Rare Run-Over Clinical Case. Evisceration of the Intestines through the Wrist

Pelvic Bone Fractures Mimicking Bone Metastases in a Patient with Hepatitis B Virus-Associated Liver Cirrhosis and Hepatocellular Carcinoma

Background: Long bone fractures either single or multiple present frequently to the emergency. The metabolic response to trauma elicits various markers amongst which is hyperglycaemia. Determination of hyperglycaemia in these two sets of patients is however yet to be fully evaluated. Objective: To compare the random blood glucose levels in patients with single and multiple long bone fractures. Design: Prospective comparative cross-sectional study Setting: Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun state Nigeria. Patients and Methods: Ninety cases of patients with traumatic single and multiple long bone fractures had their random blood glucose levels evaluated at three different times and were all treated. Main Outcome Measure: Random blood glucose level before,during and after resuscitation. Results: Ninety patients were recruited into the study with 65 and 25 of them having single and multiple long bone fractures respectively. Young males with closed Tibia fractures following road traffic accidents accounted for majority (30%) of the single fractures while those with floating knee accounted for the majority (8.8%) of multiple long bone fractures. The mean Random blood glucose at presentation, 12 hours and 24 hours after presentation were 7.7,7.1 and 5.9 (mmol/l) respectively. There was a statistically significant difference in the random blood glucose levels between patients with single and those with multiple long bone fractures. Conclusion: Patients with multiple long bone fractures appear to mount a higher metabolic response to trauma. Hyperglycaemia can be reduced with prompt and adequate resuscitation. Thus routine random glucose checks for all trauma patients should be done and serve as marker for injury severity and adequacy of resuscitation. Keywords: Random Blood Glucose, Single and Multiple Long Bone Fractures

Objective:Information regarding the burden of fractures is limited, especially among working age patients. The objective of this study was to evaluate the direct and indirect costs associated with long bone fractures in a working age population using real-world claims data.Methods:This was a claims-based retrospective analysis, comparing adult patients in the 6 months before and 6 months after a long bone fracture between 1/1/2001 and 12/31/2008 using the MarketScan Research Databases. Outcomes included direct medical costs and utilization, as well as work absenteeism and short term disability, which was available for a sub-set of the patients. Observed and adjusted incremental costs (i.e., the difference in costs before and after a fracture) were evaluated and reported in 2008 US$.Results:A total of 208,094 patients with at least one fracture were included in the study. Six, mutually exclusive fracture cohorts were evaluated: tibia shaft (n = 49,839), radius (n = 97,585), hip (n = 11,585), femur (n = 6788), humerus (n = 29,884), and those with multiple long bone fractures (n = 12,413). Average unadjusted direct costs in the 6-months before a long bone fracture ranged from $3291 (radius) to $12,923 (hip). The average incremental direct cost increase in the 6-months following a fracture ranged from $5707 (radius) to $39,041 (multiple fractures). Incremental absenteeism costs ranged from $950 (radius) to $2600 (multiple fractures), while incremental short-term disability costs ranged from $2050 (radius) to $4600 (multiple fractures).Conclusions:The results of this study indicate that long bone fractures are costly, both in terms of direct medical costs and lost productivity. Workplace absences and short-term disability represent a significant component of the burden of long bone fractures. These results may not be generalizable to all patients with fractures in the US, and do not reflect the burden of undiagnosed or sub-clinical fractures.

Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures

Introduction:Multiple bone fractures in a newborn can be associated with osteogenesis imperfect (OI). OI is a rare genetic disorder that causes Type I collagen synthesis disturbance results in bone fragility.Case Report:We present a female newborn which had numerous fractures of the humerus, bilateral clavicle, and bilateral femur. Her delivery was at 36 weeks gestation by spontaneous vaginal delivery. She had has not any pathological symptom at 2 weeks after birth, the patient had a fracture of the humerus, bilateral clavicle, and femur without any trauma. Genetic analysis of the patient was reported and OI diagnosed. The patient was followed up for 8 months with regularly and without any complication.Conclusion:Multiple fractures with OI in an infant after birth may require an accurate orthopedic plan for diagnosing and treatment.

PurposeThe blue sclera appearance is a distinctive but non‐specific clinical sign for osteogenesis imperfecta (OI), a connective tissue disorder caused by an abnormality of type I collagen. It is a challenging diagnosis because multiple bone fractures, occurring in early childhood, can be the only sign of the non‐lethal forms of OI. In these situations, differential diagnosis with child abuse is a major concern for Pediatricians. Aim: to investigate the scleral optical coherence tomography (OCT) and thickness measurement as a diagnostic test for OI.MethodsThe sclera of a 28‐year‐old man affected by a mild form of OI and presenting a blue scleral hue was examined with the sclera mode coupled with the enhanced depth imaging of the spectral domain OCT equipped with the anterior segment module device (SD‐ASOCT) (Heidelberg Engineering GmbH, Heidelberg, Germany). The scleral thickness was measured at a distance of 2000 μm from the scleral spur in eight meridians. Three measurements in each meridians were averaged and the mean and the standard deviation of the eight meridians were calculated. The examination of an age matched healthy volunteer served as a control.ResultsThe mean scleral thickness of the OI patient was lower than that of the healthy patient, 277 μm ± 43 μm vs. 470 μm ± 50 μm. The superotemporal meridian was the thinnest in both patients.ConclusionsThese findings are consistent with the pathologic features previously described. The blue color results from the visualization of the underlying choroid through the translucent and thinner sclera. The in vivo scleral thickness measurement is a rapid and non‐invasive diagnostic tool that may be useful for challenging cases, especially in children with multiple fractures.

Osteogenesis imperfecta (OI) is a group of genetic skeletal disorders, with a prevalence of 1 in 15,000-20,000 births. OI type V has been described in approximately 150 cases and all patients carry the variant (c.-14C> T) in the IFITM5 gene. However, two other variants, p.S40L and p.N48S have been reported in this gene, leading to clinical phenotypes different from OI type V. Here we described a patient with multiple bone fractures, scoliosis, skull alteration (plagiocephaly), bone deformation, bone rickets, and intramedullary epithelioid osteosarcoma that bears the recently reported heterozygous variant c.143A>G (p.N48S) in the IFITM5 gene. This case supports the pathogenicity of this new variant in the IFITM5 gene and adds information regarding its clinical phenotype.

A 15-month-old African–American boy receiving chemotherapy for Wilms tumour was diagnosed to have a fracture of left femur at the emergency department (ED) of our hospital. A month earlier, the...

Maxillofacial trauma represents a significant portion of forensic evaluations in outpatient clinics. This retrospective study aimed to evaluate the demographic characteristics, etiological factors, injury patterns, and medicolegal outcomes of maxillofacial trauma cases admitted to the Forensic Medicine Outpatient Clinic of Ordu Training and Research Hospital between 2018 and 2023. A total of 699 forensic cases were analyzed. The majority of patients were male (77.3%) with a mean age of 35.7±16.6 years. Most commonly reported causes were physical assault (53.2%), domestic violence (17.2%) and traffic accidents (14.7%). The most common soft tissue injuries were ecchymosis (45.1%) and abrasions (44.9%). The most common bone fracture was the nasal fracture 63.3%. Multiple fractures were detected in 20.3% of patients. A statistically significant relationship was identified between physical assault and both nasal and multiple bone fractures (p<0.01). Life-threatening injuries were documented in 2.3% of patients. Permanent facial scarring was noted in 2.0% of cases, and organ loss was reported in 1.2%. These findings reveal that measures against interpersonal violence in particular need to be increased.

Introduction. The choice of treatment tactics in multiple trauma patients with multiple long bone fractures of lower extremities is a relevant and controversial issue nowadays. First of all, this is due to the contradictions regarding the choice of the term and method of primary and definitive fractures fixation.Objective: to determine the impact of the proposed treatment algorithm of the multiple trauma patients with multiple long bone fractures of the lower extremities on the duration of mechanical ventilation (MV), length of stay in intensive care unit (LOS ICU) and hospital length of stay (HLOS), the incidence of complications and mortality.Materials and methods: a prospective controlled trial was conducted from September 2016 to February 2020, and included adult patients with multiple trauma, Injury Severity Score (ISS) ≥ 18p, and multiple long bone fractures of lower extremities. Patients were divided into two groups: group I included patients who were treated according to the proposed treatment algorithm. Group II includes patients who were treated in accordance with generally accepted diagnostic and treatment measures.Results: the study included 95 patients (in group I – 43, in group II – 52). There were no statistically significant differences between patients in the compared groups in terms of demographics, mechanism of injury, severity of injury and general condition of the patient, the number and location of fractures. Patients in group II, compared with patients in group I, had a higher frequency of acute respiratory distress syndrome (ARDS) (19.2% vs. 11.6%, p = 0.002), pneumonia (25.0% vs. 16.3%), p = 0.007), longer terms of MV (15.1 ± 9.4 vs. 9.6 ± 7.2 days, p = 0.004), LOS ICU (19.4 ± 12.1 vs. 13.7 ± 8.5 days, p = 0.048) and HLOS (38.7 ± 18.9 vs. 29.1 ± 15.0 days, p = 0.023).Conclusions: Complications in multiple trauma patients with multiple long bone fractures of lower extremities are often the cause of worse treatment outcomes, but the application of a differential approach, based on the proposed treatment algorithm for this patient’s category, was reduced the incidence of pneumonia and ARDS, the duration of MV, LOS ICU, HLOS, without impact on the incidence of fatal pulmonary embolism, fat embolism syndrome, sepsis, multiple organ failure and mortality.

The aim: to conduct retrospective analysis of treatment outcomes in polytrauma patients with multiple long bone fractures of lower extremities.Materials and methods: retrospective study of treatment results in patients hospitalized to the polytrauma department of Kyiv City Clinical Hospital №17 from January 2013 to December 2016.Results: among patients with polytrauma and multiple long bone fractures of lower extremities, males dominated (67.9%) and the main cause of injury was a road accident (73.3%). The most common localizations of injuries were chest trauma (82.4%), traumatic brain injury (74.8%). The severity of injury was 29.2 ± 10.5 points according to the Injury Severity Score (ISS), degree of consciousness disorders was 9.1 ± 3.3 points in conformity with Glasgow Coma Scale (GCS). Patients developed complications, including nosocomial pneumonia (40.5%), acute respiratory distress syndrome (ARDS) (19.1%) and fat embolism syndrome (10.7%), as well as sepsis (28.2%) and multiple organ failure (MOF) (16.0%). Mortality rate was 24.4%.Conclusion: It was found that among patients with polytrauma and multiple long bone fractures of lower extremities males dominated on the basis of gender, the main cause of injury was a road accident. The most common localizations of injuries were chest trauma and traumatic brain injury. Among controversial issues of treatment and diagnostic process are low frequency of pelvic binder application, ultrasound according to focused assessment with sonography for trauma (FAST) protocol and whole body multispiral computed tomography (WBMCT), which should be performed in 100.0% of patients with high-energy trauma at the time of admission to the hospital. In addition, frequency of Early Total Care (ETC) tactics application was too low, and definitive osteosynthesis in some cases was performed unreasonably late, using conservative fixation methods, which is a cause of complications and treatment prolongation in patients with polytrauma.The most common complications were pulmonary: nosocomial pneumonia, ARDS and fat embolism syndrome. Mortality rate was 24.4%.

The aim: to determine the influence of individual factors on the development of complications in patients with polytrauma and multiple long bone fractures of lower extremities.Materials and methods: a prospective study conducted inKyivCityClinicalHospital №17 from December 2016 to January 2020. The study included 57 patients with polytrauma and multiple long bone fractures of lower extremities, treated according to the proposed algorithm.Results: the most common complications were: pneumonia (21.1%), acute respiratory distress syndrome (ARDS) (15.8%), multiple organ failure (MOF) (15.8%), sepsis (8.8%), mortality (12.3%). A number of factors influenced the development of complications in patients with multiple long bone fractures of lower extremities and polytrauma were identified and the correlation analysis was conducted. These factors included: age; sex; the Injury Severity Score (ISS); the Glasgow Coma Scale (GCS); the severity of a general condition of a patient according to the Clinical Grading Scale (CGS); trauma to the head, and neck, chest, abdomen, pelvis; head and neck, chest, abdomen, pelvis trauma in accordance with the Abbreviated Injury Scale (AIS); the number of segments of damaged limbs; Gustilo-Anderson fracture type; blood loss volume; massive blood transfusions; respiratory index; duration of mechanical ventilation (MV); treatment tactics; osteosynthesis method; conversion phasing.Conclusion: the analysis allowed to identify the most significant factors that lead to complications in patients with multiple long bone fractures of lower extremities and polytrauma. Informative parameters were:− for pneumonia: GCS and CGS; chest injury; AIS head and neck, chest ≥ 4; duration of MV; treatment tactics; conversion phasing (IC = 1.0-2.1).− for ARDS: GCS and CGS; AIS chest ≥ 4; fractures > 2 long bones; blood loss volume; massive blood transfusions; respiratory index; duration of MV; treatment tactics (IC = 1.2-4.6).− for sepsis: GCS; trauma to the chest, abdomen; AIS head and neck, abdominal cavity ≥ 4; fractures > 2 long bones; conversion phasing (IC = 1.1-3.2).− for MOF: GCS and CGS; abdominal trauma; AIS abdominal cavity ≥ 4; fractures > 2 long bones; massive blood transfusions; conversion phasing (IC = 1.2-2.2).− for mortality: age, ISS, GCS and CGS; abdominal trauma; AIS head and neck; chest, abdomen, pelvis ≥ 4; blood loss volume; massive blood transfusions; duration of MV (IC = 1,1-5,9).Among the factors there were those for which the diagnostic and treatment process:− affected: the choice of treatment tactics (IC = 1,1-1,3); use of massive blood transfusions (IC = 1.8-4.8); duration of MV (IC = 1,2-2,1); conversion of the fixation method (IC = 1.2-1.8).− did not affect: GCS (IC = 1,2-3,1), CGS (IC = 1,1-1,3), AIS (IC = 1,0-6,2).

BackgroundThe differential diagnosis of multiple unexplained bone fractures in a young infant usually includes child abuse or bone disease such as osteogenesis imperfecta. Bone abnormalities can occur in 60–80% of cases with congenital syphilis and may be the sole manifestation. However, this frequent manifestation of this rare disease such as congenital syphilis is frequently disregarded. We describe a case of a young infant with multiple long bone fractures diagnosed with congenital syphilis.Case presentationThis 2-month-old male patient was referred to our hospital because of fractures of the ulna and distal radius bilaterally and noisy breathing with the suspicion of osteogenesis imperfecta. After thorough examination, the infant had anemia and a palpable spleen. We performed a screen for congenital infections among other investigations, which revealed positive non-treponemal and treponemal antibodies for syphilis. Hence the diagnosis for Congenital Syphilis was made.We performed a lumbar puncture (LP) which showed mild pleocytosis. The patient was treated with intravenous aqueous penicillin G 200 000 UI/KG per day for 10 days. In addition, a single dose of intramuscular penicillin G benzathine 50 000 UI/KG was given due to the abnormal result of CSF.On follow up admission 6 months later, the new syphilis serology had much improved and the new LP revealed no abnormal findings.ConclusionsWe present this case report in order to remind of a common manifestation of congenital syphilis, a rare disease which needs to be included in the differential diagnosis of multiple unexplained fractures in early infancy. In our case the fractures were symmetric and bilateral and they were accompanied by anemia and mild hepatosplenomegaly which led to the investigation of congenital syphilis as a possible cause. However, two thirds of infants with congenital syphilis are asymptomatic at birth. All women should have a proper syphilis screening during pregnancy.

Introduction. Severe trauma is one of the leading causes of disability and mortality in all age groups. Long bone fractures of lower extremities, in particular the femur, have increased risk of complications. The choice of surgical treatment tactic, timing and methods of fixing of long bone fractures of lower extremities in patients with severe associated trauma is relevant and controversial issue.Objective: to conduct a retrospective analysis of injury structure in polytrauma center and evaluate treatment outcomes in polytrauma patients with multiple long bone fractures of lower extremities, frequency of complications and mortality.Materials and methods: the retrospective study was conducted, included a group of patients had applied to the admission department of Kyiv City Clinical Hospital No17 during the period from January 2010 to December 2019.Results: the study included 54,613 patients at the first stage. 69.3% of patients were received outpatient care, 30.7% were hospitalized. Among all patients, 13.7% were diagnosed with polytrauma, of which 80.2% had chest injury, 78.4% had traumatic brain injury, and 71.1% had musculoskeletal injuries. In the structure of musculoskeletal system trauma the multiple bone fractures of lower extremities were in 16.7% of patients, among them long bone fractures were in 57.6%.The study included 220 patients at the second stage. The incidence of pulmonary embolism occurred in 4.1% of patients, fat embolism – 12.7%, nosocomial pneumonia was diagnosed in 38.2% of patients, acute respiratory distress syndrome (ARDS) – 16.8%. The incidence of sepsis, according to the criteria of definition «Sepsis II» was 30.9%, according to the criteria «Sepsis III» – 9.5%, multiple organ failure (MOF) – 18.6%.The duration of mechanical ventilation was 19.1±10.8 days. The length of stay in intensive care unit was 24.8±12.6 days and the hospital length of stay was 48.9±22.4 days. The mortality rate was 22.3%. Among the main causes of death – hemorrhagic shock (46.9%), MOF (34.7%), refractory septic shock 18.4%.Conclusions: the frequency of polytrauma was 13.7% in trauma structure and frequency of polytrauma with combined multiple long bone fractures of lower extremities – 0.5%. Most common localizations of injuries were chest trauma (78.6%), traumatic brain injury (73.6%), injuries of musculoskeletal system (71.1%). Multiple bone fractures of lower extremities were in 16.7% of patients in the structure of musculoskeletal system trauma, among them fractures of long bones were in 57.6% of patients.Ultrasound examination according to the protocol «Focused Assessment with Sonography for Trauma» (FAST) and whole body computed tomography were not performed after patient hospitalization in 100% of cases, as required by international protocols. The frequency of Early Total Care tactics application – 1.4% that was too low, the definitive osteosynthesis in some cases was performed unreasonably late, and 17.2% of primary and definitive cases and 23.9% of temporary stabilization of fractures were performed by conservative methods.The most common complications were pulmonary: nosocomial pneumonia, ARDS and fat embolism syndrome, and also sepsis and MOF.

Objectives. Circulating levels of VEGF-A (Vascular Endothelia Growth Factor-A), TGF-β1 (Transforming Growth Factor-beta 1), and M-CSF (Macrophage-Colony Stimulating Factor) were found to be predictors of bone healing and therefore prognostic criteria of delayed bone healing or nonunion. The aim of this study was to evaluate a potential rise of these markers in patients with multiple fractures of long bones compared to patients with single fractured long bone. Methods. 92 patients were included in the study and finally after excluding all female patients 45 male patients were left for final analysis and divided into the single or multiple fracture group. TGF-β1, M-CSF, and VEGF-A serum levels were analysed over a time period of two weeks. Results. MCSF serum concentrations were higher in the group with multiple fractures as also TGF-β1 serum concentrations were at one and two weeks after trauma. No statistically significant difference was observed in the VEGF-A serum concentrations of both groups at either measurement point. Conclusion. We did observe a correlation between the quantity of the M-CSF and TGF-β1 expressions in serum and the number of fractured bones; surprisingly there was no statistically significant difference in the serum levels between patients with single and multiple fractures of long bones.