[Is maximum management of polytrauma patients financially assured?].
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Adult↗
Biomedical subjects
S Ruchholtz
Publications and source records attributed to S Ruchholtz.
[Cost analysis of clinical treatment of polytrauma patients].
In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The average cost per patient in the studied group (n = 100) amounted to 63989.- DM. About 65% of this sum derived from the costs of intensive care, while the expenses for operations covered 19%. The group of primarily deceased patients (n = 25) generated the lowest costs of 8468.- DM (per pat.). The highest costs of 95626.- DM were caused by the treatment of patients (n = 32) that developed one or more complications (organ failure) during their stay in the intensive care unit or died (n = 10) during this therapy (101940.- DM). Since the data concerning medical equipment (i.e. surgical devices, radiological equipment) were not centrally registered in the administration department of our clinic, it was not possible to include these costs into this calculation. Thus the total costs must be presumed higher. A relationship between costs of treatment and injury severity (ISS) appeared in polytrauma only by a cost reduction in early deceased very severely injured patients (ISS > 70). The primary diagnosis (injury pattern and severity) cannot predict the incidence of complications increasing the costs of treatment. In the presented study we did not find a correlation between age and treatment costs.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Fracture healing after intramedullary nailing of simple tibial shaft fractures. A clinical comparison of reamed and unreamed procedures].
From January 1990 to June 1993, 56 patients with simple tibial shaft fractures were treated in the Surgical Department of the University/Municipal Hospital in Munich by primary intramedullary nailing, and 44 of these patients were followed up. The results in 17 who underwent unreamed intramedullary nailing (UTN) were compared with those in 27 in whom reamed procedures (RTN) were applied. There was no difference between the two groups in age, fracture type and localization. Soft tissue trauma prevailed, with 35% I degrees open fractures in the UTN group (RTN group, 3%). UTN patients were operated on an average of 45 h after trauma, and RTN patients, 5 days after trauma. Both groups showed about the same proportion of good and very good results (criteria of Johner and Wruhs), with 83% in the UTN group and 84% in the RTN group. The rate of complications was the same in both groups (11%), and we did not find any kind of infection. Two complications requiring revisions (nonunion, perforation of the nail) after UTN stress the importance of two-dimensional barring in the main fragments (especially when close to the metaphysis) and of reduced weight-bearing for 6 weeks after the operation. The slightly greater intramedullar instability after UTN did not cause a higher rate of nonunions or of fracture healing in a wrong position than RTN. The X-ray findings showed beginning osseous reunion after 13 weeks in the UTN group. This corresponds to earlier painless full weight-bearing after an average of 9.7 weeks, as against 12 weeks in the RTN group.
Adolescent↗
[Stabilization procedures in large soft-tissue and bone defects].
When stabilizing fractures with large soft tissue and bone defects, the primary concern is to avoid additional vascularization damage. Therefore, external fixation is still the standard method. In metaphysical fractures, joint transfixation should be avoided if possible. Concerning closed comminuted fractures of femoral and tibial shaft fractures, interlocking nailing shows the lowest complication rate. The introduction of unreamed nailing of open fractures shows the same low infection rate as external fixation, so it can be considered an alternative method. Early plate fixation is applied for fractures of the upper extremities as well as the proximal and distal femur, if secure covering with vital tissue can be provided. As this is not guaranteed in the case of the tibial shaft, plate fixation remains the absolute last resort. Concerning distal and proximal fractures of the tibial pylon and tibia head, plate fixation is very often applied for definitive stabilization. However, the secondary application represents a considerably lower infection and fracture-healing risk.
Adolescent↗
[Early mortality in polytrauma. A critical analysis of preventable errors].
In order to assess the impact of errors on outcome and to identify the rate of preventable deaths we investigated 40 premature deaths that had occurred among polytraumatized patients (blunt trauma; average ISS 53 points) in a prospective study (years 1986-1992) in a level I trauma centre. On analysing the patients' course on the basis of a complete set of data we detected 41 management and timing errors, 15 mistakes in treatment and 8 diagnostic problems. According to the significance of the errors the patients could be divided into three groups: in group 1 (n = 12; 30%) no errors were found, in group 2 (n = 22; 45%) there were errors but these definitely had no influence on the outcome, and in group 3 (n = 6;15%) we ascertained errors with a possible influence on the deaths. In none of the 40 cases of premature death could it be definitely shown that the adverse outcome could have been avoided. In the care of polytraumatized patients there was a clear predominance of management and timing errors insofar as they accounted for 64% of all errors that occurred and had frequently preceded possibly preventable deaths (88% in group 3). To diminish sources of error in the management of polytraumatized patients we must demand that more accurate clinical standards and algorithms be developed and introduced into the treatment of such patients.
Adolescent↗
[Practical and theoretical limits of score systems].
Trauma-scoring is a measurement of injury severity. Before conclusions can be drawn from their results, their validity, reliability and practicability need to be known. With respect to these factors the following statements may be proposed: some scores do have relatively low inter-rater reliability; retrospective interpretation of findings and diagnoses in the patient records may be equivocal; parameters contributing to the score may be lacking in some records; scoring may be time-consuming; the parameters selected to make up the score may not include all the relevant ones; the influence of time is neglected; different methods of patient selection may confound the interpretation of scoring results; most scores are only evaluated with respect to mortality; the scores are interpreted exclusively on the basis of statistical probabilities. We suggest that such scores as the ISS, PTS, (R)TS, which have been fairly well studied with respect to validity, reliability, and practicability, be prepared.
Humans↗