Das schwere Thoraxtrauma gehört zu den häufigsten und potenziell letalen Verletzungen beim Schwerverletzten. Fast 50

Non-union of the chest wall is an underrecognized but functionally significant complication of thoracic trauma, particularly when involving posterior ribs, parasternal cartilage, and the costal margin. Complex instability patterns can result in persistent pain, mechanical dysfunction, and impaired respiration. We describe two patients with symptomatic chest wall non-union. Case 1 was a 62-year-old man with posterior non-union of the seventh and eighth ribs and a secondary costal margin rupture with intercostal hernia. He underwent combined posterior rib plating and costal margin reconstruction, nerve-sparing fibre-tape sutures, and double-layer mesh. Case 2 was a 25-year-old man with a radiographically occult rupture and pseudarthrosis of the third parasternal costal cartilage. He was treated with trans-costosternal osteosynthesis and local bone grafting. These cases illustrate that dynamic and multimodal imaging are often required to diagnose non-unions, and that contemporary plating and mesh techniques can restore stability, relieve pain, and permit early mobilization.

Severe thoracic trauma is among the most frequent and potentially lethal injuries in severely injured patients. Almost 50% of polytrauma patients present with relevant chest trauma (AIS >= 3). The spectrum ranges from chest wall instability and pulmonary contusions to life-threatening injuries of the heart, great vessels, and tracheobronchial tree. While initial ATLS-based management is well established, treatment strategies for severe chest wall injuries have shifted in recent years from predominantly non-operative care towards early surgical stabilization. This paradigm change is driven by growing evidence that rapid restoration of chest wall integrity and biomechanics significantly reduces morbidity (e.g. pneumonia, ventilation time, ICU stay) and mortality. This CME article summarises current diagnostics and therapy, outlines indications and contraindications for operative interventions, and reviews complication management in severe thoracic trauma management.

Surgical stabilization of rib fractures (SSRF) has re-emerged as an important component of chest wall trauma care, yet its history is often presented as a simple timeline rather than as a source of operative and biomechanical lessons. This literature, problem-oriented historical review re-examines earlier rib fixation strategies in order to identify the mechanical and operative problems they were intended to solve, why many disappeared, and which principles remain relevant to contemporary SSRF practice. A literature review was conducted focusing on historically important fixation techniques and conceptual milestones in the management of serious rib fractures and flail chest. PubMed/MEDLINE and Google Scholar were searched from database inception to 19 March 2026 using terms related to rib fracture fixation, flail chest, SSRF, intramedullary fixation, and history. Studies were purposively selected if they described key fixation concepts, major shifts in management strategy, recurrent technical problems still seen in modern SSRF, or contemporary guideline context. Forty-seven articles were included and synthesized using a problem-based rather than purely chronological framework. Across eras, rib fixation evolved around recurring challenges: (1) restoration of chest wall stability and thoracic continuity, (2) the tension between internal pneumatic stabilization by positive-pressure ventilation and structural repair, (3) difficult access to posterior, subscapular, and upper-rib fractures, (4) implant–rib mismatch and preservation of the intercostal neurovascular bundle, and (5) a limited evidence base. Historical methods - including suture and wire cerclage, clamp-based plates, intramedullary devices, and percutaneous or limited-incision techniques - were early attempts to solve these problems rather than obsolete curiosities. Their main limitations were invasive exposure, bulky and excessively rigid implants, poor conformity to rib curvature, neurovascular irritation, and weak clinical evidence. The most important transition was conceptual: reframing rib fracture patterns as dynamic chest wall instability in which a static CT fracture map must be translated into an operative construct that restores functional thoracic mechanics while preserving the muscular and soft-tissue envelope. Modern SSRF represents the maturation - not the replacement - of historical fixation concepts under improved biomechanical, biological, and evidentiary conditions. The lasting lessons are that fixation should target the mechanically relevant instability, balance stability with biological restraint, match access strategy to fracture location and chest wall anatomy, and expand indications selectively and discipline. Reinterpreting historical techniques through this problem-oriented lens may help refine current SSRF practice, avoid repetition of past errors with new implants, and guide future development of dynamic chest wall reconstruction.

Trauma care in Germany is a critical component of public healthcare, encompassing preclinical to rehabilitative phases of patient management. Demographic shifts, workforce shortages, and increasing patient complexity challenge the sustainability of trauma care. This study aims to analyze current trauma care structures, forecast future demands, and propose strategies to secure high-quality trauma care in Germany by 2030. A mixed-methods approach was employed, combining a quantitative analysis of national hospital and ICD-coded diagnostic data (2010–2019) to model infrastructure, analyze patient volumes, and forecast demand to 2030 under different scenarios. This was supplemented with an online survey of 752 trauma surgeons nationwide to assess perceptions of future challenges and professional satisfaction, and a structured expert panel with 23 experts to qualitatively interpret the data and develop strategic recommendations. Survey respondents anticipate a significant rise in age-related trauma cases and a worsening shortage of both medical and non-medical staff. Hospital infrastructure is unevenly distributed, with particular accessibility issues in rural and eastern regions of Germany. Forecasts predict increasing trauma cases in older adults and a reduction in hospital beds, especially in rural areas. The data analysis identified critical areas for intervention including improved training, telemedicine integration, centralized trauma centers, and enhanced image and attractiveness of the trauma surgeon profession. Ensuring sustainable trauma care in Germany requires structural reforms, sectoral integration, and workforce development. Policy must support case-number independent resource orientated financing, sector-crossing cooperation, and the incorporation of advanced digital technologies. Centralized specialization combined with broad generalist competencies in the field will be essential to meet future demands.

Die vorliegende Arbeit beschreibt den Einsatz von digitalen Lösungen für die Verbesserung der Versorgung von Traumapatienten in Deutschland. Im Mittelpunkt stehen die TraumaNetzwerke der Deutschen Gesellschaft für Unfallchirurgie (DGU). Der Einsatz von digitalen Lösungen umfasst Qualitätssicherungen durch das TraumaRegister, dass eine umfassende Datenanalyse ermöglicht, sowie Voranmeldung und Ressourcennutzung über Programme wie den Interdisziplinären Versorgungsnachweis IVENA eHealth, den Rescuetrack und das Rescue-Net. Zudem wird das Predictive Hospital Resource Planning, das die Ressourcenprognose mithilfe von künstlicher Intelligenz (KI) optimiert, vorgestellt. Telemedizinische Dienste wie Medgate und teleradiologische Lösungen (Nexus/Chili) bieten zusätzliche Unterstützung, insbesondere in ländlichen Gebieten. Die Arbeit zeigt, wie die Digitalisierung der medizinischen Versorgung entscheidend ist, um die Effizienz und Qualität in der Behandlung von Traumapatienten zu verbessern. Zudem zeigt die Arbeit mögliche Entwicklungen im Bereich der klinischen Entscheidungsfindung durch KI auf.

Periprothetische distale Femurfrakturen (PPDFF) bei implantierter Knieendoprothese stellen eine zunehmende Herausforderung für die unfallchirurgische und orthopädische Versorgung insbesondere älterer, multimorbider Patient:innen dar. Die Behandlungskonzepte variieren je nach Frakturtyp, Prothesenstabilität, Knochenqualität und Patientenfaktoren [1, 6–10, 13]. Moderne winkelstabile Platten, retrograde Marknägel mit angulierten Schäften, Doppelplatten- und Nagel-Platten-Konstrukte bieten je nach Frakturtyp und Knochenqualität eine hohe Primärstabilität und ermöglichen meist eine frühfunktionelle Mobilisation [5, 6, 11, 13, 30–33]. Bei sehr distalen, osteoporotischen oder komplexen Frakturen sind Doppelplatten oft biomechanisch überlegen und reduzieren Komplikationen wie Nonunion und Implantatversagen [2, 10, 11, 13, 14, 22, 29]. Allerdings besteht auch die Gefahr, dass der Knochen hinter dem femoralen Schild nicht regelrecht konsolidiert. Bei ausgedehntem Knochenverlust oder primär gelockerter Prothese ist der distale Femurersatz indiziert [8]. Frühzeitige Mobilisation, insbesondere in der meist älteren Patientenpopulation, verbessert das funktionelle Ergebnis und senkt die Mortalität [1, 5, 11, 13, 16, 27, 30–33]. Ziel dieses Übersichtsartikels ist es, aktuelle Therapieoptionen, deren Evidenz sowie spezifische Komplikationen und funktionelle Ergebnisse systematisch darzustellen und zu bewerten.

The purpose of this study was to assess severe abdominal injury in child passengers of different ages of motor vehicle accidents and analyze the concomitant pattern of injury regarding injury severity, trauma management and outcome. Data acquisition from Trauma Register DGU® (TR-DGU) in a 10-years period (2010–2020) of seriously injured children (max. AIS 2+ / intensive care) 0–15 years of age, as motor vehicle passengers (cMVP) (n = 1,035). Primarily treated in or transferred to a German Trauma Center. Matched pairs analysis with adult severely injured motor vehicle passengers (aMVP) (age 20–50 years, n = 26,218), matching 1:4 (child: adult), was performed to identify causes of mortality. The study group (cMVP) included 1,035 children. The mean age was 9.5 years, 50.5

Background: Survivors of a major trauma experience a range of difficulties in relation to the reduction in physical, psychosocial, and cognitive functions, which can result in a reduced health-related quality of life. This study aims to explore lived experiences of major trauma survivors in the German healthcare system. Methods: Semi-structured exploratory interviews were performed with nine major trauma survivors (18-55 years; Injury Severity Score >= 16). For exploratory analyses, an artificial intelligence-based coding software was used. Further, results were clustered by using the International Classification of Functioning, Disability and Health framework (ICF). Results: Communication was one of the major topics concerning amongst others diverting opinions between different healthcare disciplines and a general lack of information. The participants showed a high demand for a contact person. Furthermore, social support was essential during recovery for those interviewed. Social network was not only important as emotional and physical support but also for overcoming of gaps in the healthcare system. The support by employers and colleagues seemed to be beneficial for our participants in relation to returning to work. Further, psychological consequences of trauma, and that mobility is a key factor for quality of life, self-efficacy and return to work were discussed. Discussion: The qualitative analyses highlight several topics such as communication, burden of sickness, support systems that the participants mentioned as important along their journey through the German healthcare system during recovery. Through the ICF model the interplay of certain components that influenced the outcome of the major trauma survivors was visualized. Implications: These results might offer a deepened understanding of modifiable components of a patient pathway in recovery process such as improvements of patient communication, provision of a contact person and others.

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures. Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines. A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60

Our aim was to update the evidence-based and consensus-based recommendations on criteria for trauma team activation (TTA) and staffing requirements for the management of patients with (suspected) multiple and/or severe injuries in the resuscitation room on the basis of available evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. MEDLINE and Embase were systematically searched to August 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared criteria for identifying severely injured patients requiring trauma team activation or different staffing components (e.g. team composition, training) for the management of patients with (suspected) multiple and/or severe injuries in the resuscitation room. We considered patient relevant outcomes such as mortality as well as prognostic accuracy outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. Twenty-one new studies were identified. Potential trauma team activation criteria included vital signs (e.g. systolic blood pressure), type and extent of injury (e.g. central gunshot wound), mechanism of injury (e.g. traffic accident), interventions (e.g. chest tube), specific criteria for geriatric patients, and combined criteria (N = 20). Staffing requirements for the resuscitation room included specific training for orthopaedic trainees (N = 1). Two recommendations were modified, and six additional recommendations were developed. All but two recommendations achieved strong consensus. The key recommendations address the following topics: inter-professional trauma teams in the resuscitation room; trauma team activation for geriatric patients; and trauma team activation criteria based on physiological, anatomical, interventional, and mechanism of injury parameters.

In mechanically cardiopulmonary resuscitated (CPR) patients, chest compressions at the level of the 3rd to 5th rib on the sternum result in reproducibly similar injury patterns: parasternal osteochondral dissociation (OCS) on both sides in combination with a sternal fracture with or without an additional serial rib fracture in the anterolateral column (ALS). This injury biomechanically impairs physiological breathing, resulting in an inverse breathing pattern. Trauma patients, on the other hand, often show a mixed pattern depending on the location of the main energy. The aim of the study was to evaluate the surgical technique of chest wall reconstruction (CWR) using transsternal refixation of the 5th rib on both sides in combination with plate osteosynthesis of the sternum and to analyze its success in comparison to the surgical strategy of CWR in the context of a traumatic genesis. Data acquisition was performed using medical records of a Level I Trauma Centre in Germany and compare patients with radiologically or clinically diagnosed flail chest as a result of cardiopulmonary mechanical resuscitation (CPR). The retrospective study included patients in the period 2018–2023 after surgical CWR. The patients were either post-CPR (n = 29; CPR) or trauma patients (n = 36; trauma). The collective was described and analyzed using the digital patient file, as well as data on ICU stay and duration of ventilation or conversion to assisted ventilation modes, reason for chest wall instability, time of surgery, length of stay and mortality. As a long-term follow-up, body plethysmography was analyzed comparatively. Primary endpoints were mean length of stay in ICU, time to surgery, ventilator dependency and mortality rate. Secondary endpoints were time to transfer to rehabilitation, ventilation disorders and long term outcome. In the period 65 patients (48 m, 17w) were included, 29 of whom had been mechanically resuscitated (CPR), 36 formed to post-traumatic cohort (trauma). The CPR were significantly older (69 vs. 58 years; p-value 0.003). The duration from CPR to surgery was on average significantly longer than trauma to surgery (16.76 vs. 4.11 days). The mean length of stay in ICU were 30 days (trauma) and 45 days for CPR (significantly longer, p-value 0.0008). The mean duration of ventilation was 188 h for trauma and 593 h for CPR. Extubation or conversion to assisted, relevant de-escalating ventilation modes was possible in both groups after a mean of 38 h post-OP. Among the CPR patients, 4 died in hospital (hospital mortality: CPR 20.7

Periprosthetic distal femoral fractures (PPDFF) following knee arthroplasty represent an increasing challenge for trauma surgery and orthopedics, particularly for older multimorbid patients. Treatment concepts vary depending on the fracture type, prosthesis stability, bone quality and patient factors [1, 6-10, 13]. Depending on the fracture type and bone quality, modern locking angle plates, retrograde intramedullary nails with angulated stems, double plate and nail-plate constructs provide a high primary stability and usually enable early functional mobilization [5, 6, 11, 13, 30-33]. In very distal, osteoporotic or complex fractures, double plating is often biomechanically superior and reduce complications such as nonunion and implant failure [2, 10, 11, 13, 14, 22, 29], although there is also a risk that the bone behind the femoral shield will not properly consolidate. Distal femoral replacement is indicated in cases of extensive bone loss or primary loosening of the prosthesis [8]. Early mobilization, especially in the mostly older patient population, improves the functional outcome and reduces mortality [1, 5, 11, 13, 16, 27, 30-33]. The aim of this review article is to systematically present and evaluate current treatment options, their evidence, specific complications and functional outcomes.

Every year ca. 60,000 people in Germany undergo cardiopulmonary resuscitation (CPR). The two most frequent underlying causes are of cardiopulmonary and traumatic origin. According to the current CPR guidelines chest compressions should be performed in the middle of the sternum with a pressure frequency of 100-120/min and to a depth of 5-6cm. In contrast to trauma patients where different injury patterns can arise depending on the accident mechanism, both the type of trauma and the injury pattern are similar in patients after CPR due to repetitive thorax compression. It is known that an early reconstruction of the thoracic wall and the restoration of the physiological breathing mechanics in trauma patients with unstable thoracic injuries reduce the rates of pneumonia and weaning failure and shorten the length of stay in the intensive care unit. As a result, it is increasingly being propagated that an unstable thoracic injury as a result of CPR should also be subjected to surgical treatment as soon as possible. In the hospital of the authors an algorithm was formulated based on clinical experience and the underlying evidence in a traumatological context and a surgical treatment strategy was designed, which is presented and discussed taking the available evidence into account.

Objective: Osteosynthesis in dislocated diametaphyseal forearm fractures is intended to restore anatomy and function. Antegrade intramedullary nailing in the radius is used to restore length, rotation, and axis within the age-specific correction limits. Sufficient stability ensures early functional postoperative treatment without load. Indications: Dislocated diametaphyseal forearm or radius fractures that cannot be closed, stably reduced, or remain outside the age-specific correction limits. Contraindications: Radius or forearm fractures located distal or proximal to the defined area. Soft tissue defects, contamination or infections located in the access path. Surgical technique: In the course of the Thompson approach, the soft spot between the extensor digitorum and extensor carpi radialis brevis muscles is located and an approx. 3-4 cm skin incision is made. Then blunt preparation down to the bone, sparing the profundus and superficial radial nerve. Retraction of the musculature with two Langenbeck hooks. Opening of the cortex with an awl. If necessary, a 2.5 mm drill with tissue protection can be used beforehand if the cortex is very hard. A titanium elastic nail (TEN) diameter is selected so that it fills approximately 2/3 of the medullary canal. It is recommended to flatten the TEN runner with parallel flattening forceps. After closed reduction, the TEN is then brought up in front of the growth plate with slightly rotating movements. The TEN is bent over at the proximal end and pinched off above the muscle bellies. Alternative procedures include Kirschner wire osteosynthesis or retrograde TEN from radial or dorsal, with or without bending. Postoperative management: The aim of osteosynthesis is early functional follow-up without load. Sports abstinence is recommended for 8 weeks. Metal removal can be performed after consolidation between 3 and 6 months. Results: Clearly dislocated or outside the correction limits infantile radius and forearm fractures show very good treatment results with a low risk profile after the described osteosynthesis technique. Pseudarthrosis and nerve damage were not observed. Secondary dislocation has not occurred.

The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.

Trauma surgical care in Germany faces major challenges. The increasing number of cases due to demographic change, combined with reduced bed capacity, requires a rethink in many areas. In order to continue to ensure basic and standard care at a high level and across the board in the future, economic incentives must be created to maintain sufficient locations for trauma care. At the same time, there is a shortage of skilled workers that will worsen in the coming years if appropriate measures are not taken to counteract it. Structural changes will also be needed to improve cross-sector networking between outpatient and inpatient care. With the increase in outpatient care, future shortages of both bed capacity and staff shortages may be buffered.