Changes in cardiac output do not explain the higher rate of myocardial infarction associated with the use of bilevel compared with continuous positive airway pressure

A case of vaginal evisceration resulting from sliding on a water chute is described. The treatment and mechanism of this rare injury are discussed.     

Lateral distraction injury to the lumbar spine. Report of spontaneous reduction

STUDY DESIGN: A patient with a lateral distraction injury of the lumbar spine that reduced spontaneously and not associated with any thoracic or abdominal injury is reported. SUMMARY OF BACKGROUND DATA: A brief summary of the clinical presentation is given as is the surgical technique employed. Lateral distraction injuries of the thoracolumbar spine associate a distraction injury with lateral bending in the frontal plane, causing unilateral disruption of the ligamentous and osseous restraints. The have been associated with life-threatening thoracic and abdominal injuries. Closed reduction of this spine injury is not believed to be feasible. CONCLUSIONS: This case introduces interesting new features to this spine lesion. It is the first reported case with documented spontaneous reduction.     

Spectrum of roller-blading injuries

We studied 32 patients who presented to the Accident and Emergency Department of Toa Payoh Hospital with injuries sustained while roller-blading (in-line roller skating). This sporting activity carries risk of injuries, often fractures, due to 3 principal mechanisms of injury. The first and main mechanism of injury is that of a forward fall with the arms outstretched as a protective gesture. This is associated with fractures of the distal radius in the majority of cases, although other injuries to the upper limb can occur. The second important mechanism is that of a backward fall with resulting injury to the back of the head. Lastly, the patient may fall sideways, often together with a twisting force to the lower limbs, resulting in ankle sprains and meniscus injuries to the knee. The vast majority of patients are young teenagers who are beginners and had not been properly clad in protective gear. Roller-blading therefore carries a very real risk of sporting injury.     

The non-operative management of collateral ligament injuries of the knee joint

Severe knee ligament injuries are frequently underestimated, and this results in later problems of chronic instability. A history of an appropriate mechanism coupled with immediate reduction in function should arouse suspicion of a major disruption. Examination with the patient under anesthesia may be required to assess the extent of the injury. If the lesion is an isolated collateral tear, the intact cruciate ligaments prevent wide displacement. Such an injury can be managed non-operatively. A long leg plaster at 90 degrees for 2 weeks followed by 4 weeks in a cast brace with motion from 45 degrees to 100 degrees is recommended. The knee is then protected in a brace during athletic activities for approximately 6 months. Thirty collateral ligament tears have been managed in this fashion. Only one has significant residual complaints. It is emphasized that an isolated collateral ligament tear is a positive diagnosis, and associated cruciate lesions must be ruled out. The recovery is faster in those patients managed non-operatively than in those who have surgical repair. There has not been a problem with late instability.     

Hypoglossal nerve injury caused by halo-suspension traction. A case report

STUDY DESIGN: A case report of injury to the hypoglossal nerve (CN XII) resulting from the use of halogravity traction in a child with severe cervicothoracic kyphosis after an anterior and posterior spinal release. OBJECTIVE: To describe one of the potential dangers of halo-suspension (gravity) traction, which has not been reported previously in the orthopedic literature. SUMMARY OF BACKGROUND DATA: Cranial nerve injuries resulting from halo-skeletal traction are a recognized complication of such treatment, especially in patients with myelomeningocele. Halo-suspension traction using the patient's body weight as counter-traction has been recommended to provide a less rigid force and to reduce complications. METHODS: The authors report on the mechanism of injury and clinical course in a 12-year-old boy with myelomeningocele and a bilateral CN XII injury caused by halo-suspension traction from onset to resolution. RESULTS: This patient had dysphagia and difficulty swallowing 5 days after surgery. His wheelchair traction at this point was approximately 40% of his body weight. The traction was reduced, and a corticosteroid was administered. The patient's symptoms began to abate 5 days later. At 6 weeks after injury, his cranial nerve function was normal. CONCLUSIONS: Although halo-suspension traction or halo-wheelchair traction may be less rigid, injury to the hypoglossal nerve can be produced with traction exceeding 40% of body weight. In the patient in the current report, resolution of this injury was complete within 5 weeks, an outcome that is consistent with those of other reported cases of CN XII injury.     

Defective gas mixers, a cause of retro-pollution of medical gas distribution pipelines]

PURPOSE: To study the distribution and mechanism of traumatic injuries to the nerves supplying the eye and muscles protecting the visual apparatus. METHODS: Brain autopsy was carried out in 12 consecutive patients who died within three days after closed head injury. A segment of the brainstem with the entire intracranial portion of nerves II-VII was dissected out in each case and fixed in formalin. The specimens were stripped of the leptomeninges and inspected thoroughly under magnification. RESULTS: Injuries to the nerves were seen in nine subjects. The oculomotor nerve was completely torn off from the midbrain unilaterally in three and bilaterally in two cases. In one patient only a portion of the superficial fibres on the medial aspect of the nerve was ripped out from the brainstem. In two patients the fourth nerve was ruptured. The root of the fifth cranial nerve was contused and the fibres between the brainstem and Gasserian ganglion crushed and separated in one case. Bilateral avulsion of the root of the sixth nerve from the brainstem was found in two cases. The initial segment of the facial nerve was crushed in two subjects. No visible injury to the optic nerves was found. CONCLUSIONS: Cranial nerves related to the visual system are subject to serious injury in a large proportion of cases of severe head trauma resulting from automobile accidents. In the majority of cases damage results from ripping the roots of these nerves out of the brainstem.     

Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma

BACKGROUND: As nonoperative management of blunt abdominal trauma has become more popular, reliable models for predicting the likelihood of concomitant hollow viscus injury in the hemodynamically stable patient with a solid viscus injury are increasingly important. METHODS: The Pennsylvania Trauma Systems Foundation registry was reviewed for the period from January 1992 to December 1995 for all adult (age > 12 years) patients with blunt trauma and an Abbreviated Injury Scale (AIS) score > or = 2 for a solid viscus (kidney, liver, pancreas, spleen). Patients with an initial systolic blood pressure < 90 mm Hg were excluded. Hollow viscus injuries included only lacerations or perforations of the gallbladder, gastrointestinal tract, or urinary tract. RESULTS: In the 4-year period, 3,089 patients sustained solid viscus injuries, 296 of whom had a hollow viscus injury (9.6%). The mean age was 35.6 years, mean Injury Severity Score was 22.2, and mean Revised Trauma Score was 7.3; 63.3% of the patients were male. A solitary solid viscus injury occurred in 2,437 patients (79%), 177 of whom (7.3%) had a hollow viscus injury. The frequency of hollow viscus injury increased with the number of solid organs injured: 15.4% of patients with two solid viscus injuries (n = 547) and 34.4% of patients with three solid viscus injuries (n = 96) suffered a concomitant hollow viscus injury (p < 0.001 vs. one organ). A hollow viscus injury was 2.3 times more likely for two solid viscus injuries and 6.7 times more likely for three solid viscus injuries compared with a solitary solid viscus injury. For solitary solid viscus injury, the frequency of hollow viscus injury varied little with increasing AIS score (AIS score 2, 6.6%; AIS score 3, 8.2%; AIS score 4, 9.2%; AIS score 5, 6.2%) (p = 0.27 between groups), suggesting that the incidence of hollow viscus injury is related more to the number of solid visceral injuries than the severity of individual organ injury. Also, when the sum of the AIS scores for solid viscus injuries was <6, the mean rate of hollow viscus injury was 7.8%. This increased to 22.8% when the sum of the AIS scores for solid viscus injury was > or =6 (p < 0.001). A pancreatic injury in combination with any other solid viscus injury had a rate of hollow viscus injury of >33%. CONCLUSION: A model of organ injury scaling predicted hollow viscus injury. Multiple solid viscus injuries, particularly pancreatic, or abdominal solid viscus injuries with an AIS score > or = 6, were predictive of hollow viscus injury. Identification of these injury patterns should prompt consideration for early operative intervention.     

Occult Boerhaave''s syndrome without vomiting prior to presentation. Report of a case

PURPOSE: Cougar attacks on humans appear to be on the rise. A review of all attacks on children was performed to determine the method of attack and injury patterns so that a treatment regimen as well as possible preventative measures could be determined. METHODS: A review of all attacks, including attacks on children, was performed, including three recent attacks treated at our institution. Situation, adult supervision, patient age, injuries recorded, survival, and mode of attack, if known, were reviewed. RESULTS: There were 50 documented attacks on children with a 25% fatality rate. Most children were not alone at the time of the attack (92%), and in many instances adult supervision was present or nearby. Severe head and neck lacerations along with puncture wounds were the most common injury. Examples of typical cervical injuries include a nonfatal vertebral artery injury, phrenic nerve injury, a fatal internal carotid artery injury, and a fatal cervical spine injury. The cougar was rabid in two cases. Pasteurella resulted in late infections in two patients. CONCLUSIONS: Based on the pattern of injuries, the authors recommend aggressive evaluation for occult cervical injuries as well as surgical debridement. Antibiotics should cover oropharyngeal flora including Pasteurella multocida. Rabies prophylaxis is indicated. Adult supervision in wilderness areas is not necessarily protective.     

Genitourinary trauma in the pediatric patient

Trauma is the major source of mortality in the pediatric population. A retrospective review was performed on patients admitted to the Children's Hospital and Health Center Trauma Program, San Diego, California, from August 1984 to May 1990. The purpose of this review was to evaluate pediatric trauma and to determine the best treatment and evaluation for genitourinary injuries. Blunt trauma was responsible for 98 percent of the injuries, with renal injuries being the most common. Bladder (7) and male urethral (2) injuries, and vaginal lacerations (8) also occurred. The most severe renal injuries (70%) and all significant bladder and urethral injuries were associated with gross hematuria. Hypotension was present in 31 percent of patients but rarely required surgical exploration for correction. Eighty-six patients underwent radiographic imaging. Computerized tomography (CT) scans demonstrated the most information about intra-abdominal solid organ injuries but was inaccurate in detecting bladder or urethral injuries. Genitourinary injury is common in children but rarely requires surgical management. CT scan is the best study to determine extent of solid-organ injury but is inferior to cystourethrography to diagnose bladder or urethral injuries.     

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery

OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.     

Is there a classification of pelvic ring injuries, which takes the trauma mechanism, morphology and stability relations into consideration and thereby gives references for subsequent therapy?

In contrast to earlier classifications, Tile's classification of pelvic ring disruptions considers mechanism of injury, clinical and x-ray evaluations and is therefore almost universally accepted. We propose a more comprehensive classification which gives a guide for treatment of these complex injuries. Moreover it can be used to compare results from different authors. We classify types A-D pelvic injuries according to stability. Type A consists of fractures of the pelvis not involving the ring, type B of stable rotational injuries. Type C and D encompass the unstabile injuries: C is purely rotational and D has a combined rotational and vertical instability. The location of injury is indicated by adding numbers 1-9 (1: rupture of symphysis pubis; 2: transpubic fracture; 3: acetabular fracture; 4: iliac wing fracture; 5: sacroiliac fracture-dislocation; 6: sacroiliac disruption; 7: sacral wing fracture; 8: transforaminal sacral fracture; 9: central sacral fracture). These numbers are arranged in increasing order, one hemipelvis after the other. Thus, in case of a complex pelvic injury with rotational instability on one side and vertical instability on the other each hemipelvis may be classified separately.     

A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group

PURPOSE: To develop a classification system for mechanical injuries of the eye. METHODS: The Ocular Trauma Classification Group, a committee of 13 ophthalmologists from seven separate institutions, was organized to discuss the standardization of ocular trauma classification. To develop the classification system, the group reviewed trauma classification systems in ophthalmology and general medicine and, in detail, reports on the characteristics and outcomes of eye trauma, then established a classification system based on standard terminology and features of eye injuries at initial examination that have demonstrated prognostic significance. RESULTS: This system classifies both open-globe and closed-globe injuries according to four separate variables: type of injury, based on the mechanism of injury; grade of injury, defined by visual acuity in the injured eye at initial examination; pupil, defined as the presence or absence of a relative afferent pupillary defect in the injured eye; and zone of injury, based on the anteroposterior extent of the injury. This system is designed to be used by ophthalmologists and nonophthalmologists who care for patients or conduct research on ocular injuries. An ocular injury is classified during the initial examination or at the time of the primary surgical intervention and does not require extraordinary testing. CONCLUSIONS: This classification system will categorize ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research stud ies regarding eye injuries.     

Delayed diagnosis of thoracolumbar fractures in multiple-trauma patients

OBJECTIVES: To determine the frequency of delayed diagnosis of major thoracolumbar vertebral fractures (T-L Fxs) in ED multiple-trauma patients, and to determine the differences between cases of delayed and nondelayed diagnoses of T-L Fx. METHODS: A retrospective chart review was conducted of 181 trauma patients with 310 major T-L Fxs (compression, burst, or chance Fxs or dislocations). Data collected included the time of the diagnosis of T-L Fx, the patient's clinical presentation in the ED, the mechanism of injury, and the outcome. RESULTS: Of the 181 patients with major T-L Fxs, 138 were diagnosed in the ED (nondelayed group), and 43 were diagnosed after the patient left the ED (delayed group). Of these, 33 cases occurred in unstable patients requiring emergent medical imaging and/or operation, 7 occurred when emergency physicians failed to detect subtle compression Fxs on ED radiographs, and 3 occurred in stable patients who were not radiographed in the ED. The delayed group were more often critical, and hypotensive, and had lower Glasgow Coma Scale (GCS) scores than did the nondelayed group. The delayed group patients also had more cervical spine injuries, multiple noncontiguous spinal Fxs, high-energy mechanisms of injury, and direct blunt assaults to the back than did the nondelayed group patients. There were 13 patients with T-L Fxs, GCS scores = 15, and normal back examinations. There were 43 patients who had neurologic deficits associated with their injuries; 11 patients with incomplete cord lesions progressed, including 3 in the delayed group. CONCLUSIONS: A delay in the diagnosis of T-L Fx in hospitalized trauma patients is frequently associated with an unstable patient condition that necessitates higher-priority procedures than ED T-L spine radiographs. Such patients should receive spinal precautions until more complete evaluation can be performed. The decision to selectively radiograph T-L spines in multiple-trauma patients should consider the mechanism of injury, the presence of possible confounders to physical examination, and clinical signs and symptoms of back injury.     

Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world

Prolonged obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by prolonged obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a medical or a social standpoint.     

Laparoscopy-assisted and -prepared hysterectomy. A series of 80 cases

OBJECTIVE: Our objective was to determine the interest of laparoscopic assisted vaginal hysterectomy. STUDY DESIGN: Between January 1991 to december 1994, 80 patients had laparoscopically assisted vaginal hysterectomy. We reviewed with particular emphasis characteristic indications, complications. RESULTS: Eighty were performed as laparoscopically assisted vaginal hysterectomy. 14 patients (17.5%) had laparotomy conversion; because of size of uterus in 3 cases, suspected ovarian tumor in 3 cases. Pelvic adherences in 4 cases, urinary tract injuries in 1 case, hypercapnia in 1 case, hemorrhage in 2 cases. 9 patients experienced febrile morbidity and 1 urinary infection. 1 patient received 2 units of packed red blood cells. The hospital stay was 5 days for laparoscopically assisted vaginal hysterectomy versus 5.9 for laparotomic hysterectomy. CONCLUSION: Laparoscopically assisted vaginal hysterectomy offers a technique to convert certain abdominal hysterectomies into vaginal hysterectomies with a 17.5% laparoconversion rate.     

Bilateral first rib fractures associated with driver's air bag inflation: case report and implications for surgery

A case of bilateral fractures of the first rib occurring in an otherwise fit road traffic accident victim is described. The only other injuries sustained were of the peripheral limbs. The driver's air bag was inflated during the crash, leading to speculation as to whether this may have contributed to the mechanism of injury. The patient was well oxygenated and cardiovascularly stable with no evidence of neurovascular damage to the thoracic aorta or its branches. Aortic arch aortography was not performed before internal fixation of the peripheral fractures was undertaken under general anaesthesia. A review of the indications for angiography in such patients follows. The policy that patients with fractures of the upper first ribs do not require angiography unless there is other evidence of neurovascular damage is supported.     

Expert assessment of coital injuries from the forensic medicine viewpoint

A 38-year-old woman was transmitted to hospital with profuse vaginal bleeding. The origin of the vaginal injuries (resulting from "normal" sexual intercourse vs. use of instruments for manipulation in the vagina) was obscure. The wound pattern is presented and the literature on the subject is reviewed with special reference to predisposing factors and genesis of coital injuries. Concerning the wound pattern, reflecting a blunt trauma, a manipulation with a (so far unknown) instrument, but also with finger or hand could not be proved with the required certainty. In the presented case the origin of the vaginal injuries from "normal" sexual intercourse as described by the accused man could not be excluded.     

Sprained ankle syndrome: prevalence and analysis of 639 acute injuries

OBJECTIVE: To document injury rates in professional rugby players in the Rugby Super 12 competition and to act as a pilot study for future studies of rugby injuries. DESIGN: Prospective longitudinal study encompassing the 1997 Super 12 rugby season. SETTING: A New Zealand Super 12 rugby squad. PATIENTS AND PARTICIPANTS: 25 professional rugby players (replacement players were used for unavailable players, so although 30 different players were used during the season, there were only 25 in the squad at any one time). OUTCOME MEASURES: An "injury" was defined as something that prevented a player from taking part in two training sessions, from playing the next week, or something requiring special medical treatment (suturing or special investigations). An injury was "significant" if it prevented the player from being able to play one week after sustaining it (that is, if it made the player miss the next match). RESULTS: The overall injury rate was 120/1000 player hours. The rate of significant injuries was 45/1000 player hours. Those playing the position of "forward" had a higher overall injury rate than other players, but there was no difference in significant injury rate between the forwards and the backs. Injuries that caused players to miss game time occurred almost exclusively during the pre-season program or in the final third of the season. The majority of injuries were musculo-tendinous sprains or strains. The phase of play responsible for the majority of injuries was the tackle. The most frequently injured body part was the head and face. No catastrophic injuries occurred during the study period. CONCLUSIONS: Injury rates increase with increasing grade of rugby, injury rates in the Super 12 competition being higher than in first grade rugby. There is very little quality data on rugby injuries, and the few studies available use different methods of data collection and injury definition. There is a pressing need for the collection of accurate ongoing epidemiological data on injuries in rugby.     

The use of bedside fluoroscopy to evaluate the cervical spine in obtunded trauma patients

BACKGROUND: Recognition of a cervical spine injury is important to prevent further injury and in planning for future care. The management of the patient with a possible cervical spine injury who remains unresponsive is controversial. METHODS: A retrospective evaluation of obtunded trauma patients admitted to the surgical intensive care unit who underwent bedside fluoroscopic cervical spine evaluation. Fluoroscopic findings and all complications were noted. RESULTS: Twenty obtunded patients with possible cervical spine injuries underwent bedside fluoroscopic cervical spine evaluation. All patients had at minimum a normal three-view cervical spine series before fluoroscopy. Thirteen patients (65%) had the fluoroscopic examination completed at the bedside and were cleared. The complete cervical spine could not be evaluated in six patients (30%). One patient (5%) was found to have a C4-5 subluxation in the bedside examination. None of the patients had progression of their neurologic symptoms after cervical spine flexion/extension, and none developed evidence of spinal cord injury after being cleared during their hospital course. Cervical collars remained in place for 5.7+/-1.41 days (range, 1- 26 days). Three patients (15%) were noted to have decubiti under the cervical collar. CONCLUSION: In this small study, the use of bedside fluoroscopy to evaluate the cervical spine appears safe and easy to perform. One unrecognized injury was identified. The technique is usually successful and gives reassurance that a significant cervical spine injury is not present.