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Five years ATLS (Advanced Trauma Life Support) in Switzerland are analysed, the problems are discussed and the changes during this period are demonstrated. ATLS Switzerland is a part of the Swiss surgical Society, introduced by the ATLS International Faculty in 1998. Switzerland with 4 official languages needs a special structure. For this reason a decentralisation of the courses was necessary with the need of five regional universities where ATLS courses are offered. Statistics of the rising amount of courses demonstrate the enormous rush for ATLS courses in our country. Three courses in 1998 where followed by six courses in 1999, up to 18 courses in 2002. 2001 was the first year with ATLS in the Swiss Army. Since 1.1.2003 Paul Martin Sutter, Biel ist the new National Director, successor of Domenic Scharplatz, Thusis.

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Between 1994 and 2000 122 open and endoscopic carpal tunnel releases were performed. 82 of them were analysed retrospectively with major interest in security and results of the endoscopic technique. 39 patients were treated with an open, 41 patients with an endoscopic carpal tunnel release (26 using the two portal technique, 17 using the single portal technique). No major irreversible complications were reported, regarding the outcome their were no significant differences. From the 39 patients with open carpal tunnel release nine had persistent complaints and one of them was reoperated because of an injury of the motoric branch of the median nerve. Eight patients out of 26 treated with the two portal technique still had complaints and one needed to be reoperated because of excessive fibrosis around the median nerve. From the 17 patients operated with the single portal technique five had persistent complaints but no reoperation was necessary. Our study showed similar findings regarding security and results using the three different operation methods. But there were no advantages for the endoscopic carpal tunnel release because of the more atraumatic procedure.

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Mild craniocerebral injury or mild traumatic brain injury (MTBI) predominates, occurring with an 80% frequency. A 1997 publication by the American Academy of Neurology clearly defines MTBI as a transient alteration of mental status, without any neurological deficit, that may or may not involve loss of consciousness or amnesia. On the Glasgow Coma Scale (GCS), mild craniocerebral injury corresponds to a score of 14 and 15. The GCS must be taken immediately. Advanced trauma life support follows primary survey methodology and ABCDE protocol. The prognosis in MTBI is significantly worse when the patient suffers from intercurrent hypotension and hypoxia. In smaller hospitals, 24-hour monitoring is imperative. Wherever computerized tomography (CT) is available, a CT examination is broadly indicated. There is no knowledge of any adverse effects on patients whose GCS worsened when the CT revealed normal findings.

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We analysed the ATLS courses organized in Switzerland since 1998. At the students courses the surgeons exceed the participants with a percentage of 45.7%, followed by the anaesthesiologist with 36.3%. The senior residents dominate with 49.1%, followed by the residents with 42.3%. The chief surgeons come only to a per cent of 4.1%. The statistics of the instructors show about the same pattern, the percentage of senior residents is even more impressive. The aim of ATLS is the same concept, the idea of ATLS in all emergency units throughout the whole country of Switzerland.

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Fractures of the neck and the pertrochanteric region of the femur in elderly patients are often treated with dynamic hip screw or endoprothesis. In the aftercare, specially in fractures that have been stabilised with a DHS, partial weight-bearing is recommended. Some other authors describe immediate full weight-bearing after osteosynthesis with the same implant. For elderly patients it is often difficult to apply partial weight-bearing on one limb only. Remobilisation as soon as possible is very important to these patients, to avoid postoperative complications. Therefore the allowance of full weight-bearing enables us to rehabilitate these old patients more appropriate. We have studied the rates of systemic and local complications in patients with different weight bearing on the operated hip with means of the data of the ASIF-documentation records. In patients who bear full weight on the operated limb immediately after operation, the rates of systemic complications are lower. The rates of local complications increased with the instability of the fracture. Both results are though not statistically significant.

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The Swiss Society of Anaesthesia and Resuscitation describes anesthesia as an activity of physicians, and a continuous presence of a medical anaesthesist is required. In small regional hospitals in the alpine region it is impossible to compete with big hospitals in the central area of Switzerland and there is no possibility to afford an anaesthesist for 365 days a year and 24 hours a day. The nurse is able to supervise the patients during the operation, but only groups I and II in the classification of ASA are allowed to be treated during surgery. The monitoring has to be optimal, even better than if anesthesia is done by a medical anaesthesist. The education and the control of this person has to be performed by a medical anaesthesist. This is the only way in keeping the high quality of medical support in the peripheral region specially in the alpine part of our country.

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In a community-hospital the problem arises how to improve the knowledge and skill of the surgeons. As mentioned, for some reasons the possibility of training outside the hospital is limited. We get closer to that problem by operating these cases together: two surgeons of two hospitals next each other. An example to describe this problem is the laparotomic cholecystectomy.

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The bilateral hip displacements are discussed. We divide these injuries in posterior, anterior and in an equal bilateral luxations of the hip. All types are rare (120 cases found in the literature), after all most of them are posterior hip luxations. Immobilisation must be considered for eight weeks, partial weight bearing to week ten, after this period full weight bearing can be allowed. Discharge from the hospital after three months. The danger of arthroses and femoral-neck necroses in this bilateral injury is discussed.

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The accurate reposition of the posterior tibia ridge is a technically exacting undertaking. On the basis of 22 screwed--all done ventrally--and 11 non-screwed Volkmann's triangles which are more than a third of the lateral extension of the distal tibia joint surface can be shown that a screwing in faulty position is worse than non-screwing. Consequently it is better to omit screwing or to do the reposition visually with the corresponding access.

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In tibia and fibula fractures the classification of Weber for malleolar fractures is not valuable. Very rare are fractures of the lower leg (tibia and fibula) together with a ruptured syndesmosis. But it exists, the surgeon has to know it, if the patient complains in addition of pain in the region of the lateral malleolus. One typical case is reported. In 4760 documented tibia fractures we had 39 cases with ruptures of ligaments. Lesions of the syndesmosis were seen in 11 cases and fractures of the Volkmann triangle in 4 cases.

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A 43 year old man is presented who suffered from the association of a toxic adenoma of the thyroid gland and a Zollinger-Ellison syndrome (ZES) due to a metastasizing duodenal gastrinoma. There were no other signs of a multiple endocrine neoplasia syndrome, type I (MEN-I). The patient presented here shows that the association of ZES and thyroid disease may also occur in patients with sporadic ZES.

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Higher speed in ski sports has in recent years increased the number of thoracoabdominal injuries. Our restrospective study concerns 30 patients from the region of Chur, Switzerland, injured between 1965 and 1976. The patients were all male with an average age of 26 years. Details of the injuries, operations and treatment are given and a few typical cases are demonstrated.

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The instable fractures of os calcis are usually treated by conservative methods with early functional mobilization. In a few cases we think that in the Tongue Type and especially in the Joint Depression Type of Essex-Lopresti a surgical treatment may be useful to reestablish the congruence and the geometry of the joint surface.

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