Additional Injury Research Articles

Altered early immune response after fracture and traumatic brain injury.

Clinical and preclinical data suggest accelerated bone fracture healing in subjects with an additional traumatic brain injury (TBI). Mechanistically, altered metabolism and neuro-endocrine regulations have been shown to influence bone formation after combined fracture and TBI, thereby increasing the bone content in the fracture callus. However, the early inflammatory response towards fracture and TBI has not been investigated in detail so far. This is of great importance, since the early inflammatory phase of fracture healing is known to be essential for the initiation of downstream regenerative processes for adequate fracture repair. Therefore, we analyzed systemic and local inflammatory mediators and immune cells in mice which were exposed to fracture only or fracture + TBI 6h and 24h after injury. We found a dysregulated systemic immune response and significantly fewer neutrophils and mast cells locally in the fracture hematoma. Further, local CXCL10 expression was significantly decreased in the animals with combined trauma, which correlated significantly with the reduced mast cell numbers. Since mast cells and mast cell-derived CXCL10 have been shown to increase osteoclastogenesis, the reduced mast cell numbers might contribute to higher bone content in the fracture callus of fracture + TBI mice due to decreased callus remodeling.

Risk factors, management, and outcomes in isolated parafalcine or tentorial subdural hematomas

IntroductionIndications for hospitalization in patients with parafalcine or tentorial subdural hematomas (SDH) remain unclear. This study derived and validated a clinical decision rule to identify patients at low risk for complications such that hospitalization can be avoided. MethodsA multicenter retrospective medical record review of adult patients with parafalcine or tentorial SDHs was completed. The primary outcome was significant injury, defined as injury that led to neurosurgery, discharge to another facility, or death. A multivariable logistic regression was performed to identify variables independently associated with the outcome in the derivation cohort. These variables were then validated on a separate cohort from a different institution abstracted without knowledge of the identified variables. ResultsIn the derivation cohort, 134 patients with parafalcine/tentorial SDHs were identified. The mean age was 63 ± 19 years with 82 (61%) male. Seventy-one (53%) had significant injuries. Variables independently associated with significant injury included: age over 60, adjusted odds ratio (aOR) 3.46 (95% CI 1.24, 9.62), initial Glasgow Coma Scale score below 15, aOR =7.92 (95% CI 2.78, 22.5), and additional traumatic brain injuries (TBIs) on computerized tomography (CT), aOR =5.97 (95% CI 2.48, 14.4). These three variables had a sensitivity of 71/71 (100%, 95% CI 96, 100%) and specificity of 12/63 (19%, 95% CI 10, 31%). The validation cohort (n = 83) had a mean age of 62 ± 22 years with 50 (60%) male. The three variables had a sensitivity of 36/36 (100%, 95% CI 92, 100%) and specificity of 7/47 (15%, 95% CI 6.2, 28%). All 39 (100%, 95% CI 93, 100%) patients from both cohorts who underwent neurosurgery had additional TBI findings on their CT scan. ConclusionsPatients with parafalcine/tentorial SDHs who are under 60 years with initial GCS scores of 15 and no addition TBIs on CT are at low risk and may not need hospitalization. Furthermore, patients with isolated parafalcine/tentorial SDHs are unlikely to undergo neurosurgery. Prospective, external validation with a larger sample size is now recommended. Study typeRetrospective Cohort Study.

Ginsenoside Rc Alleviates Myocardial Ischemia-Reperfusion Injury by Reducing Mitochondrial Oxidative Stress and Apoptosis: Role of SIRT1 Activation

Myocardial ischemia-reperfusion (MI/R) injury occurs when coronary blood supply is impaired and then re-established, leading to additional injury to the myocardial tissue, including mitochondria oxidative stress and apoptosis. Ginsenoside Rc is one of the main protopanaxadiol-type saponins, and there has been relatively little research on it. Despite research confirming that ginsenoside Rc regulates mitochondrial functions, its potential benefits against MI/R injury have not been explored. In this study, we examined the protective effects of ginsenoside Rc in MI/R injury, along with its underlying mechanisms, using an in vitro H9c2 cell model of oxygen-glucose deprivation/reoxygenation (OGD/R) and an in vivo rat model of MI/R injury. Prior to this, the H9c2 cells or rats were exposed to ginsenoside Rc with or without SIRT1 small interfering RNA (siRNA) or the selective SIRT1 inhibitor EX527. The results showed that after MI/R (or OGD/R) injury, ginsenoside Rc had a cardioprotective effect; improved cardiac function (or cell survival); reduced myocardial infarct size; decreased levels of creatine kinase-MB, cardiac troponin I, and lactate dehydrogenase (LDH) in the serum (or LDH release into culture medium); reduced cardiomyocyte apoptosis; and attenuated mitochondrial oxidative damage. Ginsenoside Rc pre-treatment also upregulated the anti-apoptotic protein Bcl-2 while downregulating the pro-apoptotic proteins Bax and cleaved caspase-3. Furthermore, the cardioprotective effect of ginsenoside Rc was concomitant with upregulated SIRT1 expression and downregulated Ac-FOXO1 expression. SIRT1 siRNA or SIRT1 inhibitor EX527 abolished the cardioprotective effects of ginsenoside Rc by inhibiting the SIRT1 signaling pathway. In conclusion, our findings demonstrate that ginsenoside Rc ameliorated MI/R injury by reducing mitochondrial oxidative stress and apoptosis, at least in part, by activating SIRT1.

Epidemiological characteristics of 1,806 patients with traumatic spinal cord injury: A retrospective study.

Traumatic spinal cord injury (TSCI) is a type of highly disabling central nervous system trauma. In this study, we investigated the epidemiological characteristics of 1,806 TSCI patients and compared the characteristics of patients with traumatic cervical spinal cord injury (TCSCI) caused by cervical fracture/dislocation and disc herniation/bulging. We retrospectively reviewed the hospital records of 1,806 TSCI patients. The detailed information included gender, marital status, occupation, age, neurological level of injury, etiology, American Spinal Injury Association (ASIA) grade, combined injuries, complications, treatment, the interval between admission and surgery, intubation/tracheostomy requirement, and the length of hospital stay. Cervical spinal cord injury (CSCI) was the most common injury. Compared to non-CSCI cases, patients with TCSCI were older, and more likely to suffer from tetraplegia and require intubation/tracheostomy, but had fewer other injuries or complications and a shorter length of hospital stay. Compared to patients with cervical fracture/dislocation, those with TCSCI caused by disc herniation/bulging were older and more likely to suffer from paraplegia, but required intubation/tracheostomy less frequently, exhibited fewer other injuries and complications, and required shorter hospitalization. Men, married individuals, manual laborers, and individuals aged 31-75 years had the highest risk of TSCI. Patients with TCSCI tended to have a shorter length of hospital stay than patients with non-CSCI. More attention should be paid to the other injuries and complications of non-CSCI patients, which may increase the length of hospital stay and delay rehabilitation. Compared to patients with cervical disc herniation, the patients with fracture/dislocation tended to be younger, but prognosis was severely compromised by tetraplegia, a greater need for intubation/tracheostomy, additional injuries, and complications.

Research progress of nano selenium in the treatment of oxidative stress injury during hepatic ischemia-reperfusion injury.

Hepatic ischemia-reperfusion injury (HIRI) is an additional injury to ischemic tissue after hepatic revascularization, and its pathological mechanism is complex. HIRI is not only involved in the molecular targets that mediate cell death, such as ion channel activation, abnormal protease activation and mitochondrial dysfunction, but also related to the down-regulation of endogenous protective signals. As a by-product of normal aerobic metabolism, reactive oxygen species (ROS) act as a multi effect physiological signal factor at low concentration. However, liver ischemia-reperfusion will lead to excessive ROS accumulation, destroy redox homeostasis, lead to oxidative stress, cause cell death through a variety of mechanisms, and drive the further damage of ischemic liver. Recent studies have found that the antioxidant treatment of nano selenium can reduce the excessive production of ROS and play a potential protective role in reducing HIRI. This paper reviews the molecular mechanism of the antioxidant effect of nano selenium for the prevention and treatment of HIRI, in order to provide further experimental basis for the clinical prevention and treatment of HIRI.

Does posterior approach always lead to poor functional and cosmetic outcomes in displaced pediatric supracondylar humeral fractures?

Supracondylar humerus fractures (SCHFs) are the most common types of elbow fractures in children. Closed reduction percutaneous pinning (CRPP) is the primary surgical treatment of SCHFs. In cases that cannot be managed with closed reduction, treatment with open reduction and internal fixation (ORIF) is necessary. We aimed to compare CRPP and ORIF through a posterior approach regarding clinical and functional outcomes in pediatric SCHF cases. Patients with Gartland type III SCHF who underwent CRPP or ORIF with posterior approach at our clinic between January 2013 and December 2016 were included in this retrospective study. A total of 60 patients who underwent surgical treatment and had available data on our hospital database and no additional injuries were included in the study. We analyzed their data concerning age, gender, fracture type, neurovascular damage, and surgical treatment. In addition, we inspected the patients' anteroposterior and lateral radiographs at 1-year follow-up visits for Baumann (humerocapitellar) angle (BA) and carrying angle (CA) and checked their go-niometer assessments of elbow range of motion (ROM). The cosmetic and functional outcomes were determined using Flynn's criteria. Demographic, preoperative, and post-operative data of 60 patients between the ages of 2-15 were analyzed. 46 of these patients had CRPP, and 14 had posterior ORIF. CA, Baumann angle, and lateral capitello-humeral angle were measured for fractured elbow and contralateral elbow and compared statistically. There was no statistically significant difference between the two surgical ap-proaches in terms of CA (p=0.288), Baumann's angle (p=0.951) and LHCA (p=0.578). At the end of 1-year follow-up, elbow ROM was measured, and there was no statistically significant difference between the two groups (p=0.190). Furthermore, there is no statistically significant difference between the two surgical approaches in terms of both cosmetic (p=0.814) and functional (p=0.319) outcomes. A comprehensive literature review of pediatric SCHF shows that surgeons do not frequently prefer posterior incisions in Gartland type III fracture that cannot be managed with closed reduction. However, posterior open reduction is a safe and effective method since it provides more control over the distal humerus, allows for a complete anatomical reduction involving both cortices, reduces the risk of ulnar nerve injury, thanks to the nerve exploration, and yields positive cosmetic and functional outcomes.

Prognostic factors for femoropopliteal vascular injuries: surgical decisions matter.

Lower limbs are frequently involved in vascular trauma, but it is still not clear which factors lead to unfavorable clinical outcomes. To determine the clinical profile of patients with femoropopliteal injuries, the trauma mechanisms, and treatment and identify which factors led to unfavorable outcomes. A retrospective study based on the medical records of patients treated from 2017 to 2021. The following data were assessed: sex, age, distance to reach the hospital, trauma mechanism, hypovolemic shock, additional injuries, treatment of vascular injuries, whether fasciotomy was needed, inappropriate intraoperative decisions, and injury severity score. Need for surgical reintervention, amputation, and death were defined as unfavorable outcomes. Univariate, bivariate, and logistic regression analyses were conducted. The sample comprised 94 patients; 83% were men; mean age was 30.8 years; combined arterial and venous injuries prevailed (57.5%); and superficial femoral vessels were the most affected (61.7%). Penetrating mechanisms prevailed (80.9%). Arterial injuries were most frequently treated with venous graft (59.6%) and venous injuries underwent ligation (81.4%). In 15% of cases, inappropriate surgical decisions were detected; most often use of the ipsilateral great saphenous vein for arterial reconstruction. Unfavorable outcomes occurred in 44.7%: surgical reintervention was necessary in 21.3% and limb amputation in 25.5%, while 9.5% of the patients died. These injuries mainly involved young men, victims of gunshot wounds. Superficial femoral vessels were the most injured; concomitant non-vascular trauma was frequent, mainly fractures. Inappropriate surgical decisions increased the need for reinterventions by 34 times. Need for fasciotomy, presence of fracture/dislocation, blunt trauma mechanism, and popliteal artery injury increased the risk of amputation.

The relationship between the presence of scapula fracture and mortality and morbidity in cases with blunt thoracic trauma.

Scapula fractures (SFs) occur as a result of high-energy trauma and are significant in terms of life-threatening injuries. There are few studies showing the relationship between SFs and mortality and morbidity in patients with blunt thoracic trauma (BTT). Our study aims to investigate the relationship between SF and mortality and morbidity in BTT. Adult patients admitted to the emergency department of Kahramanmaras Sutcu Imam University, School of Medicine with BTT between January 2019 and April 2021 were retrospectively scanned from hospital records. Patients' age, gender, trauma mechanism, additional organ injuries, need for intensive care, length of hospital stay, morbidity, and mortality rates were recorded. Statistical results were expressed as frequency, percentage, and mean±standard deviation (min-max). In comparisons between groups, p<0.05 was accepted as the significance level. Two hundred and thirty-eight cases were included in our study. The scapular fracture was present in 86 cases (36.1%). About 43% of the cases with SFs were falling from a height. Intrathoracic injuries accompanying SF were determined as rib fracture, lung contusion, pneumothorax, hemothorax, and sternum fracture, respectively (91.9%, 80.2%, 41.9%, 37.2%, and 15.1%). Extrathoracic injuries associated with SF were vertebral fractures, intracranial injuries, clavicle fractures, extremity fractures, and intra-abdominal injuries (18.6%, 16.3%, 12.8%, 10.5%, and 5.8%), respectively. When the groups with and without SF were compared, a statistically significant relationship was found between SF and the number of rib fractures, lung contusion, pneumothorax, and hemothorax (p<0.001, p=0.001, p=0.001, p=0.001). In extrathoracic injuries, there was a significant relationship between SFs and vertebral fractures, intra-cranial injuries, and clavicle fractures (p=0.004, p<0.001, p=0.005). There was no difference observed between the groups regarding sternum fractures, extremity fractures, and intra-abdominal organ injuries (p=0.288, p=0.682, p=0.261). In cases with accompanying SF, there was a significant difference in terms of length of hospital stay, need for intensive care, and mortality (p<0.001, p=0.001, p=0.002). The most common intrathoracic injuries accompanying SFs were rib fractures and lung contusion, and the most common extrathoracic injuries were vertebral fractures and intracranial injuries. Moreover, it was found that SF was highly correlated with length of hospital stay, need for intensive care, and mortality. The most common cause of mortality was found to be intracranial hemorrhage. Imaging of other systems is important in cases with SFs. Particular attention should be paid to head-and-neck injuries.

Morphometry of the Glenoid Cavity of Dry Scapulae of Human Adults

Objective: The shoulder joint is considered the most unstable in the human body and this is due to the measurement relationships between the bone surfaces of its components. This joint is subject to frequent dislocations, which can result in acute fracture or gradual bone loss, which can lead to recurrent instability, additional injury and pain. In this study, it was aimed to carry out a study of the maximum height and width measurements of the glenoid cavity of dry scapulae, correlating them with sex and dimidium. Methods: Measurements of the maximum heights and widths of 90 dry scapulae glenoid cavities were performed using a 0.01 mm precision digital caliper, 54 were males and 36 were females, with a mean age of 51.9 years. Values of p&lt;0.05 were considered statistically significant. Results: In general, the height and width measurements of the glenoid cavity, as well as the correlation between these measurements in relation to gender, were slightly higher in the right side (p&gt;0.05). When we correlated the mean height and width of the GC with respect to homologous sides and sexes, they were also higher in males, but this finding was statistically significant (p&lt;0.05). Conclusion: The findings of these measurements of the glenoid cavity represent a contribution not only for anatomy, but especially for orthopedists, when planning shoulder arthroplasty procedures, as well as helping the industry to develop more accurate and functional joint prostheses for the Brazilian population

Evaluation of functional results of primary repair in hand extensor tendon injuries according to etiological factors, associated injuries and injury sites

Purpose: The aim of this study was to evaluate the effect of surgical treatment of extensor tendon injuries in the hand with appropriate primary repair techniques on clinical and functional outcomes, taking into account the mechanism of injury, concomitant injuries and injury sites. Materials and Methods: This is a cross-sectional study in which 103 patients who were operated between 2016-2020 in Orthopedics and Traumatology Clinic were evaluated retrospectively. Existing treatment modalities were evaluated in terms of etiological factors, anatomical regions, number of injured tendons, and injuries. Complications and functional outcomes were statistically evaluated according to anatomical regions, mechanism of injury and additional injuries. Results: 114 extensor tendon injuries of 103 patients (mean age: 37.2 years) were evaluated. The mean follow-up period was 26.8 months. Among the etiological factors, it is seen that the most common one is sharp object injury (57.3%). According to the Miller classification performed at the 8th week and 12th month in sharp object injury, moderate and poor outcome and the presence of complications were found to be statistically significantly lower than other injury types. A statistical correlation was observed between the accompanying injury (n: 21/103) and the occurrence of complications and functional outcomes. While there is no difference between complications, depending on the body regions, and functional results at 8. week statistically significantly lower functional results were found in zone-2 injuries at 12 months. Conclusion: While successful postoperative recovery primarily depends on the type of injury and associated injuries, good and excellent functional results can be achieved with early mobilization after surgery with the appropriate repair technique in any region.

MANAGEMENT OF HIP DISLOCATION IN EMERGENCY DEPARTMENT

Hip dislocations following trauma are a common occurrence in the emergency room. Since the hip is a ball and socket joint with concomitant muscular and ligamentous attachments, it often takes a large amount of force to dislocate a hip. Due to the needed force, hip dislocations frequently come together with additional serious injuries. 90% of the time, hip trauma appears as a posterior dislocation when detected because the anterior ligaments are stronger. The rectus femoris, gluteal muscles, and short external rotators make up dynamic muscular support. 95% of patients who had a hip dislocation following a car accident also had an accompanying injury that needed hospital treatment. Therefore, a thorough neurologic and musculoskeletal evaluation with further x-rays or CT scans for assessment is required in cases with native hip dislocation. Standard AP (anteroposterior) scans of the pelvis often show hip dislocations clearly. However, a cross-table lateral of the injured joint is often included in comprehensive imaging. Hip dislocations can be more difficult to reduce than other types of dislocations, and most patients need procedural anaesthesia to make the reduction easier. Before considering surgical reduction, experts advise making up to three closed reduction efforts. However, 10% of hip dislocations may not be treatable in the emergency room and require surgical reduction under general anaesthesia.

The role of ipsilateral mediastinal lymph node dissection in treatment of patients with non-small-cell lung cancer

Background. Lung cancer occupies the leading place in the structure of cancer incidence and death rate. Treatment results are still not satisfactory. Five-year postsurgical survival rate is 24–30%. Patients die in different periods of time from local recurrences and distant metastases. To this day, there is no unambiguous attitude towards ipsilateral mediastinal lymph node dissection in surgical treatment of patients with lung cancer. Despite the oncologic relevance of the abovementioned lymph node dissection, there are still concerns on worsening of recovery conditions of bronchial stump, increase in the amount of lymphorrhea and additional injury rate of the surgery. There is also an opinion that the risk of development of postsurgical complications, and, as a result, the increase in lethality rate, outweigh the positive impact of ipsilateral mediastinal lymph node dissection on radicality and long-term treatment results.&#x0D; Purpose – to study the impact of ipsilateral mediastinal lymph node dissection on the course of postsurgical period in patients with lung cancer, clarifying diagnostics of spread of tumor process and survival rate of the patients.&#x0D; Materials and methods. Treatment results of 187 patients with non-small-cell lung cancer with different clinical stages from T1-3N0 M0 to T1-2N1 M0 were analyzed. The patients were divided into two groups: the first group (comparison group) consisted of 72 patients, who underwent radical operations with selective lymph node dissection. The patients of the second group, the study group (115 patients), obligatorily underwent ipsilateral mediastinal lymph node dissection. The number of removed lymph nodes in one patient ranged from 5 to 10 in the first group and from 18 to 25 in the second one. In the cases when no cancer cells were found in lymph nodes, they were managed with monoclonal antibodies to cytokeratins, expressed with cancer cells, with further microscopic evaluation. During the postsurgical period the following values were studied: duration of the surgery, the volume of intraoperative blood loss, the amount and duration of exudation, frequency and character of postsurgical complications. Comparison of survival rates of the patients was performed with the test of statistical significance of differences by χ2 criterion. Methods of non-parametric statistical estimate were used for statistical analysis of the results by the means of Statistica 6.0, SPSS 17.0 software.&#x0D; Results. Adding ipsilateral mediastinal lymph node dissection to surgical interference increased its duration by 30 minutes on average. An increase in the volume of exudate by 136,2 ± 18,4 ml was observed in early postsurgical period. Structure and frequency of postsurgical complications in both groups was similar. In most cases heart rhythm disorder, namely ciliary arrhythmia, was observed in the first days after the surgery. Postsurgical lethality rate in both groups was caused by various factors and equaled 1,4% in the first, and 0,8% in the second one. Additional usage of immunohistochemicalanalysis of lymph nodes with monoclonal antibodies to tumoral cytokeratins in patients after performing ipsilateral mediastinal lymph node dissection led to their lesion being found more frequently. Indeed, metastases were detected in 21% of 19 patients, in which N0 status was previously established in light microscopy. Also, a significant increase in three-year survival rate by 15,3% (p=0,042) was observed in patients with lung cancer, who underwent ipsilateral mediastinal lymph node dissection and had no signs of mediastinal lymph nodes lesion, and 23,2% (p=0,014) in patients with the signs of the lesion.&#x0D; Conclusions. Performing ipsilateral mediastinal lymph node dissection in patients with lung cancer during surgical interference does not have an impact on postsurgical lethality rate and frequency and structure of complications. During the study of lymph nodes, which, according to light microscopy, were considered unaffected by cancer, additional lymphogland metastases were found in 20,7% of the patients by the means of monoclonal antibodies to cytokeratins. It allows the stage of the disease to be more accurately determined and optimal type of adjuvant therapy to be chosen. Detection rate of metastases in regional lymph nodes significantly increases from 51,4% to 67,8% in patients with lung cancer after radical operations with additional ipsilateral mediastinal lymph node dissection. Obligatory ipsilateral mediastinal lymph node dissection in surgeries for lung cancer increases overall three-year survival rate, especially in patients with affected lymph nodes by 16,3%.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient.

The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. Level V.

Functional outcomes and health-related quality of life after reconstruction of segmental bone loss in femur and tibia using the induced membrane technique

IntroductionThe induced membrane technique (IMT), frequently called Masquelet technique, is an operative, two-staged technique for treatment of segmental bone loss. Previous studies mainly focused on radiological outcome parameters and complication rates, while functional outcomes and health-related quality of life after the IMT were sparsely reported.Materials and methodsRetrospective study containing of a chart review as well as a clinical and radiological follow-up examination of all patients treated with the IMT at a single institution. The clinical outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the Short-Form-36 (SF-36) and the visual analog scale (VAS) for pain. The radiographic evaluation contained of standard anteroposterior and lateral, as well as hip-knee-ankle (HKA) radiographs.ResultsSeventeen patients were included in the study. All had suffered high-energy trauma and sustained additional injuries. Ten bone defects were localized in the femur and seven in the tibia. Ten patients underwent additional operative procedures after IMT stage 2, among them three patients who contracted a postoperative deep infection. The median LEFS was 59 (15–80), and the SF-36 physical component summary (PCS) and mental component summary (MCS) were 41.3 (24.0–56.1) and 56.3 (13.5–66.2), respectively. The median length of the bone defect was 9 (3–15) cm. In 11 patients, union was obtained directly after IMT stage 2. Bone resorption was observed in two patients. At follow-up, 16 of the 17 bone defects had healed. The median follow-up was 59 months (13–177).ConclusionOur results show a high occurrence of complications after IMT stage 2 in segmental bone defects of femur and tibia requiring additional operative procedures. However, fair functional outcomes as well as a good union rate were observed at follow-up.

Magnetic resonance imaging (MRI) findings after knee, foot, and ankle traumas.

The aim of this study is to investigate the demographic and clinical characteristics of knee and ankle traumas that could not be detected in the first post-traumatic evaluation and diagnosed within 15 days after the follow-up examination and to discuss the results we obtained with current data. Patients admitted to the emergency department trauma department between January 1, 2017, and December 31, 2018, were retrospectively analyzed. Applications due to traffic accidents and all traumas except knee and ankle trauma were excluded from the study. Medical records were used to reveal the demographic characteristics of the cases, clinical findings, mechanisms of injury, additional injuries, and interventions in the emergency room. The mean age of 2,039 patients included in the study due to knee, foot, and ankle trauma was 35.69±12.01, and the median value was 36 (age range 11-71). The patients were divided into 2 groups knee trauma and ankle trauma and statistical evaluations were made. Of the patients evaluated for knee trauma (n=1,157), 463 (40%) were female and 694 (60%) were male. Of the patients evaluated for ankle trauma (n=882), 397 (45%) were female and 485 (55%) were male. It is evident that knee, foot, and ankle traumas after simple falls and sports injuries are frequently encountered by emergency physicians. It is known that post-traumatic ligament injury, bone contusion, intraarticular fluid/hematoma formation, and fractures that cannot be detected by radiographs can be overlooked in emergency departments where patient density is high.

Intraoperative neurophysiological evaluation of central motor conduction time during an untethering surgery: a case report

Tethered cord syndrome is a congenital disease associated with abnormal stretching of the spinal cord and lumbosacral roots caused by a tight terminal filum. Untethering surgery is performed to minimize or prevent ongoing neurological deficits in the lower limbs, bladder, and bowel functions. As untethering surgery itself carries the risk of inducing additional neural injuries, intra-operative neurophysiological monitoring including electromyography, motor evoked potential (MEP), somatosensory evoked potential, and bulbocavernosus reflex is essential for improving functional outcomes after surgery. However, as MEP reflects the integrity of both the central and peripheral nervous systems, monitoring it alone is insufficient to differentiate between the neural damages of spinal cord and nerve roots. Herein, we report the first case of a child in whom both central motor conduction time and MEP were measured during untethering surgery to differentiate the location of neural injuries between the spinal cord and lumbosacral roots.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case.

Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Characteristics and outcomes of patients who undergo fasciotomies for upper arm compartment syndrome.

Describe the demographic, injury-related, treatment-related, and outcome-related characteristics of patients who undergo fasciotomies for acute upper arm compartment syndrome (ACS). From January 1, 2006, to June 30, 2015, 438 patients with a diagnosis code of upper extremity (including hand, forearm, arm, and shoulder) compartment syndrome at two tertiary care centers were identified. Of those patients, 423 were excluded for a diagnosis other than upper arm ACS or incomplete documentation. A final cohort of 15 adult patients with acute upper arm compartment syndrome treated with fasciotomy was included. The electronic medical record for patient-related variables, lab data, mechanism of injury, presence of additional injuries, and treatment-related variables were reviewed. The mean age of our cohort was 52years, and 73% were male. The most common mechanisms of injury were blunt trauma (20%), vascular injury (20%), oncologic resection (13%), and infection related to intravenous drug use (13%). Humerus fractures and biceps tendon ruptures were associated with 13 and 27% of the cases, respectively. More than two-thirds of the patients had elevated international normalized ratios (INR). While 27% of cases underwent fasciotomy within 6h after injury, seven patients (47%) underwent fasciotomy more than 24h after injury. Six patients had no major deficits, while 7 patients had long-term deficits. Upper arm ACS is a potentially devastating condition that can be seen after blunt trauma, vascular injury, oncologic resection, and intravenous drug use. Clinicians should have high suspicion in cases of elevated INR and biceps tendon rupture.

Trauma recidivism is pervasive and is associated with mental and social health opportunities

IntroductionRecidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. MethodsA series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. ResultsMean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DiscussionNew injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. Level of EvidenceLevel 3 retrospective, prognostic

Treating Inferior Pole Fracture of Patella with Hand Plating System: First Clinical Results.

Inferior pole fractures of patella are notorious fractures where it is difficult to obtain rigid internal fixation by conventional methods. The objective of the study was to introduce the Hand Plating System (HPS), which was a novel surgical technique for inferior pole fractures of patella, and to report the radiological and clinical outcomes following the application of the surgical technique. The study was designed as a retrospective cohort study. Between July 2017 and December 2018, 30 patients who were diagnosed with inferior pole fracture of the patella without additional orthopaedic injuries were enrolled in this case series. After X-ray and 3D-CT examinations, all patients underwent open reduction and internal fixation by HPS with or without supplementary cannulated screw and lag screw stabilization. The bony union time, final range of motion (ROM), Bostman score, visual analog scale (VAS), and complications were measured as the clinical outcomes under a minimum of 12months of follow-up. All of the operations went well with the mean operative time of 76.2 ± 15.3 min. Bony union achieved in all the cases at an average of 9.5 ± 1.4 weeks after surgery. There was no loss of reduction, fixative failure, or surgical implant removal during follow-up. The average range of motion 1 year postoperatively was 0°-123.3°. The mean Bostman Score at the last follow-up was 26.8 ± 2.1 with the satisfactory rate of 100%. The pain feeling during walking as measured by VAS averaged at 0.9 ± 1.3. No complications developed except for one case of poor incision healing, which healed eventually after surgical debridement. HPS was demonstrated as a secure fixation and as a kind of tension band for inferior pole fractures of the patella. Satisfactory recovery of knee function and low complication rate, including no need for hardware removal, could be expected.