International Journal of Burns and Trauma最新文献

Intraoperative blood loss (IBL) monitoring is an important factor in decision-making of anesthesia, and real-time and reliable IBL is vital in the safety of the patient during the perioperative period. But even now after decades of technological development in medicine, this basic clinical issue has not been addressed. The current strategies of monitoring do not usually achieve all the needs of accuracy, timeliness, and procedural flexibility in regular clinical care. This article re-examines this critical issue of intraoperative blood loss monitoring from the perspective of actual clinical surgery and anesthesiology. We analyzed the structural reasons for the long-term unreliability of IBL clinical measurements and proposed some core principles for future surveillance strategies. Traditional methods for assessing intraoperative blood loss include visual estimation, gravimetric methods, volumetric methods, and laboratory or spectrophotometric methods. These methods all have inherent limitations. We believe these shortcomings are not isolated technical problems, but rather stem from a design philosophy that did not address the needs of clinical decision-making from the outset. To better explain the clinical challenges faced by IBL monitoring, we propose the "Irreconcilable Triangle of IBL Monitoring" model. This model consists of three conflicting requirements: accuracy, timeliness, and workflow compatibility. Optimizing one dimension of technology inevitably compromises other dimensions. Therefore, we redefine accuracy as "functional accuracy". That is, the accuracy of intraoperative bleeding monitoring should reach the level necessary to support intraoperative clinical decision-making, without pursuing absolute accuracy. Simultaneously, it should be made as time-relevant and clinically feasible as possible to meet clinical needs. This paper envisions future strategies for intraoperative blood loss monitoring. Future clinical practice requires automated equipment capable of continuously quantifying free blood, absorbed blood, and blood clots, shifting from inferential estimation to direct automated measurement. Furthermore, this equipment must be seamlessly integrated into the anesthesia workflow. The paper discusses the availability of artificial intelligence (AI) in surgical blood loss monitoring. We believe that while AI has limitations in interpretability, it can serve as a complication prediction and backend computational tool for the entire monitoring system. In the future, we hope to develop IBL monitoring into an integrated system centered on clinical usability and decision relevance through new technology development and system integration.

For the repair of complex wounds involving bone and joint infections resulting from severe trauma, the conventional approach typically involves a two-stage procedure: initial implantation of an artificial dermis (AD), followed by autologous split-thickness skin grafting (STSG) after 2-3 weeks. This report presents an innovative one-stage technique in which AD and autologous STSG were transplanted simultaneously onto a wound bed prepared with antibiotic-loaded bone cement (ALBC). The patient had sustained multiple open fractures, dislocations, bone defects, and bone and joint infections following a traffic accident. After two initial surgical procedures that included thorough debridement, fracture fixation, and ALBC placement for infection control, a one-stage skin graft was performed to co-implant AD and autologous STSG (0.15-0.25 mm thick) for wound closure. At the 18-month follow-up, the graft flap exhibits no contraction, and its color, texture, softness, and elasticity closely resemble those of the surrounding normal skin. This ALBC-assisted one-stage transplantation of AD combined with autologous STSG offers a feasible and efficient method for repairing complex wounds involving bone and joint injuries with concomitant skin and soft tissue defects. Moreover, it may reduce treatment duration and simplify the clinical pathway compared with traditional two-stage skin grafting protocols.

Objective: This study evaluates the efficacy of VELVERT, a novel antimicrobial dressing, compared to the standard Silver Sulfadiazine dressing in treating second-degree burns.

Method: Conducted at a tertiary burn care center, 63 patients were enrolled and randomized into two groups: VELVERT (n = 31) and Silver Sulfadiazine (n = 30). The primary outcomes measured were wound closure percentage and time to complete healing within 24 days, while secondary outcomes included infection control, pain relief, and adverse events. The study was registered with CTRI with the registration number CTRI/2020/12/029698 (https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDY5MDc=&Enc=&userName=).

Result: Among 61 patients who completed the study, 87% (27/31) in the VELVERT group achieved complete wound healing compared to 63% (19/30) in the Silver Sulfadiazine group. The BWAT score, assessing wound healing, showed a decline from 31.66 ± 3.15 to 15.55 ± 4.42 in the VELVERT group and from 31.55 ± 3.35 to 16.18 ± 5.37 in the Silver Sulfadiazine group (P = 0.176). Both treatments were well tolerated, but VELVERT exhibited superior wound healing outcomes.

Conclusion: These findings suggest that VELVERT may serve as a more effective alternative for second-degree burn treatment, offering improved healing rates. Further research with larger sample sizes is recommended to validate its clinical benefits over standard treatments.

Objective: Comminuted intra-articular distal radius fractures (DRFs) present significant treatment challenges due to their complex morphology and tendency for post-traumatic arthritis. Volar plating alone may be insufficient to achieve and maintain reduction in dorsally displaced fractures. This prospective study evaluated the radiological and functional outcomes of dorsal-assisted volar plate fixation in dorsally displaced comminuted intra-articular DRFs.

Methods: A total of 21 patients treated at a tertiary care trauma centre were enrolled. All underwent dorsal-assisted reduction followed by volar plating without dorsal instrumentation and were followed for a minimum of one year (mean follow-up: 19.6 ± 4.7 months). Radiological outcomes were assessed using radial height, radial inclination, volar tilt, and intra-articular step-off, while functional outcomes were measured using the QuickDASH and modified Mayo Wrist scores. The study was prospectively registered in the Department review board in department of Orthopaedic Surgery, PGIMER, under registration number DRB/Ortho/2023/49.

Results: The mean patient age was 38 years, with a male predominance (17/21; 80.9%). Most fractures (15/21; 71.4%) were AO type 2R3C3. Postoperative evaluation demonstrated restoration of wrist alignment with a mean radial inclination of 23.35°, radial height of 11.29 mm, and volar tilt of 6.70°, closely approximating the uninjured wrist. Functional outcomes improved significantly from two months postoperatively to the final follow-up (P < 0.001), achieving a mean QuickDASH score of 4.95 and a modified Mayo Wrist Score of 90. Only two patients experienced minor complications related to implant prominence.

Conclusions: Dorsal-assisted volar plating is a safe and effective technique for managing dorsally displaced comminuted intra-articular distal radius fractures, providing excellent anatomical restoration and functional recovery with minimal complications. It offers a valuable surgical option where volar plating alone may be inadequate.

Pediatric burn injuries present unique challenges due to children's physiological vulnerabilities. This article provides a detailed analysis of the nutritional management of an 11-year-old patient with extensive burns affecting 60% of total body surface area. The patient received intensive care in a specialized pediatric burn unit, highlighting the fundamental role of nutrition in counteracting catabolic states and muscle loss frequently observed in these cases. Nutritional strategies-including gastrostomy infusion, albumin supplementation, and protein-enriched diets-were carefully implemented to optimize energy intake and promote wound healing. The article also reviews the metabolic and immunological responses of burn patients, emphasizing the importance of early nutritional support to mitigate hypermetabolism and enhance immune defense. Key elements of nutritional assessment, such as energy requirement estimation and macronutrient composition, are explored. Furthermore, the role of micronutrient supplementation in accelerating wound healing and reducing infectious complications is underscored. The article concludes by highlighting the evolving landscape of pediatric burn care, stressing the importance of interdisciplinary collaboration and the integration of advanced technologies to achieve precise nutritional interventions. This case study provides valuable insights into optimizing nutritional strategies for pediatric burn patients and contributes to the advancement of pediatric critical care.

The etiology of diabetic foot ulcers (DFU) is multifactorial, encompassing neuropathy, peripheral arterial disease, and susceptibility to infection. The management of DFU remains challenging due to high recurrence rates and amputation risks. While various treatments exist, a standardized, effective approach integrating holistic care is essential. This paper presents a detailed analysis of two representative cases of complex DFU managed within our institution. Both patients underwent a structured process involving immediate holistic assessment, formation of an MDT to devise personalized treatment strategies, surgery, application of NPWTi, and structured post-discharge planning including health education. Eventually, both patients achieved successful wound closure without major amputation. The successful management of complex DFU necessitates a paradigm shift from isolated interventions to a comprehensive strategy. This strategy should encompass 1) early holistic patient assessment, 2) centralized coordination via an MDT for personalized care plans, 3) meticulous surgical debridement, 4) judicious use of advanced adjunctive therapies like NPWTi, and 5) robust post-discharge follow-up and patient education to prevent recurrence. This framework serves as a practical guide until further robust evidence emerges to refine these recommendations.

Background: Globally, burn injury is of public health concern; it is a significant health problem in both children and older adult populations. In Africa and especially in Uganda, burn injuries remain a major cause of prolonged hospital stays, disability, disfigurement and death. A lot of factors may be associated with the injury severity of burn wounds. Bacterial microorganisms take short hours to invade the burn wound and can be identified in the burn wounds less than 24 hours old. When a patient is alive after 3 days following a burn, then the commonest cause of death is infection. Bacterial infection is still the serious complication that might compromise with the patient's life after the early phase of the management, and the bacterial pathogens isolated from these wounds might still be resistant to the most common used antibiotics in our setting.

Objectives: The aim of this study was to determine the most common etiology, the factors associated with injury severity, and the bacterial susceptibility patterns of burn patients in six selected hospitals in Uganda.

Methods: This cross-sectional study was conducted in the departments of surgery at the six selected hospitals from April to July 2022.

Results: Around 76 patients admitted to those hospitals with burns during our study period were included. Those who were very severe without caretakers eligible to consent for them were excluded. The average age was 17.7 years. There were slightly more males with a male-to-female ratio of 1.05. The majority were from the rural areas accounting for 76.3%. The common etiology was thermal, accounting for 80.8%, dominated by scalds (60.5%). Patients with burn wounds at the sites mandating admission were 22 times more likely to have a severe injury. The most common organism isolated was staphylococcus aureus accounting for 45.2%, followed by Pseudomonas, accounting for 15.5%, and they % were resistant to most of the antibiotics used in our study. Despite that identified bacteria were resistant to most of antibiotics, a good number of them were sensitive to imipenem, amikacin, ciprofloxacin, and cloxacillin.

Conclusions: Implementation of burn infection control policies is needed. There is a need to include sites mandating admission in the parameters of the ABSI score. Based on microorganisms isolated, empirical treatment with ciprofloxacin or cloxacillin should be considered.

Background: Subtrochanteric femoral fractures in children are uncommon but challenging to manage due to high mechanical stresses and their proximity to the growth plate. While the Titanium Elastic Nailing System (TENS) has proven effective for paediatric diaphyseal fractures, its role in subtrochanteric fractures is less well established.

Aim: The aim of this study was to evaluate the clinical and radiological outcomes of paediatric subtrochanteric femoral fractures treated with TENS, specifically assessing union rates, complications, and functional outcomes using Flynn's criteria.

Methods: We conducted a prospective observational study of 18 children aged 5-11 years with radiologicaly confirmed subtrochanteric femoral fractures treated using TENS at a tertiary care centre. Patient demographics, fracture patterns, associated injuries, time to surgery, postoperative immobilization, time to weight bearing, fracture union, complications, and outcomes were recorded and analysed.

Results: The mean age of patients was 7.7 years, with a male predominance (61%). The most common fracture patterns were oblique and spiral. Associated injuries were seen in 4 patients, and the average time to surgery was 2.1 days. Partial weight bearing was initiated by 4-5 weeks, and radiological union was achieved in all patients, with a mean union time of 9.5 weeks. Complications included limb length discrepancy (1 case), nail irritation (2 cases), and delayed union or malalignment (2 cases). According to Flynn's criteria, 72% had excellent, 22% good, and 6% satisfactory outcomes.

Conclusion: TENS is a safe, minimally invasive, and effective treatment for paediatric subtrochanteric femoral fractures in children aged 5-11 years. When applied with proper technique and patient selection, it results in reliable union, early mobilization, and favourable functional outcomes with minimal complications.

Objectives: Over-resuscitation is a formidable complication of burn resuscitation and increased morbidity and mortality. Currently, the Advanced Trauma Life Support recommends using a modified Brooke's formula to minimise its incidence; however, supporting evidence is very limited. We aimed to compare the resuscitative and clinical outcomes between the Parkland and modified Brooke's formulas in patients with burn trauma.

Methods: A retrospective cohort study was conducted through a chart review of patients admitted to the burn unit. The patients were divided into two groups: Group 1 (2017-2019) was resuscitated using Parkland's formula and Group 2 (2020-2022) with modified Brooke's formula. The main outcome measures were mortality rate, length of stay, complication rate exceeding the Ivy index (250 mL/kg) in the first 24 h, and overall fluid administered in the first 24 h.

Results: We included 125 patients, of whom fifty-five were resuscitated using Parkland's formula and seventy using the modified Brooke's formula. Patients in group 1 had higher resuscitation volume (5.04 vs. 3.37 mL/kg/total body surface area, P < 0.0001) and were more likely to exceed the Ivy index (250 mL/kg) (32.73% vs. 12.86%, P = 0.0074) in the first 24 h compared to those in group 2. There were no significant differences in clinical outcomes between the two groups.

Conclusions: The modified Brooke's formula resulted in lower resuscitative volumes in the first 24 h than Parkland's formula, with no differences in complication rates. Our findings are consistent with currently recommended guidelines.

Traction tables have been widely used by orthopaedic surgeons for the management of femoral shaft fractures. Although complications associated with their use are uncommon, they can still occur. Among neurological complications, sciatic and pudendal nerve palsies are the most frequently reported. Recognizing the potential causes and analyzing these complications are crucial for raising awareness among surgeons and implementing preventive strategies to enhance patient safety during surgical procedures. A 22-year-old male sustained a comminuted fracture of the left femoral shaft following a road traffic accident. The patient had an intact distal neurovascular status (DNVS) at presentation. Open reduction and internal fixation (ORIF) with femoral interlocking nail (FIN) was done using a traction table. Post-operatively, he developed signs of both sciatic and pudendal nerve palsy. The simultaneous occurrence of pudendal and sciatic nerve palsy is rare. In this case, pudendal nerve palsy was likely caused by prolonged traction with sustained hip adduction throughout the procedure, while sciatic nerve palsy was attributed to postoperative hematoma formation. To minimize such complications, it is advisable to limit soft tissue dissection during femoral shaft fracture reduction and promptly release traction after interlocking screw placement. Additionally, adherence to a "tourniquet safety protocol" that is, releasing traction every 120 minutes in prolonged surgeries can be beneficial. Hip adduction beyond the neutral position should also be avoided to reduce the risk of nerve injury.