Spinal trauma

In the workup of patients suffering from spinal trauma the radiologist is eager to make a proper diagnosis asking only for few additional examinations. This can be done by a functional and biomechanical approach in reading standard radiographs. With the knowledge of the kind of injury expected the whole extent of posttraumatic changes in the spine can be delineated exactly. The goal is to make a diagnosis that answers questions of stability so the traumatologist can be aided in therapy.     

Geriatric trauma

This article reviews the salient aspects of geriatric trauma, including common injury mechanisms, physiologic differences in elderly patients, and their prehospital and emergency department evaluation. Specific organ injuries and associated mortality are also discussed.     

Pediatric trauma

Trauma is the leading cause of death in infants and children. Caring for the pediatric trauma victim requires a systematic approach which utilizes an understanding of the anatomic and pathophysiologic characteristics that make children different from adults. Child abuse frequently presents as trauma, making a high index of suspicion for mechanism and severity of injury an important component of trauma assessment. A basic approach to managing pediatric trauma with emphasis on initial stabilization is presented, followed by discussion of specific areas including head and neck trauma, chest trauma, abdominal trauma, and extremity trauma.     

Thoracic trauma

Blunt chest trauma is the leading cause of thoracic injuries in Germany, penetrating chest injuries are rare. Hereby, single or multiple rib fractures, hemato-pneumothorax and pulmonary contusion represent the most common injuries. The early management of thoracic injuries consists of detection and sufficient therapy of acute life threatening situations like tension pneumothorax, acute respiratory insufficiency or severe intrathoracic bleeding. Most of the isolated thoracic injuries are adequately treated by conservative means, sufficient analgesia, drainage of intrapleural air or blood, physiotherapy and clearance of bronchial secretions provided; operative intervention is rarely indicated. In multiple injured patients however, severe blunt chest trauma and especially pulmonary contusion negatively affects outcome with a significant increase of morbidity and mortality. Hence, patients with this combination of pulmonary injuries, such as lung contusion and associated severe injuries, carry a particular high risk of respiratory failure, ARDS and MOF with a considerable mortality. Therefore, early exact diagnosis of all thoracic injuries is essential and can be achieved by thoracic computed tomography, which becomes more and more popular in this setting. Early intubation and PEEP-ventilation, alternate prone and supine positioning of multiple injured patients with lung contusion and differentiated concepts of volume- and catecholamine therapy represent the basic therapeutic principles. Additionally, the entire early trauma management of multiple injured patients must focus on the presence of pulmonary contusion. Every additional burden on their pulmonary microvascular system like microembolisation during femoral nailing, the trauma burden of extended surgery or mediator release in septic states may cause rapid decompensation and organ failure and therefore, has to be avoided.     

Multiorgan trauma

A case is presented of a patient with multiorgan trauma. The main diagnostic problem was coexisting haemorrhage. Curable skin defects were healed after several covering them with intermediate thickness mesh grafts. The postoperative course was complicated with sepsis and acute non-inflammatory renal failure with polyuria.     

Head trauma

Progress in research includes studies concerning the pathophysiology and outcome of pediatric head injury, the pathology of the hippocampus in fatal injury, and the use of multivariate statistics to predict outcome in survivors. Recent research has confirmed and extended findings regarding the differential effects of closed head injury, depending on the age of the individual. These studies indicate that the consequences of head injury are more severe in older adults and in children younger than 2 years. Neuroimaging findings include evidence for delayed brain injury as a major cause of mortality and disability. Functional brain imaging provides evidence for cerebral dysfunction that is not appreciated by structural brain imaging techniques and may have a stronger relationship to neurobehavioral sequelae. The neurobehavioral sequelae frequently implicate frontal dysfunction, even in the absence of structural findings on computed tomography or magnetic resonance imaging. Studies of mild head injury have expanded our knowledge concerning the pathogenesis of postconcussional symptoms, including a preinjury vulnerability based on recent life events. Persistent postconcussional symptoms after mild head injury are frequently associated with emotional disturbance of clinical proportions.     

Orbital trauma

To study factors influencing the distribution of local anaesthetics in the subarachnoid space, an in vitro model is constructed which takes into account the natural curvature of the spinal column and the volume occupation of spinal cord and nerve fibres to resemble the in vivo situation. Three Marcaine solutions of different baricity (1003, 1008, 1030 kg/m3) are injected with a 22 G, a 27 G Quincke point needle and a 18 G multiport catheter into three models of non-pathological spinal columns with injection flow speeds of 0.6, 0.2 or 0.1 ml/s. Methylene blue is added for visual and qualitative assessment of drug distribution. Baricity is the main actor in the spreading of the drug solution. For all other variables, no significant difference is found after ten minutes, though the initial distribution may differ according to the geometry used. A hypobaric solution yields a remarked difference between fast and slower injections. The position of the catheter should be controlled.     

Congenital esophageal stenosis presenting as noncardiac, esophageal chest pain

A case of a 31-year-old female with congenital esophageal stenosis presenting with symptoms of chest pain caused by esophageal dysmotility is described. The involved segment in congenital esophageal stenosis has a characteristic thickening of the muscularis propria layer, as seen by EUS examination. In these patients, symptoms of dysphagia can be managed with esophageal dilation and noncardiac esophageal chest pain responds to pharmacotherapy with diltiazem.     

Congenital esophageal stenosis

Congenital esophageal stenosis caused by membranous webs occurred in three infants. There were no associated anomalies. First patient applied with respiratory symptoms while the second and third patients reported food impactions. Correct diagnosis was performed during intraoperative (first patient) and esophagoscopic examination (second and third patients). Resection and anastomosis were performed in the first patient and hydrostatic dilatations in the second and third patients. In three patients, symptoms were relieved following treatment. In this report, etiology, diagnostic aids and management of this rare pathology are discussed.     

Primary esophageal melanoma

Three cases of cartilaginous choristomas of the tongue are presented. Two lesions occurred in women of 71 and 28 years of age whose lesions were located in the middle third of the dorsum. The other lesion was found on the left lateral border in a 27-year-old man. The clinical, microscopic and immunohistochemical features are described. The lesions were easily excised with no recurrence after follow-up periods of at least 6 months. The histogenesis and the differential diagnosis are discussed, and the literature is reviewed.     

Congenital esophageal webs

Modern intracavitary brachytherapy carefully combined with megavoltage external beam radiotherapy is responsible for the high cure rates achieved with radiation treatment of invasive cervical cancers. Pelvic disease recurrence is rare after treatment of patients with tumors < 5 cm in diameter, and even patients with massive tumors 8-10 cm in diameter are cured in 30-50% of cases. Inoperable adenocarcinomas of the endometrium and superficial cancers of the vagina are also effectively treated with intracavitary irradiation. The relative radioresistance of the uterus and vagina, physical advantages resulting from exploitation of the inverse square law, and the radiobiological advantages of low dose rate radiation have combined to make intracavitary irradiation a critical tool in the management of many gynecologic neoplasms.     

Penetrating chest trauma

This article reviews the current concepts in penetrating chest trauma. The authors discuss mechanisms of injury, nursing assessment, and interventions for penetrating injuries resulting in cardiac rupture, cardiac tamponade, tension pneumothorax, hemothorax, great vessel injury, and sucking chest wounds.