Journal of trauma management & outcomes最新文献

Background: A significant proportion of patients admitted to hospital with multiple traumas exhibit facial injuries. The aim of this study is to evaluate the incidence and cause of facial injuries in severely injured patients and to examine the role of plastic and maxillofacial surgeons in treatment of this patient collective.

Methods: A total of 67 patients, who were assigned to our trauma room with maxillofacial injuries between January 2009 and December 2010, were enrolled in the present study and evaluated.

Results: The majority of the patients were male (82 %) with a mean age of 44 years. The predominant mechanism of injury was fall from lower levels (<5 m) and occurred in 25 (37 %) cases. The median ISS was 25, with intracranial bleeding found as the most common concomitant injury in 48 cases (72 %). Thirty-one patients (46 %) required interdisciplinary management in the trauma room; maxillofacial surgeons were involved in 27 cases. A total of 35 (52 %) patients were treated surgically, 7 in emergency surgery, thereof.

Conclusion: Maxillofacial injuries are often associated with a risk of other serious concomitant injuries, in particular traumatic brain injuries. Even though emergency operations are only necessary in rare cases, diagnosis and treatment of such concomitant injuries have the potential to be overlooked or delayed in severely injured patients.

Background: Severe trauma to the extremities often includes a combination of fractures and soft tissue injuries. Several publications support that the patient outcome is better when skeletal stabilization is followed by early soft-tissue coverage. In an effort to optimize the treatment of these patients, we established a formalized collaboration in 2008 between the Departments of reconstructive plastic surgery and orthopedics at the Karolinska University Hospital.

Methods: A retrospective review was conducted for all patients who had suffered severe extremity trauma and received either a free or a pedicled flap for extremity reconstruction. We compared the management of patients 0-4 years before and 0-4 years after the collaboration started especially with respect to; choice of flap, time to flap coverage, number of operations/revisions, total in-hospital stay.

Results: After initiation of the collaboration, the number of flaps increased from 13 flaps (5 free and 8 pedicled) to 44 flaps (21 free and 23 pedicled). Fewer postoperative revisions was seen, as well as shorter in-hospital stay.

Conclusions: The present study highlights the importance of formalized collaboration between orthopedic and plastic surgeons in severe extremity trauma patients. The concept of an interdisciplinary approach has led to an increased number of trauma patients referred for plastic surgical consultation, an increased number of flaps, fewer postoperative revisions and shorter hospital stay.

Background: Lower cranial nerve (IX-XII) palsy is a rare condition with numerous causes, usually non-traumatic. In the literature it has been described only a few times after trauma, mostly accompanied by a fracture of the occipital condyle. Although these types of fractures have rarely been reported one could suspect they have been under-diagnosed. During the past decade they have been seen more frequently, most probably due to increased use of CT- and MRI-scanning. The purpose of this review is to increase the awareness of complications following injuries in the craniocervical region.

Methods: We based this article on a retrospective review of the medical record of a 24-year old woman admitted to our trauma center after being involved in a car accident and a review of the literature on occipital condyle fractures associated with lower cranial nerve palsy.

Results: The multitraumatized patient had suffered a dislocated occipital condyle fracture. Months later she was diagnosed with palsy to cranial nerve IX-XII. Literature review shows that occipital condyle fractures are rare as isolated injuries and are in many cases accompanied by further injuries to the cervical spine and soft tissue structures, in many cases ending with severe disability. The exact mechanism leading to these injuries cannot always be explained.

Conclusion: Recognition of soft tissue injuries in patients with blunt head trauma is important. CT findings involving the craniocervical junction in these patients advocates further investigations including a thorough neurological examination and liberal use of MRI.

Background: The increasing use of computed tomography (CT) scans in the evaluation of trauma patients has led to increased detection of incidental radiologic findings. Incidental findings (IFs) of the abdominal viscera are among the most commonly discovered lesions and can carry a risk of malignancy. Despite this, patient notification regarding these findings is often inadequate.

Methods: We identified patients who underwent abdominopelvic CTs as part of their trauma evaluation during a recent 1-year period (9/2011-8/2012). Patients with IFs of the kidneys, liver, adrenal glands, pancreas and/or ovaries had their charts reviewed for documentation of the lesion in their discharge paperwork or follow-up. A quality improvement project was initiated where patients with abdominal IFs were verbally informed of the finding, it was noted on their discharge summary and/or were referred to specialists for evaluation. Nine months after the implementation of the IF protocol, a second chart review was performed to determine if the rate of patient notification improved.

Results: Of 1,117 trauma patients undergoing abdominopelvic CT scans during the 21 month study period, 239 patients (21.4%) had 292 incidental abdominal findings. Renal lesions were the most common (146 patients, 13% of all patients) followed by hepatic (95/8.4%) and adrenal (38/3.4%) lesions. Pancreatic (10/0.9%) and ovarian lesions (3/0.3%) were uncommon. Post-IF protocol implementation patient notification regarding IFs improved by over 80% (32.4% vs. 17.7% pre-protocol, p = 0.02).

Conclusion: IFs of the solid abdominal organs are common in trauma patients undergoing abdominopelvic CT scan. Patient notification regarding these lesions is often inadequate. A systematic approach to the documentation and evaluation of incidental radiologic findings can significantly improve the rate of patient notification.

Background: About 10% of adult patients in high-energy trauma sustain multiple rib fractures. Some of these patients suffer from flail chest leading to respiratory insufficiency. During last years interest and results for operative treatment has improved. The literature today all show positive results for surgical versus conservative treatment, specifically with regard to time spent in mechanical ventilator, complication rates and length of hospital stay.

Methods: Between September 2010 and July 2012, 60 patients with flail chest or multiple rib-fractures resulting in unstable thoracic cage were operated. 16 women and 44 men with an age between 19-86 years (mean 57). We used modern fracture techniques with plates and intramedullary splint. Thoracotomy was performed and lung lacerations were debrided (11/60). Time spent in ventilator, complications and other adverse effects was studied. The operated cohort was compared to results from six previous years, when none was operated for that diagnose (153 patients).

Results: There is a significant correlation between Injury Severity Score (ISS) and time spent in ventilator both for patients operated and not operated (p< 0,01). The mean time in ventilator was 9,01 days for not operated patients compared to 2,7 for the operated (p<0,0001). No clear pneumonias were found. We had two deaths during the acute period. The infection rate was low.

Conclusions: Open reduction and internal fixation is a safe method to treat the unstable thoracic cage with multiple rib fractures and flail chest. Complication are few. The treatment time in mechanical ventilator is significant decreased. The operative treatment is probably cost effective and can be recommended. Knowledge in thoracic surgery and modern fracture surgery is needed. This is a therapeutic consecutive, level III, cohort study with historical controls.

Background: Mallet finger injuries are usually successfully treated non-operatively with a splint. Most patients are reviewed at least twice in a clinic after the initial presentation in A&E. A new protocol promoting "self-care" was introduced at our institution. Patients were provided with structured verbal and written information, and given access to a telephone helpline.

Methods: A prospective electronic patient record was used to identify all patients who presented to the emergency department with a mallet finger with a minimum six month follow-up. A satisfaction and patient reported outcome measure was administered via a postal questionnaire. The response rate was 36/47 (77%).

Results: The median QuickDASH score was 2.3 (IQR 0 to 4.6). All patients were satisfied with the treatment plan provided. Nine used the helpline and all were satisfied with information given. Although 13 patients reported some extensor lag, or bump, they had no functional limitation. Seven patients were reviewed by the general practitioner or other clinicians during their treatment period for issues such a skin care, splint size changes or sickness certification. Five were subsequently reviewed at the end of their treatment period in a clinic at their request, or their general practitioner, but did not require further surgical intervention.

Conclusions: Self-care for mallet finger injuries, with adequate patient information and telephone back-up, leads to acceptable functional results and satisfaction.

Level of evidence: III.

Background: Although extensive research for the optimal treatment of clavicle fractures has been performed, comparative studies between monotrauma and polytrauma patients are lacking.

Objective: To compare fracture distribution and treatment in monotrauma and polytrauma patients with a clavicle fracture.

Methods: Single center retrospective cohort study. Fractures were classified by the Robinson classification. Monotrauma patients sustained only a clavicle fracture or a clavicle fracture plus a minor abrasion, hematoma, or superficial skin lesion leading to an Injury Severity Score (ISS) of 4 or 5 respectively. Polytrauma patients had an ISS ≥16 as a result of injury in 2 or more Abbreviated Injury Scale (AIS) regions.

Results: 154 monotrauma and 155 polytrauma patients with a clavicle fracture were identified. Monotrauma patients had a higher incidence of Type IIB fractures (displaced midshaft) compared to polytrauma patients (P = 0.002). No difference was observed regarding Type I (medial) and Type III (lateral) fractures. In monotrauma patients, Type IIB fractures were treated operatively more frequently (P = 0.004). The initial treatment for Type I and Type III fractures did not differ between monotrauma and polytrauma patients.

Conclusions: Monotrauma patients had a higher incidence of displaced midshaft clavicle fractures compared to polytrauma patients, and monotrauma patients with displaced midshaft clavicle fractures were treated operatively more frequently. No differences were found in the distribution and treatment of medial and lateral clavicle fractures.

We describe two cases of intravascular embolization of shotgun pellets found distant to the entry site of penetrating firearm injury. The cases demonstrate antegrade embolization of a shotgun pellet from neck to right middle cerebral artery, and antegrade followed by retrograde venous embolization through the left lower limb to pelvis. Radiologists and Trauma Physicians should be aware that post shotgun injury, the likelihood of an embolised shot pellet is increased compared to other types of firearm missile injury, and should therefore search away from the site of injury to find such missiles. Shotgun pellets may travel in an antegrade or a retrograde intravascular direction - both were seen in these cases - and may not be clinically obvious. This underscores the importance of a meticuluous search through all images, including CT scout images, for evidence of their presence.

Introduction: Hepatic pseudoaneurysm (HPA) is a rare complication after liver trauma, yet it is potentially fatal, as it can lead to sudden severe haemorrhage. The risk of developing posttraumatic HPA is one of the arguments for performing follow-up CT of patients with liver injuries. The aim of this study was to investigate the occurrence of HPA post liver trauma.

Methods: A retrospective study from 2000-2010 of conservatively treated patients with blunt liver trauma was performed to investigate the incidence and nature of HPA. After the initial CT scan patients were admitted to the department and if not clinically indicated prior a follow-up CT was performed on day 4-5.

Results: A total of 259 non-operatively managed patients with liver injury were reviewed. 188 had a follow-up CT or US and in 7 patients a HPA was diagnosed. All aneurysms were treated with angiographic embolization and there were no treatment failures. There was no correlation between the severity of the liver injury and development of HPA. 5 out of 7 patients were asymptomatic and would have been discharged without treatment if the protocol did not include a default follow-up CT.

Conclusions: In conclusion, this study shows that HPA is not correlated to the severity of liver injury and it develops in 4% of patients after traumatic liver injury. In order to avoid potentially life-threatening haemorrhage from a post trauma hepatic pseudoaneurysm, it seems appropriate to do follow-up CT as part of the conservative management of blunt and penetrating liver injuries.

Background: Scapula fractures with injuries of the Superior Shoulder Suspensory Complex are often referred to as floating shoulders. However, present studies do not allow comparative evidence on indication for surgical treatment mostly due to the lack of precise definitions and comparable classifications. The aim of this study was to retrospectively analyze common types of complex shoulder injuries and develop a feasible classification allowing a therapeutic algorithm.

Methods: The study group consisted of 107 patients with scapula fractures combined with ipsilateral injuries of the shoulder girdle treated in a single trauma center between 2003 and 2010. Three-dimensional computed tomography was analyzed for dislocation and instability and assigned to subgroups of a defined classification system. Clinical data was acquired from a previously established database of all patients treated for the diagnosis of a scapula fracture.

Results: Fifty-seven of 107 (53.3%) complex scapula fractures were non-displaced and stable representing Type A fractures. Depending on the fracture pattern, three subgroups were defined. Treatment of Type A injuries should be non-operative. Displaced fractures of the scapula with a stable shoulder girdle were considered Type B injuries and represented 18.7% of all fractures. Thirty fractures (28%) with an unstable shoulder girdle were classified as Type C injuries. Again, subgroups with common injury patterns were identified. For both groups, operative treatment is recommended.

Conclusions: The described classification system is a proposal able to categorize complex shoulder injuries and allows a comparison of injury patterns in further studies.