Anterior lung herniation: another aspect of the seatbelt syndrome

Shoulder harnesses can be a source of thoracic injury in motor vehicle crashes. Sternal and rib fractures are most commonly reported. We present a case of a traumatic anterior lung herniation secondary to shoulder harness trauma in a motor vehicle crash victim with multiple injuries. A brief review of lung hernias is provided as well as a brief discussion of the thoracic manifestations of the seatbelt syndrome.     

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.     

Nonpenetrating thoracic injuries

In patients with nonpenetrating thoracic trauma, the rib fractures and other chest wall lesions may distract the physician from dangerous internal injuries in the chest or abdomen which may not be noted unless looked for very carefully. Early vigorous correction of any ventilatory problem is essential, particularly if there is any evidence of impaired tissue perfusion. Shock is frequently due to extrathoracic injuries, particularly intraabdominal bleeding. The flail associated with multiple rib fractures may seem mild initially, but severe underlying pulponary contusion and/or associated extrathoracic injuries make early ventilatory assistance extremely important. Rupture of the thoracic aorta should be suspected in rapid deceleration injuries, but is often not considered unless there is widening of the superior mediastinum on hte chest x-ray. Aortography to confirm the aortic tear should be done if time permits, and early repair of the injury provides the best results.     

Rapid genotypic diagnosis of type 2A von Willebrand''s disease by heteroduplex analysis

We report a case of hypoglycaemic shock which occurred in a patient 18 h after injury. The patient was involved in a road traffic accident and sustained multiple rib fractures and bruising in the (R) lumbar region. Eleven hours after his last meal he developed sudden weakness, profuse sweating, air hunger, thirst, disorientation and suddenly lapsed into coma 18 h after admission. Administration of 50 ml of 50% dextrose resulted in immediate restoration of consciousness. This case shows that this complication can occur in trauma patients even though the metabolic response to trauma is usually assumed to be hyperglycaemic.     

Primary diagnosis and follow-up after thoracic trauma and lung contusion

In 212 patients after injury of the thorax (54 males, 158 females; penetrating (15), blunt (197), multiple trauma (128)) 158 cases demonstrated rib fractures and 103 radiological proven pneumo- or hematothoraces or sometimes both, 108 of 138 had to be drained. 96.5% of the effusions and 98% of the pneumothoraces were clinical confirmed. 93.5% of 97 pulmonary contusions (79 unilateral, 18 bilateral) were detected by bronchoscopy within 10 h, 72% by x-ray. Caused by anatomical problems or for additional diagnosis 4 patients underwent thoracic CT. During ICU treatment 31 patients developed septic complications without detection in x-ray studies. In CT (n = 64) we found: 5 empyema, 13 pleural effusions, 4 pneumothoraces, 4 pneumocysts, 72 condensations of a lobe. After CT we performed: 9 resections of the lower lobe, 1 pneumectomy, 1 decortication, 7 thoracotomies with drainage, 8 drainages. To detect a septic focus under treatment the CT proved being an important diagnostic tool in chest trauma and lung contusion.     

Pediatric elbow trauma

Acute pediatric elbow trauma is commonly seen in the emergency department (ED). Reports confirm that, compared to other fractures, children's elbow fractures are commonly misdiagnosed in the ED. In addition, missed orthopedic injuries are one of the leading causes of malpractice claims in emergency medicine. Radiologic diagnosis of these injuries is challenging, as a large portion of the pediatric elbow is composed of radiolucent cartilage. Knowledge of the normal anatomy and ossification centers around the elbow is essential for correct diagnosis. Acute neurovascular injury is frequently associated with these injuries, but is often difficult to assess in an apprehensive child. Immediate orthopedic consultation is indicated for any child with an elbow injury in whom neurologic or vascular compromise is suspected. Consultation should be strongly considered for children with displaced supracondylar fractures and/or significant echymosis and swelling about the cubital fossa.     

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.     

Effects of lead exposure on licking and yawning behaviour in rats

Most studies on facial trauma in the pediatric age group focus on special subgroups. This investigation encompasses all traumatic facial injuries, minor and major, of children and adolescents. Epidemiological data of the type and pattern of injury of trauma patients less than 19 years of age, treated during a 3-year-period in a large metropolitan trauma centre were reevaluated. Of the 1385 patients, 68% had soft tissue injuries, 24% had dental trauma, and 8% fractures of facial bones. More than 90% suffered from minimal or minor trauma. The leading cause of injury was a fall, predominantly at the toddler stage. In adolescents an adult mechanism of trauma prevailed: over 60% of injuries were sequelae of an assault or altercation. The male sex predominated through all age groups and for all types of injuries. The bulk of soft tissue injuries are located within a small falling zone, extending from the nose to the mental area. There was a rising incidence of fractures of facial bones towards older age groups, mandibular fractures being the most common. Condylar fractures, with their potential impact on further growth of the mandible, are seen frequently in children and adolescents, making up 80% of the fractures of the lower jaw.     

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.     

The value of physical therapy in treating whiplash-associated disorders

We describe a case of unilateral entrapment of the ureter in the sacroiliac joint of a patient who sustained blunt abdominal trauma resulting in fractures of the public rami and sacroiliac joint and multiple bladder perforations. The entrapment was discovered intraoperatively and released by external traction and reduction of the pelvic fractures. No ureteric damage was observed, and reimplantation was not necessary. The importance of evaluating the upper tracts for potential injury in patients with fractures of the bony pelvis and concomitant bladder rupture is emphasized.     

Injury panorama and medical consequences for 1158 persons assaulted in the central part of Stockholm, Sweden

This retrospective study describes assaults, type of trauma, injury panorama, the abbreviated injury scale score and medical consequences for 1158 assaulted persons. All patients were examined by surgeons at the Emergency Department, Sabbatsberg's Hospital, Stockholm, Sweden, which is open around the clock. The police were not notified. The study group included all assaulted patients who attended and were examined at the Emergency Department from 1 April 1992 to 31 March 1993: 84% men and 16% women. Their median age was 25 years (range 13-86 years). Sixty-eight percent arrived at the Emergency Department between 11 p.m. and 4 a.m. In 44% the hospital staff registered in the case notes that the victims were drunk. Blunt trauma of low-energy type predominated, 44% were hit by fists and 30% by kicks. Penetrating trauma occurred in 10% of the assaults (knife 8%), and a combination of blunt and/or cutting trauma (bottle/ glass) in 10%. Eighty-two percent of the victims suffered an injury to the head, resulting in concussion in 116 cases, 4 skull fractures, 1 intracerebral contusion, 74 fractures of nose bones, 17 fractures of other face bones, and 6 mandible fractures. Two persons died because of knifestab wounds. Eighty-two percent of the victims had minor injuries, and 16% had moderate injuries according to the score on the Abbreviated Injury Scale (AIS). The present study shows that assault in the central part of Stockholm, Sweden, is mainly a problem involving young men, especially late in the evening, and that many of the victims are drunk. Injuries to the head due to low-energy trauma are the most common (hit by fists and kicks), but severe injuries seldom occur.     

Surgical treatment of patients with open tibial fractures

Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, which usually can be prevented by prompt surgical intervention within six to eight hours after injuries occur. Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or gunshot wounds. Initial management of patients with multiple trauma injuries focuses on their life-threatening injuries before or during orthopedic surgical intervention for open tibial fractures. Orthopedic surgeons often work in collaboration with general, vascular, and plastic surgeons and perform multiple surgical procedures (eg, fasciotomy procedures for compartment syndromes, irrigation and debridement of wounds, application of external fixation devices, placement of intramedullary nails, possible limb amputations). The type and extent of open tibial fractures and soft tissue injuries determine the best treatment options for patients. Perioperative nurses should help patients focus on treatment choices for their open tibial fractures that ensure optimal surgical outcomes and maintain their quality of life.     

Long-term outcomes in open pelvic fractures

BACKGROUND: Open pelvic fractures represent one of the most devastating injuries in orthopedic trauma. The purpose of this study was to document the injury characteristics, complications, mortality, and long-term, health-related quality of life outcomes in patients with open pelvic fractures. METHODS: The trauma registry at an adult trauma center was used to identify all multiple system blunt trauma patients with a pelvic fracture from January of 1987 to August of 1995 (n = 1,179). Demographic data, mechanism of injury, and fracture type were determined from hospital records. Short-term outcome measures included infectious complications, mortality, and length of stay in hospital. Long-term outcomes of survivors were obtained by telephone interview using the SF-36 Health Survey and the Functional Independence Measure. RESULTS: Open pelvic fractures were uncommon, occurring in 44 patients (4%). Patients with open fractures were about 9 years younger, on average, than patients with closed fractures (30 vs. 39, p < 0.001). Similarly, patients with open fractures were more likely to be male (75 vs. 57%, p < 0.02), more likely to have been involved in a motorcycle crash (27 vs. 6%, p < 0.001), and more likely to have an unstable pelvic ring disruption (45 vs. 25%, p < 0.001). Open pelvic fracture patients required more blood than closed pelvic fracture patients, both in the first day (16 vs. 4 units, p < 0.001) and during the total hospital admission (29 vs. 9 units, p < 0.001). Five patients with perineal wounds did not receive a diverting colostomy; in turn, these individuals had a total of six pelvic infectious complications (one abscess, two with osteomyelitis, and three perineal wound infections). Overall, 11 patients died, six patients were lost to follow-up, and 27 were long-term survivors (mean duration of 4 years). Chronic disability was common after a pelvic fracture, with problems related to physical role performance and physical functioning, and was particularly severe after an open pelvic fracture (p < 0.05 for both as measured by the SF-36). CONCLUSIONS: Patients with open pelvic fractures often survive, need to be treated with massive blood transfusions, and often require a colostomy. They are frequently left with chronic pain and residual disabilities in physical functioning and physical roles, and many remain unemployed years after injury.     

Vertebral artery injury associated with a Jefferson fracture

BACKGROUND: The evaluation and treatment of Jefferson fractures, a burst fracture of the ring of Cl, has been well documented in the medical literature. Vertebral artery injury associated with a Jefferson fracture is very rare. METHODS: The case study technique was used to summarize the case. Review of the literature was performed to discuss the case. Retrospective chart review of the 174 patients with cervical fractures admitted to St. Michael's Hospital from 1989-1994 was also performed. RESULTS: The case of a patient with a Jefferson fracture, with bilateral lateral displacement of the lateral masses causing bilateral vertebral artery occlusions resulting in a lateral medullary and cerebellar infarction is reported. A review of the literature is provided. CONCLUSION: A high index of suspicion for this injury is paramount, especially in patients with multiple trauma, where the diagnosis of Jefferson fractures can be delayed.     

Dubowitz syndrome with keloidal lesions

Spontaneous fractures of the first rib are uncommon and are usually thought to be associated with a malignant process. However, fatigue fractures of the first rib are being encountered increasingly in association with various physical activities. Typically, the fractures occur at the subclavian groove, but in the 48-year-old woman described in this report the fracture was unexpectedly situated in the posterior portion of the rib and was the result of snow shovelling, which was a new activity for the patient.     

Mediators in polytrauma--pathophysiological significance and clinical relevance

Multiple trauma induces an inflammatory response syndrome of the whole body that is triggered by (a) hemorrhage inducing an ischemia/reperfusion (I/R) syndrome and (b) fractures or organ contusions inducing tissue-repair processes. I/R injury generates oxyradical/proteolytic metabolites and adhesion molecules, while tissue and endothelial injury directly stimulate complement, coagulation and kinin pathways. Membrane-derived phospholipase A2 and lipid mediators potentiate cellular interactions and increase microvascular permeability. The tissue-repair process mediates macrophage/monocyte and T-cell activation which releases pro- and anti-inflammatory cytokines. Mediator action follows a "three-level model", proposing that depending on the degree of traumatic injury cellular and humoral responses may spread from a cellular to an organ and then a systemic level. The systemic response can result in a severe immunological dys-homeostasis that potentially hazards the survival of the trauma patient by uncontrollable cellular dysfunction, appearing clinically as multiple organ-dysfunction syndrome. Blood-mediator concentrations often parallel the inflammatory process; initially, high levels of cytokines are followed by severe organ dysfunction. However, interpretation of these data remains difficult due to distinct beneficial or detrimental effects of mediators on the different levels of inflammation and missing prognostic threshold values, indicating a risk of adverse effects. Future studies must determine pro- and anti-inflammatory mediators directly, during the intensive care therapy, and evaluate their clinical relevance prospectively for the different levels of inflammation at local and systemic sites.     

Applying an empty-chair monologue paradigm to examine unresolved grief

The thoracic bellows mechanism consists of the rib cage and the diaphragm. The purpose of this study was to determine if nontraumatically acquired lesions of the bellows were secondary to underlying disease. Abnormalities of the bellows, specifically stress fractures of the ribs and hiatal hernia, were found in 21 dogs and cats with underlying cardiopulmonary disease, neuromuscular disease, or metabolic disease. A case-control study of Bulldogs demonstrated that hiatal hernia was associated with the more severe manifestations of brachycephalic syndrome. Stress fractures occurred mostly in females and in cats, and involved multiple ribs. Fractures were usually related to severe respiratory effort, but also occurred in association with metabolic disease. Hiatal hernia was also associated with severe respiratory effort, but may be exacerbated if a neuromuscular disorder affecting the diaphragm is present. Abnormalities of the thoracic bellows, such as rib stress fractures and hiatal hernia, may be signs of underlying disease, rather than being primary causes of disease.     

Intraarticular fractures of the foot. Talus and lesser tarsals

In the absence of historical comparative data for the treatment of tarsal fractures, commonly abided maxims of trauma care are noteworthy. A displaced fracture involving an articular surface or a fracture interrupting a mechanical axis is treated by open reduction and internal fixation. Rigid fixation is followed as early as possible with active and passive mobilization. Unlike long bones, whose motion and fracture patterns (i.e., segmental, transverse, and oblique) are understood, the tarsal bones are small bones with complex shapes and restricted motion. As a result, tarsal injuries most often occur with multiple ligamentous and bony injuries. Articular step-off is difficult to establish roentgenographically, the blood supply is tenuous, and fixation is largely dependent on screws and Kirschner wires. Good outcome can be obtained by following principles of internal fixation established in treatment of major joint injuries.     

Seat belt-related injury to the common iliac artery: case report and review of the literature

Blunt trauma to the common iliac artery is a rare phenomenon. Although seat belt injuries to the abdominal aorta and the carotid artery have been reported, there is only one previous report in the literature of seat belt injury to the common iliac artery. We report a case of common iliac arterial injury directly related to use of the lap belt and not associated with pelvic or lumbar fractures. The literature related to blunt trauma of the common iliac artery is reviewed.     

Residual and recurrent shunts after implantation of Cook detachable duct occlusion coils

Cough and chest wall pain at high altitude have only received passing mention in the medical literature. Increased minute ventilation of cold dry air at very high altitude is likely to cause airway irritation. This in turn may result in airway drying, mucus production, postnasal drip from vasomotor rhinitis, and bronchospasm acting individually or in combination to stimulate the vagal cough reflex. The cough is exacerbated further at extreme altitudes above 5500 m, and may result in intercostal muscle strain and single or multiple rib fractures. We present a case of multiple cough induced stress fractures and arthropathy documented by technetium-99 bone scan in a high altitude climber and suggest the addition of the term High Altitude Cough Syndrome (HACS) to the medical syntax to identify this discrete medical problem of exposure to very high altitude.