte eingefuhrt werden [13] (Abb. 1). Es gilt nun die Daten der praklinischen Behandlung unter Berucksichtigung dieser Standards zu dokumentieren und eine Qualitatskontrolle vorzunehmen [12, 23, 32]. Anhand einer Fehleranalyse im eigenen Patientenkollektiv soll auf kritische Punkte der notarztlichen Versorgung von Unfallpatienten hingewiesen werden. Neben der immer wieder zu beobachtenden unzureichenden Versorgung von Traumapatienten, haufen sich in den letzten Jahren auch Falle in denen nicht indizierte invasive Masnahmen durchgefuhrt werden.

In IIIB and IIIC type open tibial fractures (according to Gustilo) the primary decision that has to be made regarding therapy is wether or not the limb can be salvaged. To standardize the criteria for amputation different salvage scores have been established in recent years. In this study the Hannover Fracture Scale (HFS), the Predictive Salvage Index (PSI), the Mangled Extremity Severity Score (MESS) and the NISSSA score were evaluated regarding their clinical relevance. When ROC Analysis was performed for all these scores in our patients the HFS revealed the highest sensivity (0.91), but low specifity (0.71). The highest specifity was noted for the MESS (0.97), which in parallel showed the lowest sensivity (0.59). In general it seems to be essential to make the right decision initially in order to avoid secondary amputation. All the scores mentioned here appear to be helpful in decision making. Salvaged limbs in IIIB and IIIC fractures presented a comparable good outcome, whereas salvaged IIIC injuries with a high score presented an outcome which was as bad as in secondary amputations. Secondary amputated patients required not only significant longer hospitalization but also resulted in poor outcome compared with the patients having received reconstruction or primary amputation.

Numerous epidemiological studies about multiple trauma patients do not include an analysis of patients under the age of 18. To study this, the data of 682 patients with multiple traumata, treated between 1981 and 1991 at Hannover Medical School, Germany, were retrospectively analyzed. The patients were divided into four age-related groups: preschool age (< 6 years), school age (< 13 years), teenagers (< 18 years) and adults (L 18 years). Analyzed were the cause of trauma, localization of injuries and the cause of death. Children were less often injured as passengers in cars, but more often injured as pedestrians and bicyclists than adults. However, children showed a significant higher mortality than adults, with threefold increased risk of death when they injured as passengers in car accidents. In all groups injuries to the head and the legs were most common. Children showed a lower incidence of trauma to the thorax, abdomen, hip and arms than the adult group. Nevertheless, trauma to the thorax, abdomen and head was associated with the highest risk of death in all groups. Spinal cord injuries, especially injuries to the neck, also showed a high risk of death. Children younger than 6 years had the most severe head injuries. Safety improvements for children in cars, helmet usage on bicycles and early training in traffic safety for children might decrease the lethality in this group of trauma patients.

Quality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance. Regarding the triage, for example, it was noted that 28% of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7% of patients two additional mistakes and in 4% of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment. Preclinical intubation and mechanical ventilation was not performed in 16.5% although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38% of patients suffering from severe thoracic trauma (AISThorax > or = 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17% of all documented patients. According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.

Non-unions in the proximity of the elbow are very rare and in most cases caused by mistakes in initial treatment. Reconstruction after pseudarthrosis of the elbow continues to pose a challenge for any surgeon. The aim of our study was to analyze the initial mistakes and to underline the most important aspects of reconstructive surgery. In a retrospective study over a defined period of 10 years (1/1985 to 12/1994) we were able to treat altogether 27 non-unions in the proximity of the elbow. These patients were transferred to our hospital at an average of 44 weeks after initial therapy elsewhere.The main symptoms were in 17 cases pain and in all other patients functional deficit. Reconstructive surgery was performed an average 54 weeks after the primary injury. In 24 out of 27 cases a re-osteosynthesis, in 12 an arthrolysis , in 7 a neurolysis and in 2 cases an arthroplasty was needed. The patient could return to work an average 18 weeks after the operation and 53 weeks after injury. The initial complaints were reduced in 24 of 27 cases, with a significant improvement in the ROM and functional outcome according to the Mayo Elbow Performance Index.

Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.

This study investigated the influence of an enteral diet supplemented with arginine, omega-3 fatty acids, and nucleotides (Impact, Sandoz Nutrition, Berne, Switzerland) on the incidence of systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) in patients after severe trauma. Thirty-two patients with an injury-severity score > 20 were included in this prospective, randomized, double-blind, controlled study. Primary endpoints were the incidence of SIRS and MOF. Secondary endpoints were parameters of acute phase and immune response as well as infection rate, mortality, and hospital stay. For statistical analysis 29 patients (test group n = 16, control n = 13) were eligible. In the test group, significantly fewer SIRS days per patient were found during 28 d. The difference was highly significant between d 8-14 (P < 0.001). MOF score was significantly lower in the test group on d 3 and d 8-11 (P < 0.05). Acute phase parameters showed lower C-reactive protein serum levels (significant on D day 4) and fibrinogen plasma levels (significant on d 12 and 14; P < 0.05). HLA-DR expression on monocytes showed significantly higher fluorescence activity on d 7. No significant difference was found for T-lymphocyte CD4/CD8 ratio, interleukin-2 receptor expression, infection rate, mortality (2/16 vs. 4/13), and hospital stay. The results of the study provide further support for beneficial effects of arginine, omega-3-fatty acids and nucleotide-supplemented enteral diet in critically ill patients.

The complex injury is characterized by a fracture and/or dislocation of the elbow in association with a serial injury of the upper extremity, or a severe soft tissue trauma , or a prolonged ischemia caused by vascular injury or compartment syndrom. They are defined as complex injuries because their treatment differs from that of a simple fracture implying that standardized concepts usually cannot be employed. The results of primary treatement show a high rate of complications. They are accompanied by functional deficits including pseudarthrosis and ankylosis. As a consequence, ulnar neuropathy may occur. Inadequate treatment leads to delayed rehabilitation and several secondary operations. The main goal points at the reconstruction of the elbow joint to restore function. Therefore, the logistical pathway of individual therapy is the key for success. The operation has to include fracture stabilisation of all injuries of the upper extremity. Only stable osteosynthesis makes early mobilisation possible. Transfixation of the elbow joint should be reserved for exceptional cases. The principals of AO have proven to be practical both for the distal humerus and the proximal forearm. Successful reconstruction of the elbow joint often demands extended approaches. ORIF of the proximal ulna can be achieved by indirect reposition techniques. Dynamic stabilisation should be established by conservation of the radial head and coronoid process. For treatment of soft tissue injury it is necessary to undertake local reconstructive measures. Operative treatment is widely indicated for forearm compartment syndrom. Diagnosis and therapy of possible accompanying vascular injury should be made early to avoid prolonged ischemia. Operative treatement of nerve injury is only indicated in case of sharp dissection of the nerve. Otherwise the reconstruction should be performed, but not earlier than three months. Rehabilitation outcome depends on primary therapy. Sufficient functional results are only achieved after early mobilisation and intensive physiotherapy. If necessary, arthrolysis is planned early and combined with removal of implants at 6 months post injury.

A total of 208 multiple trauma patients with head injury (HI) were investigated who had been treated in the period from 1990 to 1995. The average age was 35.2 ± 17.7 years; the injury severity according to ISS was 30.2 ± 8.6 points; 20.5 % died as a result of the HI; the mortality of all patients was 26.5 %. The Glasgow Coma Scale (GCS) was determined at an average of 22 min after trauma (8.0 ± 4.3 points) at the scene of accident. The patients were classified according to GCS into minor HI (group 1: 14–15 points), moderate HI (group 2: 9–13 points) and severe HI (group 3: 3–8 points). Patient outcome was assessed by the Glasgow Outcome Scale (GOS) and was classified as good (GOS 4 and 5) and poor (GOS 1, 2 and 3) outcome. At the latest, 2 h after trauma, a CT scan of the head (CCT) was done. The HI groups are compared regarding frequency of types of injury. In all HI groups the fractures of the bony face occurred at the same frequency (36.0–38.9 %). The frequency of calotte fractures (Kal-Fx) increased from group 1 (8.0 %) to 2 (19.2 %) and 3 (25.6 %); fractures of the skull base significantly differed between group 1 (16.0 %), 2 (7.8 %) and 3 (33.4 %). Epidural hemorrhage (EDB) appeared only in group 2 (7.8 %) and 3 (6.7); subdural hemorrhage was found in group 1 (2.7 %), 2 (7.8 %) and 3 (10.0 %). Subarachnoid hemorrhage (SAB) was significantly more frequently seen, dependent on HI severity, in group 3 (26.7 %) compared to group 2 (11.7 %) and 1 (8.0 %). Intracerebral contusion (ICK) significantly increased from group 1 (12.0 %) to 2 (27.3) and 3 (45.6 %). Brain swelling (BS) also significantly increased from group 1 (8.0 %) to 2 (19.5 %) and 3 (49.0 %) and lesions of ventricles (VL) from group 1 (2.7 %) to 2 (11.7 %) and 3 (20.0 %). Midline shift (13.4 %) and signs of herniation (4.5 %) only occurred in group 3. The analysis of correlation/regression and receiver operating characteristics was able to predict 79 % of patients' outcome accurately using GCS (r 0.54; P < 0.0001) alone, using CCT (r 0.65; P < 0.0001) 87 % were correctly predicted with significant variables Cal-Fx, EDB, SAB and BS. CCT with GCS (r 0.74; P < 0.0001) were able to predict 88 % accurately with significant variables Cal-Fx, EDB, BS and GCS. The combination of CCT with GCS, age and ISS (r 0.78; P < 0.0001) was able to predict only 87 % correctly, although the r value was the highest; significant variables were Kal-Fx, EDB, BS, VL, GCS, age and ISS.

Background: Multiple organ failure is regarded to be the major complication of trauma victims treated in the intensive care unit. Long-term rehabilitation results of this special group of patients have not been analyzed so far. Methods: Fifty patients with multiple injuries and multiple organ failure (Injury Severity Score < 36.8) were followed-up 4.9 ± 0.3 years after the trauma. To show any organotopic sequelae, laboratory tests for the function of lungs, liver, kidney, and the hematologic system were performed. Additionally their functional (locomotion and neurologic system) and occupational rehabilitation results were investigated. Results: The laboratory tests showed entirely normal results. The only pathologic values could be found in the lung function tests. Nineteen percent of the patients showed nonphysiologic results in either spirometry, body plethysmography, or diffusion capacity of carbon monoxide. In more than 25% of the patients, permanently decreased range of motion (limitation of more than 30% of the entire range of motion) of the elbow, hip, knee, or ankle joint were found. In 40% of the patients, permanent motoric nerve lesions were identified; in 50% of the patients, permanent sensoric nerve lesions could be verified. The return to work rate was 60%. Conclusions: Patients with multiple injuries, who survived multiple organ failure during their long-term intensive care treatment, show an excellent functional and occupational rehabilitation result. They show no major sequelae in their organ function even years after the trauma. Although often these patients suffer from permanent central or peripheral paralysis and decreased range of motion, this finding does not correlate with the patients' ability to return to work.

Fractures of the elbow joint are quite rare compared with the total incidence of injuries to the extremities. However, elbow fractures often result in significant disability. Therefore in a retrospective study, we have evaluated criteria that are of prognostic value for late functional outcome. Sixty-four (10.3%) of 622 patients with closed elbow fractures and 107 (89%) of 119 patients with open elbow fractures underwent a physical examination. The mean follow-up time was 8.2 years. The functional outcome was recorded by a modified score (0-max. 15) according to Morrey. Epidemiological data from both groups revealed a greater severity and higher degree of injury in open fractures than in closed fractures. In contrast, both groups presented a comparably good functional result. The most significant factor for poor outcome (score < 5) was identified as nerve lesions. Among all nerve lesions in open fractures, 45% resulted in a functional score of < 5; in 42% of closed fractures combined with a nerve lesion a similarly poor result was also noted. A second major factor appeared to be the method of primary therapy. An external joint transfixation resulted in a score of < 5 in 32% of patients that were treated primarily by transfixation. In cases initially treated with open reduction and internal fixation, only 18.5% of open fractures and 3.1% of closed fractures presented a similar low score. According to our results the late functional outcome of elbow fractures depends less on the type of fracture than on the presence of a nerve lesion and the method of primary treatment, which should facilitate early mobilization.

We report on the case of a pneumonia caused by Bacillus cereus in a patient who sustained severe thoracic trauma, fractures of ribs 3-12, left lung contusion and haematopneumothorax. Bronchoscopic alveolar lavage (BAL) performed on ICU day four helped identifying the underlying cause of pneumonia. Inspite of early diagnosis and antibiotic treatment with clindamycin, cefotaxim and tobramycin, which rapidly eliminated the bacteria from the patient's lungs, the patient eventually died from the severe underlying injuries. However, this case emphasises that early performed BAL and rapid microbiological staining techniques can help diagnose pneumonia in critically ill patients. We also review the literature on pulmonary infections caused by Bacillus cereus.

The use of non-treated cryopreserved bone allografts has been criticized following the publication of new cases of HIV and hepatitis-C infection caused by such grafts. However, the "new" cases of HIV infection arose in 1984/1985. when HIV testing was not possible. A critical analysis of the German bone bank procedures shows that the official guidelines are not adequate. Furthermore, new sterilization techniques are propagated for clinical use. This leads to a false feeling of security, and does not help to solve the problem of virus transmission by way of bone allografts. It is therefore essential that new guidelines for bone bank management be developed as a matter of urgency, with due consideration for everything known about this problem to date. Our current bone bank procedure is presented and the various points in the official guidelines that need updating are discussed, including the necessity for 6-month HIV and hepatitis testing modified donor screening, and special guidelines for multiple organ donors.

Early enteral nutrition is widely accepted for its support of organ structure and function ("gut injury hypothesis") and reduction of infectious complications and hypermetabolism in critically ill postoperative or postinjury patients. Nineteen severely injured patients (Injury Severity Score 40.3 +/- 11.6) were studied for the feasibility of early enteral nutrition via a duodenal feeding tube. Despite maxillary fractures, rhinoliquorrhea and blunt abdominal trauma the enteral feeding was mostly started immediately after trauma. Intermittent diarrhea or constipation resolved after reduction of the feeding rate within 1 or 2 days. Total enteral nutrition could not be realized in all cases; a central venous line was always additionally necessary. However, the goal was not complete enteral nutrition but a continuous enteral supply to maintain the integrity of the gut. The study has shown that early enteral nutrition via a duodenal feeding tube is also feasible in severely injured patients. The expenditure to overcome the technical and organizational problems seems to be justified. Enterally fed patients may have a better outcome that those in whom only parenteral is employed.

We reporting four cases of HIV infection caused by bone allografts from one donor. All transplantations were performed between November 1984 and January 1985. In all, 12 recipients had bone allografts from the HIV-infected donor, 7 of whom are now HIV-negative and 4, HIV-positive. One of the patients died a natural death in her 10th decade. The donor was not been tested before the grafts were harvested, as HIV-antibody detection was not possible at the time (October 1984); no HIV-antibody kits had yet been developed. Subsequent testing of the asservated serum for HIV antibodies gave a positive result. The chronological course of the case is described and the case is discussed in detail.

In this study a group of 104 multiply injured patients (mean ISS = 34) was examined for physical status and social reintegration. Essentially it was noted that 76 per cent of all patients were able to return back to work, although this appears to be age dependent. Open fractures of the leg seem to be the dominating prognostic factor for reintegration resulting in a disability rate of between 20 and 50 per cent. Disability of more than 80 per cent was only due to major head injury. Apparently reintegration is linked to the pattern of injury and is less related to the overall injury severity. We conclude that trauma care is economically cost effective but also needs further standardization and subsequent outcome analysis.

The prognostic value of a dynamic liver-function test, based on the hepatic conversion of lidocaine to monoethylglycinexylidide (MEGX), in predicting multiple organ failure (MOF) was prospectively investigated in 28 critically ill patients after multiple trauma. The MEGX test and conventional static liver tests (bilirubin, aspartate aminotransferase, glutamate dehydrogenase, and factor V) were performed on days 1, 3, 5, and 7 after trauma. Patients were classified by a modified MOF score into a group without (n = 18) and a group with the MOF syndrome (n = 10). One patient who developed MOF on the basis of a bacterial septicemia was excluded from the general evaluation. No significant differences were observed in the MEGX values of the two groups on day 1. All patients who subsequently developed MOF, however, displayed a sharp decrease in their MEGX values between days 1 and 3. Analysis of the data using receiver operating characteristic (ROC) curves revealed that the results of the MEGX test on day 3 provided the greatest discriminating power between patients with and without subsequent MOF. A cut-off MEGX value of 30 micrograms/L on day 3 was associated with a prognostic sensitivity of 89% and a prognostic specificity of 94%.

Hypothermia is a frequent event in trauma patients and appears to be related to post-traumatic organ dysfunction, although in elective surgery hypothermia is known to prevent ischaemia reperfusion injury. Retrospectively we have analysed data from 641 trauma patients treated in our institution between 1988 and 1993. On admission to hospital the core temperature (cT) was > 34 degrees] C in the majority (64%) of patients, followed by 23.6% with a cT < 34 degrees C and 12.4% with a cT < 32 degrees C. After 24 h 99% were warmed up to < 34 degrees C. Mortality was twice as high (53%) in patients with a cT < 32 degrees C compared with patients with a cT < 34 degrees C (28%). Analysis of correlations revealed that hypothermia was associated with a longer rescue time, more severe injuries of the limbs and central hypoxia. It also showed that hypothermia is not an independent prognostic factor for post-traumatic mortality. The different effect of hypothermia in trauma compared with elective surgery may be due to a lack of energy-storing phosphates like adenosine triphosphate (ATP). Further current investigations will identify the role of ATP in trauma-related hypothermia.

We investigated whether primary (24 hours) intramedullary stabilization of femoral shaft fractures in multiple trauma patients with severe thoracic injury might be associated with an increased incidence of adult respiratory distress syndrome (ARDS). A total of 766 patients with multiple trauma admitted to Hannover Medical School between January 1, 1982, and December 31, 1991, were investigated retrospectively. Of these, 106 patients met the inclusion criteria: Injury Severity Score18, femoral midshaft fracture treated by intramedullary nailing, primary admission or referral within 8 hours after injury, and no death from head injury or hemorrhagic shock. Two groups were differentiated according to the presence or absence of chest trauma (severe chest trauma = AIS thoraxor =, group T; no severe chest trauma = AIS thorax2, group N). Selection of subgroups according to the time of femur stabilization was group I24 hours after trauma, group II24 hours after trauma. Injury Severity Scores in the four groups were TI: 29.4 (n = 24); TII 31.4 (n = 26); NI 20.1 (n = 33); NII 25.4 (n = 23). In patients without thoracic trauma the ICU time (NI: 7.3 days; NII: 18.0 days) and intubation time (NI: 5.5 days; NII: 11.0 days) were lower in the patients treated primarily (p0.05). In patients with severe chest trauma there was a higher incidence of posttraumatic ARDS (33% versus 7.7%) and mortality (21% versus 4%) when early intramedullary femoral nailing was done. In the absence of severe chest trauma primary intramedullary femoral nailing is beneficial.(ABSTRACT TRUNCATED AT 250 WORDS)

Limb injuries are often underestimated in the diagnostic procedures initiated in the resuscitation room. Missed diagnosis is therefore a frequent consequence in this issue. A systematic analysis of evidence-based procedures was therefore investigated in this paper.Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).Following admission of a multiple trauma patient vital functions have to be established in first priority. After stabilization a systematic clinical investigation and consecutive specific radiological procedures should rule out extremity injuries. These are the only evidence-based criteria leading to a complete detection of all limb injuries. All other aspects are only based on clinical experience or the opinion of expert committees.The quality of shock room management is mostly dependent on the experience of the " trauma team" (and especially of the trauma leader). Guidelines and specific trauma algorithms can provide a helpful instrument in this issue.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCSor = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

Previous scoring systems for measurement of the quality of outcome are based on scores regarding injuries to individual body regions. Known scores which describe several organ regions are of no importance for trauma patients. Therefore a new rehabilitation outcome evaluation score was developed at our hospital.Based on a prospective reinvestigation, a score system was developed that allows a quantitative appraisal of the subjective and objective outcome. A complete physical examination was performed, including ROM, neurologic examination and strength analysis. Part I (113 questions) is to be filled out by the patient; part II (191 questions) focusses on different body regions, physical examination and functional scoring. Included are the MFA, FIM, GCO and Frankel score. A final score (HASPOC) was developed to give a quantitative result of the outcome.The new score has a range from 5 to 411 points. One hundred and fifty patients were re-examined. The mean follow-up time was 2.2 +/- 0.1 years. The SF 12 indicated an outcome more than satisfactory in 63% of cases. The MFA demonstrated moderate or severe restrictions in 41%, in the case of injuries of the lower extremity in 52% of patients. The HASPOC indicated a mean of 44.5 points.This paper describes the development, structure, and the quantitative outcome of rehabilitation in polytrauma patients. This standardized rehabilitation instrument deals with a very heterogeneous patient population and shows the rehabilitation deficits accurately. Implemented recognized evaluations allow comparison of these results with those of other scoring systems.

The ventilation mode clearly influences the course of patients with multiple trauma on the ICU. Ventilation according the "open lung" approach rapidly opens up atelectatic lung regions. Generation of an adequate intrinsic PEEP enables to keep the lung open. We studied the consequences of the "open lung" approach on the lung function and monitored its side effects on patients with multiple trauma.18 consecutive patients with multiple trauma and additional thoracic trauma were routinely ventilated according the "open lung" approach between May and November 1999. We were mainly interested in data of lung mechanics, oxygenation and ventilation. Side effects on other organ systems and consequence for the infection rate were monitored.Ventilation according the "open lung" approach enables early sufficient oxygenation and ventilation of patients with severe multiple trauma and accompanying thoracic trauma. The ventilation mode helps to prevent baro-, volu- and atelectrauma and thus fulfils the requirements for a present-day ventilation mode. An immediate complete healing of the lung damages was not found. Nevertheless, as a trend the length of ventilation support seems short. Even extensive osteosynthesis at multiple fractures was possible without delay. Side effects of the high opening pressure on the lung or other organs as well as sequels of the high intrinsic PEEP on liver, kidney or intestine were not found. The infection rate was low, therapeutic doses of antibiotics were necessary only in less than half of the ICU-stay.Ventilation according the "open lung" approach is a very effective and safe way to ventilate patients after severe multiple trauma with accompanying thoracic trauma.

Primary stabilization of major fractures in polytrauma patients is known to represent an important principle of treatment and has been shown to reduce the incidence of posttraumatic complications and of organ failure. However, in critically injured patients it has been discussed that extensive primary definitive treatment may also cause adverse effects due to its systemic burden by blood loss, loss of temperature etc. Patients who deteriorated unexpectedly following primary surgery have been named "borderline patients". In these patients it appears necessary to limit the amount of operative procedures, e. g. by performing temporary fixation of major fractures primarily. The threshold beyond which surgical procedures may cause more harm than good has not been well defined. This holds true especially for the duration of primary surgery. We investigated the clinical outcome in a large number of prospectively documented multiple trauma patients with respect of the duration of primary fracture stabilization. If a primary surgical procedure exceeded 6 hours in multiple trauma patients with an ISS of 25 points, patients demonstrated a significantly elevated ventilation time, an increased mortality, and a higher incidence of death from MOF in comparison with patients that were injured comparably, but were submitted to shorter primary operative procedures.

In this prospective, randomized, double-blind controlled clinical study, 29 patients after severe trauma (ISS about 40) were randomized to receive either IMPACT (Test) or an isonitrogenous isocaloric diet (Control). The primary study endopoints were the incidence of SIRS and MOF (definitions according to Bone, Goris and Sauaia). Test-fed patients developed significantly less SIRS between days 1 and 28 (8 vs 13.3, P0.05) and especially between days 8 and 14 (3 vs 6.2, P0.001). In the control group the Goris score was significantly worse (P0.05) on days 3, 4, 6, 7, 10, 11, 16, 17 and the Sauaia score on days 8, 9, 10, 11 (P0.05, P0.01). According to the results, an arginine, omega-3-fatty acids and nucleotide-enriched diet during early enteral feeding leads to reduction of SIRS and MOF scores after severe multiple injury.

Numerous epidemiological studies about multiple trauma patients do not include an analysis of patients under the age of 18. To study this, the data of 682 patients with multiple traumata, treated between 1981 and 1991 at Hannover Medical School, Germany, were retrospectively analyzed. The patients were divided into four age-related groups: preschool age (6 years), school age (13 years), teenagers (18 years) and adults (or = 18 years). Analyzed were the cause of trauma, localization of injuries and the cause of death. Children were less often injured as passengers in cars, but more often injured as pedestrians and bicyclists than adults. However, children showed a significant higher mortality than adults, with threefold increased risk of death when they injured as passengers in car accidents. In all groups injuries to the head and the legs were most common. Children showed a lower incidence of trauma to the thorax, abdomen, hip and arms than the adult group. Nevertheless, trauma to the thorax, abdomen and head was associated with the highest risk of death in all groups. Spinal cord injuries, especially injuries to the neck, also showed a high risk of death. Children younger than 6 years had the most severe head injuries. Safety improvements for children in cars, helmet usage on bicycles and early training in traffic safety for children might decrease the lethality in this group of trauma patients.

In IIIB and IIIC type open tibial fractures (according to Gustilo) the primary decision that has to be made regarding therapy is wether or not the limb can be salvaged. To standardize the criteria for amputation different salvage scores have been established in recent years. In this study the Hannover Fracture Scale (HFS), the Predictive Salvage Index (PSI), the Mangled Extremity Severity Score (MESS) and the NISSSA score were evaluated regarding their clinical relevance. When ROC Analysis was performed for all these scores in our patients the HFS revealed the highest sensitivity (0.91), but low specificity (0.71). The highest specificity was noted for the MESS (0.97), which in parallel showed the lowest sensitivity (0.59). In general it seems to be essential to make the right decision initially in order to avoid secondary amputation. All the scores mentioned here appear to be helpful in decision making. Salvaged limbs in IIIB and IIIC fractures presented a comparable good outcome, whereas salvaged IIIC injuries with a high score presented an outcome which was as bad as in secondary amputations. Secondary amputated patients required not only significant longer hospitalization but also resulted in poor outcome compared with the patients having received reconstruction or primary amputation.

Measuring intracompartmental pressure is a well accepted method in evaluating a compartment syndrome, which may occur after limb ischemia followed by reperfusion. As a compartment syndrome is paralleled by a decreased microcirculation it should be possible to evaluate a compartment syndrome also by measuring intramuscular pO2.Anesthetized rats (spontaneous breathing via tracheotomy) were subjected to infrarenal ligation of the aorta. A pressure catheter was placed subfascial in the crural muscle group of one hind limb, whereas the contralateral side was prepared with a pO2 catheter. Besides a sham operated group, three experimental groups were subjected to either 2 hrs, 4 hrs or 6 hrs of ischemia followed by 4 hrs of reperfusion. One further group was also subjected to 4 hrs of ischemia and 4 hrs of reperfusion but received a fasciotomy at the time of reperfusion. Compartment pressure and intramuscular pO2 were recorded every 15 min. For histological examination muscle specimen were obtained after each experiment.Two hours of ischemia followed by 4 hrs of reperfusion did not result in any morphological changes and also not in any significant change in compartment pressure during both phases, whereas pO2 significantly dropped during ischemia (from 19.0 mmHg to 3.0-5.0 mmHg) and returned to normal during reperfusion. In prolonged ischemia (4hrs) morphologically a severe interstitial edema was evident, compartment pressure increased during reperfusion (from 2.0 mmHg to 8.8 mmHg) and pO2 dropped during ischemia down to 3.0 mmHg and did not return to normal during reperfusion (10.5 mmHg versus 19.0 mmHg normal). In case of 6 hrs ischemia, partial necrosis and only little interstitial edema were found morphologically. There was no significant change in compartment pressure throughout the study; and pO2 remained significantly decreased even during reperfusion (2.0-3.0 mmHg).Normal compartment pressure could mislead to false negative interpretation of compartment syndrome, whereas pO2 clearly identifies the microcirculatory state of the muscle. Thus, intramuscular pO2 monitoring presents a valuable method in evaluating compartment syndrome, especially in case of suspect clinical signs but normal compartment pressure.