key: cord-0006036-oswgjaxz
authors: nan
title: Abstracts: 11(th) European Congress of Trauma and Emergency Surgery May 15–18, 2010 Brussels, Belgium
date: 2010
journal: Eur J Trauma Emerg Surg
DOI: 10.1007/s00068-010-8888-z
sha: faea9eba63286f88622171966f3187fd677d65a8
doc_id: 6036
cord_uid: oswgjaxz

nan

Introduction: Frequently fractures of modern sport disciplines are fractures of the clavicle. Most of them are uncomplicated and still treated without operation. Therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (ESIN). Nevertheless this method becomes more and more popular, especially for young and active people. Intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients. Material and Methods: This study is a retrospective analysis of 33 patients whose fractures of the clavicle were treated by intramedullary nailing. Crucial for the decision for operation was the individual request of the patient after information of the relative indication. Included were 26 patients with fractures of the middle third, 4 fractures of the lateral third and 3 fractures with concomitant shoulder injuries from 2004 to 2008 . The duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. The functional outcome was measured by the CONSTANT-Score. The anatomical reduction was proved by measuring the difference of the length of both clavicles (3 -48 month after operation). Results: The average duration for the middle third was 66 min (22-163), for the lateral third 73 (59-100) minutes and for fractures with concomitant injuries 65 min . The mean radioactive surface dose was 1,19 cGy/cm 2 . Four complications (12%) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. One patient had developed a painful pseudobursa due to lateral penetration of the nail. Additional there were two prematurely nail extractions because of medial irritation of the soft tissue. Altogether we documented complications in 18% of the operations. Overall an open reduction was necessary in 37%. After healing there has been no significant shortening of the fractured clavicle in comparison of both sides. The CONSTANT-Score showed good postoperative results (average: 96, median: 100, lowest 75/100). Conclusion: ESIN with titan nails is an alternative method of treatment with good results. Nevertheless we documented complications in 18%. In the literature complication rates from 4 -31% has been described. The complication rate of ESIN seems to be comparable to the conservative treatment. In our opinion the relevant intraoperative radioactive dose is an often underestimated factor. The operation time is often longer than thought before starting and often an open reduction is necessary. Because of these reasons the conservative therapy should still be the standard. ESIN can be an alternative especially for young athletic ambitious patients after a detailed information about the risks. Disclosure: No significant relationships. Introduction: The optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. Recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. Therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures. However, no treatment-consensus exists at this moment. The goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of 24 weeks follow-up. Material and Methods: In a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. After a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. Outcome analysis included standard clinical follow-up, the Constant shoulder score, the Disability of the Arm, Shoulder and Hand (DASH) score and complication rate at 6 and 24 weeks after the injury. Results: Between January 2008 and October 2009 a total of 93 patients were included: 41 patients were treated operatively (90.2% men, mean age 41.5 years) and 52 patients were treated nonoperatively (82.7% men, mean age 40.9 years). Constant and DASH scores were significantly higher in the operative group compared with the nonoperative group at 6 weeks (92 vs 78 and 13.1 vs 26.5). There was no significant difference at 24 weeks (97 vs 95 and 5.6 vs 6.4). In both groups two patients developed pseudartrosis, all four required surgery. In the nonoperative group symptomatic malunion was more frequent: twelve patients at 24 weeks (23.0%) versus none in the operative group. Other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consolidation in four patients (9.8%), two broken plates due to the earlier mentioned pseudartrosis (4.9%), one early outbreak of the plate (2.4%) and one woundinfection (2.4%). Furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. At 24 weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group (56% vs 46%). Conclusion: Operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at 6 weeks after injury and in a higher satisfaction rate at 24 weeks. This study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. Furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery. Introduction: The unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. Despite a relatively high complication rate (5-30%), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (ORIF) has been the gold standard for many years. This open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. Our hypothesis is that a closed method with indirect reduction might reduce some of the complications. The goal of our study was to test the practicability of the MIPOtechnique in clavicle fractures in unstable shoulder girdles. Material and Methods: Between 2001 and 2009 we included, out of internally fixed 130 shaft fractures in total (66x plate, 64x elastic nail), 18 patients with either a floating shoulder (n = 8) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = 10), in this study. Operative technique: A locking compression plate (LCP) 3.5 with 10-12 holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. Using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. Free unloaded ROM was allowed immediately after the operation with full loading 6-12 weeks later. Follow-up examination was performed 1 to 4 years later with clinical (DASH-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination.

Results: 17/18 fractures healed without complications. Clinical and radiological length measurement showed no significant differences to the contralateral side (range: +5 mm to -5 mm). In all patients a very good functional result was achieved with an average DASH score of 4.2 (0-18). One implant failure occured two years after the initial trauma in a road workman. At reoperation only a partial consolidation of the original fracture was observed. Restabilization and bone grafting led to an uneventful healing. Conclusion: The MIPO technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. The advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. However it is technically demanding mainly due to the small size of the fractured bone. Therefore in our opinion it requires a surgeon experienced in the MIPO technique of treating fractures of larger bones as tibia and femur. Introduction: There are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. We retrospectively investigated if this was also the case in our institution in removal of LCP plate of the clavicle and if this was incidential or becoming a trend.

Material and Methods: From October 2004 till October 2009, we have removed 30 locking compression plates after claviclefracture stabilization. All of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer's recommendations. A total of 171 screws where removed. They consisted of fifty-one 3.5 mm self tapping cortical screws and hundred and twenty 3.5 mm self tapping locking screws.

Results: From the 30 locking compression plates that where removed after claviclefracture stabilization, in eleven patients (37%) a problem with removal of the plate arised. This was caused by a total of 17 self tapping locking screws. In all 17 cases jamming of the screwheads in the plate was found to be the reason. There was ''cold welding'' between the threaded head of the locking screw and the locking plate. For removal four different strategies were used. In two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. Five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. In eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit 3.5 was used to remove the screws. Two times a combination of cutting the plate and helicopter tecnique was used succesfull. In comparison the fifty-one 3.5 mm selftapping cortical screws were removed without any problem.

Conclusion: The locking compression plate is a usefull attribute in fracture treatment of the clavicle. However in one-third of the patients removal of locking compression plates and especially the 3.5 mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. We find this an unacceptably high percentage. number of mri studies it was possible to describe the intraarticular disc. Until now there was no in vivo verifying of one of these MRI protocols. The introduction of a high resolution MRI protocol using a superficial coil (3D WATS and T2FFE) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. The aim of this study is to ascertain the significance of the mentioned MRI protocol and the applicability in the clinical practice in a limited patients cohort with instability of the AC-Joint. The MRI findings are compared to the arthroscopic findings. Material and Methods: In a one year period 16 patients with chronic acromioclavicular-joint dislocation Rockwood Type II and III were seen in the outpatient clinic The major symptom was pain followed by loss of power. Inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over 18 and the indication for arthroscopic revision of the ac-joint. The radiological examiner was blinded to the clinical findings. The MRI-scan was performed on both sides. At the time of the operation the surgeon was blinded to the MRI reading. The surgical procedure was performed by arthroscopy in beach chair position. The surgical findings have been documented by video and also in a descriptive manner. The examination was performed on a 1.0 T MRI-system . Results: Throughout the radiological examination, in 9/13 patients a rupture of the intra-articular disc was suspected. In 3/13 cases degenerative alterations were described. In one case the reading was negative (e.g. ,,no rupture of the intra-articular disc''). During the surgical examination 12/13 patients showed ruptures of the intraarticular disc. In one patient no signs of macroscopical disintegration of the disc could be detected. In the case with negative radiologiocal reading, the disc was verified as intact during surgery. In all other cases the disc was disintegrated, including those with the radiological reading ''alterations without clear signs of rupture''. The significance of the described MRI protocol was 75%. 

Introduction: Cancer of the colon is a common disease. The choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. However, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. Previous studies have shown a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. The aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery. Material and Methods: All patients diagnosed with colon cancer during 2000-06 in the Linkoping area were identified through the Swedish colorectal cancer register (n = 438). A retrospective analysis of patients with colonic obstruction (n = 88) was done using various criteria from the medical records. Exclusion criteria were acute surgery due to reason other than obstruction (n = 57), non-surgical treatment (n = 44), other diagnosis (n = 13), or missing medical records (n = 11 Conclusion: Acute surgery due to colonic obstruction of colon cancer is common. Tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. However, when stratified for different TNM-stages, the worse outcome in 2-year survival for patients with acute obstructing colonic cancer still remains. The explanation for this difference is to be elucidated in further studies. Disclosure: No significant relationships.

Introduction: Acute colonic obstruction due to malignancies is often a surgical emergency. Hartmann's procedures or one stageresection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. However these procedures are associated with a significant morbidity and mortality rate. Self expanding metallic stents (SEMS) have shown their efficiency as palliative treatment in colonic cancer. Colonic stenting has been advocated as a''bridge'' towards surgical procedures in potentially resectable diseases. The aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure.

S. Tamulis, E. V. Gaidamonis 1 1 Surgical, Vilnius Unuversity Emergency Care Hospital, Vilnius, Lithuania

Introduction: To evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions. Material and Methods: Medical records for the patients treated with small bowel obstruction due to adhesions from 1995 to 2005 were reviewed. The patient's age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed. Results: There were 1594 patients admitted to the Vilnius University Emergency Hospital during 10 years period. Appendectomy as a previous operation was recorded in 40% of cases. Surgery was required in 457 of the cases (28.7%). Strangulated small bowel was found in 197 patients (43,1%). In 404 cases (88,4%) the surgical procedure was limited to adhesiolysis, whereas in 53 cases (11,6%) an intestinal resection was performed. Enterodecompresion tube was used in 156 cases (34,1%). The operative mortality was 4,8% (22 cases). Mortality after the treatment due to strangulation was 3,9% (18 cases).

Conclusion: There were 29% of surgicaly treated patients. Main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. The criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. Mortality after the strangulated small bowel resection was higher. Operative enterodekompresios reduces the risc of the postoperative complications and mortality. Disclosure: No significant relationships.

Introduction: Hartmann's procedure (HP) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis. [1] [2] [3] Nevertheless it is associated with high morbidityand mortality 1 . The aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (PA) with or without diverting loop ileostomy versus HP in case of diverticular peritonitis. 2,3. Material and Methods: We retrospectively reviewed our prospectively collected database from 1/95 to 12/08 of patients who were operated in the emergency department of Bellvitge University Hospital. Only patients operated on generalized diverticular peritonitis (Hinchey III-IV) were included. Data on patients' demographics, ASA classification, Hinchey score, Peritonitis Severity Score (PSS), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied.

Results: A total of 87 patients [median age 66 (34-94) years], female 39.1% were included. Sixty (69%) had undergone HP and 27 (31%) PA. Only in 5 patients (5.7%) a diverting ileostomy was performed.

Overall post-operative morbidity was 74.7%, most frequent complications were wound infection 33.3%, respiratory complications 20.7% and sepsis 17.2%. Overall mortality was 33.3% (29 pt). These patients had a mean PSS of 11.1 while the survival group 8.6. There was an overall reintervention rate of 17.2%, after PA 11.1% and after HP 20.0%. Significant differences were found in the HP versus PA group in ASA score (ASA I-II: 20% v 81%, ASA III-IV: 80% v 18%) and the median PSS (11 versus 8) . 62% (21/34 pt) with PSS £ 8 underwent PA, but none (0/31) with PSS ‡ 11. The post-operative morbidity was significantly higher for HP (86.2%) compared to PA (48.1%). Focusing on hospital stay there was a significant difference between PA (mean 15.1 days) versus HP (mean 27.9 days). In the stratified analysis considering patients with Hinchey III peritonitis we found a mortality of 45.7% (21/46 pt) in the HP group versus 7.7% (2/26 pt) of the PA group. The mortality rate stratified for ASA and surgical procedure shows no difference in ASA I-II, but in ASA III-IV a lower postoperative mortality for HP (20.2%) versus PA (40.0%). Including only patients with PSS less than 11 (56 patients) there is a significantly lower morbidity in PA (80.1%) versus HP (89.7%). Conclusion: Our data show that PA can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with ASA I-II, Hinchey III peritonitis grade or PSS less than 11 respectively to HP. These findings are supported by a shorter hospital stay in favor to PA.

Y. Arlettaz 1 1 Orthopaedics and Trauma, CHCVs Hô pital du Valais, Sion, Switzerland

Introduction: One of the most demanding steps of intramedullary nailing is the distal locking. Most of young surgeon are ''affraid'' to treat a long bone fracture by a nail because of the distal locking. The aim of this study is to evaluate a new frendly radiation free targeting device on cadavers.

Material and Methods: The study was conducted on fixed cadavers. 25 femurs were available. The method consists of the following steps: determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (Sirus nailÒ 12X400 (Zimmer Inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. For the second or even third screw, the targeting device needs a little adjustment.

Results: On the 25 distal locking procedures (50 screws), we observed only one failure due to the breakage of the prototype. This translates as a 98% success rate for two screws with a mean time of 8.2 min. Two surgeons conduct this study. Not only the inventor but also a inexperimented surgeon tested the new device with the same succes.

Conclusion: This new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free. It can be used in any hospital, by any surgeon. The procedure is easy to learn and reproducible. It could be adapted to any nail system and does not need external power supply. Introduction: Anterior knee pain is one of the most frequent complication of tibial nailing. Its aetiology remains unclear, potentially being a multifactorial event. The aim of this prospective study was to evaluate if anterior knee pain has any negative influence on: bone healing(the hypothesis is if the patient has anterior knee pain he or she will not put weight on the affected leg and this will not stimulate the bone healing), ability to return to work and quality of live. Material and Methods: 3 European level 1 trauma center was involved in this study. Methods: between januari 2003 and December 2004, 102 patients with a tibia fracture was admitted to the trauma departments We used a standard T2 tibia nail(Stryker) with the possibility of proximal and distal fixation with 3 screws The approach was trans or parapatellar. Results: At 4-6 weeks, 4 months, 12 months follow-up we had 11, 13, 14 patients with anterior knee painThe VAS decreased from 3,1 to 2,3, bone healing was 100% and for 70% of patients it was possible to do their previous full time job after 12 months. The quality of life (walking up and down stairs normally without any help, putting on shoes and socks, sitting/standing from a chair, total weight bearing,) was improving. Conclusion: We conclude that anterior knee pain in this study is mild, that the two different method of patellar tendon approach(trans or paratendinous approach) have no relevance and it does not have a negative influence on bone healing, ability to return to work and the quality of live.

Introduction: The aim of this study was to see if there is any difference between manual traction and fracture 

was applied in one step. Twenty-seven femurs and thirthy-three tibias were treated. The mean distraction rate was 1.6 mm (range 0.8-1.8 mm) for the femur and 1.3 mm (range 1.25-1.3 mm) for the tibia. The necessary pressure to advance the distraction in the tibia was average of 27 Bar (range 20 -42 Bar), to distract the femur, 46 Bar (range 28 -82 Bar). Results: Bone healing index for tibia 1.1 and femur 0.7 months/cm distraction. Implant failure five cases; Infections three cases. Nonunion of the distraction site or docking site four cases. We did not encounter major stiffness of the adjacent joints. Conclusion: Although the presented technique is a semi-closed distraction procedure, we find this system appealing because of it simplicity in use, low cost and the ability to immediate weight bearing. Introduction: Bone transport for treatment of segmental bone defects as a salvage procedure is related to a high complication rate. Posttraumatic soft tissue problems and callus insufficiency are to be dealed with especially in posttraumatic conditions. The Ilizarov Ringfixator allows a stable external bone fixation enabling full weight bearing. In bone defect reconstruction bone transport is commonly used. A major problem is the skin cutting wires for bone fixation. A new method of the cable transport with intramedullary cable passing avoids skin cutting thus reducing skin problems. Material and Methods: 15 Patients with a metaphyseal and diaphyseal bone defect of the tibia after open trauma and posttraumatic infection were treated with debridement, bone resection and soft tissue coverage by local and free flaps. After soft tissue healing the monolateral external fixation was replaced in each patient by a four ring ilizarov fixator with a proximal percutaneous tibia osteotomy. For bone transport a flexible cable was placed around the distal part of the segment and passed intramedullarly through the distal segment out of the tibia and onto the Ilizarov fixator and the transport clickers. The bone segment was transported after a delay of 7 days anterograd by the intramedullar placed cable one mm per day.

Results: In all patients the bone defect was closed by the bone transport. In one patient early consolidation of the regenerate occurred and a rupture of the cable. Two patients had an insufficiency of the callus. The distal docking site was augmented in all patients after the segment transport with iliac bone graft for consolidation. The one patient with early consolidation was treated by a second osteotomy; the two patients with insufficiency were augmented during the docking operation with iliac bone graft. Conclusion: The intramedullar cable transport is a new modification of the bone transport with the ilizarov ringfixator. The main advantage is the soft tissue spearing and protecting transport mechanism enabling bone transports after free flap soft tissue coverage with micro vascular anastomosis. Therapeutical course before and after amputation (number of operations before and after amputation) in relationship to co-morbidities and bacteria which caused the infection. Results: Hospital data from 63 (15 female, 48 male) patients were available for 64 septic amputations in the lower extremities on account of non-manageable infections. The average age was 56.6 years (27 to 88 years). The first age peak lies with 46, the second with 78 years. In 15 cases infected endoprostheses were found (3 total hip arthroplasties, 12 total knee arthroplasties) in 49 cases osteomyelitis was diagnosed. Before amputation the patients underwent an average of 7.5 interventions (between 0 and 28) in oder to control the infection. The average treatment period before the amputation was 39.76 days (from 1 to 117 days). Post amputationem an average 2.5 interventions were necessary (from 0 to 9). The average period of treatment was about 36.81 days (from 3 to 99 days). The analysis of the co-morbidities showed that hypertension was the most frequent, 19 cases (19.58%), followed by diabetes in 15 cases (15.46%), coronary desease in 8 cases (8.24%), obesity in 5 cases (5.14%) and COPD in 4 cases (3.88%).

Conclusion: A statistical relevant risk-assesment based on these data (correlation of microbiological findings co-morbidities and risk of amputation) cannot be carried out due to the relatively small number of patients. However, a trend may be estemated: Combination of MRSA, diabetes and cardial disease in combination with a great number of operations leads to an increased amputation-risk independent to the individuals age.

Introduction: Maggot Debridement Therapy (MDT) as an ancient method is succesfully used for the treatment of acute and chronic wound infections in trauma surgery 1 . The underlying mechanisms of action of MDT are unknown, but could provide information for a novel treatment modality against infection, which is important in these times of increasing antibiotic resistance. Therefore, in this research the effect of living maggots on planktonic cells was investigated. Furthermore, the influence of maggot excretions on planktonic cells and on bacterial biofilms was tested. Material and Methods: Sterile tubes were filled with living maggots in a bacterial suspension and every two hours samples were cultured and compared with controls. A turbidimetric assay was performed to test the susceptibility of six bacterial species to maggot excretions. Bacterial biofilms were formed in vitro on polyethylene, stainless steel and titanium and maggot excretions were added to test their influence.

Results: The results show that living maggots as well as their excretions stimulate the bacterial growth of S. aureus, E. faecalis, CNS, S. pyogenes and K. oxytoca (all p-values £ 0.0002). Only P. aeruginosa had a decrease of bacterial growth (p = 0.002). The strongest biofilms in vitro were formed by S. aureus, S. epidermidis and P. aeruginosa in contrast to the weak and inconsistent formed biofilms by E. faecalis, E. cloacae and K. oxytoca. For P. aeruginosa, stainless steel was the best biomaterial with respect to biofilm formation and for S. aureus and S. epidermidis, the best biomaterial was titanium. Maggot excretions were added to the strongest biofilms, named above, and reduced these on all biomaterials. The maximal biofilm inhibition by maggot excretions was seen on polyethylene: 82% for P. aeruginosa (p < 0.0001), 61% for S. aureus (p < 0.0001) and 92% for S. epidermidis (p < 0.0001).

Conclusion: This study shows that nor living maggots, neither maggot excretions have direct antibacterial properties. However, maggot excretions do reduce biofilms formed by different bacterial species on commonly used biomaterials. Future research will focuss on the exact mechanism and the substance(s) that cause biofilm reduction. Furthermore, possible indirect antibacterial activity will be investigated and the potential role herein of the immune system. Introduction: Tetanus is an acute disease caused by a neurotoxin produced by the bacterium Clostridium Tetani, characterised by generalised rigidity, muscle spasm and fatality. Open orthopaedic injuries are at particular risk of developing infection from tetanus spores found in the environment. The UK Department of Health has established guidelines for the prevention of tetanus infection. We assessed the adherence of these guidelines on the initial pre-operative management of tetanus prone open orthopaedic injuries in trauma patients admitted for surgery. Material and Methods: A retrospective case note review was conducted on 53 patients admitted to the orthopaedic department for intervention with a tetanus prone wound between February 2009 and June 2009. Tetanus prone injuries included open fractures, soft tissue injury requiring surgical intervention that is delayed for > 6 h, wounds with significant devitalised tissue, wounds in contact with soil and open injuries containing foreign bodies. We assessed to what extent these patients had their immunisation status ascertained, application of wound irrigation and appropriate dressing, correct tetanus prophylactic cover (tetanus toxoid booster versus human tetanus immunoglobulin) and appropriate administration of antibiotics. Results: Of the 53 patients included in the study, 32 (60%) of patients were considered to have a 'high risk' tetanus prone injury and 21 (40%) patients were deemed as having a 'low risk' clean wound based on the nature and extent of injury. Performance within the high risk category showed that 59% of patients had their tetanus immunisation status ascertained, 72% correctly received wound irrigation and betadine dressing, 75% of patients were appropriately given prophylactic antibiotics. Only 9% of patients with a high risk tetanus prone wound received tetanus immunoglobulin and 72% of patients were given a tetanus toxoid booster as a method for prophylaxis. Conclusion: Our study showed that a large proportion of patients correctly received supportive wound care and antibiotics. We also demonstrated that patients with open tetanus prone orthopaedic injuries are not adequately receiving correct tetanus immunoglobulin as the indicated prophylaxis. A large number of patients were given tetanus toxoid instead, which does not protect immunity early enough to cover the acute injury period, thus posing a major risk of developing a devastating and largely preventable infection. The orthopaedic and trauma doctor attending these patients must adhere closely to the correct initiation of simple measures in the management of tetanus prone orthopaedic wounds. All patients were irrigated and debrided, before the application of VAC system. Required debridements were maintained during VAC therapy. Time elapse between the injury time and VAC application time was 5 days on the average (min 0, max 10). When the granulation tissue became sufficient to cover the bone, these wounds have been closed secondarily with several methods. Time elapse between the start of VAC and wound closure or formation of sufficient granulation tissue for grafting was 12 days on the average (min 8, max 17).

Results: Distribution Mean postinjury time for the osteosynthesis was 44,5 hours. Three of these wounds were closed spontaneously without any need for other wound closure procedures. Split thickness grafting is applied in 8 patients, free flap to 2 patients, full thickness grafting to 3 patients, secondary suturing was applied in 1 wound to close it. There was no infection in any extremities that we had osteosynthesed by internal or external methods.

Conclusion: Wound care is as much important as osteosynthesis in open fractures. Even if osteosynthesis is successful, failures in wound care may result in loss of extremity. VAC alone does not suffice for wound closure. Expectation in this therapy is to obtain ideal granulation tissue and to prevent infection development via appropriate wound care. The greatest disadvantage of VAC therapy at the time being is its high economic cost. Introduction: Surgical haemostasis in trauma patients can be difficult and hazardous. Commercial products are promoted to accomplish this task at a reasonable cost. In this study we compared the effectiveness of two topical gelatin-based haemostatic agents, FlosealÒ and SurgifloÒ in a porcine liver trauma model. Material and Methods: We compared the activity of FlosealÒ (with human or bovine thrombin), SurgifloÒ and SurgifloÒ with added bovine thrombin in two porcine models. One anesthetised piglet mimicked ''normal'' conditions, while the other was kept in a status of hypotension, hypothermia and haemodilution, necessitating inotropic support (''critically ill''). Laparotomy was performed, after which we inflicted five identical stab wounds on each liver lobe. Each wound was treated with one of the four agents, while one wound was kept as a control. Haemostasis was evaluated clinically. After euthanizing the piglets, the pathologist performed a macroscopic, microscopic and electron microscopic evaluation, blinded for which agent was used in which wound. Results: Clinically, SurgifloÒ was able to produce a clot in some of its applications in the healthy piglet (''normal'' conditions), which was not the case in the critically ill animal, not even with the added thrombin. FlosealÒ induced clotting in every wound. Both microscopic (hematoxylin and eosin and Mallory stain) and electron microscopic examination of the stab wounds confirmed that FlosealÒ created a stable and dense agglomerate of gelatin and fibrin, firmly attached to the adjacent liver tissue, whereas with SurgifloÒ, the gelatin contained more air bubbles, there was a lot less fibrin included in the clot and the clot was not strongly adherent to liver tissue.

Conclusion: It would seem that FlosealÒ is a superior haemostatic agent, creating a dense and stable blood clot, even in a critically ill animal, hence ensuring haemostasis. Disclosure: No significant relationships. Introduction: Bleedings stemming from splenic traumas are still among important causes of morbidity and mortality. Aim of this study is comparison of fibrin glue with hemostasis effectiveness of Ankaferd Blood Stopper lower lob resections on spleen of rats.

Material and Methods: The study was performed at the animal laboratory of Istanbul University after obtaining an approval from the Ethics Committee. Twenty-four rats were randomly divided into three groups, namely, fibrin glue group (n = 8), ABS group (n = 8) and control group (n = 8). A wedge resection was performed on the lower lobe of the spleen. In fibrin glue group, spleen was hemostasis with fibrin glue (Tisseel), while ABS was administrated on the lower lobe surface in ABS group. Chronometric measurements were made to determine bleeding times. Blood samples from the tail and vena cava were used for whole blood count and blood chemistry. Histopathological scores were measured postoperatively on day 5 th.

Results: In ABS group, chronometric bleeding period is 11,5 s. Whereas in fibrin glue group it takes 10,8 secods (p > 0,05). It was noted that the hemogramme test results, hemoglobin and hematocrit levels on the 5 th days of ABS and fibrin glue groups did not show sensible differences from one another (13.5 vs 13.9) p = 0.022 (41,63 vs 42,50) p = 0,879.

Conclusion: There are no differences between the hemostasis speed and effectiveness of Ankaferd Blood Stopper and fibrin glue as an applied material in bleeding stemming from experimental partial lower lob resections on spleen of rats. of the hemoperitoneum in right iliac fossa was performed 6 and 7 days after trauma, resulting in drainage of 2600 and 4200 cc of blood. Patients were discharged 1 month later and follow up was successful.

Conclusion: In selected hemodynamically unstable patients and upon availability of appropriate facilities, NOM can be safely challenged over the usual limits. The indicators of tissue perfusion such as pH and BE seems to be more reliable and sensitive prognostic parameter than hemodynamic instability evaluated by blood pressure and heart rate, in selecting the patients needing surgical control of hemorrhage. A moderate IAH in young patients able to tolerate an increased intra-abdominal pressure, can allow a mechanical compression of the injured parenchyma achieving the arrest of hemorrhage, and extend the indications for NOM in selected hemodynamically unstable patients, without signs of severe tissue hypoperfusion. Material and Methods: Our case describes a 51 year old male who fell 7 m and landed on the right side of his torso dislocating a rib through the diaphragm, causing a transecting grade 5 liver injury to liver lobes IV and VII, the right hepatic artery and a lesion of the retrohepatic vena cava (VC). The patient presented alert, hemodynamically stable with normal breath sounds. CT scan showed right sided hemothorax and a grade 5 liver injury. A right sided chest tube drained 600 ml of blood. The patient became unstable and was transferred to the OR. Profuse haemorrhage from the liver was encountered and massive blood transfusion protocol was initiated. The right hepatic artery showed to be injured and was ligated. Pringles manoeuvre and packing of the liver were not enough to control the bleeding. An injury to the retrohepatic VC was suspected and manual compression was not sufficient to gain control. Endovascular assistance was called for and using a bilateral Femoral vein approach two occlusive balloons were placed and inflated under X-ray and open view in the VC to gain proximal and distal control.

The patient stabilized and the injury to the VC could be sutured and covered with a topical haemostatic agent. The balloons were deflated but were left in place as a security measure. The liver was then again packed. The Pringle manoeuvre had intermittently been used for approximately 2 h in total. Two vessel loops were left tension free around the hepatodoudenal ligament and brought out through the midline incision as a security measure. 60 units of RBCs, 30 units of FFPs and 2 units of platelets were given. Angioembolization of the right hepatic artery was performed after the first surgery. During the second operation, the haemostats, vessel loops and occlusion balloons could safely be removed. 15 days after the injury the patient showed increasing signs of liver failure. The patient was accepted for liver transplantation 22 days after the injury; this procedure was carried out successfully.

The combined open and endovascular approach in this case was crucial. The nature of the injury, the Pringle manoeuvre, packing of the liver and arterial embolization caused permanent damage to the liver which had to be managed with liver transplantation which was successful. The use of endovascular occlusive balloons might also have had a role in the permanent damage of the liver, but had great benefit in saving the patients life. 

Introduction: The incidence of pulmonary failure in multiple trauma patients is postulated to be influenced by several factors such as thoracic trauma and liver injury. The incidence of pulmonary failure increases in patients with an Abbreviated Injury Scale thorax ‡ 3 (AIS) and they are more likely to face poor outcome. Thus, the aim of the present study was to test the hypothesis that patients sustaining significant thoracic trauma (AIS thorax ‡ 3) in combination with a relevant liver injury (AIS liver ‡ 3) are more likely to develop pulmonary failure when compared to patients which sustained thoracic trauma without additional liver injury. Material and Methods: Records of multiple trauma patients documented in the Trauma Registry of the German Society for Trauma Surgery were analyzed using uni-and multivariate analyses. Patients were subdivided into four groups according to their liver and thoracic injury: group 1 (AIS thorax < 3; AIS liver < 3); group 2 (AIS thorax ‡ 3; AIS liver < 3), group 3 (AIS thorax < 3; AIS liver ‡ 3) and group 4 (AIS thorax ‡ 3; AIS liver ‡ 3). Potential relevant variables were subjected to univariate analysis between groups using the chi square test to predict the probability for pulmonary failure rate. Subsequently, multivariate logistic regression analysis was performed, employing pulmonary failure as the dependent variable. Differences at the level of p < 0.01 were considered statistically significant. Results: 12,585 patients with a mean age of 40.8 ± 10.7 years and a mean ISS of 28.6 ± 11.1 points fulfilled the inclusion criteria and were enrolled in this study. The overall rate of pulmonary failure was 21 ± 40%. 12% of the patients in group 1, 26% in group 2 and 16% in group 3 developed pulmonary failure. The largest proportion of patients (36%) who developed pulmonary failure was found in group 4. Those factors which proved to show a significant correlation with the incidence of pulmonary failure were included in a subsequent multivariate analysis. However, the presence of relevant lung injury, male gender, pre-existing medical conditions (PMCs), transfusion of more than 10 packed red blood cells (PRBCs) as well as ISS and age played a significant role. In contrast to our hypothesis, liver injury did not proof to be associated with the incidence of pulmonary failure. Conclusion: Pulmonary contusion and significant liver injury seem to have a synergistic effect on the incidence of pulmonary failure. However, multivariate analysis with adjustment of further relevant factors reveal, that liver injury is not a predictive factor for the incidence of pulmonary failure. Rather male gender and reported PMCs together with relevant lung injuries are more likely to develop pulmonary failure following multiple trauma. Nethertheless, patients with combined pulmonary and liver injury are at higher risk for pulmonary failure with critical outcome. Disclosure: No significant relationships.

Introduction: Thoracic trauma is the leading death cause in 25% of politraumatised patients and contributes to the death of another 25% of these fatalities. Identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. The goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome.

Material and Methods: Retrospective study of 740 politraumatised patients admitted in the Emergency Department of St. Pantelimon Hospital between Jan 2001 and Jun 2005. The followed parameters were most common injuries, severity, mortality, survival rate correlated with ISS and RTS, using data from emergency charts, hospital charts and anatomopathologic exams. Results: Out of 740 patients, 445 associated thoracic trauma, with a survival rate of 79,1%. 410 patients had blunt trauma. Injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax 15 patients (100% mortality rate), aortic and great vessels injuries 6 patients (100% mortality rate), open pneumothorax 1 patient (100% mortality rate), tension pneumothorax 10 patients (50% mortality rate), flail chest 30 patients (53% mortality rate). Conclusion: Thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. Lifesaving surgical procedures must be immediately performed, on patient arrival. It is important to adopt intervention protocols for multiple trauma, with a leading role of the Emergency Department medical staff. Disclosure: No significant relationships.

Introduction: To evaluate treatment modalities of penetrating and/or contusive hemothorax, we reviewed our experience with patients admitted for traumatic hemothorax to our Center for Thoracic Surgery. Material and Methods: From January 1998 to we treated 135 consecutive patients (mean age, 47 + 22 SD years; M/F, 111/24) presenting traumatic hemothorax: 122 patients had contusive hemothorax (CONT) following car accident (28%), fall (27%), motorbike accident (25%), crushing trauma (7%), bike accident (3%); 13 patients had penetrating trauma (PEN) following stab wound (6.5%), gunshot (2%) and impalement (1.5%). We recorded demographic data, Injury Severity Score (ISS) at admission, endo-and extrathoracic injuries, method of treatment and outcome.

Results: There were no statistically significative differences between CONT group and PEN group regarding mean age (47 vs 45 years), gender (M/F = 100/22 vs 11/2), mean ISS (30 vs 28) and ICU admission rate (51% vs 54%). The CONT group however presented a higher rate of extrathoracic lesions (bone, visceral, CNS) than the PEN group (71.3% vs 31%: p < 0.005). In all patients a chest tube was immediately inserted, as the definitive treatment in 75% of CONT pts and in 46% of PEN pts (p < 0.05). Surgical Introduction: Evaluation of penetrating injuries to the chest presented at a Level 1 traumacenter. The main study question was to see whether there was an increase in incidence in time.

Material and Methods: In this retrospective study fifty-nine consecutive patients were included with penetrating injuries of the chest during the period of June 2004 until June 2008. The penetrating injury had to be caused by gunshot or stab incident. Statistical analyses of the data was performed using SPSS 16.0. Results: The study group consisted of fifty-nine patients. Ninety percent were male with a mean age of 36 years (range 17-64). The mechanism of injury were stab (79,9%) and gunshot wounds (20,3%). Sixteen patients required a thoracotomy. In four other cases a laparotomy was performed. Twenty-two (37,3%) patients were admitted to the ICU. The number of patients treated in the first year of the study period ( Of the patients with a shotwound 25% died of their injuries and mortality rate of the patients with a stabwound was 10.7%. In the last year of the study period the mortality of gunschot wounds was 9.5%. Conclusion: There is an increase in incidence of penetrating injury of the thorax for both stabwounds and gunshot wounds. The increase of gunshot wounds was especially large in the period July 2007-June 2008. The risk of suffering a gunshot or stabwound to the chest in our traumaregion is gender related. With the increase in the number of gunshot wounds, and thus experience, the mortality seems to decrease. Introduction: Rib fractures and more specific the flail chest are currently treated conservative. In our level one trauma centre we have on average 90 patients with rib fractures and 5 flail chests/yr. Until recently we mainly treated the patients conservative. According to the literature the morbidity and mortality increases twofold with 4 or more ipsilateral rib fractures and an age > 45yrs old. 1, 2 Some studies have also shown that operative fixation of rib fractures may reduce the morbididity significantly 3 With this data and the recent development of specific dedicated osteosynthesis material for rib fractures we devised a pilot study in order to analyse the efficacy of this new MatrixÒ Rib fixation System (SynthesÒ) and the effect on the morbidity/mortality of the patient. Material and Methods: During a 6 month period we included all patients with the before mentioned criteria(4 rib fractures, > 45 yr) or with a flail chest. We analysed operation details, lenght of ICU stay, hospital stay and recorded complications. The results were compaired with a matched control group from 2008. Results: 12 patients were included with an average age of 59 yrs and a M:F distribution of 9:3. 5 patients had a flail chest and 7 patients had 4 or more rib fractures. On average all patients were operated within 2 days (0-5). On average 4 (2-6) rib were stabilized with an operating time of 77 min (40-150). No implant failures were seen. 8 patients had an average icu stay of 8 days (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) . Total hospital stay for the whole group was 18 days (6-38), specific for flail chest it was 22 days and for the ipsilateral rib fractures it was 16 days. One patient sustained an extra rib fracture due to the procedure and one patient sustained an iatrogenic pneumothorax. One patient died due to neurologic complications. One patient had a superficial wound infection. No deep infections, pneumonia or chest related mortality occurred. Compared to a matched control group of 2008, the overall length of stay was not significant different. 18 vs 15 days. The length of stay for the ipsilateral fractures was not significantly shorter, 16 vs 15. However the length of stay for the flail chest was significantly shorter in the study group 22 vs 48 (P < 0.05) The control group had significant more pneumonia, 5 vs 1 (P < 0,05). Conclusion: The new MatrixÒ system is easy and safe to work with. The system has good stabilizing capabilities. Operative treatment reduces pneumonia and length of stay with flail chest. These results warrant a randomised study, comparing operative treatment vs conservative treatment. Introduction: Severe thoracic wall injuries can result in long time ICU stay with ventilatory support substantial morbidity and even death. If the patient recovers persistent thoracic wall pain, restricted respiratory capacity and/or non union of the rib fractures can be the consequence. In a systematic review of literature we demonstrated that there is some evidence that early internal fixation can shorten the on-ventilator time, the ICU stay and lower the short time morbidity. Long term pulmonary function is not altered by internam fixation, however the rate of rib nonunion and chest wall pain is decreased. However high quality evidence is lacking. In order to evaluate the feasability of rib osteosynthesis with a new plating system: the Synthes Matrix System a preliminary study is performed and its results presented. This study preceeds a randomised controled trial comparing plate ad screw osteosynthesis and conservative treatment.

Material and Methods: 10 Consecutive patients with flail chest and or serial rib fractures involving at least five ribs necessitating measures other than analgetics to maintain pulmonary function are included and prospectively documented. Exlusion criteria: *hemodynamic instability necessitating a damage controle approach *intrathoracic injuries necessitating surgery *normal pulmonary function *patient refusing surgical treatment *patient not available for follow-up All patients are operated upon with use of the Matrixrib system. Postoperative ICU stay, on-respirator time, pain at defined moments of follow-up, healing of the rib fractures and complications are recorded prospectively. Patients grade their rate of satisfaction (functional and esthetical) on a scae of 0 to 10. The results in these patients concerning on-ventilator time, ICU stay and morbidity are compared to a historical series of patients with comparable ISS. Prospective case series with historical control group.(Level III) Results: Preliminary data indicate: *a shorter time on ventilator than anticipated (based on comparisson to historical data) * a shorter time on ICU * less pneumoniae * no intra-operative complications * good healing results of the rib fractures * no implant failures * acceptable pain scores * good overal satisfaction * acceptable cosmetic results Conclusion: Internal fixation of rib fractures (flair chest or multiple sequential fractures with pulmonary function compromise) results in a earlier recuperation of pulmonary function with shortened ICU stay. The overal satisfaction of the patient after operative treatment is good, with acceptable cosmetic results. There were no implant related complications. These results form the basis for a randomised control trial comparing operative fixation with the Matrix rib system to conservative treatment. Disclosure: No significant relationships.

A. E. Elsherif 1 , M. Fawzy 2 , N. Badr 1 , M. Marashda 3 1 Surgery, Tawam Hospital/Johns Hopkins International, Abu Dhabi, UAE, 2 Surgery, Tawam Hospital, Abu Dhabi, UAE, 3 Surgery, Tawam Hospital/Johns Hopkins International, Abu Dhabi, UAE Introduction: Acute airway emergencies result from a wide variety of malignant and benign diseases. For both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. General anesthesia is sometimes prohibited in these situations with complete loss of airway. We report our initial experience with these patients in a tertiary referral center. Material and Methods: Three patients (two males) with acute proximal airway emergencies were included. Two patients presented with acute stridor. The third presented with massive bronchial air leak and purulent drainage after an acute traumatic event. All patients were treated emergently with bronchoscopy and placement of an ultraflex bronchial stent under local anesthesia. All patients were followed up after discharge.

Results: There was no perioperative mortality or morbidity. The median age was 51. One patient had anaplastic thyroid cancer obstructing the trachea and was denied treatment elsewhere. The second patient had a malignant tracheoesophageal fistula. The third patient had an acute bronchopleural fistula following pneumonectomy for a gunshot wound. Complete symptom relief was obtained after stenting under local anesthesia in all patients. Median length of stay was 3 days for the patients with malignancy. On a median follow up of 11 months; Two patients were symptom free, One patient died from malignant disease progression. Conclusion: Stenting under local anesthesia is feasible with acute airway emergency. Obstruction of the central airways by malignant tumor is associated with poor prognosis.The alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure.

Introduction: On April 6th 2009 an earthquake measuring 6.3 on the Richter Scale stuck a large area of the Abruzzo region in central Italy. The first notice suggested a lot of injured people and destroyed structures, incuded the main hospital of the area, the San Salvatore Hospital.

Material and Methods: The National Civil Protection immediately send the field hospital (FH) of the Marche Regional Government, the neighbouring region, together with a large amount of medical staff and personnel by the non governmental organization ARES (Regional Association Sanitary Emergencies). This association, already involved during other national and international disaster situations and relief efforts, sent professionals volunteers (MD and nurses) whit disaster knowledge and specific medical specializations. The international literature demonstrated that a FH is a complex structure and often the time required to be completely functionally is very long, indeed longer than the affected people needs. Results: From April 6 th , June 6 th when the mission ended, the FH provided medical treated to almost 6000 patients, and the ARES personnel (167) where backed by the sanitary personnel of the San Salvatore Hospital. Conclusion: A well planned medical response is very important to provide health assistance during a disaster, yet it is very hard to substitute a damaged hospital in the hearth of the disaster area. A modular sanitary structure, very light at the beginning, with specific and restricted medical supplies, with a little number of specialists in disaster medicine and disaster logistics, could improve the already good results obtained in the L'Aquila Abruzzo mission. Disclosure: No significant relationships. around 100,000 people died, twice as many were injured, and almost 3million people were made homeless. In any situation of disaster, both natural and complex, may be produced a large number of victims that defeat the ability of local health resources to provide adequate health care. On one hand, the system may be overwhelmed with a high number of casualties. On the other hand, hospitals and other health care facilities generally may be compromised heavily: buildings may be destroyed or damaged and the supply of water, electricity, medical gasses, etc. may be limited. The transportation infrastructures may be severely damaged, creating problems for both people and equipment arriving at the hospital. Damage to the health care infrastructure will further compromise the delivery of health services. Material and Methods: Italian Government responded immediately to this emergency after the official request for international relief efforts from the President of Pakistan. Two days after the impact, the first Italian evaluation emergency team was already arrived in Pakistan and the initial field structure was already fully operative, offering medical care, especially advanced trauma care and life support intervention, provided by specialists. Later, when the structure had been completed and became larger provided also hospitalization, and surgical abilities, appropriate treatments and essential drugs. All the medical activities of the responding Italian mission team field hospital in Manshera were recorded and evaluated.

Results: A total of 20,212 patient contacts occurred at the field hospital during the 83 days it operated, 620 patients were admitted in the field hospital with a total number of 6949 nursing days with a average length of stay per admission of 11,2 days and with the occupancy rate of 95,2%. A total number of 365 major operations were performed.

Introduction: Mass casualty incident's (MCI) management is a present problem which is now more frequent because of Iraki, Afghan wars and terrorists actions. Numerous new plans are evolved in each emergency association or military organization. NATO as built a ''MASSCAL'' plan to help teams in role II in Afghanistan to take care MCI. Through two experiences of MCI in French Role II in Afghanistan (Kaboul) and through the litterature, we discuss the different ways of taking in charge MCI. Material and Methods: The french role II is located in Kaboul near helicopter area. There are 3 surgical teams (50 pax, 3 nationalities), 3 emergencies boxes, 4 ICU beds and 3 operating theatres. We have a pool of 42 blood units, an echograph, a first generation CT-scan and all materials for traumatologic surgery. For MCI, we use NATO triage classification. Each trauma undergoes ressucitation room, has needing X-Ray exams, FAST echography and intensive care if necessary. Patient who needs urgent surgery runs immediately to operating theatre. ISS score is calculated. The first MCI concerns 6 patients involved in a suicid bomber's explosion near the role II. All were taken in charge 15 min later. The second concerns an attack against a French Coy occured 50 km in the East of Kaboul. There were 22 casualties and 10 soldiers died. They were taken in charge belatedly between 7 to 12 h later.

Results: Fisrt MCI : 4 surgical interventions, one 90%burned, and a blast injury. Second MCI : 7 surgical interventions, 15 injuries with no surgery, 6 blast injuries. We organize for these second MCI a STRATEVAC in France for 10 casualties in less than 24 h. Mean ISS score is 8 for alive injuries and 40 for the died soldiers. Through these 2 MCI, we analyse the litterature and discuss about presents concepts in MCI management. Conclusion: The contemporary history of war, especially in Iraqi and Afghanistan constrains military surgical teams to improve their way of management of MCI. Training is necessary. First of all we have to define clearly each place of each actor, the conditions of triage, wich priority for which surgery and the possibility of modern communications and fast and efficient transports. the lower extremity (38%). 19% suffered multiple severe injuries, 9% upper extremity injury, 7% upper extremity and head/neck injury, 7% back injury, 6% head/neck injury, 6% upper and lower extremity injury, 4% abdominal injury and 4% miscellaneous. 7 patients (10%) underwent an primary amputation of one or more extremities. 3 (4%) patients underwent secondary amputation. All primary amputated limbs were shortened later. 1 patient (1%)died one day after arrival in the CMH because of multiple severe injuries.

Conclusion: This single-center, and therefore complete dataset of the repatriated military personnel demonstrates the impact of participating in a NATO mission for a small European country. It puts a high and challenging burden on the shoulders of the medical personnel in our hospital. Further it shows, in contrast to studies from Owens and Dougherty, a higher prevalence of lower extremity injuries than upper extremity injuries. Data regarding admission time, infection rate, disposition and quality of life will be presented. A lot of medical-ethical decisions had to be made about continuation of medical threatment or to decide whith patient will be treated and with patient will not be treated. As war surgeon you have to do operation for which you were not educated. Because there is no other surgeon you have to the operation or the patient will die. It gives the opportunity to learn and gives a lot of surgical experience. This can be useful in civilian circumstances also. Conclusion: The period as war surgeon in Afghanistan has been of a forse impact. I had to take a lot of medical-ethical decisions and to do operations in which I was not trained. But I have learned a lot about war surgery and on human aspects also. 

Introduction: There are a lot of unique challenges for the medical personnel which are assigned to the combat environment in Afghanistan. Especially the medical groups are in contact with patients from different nationalities and with different characteristics under special and difficult war circumstances. This article evaluates the effectiveness of the co-operation between a German and a Greek surgical team during a 2-month period in a role II hospital in North Afghanistan.

Material and Methods: From 21st July 2009 through 20th September 2009, 764 patients were admitted. There were 718 male (94%) and 46 female (6%). We reviewed the type of diseases, mechanism and location of injuries, management, type of surgical procedures performed, blood supply and outcome. Results: 72.9% of the patients were International Security Assistance Force (ISAF) personnel. Most of the patients were men in a percentage of 94%. Four children were included among the local patients. 37.6% of the patients had surgical diseases while the rest 28.9% were of orthopaedic interest patients. 35 (4.6%) patients underwent a surgical operation; 26 (74.3%) of them were operated immediately. Gunshots were the main mechanism of injury for local patients whereas ISAF personnel were usually presented with burns after improvised explosive devices (IEDs) and rocket attacks. Conclusion: The co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage war casualties. Introduction: In the emergency caused by natural and social disasters there are evident deficits between the health needs of affected population and the local health system capacity. The causes of disasters are various and not predictable, usually the health structures can not face up to the population needs. Knowing that disaster medicine has different protocols and materials from ordinary medicine structures and that improvisation during the disaster's acute phases is not a good practice, it has been created an emergency operating health group, the non-profit ARES Association. (Regional Association Sanitary Emergencies) Material and Methods: The ARES, whose members are about 600, all over the nation, is configured as an extraordinary health resource, activated by the National Civil Defence operations centre, in according with the Regional centre of Marche, in disater situations Results: The main objectives of ARES are training and organization of medical staff and structures and its growth crosses several missions including: AE Earthquake in Molise, 2002 Introduction: Cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. There is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). The purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture. Material and Methods: Thirty intact synthetic femur specimens (Model #3406, Pacific Research Laboratories, Vashon, WA) were potted into cement blocks distally for testing on an Instron 8874 (Instron, Canton, MA). A long cephalomedullary nail (Long Gamma 3 Nail, Stryker, Mahwah, NJ) was then inserted into each of the femurs. An unstable four-part fracture was created, anatomically reduced, and the cephalomedullary nail was reinserted. Mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in: 1) static and 2) dynamic modes. A paired student's t-test was used to compare the two modes.

Results: The axial stiffness of the cephalomedullary nail was significantly greater (p < 0.01) in the static mode (484.3 ± 80.2 N/mm) than in the dynamic mode (424.1 ± 78.0 N/mm) (fig 2A) . Similarly, the lateral bending stiffness of the nail was significantly greater (p < 0.01) in the static mode (113.9 ± 8.4 N/mm) than the dynamic mode (109.5 ± 8.8 N/mm). The torsional stiffness of the nail was significantly greater (p = 0.02) in the dynamic mode (114.5 ± 28.2 N/mm) than in the static mode (111.7 ± 27.0 N/mm). A post hoc power analysis with a = 0.05 and ß = 0.20 revealed that the paired t-test on 30 samples was sufficiently powered to determine a difference in mean axial stiffness of 33.0 N/mm (6.8% of static stiffness), a difference in mean lateral bending stiffness of 3.6 N/mm (3.2% of static stiffness) and a difference in mean torsional stiffness of 3.4 N/mm (3.0% of static stiffness). Conclusion: Our results show that there is a 60 N/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. This represents a 12.4% reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. The differences in lateral (4.4 N/mm, 3.9%) and torsional (2.8 N/mm, 2.4%) are small enough that they are likely not clinically significant. We felt that a difference of greater than 10% in axial stiffness and a difference of greater than 5% in lateral or torsional stiffness would be clinically significant. Our study was adequately powered to detect these differences. Given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail. Disclosure: No significant relationships.

Introduction: Minimizing tip-apex distance has been shown to reduce clinical failure of sliding hip screws used to fix peritrochanteric fractures. The purpose of this study was to determine if such a relationship exists for the position of the lag screw in the femoral head using a cephalomedullary device. Material and Methods: Thirty intact synthetic femur specimens (Model #3406, Pacific Research Laboratories, Vashon, WA) were potted into cement blocks distally for testing on an Instron 8874 (Instron, Canton, MA). A long cephalomedullary nail (Long Gamma 3 Nail, Stryker, Mahwah, NJ) was inserted into each of the femurs. An unstable four-part fracture was created, anatomically reduced, and repaired using one of 5 lag screw placements in the femoral head: 1) Superior (N = 6), 2) Inferior (N = 6), 3) Anterior (N = 6), 4) Posterior (N = 6), 5) Central (N = 6). Mechanical tests were repeated for axial, lateral and torsional stiffness. All specimens were radiographed in the anterioposterior and lateral planes and tip-apex (TAD) distance was calculated. A calcar referenced tip-apex distance (CalTAD) was also calculated. ANOVA was used to compare means of the five treatment groups. Linear regression analysis was used to compare axial, lateral and torsional stiffness (dependent variables) to both TAD and CalTAD (independent variables).

Results: ANOVA testing proved that the mean axial (p < 0.01) and torsional stiffness (p < 0.01) between the five groups was significantly different, but lateral stiffness was not statistically different (p = 0.494).

Post hoc analysis showed that the inferior lag screw position provided significantly higher mean axial stiffness (568.14 ± 66.9 N/mm) than superior (428.0 ± 45.6 N/mm; p < 0.01), anterior (443.2 ± 45.4 N/mm; p = 0.02) and posterior (456.7 ± 69.3 N/mm; p = 0.04) lag screw positions. There as no significant difference in mean axial stiffness between inferior (568.14 ± 66.9 N/mm) and central (525.4 ± 81.7 N/ mm) lag screw positions (p = 0.77). Post hoc analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p < 0.01 all 4 pairings). There were no significant correlations between TAD and axial (r = -0.33, p = 0.08), lateral (r = -0.22,p = 0.24) or torsional (r = 0.08, p = 0.69) stiffness. There were significant correlations between CalTAD and axial (r = -0.66, p < 0.01), lateral (r = -0.38, p = 0.04) and torsional (r = -0.38, p = 0.04) stiffness. Conclusion: Our results suggest that placement of the lag screw inferiorly in the femoral head when using a cephalomedullary nail to treat an unstable peritrochanteric fracture results in the stiffnest construct in axial and torsional biomechanical testing. A simple radiographic measurement, CalTAD, provides an intraoperative method of determining optimal cephalomedullary nail lag screw position to achieve greatest construct stiffness. Introduction: A potential of polymethylmethacrylate (PMMA) augmentation to increase the purchase of cephalic implants in the treatment of intertrochanteric hip fractures has been proven in sev-eral biomechanical studies [1] [2] [3] [4] . The aim of this study is to compare the cut-out ratio of PMMA augmented helical blades to not augmented ones in human cadaveric femoral heads. Material and Methods: Six pairs of osteoporotic cadaveric femoral heads were instrumented with a proximal femoral nail antirotational (PFNA) blade in a standardized manner. Within each pair, one blade was augmented using 3 ml of PMMA cement. Cyclic loading was performed at 2 Hz. Starting at 1000 N, the load was monotonically increasing by 0.1 N/cycle until failure of the construct. X-rays were taken at 250 cycle increments to monitor the movement of the blade with respect to the head. Paired nonparametric test statistics were used to identify differences between groups.

Results: A significant higher number of cycles to cut-out was found for the augmented group (p = 0.028). A significant correlation was observed between bone mineral density and cycles to cut-out for the non-augmented specimens (p < 0.001, R 2 = 0.97), whereas no correlation was found for the augmented group (p = 0. Introduction: When treating distal tibial deformities or fractures with the Ilizarov external fixator the ankle joint and foot is often transfixed within the ring construction. For some patients full weight bearing can only be achieved in assembling a walking device on the distal ring. The biomechanical effect of the indirect loading on the fixator stiffness, the osteotomy and the wire tension is still unkown. Material and Methods: On the basis of a standarized Ilizarov external fixator (4 rings, 160 mm diameter) with two 1,8 mm wires per ring applied in anatomical position on composite tibiae (3 rd Generation Sawbones) direct and indirect loading was analyzed using a universal testing machine (model 10, UTS Germany). A middiaphyseal osteotomy of 3,5 mm was performed. The following parameters were recorded: micromotion at the osteotomy, relative movement between bone and rings, compressive forces at the osteotomy and strain of the wires. Each experimental setup was tested ten times with 100 kg maximal axial loading. Results: The osteotomy gap closure occurred at 275 N at direct loading and at an average of 730 N at indirect loading. The compressive forces at the osteotomy were almost double as high at direct loading. Regarding the relative motions between rings and bone the amplitude of motion was higher at indirect loading. The stress on the wires was up to four times higher when the walking device was applied on the distal ring for indirect loading. Conclusion: The indirect loading using a walking device has a substantial influence on the mechanical characteristics of the Ilizarov fixator which determine the biomechanical environment of the osteotomy/fracture. The results showed a higher mechanical load while achieving less compressive forces at the osteotomy. In the need of the walking device we suggest to apply additional half-pins at least in the distal fragment. 9) . Three randomized groups of 6 pairs were formed. After the osteosynthesis with the implants was done the fracture (A2.2) was made with a jigsaw. For further destabilsation the troch. minor was removed. The femura were fixed in the testing machine and tested under dynamic condition with a physiologic load for normal walking (2.5x bodyweight) under 25 000 cycles. We measured the load on the Implant, the migration and rotation of the bone around the Implant. The data was dokumented with Lab view, Results: The intramedulare implants showed significant lower migration rates (mean 2.7 mm) of the head compared to the extramedular implants (mean 9.6 mm). The rotation of the head around the lag screw startet earlier within the DHS an showed higher rates (mean 32°) followed by the Gamma 3 (mean 23°) until the end of the 25 000 cycle. The best stabilisation against rotation was documented for the PFN A (mean 13°). The post X-rays showed a significant migration and sintering process of the femoral head with lateralisation and fracture of the lateral wall. This was even higher in probes with a low BMD. Introduction: Excising part of an implant through the femoral head is a rare but severe complication of osteosynthesis of proximal femoral fractures. There is little evidence in the literature about incidence and management of this complication. According to opinion leaders in an recent international user meeting most cases end up in Total Hip Arthroplasty (THA). The value of re-osteosynthesis remains unclear. Most patients that suffer an excision are geriatric and multimorbid patients, rather suitable to less invasive revision surgery. To assess the incidence and management of cutting out of the PFNA blade (Proximal Femoral Nail Antirotation by Synthes GmbH International) was the aim of this multicenter study. Material and Methods: The incidence and management of excision of the PFNA blade in trochanteric femoral fractures was assessed retrospectively in 3092 cases in 15 participating hospitals all over Europe in a time period between 2003 and 2009. All implantations were screened for this complication. The preoperative, follow up x-rays and patients' medical records including the surgical reports were collected and analysed with a special focus on revision surgery until union or THA. Results: The incidence of excision of the implant was 1.3% (41/3092). The mean age of patients was 80 years. 76% of mostly female (86%) patients sustained an unstable 31A3 fracture according to the AO classification. Final revision surgery was performed with THA in 19 cases (48%). In 21 cases re-osteosynthesis led to union (52%). Reosteosynthesis was either exchange of blade with or without cement augmentation alone or re-nailing. In 8% of THA revisions additional revision was necessary. In 45% of revisions with exchange of blade additional revision was required (all THA). 83% (5/6)of revision cases with cement augmented blades healed. In 20% of revision with re-nailing, additional surgery was inevitable. On average 2.5 operative procedures were performed after excision of the PFNA blade. Conclusion: Cutting out of the blade of the PFNA is a rare complication. Nevertheless the management after removal is challenging as indicated by the high number of surgical revisions. Revision with Total Hip Arthroplasty showed a lower rate of reoperations compared to re-osteosynthesis. Nevertheless 52% of all revision cases were managed successfully with a minimally invasive osteosynthesis. This gives a rationale for osteosynthesis in managing this complication in geriatric multimorbid patients with a high risk for operation.

References: 1. Simmermacher, R. K., J. Ljungqvist, et al. (2008) . ''The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study.'' Injury 39 (8) In a prospective series of subtrochanteric fractures with or without involvement of the pertrochanteric region and in revision procedures of this area the PF LCP was applied. In 4 out of 14 patients a fixation failure was observed. This paper reports on these fixation failures. Material and Methods: All patients with a multifragmented subtrochanteric fracture with or without involving the trochanteric or the femoral neck region which where judged to present a compromised nail entry point from May 2007 until May 2008 were stabilized using the PF LCP. The plates were applied in a minimally invasive manner through soft tissue windows (MIPO). Intrinsic stability of the fixation was increased by excentric drilling or applying the tensioning device. All patients were followed up to fracture healing. Intraoperative and postoperative complications were noticed. Intraoperative and postoperative x-rays were analysed using the CCD angle and the Gardens alignment index. Results: We report 4 out of 14 patients who sustained a fixation failure with secondary varus collapse requiring 3 revision surgeries until healing. Revision consisted in a reosteosynthesis in one, a plate exchange to a 95 o blade plate in the second and a DHS in the third patient. In all our reported cases of implant failure the posteromedial buttress was missing [two AO 31 A2 and two Seinsheimer type V], and all patients were not able to restrict wheight bearing due to different reasons like, noncompliance (alcohol abuse, limited force, advanced age) leading to increased axial bending forces and finally to breakage of the femoral neck screws with varus collapse of the fracture. Conclusion: In conclusion the PF LCP proximal femoral plate 4.5/5.0 due to its guide wire technique allows for straightforward plate application and reduction also in very complex fractures of the trochanteric region, including fractures with extension into the greater trochanter or reverse oblique intertrochanteric fractures. However in fracture patterns with missing posteromedial support and limited ability to restricted weight bearing (e.g.: advanced age, additional handicap or mal-compliance) an alternative fixation device should be considered, e.g. the hook plate extension of the LCP proximal femoral plate to apply higher intrinsic stability of the fixation when using the tensioning device. Further clinical and biomechanical studies are needed to evaluate the potentiality and limitation of this device for the treatment of these challenging fractures of the trochanteric region. The majority of the the former fixation was replaced by a blade plate. In 25% we performed a total hip prosthesis. In these cases we saw an overproportional tend to prosthesis-luxations. Conclusion: We conclude that mechanical complications like cut out are a little more frequent after DHS-implantation and should be treated by change to a blade-plate-osteosynthesis. This allows a fracture consolidation in that the minor trochanter becomes that stable, that a regular total hip replacement becomes possible. This seems to be the best prevention of mechanical complications after posttraumatic hip replacement like luxations. Disclosure: No significant relationships.

Introduction: Hip fractures often concern elderly patients with a high degree of co-morbidity and therefore susceptible for the associated postoperative morbidity and mortality. According to the literature, several factors have an influence on the amount and severity of postoperative complications after hip fractures. Low preoperative haemoglobin levels (Hb) in elderly patients seem to be associated with increased short-term morbidity and even mortality after surgery. The aim of this study was therefore to establish the impact of anaemia and blood transfusion on postoperative recovery of hip fracture patients. Results: There were 16 women and 44 men with medium age of 24,2 years (18-45 years) and with medium follow-up of 2 years (1-6 years). The lesions occur in 8 sports, 50% of the fractures occur while practicing soccer. The fractures were bimalleolar (n = 30), medial malleolus (n = 11), lateral malleolus (n = 10), with sindesmotic lesion (n = 6) and trimalleolar (n = 3). 6 months after surgery 22% of the patients returned to sports activity ant at 12 months 43%. At 12 months the younger patients (p = 0,0001) and men (p = 0,001) returned earlier to sports activity. At one year 80% of the amateur and 20% of the professional athletes, had returned to sports practice. Fractures of the lateral malleolus returned earlier in 16,2 weeks than medial malleolus fracture in 59,5 weeks. The SMFA and AOFAS scores were high in all types of fracture. Conclusion: Correct treatment of instable ankle fractures in athletes, with anatomic reduction and preservation of the integrity of the articular surface, is crucial to the return to sports practice. The fractures that influence an earlier return were younger age, male sex and less severe fracture, and negative predictors were older age and female sex. Athletes submitted to open reduction and internal fixation with adequate and precocious programme of physical rehabilitation, can return to the same level of sports practice, despite the seriousness of the fracture without pain and functional limitation(4). Results: In all cases anatomic reduction could be achieved. No secondary dislocation was observed and all fractures healed uneventfully.

Conclusion: Indirect reduction of the Volkmann triangle from anterior makes an image intensifier mandatory and has potential of not achieving anatomic reduction due intercalated tissue. In larger fragments the fixation with a lag crew from anterior, the buttressing effect might not be sufficient to avoid secondary displacement. With the use a postero-lateral approach and dorsal plate for fixation of the Volkmann triangle, it is possible to reliably obtain an anatomical reduction of the dorsal articular surface of the tibia, thus potentially minimizing the risk of posttraumatic osteoarthtitis. Introduction: After ankle-and hindfoot fractures, edema often delays surgery and postoperative mobilisation. Therefore effective treatment of edema is of great importance. The aim of this study was to evaluate the efficacy of the continuous lymphological multi-layer compression therapy and of the AV-intermittent impulse compression (AVI) in reducing ankle-and hindfoot edema. Material and Methods: Randomized, controlled, single-blinded, clinical trial. 64 patients (40 ± 15 years, 41 m, 23f) with unilateral fractures of the ankle or hindfoot pre-or postoperatively were randomized into A) the control group (elevation and cold packs), B) the continuous multi-layer compression therapy group (CCT) or C) the AV-impulse compression group (AVI). Primary outcome was the pre-respectively postoperative reduction of edema as measured with the figure-of-eight methode 20 . Results: Pre-and postoperatively the continuous lymphological multi-layer compression therapy (CCT) showed a significant better edema reduction when compared to the control group. After three days of intervention the mean preoperative edema reduction in the control group was -3.8 ± 10.4 mm (11.1%) figure-of-eight methode20 vs. -13.5 ± 6.7 mm (39.5%) in the CCT group (p < 0.01) and vs. -5.7 ± 9.3 mm (17.6%) in the AVI group. Three days postoperatively the mean edema reduction was -3.9 ± 9.8 mm (12.6%) in the control group vs. -11.6 ± 6.5 mm (34.5%) in the CCT group (p < 0.05) and -5.1 mm ± 15.6 (19.4%) in the AVI group. Pre-and postoperatively the CCT group shows moderate effect sizes after two days of intervention and large effect sizes after three days. AVI is more effective when combined with elevation during off-session periods. Conclusion: Continuous lymphological multi-layer compression therapy leads to a clinical relevant and significant better reduction of ankle-and hindfoot edema as compared to the standard treatment with elevation and cold packs. AV-intermittent impulse compression shows a tendency towards a better edema reduction compared to the standard treatment. Continuous lymphological multi-layer compression therapy reasonably can be applied when edema delays operation or postoperative mobilisation. Considering the AVI application we strongly recommend to elevate the leg during off-session periods.

Introduction: The objective of the study is to define the global hospital costs of a group of patients that suffered from severe trauma. Additionally we identify the distribution of the expenses between the different services and the different procedures fulfilled to the patient. (2), season (4), moon phases (4), times on duty (2) and weather condition (2) . The observed mortality was adjusted with the RISC based prognosis and the SMR calculated. Results: The selected collective had an average age of 40.4 years and 73% of the patients were males. The mean ISS was 26.1 and the mean hospital mortality was of 17.6%. For the time of day the highest rate of admission was between 6:00 and 7:00 p.m., with the highest numbers on Saturdays. In the times of on-call duty (weekend, public holiday, weekday between 5:00 p.m. and 8:00 a.m.) twice as much trauma patients were delivered to trauma centers as within the regularly working hours. In summer, the admission rate was highest (29.2%) and lowest in winter (21.3%), with more victims of car accidents in autumn and winter as in the warm season and more victims of motor-and bicycle accidents in spring and summer as in the cold season. But none of the mentioned factors showed an effect on survival (SMR between 0.98 and 1.00). The moon phases had no influence either on frequency of accidents nor on outcome. The effects of temperature was similar to this of the seasons: with warm temperatures/month less car accidents and more bike accidents occurred (and the opposite for cold temperatures). In the subgroup with temperatures under zero degree the mortality was 4% higher (21.5%) than in the subgroups with temperatures above zero (17,0 to 17,6, even though a similar ISS (26,4 vs. 25,9 to 26,2) . In a second step a multivariat analysis was done in order to improve the predictive power, but none of the external factors could improve the prognosis.

Conclusion: There are large variations in the incidence of severe accidents due to time of day, day of week and time of year. But there is no effect of patient's outcome in regard to medical care in German trauma centers. The quality of medical trauma care is consistent around the day, the week and throughout the year. Additionally, we observed an increasing difference between mortality rate and RISC prediction rate from -0,1% to -5,2%, means less deceased polytraumatized patients than predicted. Within the late secondary transferring patients with spinal cord injuries were leading (35%), followed by patients with pelvic injuries (26%), infections (16%) and complex extremity injuries (16%). Conclusion: With this investigation, we tried to characterize the influence of the new mapping of Germany on patient data using the example of the regional trauma network ''Saar-(Lor)-Lux-West-Rhineland-Palatinate''. Although, knowing a lot of interferences, we noticed an abrupt rise of primary admittances of trauma patients in our Level-1 hospital since starting networking. Among the load rejection for smaller hospitals this fact leads to a distinct concentration of the treatment of polytraumatized patients in specialized trauma centers. The improved routine by increased quantity could be responsible for the improvement of process and outcome quality in the treatment of severely injured patients. But, the enormous quantity of emergency patients also reflects a future challenge in dealing with emergency operations besides routine operations as well as seldom ICU-beds in these trauma hospitals. The role of the NLFC is to work in parallel to doctor led clinics, assessing and treating uncomplicated musculoskeletal injuries with a favourable natural history. Since its inception, throughput in this clinic has increased and with greater clinical exposure and training, the spectrum of referred injuries has also broadened. The aim of the present study was to determine patient satisfaction with the NLFC using a validated questionnaire with a specific emphasis on how patients viewed being seen by a nurse rather than a doctor Material and Methods: 173 consecutive patients were prospectively recruited in the NLFC in January 2008. Patients were referred by their resepective Consultants after reviewing the presenting history, examination findings and radiographs. After their consultation with the nurse, each patient was asked to fill in a 37 item questionnaire consisting of 6 different domains related to patient satisfaction based on a validated patient satisafction questionnaire adapted for use in the fracture clinic setting.

Results: There were 173 respondents, 79 men and 86 women, with a mean age of 35 years (range 2-82 years). 35 questionnaires were completed by parents, 4 by carers and the remainder by the patients themselves. The most common treated injuries were distal radial, metatarsal and metacarpal fractures. 97% of patients felt they received the best care from the staff working in the clinic with greater than eighty percent of patients registering satisfaction with the nurse's assessment of their injury, their bedside manner and the treatment and information given. Only 9% of patients felt that they would rather be seen by a doctor for their injury. The highest rates of dissatisfaction related to the building and seating comfort. Conclusion: Generally, over 85% of patients were satisfied with their clinic visit with the vast majority of patients not having any objection to seeing a nurse rather than a doctor. Patient satisfaction with treatment remains the ultimate outcome measure by which healthcare interventions should be assessed. The results of this study demonstrate the NLFC to be an effective method of managing selected patients in a clinic setting thus reducing the workload of patients which would traditionally be reviewed by the doctor. This has significant implications for improving opportunities for doctors training as well as reducing clinic waiting times. [1] [2] [3] [4] . The aim of this study is to evaluate the anatomical correlation between the lateral end of the clavicle and the attachment area of the supraspinatus tendon. Material and Methods: Using a mathematical model based upon CT-Scan data performed on healthy individuals, the 3 dimensional correlation between the lateral and of the clavicle and the rotator cuff is analyzed. Each individual is examined in supine position, using 3 different positions of the arm (maximum external rotation, maximum internal rotation and maximum abduction and external rotation (''ABER Position''), respectively). For every position the contact area of the lateral end of the clavicle and the spupraspinatus tendon is calculated. Results: Six healthy individuals (12 shoulders) could be included into the study. The average contact area between the lateral end of the clavicle and the supraspinatus tendon (%) is 51.9% for maximum external rotation, 61.7% for maximum internal rotation, respectively. In the ABER position only 4/12 shoulders showed a contact area > 1% (av. 1.6%). Conclusion: According to these morphological findings the contact area between the lateral clavicle and the supraspinatus tendon is less than 62%. This contact zone is located in the dorsal aspect of the clavicle. Therefore the additional resection of an osteophyte, especially at the anterior part of the lateral clavicle should not have a significant influence on the outcome after subacromial decompression. and good to moderate outcome in the CS (mean 69), one patient had a moderate DASH score of 57 with a poor CS of 41. Irrespective of treatment strategy the majority of the patients regained normal range of motion and grip strength in the affected shoulder. The most common complication was impingement of the shoulder, which occurred three times in the conservatively and four times in operatively treated patients. All but one conservatively treated patient with a non-union healed without complications. Conclusion: Minor ( £ 5 mm) and moderate (6-10 mm) displaced greater tuberosity fractures can successfully be treated conservatively with good to excellent long-term rehabilitation of function with a low risk of complications. Whereas there is no doubt that major displaced fractures (> 10 mm) should be treated operatively, special attention must be paid to moderate (6-10 mm) displaced fractures, as the degree of displacement may be misinterpreted on plain standard radiographs. Disclosure: No significant relationships.

Introduction: A recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. We studied impairment and disability an average of twenty-one years after injury in a cohort of Dutch patient, with the hypotheses that 1) objective measurements of impairment correlate with disability, 2) depression and misinterpretation of nociception correlate with disability; and 3) patients injured when skeletally mature and immature have comparable impairment and disability. Material and Methods: Seventy-one patients were evaluated an average of 21 years after injury. The majority of the 35 skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the 36 skeletally mature patients were treated with plate and screw fixation. Objective evaluation included radiographs and measurements of range of motion and grip strength. Questionnaires were used to measure arm-specific disability (Disabilities of the Arm, Shoulder and Hand: DASH), misinterpretation or over interpretation of pain (Pain Catastrophizing Scale-PCS-), and depression (CES-D). Multivariable analysis of variance and multiple linear regression were used to analyse the ability of the independent variables to account for variation in the DASH-score. (SPSS 17.0, SPSS inc., Chicago).

Results: There were 44 men and 27 women with a an average age of forty-one at time of follow-up (range, 20 to 81). Fractures were classified as AO/OTA-type A3 in 46 patients (simple), B3 in 18 (including wedge fragment) and C fractures in 7 patients (comminuted). The average DASH score was 8 points (0 to 54) and 72% reported no pain. Both rotation and wrist flexion/extension were 91% of the uninjured side; grip strength was 94%. There were small, but significant differences in rotation (151 versus 169 degrees, p = 0.004) and wrist flexion/extension (123 versus 142 degrees, p = 0.002), but not disability between skeletally mature and immature patients. The best predictors of DASH score were pain catastrophizing, pain, ipsilateral injury and grip strength, explaining 55% of the variation in DASH scores. Pain alone accounted for 40% of variation in DASH scores.

Conclusion: Twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over 90% motion and grip strength) and disability after non operative and operative treatment respectively. Patients that were skeletally immature at the time of injury had better motion, but comparable disability. Disability correlated with pain and pain catastrophizing rather than motion. Results: The mesenteric injuries vizualized on initial CT-scan were mesenteric vascular beading or extravasation in 6 cases, and mesenteric infiltration or hematoma in 13 cases. Associated abnormalities of the gastrointestinal tract (thickening, abnormal enhancement, perforation) were present in 11/19 cases (58%). Nine patients underwent surgery (26%), 6 patients in the early hours, and 3 others after a delay of more than 24 h. Indication for surgery was hemodynamic instability in 4 cases and suspicion of bowel perforation in 5 cases. In total, intestinal perforations were found in 8 patients. Three patients (15.8%) died of associated injuries. No false positive scan has led to unnecessary surgery. However, the negative predictive value of initial CT was 75% for intestinal associated lesions. Conclusion: The mesenteric injuries in blunt polytrauma patients are uncommon but serious. The whole body scanner is a powerful tool for the diagnosis of these mesenteric lesions. Conservative treatment is feasible but a clinical and paraclinical reassessment is essential for early detection of intestinal lesions initially undiagnosed, or aggravation of initial lesions. Disclosure: No significant relationships.

Introduction: Drug smuggling by gastrointestinal concealment, body-packers, is an increasing problem in developed countries. Although conservative treatment is usually successful in most cases, some of these patients suffer complications such as obstruction, gastrointestinal perforation or massive drug intoxication due to a leaking package. Despite an urgent surgery and a careful management in the ICU, morbidity and mortality remain high. Our aim was to assess the outcomes of conservative and surgical management of these patients in our hospital, the referral centre for this entity in Madrid. (1996) (1997) pre-hospital fatalities were more frequent (although not statistically significant), which may reflect improvement of trauma organization in recent years (1998) (1999) (2000) (2001) . Domestic (may related to delay due to victim's solitude) and urban environment (inexperienced personnel, delay due to referral to another hospital) incidents lead more frequently in pre-hospital death. Age and ISS as indicators of physiologic reserve and severity of injury were independent predictors of fatality before the victim reaches hospital. Introduction: The triad of the elbow is a complex traumatic injury. These injuries have traditionally been considered a poor prognosis for the consequences that arise as a secondary instability, stiffness and loss of functional ability. The objective of this free paper is to review from a clinical and radiological perspective our experience with 24 cases. Material and Methods: We retrospectively reviewed 24 patients with this type of injury. In 8 patients was not carried out a comprehensive treatment of all existing lesions. The coronoid process was not addressed specifically and fractured radial head was removed or and an osteosynthesis was performed. In the remaining 16 were treated by a treatment protocol trying to repair all the damaged structures (coronoid synthesis, radial head arthroplasty/ORIF and ligament repair, at least in the external lateral ligament complex). The median followup was 18 months (12-24).The results were evaluated by the scale of May Elbow Performance Score (MEPS), range of mobility, radiographic parameters and complications during follow up.

Results: Patients treated according to protocol in a systematic manner trying to repair all damaged structures had better outcomes in both the radiological point of view as functional, as well as a lower rate of complications. MEPS in these patients the average was 85 points (vs. 62 the other group), the arc of 95º flexoextensió n (vs. 60º) and the arc pronosupinació n 150º (vs105º). Conclusion: Despite being an injury traditionally associated with poor results, which have been established treatment protocols that try to treat all manner of injured structures involved in the injury outcomes have improved significantly. We think it must be performed a radial head artroplasty/ORIF (not resection), anchorage/ osteosynthesis coronoid process and a ligament repair at least of the external lateral ligament complex. If residual instabilty results it may be repaired the medial colateral ligament complex and a temporal external fixator may be used. Disclosure: No significant relationships. tion. 14 patients received a secondary implantation including 6 chronic luxations, 5 nonunions, 2 failed osteosynthesis and 1 reimplantation after deep prosthetic infection. The mean follow up was 14 ± 7 months. The functional outcome was measured by using the Mayo Elbow Performance Score. Results: We had 14 female and 7 male patients with a mean age of 69 ± 6 years. All 21 patients achieved very good results based on the ,,Mayo Elbow Performance Score'' with a postoperative mean of 97 points (range between 90 and 100 points) with a maximum performance of 100 points. The mean range of motion concerning extension and flexion was 94 degrees (55 to 115 degrees), concerning pronation and supination 144 degrees (100 to 160 degrees). The mean flexion deformity was 19 degrees (10 to 50 degrees), the mean maximum flexion was 113 degrees (90 to 130 degrees). We had two partial ruptures of the triceps tendon, one treated by operative refixation and one conservative, one temporary lesion of the ulnar nerve with complete recovery and one postoperative hematoma which needed surgical treatment. One patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. We recorded no radiographic loosening or other mechanical problems so far.

Conclusion: According to the used ''Mayo Elbow Performace Score'' all patients achieved a very good functional outcome. Eventhough they all had severe injuries of the elbow. With modern types of elbow prosthesis the rate of complications and revision surgery is quite low. Ô ur findings indicate that total elbow arthroplasty should be considered as an additional treatment alternative. Patients with a lower functional demand and of higher age benefit most from a prosthesis. For younger patients preservation of the joint should be achieved as far as possible. Introduction: It is not always possible to reconstruct complex radial head fractures. As non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. However secondary overload of the lateral facet of the humero-ulnar joint (with consequent arthritis), instability (especially in the presence of medial collateral ligament injury), painfull anteroposterior instability of the radial stump, and radial shortening (in Essex-Lopresti lesions) with wrist pain can be the result. Radial head arthroplasty widely is proposed as prevention of these complication.

However as we demonstrated in a systematic review of the litterature, radial head arthroplasty has equally high secondary arthritis rates as radial head resection. The complex anatomy of the radial head, articulating both with the capitellum and the proximal ulna is not reproduced by most contemporary radial head prostheses. Material and Methods: We describe the complex radial head anatomy based upon an analysis of 20 MRIâ e TM s of the elbow performed in healthy volunteers under standardised situations. We describe the next variables: â e¢radial head shape and diameter at the most proximal part of the PRUJ (proximal radio-ulnar joint) â e¢radial head shape and diameter at the midpoint of the PRUJ â e¢radial head height medial and lateral â e¢depth of the radial head through â e¢offset of the radial headâ e TM s through relative to the center of the radial head â e¢offset of the radial headâ e TM s through relative to the axis of the radius â e¢offset of the radial head relative to the axis of the radius â e¢angulation of the radial neck to the axis of the radius We compare these parameters to the available radial head prostheses.

Results: There is a high variability of the different parameters and no relation between all of the parameters could be determined. The existing radial head prostheses do only reproduce the anatomy to a limited extend.

Conclusion: The high rates of post arthroplasty arthritis can be related to the non-anatomical shape of the existing designs. As the proximal radius articulates both with the capitellum and the proximal ulna, a precise reconstruction of both joints is a necessity to avoid maltracking and/or edge contact in both joints. Given the high variability this only can be realised using a theoretic modular prosthesis that allows for reconstruction of the synchronisation between both joints. We found no significant differences (p > 0.05) in the deficit of the range of motion. Flexion: Screws 6 ± 10°, prosthesis 12 ± 13°, plate 8 ± 13°E xtension: Screws 7 ± 11°, prosthesis 13 ± 10°, plates 16 ± 18°P ronation: Screws 17 ± 19°, prosthesis 10 ± 14°, plates 25 ± 32°S uppination: Screws 6 ± 16°, prosthesis 13 ± 19°, plates 27 ± 30°A ccording to elbow functional evaluation criteria by Broberg and Morrey, we found excellent and good results in 60% of all patients treated with screws, in 58% of all patients treated with prosthesis and in 50% of all patients treated with plates (p > 0.05) The average DASH score of patients treated with screws was 11 ± 17 points, of patients treated with prosthesis 19 ± 17 points and of patients treated with plates was 16 ± 18 points (no significant differences, p > 0.05). The physical and mental component of the SF-36 score was at the time of follow-up within the normal range at all patients (physical component: screws 51 ± 9.7, prosthesis 46 ± 8.3, plate 52 ± 6.2; mental component: screws 54 ± 7.9, prosthesis 56 ± 6.6, plate 56 ± 4.5). In the subcategory of physical functioning, screws performed better than prosthesis (p < 0.05). No other items of SF-36 were significantly different (p > 0.05). Conclusion: According to our results osteosynthesis with only screws seem to be the best of the three studied methods. Radial head prosthesis replacement yields better functional results than treatment with plates. It must be considered that prosthesis replacement of the radial head has the long-term risk of loosening, especially in young and active patients. Plates showed worse clinical results especially in rotation of the forearm even after removing the plate in 7 patients. Disclosure: No significant relationships. S111 Is Angular Stable Osteosynthesis of the Olecranon More Economical than Traditional Treatment?

N. Spaepen 1 , K. Govaerts 1 , S. Nijs 2 , P. Broos 3 1 Trauma Surgery, UZ Leuven, Leuven, Belgium, 2 Department of Traumatology, University Hospitals Leuven, Leuven, Belgium, 3 Traumatology, University Hospitals Leuven, Leuven, Belgium

Introduction: Although tension band wiring is considered as the gold standard in the treatment of simple olecranon fractures and olecranon osteotomies, the complication rate is high (delayed healing in up to 15% of cases, hardware migration 13%). In an historical series using anatomical preshaped LCP plates, we could lower the rate of healing disturbances, but the volume of the implant did make hardware removal necessary in the majority of patients. The LCP 3,5 mm Hook plate is a low volume angular stable compression plate, designed for the treatment of simple fractures and osteotomies of the olecranon. In this study we want to evaluate the early results of using this new device for the treatment of acute fractures and osteotomies at a level 1 trauma centre. Material and Methods: We prospectively include all patients treated by LCP 3,5 mm hook plate between and. 6 months results considering range of motion (as measued by), MEPS (Mayo Elbow Performance Score), complications and radiographic results are presented. We perform a cost analysis of primary operation using the different implants available, length of stay and time off work. We also perform a cost analysis for reoperation because of delay in union Results: We included 21 patients. Average age is 55,6 years (range 17-83). There were 11 female and 10 male patients. At 6 months average extension deficit was 12°, the average flexion 130°. There was no substantial loss of pro-supination. All factures but one united anatomical (early loss of reduction, but patient refused reoperation). There were 3 complications: 1 early loss of reduction (treated conservatively), 1 CRPS (complex regional pain syndrome) and 1 arthrofibrosis necessitating implant removal). Because of symptomatic hardware two additional hardware removals have been performed. According to the Mayo Elbow Performance Score all but 1 patient scored good to Based upon the cost analysis the predicted average cost per patient is significantly lower in the hook plate group as compared to the tension band and anatomical preshaped plate group.

Conclusion: Although still a limited series, the early results of this implant are very promising. We document ranges of motion witch are comparable to those described previously in tension band wiring or anatomical plating, but at lower complication and reoperation rates.

Based upon an analysis of the cost of treatment and of reoperation we advocate the routine use of the olecranon hook plate in the treatment of simple olecranon fractures and osteotomies. Disclosure: No significant relationships. Material and Methods: Dutch surgeons (N = 23) were asked to draw two incisions for an OLAC on embalmed human specimen (N = 46). They also filled out a questionnaire of their experience. All incisions were photographed and digital measurements were taken. Each incision was compared to the gold standard on 4 criteria. Incisions should not be closer than two-thirds of the distance between: 1) Distal tip of the lateral malleolus and the Achilles tendon. There was no correlation between number of mistakes and number of procedures per year or years of experience (Spearman correlation: 0.03 and -0.04 respectively) The median of the mistakes for L-shaped incisions was 1 (IQR = 2) and 2 (IQR = 2) for J-shaped incisions (p = 0.017, Mann-Whitney). The Spearman correlation between the mistakes for the two incisions drawn by each surgeon was 0.55. Conclusion: Conclusions: Inter-surgeon variation of incision lines was high and since the number of mistakes per incision was not correlated to the surgeon's experience, CASAM can be useful in two ways: 1) Pre-operative planning using CASAM, might assist the surgeon in determining a 'tailor made' safe zone in each patient. 2) For educational purposes CASAM is able to compare a student's incision with the gold standard or the computed location of the sural nerve, thus providing personal feedback. Introduction: A precise sustentaculum tali screw placement is crucial for the fixation strength of operatively treated calcaneus fractures, as shown in biomechanical studies. Due to the complex anatomic shape of the calcaneus and the limited visualization of the sustentaculum tali fragment via the common lateral approach, the exact screw positioning is demanding and a bright knowledge of the surgeon is mandatory. With the introduction of navigation procedures an increased precision of implant positioning could be achieved for different applications, as reported for pedicle-and iliosacral screw placement. The aim of this study was the evaluation of different navigation procedures compared to the conventional technique for the placement of the sustentaculum tali screw. Material and Methods: 32 sustentaculum tali screws were placed via a standard lateral approach in artificial calcanei with a prefabricated soft tissue envelope. We used different navigation techniques: Group I: 2D-based fluoroscopic navigation Group II: 3D-based fluoroscopic navigation Group III: Fluoro-Free navigation compared to the standard procedure without navigation (Group IV). For each screw the time of procedure and time of fluoroscopy was measured. The precision was evaluated in postoperative CT scans. Results: No x-ray exposure was necessary for the standard procedure and the Fluoro Free navigation, whereas 17 ± 1.03 and 66.8 ± 0.9 s of fluoroscopy time were needed for the 2D-and 3D-based fluoroscopic navigation. Significant differences were observed for the mean procedure time: 1.26 ± 0.05 (Group IV), 3.49 ± 0.26 (Group III), 13.5 ± 0.49 (Group I) and 19.04 ± 1.41 min (Group II). No significant differences were seen for the precision with one mal-placed screw in each group. Whereas for the image based navigation procedures wide experience in computer assisted surgery was necessary, the Fluoro Free navigation procedure could easly used without that experience, due to a simplified and self-explanatory workflow. Conclusion: All three navigation procedures increase the intraoperative orientation for the placement of the sustentaculum-tali screw, but significant differences of precision compared to the standard technique could not be observed in our experimental set up. Potential reasons are a visual and tactile memory effect, despite a randomized order of drillings and a better visualization of the osseous structures in the used artificial model. In clinical situations a lack of surgical routine for this rare injuries and a limited display of anatomic landmarks exist, making all of the evaluated navigation procedures to a helpful tool. If the fracture reduction is controlled intraoperatively by an 3D fluoroscopic scan, we recommend the 3D navigation, otherwise we use the Fluoro Free navigation. Disclosure: No significant relationships. Overall satisfaction of functional status was measured using a Visual Analogue Scale (VAS; range zero to ten).

Results: Four-hundred metatarsal fractures were identified in 322 patients. The distribution of fractured metatarsals was: first metatarsal 5%, second 12%, third 14%, fourth 13%, and fifth 56%. Multiple metatarsal fractures were seen in 15.6%. Most fractures were caused by an inversion injury or fall from height (75%). More than eighty percent of fractures were undisplaced or minimally displaced, and most fracture patterns were transverse or oblique/spiral. A total of 166 patients (67.2%) returned the questionnaire with a median follow-up of 33 months. Responders were female in 56% and had a median age of 47 years (P 25 -P 75 32-58). In 51.2% of cases the left side was affected. The median AOFAS-score was 100 points (P 25 -P 75 87-100), the median VAS was 9 points (P 25 -P 75 8-10). In the univariate analysis the AOFAS and VAS score were inversely dependent of the body mass index (R s = -0.409 and -0.305; p < 0.001). Patients with known diabetes reported lower VAS (p = 0.010) and AOFAS scores (p = 0.020). Female patients reported a lower AOFAS (p = 0.034). An increase in dislocation (> 2 mm) resulted in a decrease in VAS (p = 0.017). No correlations were identified with outcome and which metatarsal was affected, number of fractured metatarsals, fracture type and location, articular involvement, and smoking habits. In the multivariate analysis the BMI correlated with the AOFAS (p < 0.001) and VAS (p = 0.011) and the dislocation with the VAS (p = 0.013).

Conclusion: This is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. Overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33 months. Outcome is dependent of BMI, diabetes, gender, and dislocation at the fracturesite. Disclosure: No significant relationships. Introduction: Incidence of fracture non-union is increased after severe trauma. The systemic inflammatory response syndrome (SIRS) resulting from major trauma appears to play a role in this healing impairment. Especially the cellular reaction associated with SIRS influences the inflammatory response, which is of vital importance in fracture healing. We hypothesize that systemic inflammation may impair healing through an altered interaction between neutrophils and stem-or osteoprogenitor cells within the fracture hematoma. We therefore investigated the effect of neutrophils on differentiation of mesenchymal stem cells (MSCs). Material and Methods: Osteogenic differentiation of MSCs was assessed using an alkaline phosphatase colorimetric assay on the adhered cell lysate after culturing MSCs for 7 days in the presence of different quantities of neutrophils. Chondrogenic differentiation of MSCs was assessed within the same samples using a glycosaminoglycan colorimetric assay in the cell medium. Proliferation was measured within the same samples using a Picogreen(R) dsDNA fluorescent assay. To assess whether any effect was mediated through release of soluble factors or through direct cell-cell contact, supernatants of stimulated neutrophils were used. Stimulation of neutrophils was achieved during 24 h with TNF-alfa. TNF-alfa in the supernatant was subsequently blocked with Humira prior to interaction with MSCs. Results: Low neutrophil concentrations resulted in increased alkaline phosphatase concentrations compared to control levels. High concentrations of neutrophils resulted in increased glycosaminoglycan concentrations and decreased alkaline phosphatase concentrations. Introduction: Angiogenesis is a cue element in the early wound healing and is considered most important for tissue regeneration. In addition to aiding research in understanding the regulatory mechanisms of angiogenesis and vasculogenesis, the concept of co-cultures has helped to better understand the mechanisms of interactions between osteoblasts and endothelial cells focusing on new therapeutic approaches for critical size bone defects. Here, we describe in detail the cellular and molecular interaction between human osteoblasts (hOB) and human endothelial progenitor cells (EPC) in a complex 3D-environment. Material and Methods: We investigated endothelial differentiation and morphological organization of human EPC in cocultures with hOB using methylcellulose sphaeroids as well as collagen biomatrices. Cocultures of human umbilical vein endothelial cells (HUVEC)/ hOB were used as controls. EPC were tracked with cell tracker red, whereas hOB were transduced using a lentiviral eGFP-vector to allow direct cell visualization using confocal laser microscopy and analysis of cell-specific gene expression. We studied the survival of both cell types and formation of vessel-like sprouts as a criterion of endothelial activity of EPC. Expression of several relevant angiogenic and osteogenic markers, as well as different extracellular matrix proteins was investigated using quantitative RT-PCR.

Results: Using the hybrid coculture technology we could clearly show that hOB regulate the survival, proliferation, and spouting of EPCs. Concordantly, expression of endothelial cell markers CD31 and vWF was significantly up-regulated by cocultivation with hOB. By contrast, EPCs did neither proliferate nor did they form any apparent vessel-like structures when cultured in a monoculture. Using the lentiviral eGFP-reporter transduction method the expression of osteoblast marker genes was also estimated accurately. We could clearly show that EPCs inhibit the terminal differentiation of hOB by interfering with expression of specific transcription factors RUNX2 and SP7. In contrast, cell proliferation and expression of the early osteoblastic differentiation marker ALP were induced in cocultures.

Conclusion: In the present study we demonstrate that human endothelial progenitor cells interact with human osteoblasts on the cellular level. We have identified a complex regulatory mechanism which accounts for endothelial cell survival and cell differentiation of both cell types. This study provides new insight into regulatory mechanisms of bone regeneration and may unveil potential applications in bone tissue engineering and fracture healing. Introduction: Failure of fixation is more common in osteoporotic than in other fractures. Early treatment of osteoporosis as well as early stimulation of the fracture healing may improve the later clinical outcome. Bisphosphonates are effective in osteoporosis treatment, and bone morphogenetic proteins (BMPs) stimulate fracture healing, although several studies show less effect in estrogen deficient models. In order to determine the effect on early fracture healing of bisphosphonates and BMPs in osteoporotic fractures, these treatment modalities were applied in estrogen deficient rats. Material and Methods: Fourty rats underwent an ovariectomy (OVX), followed by low calcium diet during six weeks. Ten rats underwent a sham operation, followed by normal diet. After six weeks, a closed femoral fracture was induced in all animals. The OVX animals were then assigned to four different groups: OVX alone, injection of bisphophonate, injection of BMP-7 in the fracture gap, or the combination of these. All animals received a normal diet after the fracture. After sacrifice at two weeks, fracture healing was evaluated using radiographs and four-point bending stiffness andstrength.

Results: Radiographs showed a higher score in the BMP-7 treated animals, with or without the bisphosphonates (p = 0.002, Kruskal-Wallis test). No delay in healing was seen in estrogen deficiency as compared to the sham group. Bending stiffness was higher in the BMP-7 treated groups compared to the others (p = 0.004, Kruskal-Wallis), as was the strength (p = 0.015, Kruskal-Wallis). No significant improvement was found by the injection of bisphosphonates Conclusion: Early fracture healing is significantly stimulated by injection of BMP-7 in the fracture gap in estrogen deficient rats.

Early treatment with bisphosphonates showed no effect on fracture healing. Introduction: Traumatic brain injury (TBI) is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly due to humoral factors. However, the pathophysiological mechanism of heterotopic ossification after TBI is still not fully understood. This study investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with TBI. Material and Methods: Blood was collected from 17 patients with severe TBI as well as ten control subjects. Primary skeletal muscle cell cultures were isolated from orthopedic surgery patients and characterized using immunohistochemical techniques. Proliferation and osteoblastic differentiation were assessed using commercial cell assays, Western blotting (for osterix protein) and the Villanueva bone stain. Results: All serum-treated cell populations expressed osterix after one week. Cells treated with serum from both study groups in mineralization medium had increased ALP activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks. Serum from patients with TBI induced a significant increase in the rate of proliferation of these cells compared to the controls (p < 0.05). Introduction: The current gold standard to establish the diagnosis of osteoporosis and to follow the pharmacological treatment is the measurement of the bone mineral density (BMD). With a growing number of predicted fractures due to osteoporosis the expenses for BMD-measurement will increase. It was therefore the objective of this study to determine parameters that possibly allow a laboratory follow-up of these patients. Material and Methods: Since 2008 we operated 166 patients (Ø 74.8 y, 84% female) with an osteoporotic fracture (group1). All of them were more than 65 years old and underwent a laboratory screening including the serum levels of Vit-D 25-OH, Vit-D 1.25-OH, calcium (S-Ca), phosphate (S-PhO), P1NP, b-Cross-Laps, intact PTH, osteocalcin, TSH and sex hormones as far as the urine concentration of Calcium (U-Ca) and phosphate (U-PhO). In Vit D 25-OH insufficient patients without treatment a therapy with Alandronat 70 lg once a week and daily calcium and Vitamin D3 substitution was started. 37 patients (Ø 68.3y, 54% female) of the orthopedic department underwent the same screening and served as a control (group2). These patients did not sustain a fracture or relevant surgery within at least 6 months. In a second part we checked the evolution of group1-patients laboratory screening at a 3, 6 and 9-months postoperative interval.

Results: Group 1 and 2 displayed significant differences with regard to S-Ca, U-Ca, U-PhO (p < 0.001), osteocalcin (p < 0.02) and Vit-D 25-OH level (p < 0.01). After separating male and female patients significant serum concentration differences of testosteron (p < 0.02) in the male patients and of FSH (p < 0.01) and oestradiol (p < 0.001) in the female patients could be observed. During the follow up at 3, 6 and 9 months we could demonstrate a significant elevation of S-Ca (p < 0.001), S-PHO (p < 0.03), osteocalcin (p < 0.03) and Vit-D 25-OH (p < 0.04) concentration. Further we found a significant elevation of FSH-(p < 0.001), LH-(p < 0.02) and Testosteron (p < 0.01) concentration as well as a significant decrease of the oestradiol (p < 0.001) concentration.

As former studies showed we confirmed by comparing group 1 and 2 a deficiency of Vit-D 25-OH, S-CA and an elevation of U-Ca in patients with osteoporotic fractures. We could also show a significant difference of the concentration of osteocalcin. By following these blood parameters during treatment we found an improvement or normalization of these differences as a result of the treatment. Therefore we believe that Vit-D 25-OH, S-CA, U-Ca and osteocalcin could serve as follow-up parameters in the treatment of osteoporosis. Further our preliminary results suggest that under the treatment there is a decrease of the testosterone level in male patients and a decrease of the FH-and increase of the oestradiol-concentration in female patients which has not been reported in the literature yet. In 20 consecutive cycli an alternating traction of 40 Newton was exerted on the subscapularis and infraspinatus, while a continuous force was applied for the supraspinatus. The motion of the tuberosities and the shaft were recorded by 2 high-speed cameras. The following parameters were investigated: Failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. Results: Group 1: Cable fixation was significantly more stable for intertuberosity motion and tuberosity-shaft motion. Furthermore we found 2 failures for the lesser tuberosity in the suture group. We found no significat difference for the metaphysis-shaft motion. Group 2: The greater tuberosity-shaft motion was significantly lower using two cables. All other parameters showed no significant difference. We found no failures. Group 3: Since the tuberosity-shaft motion and the intertuberosity motion were significant higher using fibre-wire, this series was abandoned after 6/8 pairs. Conclusion: Cable fixation is significantly more stable than suture fixation for tuberosities in shoulder arthroplasty. Double-cable fixation does not improve intertuberosity stability. We found tendencies for an enlarged tuberosity-shaft stability. Introduction: The results following prosthetic treatment of primary humeral head fractures present great variability. Dissolving of tuberosities leading to dysfunction of the rotator cuff with limited motion, pain and instability are often reported. The short term results on inverse prosthesis on the one hand are promising, whereas scapular notching turns out to be a major problem leading to a high failure rate in the long run. High complication rates are also reported. Material and Methods: In an ongoing prospective and consecutive multicentre study until today,199 cases with an inverse shoulder prosthesis system are documented. In this series we analyse the results of the cases treated for primary fracture as indication. In all cases the Affinis Ò Fracture Inverse prosthesis has been used. This implant was specially designed as a reversed treatment option for selected fracture cases. Mechanical and biological notching should be reduced due to the special design features of the prosthesis. Patients were asked to describe pain and satisfaction for the injured shoulder one week before the trauma and also to fill in the ASES Score. The Constant Score for the healthy shoulder was measured whenever possible. Postoperatively Constant and the ASES Score were assessed. The X-rays were evaluated for notching and the healing of the tuberosities.

Results: From February 2008 until today a total of n = 35 cases (29 females and 6 males) were treated for primary fracture with the fracture prosthesis. Mean age at operation was 79.4 years (range 63.4 -95.5). According to the Neer classification we treated 28 patients with a 4-part fracture, 5 with a 3-part fracture and 2 cases with a head split fracture. After a mean of 9 months (range 1 -20) the CS reached 55.8 points. Active forward elevation was 114.5°and passive 128.4°. The active lateral elevation (abduction) was 108.0°for the active movement and 112.5°passive. The ASES Score was 68.2 points at the latest follow-up and the value for pain and satisfaction were 1.9 and 7.6 respectively. We found no notching in this series and the tuberosities were judged as anatomically healed in 50% of the cases. We found no difference in the clinical outcome between patients with healed tuberosities compared to the group with non visible tuberosities. Postoperatively two complications occurred one fracture of the clavicula and one fracture of the acromion. So far we did not have any luxations or implant disconnections. Introduction: The purpose of this study is to evaluate the survival and function of splenic autotransplants using spleen imaging with Tc 99m labeled heat-damaged erythrocytes.

Material and Methods: 40 patients with splenic rupture underwent spleen imaging with Tc 99m labeled heat-damaged erythrocytes at 1 to 2 months after splenic autotransplantation (early scans); also, 15 of them underwent the same imaging technique at 3 to 6 months after operation (follow-up scans).

Results: On early scans, splenic autotransplants were faintly and the intensity of radioactivity in autotransplants was lower than in liver. The increase of intensity of tracer accumulation in autotransplants was significant higher on follow-up scans. One week after operation the levels of CD 4 , CD 8 and CD 4 /CD 8 ratio were significantly lower than those of controls and returned to normal 3 months later.

Conclusion: The spleen imaging with Tc 99m labeled heat-damaged erythrocytes is a valuable and effective method for evaluation of the survival and function of splenic autotransplants. , respectively 20/ 17 in the group ''skiers''(59%) and 6/12 in the group ''snowboarders''(50%). The AAST grade of injury was: AAST 1 1 case; AAST 2 11 cases; AAST 3 10 cases; AAST 4 6 cases; AAST 5 1 case. 3 of the 19 ''skiers''(17%) and 6 of the 12 ''snowboarders''(50%) showed a high grade (AAST > 3) splenic injury. 8 patients has an Injury severity score > 15 (4/19 skiers and 4/12 snowboarders): 2 cases of severe brain injury, 2 case of associated liver injuries, 3 cases of associated left renal injuries. 1 patient had associated colonic and pancreatic injury. Four patients were not stables at admission and had immediate laparotomy with 3 splenectomies. 25 patients were elected for nonoperative management.

Results: 6 splenectomies was performed with a splenic salvage rate of. 79%. There was no mortality and morbidity was 15%. For thr three patients who had immediate splenectomy the recovery was uneventfull. In te group nonoperative management three patients had angioembolization and four had delayed laparotomy (3 for delayed splenic rupture at post injury 4,5 and 9 resectively; 1 for SIRS).

In the 26 patients with availables data, mean hospital stay was 10 days (3-88), 7.7 days (3-88) for the group skiers and 12-25 days (5-47) for the group snowboarders. 14 patients(54%) were recovered less than 10 days. 16 patients were admitted initially in ICU ward(from 1 h to 46 days).

Conclusion: Ski accidents are in cause for more the one-third of all splenic injuries admitted to Grenoble University Hospital. The mean age is lower and male incidence is higher than splenic injuries admitted for others causes (road traffic accident, falls, other mountain accidents). An high number of snowboarder's' accidents was observed and pattern of injury is poor in these patients. The incident of polytrauma cases was the same in two groups and this observation confirm that snowboard practice is at higher risk than skiing for severe splenic injuries. In France, if number of raod traffic accidents is decreasing, the number of sport accidents is imcreasing in the last years. A better comprehension of mechanism, epidemiology and hystological findings of splenic injuries resulting from skiing and snowboarding is necessary to improve trauma preventiin programs. Introduction: Management of splenic injuries has evolved over the past three decades. Prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of the concern about ongoing hemorrhage and/or missed intraabdominal injuries. In children the nonoperative management (NOM) of splenic injuries rapidly gained interest because of the significant incidence of post-splenectomy sepsis as well as the complications associated with non-therapeutic laparotomies. The last decade has witnessed a proliferation of reports of NOM in adults with injuries to the spleen. Inclusion criteria for NOM in adults, which have been a source of controversy, continue to evolve. Moreover we noted that most publications focused on isolated splenic injury and not on patients with multiple injuries. This study was conducted to summarize the indications for the NOM of blunt splenic injury with special attention to the multiply injured patient. Material and Methods: We conducted a medline search. The search was designed to identify English language citations between 1974 and 2009: using the keywords: blunt splenic injury, conservative management, multiply injured patients and blunt abdominal trauma. The bibliographies of the selected references were examined to identify relevant articles not identified by computerised search. One hundred articles were identified. A cohort of three trauma surgeons selected 50 articles for review and analysis.

We used the methodology developed by the agency for Health Care Policy and research of the United States Department of Health and Human Services to group the references into three classes. Reviewing all data showed that the NOM of blunt splenic injury is a save treatment modality in isolated cases but also the multiply injured patient. Conclusion: Currently the non-operative management of blunt injury to the spleen is the treatment modality of choice. Important is a haemodynamically stable patient, with no signs of peritonitis on physical examination. Patients who only maintain their blood pressure by the constant infusion of crystalloid or blood products are not haemodynamically stable and need surgical intervention. CT scan findings and grade of injury are not, in themselves, criteria for laparotomy. These criteria are applied to isolated injuries to the spleen but can also be applied to the multiply injured patient. Age itself is not a contraindication. The general condition of an individual patient needs to be decisive. and finally hospitals with a low trauma incidence can safely use these guidelines in their management protocol. Introduction: The treatment of trauma patients with solid organ injury has changed over the last 15 years towards a less invasive treatment. Still our algorithms especially in dealing with trauma patients with ongoing internal abdominal haemorrhages is still based on fast control en stopping of the bleeding by any means. The use of CT-abdomen and subsequent performing angiography and embolization takes time. We analyzed the time path involved in angiographic control of the bleeding spleen. Material and Methods: A retrospective study. The study group consisted of ten patients presenting at our institution with a traumatic spleen injury in the period November 2006 till November 2008. All patients were managed according to the principles of ATLS. Data were analyzed using SPSSÒ 16.0. Results: The study group consisted of seven men and three women. Average age was 25 years (range 15 till 39). The ISS was on average 26 (range 20 -40). All patients in the study group received an angiography after CT-abdomen which showed an active bleeding focus in the spleen. Organ injury score were eight grade 4 and two grade 3 spleen injuries. Average time from admission to angiography was 139 min. Time to control of bleeding by embolization took average 50 min. Time loss between CT and angiography was on average 88 min. Conclusion: The time paths involved in managing this group of trauma patients with spleen injuries by embolization are much longer than expected. The time involved after diagnoses to actual control of the bleeding spleen injury is much longer than anticipated. Logistic changes to limit the time loss in interpretation of data from the CT-A, transfer of the patient, preparation of the angio-suite and less time consuming technique to actual embolization are needed. Articles were eligible if they reported the failure rate of NOM with or without angio-embolization (AE) in pediatric patients with splenic and/or liver injuries with a contrast blush on CT and included two or more trauma patients. Two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. Interrater differences were resolved by discussion.

Results: Nine studies were included describing 117 pediatric patients. The median sample size was five (range 2-44). Seven studies (including 71 patients) reported a total of 16 patients with failure after NOM without AE. Failure rates across these studies ranged from 4.5 to 100%; the pooled percentage was 28.2% (95% CI: 8.9%-61.3%). The failure percentages after NOM with or without AE ranged from 0 to 100%; the pooled percentage was 21% (95% CI: 7.5%-46.8%. Two studies (including 46 patients) reported a total of 3 patients with failure after NOM with primary AE: a percentage of 6.5%.

Conclusion: Despite the current low level of evidence on failure rate of NOM when a contrast blush is present on CT we emphasize that there is a significant amount of patients in whom NOM fails. We therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiological response but also when a contrast blush is present on CT. Results: Primary blast injury: this form of injury results from the deleterious effects of the blast wave passing through the body. These waves have little or no effect on solid organs but have their major destructive potential in air containing organs, especially lungs. Secondary blast injury refers to the impact on a patient's body of projectiles usually inert. The addiction of destructive metal fragment, nails and other such objects to bombs increase the severity of injury and lethality. Tertiary blast injury refers to the deceleration and impact with the ground, wall or other inanimate object of the patient whose body is displaced by the blast. Quaternary blast injury refers to the miscellaneous forms of injury by-products of explosions, burns, inhalation of dust, contamination in case of ''dirty bombs'' or penetration of allogenic body parts shrapnel. This last one asks the question of contamination by hepatitis or HIV and modalities of surveillance and treatment.

Conclusion: Blast injuries are complex and require the expertise of surgeons for their evaluation, treatment and longterm recovery. The victims of this form of terrorism sustain unusually severe and complex multidimensional forms of trauma not typically encountered in routine surgical practice. Surgeons must be leaders and active participants in disaster planning and management; they are uniquely qualified to manage the physical trauma that results from most forms of mass casualty events, including blasts. Disclosure: No significant relationships.

A. S. Dogjani 1 1 General Surgery, Military University Central Hospital, Tirana, Albania

Introduction: As the risk of terrorist attacks increases in the world, disaster response personnel must understand the unique pathophysiology of injuries associated with explosions and must be prepared to assess and treat the people injured by them. The explosions at the army depot in Gerdec village, some 10 km north of Tirana, were heard more than 50 km (30 miles) away. Introduction: During the last decades there is a debate concerning the fact if the facial fracture can cause further damage or somehow to protect the brain parenchyma from a more severe injury. The aim of our study is to analyze the effects of facial trauma exerted upon brain parenchyma.

Material and Methods: A series of 500 patients with craniofacial fractures was studied. The injuries were separated into five grades of severity based on neurological examination including cranial CT. The injuries was also grouped into three categories based of facial regional involvement CT -facial reconstruction Results: The Control group included 383 patients with head trauma but without any facial fracture or brain injury. In group A included 82 (16,4%) patients with both facial fracture and brain damage.Among them 30 diagnosed with temporal-mandibular fractures accounting for 36,5%, 6 patients(7,31%) had lower mandibular fracture, 34 patients (41,4%) diagnosed with nasal fractures and 12 patients (14,6%) had orbital fractures. In group B were categorized 35 patients with only brain damage accounting for 7%. Conclusion: The data demonstrated that patients with upper facial fractures were at greatest risk for serious closed head injury (CHI).Injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild CHI with a modest likelihood of no neurological deficits. Trauma to only the mandibular region or to only the midfacial region was least likely to involve CHI Disclosure: No significant relationships. Introduction: Post-traumatic stress disorder (PTSD) is a psychiatric disorder that results from exposure to a traumatic event. The individual may develop symptoms of three distinctive types: intrusive and unwanted recollections, avoidance followed by emotional withdrawal, and heightened physiological arousal. People who are exposed to traumatic events may also have somatic symptoms and physical illnesses, particularly hypertension, asthma and chronic pain syndromes. Hospitalized victims of suicide terror attacks are unique due to the circumstances and severity of their injuries which could have possibly affected the occurrence of PTSD and delayed the recognition of PTSD development. Our objectives were to evaluate the prevalence and severity of PTSD among hospitalized victims of suicide bombing attacks and to assess variables of physical injury as risk factors for the development of PTSD. Material and Methods: Forty-six hospitalized victims of suicide bombing attacks were evaluated for PTSD using the PSS-sr questionnaire by phone. Demographic and medical data considering the severity of injury, type of injury and medical treatment were collected from the medical files. Injury Severity Scale (ISS) was used to assess severity of physical injury.

Results: The prevalence of PTSD among hospitalized victims of suicide bombing attacks was 52.2%. Presence of blast lung injury was significantly higher in the PTSD group compared with the non-PTSD group (37.5% vs. 9.1% respectively, p < 0.04). There was no significant difference in ISS values between PTSD and non-PTSD groups. Blast lung injury and intracranial injury were found to be predictors of PTSD (odds ratio 125 and 25, respectively). No correlation was found between length of hospital stay, length of ICU stay or severity of physical injuries to the severity of PTSD. Conclusion: Hospitalized victims of suicide bombing attacks are considerably vulnerable to develop PTSD. They should be evaluated with a high level of suspicion in order to identify PTSD symptoms and treated as soon as possible in conjunction with physical treatment. Blast lung injury and intra cranial injury are predictors of PTSD. Victims suffering from these conditions should be monitored closely and treated in conjunction with their physical treatment. Conclusion: From the use of the SMART adopted for the evaluation of the code of entrance in Emergency Department, we have deduced and confirmed the facility and the speed of use of this new model of triage. The triage SMART typically holds not only besides in consideration the traumatic pathologies but also internists that, it is an usable advanced triage both on the territory and in the hospital. We can classify the model SMART triage as a valid system in case of a disaster as is reliability and sensibility of assessment of patients result to be more appropriates in comparison to the other models of triage taken in examination. Conclusion: We showed that alcohol, massive bleeding needed blood transfusion and age were risk factor of trauma and Japanese emergency medical technician attendance was effective for trauma care. We suggested the reason of detachment by the injury form was that Japanese penetrating wound include many stub wound not gun shot wound. Introduction: Rapid aging of Japanese population is causing numbers of emerging problems in trauma patients care which consists of trauma in elderly people and increased pre-existing co-morbidities such as cardiovascular diseases, neoplasms and organ failures. Nevertheless, little is known about the relationship between co-morbidities and trauma. The aim of the study was to clarify the influences of co-morbidities on the trauma mortality, using data from the Japan Trauma Data Bank (JTDB), a multicenter, nationwide and prospectively recruited trauma registry in Japan. Material and Methods: We selected the records from JTDB which fulfilled the requirements to estimate trauma injury severity score (TRISS) system. Logistic regression analysis after adjustment for baseline trauma severity based on TRISS system assessed the risk of in-hospital trauma death for following co-morbidities: hypertension (HT), diabetes (DM), psychotic disorders (PD), dementia (DE), stroke (ST), chronic obstructive lung diseases (COLD), bronchial asthma (BA), coronary diseases (CHD), congestive heart failure (CHF), liver cirrhosis (LC), chronic hepatitis (CH), chronic renal failure on dialysis (CRF) and active cancer (ACN). We conducted a couple of analysis which were adjusted or unadjusted by age in consideration for confounding between co-morbidities and elderly in age. Introduction: Monitoring the quality of trauma care is frequently done by analyzing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center traumatic deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma center for (potential) preventability. Material and Methods: All patients who died during or after presentation in the trauma resuscitation room in a two year period were eligible for review. All information on trauma evaluation and management was summarized by an independent physician. An external multidisciplinary panel individually evaluated the cases for preventability of death. Disagreements in classification were resolved during two consensus meetings. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the panel and the AMC consensus.

Results: Of the 62 evaluated trauma deaths one was judged preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the AMC consensus was moderate (Kappa 0.51). The classification of the panel was more favourable than the AMC consensus. The interobserver agreement between the review panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Most frequently mentioned errors were related to choice or order of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. Conclusion: The preventable death rate in the present study was comparable to the available literature. External review does not seem necessary to improve our current internal reviewing system. However, multidisciplinary reviewing of our trauma deaths provided us potential insights to optimize trauma care. Disclosure: No significant relationships. Arab Emirates (UAE). The aim of this paper is to report on the long term effects of our early analysis of this registry. Material and Methods: Data in the early stages of this trauma registry were collected for 503 patients during a period of 6 months in 2003. Data was collected on a paper form and then entered into the trauma registry using a self-developed Access database. Descriptive analysis was performed.

Results: Most were males (87%), the mean age (SD) was 30.5 (14.9). UAE citizens formed 18.5%. Road traffic collisions caused an overwhelming 34.2% of injuries with 29.7% of those involving UAE citizens while work-related injuries were 26.2%. The early analysis of this registry had two major impacts. Firstly, the alarmingly high rate of UAE nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. Second, the equally alarming high rate of work-related injuries led to collaboration with a Preventive Medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention.

Conclusion: Analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention. Disclosure: No significant relationships. as a result of injuries related to skating on natural ice. We analysed epidemiological aspects, diagnostically examinations, prevalence of injuries per anatomical location as well as the necessary therapeutic interventions and costs for national health services.

Results: Injuries related to skating on natural ice accounted for 47% of all 259 attendances. The mean age for man and women did not significantly differ (43,2 and 42,5 years resp.; p < 0.05), but adults aged 41-60 years are more prone to injuries. Women were affected in 60%. Radiological examinations were requested in 94% (87% Xrays; 7% CT-scans). The upper extremity was affected in 75%, with the wrist accounting for 64% of those injuries. Fractures accounted for 79% of all ice-skating related attendances. An operative therapy was indicated in 23%. The mean costs for national health services were e1416 per patient. Conclusion: Fractures, especially those of the upper extremity, were the predominate type of injury as a consequence of collectively performed skating on natural ice. This incidence is >2 times higher compared to fractures occured during skating on artificial ice-rinks [2] . Wearing wrist guards is an effective tool in protecting skaters against injuries. We recommend wearing wrist guards during skating on natural ice [1, 4] . Especially (employed) adults aged 41-60 years are very prone to injuries resulting in a high loss of work days [2] . In contrast to children, adults might be more accessible for wearing protectors [3] . In future it seems reasonable for national health services to provide steps to increase public awareness on the benefits of prophylactic safety measures. This might result in a substantial reduction of costs for health care and society. Introduction: Liver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. We therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients. Material and Methods: Using the multi-center population-based Trauma Registry of the German Society for Trauma Surgery, we retrospectively compared outcome in patients (ISS > = 9, > = 18) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis Means were compared using Student's t-test and analysis of variance (ANOVA) and categorical variables using chi 2 (p < 0.05 = significant). Results: Overall 13,527 patients met the inclusion criteria and were, thus, analyzed. 713 (5.3%) patients had a documented alcohol abuse and 91 (0.7%) suffered from liver cirrhosis. Patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. More specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted (31% vs. predicted 19%) and increased single-and multi organ failure rates. While alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality. Of note, alcohol abuse significantly decreased 24-hour mortality. Conclusion: Patients suffering from liver cirrhosis are at maximised risk for impaired outcome after multiple injuries. Pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile. Introduction: Early in-hospital treatment of severely injured patients has been internationally standardized by the implementation of algorithms such as the ATLS Ò -concept. However, due to lack of time, the instability of the patients and the complexity of injuries, there is a risk that some lesions will be missed at this stage. The purpose of our study was to evaluate the incidence and significance of these missed injuries.

Material and Methods: Retrospective chart analysis (in-hospital and follow-up as outpatient) of data prospectively collected via an AccessÒ-based documentation system was performed. Missed injuries were determined as injuries not found during primary and secondary survey. Introduction: Complication registration is important for monitoring the quality of health care. Aim of this article was to describe the incidence, type and impact of complications occurring within 6 months after the initial trauma in multitrauma patients. Second, we assessed potential risk factors for the occurrence of complications. Material and Methods: During a 2-year period all trauma patients presented to the Academic Medical Center and having an Injury Severity Score of ‡ 16 were included. Patients who were directly transferred to other hospitals were excluded. We used the prospective Dutch National Surgical Complication Registry of the AMC, a Level-1 trauma center, to assess complications within 6 months after the initial trauma. For verification we additionally performed a chart review and searched the decubitus specialists-and ICU registration. Complications were graded 0 (no real health loss) to 4 (lethal). Identification of risk factors associated with an increased risk of complications was performed by univariate analysis. We also analyzed an autopsy findings of these patients and found that 7 of 19 (36.8%) had a difference between clinical and autopsy ISS. The most frequent missed injury were rib fractures. Six of these 7 patients were hospitalized in a period when we did not use MSCT routinely in multiple injured patients. Conclusion: TRISS is not a clinical prognostic tool but is used retrospectively for clinical and epidemiological research, performance evaluation, and resource allocation. It is required as a basis for quality assessment and improvement. In combination with autopsy findings, TRISS methodology can be an valuable tool for recognition of unexpected trauma deaths and further analyze of possible treatment errors. Patients had to be operated 5,3 times and were treated 23 days in the ICU and stayed 73 days in hospital. Mortality rate was 36% and rate of multi-organ failure 28%. 15% demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the POLOchart. A personal interview was performed with 13 patients. The state of health was at least moderate in 72% of patients. In 48% interpersonal problems and in 41% severe pain was observed. In 57% problems in working ability concerning duration, as well as quantitative and qualitative performance were observed. Symptoms of post-traumatic stress disorder were found in 41%. The more distal the lesions were located (foot/ankle) the more functional disability affected daily life. In only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability. Conclusion: Even severely injured patients after polytraumatization have a good prognosis. The ISS is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. Introduction: One of the most common cause of preventable deaths in severe trauma is represented by delay in diagnosis and treatment of injuries, therefore a good teamwork aimed to reduce time consumption and errors is essential. There is in fact good evidence that the outcome of trauma care depends on effective trauma team performance (TTP). Critical points during trauma management are represented by lack of leadership, information sharing, difficult communication and decision making. To improve TTP, advanced simulators with full scale realistic patients (1) and trauma crew resource management (CRM) educational programmes are increasingly being used. Material and Methods: We made a survey among health care professionals (HCP) from 9 different level I and level II trauma centers in the Milan area that confirmed that difficulties in communication and conflictual behavior during trauma action is perceived as a barrier to ideal management. After a focus group interview to establish the need to improve performance we tested in our hospital a tailored trauma teamwork course using an advanced human patient simulator. The peculiarity of this course is the recreation of the same location of the trauma bay using same trauma team components and teamwork laboratory conducted by a professional coach as facilitator for the teamwork. This role is particular important since with this facilitation HCP can reach the awareness of wrong attitudes that lead to errors and bad performance. In particular, the tasks of the facilitator were the following: to help people understand their common goals to assists the Trauma Team to plan to achieve common goals to assist the group in achieving a consensus of any disagreements that preexist or emerge in the meeting so that it has a strong basis for future action A second survey few months after the course was made among HCP of our institute to evaluate the possible improvement of the TTP. Results: The second survey confirmed a perceived benefit among HCP who started to work in a proactive manner. In particular 78% of HCP reported the feeling of a better TTP and 86% suggested regular practice with advanced simulation. Conclusion: Integration of a tailored advanced simulation and a facilitator assisted teamwork could be a powerful method to improve quality of treatment in trauma patients. A score index to evaluate the improvement of the TTP during the course and in reality is although needed and is under evaluation. Introduction: Our university hospital is one of the only two national university hospitals in Tokyo and our emergency medial center is one of the busiest emergency center in Japan that receives 25 to 30 ambulances per day. Japan has a quite unique emergency medical system in the world. In Japan, emergency patients are stratified into 3 tiers, minor-primary, moderate-secondary, severe-tertiary. Japanese emergency doctor, that is not same as the emergency physician in the USA, take care only for the most severe emergency cases, tertiary level emergency patients. And if they find out the patient who needed an emergency operation, then they do the surgery by themselves.

If the patients need to admit to ICU, they take care the patient in ICU by themselves. This unique system was installed in mid-1970 s. Japanese emergency doctors do not only trauma cases, but also nontrauma severe emergency cases. For talking about trauma, they do not only the initial management of trauma patients but also do emergency surgery and trauma critical care. The MOU came into effect with the signatures of the appropriate representatives, acknowledging that four courses had been run in Portugal prior to its signature and that all future courses would be conducted in accordance with the essential requirements established by IATSIC. In practical terms, the first two courses run after signing the MOU must be of the form and nature as laid down by IATSIC. Thereafter, variations as determined by the NSC may be allowed. The slide material will be provided ''locked''. After the two initial courses, the ''unlock'' code will be provided. Details of all modifications must be lodged with the IATSIC. NSC will be responsible for ensuring the maintenance of high standards in the conduct of all courses and the selection of participants, ensuring that they meet the minimum standards as laid down by IATSIC. NSC is entitled to appoint two representatives at International Subcommittee meetings. Introduction: Clinical skills must be to the fore of medical occupation, especially in surgery, where the mastery of basic skills is of great importance for the young learner. The acquisition of basic clinical skills during surgery clerkships has been shown to be inadequate. This work presents an analysis of different teaching methods in a standardized training program for basic clinical skills in surgery.

Material and Methods: The program is part of a four week surgical rotation for 4 th year medical students, consisting of the one-week training program in basic surgical skills and a three-week clerkship on surgical ward. During the skills training, a maximum of 6 students per group rotate through 12 modules. In a randomized study, the effects of different teaching modalities as skills lab, simulation and role play, as well as different teaching methods as four-step-approach, short-lecture, video were tested on their effect on theoretical and practical skills acquisition.

Results: A total of 60 students participated on a voluntary basis. The theoretical and practical examinations revealed significant differences in the acquired skills comparing the different teaching modalities and methods. The use of video as part of the 4-step approach was effective for training the basic skills such us suturing and wound care. Least effective for all skills were short-lectures.

Conclusion: The choice of teaching modality and method has a significant impact on students' skills acquisition and its long term retention. Disclosure: No significant relationships.

Training in Trauma Center: Where to Pay Attention to?

L. Handolin 1 1 Traumatology, Helsinki University Hospital, Helsinki, Finland

Introduction: Systematic trauma team simulation training was started in Helsinki University Hospital in 2003. In terms of getting the optimal advantage of training and maintaining the justification of resource allocation, an advantageous balance in various team training principles has to be applied. The aim of the present study was to analyze the standardized written feedback given by trainees after training sessions.

Material and Methods: The study period was three years (2006) (2007) (2008) .

The collected data consisted of a subjective self-assessment on the level of knowledge, skills, and team work in traumaresuscitation. Also a selfassessment on the effect of training on decision making, communication, skills, team work, and leadership, as well as a general rating of training session were collected. Self-assessment was done using five step scoring system from one to five. Results are presented as means. Conclusion: The actual evaluated interspinous devices led to a significant reduction of ROM during flexion-extension, but to a significant increase of ROM for the whole specimen (L2-L5) during lateral bending and rotation, which increases the risk of adjacent level degeneration. Therefore the decision for the optimal individual treatment should be made on the knowledge of the biomechanical effect of each device and the underlying disease of the patient's symptoms. Introduction: Gait analysis is a powerful tool to monitor the degree of convalescence in fracture care after fracture fixation and during bone healing. Because of the availability of a large array of monoclonal antibodies and gene-targeted animals, the mouse has become the preferred species for molecular studies on fracture healing. Of interest, gait analysis after fracture fixation and during the bone healing process has not been performed in mice yet. We present a novel technique for dynamic gait analysis in mice and report the change of motion pattern after femur fracture and fixation. Materials and Methods: All animal procedures were performed according to the National Institute of Health guidelines for the use of experimental animals and were approved by the German legislation on the protection of animals. Ten CD-1 mice were divided into two groups: fracture group (n = 5) and control group (n = 5). All mice were anesthetized by an i.p. injection of xylazine (15 mg/bw) and ketamine (75 mg/bw). A standardized closed midshaft fracture according to AO-classification A2-A3 was stabilized by a common pin. The non-fractured tibia was additionally marked with a pin, allowing a measurement of the tibio-femoral angle by a digital videoradiography system recording 30 images/s. For the control group, one pin was inserted into the femur and one into the tibia without producing a femoral fracture. Dynamic gait analysis was performed at day fourteen after surgery in a X-ray compatible running wheel and the following gait parameters were determined: the minimum and maximum tibio-femoral angle, the stride frequency, the stride time, the stride length and the stride velocity. Eighteen representative strides per mouse were analyzed. All measurements were done using Osirix Imaging Software and the Open Source program ImageJ. All data are given as means ± standard error of the mean (SEM Introduction: Single distal locking screw insertion had been accepted as an option in clinical practice of femoral nailing. However, effect of number and location of the screw on rotational stability of the construct was still doubtful. Therefore, this experimental study was conducted to compare rotational stability of the femoral nail construct among three different conditions (two distal screws, single distal screw in different locations). Materials and Methods: Eight right femoral sawbones were selected for this study. Each of which was implanted with GK femoral interlocking nail (11 · 400 mm) and a static proximal locking screw follow by single distal screw insertion in the most distal screw hole. Then, transverse osteotomy was performed at the mid-shaft to simulate simple fracture. After the femur was stabilized on the custom holding jig, rotational force was applied to the femoral condyle by using a torque wrench connecting to the distal part of the jig starting from 2 to 8 Nm in 2 Nm increment. Total rotational angle in each situation was measured by modification of navigation system. Thereafter, testing protocol was repeated to the same specimen but two distal locking screws and single distal locking screw in the most proximal screw hole, sequentially. Different angle in each testing condition was compared among the different constructs by using paired t-test. Results: Rotational stability was significantly better in the group of two distal locking screws in every testing condition (p < 0.05). Single distal screw in the most proximal screw hole provided more rotational stability than that in the distal screw hole at 8 Nm (p = 0.003).

Conclusion: This study demonstrated that two distal locking screws provide more rotational stability than single screw in the case of simple mid-shaft femoral fracture stabilized with interlocking nail. If single distal screw was considered, insertion in the most proximal hole would be a better option in term of rotational stability than that in the most distal hole. Introduction: The exothermal reaction of PMMA leads to an extensive interaction between the bone cement and the plastics of the application system. This chemical reaction changes the structure of the bone cement and especially makes air pockets. It is necessary to develop application systems with a special composition of the plastics so that there is no interaction between the cement and the application system. In this study a new application system is presented for the first time which does not interact with the bone cement. Materials and Methods: Two different application systems for bone cement were tested in this study. One popular and frequently used system made of polyethylene and a new system made of polypropylene. A special testing unit, in which the application systems were mounted, was used. The testing unit worked with a certain pressure so that a defined amount of bone cement was injected. The resistence data and the time were digitally collected and statistically evaluated. In all 60 procedures were carried out. After the injection all application systems and the injected bone cement were microscopically analyzed. Results: Two groups, old versus new application systems, were divided. Both groups showed significant differences. When using the old application systems made of polyethylene the time frame for injection of the cement was 4 min while the time frame with new system made of polypropylene was 10 min. Microscopically there is a significant interaction between the plastics and the cement in the old systems with massive air pockets. In contrast there is no interaction, no air pockets and a homogeneous pattern of the cement when using the new systems. Conclusion: The new application system made of polypropylene showed a significant longer time frame for application of the cement as well as no interaction with the plastics. It is possible to treat more than one localization with one application system which makes it financially rewarding. Additionally there are no air pockets reducing the danger of infection und increasing the structural stability of the bone cement. Introduction: Femoral neck fractures are common fractures. Despite the frequency of this fracture and the consequences associated with it, little is known about the functional changes that can be expected during and after rehabilitation. The aim of this study was to identify prognostic factors for functional outcome, using a modified Harris Hip Score, after a femoral neck fracture treated with an arthroplasty. Materials and Methods: We included 252 patients who sustained a displaced femoral neck fracture treated with an arthroplasty. Functional outcome after surgery was assessed using a modified Harris Hip Score, and was evaluated after 1 (HHS1) and 5 (HHS5) years. We analyzed the following prognostic factors for functional outcome of patients after treatment of femoral neck fractures with an arthroplasty: age, pre-operative co-morbidity, ASA-score, type of arthroplasty (hemi-or total hip replacement), surgeon experience (resident or attending surgeon), interval between trauma and operation, blood loss, direct (associated with the arthroplasty) peri-and post operative in-hospital complications related to the arthroplasty and general post operative in-hospital complications. To challenge the outcome of the analyses we used the Cronbach's alpha coefficients for testing the internal consistency. Results: After one year the existence of co-morbidities ( ‡ 1) was a significant predictor for a poor functional outcome. With and without co-morbidities the mean HHS1 was 71.8 and 80.6, respectively. After 5 years all potential prognostic factors did not have significant influence on the functional outcome. To further analyse this outcome, internal consistency of the HHS was assessed. When pain and function of the HHS were analysed together the internal consistency was poor (HHS 1: 0.38 and HHS 5: 0.20). The internal consistency of the Harris Hip Score solely in function (without pain) improved to 0.68 (HHS1) and 0.46 (HHS5). When the potential prognostic factors were analysed with only the functional aspect, age and the existence of co-morbidities could be defined as a predictors for the functional outcome of femoral neck fractures after 1 and 5 years (r 2 24 and 19% resp).

Conclusion: Pain has such a dominant position in the Harris Hip Score that even immobile patients without pain can obtain a reasonable HHS score. The HHS, with the omittance of pain, is therefore a more reliable score to estimate the functional outcome. After using the HHS in this modification, age and the existence of preoperative co-morbidities appeared to be predictors of the functional outcome after 1 and 5 years. Many studies have shown that delay to theatre beyond 48 h has an associated increased risk of morbidity and mortality in this cohort. Our data revealed that there is certainly room for improvement regarding treated more patients within the 24 h guideline however, there will always be a group of patients whom medical input is required prior to surgical management. Lack of theatre time appears to be a significant administrative reason for delay. This is an area of potential improvement however it must be noted that any system of this nature will carry an intrinsic delay in processing. . X-rays and post-op data were analyzed on displacement, postoperative reduction, loss of reduction, and avascular necrosis (AVN) and revision rates. High volume surgeons were defined as surgeons who performed > 10 fixation procedures for proximal femoral fractures annually. Results: Mean age (72 vs. 70 years) and percentage of fracture displacement (55 vs. 58%) were equal in both groups. Re-operations following loss of reduction or infection was seen in 21 (17%) patients. Less frequent complications were AVN (8%), coxarthrosis (2%) and pain due to screws bulging out (6%) led to a total conversion rate to arthroplasty in 33%. Displaced fractures show a higher rate in loss of reduction (27%, p < 0.05) and revision (40%, p = 0.05) than non-displaced fractures (3.7%; 20.4%). Patients > 70 years showed 19% loss of reduction, 14% AVN and taking the reoperations due to coxarthrosis and pain into account, a total revision rate of 40% was seen compaired to 16, 5, and 29% in younger patients. Radiological analyses revealed that the lack of medial support lead to revisions in 52% of the cases, dorsal angulation in 50%. Low volume surgeons did not perform worse than high volume surgeons. The latter group showed 19% loss of reduction, 14% AVN and total revision rate 40%, compared to 16, 5 and 29% in the low volume group. We found no differences in the outcome of treating displaced fractures.

Conclusion: The outcome of fixation of femoral neck fractures is poor. Especially displaced fractures, inadequate fracture reduction and high age were associated with poor outcome. Therefore, arthroplasty should be considered in patients older than 70 years with displaced fractures that cannot be reduced anatomically. We could not demonstrate that high volume surgeons performed better in this group but we are convinced that further specialization of care is mandatory to improve results of this unsolved fracture. (1) (2) (3) (4) . Internal fixation has shown to provide minor results. The majority of these patients are therefore treated by a hemiarthroplasty of the hip. Since the primary goal is to regain the pretraumatic level of mobility as soon as possible(3;5), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss (6), postoperative pain(7;8) and thus postoperative mobility (9) . Material and methods: In a randomised controlled trial, 48 patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within 72 hours after trauma(10). Apart from parameters like age, ASA-Score or Body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. All data collected were compared between groups to detect statistical significant differences. Additionally the same parameters were checked for significant differences comparing patients with or without complications within their group.

Results: A significant difference between groups was found for postoperative pain within the first 72 hours and for operation time, both to the disadvantage of the minimal invasive approach group. Within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at 48 hours was rated higher in patients with complications in the lateral approach group. These results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up.

Conclusion: Despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. Still, the operation time was significantly linked to postoperative complications. In this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results. Of the 512 patients, 350 (68.3%) received a formal assessment for antiresorptive therapy. The outcomes of this assessment is as follows: 4.6% did not require any antiresorptive therapy, 0.9% awaiting bone clinic assessment on discharge, 5.4% awaiting a DEXA scan, 73.7% of patients were started on antiresorptive therapy and 14% were continued on antiresorptive therapy from pre-admission.

Conclusion: Our study highlighted that in our trust only 68.3% received this assessment formally. We can conclude that when this assessment occurs the guidelines and hence subsequent fragility fracture secondary prevention is addressed.

We have then presented this data locally and amended our integrated neck of femur documentation pathway to include a section on antiresorptive therapy assessement. To follow this up we plan to re-audit from 1st January 2010 to 1st January 2011. In the upper thoracic spine 216/297 (73%) could be placed with navigation, 157/297 (53%) were controlled intraoperatively. Occasionally, scan-setup was problematic, in addition, we experienced technical problems. Correct placement was seen for each screw, thus correlating well with theintraoperative findings.

Conclusion: The application of the combination of intraoperative 3D-imaging and navigation for posterior instrumentation of the cervical and the upper thoracic spine is technically feasible and reliable in clinical use. User-and software-dependant sources of error could be solved during the first course of the series. Image-quality at the cervical spine is depending on individual bone density, and possible metal artifacts. With undisturbed visibility of the vertebral body, the reliability of 3D-based navigation at the cervical spine is comparable to that of CT-based procedures. Additionally, it has the advantage of skipping preoperative acquisition of data as well as thematching-process. Furthermore, exposure to radiation is reduced due to the possibility of sparing pre-and postoperative CT. Disclosure: No significant relationships. The average LKA measurements in order were: 12.63°, 0.21°, 6.92°( p < 0.001), and for ACA: 14.13°, 5.83°, 6.25°(p < 0.001). While a significant difference between the averages of LKA, E/F of Group 2 and Group 3 (p < 0.05), no statistical difference was found comparing the average ACA angle (p = 0,753). While there was no significant change in E for all groups (p > 0.05), the increase in F after surgery was considered significant (p < 0.05), and no difference was observed between the averages of Group 2 and Group 3 (p > 0.05). VAS was 2.73 (0-5).

Conclusion: At the end of an average 8 year follow up period of posterior TL fractures no difference was found between the early and late period measurements of ACA and anterior height Although LKA showed a statistical loss in height the correction degree achieved in the late period was found to be significantly higher than preop. (8 cases), crushing without skeletal injuries (4 cases) In all these cases, pulse was present at the first evaluation, and the onset of acute post-traumatic ischaemia was at 8-49 hrs after trauma . Tha diagnosis, based on clinical suspicion, became definite after Doppler evaluation and arteriography. The anatomical base of ischaemia was late thrombosis (42 cases) and compressive hematoma (4 cases). Thrombosis was due to obstruction of the big arteries (39 cases) and microcirculation, due to overrun compartment syndrome-3 cases.Vascular restoration and fasciotomy was performed whenever muscles were viable, but amputation was necessary in 3 cases Results: The patients were analysed from the point of view of the corelation between the moment of onset of the ischaemia, the type of injury, the status of the muscular structures, the algorithm of diagnosis, the type of the treatment, and the clinical outcome. The study revealed that the clinical outcome was better when the time between trauma and ischamia onset was less, since the muscular ischaemic had less time to develop. In the same time, there were 4 cases in which clinical symptomes were not corresponding to the imagistic evaluation.

Conclusion: High energy trauma affect all the structures of the limbs. Clinical suspicion has particular importance especially when trauma affects one of the regions which is known as establishing a dangerous environment between the arteries and the bones / joints. In all the cases that authors analyse, complete and early diagnosis and treatment of acute post-traumatic ischaemia, based on the close monitoring of the patient and '' clinical alarm signs '' seemd to be the conditions for the favourable outcome of the patients. Introduction: The aim of presentation is to demonstrate the surgical treatment and postoperative period of a patient who was caught on a fence-pole and suffered severe injuries of perineal region and lower extremity. Material and Methods: After a long time of technical rescue the patient arrived to our department with a one meter long portion of fence in his perineal region. After the urgent extraction of metal fence we performed an intraoperative rectoscopy. During the debridement and exploration of deep perineal injuries we realised a heavy swelling around the punctated wound of the left leg. We made a femoral incision and exploration and recognised the several injury of the femoral vein and artery. We provided the 4 cm long injuries with stitches.

Results: In the postoperative period we made a second-look and debridement because of lymhphatic retention and small skin necrosis around the incision. No real vascular or circular lesions were recognised during the control period of the patient. Injuries were totally improved.

Conclusion: The edification of this case is that it's never sure that the major wound makes the biger trouble to the patient or to the surgeon. In our presentation we plan to demonstrate the intra -and postoperative pictures and the results of controll period. Results: The incidence of various types of trauma were blunt in 13 patients (31%), gunshot wounds in 3 patients (7%), and stab wounds in 26 patients (62%). Only 15 (36%) patients were hemodynamicaly stable. Isolated abdominal vascular trauma was detected in 9 patients (21%). Vessels injured included aorta 1 (2,4%), inferior vena cava 7 (16,6%), named visceral arteries 2 (5%), named visceral veins 8 (19%), iliac arteries 1 (2,4%), and iliac veins 1(2,4%), epigastric, hypogastric, intercostal arteries 6 (14,3%), epigastric, hypogastric, intercostal veins 2 (5%), gonadal vessels 2 (5%), renal veins 3 (7%), non-named mesenteric vessels with segmental bowels necrosis 14 (33,3%). Two or more vascular injuries were found in 6 (14,3%) patients. According to Organ Injury Scaling, 1 st grade injuries were found in 17 (40%), 2 nd -in 11 (26%), 3 rd -in 8 (19%), 4 th -in 5 (12%), and 5 th -in 1 (2,4%) patients. The most frequent associated injuries were small bowel -12, liver -8, colon -5, stomach 4, duodenum -4, diaphragm -3, pancreas -2, spleen -1, with an incidence of 29%, 19%, 12%, 9,5%, 9,5%, 7%, 5% and 2,4% respectively. All injuries were managed according to injury score. Infrarenal v. cava ligation was performed in all cases of hemodynamic instability. Minor named abdominal vessels were ligated in all cases. Segmental intestinal resection was performed in all patents with 5 th grade of intestinal injuries due to devascularisation. Overall mortality rate was 21%.

The vessels with the highest mortality rates were inferior vena cava (71% -5/7). There were no mortalities in isolated abdominal vascular trauma patients and in cases of 1 st grade of injury. Mortality rate in accordance to OIS was: 2 nd -3 patients (27%), 3 rd -3 patients (37,5%), 4 th -2 patients (40%), 5 th -1 patient (100%). No differences in mortality rate were found according to type of trauma (blunt or penetrating). The associated injuries with the highest mortality rates were pancreas (2/2 -100%), diaphragm (2/3 -66,6%), liver ( (8), a rupture of the heart (4) or a aneurysma dissecans with a rupture of the aorta (3).

In addidtion to the detailed forensic examination and autopsy, we took the anthropometrical measurement of all corpses in 3 dimensions, so that we were able to create a biomechanical simulation of the accidents with ''finite element models''. There the shear forces affecting the aorta can be calculated. As three forces (frontal impact, side impact and deceleration) are the most important, we will present three comprehensible example accidents. The reason of death is always the ''aortic rupture'', but every time the biomechanical way of application of the force was completely different. In detail they are a car accident (frontal collision of a small car with a wall); a downfall from the height of 25 meters in suicidal purpose and a compression of the thorax of a eight year old boy with a shovel of an excavator.

Results: Although all three accidents have completely different course of crash, we were able to see the same reason for death: a rupture of the aorta at the onset of the Ligamentum arteriosum Botalli. By using the numerical simulation, it can be shown that three main directions of force are important in an accident: the frontal impact, the side impact and the deceleration. In all these examples, it was able to simulate the reaction of the aorta in relation to the development of the force. The simulation will be presented as well as all clinical treatement made by the medical stuff.

Conclusion: Although the rupture of the thoracic aorta is a frequent cause of death, the injury mechanism has not been comletely known. A database with several victims of aortic ruture was created and 3 special accident types will be presented and simulated. Introduction: Overlooked compartment syndrome represents a catastrophic complication for patients and orthopedic surgeons. Invasive compartment pressure measurement continues to be the gold standard. However, repeated measurements in uncertain cases can be difficult to achieve. We, therefore, developed a model for a noninvasive technique to assess tissue pressure by ultrasound based elastography.

Material and Methods: A perforated plastic tube filled with saline was surrounded by a silicone sealed plastic cover, mimicking the shape of the tibial compartment. A pressure transducer inside the compartment was installed. A second pressure transducer was installed on the ultrasound probe to allow simultaneous monitoring of the pressure inside the compartment and the tissue deformity. For calibration, ultrasound images were generated at 0 and 130 mmHg. The plastic cover to tube distance was measured before and after compression (delta d). Subsequently, increments of 5 mmHg pressure increases were used to generate a standard curve (0-60 mmHg), thus mimicking rising compartment pressures. The intra-observer reliability was tested by using 10 subsequent measurements. A correlation was determined between the skin to bone distance (delta d) and the pressure measurement (p). The Pearson correlation coefficient was calculated, and a regression analysis was performed. (2), better antibiotics and computed tomography-guided percutaneous drainage (3). However, when everything else has failed, the burder of decision making the choice of a 'last resort' operation will be shifted again to the surgeon. We here described our recent experience with 10 such cases treated by abbreviated laparotomy using the Bogota bag technique (4). Results: For the seven first patients, we performed colon resection with colostomy. After extensive debridement, lavage and drainage, the peritoneal cavity was closed with a sterile gastric bag sutured on the rectus aponeurosis according to the so-called Bogota-bag procedure (5). The mean operative time was 75 minutes. A second look laparotomy was planned after 48 hours: one patient required one reexploration, four patients required two and two required three. The decision of re-exploration was based on the visual aspect of the peritoneal content, the clinical evolution and the bacteriologic results. For the last three cases, we elected perform colon resection without colostomy followed by anastomosis in two patients in the second look laparotomy and colostomy in one because of two relaparotomies. None of the ten patients required further percutaneous drainage. Two patients died in multiple organs failure (one with perforated diverticulitis and one with ischemic colon after aneurysm repair).

Conclusion: Abbreviated laparotomy with temporary closure of the abdominal wall associated with planned re-exploration of the peritoneal cavity is a simple and effective way to treat patients with severe abdominal sepsis. Introduction: Pelvic fractures usually are the result of high energy trauma and such patients often have many associated injuries. Long term outcome data of pelvic injury patients is sparse, we present our information with special emphasis on poly-trauma patients, with consideration for the combined involvement of associated injuries on functional outcome. Material and Methods: General functional outcome and clinical outcome were determined with an examination by a physician and patient assessment at a minimum of 10 years after the injury. Pelvic fracture patients that had suffered poly-trauma were categorized by fracture location: acetabular, pelvic ring, or a combination.

Results: The long term outcome in the patients with pelvic ring fractures (exclusive of acetabular fracture) was the worst clinically, as evidenced by evaluation of pain(29.3%), increased use of special medical aids(37.4%), a poor Merle d'Aubigne score(13.1%), and worse SF-12 and HASPOC scores. Patients with acetabular fracture had poorer general functional outcomes than those with combined pelvic acetabular fractures and were noted to have higher incidence of associated injuries such as type IV pipkin fractures. Further subcategorization of pelvic ring fractures into anterior, posterior or combination showed specifically those patients with combined anterior posterior pelvic ring fractures had the worst long term outcome.

Conclusion: A combined anterior posterior pelvic ring injury accounts for the worst long term outcome of pelvic injury poly-trauma patients. We found that bilateral pelvic injury and particular associated injuries greatly influence long term functional outcome. Disclosure: No significant relationships. Material and Methods: 99 canulated screws were placed in 15 human semi-cadaver models and 9 plastic pelvis models in 3d navigated, 2d navigated and conventional Matta technique. Aim of this study was to evaluate intraoperative time, intraoperative radiation dose (fluoroscopy time, area dose product and images per screw) and accuracy (amount of exactly placed screws, mean deviation of tip placement and misplaced screws per group).

Results: The accuracy of 3d navigated procedures is significantly higher (p < 0,05) than in the conventional technique. There is a significant lower radiation dose in the navigated procedures (p < 0,0001) for the operation team. The intraoperative radiation dose is increasing significantly from conventional method to 2d navigated to 3d navigated procedures for the patient (p < 0,01). There is a significant higher time per screw necessary for navigated procedures (p < 0,001).

Conclusion: The usage of flatpannel technology seems promising in 3d navigation. Our data shows a benefit from using navigated procedures in transilliosacral screw placement. The higher precision and lower radiation exposure for the operation team show that 3d navigation is superior to 2d navigated procedures. The higher accuracy of the 3d navigated procedures renders a postoperative routine CT scan obsolete thus lessening the total radiation exposition of the patient. Introduction: The purpose of this biomechanical study was to determine whether locking screws or smooth locking pegs optimize fixation of AO A3 distal radius fractures. Material and Methods: 8 pairs of fresh-frozen human distal radii were used. AO A3 extra-articular distal radius fractures were created by removal of a 1-cm-wide dorsal wedge of corticocancellous bone centered 2 cm from the articular margin of the distal radius and were fixed using palmar locking plates. The radii were divided into 2 matched-paired groups for comparison. The side order, the fixation order and the testing order were randomized. The distal fragment in group I was stabilized with 7 angular stable screws. The distal fragment in group II was fixed with 7 locking pegs. The proximal fragment in both groups was fixed with 3 screws. The probes were tested with 1.5 Nm for torsion and with 100 N axial load for 1000 cycles each. Stiffness was measured from the first 6 cycles regarding torsion and axial load. Then the differences of the stiffness were recorded during the remaining cycles. The Wilcoxon test was performed, a value of p £ 0.05 was considered statistically significant.

Results: There were no statistically significant differences in the first 6 load cycles within the eight matched pairs. After 1000 cycles the constructs with locking screws (group I) showed statistically higher stiffness values (p = 0.008) compared to the constructs with smooth locking pegs (group II Introduction: Plate fixation of the odontoid process without C1-C2 arthrodesis appears to a practicable option for the management of odontoid fractures that are not suitable for conventional screw fixation. Although previous biomechanical works have evaluated the effectiveness of different odontoid screw fixation techniques, no study has quantified the mechanical stability of odontoid fixation by a plate device. The purpose of this study was to measure the mechanical stability of odontoid plate fixation using a specially designed plate construct, and to compare the results to those after odontoid single-and double screw fixation. Material and Methods: The second cervical vertebra was removed from fifteen fresh human spinal columns. The specimens were fixed to the experimental apparatus, with the load cell at the articular surface of the odontoid process. In a first test series, stiffness and failure load of the intact odontoid were measured. Type II odontoid fractures were created by 45°oblique extension loading at the articular surface of the odontoid process. Afterwards, the specimens were randomly assigned to one of the following three groups: In Group I (n = 5) the fractures were stabilized using a specially designed plate construct, in Group II the fractures were fixed using two 3.5 mm cortical screws, and in Group III we used one regular 4.5 mm cortical screw. In a second test series, stiffness and failure load of the stabilized odontoid fractures were assessed for comparison and statistical analysis. Results: Group I (plate device) showed a significantly higher mean failure load than Group II and Group III. The mean failure load of Group I after fixation of the odontoid fracture was 84% of the mean failure load that was necessary to create a type II odontoid fracture, initially. Comparing Group II (double screw technique) and Group III (single screw technique), there was no significant difference regarding the mean failure load. In both groups the mean failure load after odontoid fixation was approximately 50% of the mean failure load of the intact odontoid. Statistical analysis also revealed a significantly higher stiffness of the stabilized odontoid after plate fixation, than after single or double screw fixation.

Conclusion: Plate fixation of the odontoid process as an alternative procedure in certain fracture patterns provided a significantly higher biomechanical stability than the technique of odontoid screw fixation. Using a specially designed plate construct fixed with two cancellous screws into the body of C2 and an additional cortical screw inserted in the odontoid process, 84% of the original stability of the intact odontoid was restored. Single or double screw fixation of the odontoid only restored approximately 50% of the original strength. Results: Extension and flexion were not influenced of all implants significantly. All dynamic implants and also the rigid implant led to a significant increase of the mobility during side bending and rotation in the area of the adjacent segments. Conurrently the cephaled adjacent segment (L2/L3) showed a significantly higher mobility than the caudal adjacent segment (L4/L5).

Conclusion: Dynamic implants such as the interspinous spacer enlarge the mobility of the adjacent segments during side bending and rotation in a comparable size as the rigid implant. To this extent is to be assumed that reinforced adjacent degeneration cannot be prevented by the use of the interspinous spacer substantially. Introduction: Osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and disrupted microarchitecture of bone tissue. The most severe consequence of osteoporosis are osteoporotic fractures. These are mainly low-energy fractures, which anamnestically, clinically and radiologically differ from fractures in healthy bone. We tried to find the answer to a queston, whether it is possible, that osteoporotic compression fractures are single events, or if they represent a gradual, progressive vertebral collapse in patients with osteoporosis. We evaluated the forces, necessary for vertebral fractures, regarding the bone mineral density. Material and Methods: 14 cadaver vertebrae were isolated with the approval of ethics committee. We mesured their bone mineral density and then subjected them to the stress-test. We used the computer-controlled hydraulic press and stress vertebrae to the fracture point and beyond, monitoring the deformation and the load. A sigma-epsilon diagram was constructed from the data. Results: With the loading of vertebrae the pressure grew exponentially as a function of deformation to the breakage point. Then we observe a plateau of saw-like shape, which corresponded to the progressive vertebral collapse. Further deformation led to gradual compacting of vertebrae and we observed once again an exponential increase in pressure. This bone compaction is therefore the first mechanisms of fracture repair. The saw-like plateau form suggests progressive collapse of vertical trabeculae and their jaming into the horizontal, which then with the increasing deformation and load also fail. A similar phenomenon can be observed in the collapse of buildings during the demolition. (The 9-11 phenomenon). Conclusion: Unlike a high energy vertebral fractures, the osteoporotic fractures are presented as a gradual vertebral collapse. They take place parallel with the processes of bone reparation and remodelation. From this standpoint, osteoporotic fracture is unique. Vertebral collapse increases the bone mineral density in the broken vertebrae, what is observed radiologically and densitometrically. repair of medium to large, but reparable, rotator cuff defects, augmented with a Restore patch or not. Patients have been randomly assigned to receive standard repair augmented with the Restore implant or to receive non-augmented standard repair As the repair procedure is exactly the same in both patient groups, and the implantation of the Restore implant does not necessitate any additional incision or measures, neither the patient nor the assessors are aware of the fact an implant has been used. The ethical committee of the University Hospitals Leuven has approved the study. All patients get full information and are enrolled in the screening program after written consent only. Clinical evaluation, both pre-operatively and at 6 months post-operative is performed by the same, independent physiotherapist trained in shoulder evaluation using the Constant score Structural evaluation is performed by ultrasonography, performed by a radiologist specialised in musculoskeletal radiology and sonography. Unpaired two-tailed t tests, performed with Prism 5 software for Mac OsX, were used to compare the results of the scores in the control group with those in the xenograft group. Fisher exact tests were used to evaluate the significance of differences in the proportions of retears in the patients for whom a sonography was obtained.

Results are expressed as the mean and standard error and significance was set at p < 0.05. Results: We included 20 patients. There were 7 female and 13 male patients. In the non-augmented group there were 3 females and 7 males. In the Restore group there were 4 female and 6 male patients. The average age of patients was 66 years of age. In the non-augmented group the average age is 65,2y (+/-2,7) years of age, in the Restore group 66,8y (+/-2,2). The mean pre-operative Constant score of the non-augmented group was 46,8 +/-6,2 points whereas it was 42 +/-5,6 points for the Restore augmented group. Post-operative The functional outcome 6 months after surgery again was scored using the Constant score. The mean score in the non-augmented group was 86 +/-4,0 points; in the Restore group it was 82,1 +/-4,5 points In the non-augmented group we documented a retear in 1/10 patients, in the Restore group we had a retear in 3/9 patients (2 small tears, 1 massive tear). Introduction: It has been estimated that up to 30% of adults suffer from rotator cuff tears [1] , which can impair their ability to work or perform household tasks [2] . Management of rotator cuff tears is difficult as a large proportion of technically correct surgical repairs re-rupture, estimated between 13-68% [3] . It has been estimated that thousands of extracellular matrix repair grafts are used annually [4] to augment surgical repair of rotator cuff tears and act as temporary scaffolds to support tendon healing. The only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus [4] . As the shoulder is subject to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. We used dynamic shear analysis (DSA), which is a form of rheology and allows the study of flow and material deformation.

Material and Methods: The shear properties of four different commercially available rotator cuff repair grafts were measured (Restore, GraftJacket, Zimmer Collagen Repair and SportsMesh). 3 mm punch biopsies were taken from the grafts and subjected to oscillatory deformation under compression. The bulk storage modulus (G') was calculated [5] and used as an indicator of mechanical integrity.

To assess how well the repair grafts were matched to torn and normal rotator cuff tendons, the storage modulus was calculated for 79 human rotator cuff specimens obtained from the edge of rotator cuff tears during surgery, from patients aged between 22 and 89 years. 14 age and sex matched normal controls were also obtained during shoulder hemiarthoplasties and stabilisations.

Results: We report a significant difference in the shear moduli of all four rotator cuff repair grafts (P < 0.001, 1 way ANOVA). 2 of the repair grafts (Restore and GraftJacket) had a significantly lower storage modulus when compared to human rotator cuff tendons (P < 0.01, Dunn's multiple comparison test). Only the Zimmer Collagen Repair and SportMesh had a storage modulus which was comparable to that of normal rotator cuff tendons (P > 0.05), and thus were most closely matched. Conclusion: With increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. There is no clear definition of the ideal mechanobiological properties. Current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. It is hoped that this study, in conjunction with others, will help to guide surgeons in deciding on the most appropriate repair graft. Three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from j 2D = 0.624 (substantial agreement) to j 3D = 0.687 (substantial agreement). The addition of three-dimensional images had limited influence on the average interobserver reliability for the recognition of specific fracture characteristics (j 2D = 0.488 versus j 3D = 0.485, both moderate agreement). Three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (j 2D = 0.398) to moderate (j 3D = 0.418) but this difference was not statistically significant.

Conclusion: Three-dimensional computed tomography is helpful for; 1) individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for 2) comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems). Disclosure: No significant relationships. Introduction: In recent years, 3D fluoroscope has used increasingly in orthopaedic surgery because it offers some advantages such as generation 3D data without anatomic registration requirement. Previous studies have focused on the clinical use of 3D fluoroscope in surgical procedures such as calcaneus or acetabular fracture reduction, or placement of screws in spinal surgery. There are no reported data on radiation exposure of 3D flu to orthopaedic theater staff. We want to correlate radiation exposure and distance concerning the patients and members of surgical team during using three-dimensional fluoroscope and study how far is enough until radiation exposure can not be measured. Material and Methods: An isocentric C-arm fluoroscope (Siremobile IsoC 3D) was used for the study. Human cadaveric extremity was used for target. Digital dosimeters (MYDOSE mini PDM-117, Aloka) were used to measure radiation exposure at specific distances. Dosimeters were systematically exposed by the following protocol.

Represented positions were direct contact and every 25-cm. radius from the center of the beam. The distances were increasing until the dosimeters could not detect the radiation. Each radius distances were designed to record 4 different positions; top, bottom, left and right side. Dosimeters were exposed and removed (4 dosimeter positions at a time from each radius). First we used low resolution scan technique to obtain the images. After all radiation exposure records were collected, we changed to use high resolution scan technique and repeated the protocol. Each technique was repeated in 3 times to obtain the mode of data. Results: Radiation dose at ground zero is 49 lSv in high resolution and 21 lSv in low resolution. Radiation in high resolution technique can not be measured beyond 1 meter from the center of the beam at the top, bottom, and right direction and 1.5 meters at the left direction. In low resolution, radiation cannot be detected farther than 75 cm. in the top, bottom and right direction and 1.25 meters at left direction.

Conclusion: Radiation dose measurements in each direction are decreased during increasing distance and dose in left direction is higher and farther than others. Beyond 1.5 meters is safe from radiation in knee application. High resolution gives higher radiation and farther than low resolution. Introduction: Tibial plateau fractures with impression are often associated with poor outcomes and a high rate of complications. The current guidelines advocate anatomic reduction, re-establishment of tibial alignment, stable fixation, and filling of the sub-articular defect. We hypothesized that fixed-angle LISS-plates provide adequate stabilization with less need for void filling, minimal complications and good radiological outcome.

Material and Methods: Retrospective evaluation study. In the period 2004-2008, we operated 55 patients with an intra-articular tibial plateau fracture. Forty were treated with a LISS-plate. Mean age was 57 years, 14 were male. All fractures were classified as AO type B or C; 16 were Schatzer type II, 2 type IV, 2 type V, and 20 type VI. Five patients were initially treated with external fixation. Mean time until definitive surgery was 9 days (range, 1 -47 days).

In 12 fractures, the subchondral void was filled with either hydroxy or bone graft, in the other 28 cases no graft was used. Demographic data and fracture classification were equal in both groups. Articular impression was measured by 3 independent evaluators pre-operatively, post-operatively and 6 months after surgery on plain X-rays.

Results: Mean pre-operative impression was 6.9 mm (with void filling 8.0 mm, without 6.5 mm, ns). Thirty-four fractures were additionally stabilized with K-wires or screws. The post-operative impression was on average 2.8 mm. Evaluation criteria included the Lysholm and Tegner Activity Score. All fractures were stabilized post primarily. The surgical main approach was strictly medial. Exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. The posterolateral impaction was addressed directly through the main fracture gap. Small fragments were removed, larger reduced and preliminarily fixed with separate Kwire(s). The posteromedial part of the condyle was then prepared for main reduction and application of a buttress T-plate in a posteromedial position, preserving the pes anserinus and medial collateral ligament. In addition a parapatellar medial mini-arthrotomy through the same main approach was performed for reduction and PDS-suture-fixation of the anterior eminence (ACL and anterior horn of lateral meniscus). Results: We treated 28 patients with 29 fractures. Median age was 48 years (20-77). We could evaluate 25 patients (89%), 3 patients were lost to follow-up due to foreign residency. The fractures were treated post primarily at an average of 4 days, 18 of them in a twostaged procedure with initial knee-spanning external fixator. All fractures healed without secondary displacement or infection. 24 patients showed none to moderate osteoarthritis after a median of 4 years. One patient showed a severe osteoarthritis after 8 years. All patients judge the result as good to excellent. The Lysholm score reached 95 (75-100) and the Tegner Activity Score 4 (3-7). All patients have achieved a minimum flexion of 100°. Conclusion: In our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. With our strategy we achieved good results in nearly all patients. The described larger medial approach allows addressing most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). Material and Methods: It is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator (SIF). There is no contact between bone and internal fixator in fracture area. It has been widely investigated biomechanicaly. In clinical use it has been applied to 119 metaphyseal fractures of distal femur and proximal and distal tibia. The age of patients was from 18 to 86 years. This internal fixator is applied by two small incisions. Reduction is achieved using standard traction table or using special reduction device. For opened fracture it has been used high mobile external fixation system as temporarily (39 fractures) or definitive (49 fracture) method. Results: Received clinical results are promising, as it has been shown early callus formation and radiological union within the 2.5-4 months. It has been allowed to patients early full weight bearing, if fractures not intraarticular. During the treatment it has been confirmed working of self-dynamisation concept, which probably all together with 3D configuration resulted in unexpectedly quick fracture healing. Follow up was 19 months (6-60). When used external fixation system, axial dynamisation has been regularly activated. Conclusion: According to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site if no intraarticular dislocation. It can be used as primary method or soon after external fixation if damaging control concept used. Introduction: Disaster, is the disproportion between the need for medical care and the means available in the community. This discrepancy of needs /means is the major problem in every step of the Rescue Chain, when a disaster situation is present. This is more obvious at the end of the Chain, which is the Hospital and especially, the bottleneck of the entire disaster's management system, the Emergency Department. Material and Methods: In Greece, the most common and frequent disaster situation is the earthquake. And so, the most expected pathology of the victims is trauma. Because of the lack of 1. special organization of Emergency Medicine and 2. independent modern Emergency Departments in greek Hospitals, their directors did not give the appropriate attention to organize a disaster plan (internal or external Introduction: Accurate response to major incidents requires accurate decisions on all levels, from command level to the care of the individual patient. Development, evaluation and training of the process of decision-making requires standardized models providing complete and accurate information as a base for the decisions; a decision based on incomplete or incorrect data can not be properly evaluated. The aim of the present project was to design a simulation model that could be used both for evaluation of different methods in the response to major incidents and for training and evaluation of skills in making correct decisions. Material and Methods: A system was created providing the information required for this process in the whole chain of management and performance: Scene, transport, hospital response, co-ordination and command. Input data were based on real scenarios and real resources. For evaluation of methodology, all parameters except the one studied, in this study triage, were standardized. The results from (a) physiological and (b) anatomical triage, performed by staff on different levels of competence and experience, serving as their own controls, were compared. For training, the system was used in courses in medical response to major incidents with training of the whole chain of management and performance, from prehospital patient management to over all co-ordination and command.

Results: The methodological evaluation showed differences in priority and outcome between anatomical and physiological triage related to the level of experience and to the position in the chain of response, providing a base for choice of method related to those factors. The results from training with the use of the system, so far only evaluated by the participants own ranking, showed high percepted improvement of relevant skills. Conclusion: A methodology for simulation of major incident response designed for scientific evaluation of methodology also provides a very good educational tool, since correct and complete data as a base for decision making also gives an effective and realistic training. Disclosure: One of the authors, SL, has the copyright to the MAC-SIM system, a non-commercial system intended mainly for scientific use. Equipment for training can be produced by users, but also purchased for production costs. Introduction: Interhospital referral of traumapatients for reasons of special (most neuro-)surgical competencies to a specific Level 1 traumacenter, is common practice in the Netherlands. These traumapatients are sometimes admitted directly through specialized intensive care units and therefore do not enter the Emergency Department (ED). Therewith the standard assessment according to the ATLS guidelines is bypassed in these cases. This withholds the risk of an incomplete assessment. We therefore consistently coordinate the assessment of all transferred traumapatients. In this study we analysed the number of newly found injuries in referred polytraumatized patients and the clinical consequences in terms of extra treatment, permanent damage or death to the patient. We also analysed possible risk factors for missing injuries. Introduction: Synchronous admission of large numbers of patients into the hospital requires a perfect coordination of activities of designated teams in the process of reclassification at the entry to the hospital and subsequent continuous provision of medical care for the patient in the course of examination and treatment, up to his hospitalisation at the target department, in accordance with the characteristics of the injury and seriousness of his medical condition. This process cannot be accomplished through improvisation but only with creating a uniform organisational scheme, defining the recommended structure of medical teams and their activities during a multiple admission of casualties into the hospital. In this article, we present a proposal of such consensual organisational scheme, partially verified in practice.

The organisational scheme is defined in the following areas: -space arrangements -places of admission and organisation of work -creation of mini trauma teams (anaesthesiologist, traumatologist and surgeon or another traumatologist take over the most serious patients, the teams are accompanied by consulting specialists of relevant specialities (neurologist, neurosurgeon, radiologist), the whole teams or at least parts of them, accompany the patients for the whole period up to the definite treatment at operating theatre, or his placement at a destination department -the continuity of care is secured in this way, without the need to pass on any findings and information -placement of patients into individual hospital departments (follows certain rules, it is necessary to direct all the admitted patients into as few departments as possible (one or two), and thus keep the best possible view over the priorities during their treatment -entry corridors -,,green corridor'' -patients are immediately transported through this area by transport teams into the ''green'' designated area, the ''red'' and ''yellow'' entry area does not have to be extremely large, however it requires an adequate equipment from the material and technical point of view Results: Multiple admission of patients must be well-organised and managed, most often by a head-physician of the UA department, or another authorised specialist (in hospitals without the UA department). The idea of the TraumaNetwork D DGU is to built up regional networks of various trauma centers with the objective to standardise and optimise the treatment of severely injured patients -with the additional involvement of rescue services, physicians and competent facilities and centres for the treatment of specific injuries as severe burn or spinal cord injuries etc. To assure that all participating hospitals meet the criteria needed for the treatment of trauma patients, a certification firm (DIOcert) was assigned to accomplish the audits and to control the process of certification. Thus, every hospital has to pay a sum of nearly 6 000 EUR for audit, certification, benchmarking, yearly quality reports and the use of special IT-tools which were designed for the TraumaNetwork D DGU. Material and Methods: Coordination of traumanetwork implementation Coordination of audit and certification process Results: Since the beginning in the year 2006 actually 781 hospitals are participating the TraumaNetwork D DGU. These hospitals are organized in 48 regional traumanetworks. 26% of the hospitals are preliminary categorized as local trauma centers, 28% as regional trauma centers and 11% as over-regional traumacenters (the highest category). 33% still aren¢t categorized. 407 hospitals have already signed the contract with the German Trauma Society and paid the participation fee. 250 hospitals meet the criteria for audit and 153 hospitals are already audited by the firm. In october 2009 the first regional trauma network (trauma network east bavaria / TNO) was certificated with a total of 25 participating hospitals. Conclusion: In the past 3 years the number of participating hospitals increased year by year. The nationwide acceptance and the high level of participation in the TraumaNetwork D DGU in Germany show that the treatment of severely injured patients is one of the main topics and exercises for trauma surgeons in Germany. If the expected improvement in treatment quality and the decline in trauma mortality is only wish and fiction or reality and fact has to be proven by studies in the next years. Therefore a working group with focus on quality improvement, changes in mortality, improvement in rehablitation results etc. was founded. Introduction: One of the challenges in trauma care is diagnosing all injuries. Any delay in treatment can lead to increased morbidity, prolonged length of hospital stay, costs, and even mortality. Despite the use of standardized guidelines for initial evaluation such as ATLS, the incidence of missed injuries in the literature is considerable. The aim of this study was to assess the rate of missed injuries in trauma patients evaluated in two Dutch Level-1 trauma centers and to determine potential factors that contribute to injuries being missed.

We assessed all radiological reports during initial admission and operation records of the 1124 patients included in the prospective randomized REACT trial. This study was part of a randomized trial conducted in two Dutch Level-1 trauma centers investigating the role of CT scanning in the trauma room. Missed injuries were defined as not diagnosed during initial radiological evaluation in the trauma room. We assessed all missed injuries and the phase in which these injuries were diagnosed. Second, we assessed potential contributing factors by univariate analysis. Results: There were a total of 129 total calls performed with real patients and 328 test calls. Of the actual calls, 111 (86%) were performed while moving and 18 (14%) were done from a stationary position. Initial video quality in was rated good in 98 cases (76%) and initial audio quality was rated good in 97 (75%) cases with actual patients. 107 of the actual calls (83%) experienced some sort of temporary video drop during the entirety of the call and 93 calls (72%) experience some sort of temporary audio drop. These drops were a result of the setup of MESH WiFi and the need to jump from router to router. Users in the hospital found the program to be a very useful trauma and emergency medicine tool, but adjustments need to be made to improve the network. Conclusion: The use of telemedicine in a pre-hospital setting may play a significant role in the management and treatment of trauma and critically ill patients as hospital medical staff can intervene in real time during transport. Patients can be evaluated in real time which allows the necessary staff and resources to be available on arrival. Initial user feedback has been encouraging with users acknowledging its usefulness as a pre-hospital tool. (1) In the elective setting it is logical that a lower eGFR reflects poor renal function and low overall physiological reserve. The same is not obviously true for emergency patients who may have an ''artificially'' low eGFR merely as a reflection of acutely altered fluid balance. Change in eGFR from admission to hospital to ITU admission was also significantly different between survivors and nonsurvivors. This would suggest that eGFR reflects a response to treatment as well as renal function. This study supports the use of eGFR in the decision making process when trying to predict outcome in emergency general surgery patients. Introduction: The Surgical Medium Care (SMC) in our hospital is a 6 bed ward with monitoring facilities, and is used critical ill patients from the trauma and other surgical wards. Over the last years there has been an increase in the number and severity of trauma patients admitted to out hospital, as well as there has been an increase in patients undergoing major elective surgery. The aim of this study was to verify if these trends are reflected in an increase in patient-and workload on our SMC. In this study we describe the patient-and workload on the SMC between 2000 and 2008 using the TISS-28. The modified Therapeutic Intervention Scoring System (TISS-28) is a validated score of therapeutic activities and an alternative approach to evaluate outcome of critically ill patients (1) (2) (3) . Material and Methods: A prospective cohort study of all consecutive patients admitted to the SMC between 01/01/2000 and 31/12/2008 was performed, using the TISS-28 database. Of all admitted patients a daily TISS-score was performed. Besides the TISS data, patients demographics, referring ward, discharge destination, length of stay, and hospital mortality were retrieved from the database.

Results: There were a total of 5455 admissions of 4667 patients in the study period. 64% of patients were male, 36% were female. The median Length of stay was 3 days (0-97). The overall hospital mortality rate was 6,4%, with no significant differences over the years. 40% of the patients admitted to the SMC came from the ICU, 15% came from the emergency department, 1,5% came from home, 5,5% came from the recovery ward, and 38 % came from the trauma and surgical ward. These percentages did not change over time. The average TISS score during the study period was 20 and did not significantly differ during the study period. There was, as expected, no significant difference in TISS score between patients who survived and the non survivors. Introduction: The demands placed on systems and organisations that protect the general population are constantly growing. The reasons for this include, among other things, circumstances altered by the threat of inter-national terrorism and the increasing frequency and magnitude of mass public events and natural catastrophes. Crisis situations such as these present unique, often completely unprecedented chal-lenges to those affected and to all actors with responsibility for crisis management and the protec-tion and rescue of people.With regard to effective interdisciplinary crisis management, both Germany's security and rescue forces and its general population suffer from widely acknowledged and scientifically proven deficits.

impact on people and the society. In this context, all natural and man-made threats will be considered (''all hazards approach''). Elearning and virtual reality modules based on these scenarios will be offered to target groups via the Internet on an individualised basis.

Results: The aim of this project is to develop a platform to prepare security and rescue forces, doctors, caregiv-ers and the general population for terrorist attacks, crises and disasters. An online platform with a modular structure (employing teaching methods such as e learning, blended learning etc) will offer innovative and specialised instruction and advanced training to all users. Conclusion: Experts agree that the modern teaching methods and computer-based simulations mentioned here (such as virtual reality methods) are excellent tools to help train people efficiently to respond to events that cannot be planned, such as terrorist attacks and other catastrophes. The use of these innovative methods and com-pletely novel, userfriendly, web-based instruction and information modules is designed to address -to a heretofore unprecedented degree -all security and rescue forces concerned as well as the general population in particular. Ultimately this will signifi-cantly improve security and rescue operations in the event of terrorist attacks, crises and disasters. Conclusion: In a proper setting, laparoscopic emergency is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients. The diagnostic and therapeutic versatility afforded by the laparoscopic approach avoids extensive preoperative studies, averts delay in operative intervention and minimize morbidity and shorten the postoperative hospitalization.

We do think that laparoscopy should be incorporated into general surgeon's armamentarium for the management of patients with acute abdomen as just as another tool to be used selectively when indicated. Laparoscopy, however, must not be used as an alternative to good clinical judgment. About our algorithm in patients with acute abdomen: if there aren't any contraindications to laparoscopy, obtained an informed consensus, in presence of a well trained surgical team in minimally-invasive surgery, excluded any major gynaecological diseases (about which we and our gynaecological colleagues haven't a skilled experience with a laparoscopic approach), we always approach laparoscopically. Introduction: Stable patients with thoracoabdominal penetrating or blunt injuries resulting in diaphragmatic injuries represent a difficult and challenging management dilemma. Although laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic and treatment modality of these injuries, a conversion to laparotomy for mere evidence of peritoneal penetration and or diaphragmatic injuries is common for most trauma surgeons.

We hypothesized that laparoscopically-assisted mini-thoracotomy for repair of diaphragmatic injuries will be as effective as open laparotomy or thoracotomy and will prevent the morbidity associated with open technique and should be used in hemodynamically stable trauma patients. We designed a minimally invasive technique that combines laparoscopic exploration of the intraperitoneal cavity and existing injury site as an entrance to the injured site or organ. Open Hassan technique, using vertical midline incision is used to create the pneumoperitoneum. Additional two to three 5 or 10 mm ports are placed to enable thorough examination of the peritoneum, running the small bowel and examining other abdominal viscera. Diaphragmatic lacerations are repaired by extending (3-4 cm) the existing thoracic stab or gunshot wound. The diaphragm is grasped with two graspers and brought to the operative field. Continuous or interrupted suture are used for repair. We applied this technique to 8 hemodynamically stable trauma patients (LA group) treated over a 4 year period at the university Level I trauma center and compared to 10 trauma patients requiring laparotomy (OG) for isolated diaphragmatic injury repair . All laparoscopically assisted procedures were performed by the senior author (RL). Length of stay, morbidities and complications were studied in both groups. Both groups were matched for ISS, age, and gender and mechanism of injuries.

Results: There were 8 patients (five with stab, two with gunshot wound and one with blunt trauma and chronic diaphragmatic injury) in the LA group. Introduction: Acute small bowel obstruction is mostly due to adhesions (83%), while internal hernia can cause acute small bowel obstruction in 2% of cases. This clinical condition has been considered for many years a relative contraindication for laparoscopic surgical treatment. With the introduction of CT-scan in the diagnosis of this clinical situation and the experience in laparoscopic techniques, more surgeons are now attempting laparoscopic management for this indication. The advantages of laparoscopy in abdominal surgery are now well defined, such as a shorter intestinal function recovery, a shorter hospital stay and less post-operative pain complained by the patients. In our presentation we want to analyse the importance of laparoscopy in the diagnosis and the treatment of acute small bowel obstruction, in order to underline advantages and limits of this technique. Material and Methods: In San Raffaele Hospital Milan (Italy) a total of 136 patients underwent a surgical intervention for small bowel obstruction from January 2007 to December 2008. 98% of the obstructions was due to adhesions, 2% to internial hernias. All the patiens underwent preoperative abdominal X-Ray and CT-scan. Results: Of the total of patients, 30 have been operated on with a laparoscopic approach, with a conversion rate of 33.3%. Postoperative morbidity was 0% in the laparoscopic group and 1.22% in the traditional surgical approach, with a shorter hospital staying in the first group.

Conclusion: The analysis of our data suggests us that the selection of patients that can benefit from a laparoscopic approach to acute small bowel obstruction has to be made accurately, better with the use of CT-scan, in order to limit the percentage or useless laparoscopy and to diminish the conversion rate and to give the patient the better curative option. Introduction: Intestinal obstruction has remained one of the most common surgical emergencies. The aim of our study is to evaluate the feasibility, safety and palliative role of laparoscopic bowel surgery in the management of large bowel obstruction. Material and Methods: In a period of 2 years, 15 patients were subjected to loop sigmoidostomy. In 12 patients the diagnosis was bowel obstruction due to rectal cancer. In 3 patients the obstruction was attributed to ovarian cancer. From those 12 patients with rectal cancer, 10 patients had contominant liver and lung metastases and 2 had an unresectable liver lession. In that period 2 lapassisted ileo-transverse anastomosis were performed due to obstruction from cecum carcinoma together with mlitple liver and lung metastases. Single surgeon-performed POCUS in the evaluation of acute appendicitis led to a correct diagnosis in 87,6% (177/202). Surgeons trained in US ordered a CT scan in 8,9% of cases and ratio of negative appendectomy was 1,5%. Surgeons not trained in US ordered a CT scan in 61,5% and their ratio of negative appendectomy was 28,2% (including pts that underwentent surgery on clinical investigation basis only). Conclusion: Surgeon-performed POCUS has a high sensitivity in the assessment of acute appendicitis and it is a powerful tool that minimize the use of CT scan and ratio of negative appendectomy with reduction of hospital and social costs; furthermore an advantage for the patients in terms of radiation exposure can be achieved. Moreover, to reduce additional costs, laparoscopic approach should be indicated only when the appendix cannot be perfectly visualized and localized. Introduction: Severe bleeding is, besides head injury, the most important predictive factor in severe trauma. Therapy of hemorrhagic shock starts already at the scene of accident. However, the best strategy regarding preclinical volume therapy is controversially discussed. The TraumaRegister of the German Society for Trauma Surgery (TR-DGU) observes the routine management of severely injured patients since many years. This registry will be used to describe the behaviour of preclinical volume administration as well as the consequences in early hospital care and its changes during the last ten years. Material and Methods: The TR-SDGU is a voluntary anonymous documentation of severely injured patients for the purpose of quality management. Data collection started in 1993. About 100 parameters are collected per patient. For the present investigation only adult patients (age >=16) admitted directly from the scene to one of the participating hospitals during the past ten years (1999-2008) were considered. A minimum injury severity of ISS > = 9 and available data for volume administration and blood transfusion were required. Means and prevalence rates were analyzed on a yearly basis.

Results: A total of 25,935 patients injured between 1999 and 2008 were analyzed. Mean age was 44.2 years, and 73% of patients were males. In 95% of cases there was a blunt trauma mechanism, and 30% of cases were unconscious at the scene (GCS £ 8 years that required presentation in one of the two Level-1 trauma centers (AMC or VUmc) were eligible. In the AMC the CT scanner was located in the trauma room (intervention group) and in the VUmc the scanner was located in the Radiology Department (control group). Randomization was performed prehospitally at the time of dispatch from the scene. Primary outcome measure was the number of non-institutionalized days within the first year following trauma. Secondary outcomes were mortality, length of initial admission and transfusion requirements. Preplanned subgroup analyses consisted of multitrauma patients and severe traumatic brain injury (TBI) patients.

Results: In total, 1124 patients were included for analysis of which 264 were multitrauma patients and 121 had severe traumatic brain injury (TBI). Demographic data were comparable between both groups except that there were more multitrauma patients evaluated in the AMC. Introduction: The effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of common injury patterns, incidence, mortality, and consequences. The needed inital radiological imaging remains controversial and should be adapted to the expected injury pattern. Material and Methods: In this retrospective study, the injury patterns of 56 polytraumatized paediatric patients (age £ 16 years) in the period from December 2001 to May 2009 were evaluated. All children were initially diagnosed with a whole body CT scan. The cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. The AIS (Abbreviated Injury Scale) and ISS (Injury Severity Score) were used to classify the severity of injuries in different body regions. Moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. Results: The mean score of the ISS was 30 ± 13 in 38 boys and 18 girls with a mean age of ten years. The lethality was 11% and only 4% in the first 24 hours. The most severe and most frequent injury was craniocerebral trauma in 89% with an AIS ‡ 3 in 80%. Surgical intervention of the head was done in 41%. Thorax injuries were found in 63% with 57% with an AIS ‡ 3 and in 11% a thoracic drainage was needed. Abdomial trauma was found in 34% (surgery 4%) with an AIS ‡ 3 in 32%. Fractures of the spine occured in 14% (surgery 5%) with an AIS ‡ 3 in 4% and pelvic injuries were diagnosed in 16% (surgery 4%) with an AIS ‡ 3 in 14%. Injuries of the upper extremity were found in 23% (surgery 11%) with an AIS ‡ 3 in 5% and of the lower extremity in 32% (surgery 16%) with an AIS ‡ 3 in 13%.

Conclusion: Especially because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery the authors recommend a whole body CT scan in children who are potentially polytraumatized. Not only in adults but especially in children the authors suggest the initial use the quickest imaging with a high sensitivity-the whole body CT scan. Introduction: Patients who suffer physical injuries following a traumatic event are at risk for developing posttraumatic distress. Care workers in hospitals treating polytrauma patients are in an optimal position to screen and identify patients developing posttraumatic stress disorder (PTSD). To start early intervention procedures and possibly lower the prevalence, a screening instrument to identify patients at a higher risk is needed. Aims of this study were to determine if the severity of injury is related to the prevalence of PTSD and to review the personality traits of patients with PTSD. With these results a screening instrument might be developed. To simulate an unstable extraarticular distal radius fracture, an osteotomy with a 5 mm gap was made. Axial loads of -10 to -100 N and torque loads of -1,5 to 1,5 Nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. After that, 1000 cycles of dynamic torque load alterations of 0,5 to 1,5 Nm (or -0,5 to -1,5 Nm convenient to side) at 0,5 Hz with a preload of -10 N were performed. In the specimens that were still intact after 1000 cycles, loading in torque was continued until failure occurred. Axial and torque stiffnesses of the osteosynthesis system were calculated. Results: With a median of 136,0 N/mm axial stiffness of XSCREWÒfixed specimens was higher than of DNPÒ-fixed specimens with a median of 69,5 N/mm but did not reach statistical significance. With a median of 0,163 Nm/°torque stiffness of XSCREWÒ-fixed specimens was significant higher than of DNPÒ-fixed specimens with a median of 0,068 Nm/°. The XSCREWÒ-group reached 33% of the axial stiffness and 49% of the torque stiffness and the DNPÒ-group reached 14% of the axial stiffness and 20% of the torque stiffness of the intact radii. Conclusion: Fixation of unstable extraarticular distal radius fractures with a XSCREWÒ provide biomechanically more stability than a fixation with a DNPÒ. Disclosure: No significant relationships. after distal radius fractures occur in 4% to 7% of fracture cases. The resulting deformity resembles Madelungs deformity and is also called pseudo-Madelungs deformity. This deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (DRUJ). Several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described. The Taylor Spatial Frame (TSF) is a hexapod based external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb. TSF-planning is web based (www.spatialframe.com) but its use is only available for lower extremities. The purpose of this study was to apply the TSF to the upper extremities to correct pseudo-Madelung deformities. Material and Methods: Defining the nomenclature To correct bony deformities with the TSF, one must determine the deformity parameters, the frame parameters, and mounting parameters for the web based planning program. The six deformity parameters and the four mounting parameters use the anatomic nomenclature for the lower extremities. To use the TSF on the forearm, one must transfer the nomenclature of the deformity parameters and the mounting parameters to the nomenclature of the forearm With the transferred nomenclature, one can correct forearm deformities with the correction mode Long Bone of the planning program for the lower limb. Patients Two boys (Patient 1, 13 years, Patient 2, 14 years old) and two girls (Patient 3, 8 years, Patient 4, 7 years) were seen in our clinic with progressive pseudo-Madelung deformities after an epiphysial fracture of the distal radius at age 12 in the boys and 6 in the girls. Skeletal maturity (RUS, TW3 method) was equivalent to the patientâ e TM s age. Results: In the four patients, the multiplanar deformitiy of the distal radius could be corrected anatomically with the TSF. There were no frame changes or frame modifications necessary for deformity correction. Patient 2 was slightly overcorrected because of some growth in the distal ulnar growth plate. During the distraction, each patient had two low-dose CT scans for better visualization of the radiocarpal and radioulnar joint. The web-based planning program was adjusted twice until total deformity correction was achieved. No further immobilization after frame removal was required. The one-year follow-up showed an anatomic aligned forearm/hand relation with increased pronation and supination compared to the preoperative range of motion in all patients. The wrist and especially the DRUJ were stable and reduced at the one-year follow-up examination. The patients did not complain about any pain or functional deficits in the hand. Conclusion: In conclusion, the power of the TSF with the ability to move two fragments precisely can be transferred to the forearm. This allows for the correction of multiplanar radial deformities simultaneously without the need for frame modifications of rotational and translational deformities, as is necessary with the standard Ilizarov system. Material and Methods: Thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent CT and MRI within ten days after trauma. CT-reconstructions were made in planes defined by the long axis of the scaphoid. The reference standard for a true fracture of the scaphoid was 6-week follow-up radiographs in four views, based on current available evidence in the literature. A panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. We calculated sensitivity, specificity and accuracy as well as positive (PPV) and negative predictive values (NPV) for both imaging modalities.

Results: According to the reference standard there were six true fractures of the scaphoid (prevalence 18% Both MRI and CT are better at ruling fractures out than in ruling them in and both were subject to false positive and false negative interpretations. The best reference standard for a true fracture is debatable, but for now it is not clear when bone edema on MRI and small unicortical lines on CT represent a true fracture. We advice CT because costs are lower and overall availability is higher. 

Introduction: The scaphoid bone is the carpal bone most commonly fractured in wrist trauma. Traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. Conversely, displaced fractures are recognised as unstable, with a significant risk of non-union if not treated surgically. There is a current trend in orthopaedic practice, however, to treat non-or minimal displaced fractures also with early open reduction and internal fixation. This trend is not evidence based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarise the best available evidence. Material and Methods: Fourty fresh frozen cadaver scaphoid bones have been sampled at our disposal for testing of screws. The bone density measurement of all specimens has been performed using a qCT scan. A transverse osteotomy will be performed at the waist of each scaphoid simulating a B2 fracture according to the Herbert classification. A load cell will be interposed, in an already established method, between the proximal and distal pole of the bone to measure compression force while introducing the screw. The screws will be applied as recommended by the manufacturer using original instruments. The intrascaphoid compression will be recorded at the peak during insertion of the screw, and after 30 and 60 seconds, 2, 10, 30 and 120 minutes.

Results: Preliminary results determined that a greater compression can be sustained over a time by headless compression screws with significant differences between those screws. The tests will be finished at the end of January and we will present the final results. Conclusion: In more than 50% of our cases a fracture was missed with the initial radiograph. Bone scintigraphy is still a good choice to detect an occult fracture around the wrist. Introduction: Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the extent of the inflammatory response. The aim of this study was to evaluate the operative burden related to femoral intramedullary nailing. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause lesser inflammatory response than traditional reaming (TR) due to a lesser intramedullary pressure increase and thereby reduced intravasation of bone marrow content. Material and Methods: Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary reaming and nailing with the two different reaming system; the TR (n = 8) and the RIA (n = 7) reaming system, and compared to a control group (n = 7). The animals were followed for 72 hours. Simultaneously arterial, mixed venous and femoral vein blood were withdrawn peroperatively and until two hours after the nail was inserted for demonstration of pulmonary, systemic and local activation.

Results: Significantly procedure-related increased levels were found for TAT, t-PA and IL-6 in the TR group and TAT in the RIA group.

The local and the pulmonary activation of coagulation, fibrinolysis and cytokine response was more pronounced in the TR than in the RIA group, but the difference did only reach significance for IL-6 (femoral vein) and PAI-1(arterial). The arterial levels of IL-6 and TAT exceeded the mixed venous levels indicating an additional pulmonary activation. These differences, however, did not reach significance. Two animals in the TR group, who died prior to planned study end point, demonstrated higher inflammatory response compared to rest of the TR group.

Conclusion: The inflammatory response to the reaming and nailing procedure was modest, and the response was lesser in the RIA group than in the TR group. Introduction: Approximately 1.5 million joint arthroplastic operations are performed annually worldwide. Implant failure due to massive bone loss and aseptic prosthesis loosening, however, is a major complication of joint replacement. It is generally accepted that small particles (''wear debris'') and activated macrophages play a key role in aseptic loosening. But also the Prosthesis Loosening Fibroblast (PLF) plays an important role. Material and Methods: Between 1992 and 1998 208 ABG-1-hip arthroplasties were implantated. After a 7 year analysis 40% had to be removed because of massive wear of polyethylene (PE) and consecutive acetabular osteolysis. We analysed the influence of patient and surgeon, the implantdesign incl. PE-thickness, anchorage coupler, material roughness i.e. and the material i. Medtronic) The application of the cements was done according to the specifications of the manufacturer. After extrapedicular kyphoplasty on cadaveric lower thoracic spine vertebrae (Th 6-12), the intervertebral distribution pattern was investigated by microtomography (Â lCT). Besides creating high resolution 2D and 3D reconstructions, the mathematic calculation of the porosity of the vertebra, the bone substitute material and the relative part within the different compartments was performed. Of special interest were the characterization of the bone substitute material -spongiosa -interface and the penetration of the calcium phosphate cement into the adjacent spongiosa. The following parameters were investigated: 1. Trabecular structure, porosity and hydroxylapatite concentration of the native vertebrae 2. Structure (homogeneity, distribution of pores) of the bony substitute material 3. Characterization of the bone-bone substitute-interface a. Central located, filled kyphoplasty defect b. Transition zone with spongiosa and bone substitute material c. Solitary spongious bone Results: The investigation of the native spongiosa yielded a comparable trabecular structure, porosity and hydroxylapatite concentration in the intra-individual comparison of the vertebrae of the lower thoracic spine. Between the cements differences in the solitary structure as well as distribution pattern during kyphoplasty were observed. Especially the analysis of the ability to penetrate into the spongiosa adjacent to the centrally located kyphoplasty defect yielded significant differences.

The main influencing factor of the ability to penetrate into the spongiosa is the different viscosity of the -according to manufacturer specification -used calcium phosphate cements. The cements differ in their native structure as well as in their distribution pattern during kyphoplasty. The differences in micro-morphology of the calcium phophate cements have a high probability to influence the degradation of the sedimentation products and later osseointegration. Disclosure: This research was funded by a grant of AO Germany.

Introduction: It is difficult to predict the long-term clinical outcome in the early period following an acetabular fracture. 

Introduction: The tremendous increase of acetabular fractures in the elderly provides new challenges for the surgical treatment of acetabular fractures. Surgical reduction of the acetabular joint represents the most reliable possibility to prevent the development of premature arthrosis even in the elderly. Biomechanical studies showed, that plates with periarticular long screws result in an increased stability of the osteosynthesis, it has to be considered that the insertion of these screws always bears the risk of penetrating the joint The aim of this study was to evaluate the biomechanical properties of these standard plates and newly developed minimal invasive osteosynthesis techniques for stabilization of an anterior column combined with posterior hemitransverse fracture type (ACPHTF), which represents a typical acetabular fracture in the elderly. Material and Methods: Using a single-leg stance model we analyzed 3 different implant systems for the stabilization of ACPHTFs in synthetic pelvises (standard reconstruction plate, new developed prototype and definitive RepoFix Ò (ADI -AO Foundation, Switzerland). Applying an increasing axial load in a biomechanical testing machine, fracture dislocation was analyzed with a multidirectional ultrasonic measuring system (Zebris, Germany). Differences in change of center of gravity are statistical analysed by Man-Whitney-U -Test.

Results: Analog to a long bow, the RepoFix Ò supports the quadrilateral surface sufficiently and reconstructs the surface of the pelvic brim from the inner side of the pelvis. In synthetic pelvises, the new RepoFix Ò is associated with a significantly less pronounced dislocation (center of gravity) of the fractured quadrilateral surface when compared to prototype and the standard reconstruction plate. The biomechanical results could be seen at a measuring point at the quadrilateral surface and in the rotation around the X -axis (angle Y Results: We collected data on 68 acetabular fractures. A conventional image intensifier was used in 37 cases (Group A), 3D-navigation was used in 31 cases (Group B). In Group A the Kocher-Langenbeck-Approach was used in most of the cases (59%), followed by the Maryland-Approach (27%). In Group B, the Kocher-Langenbeck-Approach and the Ilio-Inguional-Approach were used in an almost equal number of patients (32% / 35%), but extended approaches were only used twice. In 28% of the cases in Group B fractures were stabilised by navigated placement of percutaneous lag screws. When we excluded the percutaneous operations in group B (n = 8), the difference in OR-time between navigated (n = 23, 365 ± 129 min) and conventional treatment (n = 37, 264 ± 100 minutes) was significant (p < 0,001). In group A we detected relevant postoperative complications in 35% of patients. The complication rate was significantly lower in group B (4%, p < 0,006). The postoperative radiological analysis revealed a better qualitiy of reduction in group B (n = 23) with an average post-op fracture gap of 0,34 mm vs 1,58 mm in group A (p < 0,025). Conclusion: By using a navigation system and a 3D image intensifier we found a significant increase in the OR-time in the navigated group. However, in the postoperative radiological analysis, we detected a better quality of fracture reduction in the navigated group. Navigation in combination with the 3-dimentional pictures of the ISO-C 3D led to a better visualisation of the acetabulum, therefore the need for extended approaches was reduced. To our opinion, this explains the significant reduction of postoperative complications in group B. We conclude that navigation and a 3D image intensifier should always be used for ORIF of acetabular fractures. Disclosure: No significant relationships. Introduction: The traumatism is the first cause of the mortality in patients under 40. It means a serious incapacity in 1 of 4 trauma patients. The initial management in trauma patients is essential to improve these results Material and Methods: This is a prospective and multicentric study with the participation of 10 hospitals in Catalunya (Spain). The objectives are to improve the evaluation and the initial management of trauma patients, and to improve the knowledge of the frequency, the magnitude and the approach of these trauma patients. We defined 7 points to improve which are: To intubate patients with Glasgow < 8 (1); To not remove the cervical collar without clinical or radiologic cervical exploration (2); To move trauma patients monitorized (3); To not move haemodinamically instable trauma patients (4); To use two thick intravenous cannulations (5); To take thorax and pelvic simple radiographies in the trauma box (6); To fix pelvis fracture with a grassland before moving the patient (7) We took more thorax and pelvic radiographies in the trauma box (from 45.2% and 27% in the first period to 62.3% and 50.5% in the second period, p < 0.05). And we also fixed more pelvis fracture with a grassland before moving the patient, from 24% in the first period to 48.6% in the second period.

Conclusion: The registration of the information about trauma patients allows the identification of the points to improve. We improved the evaluation and the initial management of the trauma patients, especially in the monitorization of trauma patients and in the management of the thoracic and pelvic traumatism Introduction: There is wide evidence about the importance of having good protocols for assisting Trauma Patients and a teaching system for the personnel involved in this assistance is needed. It is also well known that the formation for assisting trauma patients in Spain is not very much spread in general. Material and Methods: We describe how we have arranged the care for this type of patients in a level II center and a teaching system for our staff and we prospectively analyze the impact of this specific formation by means of a questionnaire and analyzing how correctly the trauma team is activated.

Results: From November 2006 through October 2008 (23 months), 5 editions of our Course have taken place and 54 people have participated (29,5% of the staff for whom the course is aimed to). We found a clear improvement on the results of the test (prior and after the course: 55% of improvement for physicians and 85% for nurses, p < 0.001) and the qualification of the final exam was superior. The incidence of rightly activated trauma team improved as the staff was completing the course. Conclusion: We conclude by enhancing the importance of having adequate protocols for treating these patients and the correct means for teaching the personnel because they can improve the care of these patients. (TONK) score. This system is specialty specific and tries to eradicate the weaknesses in a previously published scoring system, which was generic. Material and Methods: A total score of 100 is assigned to each firm from the beginning and marks are deducted for missed documentation. 2 sets of notes are randomly selected from discharged patients for each firm, one from trauma and one from elective surgery, each having at least 2 entries. Each case note is given 50 marks and the total deduction for both case notes are then subtracted from the total score of 100 to give the resultant score.

The TONK score has four major parts comprising initial clerking, subsequent entries, discharge letter and legibility. An objective system of scoring the legibility of medical notes is part of the TONK score. This scoring system is easily reproducible and it's been validated using the Kappa statistic. Introduction: Despite the increasing mechanization in medicine, clinical skills must be to the fore of medical occupation and consequently must have a main focus in medical training. Especially in surgery, the mastery of basic clinical skills is of great importance for the young learner as it besides the knowledge of elementary principles substantially contributes to the understanding of the subject, the development on the wards, the operation theatre and the ambulance. In order to assure a standardized training using reliable, effective modern teaching methods, a ''Train-the-Teacher''-Course was developed. Material and Methods: In an 8-hour training, the important teaching modalities and methods for surgical skills as skills lab, simulation, role play, 4-Step approach are presented and trained in small groups with a maximum of 6 participants per group. Furthermore, the training focuses on ,,Giving adequate Feedback'' and examining practical skills. The training is evaluated using a standardised evaluation form. Furthermore, the teachers are evaluated by their students after each of their teaching sessions before and after the training.

Results: A total of 32 surgeons participated in the training program (5 chief physicians, 10 senior physicians). Overall, the training was rated to be very good (54%) or good (46%). In students' evaluation, there was a significant increase in positive ratings for teachers' didactical compentencies as well as for their overall training after the participation in the training program. Introduction: Sports injury risk management and prevention is a very complex challenge that must be addressed 1 . One of the basic tasks is to perform epidemiological studies to estimate the risk in different types of sport. Up to now many studies were conducted on injury rates in specific organised sports 2 . Just a few taking into account any physical activity (PA) 3 . Therefore only for specific sports data about the influence of higher sport skills on injury risk can be found 4 . The goal of our study was to investigate the relevance of motor skills and sport education on injury risk, including the total PA and the occurrence of any injury in any type of sport. Material and Methods: In two Austrian secondary schools (Gymnasien) fifty-five of 63 classes were asked to fill out a two sided questionnaire regarding PA and sports injuries within the last year.

Demographic data and information about the types of sport, the intensity and the occurrence of injuries was collected. 1090 pupils, 469 from a ''normal'' school (NG) and 621 from a ''sports-school'' (SG) filled out the questionnaire. In the SG every child has to pass an entrance exam containing basic coordinative and motor tasks as well as complex motion sequences in different types of ballgames. In the educational program of this school a strong emphasis is placed on sports. In the NG just the basic sport lectures are held.

Results: The total physical activity (PA) containing organised, unorganised sports and leisure time activities was significant higher in the sports-school (SG), 9.9 hours per week vs. 7.6 h/w (p < 0.01). The most performed types of sport were similar: in the SG soccer (n = 202, 43%), riding bike (n = 197, 42%) and running (n = 176, 38%); in the normal school (NG) riding bike (n = 260, 42%), soccer (n = 191, 31%), snowboarding (n = 171, 28%) and running (n = 154, 25%). Proportionally there were more boys than girls in both schools: 64% boys, 36% girls vs 51% boys, 49% girls. Boys (11.3 h/w, 9.5 h/w) were more active than girls (9.1 h/w, 5.5 h/w) in both schools. The rate of injury was statistically significant higher in boys (0.60) than in girls (0.47) (p < 0.01). The mean age was higher in the normal school 14.0 vs 13.4 years. The proportion on injured children was at the same highest level (34%) in 10 and 11, 12 and 13, and in 14 and 15year-olds. The ratio of injury per pupil is statistically significant higher in the SG (0.62) than in the NG (0.49) (p < 0.01). But including the extension of activity the injury risk is a little bit lower in the SG: 1.20 injuries in 1000 hours of PA vs 1.24. Conclusion: It seems that better motor skills and intense sport education have no effect on the population risk 1 . The individual risk has to be investigated more extensively in future studies.

References: 1 Fuller, 2 Spinks, 3 Spinks, 4 Schwebel Disclosure: No significant relationships.

Introduction: Pain is one of the main complaints of trauma patients in emergency medical care (1). In the Netherlands, a third of all prehospital emergency medical systems (EMS) rides concern trauma patients and yearly 860.000 patients are treated in the Accident & Emergency department (ED) due to an injury. Significant deficiencies in pain management in emergency medicine have been identified (2) . As a consequence, patients unnecessarily suffer from pain, and also recovery and healing are delayed. Furthermore, chronic pain is reported one year after trauma (3). There is no appropriate systematic approach to acute pain management in the chain of care for trauma patients in prehospital EMS and the ED. Aim: The aim of the research project is the development of a national evidence-based guideline for the management of acute pain in adult trauma patients in prehospital EMS and the ED. During the open reduction we applied a incision allowing to remove soft tissues and to set fragments of fractured bone correctly. In 2 patients we performed close reduction of the fracture without the fixation because of a patient's age. Results: XR 3 month after surgical procedure was done and in all cases we achieved consolidation of the ulnar fracture and good of radial head reduction. Complication after the treatment was the paresis of the median nerve, neurosurgical procedure needed. The nails were remove 6,5 month after procedure (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) . After obtaining the union of the fracture and rehabilitation of the limb we removed the nails (3-6 month after procedure). Conclusion: Featured way of the operative treatment doesn't claim wide opening region of the fracture and reduces possibility of complications. Dislocated radial head after close reduction and immobilization period shows full stability. years. Data and X-rays were retrospectively gathered and analyzed. All fractures were scored according to the AO-pediatric classification. 58 patients were treated with solely closed reduction and cast immobilisation and 42 patients were additionally treated with K-wire fixation. SPSS version 15.0 was used for all statistical analysis. Results: Incidence of recurrent dislocation was significantly higher in patients treated solely with closed reduction (41%) compared to patients treated with additional K-wire fixation (19%) (p 0.018). The proportion of patients requiring a second surgical intervention was also higher in patients treated with closed reduction: 21% versus 5% of patients treated with additional K-wire fixation (p 0.023). Additional K-wire fixation results in a Relative Risk reduction of 54% and 77% for recurrent dislocation and secondary surgical interventions respectively. Complications of K-wire fixation comprised local infection (n = 2) and K-wire migration (n = 2). Conclusion: Additional K-wire fixation might reduce the incidence of recurrent dislocation and secondary surgical interventions after closed reduction of displaced distal forearm fractures in children. Larger and randomized studies will have to be obtained to confirm the results from our data. Radiographic controls were planned after one and six month and until the removal of the intramedullary nailing. We documented all peri-and postoperative morbidity, further operative procedures, the radiographic findings as classified by Capanna and the time till removal of the Nails.

Results: A cohort of 10 children (four girls, six boys) was recruited. Mean patient age was 12,4 years (9-15 y). The bone defects included eight juvenile and two aneurysmatic bone cysts. Four patient suffered earlier unsuccessful treatment after pathologic fracture. The other six presented with acute pathologic fractures (five humeral, one femoral). No postoperative complications occurred after the treatment combination of elastic intramedullary nailing, curettage, artificial bone substitute and autologous platelet rich plasma (GPS Ò-System). The radiographic findings showed at six month a total resolution of the cysts in eight cases (Capanna Typ I), in two cases a tiny residual cyst remained (Capanna Typ II). The removal of the Nails was possible after six to nine month. One fourteen year old boy (Typ II Capanna) wished a further GPS application to reach a total resolution. All patients showed very good functional results and no refracture occurred.

Conclusion: The GPSÒ-System enhances the treatment of bone cysts in children. It is a save method without additional perioperative complications. By this, total treatment time can be shortened and secondary procedures as difficult changes of the elastic nails will be lessened. Technically the decisive factor is the debridement of the . Albumin values were significantly lower in patients with two or three complications than those with zero complications (zero and two complications p = 0.001, zero and three complications p = 0.004). No significant difference in levels was found between one and zero complication (p = 2.94). Admission albumin was not significantly lower in patients with wound infection than those without (30.20 ± 2.58 g/l versus 34.95 ± 5.47 g/l, p = 0.064). Patients with a dry and intact wound had a higher mean albumin value than those with wound healing complications (mean albumin 38 ± 4.24 g/l versus 31 ± 4.23 g/l, p = 0.0001).

Conclusion: Our study findings support the hypothesis that lower preoperative albumin levels are associated with a more adverse inpatient post-operative recovery. These patients can be identified and optimised early in preparation for adverse events likely to occur in the post-operative period. Material and Methods: The Targon FN is a new kind of side plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur with angle stable 4.5 mm cortical screws. The proximal holes allow the implementation of up to four ''TeleScrews'' which cross the fracture site. These 6.5 mm screws are dynamic and allow therewith the collapse of the fracture at the femoral neck. We present a prospective study on 30 patients with a comparative 30 patients case control with a total hip cementless arthroplasty for the same indication at the same period.

Results: This new device show a lower incidence of complications on the first 3 weeks than with the total hip group. Wereas the 3 month control show no difference between the two groups. There are an X rays neck collapse one year folow up in osté oporotic patients with Singh 1 an 2 stade with no significant consequences on the functional score.

Conclusion: Targon FN is a good alternative for older and multimorbid patients with less surgical burden and reduced early access morbidity in comparison to the prosthesis group. Conclusion: The number of re-interventions and the mortality within one year after hip fracture surgery is sizable. Nonetheless, our numbers are not unfavourable in comparison with international literature. The percentage of re-interventions in the cannulated hip screw group is significantly higher than in the other subgroups. On the contrary, the mortality in this group is low. This is undoubtedly an expression of our attempts to preserve the femoral head in vital, active patients. Possibly, the combination of the two standardsnamely the re-intervention and mortality-is a new accurate performance indicator. informed. The operative treatment with LCP and tension bandages shows small morbidity regardless the comorbidities and the geriatric cohort. It remains standard procedure for periprosthetic fractures of the femur at our institution. We are expecting the number of periprosthetic fractures to be increasing rapidly. Introduction: Periprosthetic femoral fractures are rare but severe complications following total hip-or knee-arthroplasty. The incidence for of these fractures are increasing, caused by a raising frequency of total arthroplasty for both younger and elderly patients as well as by a higher life expectation. So far there are very little long-term results regarding this issue. Material and Methods: 25 patients (15 female, 10 male) with a mean age of 76 years (56-92) were clinically and radiologically examined on average 30 months after surgery. We investigated the prosthesis (total hip arthroplasty vs. total knee arthroplasty) and compared the treatment (revision arthroplasty vs. osteosynthesis) in this study.

For the clinical examination we used the Harris-Hip-Score (HHS), Oxford-Hip-Score (OHS), the Oxford-Knee-Score (OKS), the SF-36 and the Funktionsfragebogen Hannover (FFH) which measured the functionality of patients in his daily routine in his environment. Results: THA + osteosynthesis (n = 8) 25% of the patients had fair or better results with an average HHS of 61. 38% of this group had a good or excellent result with an average OHS of 33 and 12% had a FFH score of ‡ 50%. 50% of the patients had a possible hip flexion of ‡ 100°and (66% ‡ 90°). The average SF-36 score for this group was 28. THA + revision arthroplasty (n = 12) 50% of the patients had fair or better results an average HHS of 70. 58% of this group had a good or excellent result with an average OHS of 29 and 45% a mean FFH score of ‡ 50%. 75% had a possible hip flexion of ‡ 100°(100% ‡ 90° 

The results of the scores are mainly caused by the high age, the common multimorbidity and the low overall functionality of the patients and confirm the severity and importance of these kinds of fractures. Most authors suggest a treatment of these fractures according to the classification by using osteosynthesis to treat stable fractures and revision for unstable fractures. However we see a slightly better outcome of the revision arthroplasty compared to the patients that were treated with osteosynthesis. We suggest more studies with a higher number of patients regarding this issue. Introduction: Fracture dislocation of the proximal humerus is a rare but challenging situation for the orthopaedic surgeon. If a closed attempt to reduce the dislocation fails, a demanding surgical procedure is required and the emergency setting is not always the best situation to face difficult cases. As a matter of fact a proper approach to this fractures involve an experienced surgeon, more than one assistant and a variety of instrumentation that often lack in emergency. Fracture dislocation of the humeral head is related with a significant increase of the risk of the humeral head necrosis and it is widely accepted that these lesions are best treated in emergency, but there are no reports on the influence of the dislocation time on the results of the surgical procedure. With this study we wanted to determine if a delayed procedure could affect the outcome of these lesions and if there is a rationale in postponing the procedure to allow a better organisation of the surgical time.

Material and Methods: We retrospectively analysed the clinical and radiological records of 22 patients admitted at out institute for FDHH between Jan 2005 and Jan 2008. Ten out of them were operated in emergency while 12 with a minimum delay of 24 hours. All the patients underwent open reduction and fracture fixation with locking plates.

Results: The results of the two groups were similar and influenced mainly by the bone quality and age of the patient. It seems that a delay in the procedure do not alter the result in terms of rate of necrosis of the humeral head or influence a worse clinical outcome Conclusion: On the basis of these results we do not consider these fractures as emergencies anymore: our preference is still an immediate operation provided the presence of an experienced surgeon, assistant and nurse and the availability of the proper instrumentation, conversely we believe that the risks of an immediate procedure overwhelm its benefits. Introduction: Minimal invasive plate osteosynthesis (MIPO) should belong nowadays to the armentarium of each trauma surgeon. Applied correctly, MIPO not only meets the criteria of a ''biological'' osteosynthesis by minimizing invasivity as well as iatrogenic soft tissue damage caused by the operation, but can also provide adequate reduction and stability for fracture healing and early functional aftertreatment. Up to date, only few publications report on MIPO of humeral shaft fractures mainly using the antero-lateral deltopectoral approach for plate insertion 1-3 . Material and Methods: In this present study, we evaluated 29 patients (mean age 77 years, range 48-95) with displaced metadiaphyseal fractures of the proximal humerus treated in MIPO technique using an angular stable long PHILOS Ò -plate. A lateral deltoid-split approach was used proximally and a brachialis/ brachioradialis intermuscular approach with exposure of the radial nerve was used distally. There were 23 acute fractures including two periprosthetic as well as one pathological fracture. Three patients were operated after failed conservative treatment, one for delayed-union and two cases were revision surgeries.

Results: There were no infections and no iatrogenic injuries to the axillary and radial nerve, respectively. All the 29 patients were immediately allowed active shoulder and elbow movement. One patient had to be reoperated ten weeks postoperatively for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. This patient was successfully operated using the same method and implant. Whereas one patient refused follow-up, 28 patients showed entirely healed fractures and satisfactory shoulder and elbow function after a mean follow-up of 8 months (range 3 -12 months). Conclusion: Minimal invasive long PHILOS Ò -plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe and viable procedure for the treatment of metadiayphyseal fractures of the proximal humerus with low morbidity and good functional outcome. Introduction: Plating for reduction and stabilization of proximal humerus fractures is a common orthopaedic procedure. However, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. We checked the accuracy of a computerized navigation system(Vector vision trauma navigation system, Brain LAB) to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. Material and Methods: 5 men and 7 women aged 36 to 78 (mean, 56) years underwent PHILOS plate fixation for proximal humeral fractures. All fractures were closed with no associated injuries and classified as 11-A3 (n = 7), 11-B1 (n = 4), and 11-B2 (n = 1), according to the AO classification. The cases were assessed operation time, radiation time. And accuracy measurements were taken. Results: Patients were followed up for 6 to 37 (mean, 16) months. All the fractures united and occured no avascular necrosis. The mean operation time and radiation time were 74 minutes (range, 56-91) and 3.2 minutes (range, 1-7). The mean distance between fluoroscopy and navigation of reduction accuracy at the fracture site were 1.5 mm (range, 0-5).

Conclusion: The fluoroscopic operation using PILOS plate was troublesome, but navigated operation was easy to reduce the fracture because of the 2 direction visualization at the same time. And computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements at proximal humerus fractures. Introduction: The proximal humerus fracture is a frequent fracture in the elderly people. The lower density of the bone with increasing age is one of the main reasons for implant failure after osteosynthesis with a range of 10-50 %. The options of therapy are including the screw-, platelet-or nail-osteosynthesis or the endoprosthesis.Belonging to failure rates and the demand for early activity there is a tendency to be seen for early and strong stabilisation. Material and Methods: Since August 2006 114 proximal humerus fractures were operated with the RETRON-Humerus-Shortnail. The average of age was 73,6 +-15,4 (28-96) years. The demographic data, bone quality and fracture classification were documented including procedure of reposition, details of the implants, complications and postoperative course.

Results: There were 8,3% A3 fractures, 52,1% C1, 27,1% C2 and 8,3% C3 fractures (AO-Classification). The reposition was done in a closed mannor with a direct percutaneous assistance respectively. Intraoperatively 2 secondary dislocations and 1 corticalis brake was to be seen. There have been 2 insufficient nailing procedures. 6 screws had to be exchanged. The gymnastic began immediately after operation or with a delay of 1-2 weeks depending on the fracture classification. The evaluation of the Constant Score is on the way. The results show a good stability of the nail especially in osteoporosis. Comparing with platelets or antegrade nailing it is a minimal invasive procedure. The exraarticular access avoids any damage to the shoulder structures, especially to the rotator muscles. Therefore early gymnystic of the shoulder is possible. Shoulder impingement, screw dislocation and problems with the shoulder are avoided principally. The learning curve is short. shoulder score was used to evaluate functional outcomes. Anova was used for statistical analysis, with significance set at p < 0.05. Results: 307 files were available on 302 patients. Failure rate was 15.6% at mean follow-up of 4.3 years and a mean ASES-score of 75.3. There was a reoperation rate of 23.8%. Mean age at operation was 62.4 years. Mean operative delay was 4 days (range 0-98). Delay did not influence outcome. Young age at operation was associated with better results. When evaluating fracture characteristics significant better outcomes were evaluated with AO type Aand B-fractures, valgus or neutral fracture type, the presence of impaction and less displaced fractures. Quality of reduction and fixation of the fracture was evaluated with significant better results with anatomic reduction of the medial cortical border, less residual displacement and a CCD-angle that was corrected or in residual valgus. Osteosynthesis failed significantly more in C-type fractures, in fractures with an avascular head fragment, in varus displaced fractures and in fractures where an anatomical reposition was not obtained. Introduction: Fractures of the proximal humerus are responsible for 4-5% of all fractures.The most extensive used operative treatments are the plate osteosynthesis and the intra-medullarry nail fixation with proximal locking nailsscrews. Especially the latter technique can give iatrogenic injury of the axillary nerve. In this study, we define a safe-zone by using radiological parameters Material and Methods: The following procedure was performed in ten shoulders of embalmed specimen. First, the deltoid muscle was dissected from the clavicle. Then the axillary nerve was identified together with its branches and was marked with clips and radioopaque wires. The muscle was then re-attached to its anatomical position.Standard AP radiographs were made with the forearm in neutral (anatomical) position and exorotation. On these radiographs, the distance between the cranial side of the humeral head and the axillary nerve and its branches was measured.

Results: The median distance from the head of the humerus to the axillary nerve is 52 mm (SD = 4.5 mm, range 48-58 mm) measured on the AP radiograph in 90 degrees exorotation. The mean number of branches to the deltoid muscle is 3 three. The distances vary from 23 to 78 mm. The median distance from the first proximal branch measured from to the humeral head is 36 mm (n = 10, range 24-48 mm), to the second branch 54 mm (n = 10, range 40-66 mm), to the third branch 47 mm (n = 6, range 45-52 mm) and to the fourth branch 73 mm (n = 3, range 58-78 mm).

Conclusion: There is a great variation in the course of the axillary nerve and its branches. With the insertion of an intra-medullar nail from the proximal side or by placing locking-screws nails the surgeon has to reckon with the course of this clinically important nerve. It is unsafe to place the locking-screws nail in the zone between 24 mm and 78 mm from the humeral head with the arm in exorotation. The greatest risk to damage the main branch of the axillary nerve is in the zone between 48 and 58 mm. This study provides distances to avoid damage to the axillary nerve. In contrast to the existing literature these distances are measured from the humeral head.

There are several reasons to use the humeral head instead of the acromion are: First, The distance between the humerus and the acromion can vary due to the preceding trauma, relaxation of the deltoid muscle or by manipulation of the arm. Second, from an anatomical perspective, the position of the axillary nerve is determined by the position of the humerus due to the connection to the deltoid muscle. Results: 15 EMG/ENG records were without pathologic variances of the axillary nerve. 5 of them pre-operatively showed pathologic variances. 2 of these 5 continued to show variances 3 months after the operation, which indicates a chronic lesion. Just one patient showed a pathologic ENG after surgery which was not seen before. The constant score was as expected. Introduction: Patella recurrent dislocation and patellofemoral pain syndrome is a common cause of instability in young patients and especially athletes. In the present study we present the results of the extension mechanism realigment throughout the Fulkerson oblique osteotomy of the tibial tubercle and soft tissue balancing. Material and Methods: During the last two years 11 patients (7men, 4 women, mean age 29.6/ range 20-39) were treated operatively for recurrent dislocation of the patella using the Fulkerson procedure. All our patients had as onset a traumatic dislocation of the patella that developed to recurrent. All patients were underwent knee arthroscopy for the treatment of potential chondral trauma or loose bodies removal and lateral retinaculum release. After that, we performed oblique osteotomy of the tibial tubercle, medialization and internal fixation with two cortical screws. This oblique osteotomy provides additionally to the medialization, anteriorization of the tibial tuberosity as we move it medially. Moreover we perform medial plication. All patiens used functional brace locked in 0Â º immediately after the operation and gradual ROM increase untill the 8th p.o. week. Results: The patients had no initial or long term complication. During their last follow up examination had a painless knee with full ROM and marked improvement of the patella tracking. The mean Lysholm score was improved from 63.2 to 90.5. No patella dislocation was referred. Conclusion: Our findings show that Fulkerson procedure of the tibial tubercle osteotomy and anteriomedialization, with additional intervention on the lateral and medial patella retinaculum is an excellent option for the treatment of recurrent patella instability and relief of patellofemoral pain. Disclosure: No significant relationships.

Introduction: Injuries to the knee involving the anterior cruciate ligament (ACL) are very common related to sports especially in soccer and skiing. More than 50% of those with ACL injury will develop radiographic osteoarthritis (ROA) within 15 years of injury although it is not known if return to sports is a risk factor for longitudinal ROA development. In this retrospective study, we evaluated the long term radiographic and clinical results of ACL reconstruction by comparing the injured knee with the contralateral knee in athletes returning to pre-injury sports. Material and Methods: Twenty-eight patients (20 men and 8 women, mean age 20 years at the time of ACL surgery, BMI 24.9 ± 2.9 kg/ m2) were studied. Patients returning to previous sports and without meniscal injury at baseline were selected. ACL reconstruction was performed using patella tendon or hamstrings tendon graft. Radiological assessments using X-ray and a 3-T MRI of both legs were obtained at a mean follow up of 8 years after ACL reconstruction. ROA was determined according to the classification of Bohndorf. The IKDC score and Tegner activity index were used for clinical evaluation and the Knee Injury and Osteoarthritis Outcome Score (KOOS) for evaluating self-reported knee function. Results: The 3-T MRI revealed positive signs of ROA on the operated knee in 36% and on the non-operated knee in 25%. These changes were however limited to small localized areas of the knees. The statistical difference of morphological and clinical outcome of ACL reconstructed patients 4 weeks after injury vs. replacement after this period showed no significance (p = 0,09-1.0). The total IKDC score was 89.2 ± 9.3 points and the total KOOS was 92.7 ± 7.8. The median pre-injury Tegner score was 8 (range 3-9) corresponding to 7 (range 3-9) at follow up. In 68% of the patients the Tegner score was unchanged from pre-injury to follow up. According to the IKDC score 61% had type A symptoms, 36% type B, 3% type C, and none type D.

Conclusion: Eight years after ACL reconstruction in athletes returning to pre-injury sports, the risk of developing knee ROA in the injured knee was not higher than the risk of developing ROA in the contra lateral knee. Disclosure: No significant relationships. Radiographs and a MRI of the knee were available for all patients. All patients were followed prospectively and Lysholm, Tegner and IKDC score were surveyed before treatment and after at least 12 months. After diagnosis, a brace immobilization with tibial supporter with full extension of the knee was applied for 6 weeks followed by another 8 to 12 weeks of PCL brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. All patients received concomitant physiotherapy. After at least 6 weeks, stress radiographs were taken for evaluation of the PCL. The further treatment depended on the Harner classification based on the stress radiographs. In cases of grade A or asymptomatic grade B injuries, conservative treatment was continued. In cases of symptomatic grade B, grade C or D injuries, operative treatment with arthroscopic transtibial PCL reconstruction using single bundle hamstring tendons was performed.

Results: 27 patients were treated conservatively (group I), 18 patients had an arthroscopic PCL reconstruction (group II). Mean patient age was 30.7 years (range 17 -50 years). The mean Tegner score in group I raised from 2.5 before treatment to 5 at follow up, in the operative group from 2.4 to 4.6. The mean Lysholm score ascended in the conservative group from 49 to 83, in group II from 42. Introduction: The virtual reality (VR) 3D arthroscopy surgical simulator provides arthroscopy training on knees in a controlled, stressfree, and virtual-reality environment. It is unknown whether better visomotoric three-dimensional (3D) condition will facilitate arthroscopic training. Therefore, our objective was to evaluate the visomotoric condition to novice individuals and assess whether visomotoric abilities ameliorates arthroscopic performance within a 2D surgical environment. Material and Methods: 164 medical students without any knee arthroscopic experience were investigated. Both groups received a fixed protocol of simulator based arthroscopic skills training and a visomotoric skills test. This consisted of an arthroscopy of a longitudinal meniscus tear on a VR knee arthroscopy simulator. . Their learning curve was assessed objectively using motion analysis. Time taken, path length and roughness for probe and camera were recorded.

Results: Motion analysis demonstrated objective improvement in performance during simulator training, if visomotoric skills performed better.

Conclusion: Better condition of visomotoric skills lead to subsequent improvement at an arthroscopic VR skills training simulator. This may assume that visomotoric skills training before arthroscopic VR skills training is a useful tool. However further studies are necessary to find preliminary practice exercises to get a better performance at an arthroscopic VR skills training simulator. -II and C-III after Tscherne  § open fractures O-II  and O-III after Gustilo o urgent operative treatment  § first stabilisation with miniosteosynthesis and external fixation  § soft tissue  debridement and their temporary closure o second look after 48 -72 hours, next looks after the soft tissue condition o delate treatmentdefinitive stabilisation -osteosynthesis conversion in 7 -10 days after injury. o type of osteosynthesis § ORIF with LCP distal tibia platesmedial or anterolateral § imterlocked intrtamedullary nail § external fixation -in cases of serious soft tissue defects we prefer fracture stabilisation AE serious soft tissue defects closing with rotation or microsurgery stem lobs. Introduction: Fractures of the distal tibial metaphysis account for 7.2% of fractures over the distal end of the tibia. Many of them are high-energy injuries causing extensive articular damage and compromise the soft tissues. Managing these fractures continues to challenge most orthopaedic surgeons, as soft tissue injury could be further compromised by unjudicious surgical technique. Aim of the treatment is to restore physiological alignment of the distal tibia and stabilize the fracture with minimal damage to soft tissues. Material and Methods: We designed an implant for the stabilization of distal tibial metaphyseal fractures, and gave the name ''angle stable''. The features of the implant are: precontoured plate with holes above the distal metaphysis providing positioning of screws with angular stable characteristics. The screws are self tapping and self cutting at the threaded part (far end) and have a cylindrical shape with a rim at the near end, that tightly fits into the holes at a special angle, guided by a targeting device. The distal screws penetrate the opposite cortex, and when they are tightened, compression is achieved. The plate is introduced through a small incision and guided onto the surface of distal tibia. 4 screws can be inserted distally, proximal screws are inserted through stab wounds. Biomechanical tests of this system were performed on cadaver bones. Since 2005 the ''angle stable'' system has been used in 41 patients in 35 cases as a primary stabilization, and in 6 cases as conversion of external fixation. Follow-up time was 18 months. Outcome was assessed with regard to function, pain and alignment. Introduction: The fracture of the distal lower limb with or without participation of the ankle joint remains a challenge to the surgeon. Due to the high energy released at the time of fracture, these injuries are usually accompanied by a severe soft-tissue damage. The success of the surgical therapy of tibial pilon fractures depends largely on the extent of the soft tissue damage as well as the quality of reconstruction of the tibial joint surface. A problem of the minute anatomical reconstruction is an increase in soft tissue problems and bone infection. Aim of this study was to investigate the results gained by a primary stabilization by external fixator followed by a multidirectional locked plate osteosynthesis after soft tissue consolidation. Material and Methods: Setting is a level 1 trauma centre, the design a consecutive series with a retrospective data evaluation. Between 2002 and 2005, 42 patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: 1. the fracture was stabilized with an external fixator immobilizing the ankle joint. 2. after stabilization of the soft tissue situation (mean 9.2 days) internal fixation with a locked-screw plate was performed. The implant used was a multi-directional locking internal plate fixator (Tifix, LITOS, Hamburg/Germany), made of pure titanium with locking holes for titanium screws which can be fixed in different angles and is available in seven different lengths (3-7 holes in the diaphyseal area). The mean follow-up time was 27.8 months. All follow-up examinations were supervised by a specialized orthopedic trauma Surgeon. The examination consisted of a set of standardized questions, clinical evaluation, the AOFAS Score and radiographs.

Results: Superficial wound-necrosis was noted 3 times, conservative treatment led to complete wound healing. DVT of the injured leg occurred in 2 cases. In 2 cases autologous bone graft was necessary after 2 and 3 months. Deep wound infection or postoperative osteomyelitis was not observed. The definitive treatment was performed after an average of 9.6 days. In 9 cases an autologous bone graft was used. In a further 2 cases a later autologous bone graft was performed for delayed union at 9 and 13 weeks after ORIF. Full weight bearing was reached after an average of 11.8 weeks. Bony union was achieved in all cases after an average of 4.1 months as determined by conventional radiographs. In 6 cases range of motion (ROM) of the ankle did not show any restriction compared to the opposite side. In 18 cases the range of motion was reduced by less than 1/3 compared to the opposite side, of up to 2/3 in 14 patients and restriction of > 2/3 was not noted in 4 cases. The mean AOFAS Score was 73.4. Conclusion: A twostage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result. Disclosure: No significant relationships. Introduction: The internal fixation for complex distal tibial fractures is sometimes challenging. Nowadays, successful outcome were reported about osteosynthesis through medial and anterior approaches including minimally invasive plate osteosynthesis (MIPO). However, there are cases in which such methods are not indicated because of their soft tissue problems or their fracture pattern. In this presentation, the new posterior plating procedure using the MIPO technique is reported. Material and Methods: This procedure was indicated only when no other internal fixation methods were present, which includes intramedullary nailing or medial/anterior plating, were found. So the indication for this procedure was extremely rare. From 2005 to 2009, 34 cases of AO classification 43-A and C type fractures were treated operatively in our institution. 2 cases met the criteria. Both of them were female and aged 66 and 37. The follow up period was 24 and 12 months. The procedure was as follows; Before the operation, the spanning external fixator was applied and the alignment was reduced as properly as possible. The patient was in the supine position and the knee was flexed at about 90 degrees. The distal window for MIPO was positioned between the distal fibula and achilles tendon, which is called a ''Posterolateral approach.'' Blunt dissection was performed, and exposed the edge of the flexor hallucis longs muscle (FHL). The tunnel over the periosteum at the posterior surface of the distal tibia was made and the plate was inserted. Then an incision was made at the posteromedial border of the tibial shaft and exposed the proximal part of the plate (Proximal window). The plate was placed properly under the image intensifier and fixed with screws. The wounds were irrigated and sutured in layers. Postoperative rehabilitation included a range of motion exercise and non-weight bearing gait and use of crutches immediately begun. Full weight bear was permitted around twelve weeks post operatively. Time to union, complication and final ambulatory ability were evaluated.

Results: Bony union was uneventfully completed within three months in both cases. There were no complications such as infection, skin problems, or plate irritation/impingement. Free gait was achieved within four months in both cases.

Conclusion: Posterior plating using the MIPO procedure for complex distal tibial fractures can be a good option, although our experience is very limited. However, this procedure should be indicated only when no other osteosynthetic methods are found because irritation/ impingement of the FHL or the achilles tendon or some other complications may arise, which has already been reported in open reduction and internal fixation through posterolateral approach.

References: Hayes AG, Nadkarni JB. Extensile posterior approach to the ankle. J Bone Joint Surg 1996;78B:468-470. Disclosure: No significant relationships.

Introduction: Even the most modern technology has failed to induce satisfactory functional regeneration of traumatically severed peripheral nerves. Delayed neural regeneration and in consequence slower neural conduction seriously limit muscle function in the area supplied by the injured nerve. This inferiority study aimed to compare a new nerve coaptation system involving an innovative prosthesis with the classical clinical method of sutured nerve coaptation. Besides the time and degree of nerve regeneration, the influence of electrostimulation was also tested. Material and Methods: The ischiatic nerve was severed in 14 female Gö ttinger minipigs with an average weight of approx. 35-40 kg. The animals were randomized electronically to four groups: Group I: nerve prosthesis without stimulation; Group II: nerve prosthesis with stimulation; Group III: microsurgical coaptation without stimulation; Group IV: microsurgical coaptation with stimulation. In groups III and IV, the nerve was sutured microsurgically, while the animals in groups I and II received the new nerve prosthesis. Postoperative monitoring and the stimulation schedule covered a period of 9 months, during which axonal budding was evaluated monthly.

Results: Preliminary data indicate that results with the nerve prosthesis are comparable to those with conventional coaptation.

The results of this pilot study indicate that implantation of the nerve prosthesis allows good and effective neural regeneration. This new and simple treatment option for peripheral nerve injuries can be performed in any hospital with surgical facilities as it does not involve the demanding microsurgical suture technique that can only be performed in specialized centers. Disclosure: No significant relationships. In mean there were 5,6 previous operations. In 166 cases a change of osteosynthesis was neccessary. In 42 cases BMP 7 was used alone. In 223 cases BMP7 was expanded by autologeous bone grafting. In 21 cases the BMP was extended by autografts or ceramic scaffolds. Results: Divided in a healing group and a not healing group we found in the healing group a excellent clinical result by 8.9 Points (able for sports) for the atrophic non unions and a good result of 8.1 points (walking long distances) for the post infected non unions. The radiological score is as high 8.1 / 7.9 (3 cortices healed and bridging callus). In the non healing group the clinical rate was 5.5 /4.9 (walking with splint) and the radiological rate was 4.9 / 3.4 (two cortices healed) The overall healing rate was 79%. Divided in several groups the healing rate increases from 68% (infected non unions not tibia) to 93% (atrophic aseptic non union tibia). Overal the secondary intervention rate was 14%. The healing time is 6.5 months in the middle. We see only mild side effects in 6%, like swelling. The most serious complication was the bony reinfection in 9%. There were 2 amputations.

Conclusion: Compared to the literature the healing rate of non unions could be increased using a strong concept in the treatment. As a part of the treatment the BMP treatened group increases the healing rate from 81% (Friedlä nder) to 93%. The results are similar to the papers from Kanakaris or Zimmermann. There were no significant side effects noticed. Material and Methods: Methods: At our level I trauma institute, from July, 2007 to September, 2008 each patient who presented with a clavicle fracture that was deemed operative received plate fixation alone or supplemented with bioresorbable calcium phosphate cement or autogenous bone grafting. Patient records and radiographs were retrospectively reviewed. Follow-up included standard radiographs to evaluate union at a minimum of 6 months. All complications were also reviewed. Results: Results: Two different clavicle plating systems, Smith and Nephew (Smith and Nephew, Memphis, USA) (23 clavicles) and Implant Technology Systems (I.T.S., Lassnitzhohe, Austria) (30 clavicles), were used with ORIF alone (11), autogenous bone graft (14 patients), or bioabsorbable calcium phosphate (28 clavicles). Of 53 patients treated with open reduction internal fixation, 6 complications have occurred at a minimum of 6 month follow-up. Three prominent hardware occurrences necessitated plate removal. One nonunion, one distal screw cut-out and one hardware breakage have been treated successfully with revision plating. Using Fisherâ e TM s exact test, no statistical significance was seen between the ORIF alone, autogenous bone grafting (2) and bioabsorbable calcium phosphate (4) in regard to overall failure incidence (p = 0.66).

Complications necessitating revision ORIF with bioabsorbable calcium phosphate (2) and bone graft (1) were not statistically significant either (p = 0.73).

Conclusion: There appears to be no statistically significant difference between union and complication rates between ORIF alone, or ORIF augmented with bioresorbable calcium phosphate cement or autogenous bone graft in this retrospective study. Introduction: The purpose of the present study was to determine the effect of two anti-osteoporotic treatments on fracture healing in osteoporotic OVX rats, 28 days after fracture occurrence. PTH which has been proven to influence fracture healing in OVX rats, was taken as a control treatment. Strontium ranelate is acting on both resorption and formation. We combined the rat model of a closed, standardised diaphyseal fracture of the femur with the model of a post-ovariectomy osteopenic rat, mimicking post-menopausal bone loss.

Material and Methods: Forty-five animals were ovariectomised at the age of 12 weeks and a further 15 were sham operated. At the age of 24 weeks, osteopenia in the OVX rats was diagnosed. Then, in all animals, a standardised mid-diaphyseal fracture was induced. At the time of fracture, the animals were divided into four groups. Group 1 was the SHAM control group, Groups 2, 3 and 4 were the OVX treatment groups. Groups 1 and 2 were treated with NaCl 0.9% s.c. daily, Group 3 was treated with 600 mg/kg/d strontium ranelate p.o. daily and Group 4 received 20 lg PTH 1-34 3x/ week s.c. The animals were killed after 28 days and the fractured femur removed. The samples were scanned using MicroCT 80 by Scanco Medical, Zurich, Switzerland. The evaluation of the data focused on outer callus contour, cortical contour and marrow contour as well as cortical thickness. Torsion testing on the bones was carried out using the axial-torsional 8874 system by Instron (Darmstadt, Germany). Results: Treatment with strontium ranelate significantly improved the mechanical properties of the callus when compared to the OVX control group, while the improvement induced by the treatment with PTH 1-34 did not reach significance. PTH 1-34 and strontium ranelate both showed a significant increase in bone volume of the callus when compared to OVX control rats with no significant difference between the two treatments. As for the callus tissue volume, the increase induced by strontium ranelate was significant compared to OVX whereas PTH induced no change and the difference between both drugs was significant . In both the PTH 1-34-and strontium ranelate-administered animals BV/TV was significantly increased compared to the OVX control rats . The BV/TV of the PTH-treated rats was even higher than in the SHAM rats.

Conclusion: This is the first report on the enhancement of fracture healing with strontium ranelate. The callus in strontium ranelatetreated animals is even more resistant to torsion in comparison to OVX and SHAM-untreated animals and even to those treated with PTH 1-34. PTH did not significantly enhance the resistance of the callus versus OVX, despite a significant increase in BV/TV within the callus. The superior results obtained with strontium ranelate compared to PTH could be the consequence of a better quality of the new bone formed within the callus. Introduction: Recent clinical and animal studies suggest an elevated homocysteine serum concentration to be a risk factor for osteoporosis and fragility fractures (1) . In vitro studies showed that increasing homocysteine concentrations stimulate the activity of human osteoclasts (1). However, there is no data demonstrating that circulating homocysteine is related to structural and biomechanical properties of human bones. This study aimed to investigate the relation between morphological as well as biomechanical bone properties and homocysteine serum concentrations in humans. Material and Methods: Fasting blood samples and femoral heads were obtained from 94 males and females who underwent hip arthroplasty. Bones were assessed by dual energy X-ray absorptiometry (DXA), biomechanical testing (indentation method), and histomorphometry. Blood was sampled to measure homocysteine, folate, vitamin B6, and vitamin B12. According to their homocysteine serum concentration, subjects were classified as hyperhomocysteinemic (> 12 lmol/L, n = 47) and normohomocysteinemic (< 12 lmol/L, n = 47). Results: Folate and vitamin B6, but not vitamin B12, were significantly lower in hyperhomocysteinemic subjects when compared to controls. However, DXA, biomechanical testing, and histomorphometry did not reveal significant differences in bone quality between hyperhomocysteinemic subjects and controls.

The results of the present study do not indicate a significant relation between circulating homocysteine and morphological as wells as biomechanical bone properties. Introduction: Sometimes fractured bones heal poorly with standard treatment and sometimes a bone defect is a major problem. Although the bone grafting technique is considered a standard, there is a need for enhancement of this procedure. Healing of the cancellous bone is a complex process in which many inflammatory and signaling molecules take part. To improve the outcome of the healing process, one can influence it by applying platelet rich plasma gel locally, thereby releasing cytokines and growth factors (1). Cancellous bone is rich with mesenchymal stem cells that produce new bone when stimulated.

Material and Methods: We enlisted 8 patients with hard to heal fractures and fractures that demonstrated poor healing in the study. Five of the patients had osteomyelitis in the fracture and all fractures resulted in a bony defect as a serious complication after treatment. We designed a protocol for the preparation of allogeneic platelet rich plasma gel with suspended autologous cancellous bone, based on laboratory experiments in vitro (2) . Cancellous bone was harvested from iliac bone crest. We used standard AB0 and RhD identical, leukocyte depleted and irradiated platelets from a blood bank. Activation of the platelet gel was achieved by using a CaCl2 and thrombin mixture. We accepted patients after fulfilling the inclusion criteria and they were operated on in a standardized manner by their elected surgeons under technical supervision. In their follow-up, the ingrowths of bone grafts were measured by using x-ray analysis (3). Results: In 6 patients the transplant was sufficiently incorporated in the fracture to give a limb full function. There were no major complications related to the platelet rich plasma additives. In one patient a nerve paresis was observed, which resolved spontaneously. In 2 patients bone graft was not sufficiently incorporated, once because of poor compliance and the other time because of complex nature of distal tibia fracture. The clinical outcome of the operated patients (75%) is satisfactory and encouraging. Conclusion: The preliminary clinical results show that using platelet rich plasma and cancellous bone in the treatment of large bone defects has a promising therapeutic potential.

(1) Marx RE. Platelet-rich plasma: evidence to support its use. Time from injury to reduction and to surgical intervention was noted. Apoptosis was verified by microscopy with TUNEL, hematoxilin and eosine stained specimens after decalcification of the samples, a time consuming process. The number of live, apoptotic and necrotic chondrocytes were counted. The patients are followed with Harris Hip score, Merle de aubigne score and radiographs for two years. Results: 7 patients were admitted directly to our hospital, the rest transferred from other hospitals. 18 patients had their hip reduced after a mean time of 276 minutes. 2 had femoral traction applied and 3 patients were not reduced. Mean time from trauma to operation was 6 ± 3.8 days. Three patients received total hip arthroplasty. The results of will be presented at the congress. Conclusion: The conclusions will be given at the presentation. Introduction: Distal inter-locking using free-hand technique in intramedullary nailing is always a time consuming procedure. The use of Xray amplifier is mandatory and the exposure to radiation is rarely modest. If we use navigation devices we rarely trust the device completely and that is why we check the position with X-ray amplifier more than we need to. That is why we did laboratory testing of the new system using the electromagnetic navigation with the use of micro sensors for free-hand interlocking technique in laboratory without the use of X-ray amplifier to ensure the use of system in the operating theatre. Material and Methods: Three residents with little experience in distal interlocking and no experience with this device were testing the electromagnetic navigation system with the use of micro sensors for free-hand interlocking technique. 100 interlocking holes were drilled by the use of Guiding star platform in Lidis module, Ekliptik, Slovenia. The system producer had 20 minutes of introduction time, afterwards drilling was done. Distal locking was done on UTN Synhes nail and instead of bone, cannulated hard wood rods were used. We measured time needed for calibration and time needed for reaming and weather we were successful or not. Introduction: Percutaneous catheter drainage (PCD) is a useful method to manage pericardial effusion. However, PCD is not always effective in a case of hemopericardium due to clot. To perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method following finger dissection by subxiphoid approach, which was preliminary reported in 2005. We present the final data to report the usefulness of blind subxiphoid pericardiotomy (BSP) for emergency cases with acute hemopericardium.

Material and Methods: We designed a study to determine a favorable management for cardiac tamponade due to hemopericardium. Emergency 148 patients with acute hemopericardium secondary to trauma (n=12), acute aortic disease (n=122) and cardiac rupture following acute myocardial infarction (n=14), were the subjects. Board certified surgeons performed BSP (n=16) and other emergency physicians performed PCD (n=67) for patients with cardiopulmonary arrest (CPA) or near CPA due to cardiac tamponade from 2000 to 2004. Since 2005, BSP (n=37) or PCD (n=28) has been performed at the physicians' discretion.

Results: BSP was effective to relieve cardiac tamponade in all 53 cases but PCD was ineffective in 12 cases (12.6%, p=.008) because of clot in pericardium (n=10) or right ventricular puncture (n=2). In addition to ineffective drainage, acute occlusion of percutaneous drainage tube (n=4) were observed and resulted in 2 deaths in the PCD group. Procedure-related complication rates of BSP and PCD and survival rates of BSP and PCD were 0% and 16.8% (p=.001), 18.9% and 6.3%, respectively (p=.018). Sixteen patients (BSP, 10; PCD, 6) could discharge following emergency surgery (n=13) or conservative treatment (n=3). Conclusion: Blind subxiphoid pericardiotomy was safe and could be performed quickly in an emergency situation. Percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clot in pericardium in some cases. Disclosure: No significant relationships. Introduction and Objectives: Heart trauma, mostly penetrating, is not common in our community, but carries a significant morbidity. Its clinical presentation can be variable. Our objective was to asses the incidence, clinical presentation, associated injuries and mortality of our patient population with trauma to the heart. Material and Methods: Observational, descriptive, retrospective analysis of patient with heart trauma included in our trauma registry between 1993 and 2007. We reviewed demographic characteristics, mechanism of injury, associated injuries, Injury Severity Score (ISS) and New Injury Severity Score (NISS), mortality, TRISS probability of survival (Ps), and hospital length of stay. Results: We found 17 (1.1%) patients with cardiac traumatism out of 1.575 patients included in our registry, 6 (35%) with associated injuries and 11 (65%) isolated; 13 (76.5%) were from penetrating trauma, and only 4 (23.5%) were from blunt trauma. Mean ISS and NISS were of 28 (+/-12) and 35 (+/-14), respectively. Three patients presented ''in extremis'' (agonal status), nine presented with hemodynamic ''stability'' (SBP> 90 mmHg) (33% of them with a HR> 120 bpm), and five patients presented with hemodynamic instability. Only 30 % of the patients presented with cardiac tamponade, without hemothorax. Two pericardiocentesis (12%), 3 pericardial windows (18%), and 4 emergency room thoracotomies were done (23.5%).

The most frequent location was in the left ventricle, followed by right atrium and right ventricle. The most frequent associated injuries were in the lungs (53 %), followed by the abdomen and vascular injuries (44.4 %). Fifty-nine percent required ICU admission, with a median length of stay of 25 days. Ten patients died (59%), and three of them (17.6%) were dead on arrival. Two patients (22.2%) died with a Ps > 0.50. Conclusion: Heart trauma is not frequent in our community, and displays great variability in its clinical presentation, with a high mortality. Over half of the patients presented with hemodynamic ''stability''. Disclosure: No significant relationships.

Approach of Two Cases of Secondary Aortoesophageal Fistula Results: The 1 st patient was a 57-y-old man in which fistula was secondary to a fish-bone ingestion, 10 days before the admission. In the 2 nd cause, a 66-y-old man, fistula was secondary to rupture in oesophagus of a known thoracic aortic aneurysm. Diagnosis was made by a contrast-enhanced CT scan; a gastrografin X-ray in the1 st and an endoscopy in the 2 nd case completed the examination. In both cases the lesion consisted of a few-mm-diameter defect of the oesophageal wall. In the I case an emergent endovascular repair of thoracic aorta by Bolton Relay 28·110 mm stent graft was per-formed; in the II case, endovascular repair of thoracic aorta (by Bolton Relay 28x145 mm) was associated to an endoprosthesis placement for primary treatment of a preexisting infrarenal abdominal aortic aneurysm. Postoperatively TPN was administered. Definitive treatment of fistula was performed in both cases by an explorative right thoracotomy (in V and VII post-operative day respectively): oesopagus was primarily repaired and reinforced by a pedicled intercostal muscle flap and a nutritional jejunostomy was associated. Subsequent post-operative course consisted in NE administration, prolonged nasogastric suction, resuscitation with fluids, antibiotics. Hemorrhagic complications or infections were excluded by repeated CT scan. Oral feeding was in 19 th and 7 th postoperative day, after exclusion of a persistent fistula at a gastrografin X-ray of oesophagus. Hospital stay was of 30 days in both cases. No late complications were registered at follow-up. Conclusion: When an aortoesophageal fistula occurs (if consists of a small oesophageal lesion), emergent treatment of endovascular aortic repair can be successfully associated to a second-step primary repair using a pedicled intercostal muscle flap via a right thoracotomy. Results: Case 1: A 51-year-old male is taken to our hospital after a car crash. On CT scan there was a periaortic hematoma from isthmus to diaphragm, multiple rib (flail chest) fractures, and a pelvic fracture. The aorta was repaired with an endograft with good immediate results. Case 2: A 55-year-old male, injured in a frontal car crash. On CT scan a mediastinal periaortic hematoma was seen, with a pseudoaneurysm at the origin of the descendent thoracic aorta, distal to the sublavian artery. The aorta was repaired with an endograft, which was replaced at day 16th because of a leak. On follow-up he is doing very well. Case 3: A 26-year-old male, injured in a car crash. CT scan findings were as follows: a left diaphragamatic herniation, bilateral lung contusion, traumatic laceration of the descending aorta, pelvic fracture and spleen laceration. He underwent an emergency laparotomy with splenectomy and diaphragmatic repair. On the 2 nd postop. day an endograft was placed at the descending thoracic aorta, without complications. Case 4: A 68-year-old male, injured in a frontal car crash. On CT scan there was a thoracic aortic laceration, distal to the isthmus, and an aortic endovascular repair was undertaken at day 10 th , after complete hemodynamic normalization. The patient died at day 58 th from multiple organ failure. Conclusion: Traumatic thoracic aortic injuries are frequently associated to severe thoracic, abdominal and orthopaedic injuries. Traditional early surgical aortic repair through thoracotomy, with single lung ventilation and, occasionally, extracorporeal circulation carries a high morbidity and mortality. That is the reason why aortic repair has classically been delayed, but this carries an additional mortality rate of between 6% and 9%. Endovascular treatment allows for an early management in severely traumatized patients who otherwise wouldn't stand such a risky surgery. It has also revealed lower rates of paraplegia after 10 years of follow-up. Introduction: Injuries in zone I of the neck are rare and difficult to manage particularly in environment of war. This area gathers aerodigestive, vascular, lymphatic and nervous elements. All the difficulties lie in diagnosis of the lesions, in the decision of a surgical exploration and in the way of repair if necessary. In that situation, fistula between carotid artery and jugular vein is very uncommon, accounting for 4% of all arterial injuries. Through one case, which has occurred in Afghanistan, we discuss the various possible solutions to repair such a lesion. Material and Methods: We report one case of a french soldier, 30 yo, who was wounded by a rocket splinter on left side of the area I of the neck. He was transported immediately in French Role II in Kaboul. Respiratory tracks are not injured, there's no neurologic lesions. He had a huge haematoma of the area with a tracheal back pushing (Xray exam). During an effort of cough, a haemorrhage through the wound occurred requiring an oro-tracheal intubation and a surgical exploration by a cervicotomy. No obvious vascular lesions were found but just a thrill at the base of the neck. The patient was hemodynamically stable. He was transferred by medevac to France in the night. An angioscanner showed a fistula between carotid and jugular vein (2 photos).

Results: He was re-operated 24h after. The fistula was just behind the first rib requiring an enlarging by sternotomy to control the origine of left carotid. There was a section of left pneumogastric nerve. After exclusion of the fistula and the vein, we interposed an allograft on carotid artery (3 photos). The patient discharged from the hospital one week later without lateral damage except a bitonal voice with no need of re-education. Conclusion: Arterio-veinous fistula is an uncommon consequence of carotid injury. The taking in charge of this patient and the decision of the kinds of repair are difficult. Stenting has also been used to repair distal internal carotid injuries that are not easily approached surgically.

The favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae. Allograft or vein graft, if possible, is also a good solution for this kind of injuries. Introduction: We report 3 cases of subclavian artery injury caused by traffic accidents. In all cases, surgical vascular reconstruction was undertaken. In 2 of the cases, the subclavian artery was obstructed by intimal dissection caused by falling down from a motorcycle. In the remaining case, subclavian artery aneurysm caused by seat belt injury occurred. Material and Methods: Case 1: 59-year-old male While driving a large motorcycle, the patient collided with a car and the left side of his body was trapped in the car. This resulted in traumatic pneumothorax and severe ischemia of his left upper limb, and he was transported to our Level 1 trauma center for surgical treatment. Bypass surgery using a 6mm diameter PTFE was performed. Postoperative arteriography showed good patency of the graft and the patient was discharged. Recovery from the motor dysfunction caused by brachial plexus injury took 7 months. Case 2: 19-year-old male For this case, the patient ran into a wall while driving a 50 cc motorcycle. Bypass surgery and clavicular ORIF were undertaken simultaneously for right clavicular fracture and ischemia of the right upper limb. Postoperative arteriography showed good patency of the graft and the ischemia improved. However, rehabilitation was needed for the motor dysfunction caused by brachial plexus injury. Case 3: 68-yearold female The patient ran into a tree while driving a car resulting in hemorrhagic shock caused by bilateral femoral and humeral fractures. She was transported to our center by helicopter. A scar from seat belt injury was found in the right cervical area. She presented with an expanding mass around the subclavian artery with accompanying pulsating pain. Arteriography detected a 5 cm-diameter pseudoaneurysm and aneurysmectomy was undertaken. Postoperative computed tomography confirmed the disappearance of aneurysm and she was discharged. Results: These 3 cases showed favorable outcomes with surgical vascular reconstruction. Conclusion: Traumatic subclavian artery stenosis is caused by crushinduced local dissection and is frequently complicated with brachial plexus injury. Subclavian artery aneurysm caused by seat belt injury occurred. Disclosure: No significant relationships. Results: Case description: 40 years old male patient who was brought in after receiving a large stab wound below the mid-portion of the left clavicle. Severe external bleeding was prevented by manual compression in transit to the hospital. Three Foley catheters introduced through the wound at the ED failed to temporarily control the bleeding due to its large size, and he was rushed to the OR. An emergency left antero-lateral thoracotomy allowed for the blind manual compression of the bleeding vessel from within the thoracic cavity, and was very successful in stopping the external bleeding. A long supra-and infra-clavicular incision was done, and the clavicle was divided. This failed to expose the bleeding vessel, due to the large muscle mass of the patient. A decision was taken to split the sternum in a ''trap-door'' approach, which nicely exposed a large laceration of the subclavian vein. This was suture-ligated, and the incision closed, in a surgical field with profused oozing from coagulopathy. He was taken to the ICU, and then back to the OR two hours later because of persistent bleeding through the chest drains. The ''trap-door'' incision was reopened and careful haemostasis was performed. The patient had a protracted course in the ICU but eventually recovered. As a striking and very uncommon sequel he developed severe blindness from bilateral ischemic optic neuropathy attributed to hypotension and use of vasopressors. He is free of pain at the incision and with good cosmetic results Conclusion: ''Trap-door'' incisions are very infrequently used nowadays, but should be kept in mind in the armamentarium of trauma surgeons. Disclosure: No significant relationships. Conclusion: Mortality in patients with IVC injuries can be well predicted by hemodynamic parameters on arrival and intra-operative findings .Hemodynamic instability and intraoperarive findings of expanding hematomas and active intra-peritoneal bleeding are associated with high mortality.

Introduction: Vascular complications due to intravenous drug abuse pose significant challenges to vascular surgeons and no standardized surgical management of the resultant infected pseudoaneurysm was established.

Material and Methods: We present our successful management of a case of an expanding retroperitoneal haemathoma due to external iliac artery pseudoaneurysm caused by self inflicted trauma (heroin administration). MRI showed an external iliac artery pseudoaneurysm surrounding by an infected old haemathoma, venous thrombosis (external illiac and femoural) and multiple muscular abscesses of the left thigh. A self-expandable stent-graft was deployed across the pseudoaneurysm after crossing the lession with an exchange glide wire through the left brachial artery route. Post-stenting angiography showed complete exclusion of the pseudoaneurysm with no residual stenosis. We decided local surgical debridement; after haemathoma evacuation we identified external illiac artery presenting a stent graft and reinforced it by double layer of tissue sealing surgical patch. Results: Postoperative course was favorable under complex general and local therapy.

Conclusion: Endovascular treatment of arterial pseudoaneurysms has become feasible as natural extension of the endovascular techniques. CT, MRI, sonography and angiography may all be valuable in the imaging working of pseudoaneurysms. Prompt diagnosis and treatment are necessary to avoid the morbidity and mortality secondary to hemorrhage and rupture. Although endovascular stent-grafting is not considered a standard therapy for infected aneurysms, our case suggest that stent-graft deployment, secondary surgical debridement and major antimicrobial therapy may be the most favorable treatment option for patients unfit for major surgery. Introduction: The incidence of traumatic vascular injuries (TVI) has increased significantly in the last decades, with penetrating trauma as the most frequent mechanism. Our aim was to estimate the incidence, management by interventional radiology, and the preventable death rate in our patient population. Material and Methods: A retrospective observational study based on our Trauma Registry covering a 14-year period (July 1993 to July 2007) . We have assessed the demographics, severity, diagnostic and therapeutic approaches, outcome, and TRISS probability of survival (Ps). Results: 76 patients (80% males, with a mean age of 37 years) suffered a TVI located at the head (2), neck (7), thorax (20), abdomen (4), upper extremities (19) and lower extremities (24), respectively. 39 (51.3%) were caused by a blunt mechanism, and 37 (48.7%) by an open one. The average time spent before being taken to hospital was 60 minutes. Upon arrival to hospital, 20 were in shock, 22 required orotracheal intubation, and 2 a cardiac massage. The diagnostic methods used were a CT scans in 54, DPL in 1, FAST in 7, angiography in 16, echocardiogram in 4 and duplex-doppler in 1. 69 (90.8%) patients underwent emergency surgery and 8 (10.5%) were treated with interventional radiology (7 of them associated with surgery). Only 6 (7.9%) were treated conservatively. Overall mortality was of 12 patients (15.8%) (6 of them died upon their arrival to hospital or in the operating room, all of them with an aortic injury), out of which 5 (6.6%) had a TRISS Ps > 0.5. The incidence of TVI increased from 15 cases in the 1993-1997 period to 30 in 1998-2002, remaining stable in 2003-2007 (31) . However, the mortality rate has shown a steady decline over the years (from 33% in 1993-1997, to 16% in 2003-2007) .

Conclusion: The incidence of traumatic vascular injuries has increased considerably during the last years in our hospital. These injuries are most commonly located in the lower extremities, followed by the thorax. 10% of patients could be managed by interventional radiology techniques. Introduction: The tip apex distance (TAD) is a simple measurement that predicts screw cut out in the femoral head in peritrochanteric fractures treated with a fixed angle sliding hip screw device. We wanted to assess whether the TAD measurements in our centre were comparable to previously published results, how reproducible these measurements were between observers and how accurate we were at reducing the fractures. Material and Methods: A retrospective review was conducted of 102 consecutively treated peritrochanteric fractures over a 12 month period. 11 patients were excluded because they did not sustain a peritrochanteric fracture, had treatment of a pathological fracture or because of incomplete radiographic data. Three observers used a standardised method to measure the TAD (from 2 orthogonal projections with a correction for magnification). The stability of the fracture patterns and the accuracy of reduction were measured according to criteria from the original Baumgaertner paper 1 Introduction: Distal locking screw insertion of the short Gamma 3 nail is normally performed by using a targeting device attached firmly to the proximal part of the nail. Generally, the accuracy of targeting device should be promising. However, missing the target in the process of drilling might be a potential risk. We report 5 cases of such condition in term of early radiographic finding, method of solving and the result of treatment.

Material and Methods: The patient records, operative notes and intraoperative c-arm images of the patients underwent short Gamma 3 nailing for unstable pertrochanteric fractures during October 2008 to October 2009 have been reviewed in order to identify an error of distal locking screw insertion via a targeting device. The intraoperative radiographic finding, solving procedure and the outcome has been analyzed.

Results: There were 64 cases of short Gamma 3 nailing over the past one year in our institute. Five of which had an error during distal screw insertion even using the targeting device. An error occurred in the drilling process in all cases. Intraoperative images showed that the drillbit missed its target posteriorly after perforating the near cortex of the femur. All has been corrected by using a free-hand technique under c-arm guidance. No any serious complication afterword and all fractures healed in an appropriated time.

Conclusion: Distal screw insertion during Gamma 3 nailing can be missed even though using the targeting device. Therefore, radiographic confirmation on the lateral view after perforation the near cortex is recommend in all cases in order to obtain early detection prior to bicortical perforation. Freehand technique can be carried out in order to correct the error. . Systemic antibiotics were used in 36 patients (92%). Ten different types of antibiotics were used after wound exploration for a period between 1 and 12 weeks. In-hospital mortality was 15%. Sixty-nine percent (n=27) was finally discharged from follow-up. Conclusion: We conclude that our infection rate was higher than reported in literature and the infections classified initially as superficial required a prolonged treatment as well. Moreover, the treatment of this disastrous complication showed no uniformity whatsoever and should be the topic of further research, resulting in a clear protocol to increase survival and decrease morbidity. Introduction: Allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. Medium-term and long-term results after meniscal allograft transplantation in the knee are scarce. In this study patients who received an arthroscopically assisted meniscal allograft transplantation with a follow-up between 5 and 15 years were evaluated using subjective questionnaires, a clinical and a radiographical evaluation. Material and Methods: Demographic data of all patients were collected and pre-operative results, using the KOOS (Knee injury and Osteoarthritis Outcome Score), the Lysholm score, the Tegner score, the SF 36 and the VAS (Visual Analogue Scale) for pain were compared with actual results of those questionnaires to evaluate the therapeutic effects of allograft meniscal transplantation in the knee during medium-term follow-up. Patients were evaluated with a standardized clinical examination of the knee to objectivate knee related symptoms. Standard weight bearing radiographs and a full leg standing radiograph were performed to evaluate the evolution of osteoarthritis and malalignment. Results: For all questionnaires (VAS, KOOS, Lysholm, SF 36) there is a significant (p<0,0001) and clinically relevant increase in postoperative score. This improvement stays consistent during the followup period. The more severe the osteoarthritis, the lower the improvement. Despite the meniscal transplantation, there is still a significant (p=0,0006) increase in osteoarthritis. An increase in osteoarthritis grade was seen in 42% of the patients, as scored following the Kellgren-Lawrence classification. When strictly respecting the indications, there is no significant correlation between preoperative cartilage damage, pre-operative osteoarthritis, alignment deviation, gender and body mass index on the one hand and outcome scores or improvement on the other hand. Conclusion: Meniscal allograft transplantation results in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. Strictly following the indications, meniscal transplantation can give good and predictable results. Introduction: Intramedullary nailing of the tibia has become the conventional therapy for tibial shaft fractures. One of the most common complaints associated with this procedure is chronic knee pain. Incidence rates between 10% and 86% have been reported and a significant number of patients have problems in kneeling, affecting professional and recreational activities. Surgical damage to the infrapatellar nerve is one possible causative factor for post-nailing knee pain. The infrapatellar nerve is exclusively sensory and runs subcutaneously almost perpendicular to the patellar tendon just below the patella. The purpose of this study was to determine the prevalence of chronic knee pain in our institute and its relation with sensory disturbances in the knee area. Material and Methods: A chart review was conducted. All patients between 15 and 65 years with healed traumatic tibial shaft fractures treated with an intramedullary nail between 1998 and 2008 were included. Exclusion criteria were: fracture lines extending into the knee or ankle joint, any other fracture in the affected leg, lacerations in the knee area, pre-operatively existing knee pain and loss of follow-up. Chronic knee pain was defined as persisting pain in the knee area 6 months after tibial nailing. Sensory disturbances were defined as hyperesthesia or anesthesia at the nail entry site. Introduction: Femoral nailing causes an influx of fat in the circulation. In the multiply injured patient, especially in the patient with concomitant lung or brain contusion, this can lead to ARDS, fat embolism syndrome and multiple organ failure. The timing and kind of fixation of femoral fractures in patients with multiple injuries is controversially. The advantage of damage control orthopaedics (external fixation) would be less fat embolisation but some authors report more problems of infection and delayed healing. The aim of our study was to investigate the effect of external fixation on healing and infection rates of femoral shaft fractures in the multiply injured patient.

Material and Methods: Between January 1998 and Januari 2008, we treated 230 femoral shaft fractures. In this group there where 122 polytrauma patients with a total of 137 fractures. We compared the rate of infection and delayed union in the group treated by damage control external fixation to the group primarily treated by intramedullary nailing.

Results: No significant difference in infection or union rates could be demonstrated between the damage control external fixation and the primary nailing group. We also noted that there's a correlation between the complexity of the fracture and the percentage of prolonged healing. And although not statistical significant there seems a tendency of less healing problems with the reamed femoral nail in comparison with the unreamed femoral nail. Introduction: The diagnostic information power of a level one emergency room has risen excessively within the last years. The need for quality control, judicial regulations, insurance claims and forensic reasons still lead to a high number of autopsies being performed in patients not surviving the first 48 h after admission to the ER. However, the number of autopsy clarification featured in a level one trauma centre after trauma related deaths considerably vary and also the rate of deathly diagnoses missed within ER assessment of early stage deceased patients differ in the literature. The aim of this study was to assess the value and necessity of autopsy after modern ER assessment with a multi-slice CT-scan as an integrated part of the diagnostic algorithm. Material and Methods: Prospectively reviewing our emergency database, case histories, laboratory values and radiological findings compared to findings in autopsy between Jan 2004 and Sep 2007, we charged for missed deathly diagnoses in 87 early stage deceased trauma patients (<48h). Patients were classified into two groups: group 1: patients with limited diagnostic assessment (conventional xray, sonography). Group 2: patients with full ER assessment (MSCT). All patients in group 1 could not be sufficiently stabilised in terms of circulation patterns and therefore did not receive full assessment. Non-trauma patients and patients reaching the ER under CPR were excluded. Results: The autopsy rate of all included patients was 86%. The overall incidence of missed deathly diagnoses was 9.2%. In terms of missed deathly diagnoses, groups varied significantly (group 1: 35.7%;group 2: 4.1%).The ISS after autopsy increased significantly in group 1 from 25 to 37.5. In group 2 there was no difference of ISS between status emergency room and after autopsy.

The most concerned region of missed deathly injuries was thorax with 62.5% of all patients with autopsies followed by pelvic (25%) and spine injuries (12.5%).

Conclusion: In spite of complete and nearly ideal conditions within a modern emergency room assessment nowadays, detecting all diag-noses is still challenging. Overall, our findings show that almost every tenth early stage deceased patient showed at least one missed potential deathly diagnose in a level one trauma centre. Regarding the insufficient assessment performance in group 1, the relative high rate of missed diagnoses seem explicable. Nevertheless, even having acquired full assessment power (group 2), still 4.1% deathly diagnoses were missed. For this reason, autopsy is still the most powerful and indispensable tool in finding the ''whole'' diagnosis. Completeness of autopsies after trauma related death therefore is essential referring a continuous gain of quality. Introduction: In a physiological environment metallic biomaterials undergo corrosion through a variety of mechanisms. This study investigated whether, beside the well recognized electrochemical aspect of corrosion, human osteoclasts are able to directly corrode titanium alloys, uptake and finally release corresponding metal ions into their environment. The released ions are believed to cause inflammatory reactions and activate osteoclastic differentiation and activity, which most likely play a role in the pathophysiological mechanisms of aseptic loosening [1] . Material and Methods: Human monocytes and in vitro generated osteoclasts were seeded onto titanium and aluminum (positive control) foils. After 21 days scanning electron microscopy analysis was performed in order to assess whether monocytes were able to grow and differentiate on the metals. In order to visualize uptake and distribution of intracellular metal ions, a novel protocol using confocal microscopy analyses with Newport GreenTM DCF Diacetate Ester staining was developed [2] . Additionally, the concentrations of metal ions released into the culture supernatant were measured using atomic emission spectrometry. ). Nine BRE-GFP mice were used. Mice were allowed unrestricted activity. A mini-external fixator fixed to the proximal and distal tibia was applied under general anesthesia on day 0. The animals were permitted full weight baring and unrestricted activity after awakening from anaesthesia. The GFP signal of tibia and fibula in bilateral limbs was measured on days 1, 3, 7, 10 and 14 after application of the external fixator.

Results: Baseline measurements of the GFP-signal ranged from 6.8x10e9 photons to 3.1x10e10 photons between individual mice. After application of the external fixator, the GFP signal of the unloaded tibia and fibula decreased in all mice to on average 87% of baseline on day 1 (SD ± 23%, p = 0.07), 71% on day 3 (SD ± 31%, p < 0.05), 71% on day 7 (SD ± 41%, p < 0.05), 80% on day 10 (SD ± 41%, p = 0.09) and 71% on day 14 (SD ± 23%, p < 0.01). In the contra-lateral non-operated limb, the GPF signal increased to an average 129% on day 1 (SD ± 88%, p = 0.17), 154% on day 3 (SD ± 85% p < 0.05), 164% on day 7 (SD ± 105%, p = 0.05), 150% on day 10 (SD ± 58%, p < 0.05) and 172% on day 14 (SD ± 82%, p < 0.05). Introduction: The aim of the present study was to assess the effect of antibiotic loaded fresh-frozen allografts and compare it with antibiotic loaded acrylic bone cement in staphylococcal tibia osteomyelitis and to combine the effects of bone repair and eradication of infection in one stage surgery. Material and Methods: A unicortical 6.5-mm-diameter defect was created in the proximal tibial metaphysis of thirty-six New Zeland albino rabbits. After contamining the wounds with 2x10 8 colony forming units of staphylococcus aureus, we divided the animals into four groups. The negative control group received no treatment, the positive control group received teicoplanin-impregnated polymethylmethacrylate beads, the allograft group received fresh-frozen allografts and the experimental group received teicoplanin-impregnated fresh-frozen allografts. Histopathological evaluation with light microscope were made and intraosseous tissue cultures were performed on postoperative day 28. Clinical evaluation in a daily-routine were made. Results: The cultures showed no evidence of intramedullary infection in the experimental or the positive control group in eight of the nine rabbits, but they were positive for staphylococcus aureus in one of the nine rabbits in the experimental group, one of the nine rabbits in the positive control group and all of the rabbits in the negative control and allograft groups. The experimental group and the positive control group has similar effects in eradication of the infection. Conclusion: Teicoplanin-impregnated allografts was effective in preventing intramedullary staphylococcus aureus infection in a staphylococcal tibia osteomyelitis model. This combination therapy could potentially eliminate the need for surgical removal of cement beads. Using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be carried out in a one stage procedure. Introduction: We first report a case of an infection in humans by streptococcus pluranimalium, a new streptococcal species that has been isolated in the genital tract and tonsils of cattle, tonsils of a goat and a cat, and from the crop and the respiratory tract of canaries. According our knowledge there are a few reports in the literature reporting infections by this strain of streptococcus in animals, but never since now in humans.

A 57 year old farmer, fit and well, nonimmunocompromised has been treated in our department, for a close tibial plateau fracture (Schatzker VI), with a circular external fixator. Postoperatively, i.v antibiotics -cefuroxime 1500 mg every 8 h was administrated for 24 hours. Radiological and clinical healing of the fracture achieved successfully within 11 weeks of the fracture. The frame removed and the patient was followed up as an outpatient. Six days after the removal of the frame, the patient turned up to the A&E department, systematically unwell, complaining for a swollen painful knee, and a discharging abscess in one of the proximal pin sites near by the joint line.Fluid samples from the abscess and the knee aspiration, obtained and revealed streptococcus pluranimalium in all samples. Debridement of the abscess and an arthroscopic wash out was performed twice, followed by i.v antibiotics according to the sensitivity test (Levofloxacin (500 mgx2) Ceftriaxone (2grx2)) for six weeks, and p.o antibiotics (clarithromycin 500mg every 12 h and Levofloxacin 500 mg every 12) for another two weeks. Results: Symptoms were settled and the patient is free of infection for the last 12 months. Conclusion: We hypothesized that the bacterium was settled on the wires of the circular fixator and was inoculated in the patient during the removal of the frame. According our knowledge, it is the first case of infection in a human individual by this specific strain of streptococcus. Disclosure: No significant relationships. Introduction: Post traumatic knee joint contracture is the most difficult complication of the lower limbs traumas, considerably limits the functional abilities and make the patients invalids. Besides, the frequent consequence of knee joint injure is gonarthrosis, and kinesitherapy is one of the element of the complex treatment. The basis of the procedure is the joint relief, leading to adjoining muscles tonus lessening, and paraarticular tissues general tense lessening and infrajoint hydrostatic pressure, joint tissues nourishing improvement. The Introduction: Ilizarov frames are still removed in the operating theatre in a lot of centers. This is due to a variety of reasons, the main one being that it is a painful procedure. We decided to evaluate patient satisfaction and pain experienced on removal of Ilizarov frames in an outpatient setting, using oral analgesia and Entonox. Material and Methods: Seventy consecutive patients, who had their frames removed in the Out Patients Department, had their level of pain scored using a Visual Analogue Score (VAS) and a simple questionnaire.

Results: The mean score for frame removal was 4.7 on the VAS. There was no difference between male and female scores. The age of the patient does make a difference in the pain score, the pain score decreases with the age of the patient. Pain increases when there are 4 or more olive wires to be removed Conclusion: Removal of Ilizarov frames in the Outpatient department is a moderately painful but well tolerated procedure. Introduction: The proximal metaphyseal tibial fractures are difficult to treat due to their frequent association with tibial plateau fracture and due to their aspect, which is often comminuted and has a significant impact on the function of the knee. Surgery has to restore local anatomy and to allow early rehabilitation, meaning proper evaluation and stabilization of the fracture. Material and Methods: 24 cases, operated between 01.01.2005 -01.06.2007 (mean age 22-59 yrs) with proximal metaphyseal tibial fractures, were analysed. Pre-operative planning using CT scan was used. The fractures were complicated with compartment syndrome (4 cases) which needed additional fasciotomy.The fractures were stabilized with : plates and screws (16 cases) or external fixation (8 cases) depending on the soft tissue status. Bone graft was used in 2 cases. The patients were monitorised at 1,2,6,12 and 24 months postoperative, concerning: bone healing, restoring of the axis of the knee, joint mobility, septic complications.

Results: The axis of the knee were completely restored in all the cases. Bone healing appeared in all the patients (starting from 2 months-8 cases, at 3 months in the rest of the fracture) depending on the initial aspect of the fracture. Flexion of the knee was limited in 6cases (25% of the pactients) and extension was affected in 4 patients, depending, also, on the initial characteristics of the fracture. The frequency of the complications depended on the initial aspect of the fracture, initial stabilization, time from intial stabilization to final fixation. Conclusion: Results after surgery for tibial plateau fractures depend on the initial aspect of the fracture, but also on the results of surgery . The method proposed by the authors, which allows the suspension of the articular surphace, is valuable especially when the fracture is cominuted and has small fragments. The double plate fixation (medial and lateral) with single anterior incision is the best, effective and simple procedure in treatment of complex proximal tibial fractures (type V and VI of Schautzker classification).

Introduction: Compartment syndrome is one of the most frequent complications after proximal metaphyseal tibial fractures, due to the anatomical characteristics of this area. The importance of the problem is that the compartment syndrome radically changes the local and general and especially the type of fixation of the fracture. The purpose of this study is to evaluate the impact of the compartment syndrome on the outcome of the patients with this type of fracture, when recognized and treated early and complete.

Material and Methods: The authors analyse 52 cases of proximal metaphyseal tibial fractures treated in the Emergency Hospital, Bucharest, between 01.06.2004-01.06. 2008 . From these, in 28 cases, Compartment Syndrome was diagnosed. In all these cases, the patients were operated and the fracture stabilized (with plates and screws in 36 cases and external fixation in 16 cases). Decompressive fasciotomy was performed in all the 16 cases with installed compartment syndrome and intra-compartimental pressure was monitored post-operative in all the other 12 cases. Frome these, in 3 cases secondary Compartment syndrome developed and fascitomy was necessary 24-48 hours after surgery The patients are analysed concerning: the moment of surgical treatment, and the characteristics of the patient in that moment, post-operative treatment, the postoperative local and general outcome, local and general complications.

Results: The incidence of the complications was influenced by the time between trauma and complete surgery. There were 4 cases of superficial infection and 1 case of deep infection, without needing implant removal. All the fractures healed, the interval proved to be longer when external fixation was first used. There were no systemic definitive complications after these trauma. Conclusion: Compartment syndrome is frequent after proximal metaphyseal tibial fractures and the incidence of this complication was significant in the group of patients we studied, and the outcome was good when the treatment was early and complete . The Compartment Syndrome influenced the local and general prognosis, due to the importance of microcirculation in healing after trauma. Results: A CT pulmonary angiogram illustrated a metallic density, which appeared to lie in the lumen of the main pulmonary artery just proximal to the pulmonary valve. Conclusion: In this case, the respiratory symptoms and signs were due to a metallic pulmonary embolus rather than fat or thrombus. Formal anticoagulation was initiated and the patient's clinical condition consistently improved without the need for cardiothoracic surgery, although this is described in the literature with retained catheter fragments. Eight months after the injury, the fracture has consolidated with the patient returning to work. toid is often necessary to obtain adequate exposure. As an alternative to this we promote the minimal invasive transdeltoid approach. Material and Methods: The operative technique of the minimal invasive transdeltoid approach is explained in a first section. This approach has the advantage of direct access to the fracture site with more opportunities for adequate reduction and good plate placement without extensive distraction of the muscles. An important step in the procedure is the palpation of the axillary nerve. In a second section the results of a prospective cohort of the first 14 patients treated with this technique will be presented. The Neer criteria were used as guidelines for operative treatment. Fractures were classified according to the AO-classification. The ASES shoulder score was used to evaluate functional outcomes. Preoperative xrays were used to evaluate displacement, vascularity of the humeral head (according to the Hertel criteria) and AO fracture type. Postoperative X-rays were analyzed for quality of reduction of the CCD angle, reconstruction of the medial hinge and reposition of the tuberosities. Follow-up X-rays were evaluated for healing, avascular necrosis, loss of reduction and implant related failures of osteosynthesis. The 67-year-old male patient was taken to hospital after a traffic accident. He was a pedestrian hit by a car. He suffered comminuted proximal humeral fracture on the dominant right side. The fracture was closed. The glenoid cavity was damaged and acromion was broken. The fractures of the V-VI th ribs were found without complication. Otherwise the patient's condition was good. He had only a controlled hypertension. For preoperative planning CT scan was performed. As pieces of the humeral metaphysis wedged into the glenoid cavity insertion of glenoid component seemed uncertain. An early shoulder replacement was done on the 7 th day. The denudated fragments were removed. The tubercles with the muscle attachments were preserved. As a long bone defect remained in the metaphyseal zone normal stem would have been insufficient. A 220 cm long stem used in tumor cases was implanted. The length of the arm and size of the humeral head were compared to the intact side. The tubercles were attached to the prosthesis by non absorbable sutures. After the operation long bone defect remained which was filled up by heterotopic bone visible on X-ray. The postoperative period was complication free. Fever, severe pain, hematoma did not occur. The arm was in rest for 6 weeks, only controlled pendulum exercises were done from the second week. Active physiotherapy was started on the 7 th week. After 5 months the patient finished the follow up treatment. He was pain free and self-sufficient. Conclusion: For three-or four-part displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment/1,2/. In trauma cases short prosthesis stem is usually sufficient but in comminuted fractures involving the metaphyseal zone long stem has to be used for certain bone-prosthesis contact. Introduction: There is a trend to apply plate and screw fixation directly medial and lateral (so-called parallel plating), and many implants designed specifically for the distal humerus extend more laterally to improve fixation. This may risk injury to the origins of the common extensor and flexion musculature and the collateral ligaments either via operative dissection or by damage to the blood supply. Internal plate and screw fixation is often accomplished with subperiosteal elevation of muscle attachments and tight apposition of the plate to the bone, but this should not be done over the epicondyles. Plates applied to the medial and lateral aspects of the lateral and medial epicondyles should be placed directly over the soft tissues without elevating or disturbing them. Damage to the collateral ligaments could cause elbow instability. Material and Methods: In order to emphasize these important technical aspects, we report three patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle led to post-operative instability after open reduction and internal fixation of a fracture of the distal humerus.

Results: While the cases are very complex and the exact cause of elbow instability by necessity somewhat speculative, our concern is that the operative dissection performed to apply implants to the lateral side of the elbow contributed to the ulnohumeral instability. Injury to the LCL is the most common cause of recurrent elbow dislocation. Attempts to place a direct lateral implant directly on the bone by elevating soft tissues will put the origin of the LCL at risk. It is preferable to place implants directly over the soft tissues, although there is a risk of interfering with blood supply leading to soft tissue insufficiency. It seems safe to assume that the operative treatment contributed in some way to the instability in each patient. Patient one in particular had osteoporotic bone noted intraoperatively, so that one would expect failure to occur through bone with any subsequent trauma. The failure through the ligamentous structures seems to implicate the operative technique.

Conclusion: In any case, these three patients establish that instability of the ulnohumeral joint is an uncommon complication or sequel of the operative treatment of a bicolumnar fracture of the distal humerus. Our intention in reporting these cases is to increase awareness of these potential complications and we encourage others to report any similar cases so that we can learn enough to limit the risk of this complication.

Introduction: ORIF of comminuted distal humerus fractures carries a high risk of complications such as secondray loss of reduction, pseudarthrosis and heterotopic ossifications. Especially elderly patients with osteoporotic bone quality are struck by these complications. Therefore total elbow arthroplasty (TEA) is gaining more and more in importance as it has proven to achieve good results in elderly patients with poor bone quality. The Latitude total elbow system (Tornier Inc., Stafford, USA) is a modular, convertible implant that allows not only linked and unlinked TEA with or without radial head replacement but also hemiarthroplasty. The aim of this system is to reproduce the patient's anatomy to reconstitue the elbow's physiologic kinematics. Therefore the Latitude prosthesis is offered in four different sizes, respecting the flexion-extension axis and three different humeral offsets based on anatomical findings. The purpose of our study was to evaluate the short-term results after elbow arthroplasty with the Latitude system. Introduction: It is not always possible to reconstruct complex radial head fractures. As non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. Other authors propose radial head arthroplasty as an alternative to radial head resection to avoid the complications of radial head resection. Different concepts of radial head prostheses are available: silicon prosthesis, monopolar prosthesis (loose fit and cemented/thight fit) and bipolar prostheses. Evidence is lacking on the exact place for arthroplasty as opposed to radial head resection. To answer this question we performed a systematic review of litterature. Material and Methods: Inclusion criteria are clinical studies reporting on radial head resection or radial head arthroplasty, published between 1995 and today in english, french, german or dutch language. A search has been performed using the Pubmed and Embase databank. A secondary search has been performed based upon the reference list of the included publications. Exclusion criteria are: â e¢cadaver or animal studies â e¢biomechanic studies â e¢clinical studies with a follow up of less than 2 years â e¢clinical studies with less than 10 patients Data extraction â e¢elbow function â e¢complication rate â e¢arthritis rate Data are reported according to the MOOSE guidelines. Results: Only low evidence studies are available. We did not find any randomised controlled trial comparing resection to radial head arthroplasty. There is evidence that radial head resection results in high complication rates (including arthritis) and poor function in case of elbow instability and/or Essex-Lopresti lesions. The rate of complications in these indications is higher than for radial head arthroplasty. In cases without instability or Essex-Lopresti lesion there is a trend to better function in radial head resection. Complication rate is higher in the prosthesis patients. The rate of post-traumatic arthritis is not significantly differing between the resection and the arthroplasty group, and remains very high (+/_ 70%).

Conclusion: Complex radial head fractures remain difficult to treat. Based upon the findings of this systematic review we suggest: â e¢that adequate level of evidence studies are a necessity â e¢that in case of fracture without evident instability or Essex Lopresti lesion resection results in better function and less complications than arthroplasty â e¢that in case of fracture with evident instability or Essex Lopresti lesion resection results in worse function and higher complication rates than arthroplasty â e¢As secondary arthritis rate remains 70%, further therapeutic optimisation is a must. often, mortality. A new pelvic stabilizer (T-POD Ò ) provides secure and effective simultaneous circumferential compression of the pelvis. Material and Methods: In this study we have managed fifteen patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the T-POD Ò . Before and 2 minutes after applying the T-POD Ò , heart rate and blood pressure were measured. An X-ray before and after applying the T-PODÒ was made to measure the effect on reduction in symphyseal diastasis.

Results: Application of the T-POD Ò reduced the symphyseal diastasis with 60% (n=12; p=0.01). The mean arterial pressure (MAP) increased significant from 64.7 to 81.2 mmHg (n=10; p=0.04) and the heart rate declined from 106 beats per minute to 93 (n=10; p=0.04). In ten patients of whom circulatory response before and after the T-POD Ò was recorded, there were seven good responders, one transient and two poor responders. Conclusion: In the acute setting, the T-POD Ò device has a clear compressive effect on the pelvic volume in unstable pelvic fractures.

The T-POD Ò is therefore an easy to use and effective way of (temporarily) stabilizing the pelvic ring in an acute setting. Introduction: Thoracolumbar and lumbar fractures treated with surgical methods aim to decompress the spinal cord and correct the deformity. We aimed to compare the effects of anterior, posterior and anterior-posterior surgery on the local kyphosis angle in thoracolumbar and lumbar vertebral fractures. Material and Methods: Thoracolumbar and lumbar, burst or compression fractured and surgically treated 62 patients were evaluated retrospectively. Preoperative, postoperative and follow-up local kyphosis angles were measured on the X-rays and changes in these angles were compared according to the applied surgical treatment methods.

Results: Early application of surgical treatment following trauma decreases the correction loss suffered after surgery. The increase in correction loss continues after removal of the hardware. It is observed that laminectomy applied in the course of posterior surgical interventions has no effect on the correction loss. The length of the implantation, fusion and the addition of a hook to the lamina of the vertebra which is located one segment lower than the transpedicular screw applied vertebra do not affect the loss of correction.

Conclusion: In the surgical treatment of thoracolumbar and lumbar vertebral fractures, different degrees of correction loss are observed after each surgical treatment modality. Considering the corrective effect of combined anterior-posterior surgery on the correction of kyphotic derformity due to trauma and the preoperative local kyphosis angle, follow-up correction achievement is higher when compared with anterior and posterior surgical approaches.

Domain questionnaire (EQ-5D), the 10 point self-rated back pain (VAS) and device and/or procedure related adverse events. The ethic committee of the hospital did not accept a randomized study because of the results in this proof of concept, they accepted the study with a minimum of 69 patients (based on the results of a previous proof of concept). The incidence of missed injuries without the application of the tertiary survey was 45% and this incidence has been reduced to 4% with the application of the tertiary survey (it means a reduction of the 91.1% in the incidence of missed injuries). The incidence of clinically significant missed injuries without the application of the tertiary survey was 23% and it has been reduced to 0% with the application of the tertiary survey (it means a reduction of the 100% in the incidence of missed injuries).

The tertiary survey is an essential task in the management of the trauma patients to reduce the incidence of missed injuries and clinically significant missed injuries. Introduction: Knee-Arthroscopy is a complex surgical ability. It is a combination of factors like anatomical knowledge, hand-eye coordination, three-dimensional mental activity and operating experience. Surgeons as well as students were not able to train knee arthroscopy before. Parts of these abilities were trained by playing video games. Former studies indicated a correlation between a better performance in virtual reality (VR) laparoscopy simulation and video game experience. The aim of this study is to show that experienced video gamer perform better in a virtual arthroscopy simulation.

Material and Methods: 164 medical students did an arthroscopy of a longitudinal meniscus tear on a VR knee arthroscopy simulator (the insight Arthro VR Ò GMV, Madrid, Spain). The students completed a questionnaire asking for their game experience: none (n = 123), monthly (n = 20) weekly (n = 17) daily (n = 6) before they did the arthroscopy. The simulator assessed 4 different parameters: time, distance moved and roughness both for probe and camera and a global score (combination of all metrics). Results: Students with game experience (n = 43) performed significantly (p <= 0,05) better than not experienced students (n = 123).

There is a tendency that the performances get better with more game experience.

Conclusion: Gamer performed better in a VR knee arthroscopy than not gamer. These result correlates to the laparoscopic simulator training. There is a tendency of achieving a better performance in VR arthroscopy simulation due to a higher frequency of playing games. Extensive training on the simulator improves the abilities of nongamers with respect to their arthroscopy skills. We will evaluate these dates in the future. ) and mostly injuries of tendons (n = 10) and/or vessels / nerves (n = 6). Buzzsaws of different manufacturers and different price ranges were used. The work conditions were well in all cases, the saws were placed firmly on the ground and the lighting was sufficient. Most injuries appeared on the week-end (Friday n = 9, Saturday n = 8). A break or a meal, taken shortly before the accident, had no influence on the injury risk. All patients had a several years lasting experience in dealing with buzzsaws, half of the patients even for at least 20 years. The safety device of the saw was folded back in most cases (n = 25), only few patients (n = 15) had correctly put on the saw safety device at the accident time, 4 patients provided moreover no information. The accident had entered in 12 cases shortly before working end, mostly with the last cut. In 10 cases a wooden piece had become stuck in the saw and the patient had tried to solve it. Conclusion: A many years' routine in dealing with buzzsaws can lead to the fact that necessary safeguarding measures are not followed any more and so cause an increased injury risk. In particular shortly before working end the attention decreases and the injury risk rises. An especially injury-laden situation is becoming stuck of wooden parts in the saw. The attempt to solve these parts without switching off the saw before bears a high injury risk. The patients showed predominantly heavy injuries. This might be the result of our clinic as a university clinic. Patients with less severe injuries are concerned to be treated in smaller clinics next to their residence . Ethibond was then used to anatomically oppose the ends of the sleeve fracture. The construct was reinforced with a circlage wire with the wire twisted so that it could be retrieved later through a small lateral incision Post operatively the legs were immobilised in lightweight casting material for a period of 6 weeks followed by an unlicked hinged knee brace for 4 weeks. The circlage wires were removed at 6 months.

The child now has full, pain free range of motion. The knee is stable and he has no functional problems. Conclusion: We report a rare case and emphasize the timing of diagnosis as being crucial in outcome. Early operative intervention with accurate open reduction will yield good results. This publication serves to educate and refresh those who deal with general and paediatric lower limb trauma.

Introduction: The purpose of this study was to evaluate the effect of electromagnetic fields in healing progression of delayed union of long bones in the lower extremities. We defined delayed union, as failure of expected healing progression and nonunion when a minimum of nine months has elapsed since injury and failure or halting of healing progression was observed in three successive monthly radiographs (infection ruled out Results: An average of 4.7 x-rays were performed on each patient from the time of diagnosis to discharge from clinic. None of these fractures displaced on follow up x-rays. Conclusion: Stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. Hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources. (1). We aim to describe the rate of postoperative complications after calcaneal plate osteosynthesis in relation to the hospital fracture load as a means to increase insight into the clinical audit data. Material and Methods: A search was performed using the disease code for intra-articular calcaneal fractures and operative code for ORIF for the period 2000-2009. The medical records of all included patients were obtained. As postoperative complications we included superficial and deep wound infection, mobilisation problems with need for orthopaedic shoes or walking aid and secondary arthrodesis. Current complication rate of deep infection and arthrodesis rate from the clinical audit were compared with the mean logarithmic correlation coefficient relating complication rates with the institutional fracture load data, reported earlier in the literature (1) . Results: Over a period of 108 months a total of 53 intra-articular calcaneal fractures were reconstructed with a calcaneal plate using ORIF (mean institutional fracture load = 0.49 fractures per month). Eight patients had a wound infection, six of them were treated with antibiotics and two of them needed surgical debridement. Thirteen patients have mobilisation problems, 5 patients suffered from pain when walking, 7 patients used orthopaedic shoes and one patient mobilised using a wheelchair. Two patients had an secondary arthrodesis (n = 2, 3.8%). In seven patients the osteosynthesis was removed due to pain. Both deep infection rate and arthrodesis rates related to the institutional fracture load were below the 95% CI reported in the literature.

The outcome of open reduction and internal fixation of intra-articular calcaneal fractures is known to be determined not only by factors related to patient and the fracture, but also to the institutional fracture load (1) . The complication rate regarding deep wound infection and arthrodesis is below the data reported in the literature, related to the institutional fracture load. Clinical audits studying the complication rate should take the institutional fracture load into account. Introduction: Toe fractures are the most common fracture of the foot. There is little data on demographics and no studies on functional outcome of toe fractures. Material and Methods: The initial radiographs of all consecutive patients with toe fractures treated between January 2006 and September 2008 at the Reinier De Graaf Groep in Delft, the Netherlands were re-evaluated; patient and fracture characteristics were collected. All patients in aged 16 to 75 (264 patients) were sent a questionnaire concerning pain, activity and functional limitations, footwear, walking distance, and gait (AOFAS midfoot score). Overall satisfaction was measured using a Visual Analogue Scale (range zero to ten).

Results: A total of 339 patients with 368 digital and 370 phalangeal fractures of the foot were identified. The distribution of fractured toes was: first 38%, second 11%, third 7%, fourth 14%, and fifth 30%. Multiple digital fractures were seen in 5.9%. Most fractures were caused by stubbing the toe or a crush injury (75.6%). More than 95% of the fractures were undisplaced or minimally displaced and most fracture patterns were transverse or oblique/spiral. A total of 141 patients (53%) returned the questionnaire with a median follow-up of 27 months. Responders were female in 57.4% and had a median age of 45 years (P25-P75 31-58). In 46.8% of cases the left side was affected. The median AOFAS-score was 100 points (P25-P75 93-100), the median VAS was 10 points (P25-P75 8-10). No correlations were identified with outcome and which toe or phalangeal bone was affected, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and diabetes. In the univariate analysis a trend was found for dislocation and AOFAS score (p = 0.058). In the multivariate analysis the VAS was dependent of age (p = 0.047) and gender (p = 0.049). The AOFAS midfoot score was not influenced by any of the parameters. Conclusion: This is the first investigation using two validated outcome scoring systems to determine functional outcome. Almost all toe fractures were healed without complaints at 27 months. Patient satisfaction is slightly less in younger female patients. The appendix has been one of the most common site of carsinoid tumors(1). Carsinoid tm is seen incidental in appendectomised cases(0,3-0,9) and frequently in female(2,3). Mean diagnosis age is between 39-49 in literature, whereas in our serise it is 32(4). Postoperative living prognosis is good in incidental carsinoid tumors of appendix (5) .In our cases, Additional surgical procedure was not applied because tumor is less than 2 cm, mesoappendix is healthy, and vascular invasion was not seen in hystopathologic examination. Introduction: For clinical importance, two cases are presented who were operated with diagnosis of acute apppendicitis. Intraoperatively,appendixes were normal, for this reason meckel's diverticulas were explored and diverticulitis were seen. Material and Methods: Two cases are explored retrospectively Results: Case 1:The case is 40 years old male patient.He admitted to emergency department with abdominal pain for 2 days.There were defans and rebaund on the right inferior quadrant of the abdomen. Leucocytosis(15,0x10 3 /mm 3 ), aperistaltic intestinal ans in ultrasonografic examination were seen. In the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at 80th cm from ileocecal valve.Wedge resection for diverticulitis and appendectomy for appendix were performed.In microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen Case 2:The case is 32 years old male. He admitted to emergency departmant with abdominal pain for 3 days because his pain increased last 2 days. He has nausia, vomiting, fever(38,3°C), leucocytosis(16,0x10 3 /mm 3 ), defans and rebaund on the right inferior abdomen. In the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at 100th cm from ileocecal valve.Wedge resection for diverticulitis and appendectomy for appendix were performed.In microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen. Conclusion: Meckel's diverticula is the most congenital anomalies of the gastrointestinal anomalies and it was found 2% in autopsy ser-ies. (1) .It is asymptomatic generally. Risk of complication is 4-6%(2). Preoperative diagnosis may not be done frequently, so to delay of operation may be serious complication.(3)In our clinic, we explore meckel's diverticula, over(in female) and duodenum, if we do not see pü rü lant material on the appendix. Results: Patients with abdominal TB were diagnosed by laparoscopy and peritoneal biopsy in 9 cases and by laparotomy in 2 cases. From these 11 patients we observed peritoneal TB in 8 cases, intestinal TB in 2 cases, mesenteric lymph nodes TB in 1 case. At admission 5 patients presented complications: 2 cases with perforations and peritonitis, 1 case with intestinal obstruction and 2 cases presented as ileo-cecal ''tumors'' (solved by right colectomy); other surgical procedure performed was enterectomy with either entero-entero-anastomosis, either ileo-colic anastomosis. In abdominal tuberculosis ascites was present in 8 cases. Other common findings were weight loss (6 cases), weakness (4 cases), abdominal pain (10 cases), anorexia (8 cases) and night sweat (2 cases). Only 2 patients had chest radiography suggestive of a new TB lesion. In those patients with peritoneal tuberculosis subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white ''miliary nodules'' or plaques, enlarged lymph nodes, ascites, ''violin string'' fibrinous strands, and omental thickening. Biopsy specimens revealed granulomas, while ascitic fluid showed numerous lymphocytes. Postoperative management was applied by the TB Medical System. All patients were treated for 6 months by specific drug therapy, with favorable evolution. PCR of ascitic fluid was positive for Mycobacterium tuberculosis (M. tuberculosis) in all cases. Introduction: Abdominal trauma represents an important cause of morbidity and mortality in children. Conservative management is preferred in blunt trauma with hemodynamic stability although there is a risk of intestinal damage when free fluid without solid organ injury is found in image studies. Early laparotomy may be unnecessary in most cases but a delay in diagnosis of bowel perforation could lead to increased rate of complications. On the other hand the presence of a penetrating abdominal trauma is considered an absolute indication of laparotomy. We present five cases of abdominal trauma treated in our department in which laparoscopy proved to be an optimal diagnostic and therapeutic tool. Material and Methods: Chart review of our cases and literature review Results: Three cases of blunt abdominal trauma underwent laparoscopy. We found a small bowel perforation in one case that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions that were treated by peritoneal drainage. Two cases of penetrating trauma underwent laparoscopy. One of them presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. Conclusion: In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure in blunt abdominal trauma in stable children with abnormal abdominal examination and moderate free fluid and no solid organ injury in image studies, and it could be a first and sometimes definitive approach to minimal penetrating abdominal trauma. 3%) patients, biliary tract injury in 3 (13.04%) patients, multiple stones in the abdomen due to perforation in 2 (8.6%) patients, inadequate technical equipment in 2 (8.6%) patients, liver injury in 1 (4.3%) patient, intraoperatively detected umbilical hernia in 1 (4.3%) patient, uncontrollable bleeding in trocar entry site in 1 (4.3%) patient, insufficient insufflation in 1 (4.3%) patient, and unstoppable bleeding of arteria cystica in 1 (4.3%) patient, respectively. Conclusion: Although laparoscopic cholecystectomy is the golden standard of treatment in cholecystectomy, it involves the risk of conversion to open surgery. The rate of conversion to open surgery has been reported to be between 2-20% in many series and is considered to be 5% on average. In our study, we found it as 6.2%, a rate which is close to the rate reported in the literature. Chief reasons for conversion from laparoscopic to open cholecystectomy include the difficult dissection of Callot's triangle due to obscured anatomy and adhesions, gallbladder perforation, bleeding, the failure to produce pneumoperitoneum, gallbladder cancer, and injury in main biliary tracts and neighboring organs. The presence of pericholecystic adhesion and liquid in acute cholecytitis cases and the presence of edema in the tissue affect regional anatomy and complicate dissection, which increases the risk of gallbladder perforation. In our study, changes due to acute cholecytitis and difficulties in the preparation of Callot's triangle ranked first among the indications for open cholecystectomy with a rate of 47.8% (11/23 Introduction: The most difficult decision in the management of the patients with severe necrotizing pancreatitis is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. Recently a great deal of data has emerged suggesting that a pulsating irrigation stream delivered at high pressure and with a high flow effectively decreases bacteria, foreign bodies, and necrotic crushed tissue in wounds and decreases the incidence of resultant wound infection. This study evaluates the effect of Inter pulse jet irrigation, used for the first time in open abdominal surgery. Material and Methods: Twelve patients presenting proven infected/ non-infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological or laparoscopic drainage were prospectively offered necrosectomy using itner pulse jet irrigation. Open necrosectomy and subsequent jet irrigation were performed using a midline laparotomy. In all patients, 1 to 3 tube drainages were placed during necrosectomy for continuous closed lavage. Temporary abdominal closure using modified mesh-foil laparostomy was applied for relief of abdominal compartment syndrome.

Results: No intraoperative complications were recorded with a median operative time of 112 +/-34 minutes. In 7 cases two sessions of necrosectomy were sufficient to completely clear the necrotic tissues. Another 5 patients with extended retroperitoneal necrosis required 3 irrigation procedures. Necrosectomy using Inter pulse jet irrigation was successful in all patients, and none required complementary surgical or radiological treatment. Introduction: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), have been described often in patients with abdominal trauma or after emergency abdominal surgical operations. We present 3 patients with vomiting, meteorism, acute abdomen and acute respiratory insufficiency provoked by phytobezoars. Aetiopathogenesis, symptoms and differential diagnosis are analyzed and a brief report of the literature is discussed. Material and Methods: Three patients, were admitted to the emergency department of our hospital during the last year. All patients were presented with acute respiratory failure, abdominal pain, discomfort, meteorism and vomiting. The first patient, a 57 years old man, alcoholic was admitted with meteorism, acute abdominal pain and discomfort. A 26 Fr nasogastric tube was introduced and the symptoms were remitted after gastric evacuation. The second patient suffered from bowel obstruction after closure of colostomy as a result of traumatic injury of sigmoid colon. A laparotomy was performed and a phytobezoar was revealed at the level of anastomosis. The last patient was presented with meteorism, vomiting and dyspepsia, as a result of enlarged gastric mass, revealed after endoscopy.

Results: Gastric evacuation in the first patient revealed 5 lt of fluid mixed with a smelly gas under pressure (IAP = 33 cmH2O after evacuation) followed by washouts. Laparotomy was performed in the second patient revealing a large phytobezoar at the level of anastomosis. Mini laparotomy and gastrotomy in the third patient (after two unsuccessful gastroscopies) revealed large phytobezoars. Introduction: The objective was the substantiation of using DCS tactics in wounded with CTMI. Material and Methods: In case of cranial injuries DCS tactics implied treating superficial wounds of skin, arrest of exterior bleeding and subsequent evacuation of the wounded within the first hours after getting trauma. In case of extremity injuries, DCS tactics implied first of all the operations on the occasion of gunshot injuries, including the arrest of bleeding, application of the external fixation apparatuses, application of temporary shunts for injured vessels. The burn wounds treating were carried out after helping the patient out of shock. In case of the wounded with chest injury in the presence of hemo-and pneumothorax, drainage of pleural cavity of silicone tubes with active air aspiration was fulfilled. In case of abdomen injuries after laparotomy abdominal cavity was cleaned and inspected including examination of the most probable sources of bleeding: liver, spleen, magistral vessels. On the background of unstable hemodynamics the abdominal cavity tamponage along the right and left side canals, supraliver and underliver space and small pelvis. Results: Thus, in accordance with DCS principles in case of CTMI, operations regarding gunshot injuries were made in the first turn, and operations connected with burns -in the second turn. The first were urgent operations. Then, intensive therapy in the conditions of resuscitation unit. Conclusion: The repeated operation of the second stage -final removal of lesions -was carried out after the condition of the wounded had been stabilized. Introduction: The AA highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. Material and Methods: Man, age 78, 3 rd pod after total gastrectomy with precolic reconstruction for gastric cancer (T2N2MxR0) in another institution. No significant past diseases. Mechanically ventilated, in septic shock, with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant, after ''methilene blue'' swallow. Distended abdomen. Relaparotomy with median frenotomy (Pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (DAC, Rotondo and Schwab) and intensive care unit (ICU). On 5 th pod, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, DAC and ICU. On 8 th pod, anastomotic leak: a Ttube (Kehr) has been placed as a minimal drainage procedure; DAC and ICU. On 10 th pod, descendent feeding jejunostomy and abdominal closure. On 14 th pod, subfrenic abscess on CT scan: surgical drainage through the upper third of the previous closed laparotomy. On 32 nd pod, intestinal suboclusion: drainage jejunostomy above the feeding one. On 41 st pod, right pleural drainage: oesophagoscopy, T-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. On 62 nd pod, patient left the ICU. Results: On 77 th pod, patient sent back to the institution where he has been operated first. On 99 th pod, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home.

Conclusion: This case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. Disclosure: No significant relationships.

Y. El-Ashaal 1 , A. Hefny 1 , Y. Saadeldinn 2 , F. M. Abu-Zidan 3 1 Al-Ain Hospital, Department of Surgery, Al-Ain, United Arab Emirates, 2 Al-ain Hospital, Department of Radiology, Al-Ain, United Arab Emirates, 3 Surgery, Department of Surgery, UAE University, Al-Ain, United Arab Emirates

Introduction: Acute gastric dilatation due to superior mesenteric artery syndrome in healthy subjects is extremely rare. Herein we report its sonographic findings and highlight the value of point of care bedside ultrasound in such a case. Material and Methods: A 17-year old female was admitted to Al-Ain Hospital complaining of epigastric pain of two days duration following excessive eating. She was nauseated but could not vomit. Succussion splash was positive. Bedside ultrasound has shown a hyperactive duodenum, a distended stomach compressing on the IVC, and a narrowed angle between the superior mesenteric artery and the aorta. These findings were confirmed by abdominal CT scan. The angle between the aorta and superior mesenteric artery was only 8 â -p p . Gastrographin follow through has shown complete obstruction of the third part of the duodenum. Nasogastric tube immediately drained 3500 ml of yellowish fluid. Results: Five days later gastrographin follow through has shown free passage of the dye to the small intestine with significant reduction in the stomach size. The patient was discharged home in a good condition.

Conclusion: Bedside ultrasound has proven extremely useful for both the diagnosis and management of this rare case. Introduction: A rare and potentially lethal complication during right hemicolectomy Material and Methods: A 75 year-old male, underwent a right hemicolectomy due to malignancy in the cecal region. During the operation the relatively constant venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas was injured, resulting in excessive haemorrhage. In the effort to manage the bleeding, the superior mesenteric vein (SMV) was torn, and after multiple unsuccessful efforts to repair the vein, we finally had to ligate the SMV. The operation was completed by typical right hemicolectomy and the abdomen was closed. Five hours later the patient showed acute distention of the abdomen together with respiratory distress. Due to increased abdominal pressure (> 35 cm H 2 O), the patient was taken back to the OR. The small bowel was edematous, bluish but viable.

The abdomen left open and was closed by using the VAC. The patient was taken to the ICU. Six days later the small bowel returned to normal colour and thickness, but the generalized edema made the closure of the abdomen impossible. By day ten the patient was on full enteral feeding, and was taken to the OR, where free partial thickness skin grafts were used to close the abdomen. Results: The patient was extubated by day sixteen and was taken to the rehabilitation center. Conclusion: Accidental injury of the venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas, may prove a potentially life threatening condition. We present this case in order to point out this rare complication of right hemicolectomy.

aimed to explore the influence of different surgical diagnosis groups on long term health status and to make comparisons with general population norms. Material and Methods: QoL was measured in all surviving surgical ICU patients admitted to a Dutch teaching hospital between 1995 and 2000. Patient-reported data on QoL were collected with the EuroQol-5D + after a mean follow up of 8 (range 6-11) years. Patient characteristics, surgical diagnosis group, length of ICU stay and survival were prospectively registered. EQ-utility scores (EQ-us), EQ Visual Analoge Scales (VAS) and prevalences of domain-specific health problems were calculated. The effect of surgical diagnosis group on EQ-us/EQ-VAS was assessed by multivariable generalized linear regression analysis. Logistic regression was used to explore the influence of surgical diagnosis group on domain specific health problems. Long term quality of life of surgical ICU patients was compared to an age-and sex-matched general Dutch population using the T-test analysis.

Results: 834 patients survived the ICU and were available for follow up. In 598 (72%) patients the health-related QoL was measured. For all surgical groups combined, after 6-11 years nearly half of all patients still suffered from problems in the dimensions mobility (52%), usual activity (52%), pain (57%) and cognition (43%). Compared to the age-and sex matched general Dutch population HRQoL was worse with a difference of 0.11 on the EQ utilities score (range 0-1). Oncological surgery patient had the best (EQ-us 0.83) and vascular patients had the worst (EQ-us 0.72) HRQoL. Trauma (odds ratio between 2.47-3.47) and vascular surgery (2.27-5.37) showed significantly increased prevalences of problems in mobility, self-care, usual activities and cognition. Conclusion: More than 6 years after a surgical ICU admission, quality of life of this patient population is largely reduced. Many patients still suffer from a variety of health problems, including decreased cognitive functioning. Treatment advances should be made to reduce the current health deficit of surgical ICU survivors compared to the general population. Disclosure: No significant relationships.

U. Sekmen 1 , G. Altaca 2 , S. Aktas Kalayci 3 , G. Moray 2 1 General Surgery, Baskent University, Ankara, Turkey, 2 General Surgery, Baskent University, Ankara, Turkey, 3 Internal Medicine and Division of Gastroenterology, Baskent University, Ankara, Turkey

Introduction: Predicting the prognosis in severe acute pancreatitis is cruciate in order to constitute effective treatment strategies. Material and Methods: Thirteen consecutive patients admitted with the diagnosis of severe acute pancreatitis according to Glasgow or Ranson criteria were evaulated. We searched the prognostic values of age, gender, etiology of pancreatitis, comorbidity and labarotory values and their affects on complications and length of hospital stay. Results: Mean age was 57,6 years (range: 27-83 yrs). Etiology was biliary in 9 patients (2 after ERCP). Acute cholecystitis was also present in 7 patients. 4 patients had diabetes mellitus. Two patients had percutaneous cholecystestostomy. Five patients had ERCP at a mean of 2,5 days after admission. Cholecystectomy was performed in 8 patients, either at the first admission (n:4) or after 6-8 weeks. Mean WBC, ALT, AST, and LDH values on admission and mean highest hsCRP levels and mean lowest serum calcium (Ca) levels in the first 48 hours were 14750/mm 3 , 205 U/L, 190 U/L, 438 U/L, and 106 mg/L and 8 mg/dl, respectively. Pancreatic necrosis (30,8%) was diagnosed by computerised tomography in 4 patients (2/4 in diabetics, 2/9 in nondiabetics); a total of 5 patients (38%) had systemic complications. Mean LDH (594 U/L vs 360 U/L) and lipase levels (4503 U/L vs 2952 U/L) were higher in patients who developed necrosis, though not statistically significant. Other parameters were similar in patients with or without necrosis. Two patients who had pancreatitis due to ERCP underwent pancreatic necrosectomy. Median hospital stay was 9 days (range: 3-75 days). All patients survived. Mean highest hsCRP and lowest Ca levels in the first 48 hours correlated significantly with the hospital stay (r: 0.65 p: 0.041 for hsCRP, and r: -0.689 p: 0.04 for Ca).

Conclusion: Although we have a limited number of patients, we may conclude that high levels of LDH, lipase, hsCRP and low levels of Ca can be used as predictive factors for severe pancreatitis. Pancreatitis seen after ERCP and in diabetic patients tend to be more severe.

abdomen. Abdominal imaging reveals persistent bleeding and multiple bone lesions compatible with bone hemangioma with low blood platelets count -Kasabach-Meritt syndrome. Patient is transferred to a central hospital for arterial embolization of the right hepatic artery that is not effective. The authors describe surgical control of the bleeding without liver resection. Second look surgery was undertaken with removal of hepatic packing and Pringle's manoeuvre with temporary control of the haemorrhage with haemostasis and ligation of the right hepatic artery. It was needed several surgery's more with additional packing, haemostatic mesh and haemostatic products in order to control the bleeding. The patient was proposed for liver transplant during the process but was not accepted. Introduction: Management of splenic injury has evolved over the past 25 years. Nonoperative management has gained currency, first in children and after in adults.

Material and Methods: We present a case of a 60 years-old man who falled for 2 m, haemodinamically stable, presenting pain on the left part of thorax and upper abdomen. Results: The patient fall for 2 m 4 hours before the arrive in our ER; he was haemodinamically stable (BP=130/70 mmHg, AV=95 bpm) and presented pain on the left thorax and left hypocondrium. Laboratory showed 12,3 g/dl haemoglobin. Radiologic test: laterally 10 th left rib fracture. Ct scan revealed IV grade spleen injury and perisplenic hemoperitoneum. We choosed non-operative managementafter 7 days Ct scan showed reduced dimensions of dilacerated spleen injury and no hemoperitoneum. The patient status was stable during the 10 days hospitalisation. Imagistic control after 1 month: homogenous spleen structure. Conclusion: The haemodinamic status of the patient is the most reliable criteria for non-operative management, not Ct aspect of the injury.

27 years old) submitted to upper partial splenectomy for blunt trauma. Residual spleen after surgery was 1/3 and 2/5 respectively. CEUS was preceded by standard B-mode US with color flow mapping in all cases; videoclips of each exam were stored for forensic medicine issue too. Mean time for CEUS exam was 5-7 minutes. Results: CEUS allowed to recognize regular perfusion of the residual spleen in both patients. Conspicuity of CEUS imaging was high and impressive. Homogeneous complete distribution of the contrast medium in the parenchyma was observed on day 5 in both pts. CEUS follow-up on day 10 and 30 did not add any supplementary information. Pts were discharged on day 7 and day 11 respectively, without indications for vaccinations or antibiotic prophylaxis. Conclusion: CEUS is an effective method for assessing perfusion of the residual spleen after partial splenectomy. CEUS can be performed bedside by the surgeon in the early po period or on an outpatient basis. Imaging interpretation is immediate and distribution of the contrast medium assure about viability of the splenic tissue. CEUS imaging allowed us to omit prophylactic vaccinations. It is the first description of the use of CEUS in this particular setting. Introduction: Injuries to the abdominal visceral vessels are uncommon but devastating entities that incur extremely high rates of mortality.The rarity of these injuries prevents many trauma centers and trauma surgeons from developing a significant knowledgement learning curve. The authors describe a case with abdominal visceral vascular abdominal blunt trauma, presented with laceration in the confluence of inferior mesenteric vein and splenic vein, laceration of the hepatic artery associated with hepatic hematoma, periduodenal and peripancreatic hematoma. The routine principles of vascular surgery were applied to the management of these visceral blood vessels injuries :adequate exposure, proximal and distal control, dé bridement of the vessel wall,meticulous arteriorraphy and venorraphy with fine monofilament vascular sutures and early instituition of damage control resulting a successfull repair.

Material and Methods: The authors made a review of several large series in the literature wich are also consistent with a low incidence of visceral vessel injuries. Vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment A broad spectrum of surgical specialities are involved in the ressuscitative phase of trauma care including general, trauma, thoracic and vascular surgery . Despite a relatively low incidence of vascular trauma in Portugal, the results are satisfactory because of active and early management by surgeons on call, weather with vascular training or not, treating all kinds of vascular surgical emergencies. A trauma and emergency surgical speciality is a challenge. Results: Little information describing the first repair or ligation of any visceral vessel injuries can be found in the literature. Visceral vascular injuries carry a significant mortality rate. Vascular injury poses a small but significant challenge in Portugal trauma care. Opportunities such as better practise guidelines and minimum standars will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. Training in the management of vascular trauma surgery with integration of vascular and general surgeryin trauma care should optimize outcomes. Conclusion: From reviews of large series dealing with the management of abdominal vascular injuries, the incidence can be estimated to be between 0.01% to 0.1 %of all vascular injuries. Few data are available describing the mortality rate for patients with portal veins injuries. Te author's vision is that all vascular and general surgery trainees would eventually undertake the Definitive Surgical Trauma Care Course and improve outcomes and reduce mortality.

Introduction: High rates of intra-abdominal pressure, has been proved to increased mortality, especially in multi-trauma patients followed laparotomy. Multiple organ failure syndrome (MOFS), derived by intra-abdominal hypertension, has been called abdominal compartment syndrome (ACS), the epidemiology and the characteristics of which, have not been thoroughly determined. Introduction: Intercostal pulmonary hernias are rare and mostly resulting from complications related to the chest trauma.The authors report a case of traumatic intercostal pulmonary hernia in a 35-yearold man. He was admitted to the hospital as a traumatic patient after a motor-cycle accident . Material and Methods: Beside multiple polytraumatic injuries the patient had a blunt injury to the left chest.Physical examination revealed a bulge on palpation of the left chest wall.Computed tomography (CT) scan of the chest revealed the protrusion of lung tissue outside the intercostal space.Size of hernia, incarceration and respiratory insufficiency mandate immediate surgical intervention.Postoperative course was uneventful, and there has been no sign of recurrence of hernia.

Results: Post -traumatic lung herniation through a defect in chest wall is an uncommon injury .Various methods of tratement and repair have been described, including both purely thoracoscopic to full open techniques.The authors repaired a case using a minithoracotomy. Conclusion: Lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall.Chest trauma is the most common cause.Timely surgical intervention is critical to favorable patient outcomes.Effective management, surgical approaches and repair of thoracic injuries are discussed and the available literature.

of the hernia from the outside, dé bridement and closure layer-bylayer with Maxon-0 was performed. The postoperative course was uneventful.

Conclusion: A TAWH after blunt trauma is a rare entity. The reported incidence of acute hernia ranges from 02,%-3,6% 1 . In our case the TAWH was already diagnosed in the trauma room. Mahajna et al. 2 reported the case of herniation of the right colon with vessel strangulation, which wasn't seen in the primary survey. A right hemicolectomy had to be performed on the 2 nd posttraumatic day. In our case we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh repair. The potential advantage of a mesh implantation lies in the augmentation of the abdominal wall, thereby potentially lowering the risk of incisional hernia. However, the benefits of such augmentation should be cautiously weighed against the risk of foreign body contamination when resecting bowel during the same operation. Introduction: Impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. Impalement injuries from falls are rarely seen, because most of the patients die at the scene of injury. We present an unusual case in which a patient survived a perineal impalement after a fall.With reference to our latest case and discuss the initial management and the operative treatment of this rare injury according to a literature review.

Material and Methods: A young man was working on a construction site when he suddenly lost his footing and fell 7 m off a scaffold. He orientated such that he landed in a sitting position on a vertical aluminium u-tube, which penetrated his perineal region and stucked. Upon arrival at the emergency room he was in stable condition, intubated. After the initial treatment and diagnosis according to ATLS a CT of the abdomen was performed; it showed a penetrating tube perianal left, from caudal into the cavity of the pelvis, the point of the tube stucked in the sacrum -in the hole of neuroforamina S1. There was no intraabdominal or laceration. The patient was taken to the operating room in stable condition. The laparotomy was performed. There was no laceration detected, explorating the praesacral cavity brought out a profuse bleeding of the main pelvic vein. After the active bleeding was stopped the tube was removed from the outside. After lavage and positioning of drains, a protective loopileostoma was placed to avoid further contamination. The perineal wound was carefully debrided, drains were inserted and the wound was not completely closed by adapting stitches. A wash-out of the colon was performed, he received antibiotics and the perineal wound was rinsed daily. He was dismissed 18 days post-trauma. Results: Impalement injuries result when a solid object pierces a body cavity or extremity. The object often remains fixed within the body. This case report showed a positive outcome. Impalement injuries are impressive but also rare, so it is important to show an algorithm in management of such injuries. The object should be in situ during transport. In large or immoveable objects, the impaling device should be cut just above the skin. The management of the injuries depend on the particular body region of penetrating. Perineal impalement often appear quite complex. These injuries may need the assistance of gynecology and urology surgery Praesacral drainage and distal rectal washout is recommended. Wound care is essential in the care of impalement injuries. The skin should generally left open. Even uncomplicated wounds have to be treated with antibiotics. Conclusion: Impalement injuries are rare and treating is a challenge for the surgeon. The degree of the injury determines the functional result. Strict adherence to the transportation and management principles outlined in this paper are necessary to decrease morbidity and mortility Disclosure: No significant relationships. Introduction: The insertion of foreign objects into the anus and rectum is a well-known phenomenon. Rectal foreign bodies can present a difficult diagnostic and management dilemma. . A foreign body may be inserted by a doctor for diagnosis or treatment like rectal thermometer, enema tubes or anal packs, by the patient for self eroticism or by a third party as a result of assault or sexual activity, but the most common cause for insertion of a foreign body is sexual stimulation. 1,2,3 . Anorectal foreign bodies are more common in men than in women . They can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, rectal bleeding and can be associated with perforation or delayed injury. Material and Methods: In this study, In the ten years from 1999 to 2009, we used the medical records of 7 patients with foreign bodies in the rectum have been diagnosed and treated,at Izmir Teaching and Research Hospital,Izmir. Results: All patients were men.They ranged in age from 33 to 68 (mean age 48).Two of these 7 patients had impulse body spray, two patients had bottle, one patient had eggplant,one patient had brush and one patient had wishbone (after oral ingestion) in the rectum. Five objects were removal transanally extracted by anal dilatation under general anesthesia.Two patients required laparotomy.One patient of these the object was high lying in the rectosigmoid and performed laparotomy.The object was removal transanally extracted by abdominal manuplation.One patient had a intraperitoneal rectosigmoidal perforation.The perforation was treated by primer suture, proximal colostomy and appropriate antibiotic therapy. Routine rectosigmoidoscopic examination is performed after removal.One patient had perforation of the rectosigmoid and 4 had lacerations of the mucosa. No patient had a mortality. Conclusion: Foreign bodies in rectum should be managed in a wellorganized manner. The diagnosis is confirmed by means of plain abdominal radiographs and rectal examination. Manual extraction without anaesthesia is usually only possible for very low lying objects. Patients with high lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction.Open surgery should be reserved only for those patients with perforation, peritonitis and impaction of the foreign body.

Results: Definitive pathological examination confirmed the diagnosis of pancreatic pseudocyst. The patient postoperative outcome was unremarkable and was discharged from the hospital at the seventh postoperative day. Conclusion: Retroperitoneal and ''well protected'' location implies that a high energy traumatism is needed to injury the pancreas. The fact that in this case a non-classical injury mechanism has occurred, makes the diagnosis more difficult to reach. Pancreatic pseudocyst is the most frequent complications in this type of traumatisms. 

Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch

Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study

Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years

Disclosure: One or more of the authors received funding from the Small Bone Innovations (DR)

Fractures of the neck of the talus. Long-term evaluation of seventy-one cases

Tuberosity malposition and migration: reasons for poor outcome after hemiarthroplasty for displaced fractures of the proximal humerus

Tuberosity osteosynthesis and hemiarthroplasty for four part fractures of the proximal humerus

Abdominal 64-MDCT for suspected appendicitis: the use of oral and IV contrast material versus IV contrast material only

Socioeconomic factors, medicolegal issues, and trauma patient transfer trends: Is there a connection?

Are patients being transferred to level-I trauma centers for reasons other than medical necessity?

The Delaware trauma system: impact of Level III trauma centers

Improving outcomes in a regional trauma system: impact of a level III trauma center

Jupiter -Metaanalysis: Nondisplaced scaphoid fractures. Operative vs. nonoperative management(update to Nov

Dodds -Minimally invasive management of scaphoid nonunions

Chess -A biomechanical analysis of intrascaphoid compression using the Herbert scaphoid screw system. An vitro cadaveric study

Is the mortality rate for septic shock really decreasing?

Systemic inflammation after trauma

In vivo effects of a synthetic 2-kilodalton macrophage-activating lipopeptide of Mycoplasma fermentans after pulmonary application

Alveolar macrophages from septic mice promote polymorphonuclear leukocyte transendothelial migration via an endothelial cell Src kinase/NADPH oxidase pathway

Macrophage inflammatory protein-1 alpha mediates lung leukocyte recruitment, lung capillary leak, and early mortality in murine endotoxemia

Fracture-Dislocation of the Hip Joint. The Nature of the Traumatic Lesion, Treatment, Late Complications, and End Results

Cervical spine trauma in the pediatric patient

Spinal injuries in children and adolescents

Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children

Elastic stable intramedullary nailing as alternative therapy for pediatric Monteggia fractures

Unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing

Delayed radial paralysis after Monteggia fracture-a case report, Unfallchirurg

A Simple Modified Arthroscopic Procedure for Fixation of Displaced Tibial Eminence Fractures

A Fracture of the Intercondylar Eminence of the Tibia Treated by Arthroscopic Fixation

An analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine

Modified Arthroscopic Suture Fixation of a Displaced Tibial Eminence Fracture

Tibial Spine Fractures in Children

Fractures of the Tibial Spine in Children

Seventeen-Year Follow-up of a Reattachment of a Nonunited Anterior Tibial Spine Avulsion Fracture

Arthroscopic Fixation of Displaced Tibial Eminence Fractures: A New Growth Plate-Sparing Method

The mechanism of clavicular fracture: a clinical and biomechanical analysis

Functional outcome following clavicle fractures in polytrauma patients

Evidence-Based Orthopaedic Trauma Working Group. Treatment of midshaft clavicle farctures: systemic review of 2144 fracturese: on behalf of the Evidence-Based Orthopaedic Working Group

Harnroongroj T, Vanadurongwan V. Biomechanical aspects of plating osteosynthesis of transverse clavicular fracture with and without inferior cortical defect

Autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects

Iliac crest autogenous bone grafting: donor site complications

Clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery

Healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration

Literature review of current techniques for the insertion of distal screws into intramedullary locking nails

A new fluoroscopy-free navigation device for distal interlocking screw placement

Disclosure: We all are surgeons at Gregorio Marañ ó n Hospital, Madrid. Dr. Turegano is the chief of the Emergency Surgery department. References: 1-Nandapalan and al

Factors related to mortality in inferior vena cava injuries: A 5 year experience

Disclosure: We certify that all our affiliations with or financial involvement (employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending) with any organization or entity with a financial interest. References: 1. Blaisdell, F.W. The Pathophysiology of Skeletal Muscle Ischemia and the Reperfusion Syndrome: A Review. References: Robinson CM

Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in

Meniscus allograft transplantation: a current concepts review

Homologous meniscus transplantation: Experimental and clinical results

Cell survival after transplantation of fresch meniscal allografts: DNA probe analysis in a goat model

Freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale

Meniscus replacement with bone anchors: a surgical technique

Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations

Clinical evaluation of arthroscopic-assisted allograft meniscal transplantation

Knee joint biomechanics following arthroscopic partial meniscectomy

An evaluation of a shockroom located CT scanner: a randomized study of early assessment by CT scanning in trauma patients in the bi-located trauma center North-West Netherlands (REACT trial)

Overlooked spine injuries associated with lumbar transverse process fractures

Frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal CT in patients with trauma

Traumatic lumbosacral dislocation: report of two cases

References: Prevalence of suicide ideation and suicide attempts in nine countries

Uptake and intracellular distribution of various metal ions in human monocyte-derived dendritic cells detected by Newport Green DCF diacetate ester

Biomechanical analysis of bicondylar tibial plateau fixation:how does lateral locking plate fixation compare to dual plate fixation?

Operative treatment of 109 tibial plateau fractures.:five to 27 years follow-up results

Treatment of high energy tibial plateau fractures with half ring external fixation combined with minimal internal fixation. Nan Fang Yi Ke Da Xue Xue Bao

Disclosure: No significant relationships

De Smet L, Debeer P, Degreef I. Fixation of a periprosthetic humeral fracture with CCG-cable system

Results of non-operative and operative treatment of humeral shaft fractures. A series of 104 cases

Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. Surgical technique

The anteromedial facet of the coronoid process of the ulna

Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process. Surgical technique

Broberg MA, Morrey BF. Results of Treatment of Fracture-Dislocations of the Elbow

Disclosure: One or more of the authors received funding from the Small Bone Innovations (DR

Perilunate and Axial Carpal Dislocations and Fracture Dislocations

Evaluation of the Spanish Versió n of the DASH and Carpal Tú nel Síndrome Health-Related Quality-of-Life Instruments: Cross-cultural Adaptation Process and reliability

Philadelphia: W. B. Saunders Company; 1992. p. 645-63. 2. Meyer PR. Complications of treatment of fractures and dislocations of the dorsolumbar spine

No significant relationships. References: 1. General Medical Council. Consent: Patients and doctors making decisions together

Is informed consent effective in trauma patients

Is Informed Consent in Trauma a Lost Cause? A Prospective Evaluation of Acutely Injured Patients' Ability to Give Consent

Factors affecting the quality of informed consent

The impact of objective assessment and constructive feedback on improvement of labrascopic performance in the operating room

United Arab Emirates, 2 Medical Education

at the main trauma hospital. Results: 2573 patients were studied (86.6% males) having a mean age of 31.4 years. 50% of patients were from the Indian subcontinent and 18% were UAE nationals. 99% of patients presented immediately following injury. Ambulances brought only 34% of the patients. 40% of trauma took place in the street or highway, 29% in work places and 20% at home. The mechanisms of injury were road traffic collision in 41% and falls in 34%. 45% of injuries were to extremities, 27% to head, face and neck, and 12% to chest. The mean ISS was 5.6. The mean (range) hospital stay was 9.2 (1-150) days; 202(8%) patients needed ICU admission of whom 28 (13.9%) died. The Mean ICU stay was 5.8 days (range 1-35). Overall mortality was 56 (2.2%). Conclusion: Road traffic collisions and falls are the main cause of trauma admissions in Al Ain city. Extremities, head, neck, face and chest are the main body regions sustaining injuries. Disclosure: No significant relationships

Hip Fractures in the Elderly: A World-Wide Projection

Disclosure: No significant relationships. References: D. Ring et al.: Predictors of Acute Carpal Tunnel Syndrome Associated With Fracture of the distal Radius

PM047 Non-Surgical Treatment of the Distal Radial Fracture. Is There an Advantage in Immobilization in 20 Degrees Dorsiflexion Compared to Immobilization in a Neutral Position?

Janzing 3 , L. Horta 1 1 Emergency Department, Viecuir medical centre

The Netherlands Introduction: According to the literature immobilization of Collespoints where radiological (dorsal dislocation, radial inclination), functional, the necessity for surgical intervention

A comparison of 2 methods of plastic cast fixation in treatment of loco classico radius fracture. A prospective, randomized study, Unfallchirurg

PM048 Buzzsaw Injuries: Mechanisms of Damages And Predisposing Factors R. Ziegler 1 , W. Knopp 1

Woodworking injuries: An epidemiologic survey of injuries sustained using woodworking machinery and hand tools

References: Beasley LS, Vidal AF. Traumatic patellar dislocation in children and adolescents: treatment update and literature review

Long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum 5-year follow-up

MRI of traumatic patellar dislocation in children

Reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children

Injuries to the inferior pole of the patella in children

Disclosure: No significant relationships

PM055 Results of Electromagnetic Fields in Healing Progression of Delayed Union in the Lower Extremities

The effect of Low-Frequency Electrical Fields on Osteogenesis

References: Complex trauma of the limbs with vascular injuries-Olivera Lupescu, Mihail Nagea

Carcinoid tumour of the appendix:an analysis of 1485 consecutive emergency appendectomies

Tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy. Dig. Liver Dis

At perforated ulcer treatment, suture of the place of prefotation was used at 205 (94,91%) people, Billroth II stomach resection at six (2,78%), suture of the place of prefotation with PSV at three (1,39%), and Billroth I stomach resection at one (0,46%) patient. Postoperative complications were noticed at 14 (6,48%) people. We had postoperative mortality at four (1,85%) patients. Recidive ulcer was registred at 10 (4,63%) patients who were surgically treated for perfored ulcer before. Conclusion: Ulcer perforation is an acute complication of the ulcer disease that appears most frequently after bleeding and which usually requires surgical treatment. References: 1. Behçet disease complicated by a perforated ileal ulcer presenting as an acute abdominal emergency

Gastro-duodenal ulcers with perforation caused by short-term acetylsalicylic acid ingestion: case report CulafiÄ à D, MatejiÄ à O

Perforated gastroduodenal stress ulcer Melinte C, Dragomir C

PubMed -indexed for MEDLINE] Spontaneous rupture of the spleen as immediate complication in autologous transplantation for primary systemic amyloidosis

Delayed splenic rupture as a cause of haemoperitoneum in a CAPD patient with amyloidosis

Boluda Garcà a F, Calvo Català ¡ J, Campos Fernà ¡ndez C, Parra Rà 3 denas JV, Gonzà ¡lez Cruz MI

Laparoscopic cholecystectomy for acute cholecystitis

Disclosure: No significant relationships. References: 1. Pokorný J. et al. Urgentní medicína, 1. st edition: Praha, Galé n 2004 2. Stetina et al. Medicína katastrof a hromadný ch neštÄ >stí

PT018 Perforation of Oesophagojejunal Anastomosis by

Venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in 58 cadavers

PT021 Validation of Fournier's Gangrene Severity Index score (FGSIS)

General Surgery

Dobrzanska L, Newell R. Readmissions: a primary care examination of reasons for readmissions of older people and possible readmission risk factors

PT025 Spontaneous Rupture of Giant Cavernous Hemangioma of the Liver in a Patient With Systemic Hemangiomatosys and Kasabach-Meritt Syndrome. An Interactive and Multidiscipline Case B

General Surgery

General Surgery

Portugal Introduction: Hemangiomas are frequent benign tumors of the liver

Nonoperative management of blunt splenic and liver injury

Is CT grading of splenic injury useful in the nonsurgical management of blunt trauma?

Management of blunt splenic trauma: CT contrast blush predicts failure of nonoperative management

References: 1. Ochsner MG. Factors of failure for nonoperative management of splenic injuries

Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management

Introduction: Aim. To establish the diagnostics and management trauma, 193(65,2%) -head trauma, 96(32.4%) -limbs injuries, and 74(25%) -severe shock. In cases the splenic injury was initially manifested -223(75.3%), and in 73(24,7%) cases the clinical signs developed later (p < 0.001)

Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma: The EAST Practice Management Guidelines Work Group

Diagnostic accuracy of surgeonperformed focused abdominal sonography (FAST) in blunt paediatric trauma

Surgeon-Performed Bedside Organ Assessment with Sonography after Trauma (BOAST): A pilot study from the WTA Multicenter Group

Disclosure: No significant relationships. PT035 Incidence of Abdominal Compartment Syndrome in Patients with Multiple Injuries. A Single Institution Experience

Koulas 1 , O. Mousafiri 2

Hatzikosta General Hospital, Ioannina, Greece, 2 Intensive Care Unit, G. Hatzikosta General Hospital

Intensive Care Unit, G Hatzikosta General Hospital

Delayed presentation of traumatic parasternal lung hernia

Management of retained colorectal foreign bodies:Predictors of operative intervention

Disclosure: No significant relationships. treatment. Disclosure: No significant relationships. References: 1.Demetriades D, Velmahos G. Technology-Driven Triage of Abdominal Trauma: The Emerging Era of Nonoperative Management

Management of High Grade Renal Trauma: 20-Year Experience at a Pediatric Level I Trauma Center

PT045 Blunt Abdominal Trauma. 5 Year Experience In Our Department

Greece (4,4%), without spinal fractures. Resection/anastomosis was permorbidity. In first group, there were 3 deaths (16,6%), 2 cases due to intestinal injuries. The second group (without seatbelt sign) had 8 deaths (8,8%), none due to intestinal injuries but related with multiple thoracic and cranial lesions. Conclusion: In this study we found a consistent evidence that ''seatbelt sign

Small-bowel and mesentery injuries in blunt trauma

Mortality reduction with air bag and seat belt use in head-on passenger car collisions

Disclosure: No significant relationships. References: Management strategies in isolated pancreatic trauma

Disclosure: No significant relationships. References: Enterocutaneous fistula complicating trauma laparotomy: a major resource burden

The American Surgeon

Staged Management of Giant Abdominal wall defects

Injured Patients -Documentation of Black Spots

J. Heinzmann 1 , U. Culemann 2 , T. Pohlemann 3 1 Universitä tsklinik des Saarlandes, Klinik fü r Unfall-, Hand-und Wiederherstellungschirurgie, Homburg, Saar, Germany, 2 Trauma-, Hand and Reconstructive Surgery, University of Saarland, Homburg, Saar, Germany, 3 Klinik fü r Unfall-, Hand-und Wiederherstellungschirurgie, Universitä tsklinikum des Saarlandes, Homburg, Saar, GermanyIntroduction: Nonunions of the tibia represent a complex problem, particularly if they occur at the distal third of the tibia. The aim of the study was to evaluate a standardized treatment concept to manage different types of nonunions of the tibia with regard to their location within the tibia. Material and Methods: Prospective, non randomised study (01/03-06/08); nonunions of the diaphyseal and metaphyseal tibia (AO type 42/43); standardized treatment concept: diaphysis: reamed intramedullary nailing; dia-metaphyseal junction and pilon: LCP with a minimal invasive approach or an open approach plus bone grafting from the iliac crest; infected nonunions: external fixator. Analysis parameters: demographic data, fracture type (AO classification), primary surgery, healing process, time to union (radiographic), complications. Results: Forty-eight patients (39 m, 9 f; mean age 45,2 y) with 15 hypertrophic (primary surgery: 13x nail, 2x external fixator) and 33 atrophic nonunions of the tibia (primary surgery: 13x nail, 13x plate, 4x screws and 3x external fixator) were included in the study. Fifteen tibial nonunions had been primary treated in our department, 33 patients had been admitted from other hospitals. Seventy-three% of all nonunions were located at the distal third of the tibia (45% at the diaphyseal-metaphyseal junction, AO-classification type 42; 55% at the pilon, AO-classification type 43). Seventy-five% of the dia-metaphyseal fractures and 10% of the pilon fractures were primary treated with an intramedullary nail. The mean time between injury and nonunion-surgery was 10,3 (6-39) months. Follow up: 41/48 patients (85%) for an average time period of 22,2 months; union-rate: 37/41 (hypertrophic nonunions 11/13; atrophic nonunions 26/28: 2 re-nonunions each). Complications: 1 death by lung embolism, 1 re-nonunion (united after second surgery), 1 implant (plate) loosening with the need of reosteosynthesis, 2x varus malalignment, 1x valgus malalignment, 1x peroneal nerve lesion. Conclusion: Especially the distal third of the tibia still represents a high risk area for nonunions. Impaired perfusion, thin soft tissue coverage, as well as the rising number of nailing even of distal tibial fractures 1 are some of the causes. We think that the herein introduced treatment concept is effective to manage tibial nonunions. Thus, the union-rate in this study population was 90% 2,3 . An adequate primary osteosynthesis as well as the prevention of extensive soft tissue damage during surgery are mandatory to improve the outcome of tibial fractures. Besides, new therapy options as e.g. the application of growth factors and ultrasound have to be considered also for the treatment of tibial nonunions.

G. Heinrichs 1 , A. P. Schulz 2 , E. Wilde 3 , R. Oheim 4 , C. Jü rgens 4 1 Trauma&orthopedics, University Lü beck, Lü beck, Germany, 2 Trauma&orthopaedics, University Lü beck, Lü beck, Germany, 3 Trauma + Orthopaedics, University Lü beck, Lü beck, Germany, 4 Trauma&orthopedics, University Lü beck, Hamburg, GermanyIntroduction: High energy tibial head fractures with bicondylar involvement have a much poorer outcome compared to the other forms of tibial head fracture. Soft tissues are almost allways compromised. Bilateral plating carries the risk of soft tissue and bone infections. Due to loss of reduction, steps or gaps might remain in the joint surfaces. Aim of this study was to evaluate the clinical and radiological outcome of Schatzker 4, 5 and six type fractures treated with locked osteosynthesis plating. Material and Methods: Between January 2003 und January 2005 we treated 97 patients suffering from a tibial head fracture. In 26 cases osteosynthesis was performed with the use of an angular stable implant, this group forms the study population. Indication for locked screw plates were bicondylar fractures treated unilateral to avoid bilateral approach with double-plate osteosynthesis and tibial head fractures with a shaft involvement (Schatzker 6). Follow-up was performed after an average of 7.5 months after surgery. We treated 16 male and 10 female patients with an average of 52.5 years of age (17 to 73 years). There were no patients with open fractures or primary nerve injury included in this study. Operative treatment was performed after an average of 1.7 days after trauma. We used an angular stable plate fixator made from pure titanium (TiFixÒ, Litos, Hamburg/ Germany). The plate is consisting of the softer titanium Grade 1; the screws are made from harder titanium Grade 2.Results: There was one case of a postoperative peroneal nerve lesion with spontaneous regression after two weeks. No postoperative wound necrosis or infection occured. All patients showed bony consolidation after a mean of 8.4 weeks as judged by radiographs. Additional autologous bone transplantation was not necessary. We did not observe any secondary loss of reduction or loosening of the internal plate fixator when comparing direct postoperative radiographs to those at follow up. ROM of the knee did not show any restriction compared to the opposite side in 9 patients. 13 cases showed mild and 4 cases a remarkable restriction of ROM compared to the not injured side.Applying the Rasmussen score, 17 cases achieved a good and very good result. 6 patients had to be judged as moderate and 3 as poor Conclusion: Unilateral plate fixation for the treatment of bicondylar tibial head fractures seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures. Results: The adjacent level Th-L fracture was found in 6.5% (3/46 patients) in kyphoplasty group and in 7% (2/27 patients) in vertebroplasty group. We did not found any serious complication but established postoperative BMD loss. We did not found any intradiscal cement leakage in cases with adjacent level fractures. Intraoperative correction of kyphosis was better achieved in kyphoplasty group; pain relief was similar in both groups.Conclusion: Natural process of further bone loss seems to be the most influent factor for future compression fractures in elderly patients. Trauma patients represent a challenge in terms of obtaining informed consent as they are often in significant pain and maybe under the influence of strong medication at the time of the consent process. We designed a prospective, randomised un-blinded control study to test the hypothesis that there would be no difference in the ability of trauma patients to recall details of the consent process whether the patients were given verbal compared with verbal and written information.Material and Methods: A consecutive cohort of trauma patients presenting to a major teaching hospital were recruited and randomised into two groups. Group A received structured verbal information only. Group B received structured verbal information and written information about the proposed procedure. All patients were interviewed within the first post operative week (mean 3.2 days) and scored on their ability to recall key facts given in the original consent interview. Results were analysed using the Mann-Whitney U test.Results: 119 patients have been recruited. Information recall was significantly improved in the group receiving written information (mean questionnaire score 64% vs 41% for verbal information alone, p=0.0014). Patient satisfaction with the consent process was also significantly improved in the group receiving written and verbal information, with 97.9% of patients reporting they understood the risks of surgery when they signed the consent form, compared to 83.2% who received verbal information alone (p=0.01).Conclusion: Written information improves patient recall of the consent process. It is a simple, cost-effective intervention with high patient acceptability. Introduction: Survivorship of second hip fracture patients is worse than initial hip fracture patients. However, previous studies included in-hospital mortality. The actual survivorship of initial hip fracture patients with subsequent second hip or major long bone of extremity or vertebral body fracture by exclusion of in-hospital mortality patients have not been studied. We aim to compare the actual survival of initial hip fracture patients with and without second hip or subsequent major fracture. In addition, risk factors, mortality causes, and hazards ratio of each fracture groups were studied. Material and Methods: In 2000-2008, after exclusion of in-hospital mortality patients, 1038 initial hip fracture patients were reviewed and divided into four groups. Group I, II, III, and IV were initial hip fracture patients with second hip, subsequent major long bone of extremity, vertebral body fracture, and without any subsequent fractures, respectively. We set group I, II, and III as study groups comparing the data with group IV (control group). Age, gender, mobility-status, co-morbidity, causes of death, and survival years after hospitalization of last fracture treatment of each group were recorded. Actual survival rate and risk factors difference between initial hip fracture with and without subsequent fracture were analyzed by Chi-square test. Hazards ratio differences among the groups were analyzed by Cox regression models.Results: There were 34 (3.3%), 71 (6.8%), 160 (15.4%), and 773 (74.5%) subjects in group I, II, III, and IV respectively. At one-year and one-to-five year mortality of group I were 8.8% and 5.9%, group II were 5.6% and 1.4%, group III were 1.3% and 1.9%, and group IV were 4.7% and 1.4% respectively. Statistical analysis by using Chi square test of one-year mortality and one-to-five year mortality rate showed no significant difference among four groups (p > 0.05). But from Cox regression analysis, second hip fracture produced significant hazards ratio as 7.98 (p = 0.02).

The actual survivorship of initial hip fracture patients with second hip or other subsequent fracture were not different from patients who have only one hip fracture. However, special care should be focused in patients with second hip fracture which produced significantly highest hazards ratio for mortality.reduction or redislocation after one week of treatment. Due to the lack of sufficient patient data a statistical analysis was not carried out. It was obvious that the dorsal dislocation after reduction was worse in the dorsiflexion group. There was no obvious difference in radial inclination or functional outcome between the two groups. Conclusion: Mainly the dorsal inclination was worse in the 20 degrees dorsiflexion group. A possible explanation for these results is the technique used when modeling the plaster cast. In our hands immobilization in dorsiflexion yielded poorer results then immobilization in a neutral position. Due to the poor results the study was terminated prematurely.

The traumatic patellar luxation in adult patients is operatively treated with medial reefing and lateral release. The value for the treatment of adolescents is still discussed controversially in literature. The aim of the present study was to evaluate the efficacy of the minimal-invasive treatment of traumatic patellar luxation in adolescents. , that was treated with acute angular shortening using a monolateral AO fixator followed by gradual correction using the Taylor Spatial Frame (TSF). The conversion in the TSF was achieved in exchanging only two half-pins. Results: The deformity was anatomically corrected without any soft tissue complications. The fixator was worn for 12 weeks under full weight bearing while the actual correction took only 14 days. We did not see any typical external fixator complications like pin trac infection. Conclusion: Acute angular shortening can lead to direct soft tissue closure without any additional plastic surgery. The accuracy the the fixator allows the gradual anatomical reduction of the fracture and simplifies the correction of the mostly multiplanar deformities. When the surgeon is familiar with the TSF even a primary treatment of such fractures could be recommended. The image control (plain x-rays, CT) revealed and definitively determined whether a two-part or three part triplane fracture in the distal tibial physis were present, the amount of the displacement, and the co-existed fracture of the fibula. The principal goal must be the anatomical reduction of the fracture initially closed and in failure

opened. An open reduction and fixation with 3 Steinmann via anterior approach followed. A long-leg cast worn for initial 4 weeks, followed by a short-leg cast for 2 weeks. Results: At a minimum of fourteen months of clinical follow -up all patients lacked complaints and had full range of motion in ankle.Conclusion: These injuries occur in the adolescent age group generally slightly younger than the child with a Tillaux fracture, needed good image control (CT) and must reduced anatomically and fixed. Disclosure: No significant relationships. It is necessary in 15-25% of patients. To provide dynamisation using conventional methods, it is necessary to perform one additional surgery. In this presentation it is shown one new method of selfdynamisation. Material and Methods: It is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator. There is no contact between bone and internal fixator in fracture area. It has been widely investigated biomechanicaly. In clinical use it has been applied to 1,349 patients in treatment of femoral fractures. The age of patients was from 14 to 88 years. This internal fixator is applied by two small incisions. Reduction is achieved using standard traction table or using special reduction device. This reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. Results: Received clinical results are promising, as it has been shown early callus formation and radiological union within the 3-4 months. It has been allowed to patients early full weight bearing. During the treatment it has been confirmed working of self-dynamisation concept (in 24% of patients), which probably all together with 3D configuration resulted in unexpectedly quick fracture healing. Follow up was 20 months (6-61 The severity of injury was measured by the Injury Severity Score (ISS). The outcomes for categorical variables were tested using v 2 test and a significance level at P < 0.05 was maintained. Delayed complications were defined as any complication directly attributable to the splenic injury that occurred more than 48 hours after injury. The following data was retained: age, sex, mechanism of injury, ISS, number of ICU days, overall length of stay, number of blood units transfused, day of operation and discharge status. Results: Our study found 10,4% incidence of delayed complications after NOM. These complications include delayed hemorrhage (4 cases), splenic artery pseudoaneurysm (1) and splenic abscess (1 case). The need for operation due to ongoing bleeding was retained in following situations: more than 4 U of blood to maintain a Hb higher than 10 g/dL, systolic pressure to less than 90 mm Hg despite resuscitation and evidence of peritoneal signs. Of the 6 patients failing NOM, 67% failed between days 3 and 5 and 83% in the first week. In all cases a splenectomy is performed with no mortality rate.

The results of this study indicate 2 independent risk factors of failure of NOM: a high CT grade of splenic injury (grade III and above) and a transfusion with more than 3 U of blood. Results: Results : Out of the 14 patients suffering of liver injuries 10 patients had Grade 1,2 and Grade 3 liver injuries and were treated conservatively. 4 patients had Grade 4 and 5 liver injuries and were operated. 1 patient who was initially managed conservatively was operated due to inability to control the blood loss. Out of the 10 patients suffering injuries of the spleen, 4 were grade 4 and grade 5 and were successfully operated and 6 were grade 1 and 2 and were treated conservatively. All patients suffering of injuries of the retroperitoneal space, unilateral kidney injuries and injuries of the hypogastrium were managed conservatively. Conclusion: blunt abdominal injuries can be managed successfully and safely by conservative treatment whenever it is allowed by the circumstances. The CT scan is a very sensitive diagnostic scanning, capable of diagnosing intrabdominal haemorrhages retroperitoneal lesions as well as the extent of the organ injury and is a necessary tool for the physician in order to diagnose accurately any abdominal injury. Disclosure: No significant relationships.

Introduction: More and more hepatic injuries are treated non operatively if the hemodinamic's and lesion's stability is confirmed. The count and the scaling of lesions doesn't directly influence surgical indications. We report about 6 cases of blunt trauma with serious hepatic and renal lesions treated successfully with a non operative management Material and Methods: We treated 6 liver and renal injury associated in a period from 2007 to 2009. Patients were admitted to Tor Vergata -Roma and Hospital Universitario Clínico San Carlos-Madrid. Data collected were: age, sex, comorbidities, sequence of events, type and number of associated lesions, management, morbidity and mortality. All liver and renal organ's injuries were evaluated by abdominal CT scan with contrast and classified according to CT-based scale Results: Middle age was 36 ± 11 SD years. Patient were male in (66,6%) of cases. CT scale of liver lesion was 3°for 4 (66,6%) patient and 4°for two (33.3%) patients. Renal lesions were I°category in 5 cases (83,3%) and II°category in 1 patient. No ureteral or major vessels rupture were founded. All patients have been treated non operatively. A CT based follow up of lesions was planned (at admittance, after 48 hours, after a week and after a month). The mean length of hospitalization was 12 ± 6 SD days. During hospitalization, patients were monitored by clinic and labs daily. All patients were dismissed in good conditions and are in in health on a 6 months follow up. At CT follow up, one patient presented an intra-hepatic biloma, that was successfully treated with CT-guided drainage Conclusion: This work support the hypothesis that the association of liver and renal lesions in a blunt abdominal trauma, doesn't necessarily influences indications for an explorative laparotomy. If an ureteral rupture is suspected, a more aggressive treatment is necessary, in order to prevent peritonitisIntroduction: The aim of this study is to analyze the most frequent mechanisms of injury, the evaluation in the emergency department and the period of increase of the blunt abdominal trauma incidence. Material and Methods: During the last 5 years (2005-2009) 147 patients were admitted to our department for blunt abdominal trauma.The most frequent mechanisms of injury were: traffic accidents (automobile crashes and motor vehicle collisions)110(74,8%) Work accidents 26(17,6%) 3. Others (fall from high altitude, beating) 11 (7,5%) We analyzed the most frequent injuries observed, the final treatment for these patients and the period of increase of blunt abdominal trauma.Results: The peak incidence occurs in persons aged 18-42 years. The male/female ratio was 7:3. The most frequent abdominal injuries regarded: Spleen 113(76,8%), liver 24(16,3%), large bowel 5 (3,4%), small bowel 3 (2%), pancreas2 (1,35%).134 patients underwent surgical treatment (91,15%). The incidence of missed injuries is quite low, one case with pancreatic injury and one with small bowel injury. During summer period a significant increase in blunt abdominal trauma incidence occurs because of the increase of population due to tourism. The initial physical examination, after appropriate primary survey and initial resuscitation with the help of diagnostic studies such as ultrasonography, abdominal CT scan, is essential for the final treatment for these patients, operative or not operative. Abdomino-throcal injuries were found in 23(17%) patients.Abdominal organ injuries were found in decreasing frequencies in small bowel(29%),liver (26%),large bowel (21%), spleen (18%), major vasculer, stomach and others. Thoracal injuries were found in lung and heart in 21 and 2 cases.One organ injury was found in 39(30%) patients,mostly small bowel,and these group had a good haemodynamic status.Thirty-two(25%) patients had two organ injuries which 6 of them associated with lung injury.Three,4 and < 4 organ injuries were found in 13, 2 and 3 patients. Haemodynamic unstability at presentation,and shock was found in five patients(1,2 and 3 organ injury in 2,1 and 2 cases). The overall mortality was found in 8(6%) patients.Mortality from gun injury was 50% from major vascular injury 2,lung,pancreas and large bowel 1,lung and large bowel one.Mortality from penetrating trauma was 40% from lung and multipl abdominal organ injury 1,heart 1,lung,spleen and stomach injury 1 and major vasculer injury from blunt trauma in one (10%) patient. Five patients who remain haemodynamically unstable after resuscitation died intraopreoperative period.These group was not received some resuscitation, and they referred to our hospital later than 8 hours of injury. Introduction: Retroperitoneal location of the pancreas makes the diagnostic of any traumatism to be difficult, especially when this is not suspected. We report on a case of blunt pancreatic trauma with 6 months delayed diagnosis, after injury due to maneuvers in a difficult birth. Material and Methods: We report on a case of a twenty-nine year-old female who consulted at the emergency department for constant right upper quadrant pain that didn't ease with any analgesic prescribed by the general practitioner. These symptoms started after a birth six months before and loss of 15 Kg of weight was associated. After reviewing the previous history of the patient, the birth had been difficult and forceps, suction pad and repeated abdominal pressure maneuvers were needed. Abdominal examination showed a painful non-pulsatile mass located at epigastrium and both right and left upper quadrants. Abdominal ultrasonography and enhanced CTscan were performed and demonstrated the presence of multicystic 15x14x11 cm mass located between the stomach, spleen and left kidney. The high density content seemed to be blood. The mass was pushing the stomach anteriorly and no communication between both of them was shown. The splenic vein was pushed superiorly and thinned and plenty collateral circulation was evidenced. The tail and the body of the pancreas were not identified in any of the studies. The first choice diagnosis was posttraumatic complicated (with bleeding) pancreatic pseudocyst. The patient underwent emergency operation and a big cystic pancreatic mass was encountered, with plenty of collateral circulation. Intraoperative biopsy confirmed that it was a pseudocyst and therefore, the majority of the cyst was removed and Roux-en-Y pancreatojejunostomy was performed. Cholecistectomy was also done. Introduction: Unnoticed traumatic injuries produce avoidable morbidity, mortality and a higher medical cost. We present a special case of the reconstruction of a catastrophic abdomen with several intestinal fistulae and giant abdominal wall defect. Material and Methods: We present the case of a 26 year old woman with blunt thoraco-abdominal trauma secondary to a road traffic accident. Several lower left rib fractures, a fast echo with free fluid without solid organ injury and fractures of L1 and L2 were seen in the initial assessment. On the third day surgery was required due to septic shock with diffuse peritonitis due to a jejunal laceration and section of the body-tail of the pancreas. Simple suture of the jejunal laceration, distal pancreatectomy, and abdominal packing without closure of the abdomen was performed. She developed several intestinal and colonic fistulae. Over 40 surgical procedures were performed on her and she was discharged 9 months later with night parenteral nutrition, a closed abdomen by secondary intention and intestinal fistulae. She was readmitted a year later for reconstruction. We performed monoblock resection of the abdominal wall and the fistulized loops, subtotal colectomy and bowel transit reconstruction with three enteroenteric and an ileosigmoid anastomosis, leaving 1,8 m of small bowel. Abdominal plastia with Permacol mesh was also performed. Results: Surgical time was of 420 minutes and oral tolerance was initiated on the 7th postoperative day. She was discharged on the 14th day postop. The only complication was a fever secondary to infection a central venous catheter on the 3rd day.