Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma

A recent retrospective analysis of femur fractures concluded that early surgical fixation in patients who have sustained blunt thoracic trauma (AIS score for Thorax > or = 2) was a risk factor for postoperative pulmonary failure. We conducted a review of all femur fractures admitted to a level I trauma center from November, 1988 to May, 1993. Inclusion criteria were ISS > or = 18, mid-shaft femur fractures treated with reamed intramedullary fixation, and no mortalities secondary to head trauma or hemorrhagic shock. One hundred thirty-eight patients met these criteria. Four patient groups were created: N1--no thoracic trauma (AIS score for thorax < 2), and early surgical fixation (< 24 hours after injury, n = 49); N2--no thoracic trauma and delayed fixation (> or = 24 hours, n = 8); T1--thoracic trauma (AIS score for Thorax > or = 2) and early fixation (n = 56); T2--thoracic trauma and delayed fixation (n = 25). There were no significant differences in age, Injury Severity Score, or Glasgow Coma Scale score between the four groups. Mortality rate, length of stay (LOS), LOS in the TICU, and duration of mechanical ventilation tended to be greater in patients with delayed fracture fixation, however, this was not statistically significant. The N2 patients had a pneumonia rate of 38% compared with 10% in group N1 (p = 0.07). The T2 patients had a pneumonia rate of 48% compared with 14% in group T1 (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)     

Confirmed abuse cases in public residential facilities for persons with mental retardation: a multi-state study

Our experience with 10 patients who suffered midshaft fractures of the femur and injuries to their ipsilateral hips has resulted in a treatment protocol that we believe can avoid unnecessary complications. The surgical protocol is a three-stage procedure based on (1) intramedullary nailing of the femur with interlocking for preserving the anatomic length and rotation of the femur; (2) treatment of the hip joint injury by means of open reduction and internal fixation of the acetabular fracture and/or reduction and fixation of the fractured femoral neck; and (3) repair of the extensor mechanism. Eight patients received this treatment and had fast recoveries. Union of the femoral fracture and full range of motion of the knee joint were observed within 3 months. In contrast, two patients who had received different surgical treatment had incomplete functional recoveries. This study offers a treatment protocol for ipsilateral disruption of the extensor mechanism, hip joint injury, and midshaft fracture of the femur in the multiply injured patient that can achieve full recovery with no complications. This relatively rare combination of injuries is definitely worthy of special attention.     

Administration of modified spherosome suspension (BY963) leads to an increase of acoustic impedance in dog brain tissue

OBJECTIVE: To determine if reamed femoral intramedullary nailing increases the pulmonary complications seen in chest-injured patients. DESIGN: Retrospective review of prospectively collected trauma database data from January 1991 to October 1994. SETTING: Methodist Hospital, Indianapolis, Indiana, Level I Trauma Center. PATIENTS: Group I: Chest-injured patients [chest Abbreviated Injury Score (AIS) > or = 2] without femur or tibia fractures. Group II: Chest-injured patients (chest AIS > or = 2) with femoral reamed intramedullary fixation. Group III: Chest-injured patients (chest AIS > or = 2) with femoral shaft fixation using nonreamed fixation (rush rods, plating, or external fixation). Group IV: Non-chest-injured patients (chest AIS < 2) with femoral reamed intramedullary fixation. MAIN OUTCOME MEASUREMENT/HYPOTHESIS: Reamed femoral intramedullary nailing does not alter pulmonary outcomes, even in chest-injured patients. RESULTS: Groups I and II had a very similar incidence of adult respiratory distress syndrome (ARDS), pneumonia, and number of ventilator days. Group III had a significantly higher incidence of ARDS and number of ventilator days than did Group I or II. Group III did not have a chest AIS score significantly different than Groups I and II. Group II had significantly higher ARDS and more ventilator days than did Group IV when only analyzing raw data. When injury severity was adjusted, there were no significant differences in pulmonary outcomes. CONCLUSION: Reamed intramedullary femoral fixation did not increase pulmonary morbidity in chest-injured patients.     

Identification of ethanol-intoxicated patients with minor head trauma requiring computed tomography scans

OBJECTIVE: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol- intoxicated patients with presumed-minor head injuries. METHODS: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared. RESULTS: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9-15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2-6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchymosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour. CONCLUSION: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries and evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

The role of neuroimaging in the initial management of patients with minor head injury

STUDY OBJECTIVE: To determine whether omitting neuroimaging in the primary assessment of patients with minor head injuries in the emergency department is safe. DESIGN: Prospective cohort study. SETTING: University hospital, Copenhagen County Hospital, Glostrup, Denmark. PARTICIPANTS: The study group consisted of 2,204 patients presenting to the ED after sustaining minor head injuries. Only patients able to talk and walk were included. MEASUREMENTS AND MAIN RESULTS: The decision to admit was based exclusively on clinical guidelines in which the findings in the ED were of highest priority. Seven patients (0.3%) had a skull radiograph; computed tomography was not used in the primary evaluation. Four hundred thirty patients (19.5%) were admitted. After hospitalization, four patients developed intracranial complications. One required surgery, two required hyperventilation, and one was observed. Follow-up demonstrated that no patient with an intracranial complication had been missed. CONCLUSION: We found it safe to exclude neuroimaging in the primary assessment of patients with minor head injuries in the ED, and to rely instead on clinical criteria.     

Lectins and antibodies to blood group antigens as markers for the basal cells of the human respiratory epithelium

We evaluated personality change following head injury in 68 patients at 6 months postinjury using the NEO Five-Factor Inventory to assess the five personality dimensions of the Five-Factor Model of Personality. All items had to be rated twice, once for the preinjury and once for the current status. Twenty-eight trauma patients with injuries to other parts of the body than the head were used as controls. For the head-injured group, 63 relatives also completed the questionnaire. The results showed no differences between the ratings of head-injured patients and the ratings of trauma control patients. Both groups showed significant change in the personality dimensions Neuroticism, Extraversion, and Conscientiousness. Compared to their relatives, head-injured patients report a smaller change in Extraversion and Conscientiousness. Changes were not reported on the Openness and Agreeableness scales, by neither the head-injured or their relatives, nor by the trauma controls.     

Mortality in multiple trauma patients with fractures

A multicentered study was performed to determine the mortality rate of patients with multiple injuries with major pelvic and long bone fractures who have early total care of their injuries. A 2-year review of patients with ISSs > or = 18 with major fractures treated at the trauma centers in Buffalo, New York, Camden, New Jersey, Nashville, Tennessee, Baltimore, Maryland, Tampa, Florida, and Seattle, Washington was performed. This group of 676 patients was compared with a similar group of 906 patients from the American College of Surgeons' Multiple Trauma Outcome Study. Mortality was significantly reduced in the patients who had early total care of all their injuries including fracture stabilization for patients less than 50 years of age and those 50 years and older. In a subgroup of patients less than 50 years of age and an ISS of 18-34 and 35-45 there was a mortality reduction from 11.8% to 5.1% and from 25.8% to 11.5%, respectively, when the fractures were managed acutely. Similar reductions in mortality were found in the patients 50 years of age and older with early fracture stabilization with a reduction from 26.4% to 8% in patients with ISSs of 18-24 and a reduction from 42.3% to 18.4% in the patients with ISSs of 35-45. This study clearly shows the additional benefit of early fracture stabilization in reducing mortality rates in the patient with multiple injuries.     

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.     

Self-reported sleep and mood disturbance in chronic pain patients

BACKGROUND: Gastrostomies provide reliable long-term enteral access in patients with traumatic brain injuries. The impact of technique of gastrostomy on total hospital cost is not known. METHODS: A retrospective analysis of patients who sustained head trauma and required gastrostomies for long-term enteral access between 1 July 1990 and 1 July 1996 was performed. RESULTS: The patients who received percutaneous endoscopic gastrostomies (PEG) were similar to patients who received Stamm gastrostomies (OPEN) with respect to age, injury severity score, mechanism of injury, associated injuries, complication rates, and deaths. Total hospital costs ($ x 10(3)) were lower for patients who had PEGs placed in the intensive care unit (78.2 +/- 37.4) or endoscopy suite (71.9 +/- 37.7) compared with PEGs placed in the operating room (122.4 +/- 75.7) or OPEN gastrostomies (119.8 +/- 65.1). CONCLUSIONS: In head-injured patients, PEGs are a reliable method of obtaining long-term enteral access with a complication rate equivalent to Stamm gastrostomies. If performed in either the intensive care unit or the endoscopy suite, PEGs are associated with significantly reduced total hospital costs.     

Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.     

Vascular complications in injuries about the knee joint

In 1,377 patients who had severe injuries about the knee joint, vascular complications were present in 28 (2%). Injuries to the popliteal artery or its branches present serious problems. Amputation was necessary in 13 patients, and 12 patients had a Volkmann's syndrome. In fractures of the lower end of the femur or upper end of the tibia, and in knee dislocations, the importance of early diagnosis of the acute ischemic syndrome cannot be overemphasized. Tibial plateau fractures produced the highest percentage of vascular complications and indicate immediate application of therapeutic measures.     

Monteggia fractures in adults

The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. The remaining patients had fixation with a plate and screws. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries.     

Subdural tension pneumocephalus following head injury: report of five cases

Intracranial air is a radiographic finding not uncommon in head-injured patients. It is a relatively benign complication which usually resolves spontaneously. However, under unclear mechanism, tension pneumocephalus (the entrapment of intracranial air under pressure) may be formed and cause neurological symptoms. Five cases of patients with subdural tension pneumocephalus following head injury were reported. All had a basal skull fracture involving the paranasal sinuses or mastoid air cells with coexisting cerebrospinal fluid leakage. The patients showed symptoms and signs of increased intracranial pressure and compression on frontal lobes. Characteristic computerized tomographic findings were noted. Four patients clinically improved with conservative strategy. Only 1 case needed operative correction.     

The effect of associated injuries, blood loss, and oxygen debt on death and disability in blunt traumatic brain injury: the need for early physiologic predictors of severity

Studies of 4590 patients with blunt trauma injuries admitted to a Level I Trauma Center, have shown that 37% had a blunt traumatic brain injury (BTBI). Of these brain injured patients 60% has an associated other injury. Examination of mortality has shown that those with an isolated brain injury had an 11% mortality compared with 21.8% in those with an associated systemic injury. Further investigation demonstrated that the cause of the increased mortality was related to the blood loss associated with the injuries and that when hypovolemic shock resulted, mortality rose from 12.8 to 62%. The severity of the associated injuries effect on the brain injured patient could be estimated by a parameter of oxygen debt, the base deficit and this allowed for a quantitative estimate of the probability of death as an index of severity. A combined linear logistic model using the admission Glasgow Coma Score (GCS) as a measure of brain injury and the base deficit as a measure of physiologic injury provides such a predictive score. The effect of associated injuries in patients with moderate brain injury (AIS 2,3) was to increase the average total cost of medical care in the first year of injury by three-fold ($12,489 to $36,177) and for severe brain injury (AIS 4,5) to increase average cost from $59,000 in isolated BTBI to $90,000 in BTBI with associated injury. The high incidence of brain injuries in motor vehicle crashes (MVC) caused by lateral impacts and their association with other side-impact injuries (lungs, spleen, kidney, and pelvic fractures) in which large blood volume losses are common, focuses attention on the need for side impact protection standards that simultaneously protect brain, thoracoabdominal viscera, and pelvis as a means of reducing the severity and cost of lateral impact MVCs.     

Comparison of sequential compression devices and foot pumps for prophylaxis of deep venous thrombosis in high-risk trauma patients

Multiple-trauma patients are at increased risk for deep venous thrombosis (DVT) but are also at increased risk of bleeding, and the use of heparin may be contraindicated. Sequential pneumatic compression devices (SCDs) are an alternative for DVT prophylaxis. However, lower extremity fracture or soft tissue injury may preclude their use. In these circumstances, foot pumps (FPs) are often substituted, yet little clinical data exist to support their use. We identified 184 consecutive high-risk trauma patients who received DVT prophylaxis with compression devices. We reviewed demographic data, mechanism of injury, Injury Severity Score, injury pattern, and method of prophylaxis. Generally, SCDs were preferred, but FPs were substituted in patients with lower extremity injuries. Occurrences of DVT or pulmonary embolism were also noted. Patients surviving less than 48 hours were excluded. SCDs were used in 118 patients (64%) and FPs in 66 patients (34%). There were no differences in age, Injury Severity Score, or presence of shock on admission. As expected, FP patients were more likely to have lower extremity fractures (65 vs 26%; P < 0.05) and were also more likely to have associated pelvic fracture (59 vs 25%; P < 0.05) and chest injury (61 vs 26%, P < 0.05). There was no difference in the incidence of head injury, although SCD patients had more severe head injuries (Glasgow Coma Score, 7.9 vs 10.5; P < 0.05). The overall incidence of DVT was 5.4 per cent (10 of 184), with no differences between the two groups (SCD 7% vs FP 3%). Three patients had a pulmonary embolism (FP, two; SCD, one), none of which were fatal. Compression devices provide adequate DVT prophylaxis with a low failure rate (3-8%) and no device-related complications. FPs appear to be a reasonable alternative in the high-risk trauma patient when lower extremity fractures precludes use of SCD.     

406 femoral fractures in children

406 fractures of the femur in persons younger than 17 years of age were treated at Haukeland University Hospital, Bergen, from January 1980 to December 1993. The incidence was 35/100,000 per year; 57/100,000 for boys, and 24/100,000 for girls. No significant changes in the incidence occurred during the study period. 70% of the fractures occurred in boys. 78% had an isolated fracture, while 7% had other fractures, 7% head injuries and 8% injuries of multiple organs as well. Traffic accidents accounted for 35% of the fractures. 65% of the femur fractures were treated by skeletal traction (mean hospitalisation 30 days), 21% were operated on initially (hospitalisation 12 days), and 14% were given early spica cast (hospitalisation three days). The results of the treatment were generally satisfactory. Neither anisomelia (8.5% more than 10 mm) nor malrotation (12% more than 10 degrees) of the femur was a serious problem, but the length of time the patients were hospitalized was rather long.     

Noninvasive blood glucose monitoring

This prospective review of adult patients with head injuries examines the incidence of head injuries due to falls caused by seizures, the incidence and severity of intracranial hematomas, and the morbidity and mortality rates in this patient population. A head injury was attributed to a fall caused by a seizure if the seizure was witnessed to have caused the fall, or the patient had a known seizure history, appeared postictal or was found convulsing after the fall, and no other cause for the fall was evident. A total of 1760 adult head-injured patients were consecutively admitted to the authors' service between 1986 and 1993. Five hundred eighty-two head injuries (33.1%) were due to falls and 22 (3.8%) of these were caused by seizures. Based on the prevalence rates for epilepsy in the general population of 0.5 to 2%, these results indicate that epileptics are several times more likely to suffer a head injury due to a fall. Mass lesions were found in 20 (90.9%) of these 22 patients and the remaining two patients suffered mild diffuse head injuries. There was a high incidence of extraaxial mass lesions: 17 (85%) of the 20 intracranial hematomas were either epidural (five cases) or acute subdural (12 cases) hematomas. Eighteen (81.8%) of the 22 patients required evacuation of a hematoma. Both the incidence of intracranial hematomas (90.9% vs. 39.8%, p < 0.001, chi-square analysis) and the rate of hematoma evacuation (81.8% vs. 32.3%; p < 0.001) was significantly greater in patients injured in falls due to seizures (22 cases) than in the group injured in falls from all other causes (560 cases). The higher incidence of hematomas and the need for evacuation were not explained by differences in age, seventy of head injury, or incidence of alcohol intoxication. Despite the greater incidence of mass lesions and the need for operative treatment in patients injured because of seizures, their mortality rate was similar to that of patients injured in falls from other causes. On the basis of their review of patients admitted to a neurosurgical center with complaints of head injury, the authors conclude that patients with head injuries due to a fall caused by a seizure should undergo computerized tomography scanning early in their management. Until a mass lesion has been excluded, any decrease in level of consciousness or focal neurological deficit should not be attributed to the seizure itself.     

The routine use of radiography and arterial blood gases in the evaluation of blunt trauma in children

STUDY OBJECTIVE: To evaluate the usefulness of routine radiographs and arterial blood gases in children with blunt trauma. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Ninety patients who met triage criteria for our trauma team evaluation and who were less than 15 years old were evaluated. Patients with a Glasgow Coma Scale score (GCS) of 15 (lie, mild to moderately injured children) were the focus of this study. METHODS: Children seen from May 1991 through August 1992 had charts reviewed systematically and within 24 hours of emergency department evaluation. Standard radiologic evaluation, including cervical-spine, chest, and pelvic radiographs, as well as arterial blood gas analysis, were obtained. The severity of injury was graded according to the Modified Injury Severity Scale. RESULTS: The mean age of patients was 6.4 years, and the injuries observed were exclusively extremity fractures. The correlation between physical examination findings and radiologic evaluation was assessed. Forty-three patients had an abnormal physical examination (ie, gross deformity, limitation of motion, or pain), and 26 had a fracture identified on radiograph. Forty-seven patients had a normal physical examination and none had a fracture identified on radiograph (P < .001; sensitivity of positive signs and symptoms, 100%; false-negative findings, 0%). Four patients with abnormal blood gases are described. No patient had any vascular or solid organ injury identified. CONCLUSION: In children with a GCS score of 15, selected radiologic and laboratory tests based on clinical findings are recommended. Careful observation and repeat examinations by trained clinicians can select a group of children at low risk for occult injury.     

Preferential benefit of implementation of a statewide trauma system in one of two adjacent states

BACKGROUND: Implementation of Oregon's trauma system was associated with a reduction in the risk of death for hospitalized injured patients. An alternative explanation for improved outcome, however, is favorable concurrent temporal trends, e.g., new technologies and treatments. PATIENTS AND METHODS: To control for temporal trends, seriously injured hospitalized patients in Oregon and Washington were compared before either state had a trauma system (1985-1988) and when only the Oregon trauma system had been implemented (1990-1993). The study group consisted of hospitalized injured patients aged 16 to 79 years with one or more index injuries in six body regions, i.e., head, chest, spleen/liver, femur or pelvis fracture, and burns. Hospital discharge claims data were analyzed, converting International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis codes to Abbreviated Injury Scale scores and Injury Severity Scores using a conversion algorithm. Multivariate logistic regression models were used to estimate the differential risk-adjusted odds of death in Oregon compared with Washington after adjustment for demographics, injury type, and injury severity. RESULTS: Findings indicated no difference in the risk-adjusted odds of death between Oregon and Washington while both states functioned under an ad hoc trauma system (1985-1988). A significant reduction in the risk of death, however, was noted in Oregon for patients with an index injury and an Injury Severity Score > 15 compared with Washington (adjusted odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.70-0.91) after trauma system implementation in Oregon (1990-1993). Specifically, reductions in the risk of death were demonstrated for patients with head injuries (adjusted OR = 0.70, 95% CI = 0.59-0.82) or liver/spleen injuries (adjusted OR = 0.73, 95% CI = 0.54-0.99). CONCLUSION: Assuming that the two states demonstrated similar concurrent temporal trends, the findings support the conclusion that improved outcomes among injured patients in Oregon may be attributed to the institution of a statewide trauma system.     

How many severely injured multiple-trauma patients can benefit from the biomechanical advantage of early mobilization following femoral intramedullary nailing?

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.