Proceedings of the british trauma society

Injury (1992) 23, (3), 209-216

209

Proceedings of the British Trauma Society

The 3rd Annual Meeting of the British Trauma Society was held at the Clifton Arms Hotel in Lytham St. Annes UK, on 4-5 October 1991. The Guest Lecturer was Major W. F. de Mello, RAMCwho delighted the Society with his experiences during the Gulf War as part of a Medical Support Team in 'Operation Granby. Scientific presentations were as follows:

E. D. Fern, J. Kennedy, E. Walker and C. Beauchamp (Chesterfield, UK) The management of Trauma in a Distn'ct General Hospital

The Chesterfield and North Derbyshire DGH is equipped with its own CT scanner and is sited 12 miles from Regional Neurosurgical, Cardiothoracic and Plastic Surgical Units. Poor documentation and general dissatisfaction with the management of injured patients led to the introduction of a Trauma Team, consisting of registrars in anaesthesia and orthopaedic and general surgery; as well as a radiographer and a haemotologist. Documentation was improved by using a standard 'trauma file', facilitating a comprehensive audit of trauma care in the unit. During the first 18 months, 70 patients were managed by the team (60 RTA's, 3 industrial, 5 domestic and 2 climbing accidents). Of the patients, 48 per cent had an ISS greater than 15. Standard TRISS methodology identified no 'unexpected survivors', 4 'expected deaths' (3 severe head injuries, 1 ruptured liver) and 6 'unexpected deaths'. Three 'unexpected deaths' were due to isolated neurological injuries and I from ARDS after repair of a ruptured liver and multiple fractures. Two potentially preventable deaths were identified. The audit has identified problem areas in the management of injured patients including lack of a uniform standard of care, lack of designated team leaders and the logistics of the 'outof-hours' service. As only 3 patients required transfer to the Regional Neurosurgery Centre, we believe that our facilities are adequate for our needs. Designation of a resident, experienced team leader will facilitate education of medical and nursing staff and provide a more uniform service. We believe that trauma can be managed adequately in most district general hospitals given similar facilities.

and chest injuries. Penetrating trauma was present in only 20 patients (I3 per cent). Twenty-two patients died (I4 per cent): 10 of 9I (I 1 per cent) in Bristol and 12 of 64 (19 per cent) in Plymouth. 'Unexpected deaths' occurred in 2 (20 per cent) in Bristol and in 8 (67 per cent) in Plymouth, mostly due to very severe head injuries. There was one 'unexpected survivor' in each hospital. The outcome in both hospitals was equal to that of the North American norms: DEF statistics Z = 0.48, W = 1.0, M = 0.66. We conclude that, with appropriate organization and facilities at District level satisfactory care of the severely injured can be achieved in this Country without establishing Regional Trauma Centres as proposed by the Royal College of Surgeons of England. K. D. Boffard and P. Driscoll (Johannesburg) Organisation of a trauma resuscitation team - how to make a difference

ATLS training emphasises trauma care, but places little emphasis on how a trauma team should function. Industrial research suggests that a simultaneous 'Horizontal' team approach is the quickest type of organization. A prospective study was conducted into the resuscitation room management of trauma patients admitted to two Level 1 trauma centres in the USA and two Level I centres in South Africa. Patients were matched using ISS, age, RTS and sex. The effects of alteration to the make up of the trauma team were studied. The times taken to complete the various stages in resuscitation were noted as follows: (a) time for initial vital signs; (b) time to examine the patient; (c) time to complete Advanced Life Support; (d) time for definitive management plan. There were significant differences between the centres, but these were unrelated to numbers in the team or their seniority. Organizational changes were the most important in lowering times. Resuscitation time can be reduced by introducing task allocation and horizontal organization. The time taken to complete Advanced Life Support has a significant correlation with improvement in the Revised Trauma Score.

D. Richie, D. Gentleman, G. Welch (Glasgow) Death after trauma in a major city - epidemiology and management

A. J. Ward, E. J. Smith, J. P. Hayter, I. J. Leslie (Bristol and Plymouth, UK) Trauma care in the severely injured Regional Trauma Centres have been proposed to improve the outcome for patients with major injuries. This prompted a comparative study of trauma care of the severely injured in Bristol Royal Infirmary, (a teaching hospital) and Derriford Hospital, Plymouth, (a District General Hospital.) The aetiology, patterns of injury and outcome were reviewed in 155 patients, aged 70 years or less, with Injury Severity Scores of 16 or more admitted directly to the two hospitals in 1989. TRISS methodology was used to compare the mortality outcome with norms for North American Trauma Centres. The severity of the injuries in the two hospitals were comparable (mean probability of survival = 0.85), with each having similar numbers of severe head © 1992 Butterworth-Heinemann Ltd 0020-1383/92/030209-08

This report was of a retrospective analysis of 506 consecutive deaths following trauma which occurred in Glasgow during the three years 1987-89. Cases identified from the records of the Regional Procurator Fiscal for Glasgow, to whom all deaths after injury must by law be reported. Deaths from hanging, drowning, electrocution and smoke inhalation were excluded from this study, as were deaths following isolated fractures of the neck of femur. The principal mechanisms of injury were road traffic accidents (171 cases), falls (182), and assaults (96). Of the 506 cases, 157 were dead at the scene of injury, 100 were dead on arrival at hospital, and 249 reached hospital alive but died later. A detailed analysis of the case notes and post mortem reports of these 249 patients allowed a judgement to be made in each case about the preventability or inevitability of the fatal outcome. In 59 (24 per

210

Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 3

cent) of the 249 we identified one or more adverse factors which probably or possibly contributed to death. These cases were discussed in detail. Evidence was represented to suggest that better management in hospital might have prevented a significant proportion of deaths after trauma. Speculation suggested that this was the 'tip of the iceberg' reflecting a larger problem of suboptimal care among the survivors of serious trauma.

scious had a collar applied, and only 66 per cent were intubated. Of those transferred for neurosurgical care 33 per cent were not intubated. Analysis of police accident statistics showed that 17 per cent of these cases had not been recorded. Ninety per cent of accidents were due to pedestrian behaviour, only 34 per cent of involved drivers were breath tested and elevated blood alcohol among victims was uncommon.

S. Caiach (Dundee, UK) Road traffic deaths in a Scoth'shregion- who

H. R. W. Simpson (Oxford) Prevention of bicycle accidents The objective here was to elucidate possible ways of reducing the number of bicycle accidents. A prospective study of all bicyde accident casualties attending an accident unit for a 29-month period was reported, A more detailed questionnaire enquiring about the causes of the accidents was used for the last 12 months of the study. In addition the patient was asked to draw a map of the road indicating the positions of the vehicles involved. There were 1831 cyclist casualties, 818 during the last 12 months of the study. The authors judged that 87.5 per cent of the accidents in the 0-7 age group and 66.2 per cent in the 8-12 age group were due to the error of the cyclist. Eight to 12 year old cyclists were more likely to have caused the accident if they had not had formal training (risk ratio = 2.0 (0.7-5.3, 95 per cent confidence interval)). Of the accidents involving cyclists over the age of 18, 41.4 per cent were due to another road user. These were mainly caused by cars running into the back of bikes which were waiting to turn right or cars hitting bicycles as they overtook them. Overall, a motor vehicle was involved in 633 of the 1831 accidents. Other studies have shown that children less than 8 are unable to judge distance and speed. The results of this study agree with this and we would recommend that children under the age of 8 should not be allowed on public roads. Other children should only be allowed on the roads after formal training. This could become part of the school cufficulum. A campaign to increase the awareness of motorists Would be expected to reduce the number of cycle accidents. As a third of all the accidents involved a motor vehicle a further reduction in accidents should result from greater segregation of traffic and it would be beneficial to allocate more roads and tracks for a 50 per cent reduction in the number of accidents. For the remainder that it has been not possible to prevent, the aim should be to minimize the effect on the patient and to this end cyclists should be encouraged to wear more protective gear.

dies, when and where? A retrospective study was undertaken of all road traffic deaths in the Tayside and North Fife Area. This area covers a large section of the North of Scotland with a possible catchment population of around 400 000. Thirteen per cent of all Scottish road deaths are reported in this area and road traffic accidents account for 70 per cent of local accidental deaths. The post mortem reports, initial police reports and casualty department admission records were the source of data. Two hundred consecutive deaths occurring in the period 1988-90 inclusive were studied. Six other deaths had occurred in this period but had inadequate post-mortem information. There were 156 males and 50 females. The average age was 40 years. Only 25 per cent reached hospital alive but a further 15 per cent were noted to be alive at the site of injury and died before reaching hospital. The average ISS for those who died in hospital was 23.9. Car occupants accounted for 66 per cent of all deaths, pedestrians 26 per cent and motor cyclists 5 per cent. Most fatal accidents were high velocity vehicular incidents occurring some distance from the nearest Accident Department (70 per cent > 2 miles). Accident and Emergency services are provided by five different hospitals, none of which have the full range of trauma specialties and the region has no Accident and Emergency Consultant. The departments are overseen by either general or orthopaedic surgeons. This study shows that there is some variation in the nature of trauma deaths between regions in Britain as both the proportion of cases reaching hospital alive and the dass of road user differs markedly from other studies. This reflects the geography and perhaps climate of the region. These factors may be helpful in planning future trauma services in the area. There was a sustained increase in numbers of fatalities over the period suggesting that centralization of local resources and expertise may improve patient survival.

D. N. Teanby, D. F. Gorman, D. A. Boot (Warrington, UK) Analysis of PedestrianAccidents in the Mersey Region During a 12 month review, 160 serious pedestrian accidents (ISS > 15 or death), were identified in a population of 3.2 million. Thirty-five died at the scene, 125 arrived at hospital alive and 54 per cent subsequently died. Twenty-two per cent were children and 39 per cent were aged greater than 60 years. The median ISS values were similar between the age groups. RTS and APACHE II scores showed significant differences between those that lived and died. TRISS analysis revealed that 32 per cent of deaths and 12 per cent of survivors were 'unexpected'. Head injuries were more severe and common in children, whilst chest injuries were more common in adults and the fatally injured elderly. Abdominal injury was rare. Pre-hospital ambulance care was inadequate, with only small volumes of IV fluid given and less than half of the unconscious patients having a collar applied. Pre-hospital care also significantly delayed transit to hospital. In Accident and Emergency only 38 per cent of those uncon-

D. F. Forman, M. P. Sinha, D. N. Teanby, J. Wotherspoon, D. A. Boot, A. Molokhia (Merseyside and North Wales, UK) The epidemiology of major trauma in Mersey Region and North Wales A prospective study of major trauma (ISS > 14) occurring in a population of 3.2 million during a 12-month period was undertaken. 1088 patients were included; 430 were brought in dead, 309 died later and 349 lived to be discharged. Types of injury were: blunt 76 per cent, penetrating 3.6 per cent, bums 5.8 per cent, drowning 4.6 per cent, hanging 7.5 per cent, electrocution 0.7 per cent and asphyxia 1.4 per cent. The overall incidence of blunt injury was 26 in 100,000 but was 19 in 100,000 for patients arriving alive at hospital. Blunt trauma accounted for 0.08 per cent of new A & E attendances, varying from 0.02 per cent to 0.22 per cent between hospitals. In all blunt trauma groups there were 2-3 times more males. 8.2 per cent of blunt trauma victims were children (under 14) 68 per cent adults from 15-64, and 24 per cent over 65 years. Road Traffic Accidents accounted for 66 per cent and falls for 24 per cent; whereas for children the proportions were 69 per cent and 15

Proceedings of the British Trauma Society per cent; for patients over 59 years that were 53 per cent and 43 per cent respectively. In blunt trauma patients arriving alive, those who died later were significantly older (median 59 vs 29 years), more severely injured (median ISS 36 vs 25), more physiologically impaired (median RTS, 5.03 vs 7.55); had significantly lower conscious levels (median GCS, 5 vs 14) and higher APACH II scores (median, 23.5 vs 11), but did not have a significantly different shock index (median 0.7 each). Hospital mortality was 45 per cent for blunt trauma, 43 per cent for penetrating trauma and 67 per cent for bums. In 557 blunt trauma patients with complete data, TRISS methodology indicated that in 47 per cent of deaths and 6.3 per cent of survivors, the poor outcome was 'unexpected'. Preventable deaths occurred in 16 per cent of blunt trauma patients, 17 per cent of patients sustaining penetrating injury, as well as 17 per cent of drowning cases.

A. J. Botha, R. J. Earlam, A. W. Wilson (London, UK), The Royal London Hospital Helicopter Emergency Medical Service (HEMS); first phase 1990 In December 1988, Lord Stevens, Chairman of Express Newspapers, provided a helicopter for use by the NHS to improve trauma care in the South East of England. This paper describes the setting up of a helicopter emergency medical service based at the Royal London Hospital, its system of call-out, the network of hospitals involved and the workload for the whole year of 1990. The Greater London population is 6.7 million and the total for the four Thames regions is 13.9 million. A provisional figure for major trauma in this area is 1500 per year or about 4 patients per day. Hospitals in the South East of England were assessed as to their landing facilities for receiving and transferring seriously ill patients by helicopter. Sixty-two hospitals had landing sites within a short ambulance journey from the Accident and Emergency Department but in only 12 was the landing site adjacent to the A & E Department. The callout of the helicopter is coordinated by a HEMS desk in the control room of the London Ambulance Service at Waterloo. It was extremely difficult to select the 4 or ,5appropriate trauma calls from 2000 emergency calls received each day. The Dauphin 365N twin engined helicopter sits during daylight hours on the rooftop helipad at the Royal London Hospital. It does not fly at night. The crew consists of a pilot, copilot, doctor and a paramedic. The helicopter was unavailable for 22 per cent of the time last year. The LAS initiated 878 primary rescue missions and 623 missions had to be aborted. HEMS was involved with 255 injured patients at the scene of the accident. A further 107 patients were transferred between hospitals. Eight-four patients were transported from accident scenes to hospital. Twenty-three different hospitals were involved. The 107 patients were transferred from 58 different hospitals to specialist centres. The HEMS team arrived at the accident scene within 10 rain from call out. Invasive procedures were performed on 65 of the 84 patients. Thirty-five patients had an ISS greater than 16 and of these 19 died. The year I990 represented the start of the helicopter emergency medical service with gradual improvements occurring in all the different components of the system. A major problem has been the unnecessary call out rate. The major step forward has been in the greater cooperation of the hospital staff with the three emergency services, i.e. ambulance, fire-brigade and police. The current monthly workload is 100 missions which include 70 where patients are treated at the scene, 5 interhospital transfers and 25 aborted missions.

211 K. D. Boffard, A. Roux, V. van Heerden, E. Pos (Johannesburg, South Africa) Transport of critically injured patient by air ambulance - how safe is it? South Africa is a country of vast distances with specialist ICU's found only in referral centres. Patients in outlying areas may need to be transported several hundred kilometres to one of these specialist centres. How safe is this? Of a total of 1000 missions performed in 1990, 339 interhospital transfers were analysed, and a retrospective analysis was carried out. The total number of transfers, clinical categories, destination hospitals, and time involved were collated, as were all episodes of morbidity and mortality. The critically ill patient is monitored beat-by-beat and breath-bybreath with various doctors and nursing staff available immediately should any change occur. Resuscitation trolleys, drugs and consultant medical staff are readily available to handle any eventuality. The average trauma score of the trauma patients was 5.27. The average ISS was 24.4:42.2 per cent of patients were intubated and ventilated, and 129 per cent were receiving vasoactive agents during transfer. There was a 14.7 per cent incidence of morbid events and a 1.7 per cent mortality. Taking into account the severity of illness of the patients transferred, and the long distances involved, the incidence of morbid events was found to be remarkably low (compared to conventional road transport), and corresponds to that of other series. L. Williams, C. L. Muwanga, P. H. Worlock. C. G. Moran, K. Price, (Sunderland and Oxford, UK) Teaching trauma management in the Accident and Emergency Department In many Accident and Emergency departments the initial management of the seriously injured patient is by relatively inexperienced junior staff. Advanced Trauma Life Support (ATLS) training for these staff can only be a realistic aim with expansion of the ATLS programme in future years. Until then, demand for places on ATLS provider courses will far outstrip supply, with places being preferentially allocated to Consultant and Senior Registrars. It is incumbent upon ALTS providers and instructors to design local courses, based upon ATLS principles, to train their own junior staff to adopt a structured approach to managing the seriously injured patient. An intensive short course, taught over two 3-h sessions has been developed in Sunderland. Aimed at Senior House Offices joining the Accident and Emergency Department, the course fulfils those ATLS objectives necessary to the management of the seriously injured patient on reception to the resuscitation room. M. Needoff, P. Radford, R. Langstaff, (Nottingham, UK) How soon after admission do we operate on patients with fractures of the neck of femur? It has been our impression in this department that elderly patients with fractures of the proximal femur are subject to significant delays in being operated upon, not as a result of any medical circumstances but as a result of inadequat e provision of operating theatre facilities for injured patients in general. A prospective study was performed on 100 consecutive such patients admitted in the months of April and May i990 to audit such delays, identify the reasons for them, implement any changes that were possible and then repeat the study over the same time period in 1991 to see if there were any improvements. All patients with this diagnosis were included except for young patients with such fractures through 'normal' bone e.g. as a result of high energy trauma (RTA's, etc) The first study comprised 106 patients and the second 103 successive patients. Three patients in each group did not receive an operation (3 deaths, 3 non-operative) and in respects of age and

212

Injury: the British Journal of Accident Surgery (1992) Vol. 23/No, 3

sex the groups were entirely comparable. The average delay in getting the first group of patients to theatre (corrected for 'medical' problems) was 38 h. This was clearly unsatisfactory. We are currently unable to have any theatre time, and so we discussed with the anaesthetic department and theatre staff if we could use our allocated trauma lists more effectively. We agreed to provide one surgeon for the Whole day list, the anaesthetists agreed to provide two anaesthetists to ensure an early start and minimise delays and the theatre staff agreed to provide cover over the normal lunch period so that the list could proceed without interruptio n . We then repeated the study to see if there was any significant improvement. The average time delay for the second group of patients (corrected) was 33.4 h which approaches but does not reach statistical significance. These figures clearly show that the average delays in operating on these patients are well in excess of those recommended in the recent Royal College report and that using our theatre time as efficiently as possible made no significant difference. This clearly has major resource implications in the new style 'contracting' NHS both in bed costs and for any time targets that are set, apart from any deleterious effects on the patients themselves. M. Parker (Peterborough, UK) Who should operate on patients with

hip fractures? A total of 1026 consecutive patients treated at two hospitals by either Dynamic Hip Screw (DHS) fixation of extracapsular fractures or insertion of a hemiarthroplasty for subcapital fractures, were studied prospectively to determine if a relationship existed between the number of operations performed by a given surgeon and the incidence of surgical complications. An analysis was also performed of the financial cost of treating complications. Surgical complications recorded were deep wound sepsis, dislocation of hemiarthroplasty, fracture of the femur on insertion of the hemiarthroplasty, cutting out of the DHS or refracture around the DHS. The incidence of surgical complications for surgeons varied from 0 to 20 per cent. There was a strong relationship between the incidence of surgical complications and the number of hip fracture operations performed by a surgeon over the study period, with those surgeons who performed the most operations having the best results. The cost of treating surgical complications was considerable. In addition those surgeons who performed the operation most frequently had a reduced operating time, reduced blood loss and length of hospital stay. Establishing a system similar to that which already exists in some hospitals in the Scandinavian countries, where hip fracture surgery is performed in designated centres, will result in a considerable improvement in the standard of treatment and will also result in financial savings.

A. Sutcliffe, M. Parker (Birmingham and Peterborough, UK) Grade of anaesthetist and mo#ality from hip fractures A total of 798 patients were studied prospectively in two hospitals over a period of 4.5 years. Consultants and Senior Registrars had a significantly higher mortality rate than Registrars or Senior House Officers. There was no difference between the grades when patients 'fitness' was assessed by reference to age, ASA grade, mobility score and mental test score. The length of operation was similar for all grades. Consultants and Senior Registrars administered more spinal anaesthetics. Elective anaesthetics, defined as anaesthetics carried out between 9 and 5 pro, were more frequently administered by Consultants and Senior House Officers. The finding that senior anaesthetists have a higher mortality rate was not unexpected as it is customary for senior doctors to manage the most severely ill patients. The fact that the measures of patient 'fitness' showed no significant differences between the different grades of anaesthetists was, therefore, a surprise. There

are many possible explanations. The ASA system of grading medical fitness, the mobility score and the mental test score are all crude measures of patient fitness. It could be that more sensitive measures, which at present senior anaesthetists nebulously label as 'experience' are required. It is also possible that multivariate analysis would show that combinations such as ASA grade and mobility score, would be a more sensitive measure of 'fitness' It is tempting for senior anaesthetists to suggest the forgoing explanations or alternatively to blame an inexperienced or unskilled surgeon for the poor outcome. The operative time was, however, the same for all groups and suggests that the latter suggestion is untrue. It is also possible for surgeons to suggest that the delay between injury and operation was an important contributory factor because consultants administered more elective anaesthetics. It is, therefore, notable that Senior House Officers, who had the lowest mortality, also gave the greatest number of elective anaesthetics. There are other possible explanations. Senior anaesthetists were involved with only 21 per cent of the patients. They may, therefore, have less day to day experience of anaesthesia for hip fractures than their junior colleagues so that their choice of anaesthetic technique was inappropriate or they administered the anaesthetic with less skill. From the data available, it is not possible to say whether the greater use of spinal anaesthesia by consultants was, or was not, appropriate. Nor is it possible to comment of the skills of the anaesthetists concerned. These results have no room for complacency. Further study is needed to evaluate their true significance.

C. M. Robinson, J. F. Keating, C. Court-Brown, J. Christie (Edinburgh, UK) Re-operation for complications following hip fracture - the influence on outcome A total of 70 patients who developed complications requiring further surgery following operations for hip fracture were studied. There were I3 males and 57 females with a mean age of 78 years. There were 10 undisplaced subcapital fractures treated by Asnis screws and 30 displaced subcapital fractures treated by hemiarthroplasty and 8 treated by primary total hip replacement. All the remainder, pertrochanteric, were fixed with a sliding hip screw. The mean follow up was I8 months. A total of 155 operations was performed on these patients. The main complication in pertrochanteric fractures was failure of fixation (73 per cent of failures) occurring at a mean post-operative time of 3 weeks. Infection explained 26 per cent of failures. The hospital mortality was 1i per cent. Undisplaced subcapital fractures had 8 fixation failures and i infection. Failed arthroplasties either suffered dislocations (48 per cent) or infection (49 per cent). Nine patients had primary excision arthroplasty, and the other 28 patients underwent attempted revision. This was complicated by infection in 6 patients, dislocation in 10 (6 of these eventually needed excision arthroplasty). The hospital mortality was 30 per cent. At the time of follow up 41 per cent had died. Of those treated by intemaI fixation, 75 per cent were still alive and 50 per cent were at home. However, of arthroplasty failures, 58 per cent were dead, only 23 per cent were at home and 77 per cent were in other long term accommodation. Over half of survivors had persistent hip pain. In patients who suffer surgical complications after proximal femoral fracture: further complications are high; the long term functional outcome is poor; hospital mortality rates are high; especially in those treated by hemiarthroplasty.

P. J. Radford, M. Needhof, J. Webb (Nottingham), UK Intramedullary (Gamma Nail) or extramedullary (DHS) fixation of pertrochanteric fractures of the femur The Gamma locking nail is claimed to offer a biomechanical advantage over the sliding screw and plate, as well as a lower

Proceedings of the British Trauma Society incidence of wound complications as it is a semi-closed operation. Two groups of 100 patients were studied in a randomized prospective trial using the Gamma nail and AO Dynamic Hip Screw for pertrochanteric fractures of the femur in elderly patients - average age 80 years. Subtrochanteric fractures were not included in this study. Follow up was to radiological union or a minimum of 6 months. Overall results showed no significant difference between the two groups in most clinical parameters except peroperative blood loss, fall in haemoglobin and wound complications - all less in the Gamma nail group - related to the less traumatic operative technique. The occurrence of a number of peroperative shaft fractures early in the Gamma nail series led to modifications to the operative technique. Six fractures occurred during the operation and 6 afterwards; due to a mismatch between the shape of the nail and the proximal femur. We suggest that the nail be redesigned before it is used widely for pertrochanteric fractures in this age group. S. G. Royle (Manchester, UK) Compartment syndrome following forearm fracture in children Between May 1987 and October 1990, 408 patients under 10 years old were admitted with displaced fractures of the distal radius and ulna. Thirteen cases developed volar forearm compartment syndrome. Eleven had sustained the so-called 'pronator quadratus' fracture. The clinical diagnosis of compartment syndrome was recognized by excessive pain (92 per cent), pain on passive finger extension (100 per cent), and paraesthesiae (28 per cenl:). Eight fractures were irreducible closed, and required primary open reduction and internal fixation. The other 5 were manipulated initially, often several times and 2 were later internally fixed at the time of decompression. Only 2 compartment syndromes were diagnosed at the time of initial treatment. Compartment pressures were recorded in 7 of these patients as well as in 8 of the other forearm fractures. In those with abnormal pressures a full volar and carpal tunnel decompression was performed. An immediate satisfactory post-operative clinical recovery was observed with reduced pain levels and increased passive and active extension of the fingers. At the time of fracture union (about 6 weeks) a satisfactory clinical outcome was seen in only 4 cases. Six children had delayed recovery for up to 4 months after injury with limited extension suggesting muscle damage/contracture. One child had permanent disability from flexor muscle contracture, one suffered a malunion with loss of pronation/supination and one developed non-union of the ulna which required plating and bone grafting. The 8 patients with normal pressures recovered completely. The 'pronafor quadratus' fracture is high risk for compartment syndrome there is a need for careful pre- and post-operative assessment together with compartment pressure measurement. F. P. Monsell, D. J. Pegg, D. L. Shaw, R. B. Smith (Preston, UK) Anterior cruciate ligament rupture - a review of I28 cases. The mean age at injury was 27 years, and 87 per cent were male. The right knee was affected in 60 per cent of cases. The cause was football in 40 per cent and industrial and road traffic accidents in 21 per cent. The diagnosis was confirmed arthroscopically in all cases. Ninety-four per cent had positive pivot shift tests under general anaesthetic and 96 per cent had demonstrable antero-posterior laxity. An associated meniscus injury was present in 44 per cent of cases. A. S. Paul, D. R. A. Davies, P. Turner, P. Bowker, P. R. Kay, S. Rithalia (Manchester, UK) Long term results of treatment of anterior cruciate ligament injuries using the Leeds-Keio technique. Thirty-eight patients treated with the Leeds-Keio ligament

213 between 1984 and 1991 were all operated upon by one surgeon and followed by two independent assessors. Twenty-five patients' knees were assessed objectively using a specially designed machine (the Salford Knee Tester). The tests were performed preoperatively, 1 and 5 years post-operatively. Clinical tests were also performed - Lachman, pivot shift and the anterior drawer. In 85 per cent clinical tests correlated well with quantitative machine tests. The Knee Tester machine has now been set up to provide a Regional service to assess cruciate instability, the 5 year follow-up results are very encouraging and better than expected. R. N. Brueton, D. R. Cox, M. R. Smith (St. Thomas, Hospital, London, UK) Reducing costs and raising standards of trauma by a change in working practice. In a hospital with only one operating theatre covering all surgical emergencies, and no extra resources available for trauma lists, orthopaedic emergencies are often postponed at night. From January to May 1989, 43 per cent of the 132 orthopaedic emergencies admitted were operated on at nighL compared with 37 per cent in the mornings and 20 per cent in the aftemoon sessions. From January 1990 daily Consultant-led fracture meetings were held to discuss patients and their management admitted on the previous day. A Registrar was made available to operate each morning from 8.30 am since the general emergency session was only in use 30 per cent of the time. As a result of this organizational change, 51 per cent of the 139 orthopaedic emergencies admitted from January to March 1991 were operated on in the morning and 32 per cent in the afternoon. Only 21 per cent were operated upon at night. With no additional resources limited daily morning trauma lists were created by using an average of 16 daytime-hours per week of previously underused theatre time. By moving 20 per cent of the emergency orthopaedic operations from night to daytime, the Operating Department Assistant's on-call night duties were reduced by 22 h from 54 h. The on-call Radiographer's hours were reduced by 23 h from 36h during these equivalent periods. Approximate cost savings were £2850 per year. The more efficient use of resources has also improved the working environment of the staff. R. R. Macmillan, D. N. Teanby, D. A. Boot (Merseyside, UK) The value of intensive care in trauma management A population of 437 trauma victims with an ISS of greater than 15 were studied; from 16 hospitals in the Northwest of England and Wales. Patients admitted to the wards were compared with those admitted to Intensive Care Units. Increasing age reduced the likelihood of admission to ICU. Age-matched groups were compared using survival on discharge from hospital as the end point. Those admitted to ICU had a consistently higher survival (e.g. age 60-70; ICU survival 60 per cent, ward survival 20 per cent). Patients with an ISS greater than 25 were compared: ICU survival was 76 per cent compared with 20 per cent for ward care. Access to ICU is limited probably due to inadequate bed numbers, but ICU care has a marked effect on reducing hospital mortality. For reasons that are as yet unclear patients sustaining serious injury are still denied admission to Intensive Care Units. Prof. J. D. Knottenbelt, J. W. van der Spuy (Cape Town, South Africa) Traumatic haemothorax - a protocol for avoiding empyema. Incomplete or prolonged thoracostomy drainage of the pleural cavity may lead to the development of empyema, with long term morbidity. With vigorous physiotherapy and early withdrawal of the thoracostomy tube, the empyema rate in 1845 patients treated

214

Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 3

for traumatic haemothorax was limited to 0.8 per cent (15 patients). Prophylactic antibiotics were not given. The incidence of empyema was significantly increased in those with a large haemothorax and prolonged drainage time. The average tube thoracostomy drainage time was 27.1 h. Hospital stay was 48 h or less in 81.8 per cent patients. In all, 152 haemothorax patients (8.1 per cent) required either early or late thoracotomy; 46 of which were for associated cardiac injury. There were 5 deaths (0.27 per cent), none related to empyema. Early identification of patients requiring operative or other intervention minimises the hospital length of stay and complications associated with residual blood in the pleural cavity. S. D. Deo, E. K, Alpar (Birmingham, UK) A study of patients with

chest injuries. Between May 1989 and April 1991 a total of 98 patients were admitted with chest injuries to the Major Injuries Unit (MIU) of the Birmingham Accident Hospital. The age range was 13-93; there were 71 males and 27 females. Of these 59 per cent were involved in RTAs, 16 per cent in assaults, 11 per cent in falls in the home and 10 per cent at work: 80 per cent blunt injuries, only 17 per cent were penetrating with 3 per cent due to crushing. The mortality rate in chest injury patients was 24 per cent compared with other MIU admissions (15 per cent). The mean ICU stay was 5 days and the mean total in-patient stay was 16 days. Thirty-four per cent had three or more rib fractures and 60 per cent had lung and/or heart injuries, 28 per cent had no rib fractures in spite of lung/heart or great vessel injury; 17 per cent had emergency surgery (thoracotomy, laparotomy, burr holes) and another 25 per cent had operations later. There were significant differences in hospital stay and mortality between groups with isolated chest injuries compared with multiple injuries. Age is also a big factor: below 55 years there is a lower RTS on arrival, higher ISS, higher operative intervention and earlier death. Delayed death in the older group may have benefited from more intensive or preventative treatment in the acute phase. Of the 6 patients requiring emergency thoracotomies 2 survived. The results compare with studies in USA, Canada and Scandinavia.

Prof J. D. Knottenbelt, J. van der Spuy (Capetown, South Africa) Transmediastinal wounds: is exploration mandatory? In a prospective study of chest trauma, 47 patients with penetrating wounds of the thorax had transmediastinal wounds as evidenced by intrapleural pathology on the side opposite to the entry wound. Only 7 patients required thoractomy - 3 urgently. In those patients whose entry wound was in the neck 3 out of 4 needed thoractomy. There were no deaths recorded in this group and complications were not significantly different from other nontransmediastinal haemothoraces. Thoracotomy is not mandatory in the management of transmediastinal wounds. R. D. Sayers, P. C, Bewes, K. M. Porter (Birmingham, UK) A

10 year prospective review of laparotomiesfor abdominal trauma at the Birmingham Acddent Hospital. Between 1977 and 1987 153 patients (124 males, 29 females) with a mean age of 32 (range 5-85) underwent laparotomy for suspected intra-abdominal injury. Blunt injuries occurred in 111 (73 per cent) and were penetrating in 42 (27 per cent). Road Traffic accidents were the commonest cause. Hypovolaemic shock was present in 57 (37 per cent). The commonest indication for lapartomy was peritoneal irritation (53 patients, 35 per cent). Peritoneal lavage was performed in 62 (41

per cent) and 59 of these were positive. The false positive and negative rates were both 3 per cent. Liver trauma occurred in 52 (34 per cent); splenic trauma in 46 (30 per cent) and mesenteric/omental haemorrhage in 19 (12 per cent). Gastrointestinal tract perforation occurred in 36 (24 per cent) and urological injury in 13 (8 per cent). The findings at laparotomy were negative in 24 patients (16 per cent), but all 3 in which serious intra-abdominal injury was missed, died. Associated injuries were common: 60 patients (39 per cent) had chest injuries - 27 of whom died, 10 required thoracotomy and 6 died. Long bone fractures occurred in 47 (31 per cent), pelvic fractures in 35 (23 per cent) and spinal fractures in 12 (8 per cent). Head injuries were relatively rare with only 17 (11 per cent) having a Glasgow coma scale less than 7 (14 of these died). The overall mortality was 29 per cent (45 deaths) including 5 patients with no intra-abdominal injury (these all had an ISS score greater than 16). Abdominal injuries continue to have a high mortality rate, especially in patients with multiple injuries. These should be managed by senior medical staff who are experienced in the management of trauma victims.

L. D. Wijesinghe, E. K. Alpar, S. Tsui (Birmingham, UK) Liver

trauma study Between 1980 and 1991, 36 patients with hepatic trauma were treated in the Major Injuries Unit of the Birmingham Accident Hospital. The average age of the patients was 39 years (age range 4-87 years) and 69 per cent were male. Seventy eight per cent of injuries were blunt, the rest were classified as penetrating. Most injuries (61 per cent) were in drivers or passengers involved in road traffic accidents, 19.5 per cent were in pedestrians, 16.5 per cent stab wounds and 3 per cent gunshot wounds. Multiple organ damage was present in 86 per cent leaving only 14 per cent with isolated liver injuries. Fourteen patients (39 per cent) suffered trauma to three or more organs. One survivor injured eight organs, 10 patients (28 per cent) had a concomitant head injury and 60 per cent of these died as a result of that injury. The degree of liver injury was graded 1-4 according to Calne's classification: 75 per cent had grade I or 2 injuries, 16.6 had grade 3 and 8.4 per cent had grade 4 injuries. The volume of blood transfused was, on average, 8 units in penetrating injuries and 19A units in blunt injuries. Survivors were transfused an average of 9.4 units and those who died 25.4 units. There were 19 deaths (53 per cent). The mortality of penetrating injuries was 12.5 per cent compared with 64 per cent in blunt injuries. The mortality was 100 per cent in grade 4 injuries, 83 per cent in grade 3, 65 per cent in grade 2 and zero in grade 1. Thirty-two per cent of deaths occurred within the first 24 h after admission, 21 per cent 24-48 h later. A further 32 per cent died between the third and tenth days. There were no deaths at 6 • months follow up in patients who were discharged from the ward.

R. J. Baigrie, M. Dallman, P. M. Lamont and P. J. Morris (Oxford, UK) The cytokine response to major surgical injury Major surgery induces an immunodeficient state which increases susceptiblity to post-operative infection. Cytokines are important immune mediators in both the acute phase response to sepsis or trauma and in communications between immunocompetent cells. Although the role of cytokines in major sepsis is now well characterized, little is known of the normal cytokine response to major surgical insult. This study has examined the cytokine response to abdominal aortic surgery to determine whether these responses have any bearing on post-operative complications. Twenty patients undergoing elective abdominal aortic aneurysm repair were frequently sampled during and after surgery and

Proceedings of the British Trauma Society their plasma assayed using ELISA for cytokines interleukins 1 and 6 (IL-1 and IL-6), tumour necrosis factor (TNF) and interferongamma (IFN). A brief IL-1 response preceded the IL-6 response. Three patients developed major post operative complications. Their IL-6 response was significantly greater than the uncomplicated group as early as 4 h after incision (P< 0.001; Mann Whitney U) and preceded the clinical onset of complications by 12-36h. Plasma TNF and IFN were not detected. There was no correlation between these results and operative factors, including blood transfusion, duration of surgery or aortic clamp time, although there was some correlation between IL-6 and APACHE II scores (R-~0.48; P< 0.05). This sequential IL-1 and IL-6 response has not been noted before in vivo and would seem to provide evidence for the in vitro observation that IL-1 induces IL-6 synthesis and release. Interleukin-6 may prove valuable as a predictor of patient outcome as early as 6--12 h after incision. S. P. R. Mcleod, D. R. Macintyre (Scotland, UK) Audit of aeh'ology of facial fractures in the highlands of Scotland: a 20-year review 1971-90. A total of 1570 fractures were seen in 145 patients. More fractures were seen in men and in both sexes mandibular fractures were the most common. Road Accidents were the commonest cause. A recent national UK study and various local studies have shown a significant decrease in road accidents as a cause of facial fracture in the last decade. This trend has not been seen in the Scottish Highlands. There is a need for nationally agreed categories of injury and anatomical nomenclature to allow comparison between geographical areas and the accurate recording of data to facilitate audit. Accurate information is needed about compliance with vehicle legislation, such as the wearing of seat belts in rural areas. A. T. Reece (Leicester, UK) Cervicalfracture dislocations-problems

in diagnosis and management A total of 61 patients who had sustained fractures, dislocations or both at the Leicester Royal Infirmary in the 5 year period to July 1988 were reviewed. There were 42 males and 19 females. Road accidents (57 per cent) and falls (31 per cent) were the major causes. Seventeen patients had other injuries and 8 had multiple cervical injuries. Two patients had major neurological complications and were transferred to the Regional Spinal Trauma Centre within 48 h. Of the remaining 59, 32 were diagnosed and treated as stable and 27 as unstable. In the former group, 2 fractures were missed at initial presentation and 2 were subsequently shown to be unstable. In the latter group, 8 cases were missed initially and 7 others developed complications during their treatment. There were no complications as a result of missed diagnoses although 2 patients are pursuing claims for negligence. Analysis of the available radiographs (44 of 59) revealed that 27 (61 per cent) were inadequate examinations, including 5 of the 10 fractures which initially went undiagnosed. The abnormalities apparent on the radiographs of the other 5 cases were not noticed. Decisions regarding instability were reached from plain lateral films, flexion/extension views, CT scans or a combination of these. Misleading results, from some of these investigations occurred in 3 instances. Two of these resulted in complications. Radiographs of the cervical spine are frequently difficult to interpret, some cases requiring several different views or modalities. Such examinations must be adequately performed. If there is any doubt regarding stability, patients should be admitted and thoroughly investigated. If the injury is unstable, the simplest, safest and most familiar treatment should be used.

215 P. R. Kay (Manchester, UK), P. G. Turner (Stockport, UK), M. E. Ellis, B. K. Mandal, I. Dunbar (Manchester, UK) Trauma and hyperbaric oxygen therapy We report the use of hyperbaric oxygen therapy following trauma over a 13 year period in the North West Region. During this time, 28 cases of skeletal trauma were referred to the Regional Centre for Infectious Disease at Monsall Hospital Manchester, for hyperbaric oxygen therapy because of anaerobic infection. Review of these cases demonstrate that the hard learnt lessons of war time are forgotten in peace time. Inadequate wound debridement, the primary closure of compound injuries and the reliance on antibiotics rather than adequate surgical intervention were the prime causes of severe anaerobic infection leading to referral for oxygen therapy. Hyperbaric oxygen therapy is effective and can be life saving in treating anaerobic infection following trauma often when further surgery and antibiotic therapy has failed. A primary indication for its use may exist in the treatment of crush injuries resulting in mixed infections of macerated skin and soft tissues without true degloving. It is concluded that the civilian trauma surgeon can forget the basic surgical principles of wound management falsely relying on powerful new antibiotics and technological advances in surgery to protect their patients from potentially life threatening infection. If severe anaerobic infection does occur, the trauma surgeon must be aWare that there are over 20 centres in this country that can administer hyperbaric oxygen therapy and refer early. J. K. O ' D o w d (London, UK) Locked intramedul[ary nailing in a

districtgeneral hospital A retrospective study of locked intramedullary nailing of femoral and tibial shaft fractures in a district general hospital was performed. Fifty-eight Gross and Kempf nails were inserted in 56 patients over a 4 year period with a minimum follow up of 10 months, of these 25 were tibial nails and 33 were femoral. The average age was 33 with a range of 27 to 82. Of the tibial fractures, 14 were caused by high veloci~ road traffic accidents and 11 were caused by low energy injuries e.g. sport. Of the femoral fractures, 21 were high energy and 11 were low energy including 6 pathological fractures due to bony metastases. Ninety-three per cent of the fractures were closed or Gustilo type I compound. Peroperative image intensification dosage was measured using exposure times. The average was 5.3 rain for tibial and 9.0 rain for femoral nailing. The time correlated with technical difficulty of the procedure and with the surgeon's experience. The overall complication rate for tibial nailing was 40 per cent and for femoral nailing was 45 per cent. Most of these were technical complications of the nailing procedure or post operative complications specific to the nail. The study shows that the period of reduced weight bearing and the post operative hospital stay were significantly increased in the presence of these complications.

C. M. Court-Brown, J. Christie, M. M. McQueen (Edinburgh, UK) Primary Intramedul[ary Nailing in the Treatment of Type IIIa and Illb Open Tibial Fractures Between July 1987 and March 1990, thirty four type III open tibiat fractures were treated with primary reamed intramedullary nailing using the Gross and Kempf intramedullary nail. There were sixteen IIIa and 18 IIIb fractures in 33 patients (27 male and 6 female) with an age range of 17-89 years and a mean age of 39 years. All fractures were treated by primary nailing after wound debridement. The wounds were reinspected 36-48 h later and definitive flap cover performed at that time or shortly thereafter. Bone grafting where necessary was performed early at 6-8 weeks.

216

Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 3

The patients were all followed up for one year or until union. The 16 IIIa fractures united in an average time for 26.5 weeks. There were no infections or malunions and no open bone grafting was required although six patients needed exchange nailing to stimulate union. Full knee ankle and subtalar movement was regained in 75 per cent of the group. All 18 IIIb fractures united in an average time of 50.6 weeks (32-94 weeks). There were three infections (16.6 per cent) and two malunions (11.I per cent), 10 patients (55.5 per cent) required open bone grafting. Ninety per cent of the group had residual joint stiffness. Further evaluation of the IIIb fracture group showed two distinct sub groups. Ten patients had bone loss of more than 2 cm and 50 per cent of the tibial circumference. Their average union time was 68 weeks and all required open bone grafting. The patients with less bone loss all healed without bone grafting although three required exchange nailing. The average union time for this group was 39 weeks. The results for union and infection compare well with the best results for external fixation. They refute the theory that damage to the intramedullary vasculature is detrimental to fracture union. Analysis of the incidence of malunion, joint stiffness and the requirement for bone grafting suggests that reamed nailing gives superior results to external fixation. J. F. Keating, M. M. McQueen, J. Christie, C. M. CourtBrown (Edinburgh, UK) The management of the infected h'bial

inframedullary nail One of the criticisms levelled at tibial intramedullary nailing is that it carries a high infection rate particularly if used to treat open fractures. Surgeons have been concerned about the possibility of pan-osseous osteomyelitis. There has been very little research into the aetiology and management of tibial osteomyelitis associated with nailing. Between November 1986 and April 1991, 391 closed and Type I open tibial fractures were treated in the Edinburgh Orthopaedic Trauma Unit by the use of primary reamed intramedullary nailing (Group I). During this period 68 Type II and Type III open fractures were primarily nailed (Group 2). There have been six infections in Groups I and seven in Group 2, giving infection rates of 1.5 per cent and 10.3 per cent respectively. All cases of infection in Group 1 were detected between two and eight weeks after operation. Three cases presented with no significant pyogenic collection and were treated with bed rest and high dose antibiotics. All settled without surgery with union occurring at an average of 17 weeks. After union, the nails were removed and the medullary pyogenic membrane excised using reamers. The remaining three Group 1 cases presented with significant pyogenic collections. These patients were treated by open drainage and exchange nailing. All the fractures healed, but two required open bone grafting. The mean time to union was prolonged at over 30 weeks. Infections in Group 2 presented between four and fifteen weeks after operation. All were treated by high dose antibiotics with open resection of avascular bone and subsequent flap cover, All

patients required bone grafting and five healed in an average time of fifty weeks. The remaining patients eventually developed further infection in a free fibula graft and had a below knee amputation. It is of interest that in five of the infections in Group 2 surgical errors could be demonstrated at the time of ~he original fracture surgery. No pan-osseous osteomyelitis has been encountered. Pus tracking along the intramedullary nail has not proven to be a clinical problem and all infection has been localized at the fracture site. The infection rates for tibial nailing are comparable with other methods of fixation. Should infection occur, it can be dealt with successfully. Early infection should be treated by high dose antibiotics with drainage of a significant pyogenic collection. The nail should not be removed although an exchange nailing procedure may be performed. Late infection requires resection of all avascular bone followed by flap cover and bone grafting. M. G. Matthews, M. C. Moss, S. Roysam, A. Karidis (Surrey,

UK) Pulmonary embolifollowing delayed intramedullary nailing of tibial fractures In recent years there have been many reports of intramedullary nailing as an effective treatment for displaced fractures of the tibial diaphysis. In a consecutive series of 20 such fractures treated at St Peter's Hospital, Chertsey, with reamed tibial intramedullary nails, we have experienced three clinically significant pulmonary emboli. Each was confirmed by ventilation/perfusion scan. We have been unable to identify any specific risk factors in these patients. Such a high incidence of this complication has not previously been reported. It is also worthy of note that all pulmonary emboli occurred where nailing was delayed longer than 7 days and none occurred where nailing was carried out at less than 7 days. A review of recent literature includes a total of 705 tibial fractures treated with reamed intramedullary nails. Cases reported include both immediate and delayed nailing procedures. Only two pulmonary emboli are reported. These occurred where open fractures were treated by primary external fixation followed by delayed intramedullary nailing. Both were managed by anticoagulation and insertion of inferior vena cava filters. This overall incidence of only 0.28 per cent pulmonary emboli in the published literature is at marked variance with the 15 per cent incidence in our series. It is also significantly lower than the generally accepted incidence of pulmonary emboli following orthopaedic operations. We are unable to explain this difference. Our cases also indicate that delay in carrying out the nailing procedure may further increase the risk of symptomatic pulmonary emboli. We feel that further study is indicated.

At the subsequent Annual General Meeting the link between the Society's membership and Injury was confirmed. The next meeting of the British Trauma Society is to be hosted by Mr. C. Court Brown in Edinburgh on the 9th and lOth October, 1992.