Catastrophic pelvic and perineal trauma with associated traumatic hemipelvectomy is extremely rare and carries a high mortality risk. These injuries often involve multisystem destruction, including genitourinary, anorectal, musculoskeletal, and vascular structures, presenting extraordinary challenges for surgical management and reconstruction. Reports of survivors, particularly from resource-limited settings, remain limited. A 52-year-old man presented in 2022 with devastating pelvic-perineal trauma following a high-energy motorcycle crash. He received initial first aid at a district hospital before being urgently transferred to our tertiary care center in Vietnam. Upon arrival, he was in profound hemorrhagic shock, with non-palpable pulses and unrecordable blood pressure. Operative findings revealed complete avulsion of the left hemipelvis, severe crush injury of the left lower limb, full-thickness rectal transection, bladder rupture, and complete loss of the external genitalia. He underwent prompt resuscitation, left hemipelvectomy, and fecal and urinary diversion, followed by staged reconstruction. Definitive wound coverage was achieved using a combination of local rotational flap, right profunda artery perforator (PAP) flap, and autologous skin grafting. The patient recovered well and was discharged after 112 days with stable vital signs and functioning urinary and fecal diversion. This case demonstrates the survivability of catastrophic pelvic-perineal trauma with traumatic hemipelvectomy. It emphasizes the importance of multidisciplinary care, early hemorrhage control and surgical intervention, as well as adaptable reconstruction strategies in low-resource settings. Not applicable.

Transforaminal full-endoscopic spine surgery (TF-FESS) in the upper lumbar spine poses a risk of visceral injury. Standard supine imaging frequently overestimates the safety margin due to gravity-dependent visceral mobility. This study aimed to quantify the positional discrepancy between supine and prone imaging and to identify predictors of a narrow corridor using prone-position computed tomography (CT). Preoperative prone-position CT images of 57 consecutive patients who underwent TF-FESS at L1/L2 or L2/L3 were retrospectively analyzed. We measured the visceral limit and the nerve root limit. Additionally, a subanalysis of 23 patients compared the safety margins between supine and prone positions. Multivariable linear regression analysis was performed to identify independent predictors determining the width of the safety margin. Supine imaging significantly overestimated the safety margin compared with prone imaging (mean difference: 18.0 mm, P < 0.001). Anatomically, the nerve root was located 21.2 mm medial to the visceral organs (P < 0.001), indicating that it is the first obstacle encountered; however, the visceral limit constitutes an inviolable boundary. A critically narrow safety margin (≤50 mm) was observed in 24.6% (14/57) of patients. Multivariable analysis identified lower body mass index (P < 0.001) and a larger entry angle (P = 0.006) as significant independent predictors of a narrow margin. Relying on supine imaging poses a significant latent risk because it overestimates the safety corridor by approximately 2 cm. Although the nerve root is the primary anatomical constraint, the retroperitoneal organs represent an absolute danger zone that cannot be manipulated. Preoperative evaluation using prone-position CT is essential to accurately visualize the "actual" proximity of retroperitoneal organs, particularly in lean patients. This study underscores the necessity of prone-position imaging for surgical planning in upper lumbar TF-FESS, particularly for patients with low body mass index, to avoid catastrophic visceral injury.

Horse racing has faced increased scrutiny because of concerns about equine welfare and the safety of both equine and human participants. Sudden death (SD) in racehorses is relatively uncommon, and its causes are still unclear. Little information and considerable confusion exist regarding the clinical significance of microscopic lesions in the hearts of horses with SD. We examined the hearts of 29 horses that suffered exercise-associated sudden cardiac death (EASCD) and 29 clinically healthy control horses that were euthanized because of catastrophic musculoskeletal injuries. Acute cardiomyocyte injury (ACI) was found at a significantly higher overall prevalence and with a significantly higher severity score in the left atrial appendage in horses with EASCD than in control horses. ACI may be a very early stage of cardiomyocyte degeneration, perhaps driven by myocardial ischemia during high-intensity exercise. We found no significant differences in the prevalence, severity, and distribution of inflammation, fibrosis, or miscellaneous lesions between the 2 groups. Inflammation, fibrosis, and miscellaneous lesions in the heart may have clinical significance in individual cases, but they can also be confounding background lesions. Postmortem confirmation of sudden cardiac death (SCD) remains difficult, given that fatal arrhythmias can occur with no associated microscopic cardiac lesions. Elevated hepatic cobalt concentrations were overrepresented in SCD horses. Toxicology results for other performance-enhancing drugs or xenobiotics were negative or inconclusive.

The effect of a structured injury prevention program on injury severity and type in elite Adolescent and Young Adult Taekwondo athletes.

Endoscopic third ventriculostomy (ETV) achieves favorable outcomes in adults with secondary hydrocephalus, with reported success rates of approximately 78.8%. However, inflammation caused by tumor, infection, or previous surgical intervention frequently leads to thickening of the tuber cinereum (TC), observed in nearly half of such cases. When the TC becomes opaque, the basilar artery (BA) and its perforating branches cannot be visualized, substantially increasing the risk of catastrophic vascular injury during fenestration.To address this challenge, we used intraoperative indocyanine green (ICG) videoangiography to visualize the BA complex through the thickened TC. We retrospectively reviewed adult patients with secondary hydrocephalus who underwent ETV with endoscopic ICG videoangiography between November 2018 and June 2025 (n = 4). In all cases, flexible neuroendoscopy revealed a markedly thickened TC, prompting a switch to a rigid 4K ICG endoscope. Intravenous ICG administration enabled real-time identification of the BA and its branches despite the opaque TC. ICG videoangiography provided clear vascular delineation in all 4 cases, and no BA or branch injuries occurred. These findings demonstrate that 4K ICG videoangiography offers reliable, real-time vascular guidance and serves as a valuable adjunct to enhance the safety of ETV in patients with thickened third ventricular floors.

Condylar stress fracture of the third metacarpal bone (MC3) in Thoroughbred racehorses is a common catastrophic injury, and identification of horses at heightened risk remains subjective. Standing computed tomography (sCT) is a practical screening tool that enables patient-specific finite element analysis (FEA) of the distal MC3 and prediction of subchondral bone strain, as a potential objective classifier of racehorses at heightened risk. The goal of this study was to compare two independently developed sCT-based subject-specific FEA pipelines for virtual mechanical testing of the distal MC3. One pipeline models the full three-dimensional (3D) distal MC3 (UWMSN), while the other uses a simpler approach by using single sCT slices (UMELB). Four (n = 4) MC3 condyles from four Thoroughbred racehorses were selected for the study. Models were generated using both pipelines, and the predicted subchondral bone strain was compared. UMELB predicted smaller subchondral strain compared to UWMSN, likely due to more limited modes of deformation. Although the UWMSN pipeline can identify elevated subchondral strain in horses with high fatigue damage, it is more labor-intensive and computationally expensive. With further tuning and validation, the UMELB pipeline could be used as a simpler and faster approach for the prediction of subchondral strain in the distal MC3.

Anesthesia-Related Neurologic Risk in Patients of Venezuelan Descent: Implications for Ophthalmology.

The ethics of preservation: Balancing clinical utility and duty in catastrophic brain injury.

Axial headfirst impacts can cause catastrophic cervical spine injuries when the head is rapidly decelerated and the cervical spine is compressed by the torso's inertia. The goal of this study was to quantify the cervical vertebral translations, rotations, eccentricity and curvature, and the head rotation in human subjects exposed to non-impact inverted freefalls that represented the pre-impact dynamics of a headfirst impact. Eleven human subjects were exposed to 4 headfirst freefalls (2 relaxed, 2 with pre-bracing) while secured in a race car seat fixed to a carriage that was inverted and released to freefall over 312.5ms (0.479m) before being decelerated to rest. Sagittal fluoroscopy of the cervical spine was acquired and analyzed at freefall onset and end to extract vertebral and head posture variables. Linear mixed models were used to assess the effect of time (freefall onset/end) and condition (relaxed/braced) on the posture variables. Subjects consistently moved their cervical spine anteriorly and inferiorly, rotated their vertebrae and head in flexion, and increased their spinal eccentricity. Small changes in spinal curvature and intervertebral angles suggested that the subjects responded using an "en bloc" rotation of the cervical spine and head about a point inferior to C6. Compared to the relaxed condition, pre-freefall bracing produced a different initial posture but a similar end posture. Despite considerable inter-subject variability, a consistent neck and head reorientation was observed, albeit with variable underlying segmental cervical spine posture, providing valuable input for cadaveric tests and computational models simulating headfirst impacts to improve injury prediction.

Life care planning is a vital tool for individuals with disabilities, catastrophic injuries, and complex care needs, providing a structured projection of necessary medical care, support services, and resources to optimize long-term outcomes. Yet one critical domain remains absent from many life care plans: disaster preparedness. Individuals with disabilities face heightened risks during disasters, including disruptions to essential medical care, assistive technology, and accessibility accommodations. Despite evidence from disaster management and disability research, life care plans rarely incorporate strategies to address these vulnerabilities. This article examines the intersection of life care planning and disaster preparedness, highlighting the current lack of research and formal guidance on integrating emergency readiness into life care plans. Drawing from interdisciplinary sources, this article outlines why disaster preparedness is important as a standard component of life care plans and offers practical recommendations for life care planners to incorporate this critical, yet often neglected, element into professional practice and work.

Background Despite widespread adoption of laparoscopic cholecystectomy (LC), major bile duct injuries (BDIs) continue to occur, particularly in real-world, resource-limited settings. Methods This retrospective study analysed a prospectively maintained BDI-benign biliary stricture registry at the hepatopancreatobiliary (HPB) and gastrointestinal (GI) surgery unit of Indira Gandhi Medical College (IGMC), Shimla, a tertiary HPB referral centre in the sub-Himalayan region. All adult patients referred between January 2020 and December 2024 with major iatrogenic BDI requiring definitive surgical reconstruction were included. Minor biliary injuries managed conservatively or endoscopically were excluded. Demographic data, injury characteristics, surgeon experience, referral patterns, management, and outcomes were evaluated. Results Twenty-three patients underwent Roux-en-Y hepaticojejunostomy for major BDIs. Most injuries occurred during LC (91.3%) and were associated with difficult gallbladder anatomy (73.9%). Seventeen injuries (73.9%) were caused by surgeons with less than three years of post-training experience (p = 0.028). Primary repair was attempted at the index centre in 43.5% of patients, frequently in high-grade injuries. Referral beyond 72 hours occurred in 91.3% of cases. Three additional patients with catastrophic vasculobiliary injury died before reconstruction. All reconstructed patients had favourable medium-term outcomes. Conclusion Major BDI remains largely preventable. Early referral, avoidance of unsafe repair, adoption of bailout strategies, structured early-career supervision, and improved infrastructure are essential to reduce preventable morbidity and mortality.

Purpose Paediatric rehabilitation patients who are slow to recover present a unique challenge to support in an intensive rehabilitation setting. Traditional intensive, goal-directed rehabilitation models of care that focus on recovery do not cater for the complex presentations and poorer functional outcomes associated with catastrophic injuries in a paediatric population. Materials and Methods A group of 24 experts from a paediatric rehabilitation setting have developed a series of consensus statements through a modified Delphi process. The primary purpose was to develop and describe a new expert consensus based model of service delivery (Homehabilitation) that supports children requiring a slower stream approach to rehabilitation in an inpatient setting. Results This paper provides two options for children to be supported through either an; i) intensive goal-directed model of rehabilitation or ii) a slower approach that focuses on optimising goals of comfort, participation and ease of caregiving whilst supporting a timely, safe and sustainable discharge home. Conclusions Developing a well-defined, slow stream model of care that focuses on optimising the patient’s comfort, maximising remaining skills and providing family education will help assist children who are slow to progress. This approach provides families with a more structured and supportive discharge process.

In 2007, the Office of the Assistant Secretary of Defense issued guidance to routinely monitor post concussive symptoms following mild traumatic brain injury (mTBI). Subsequent clinical practice guidelines published as early as 2009 further underscored the importance of routine symptom monitoring following mTBI using standardized assessments such as the Neurobehavioral Symptom Inventory (NSI), though the NSI was not specifically recommended until 2015. The study objective was to describe the frequency of NSI administration, as documented in the Military Health System (MHS) electronic medical record (EMR), within one year after mTBI diagnosis among post-9/11 Active-Duty Service Members. Data for this effort were extracted from the Military Health System (MHS) Data Repository and used to identify Service Members whose first mTBI (i.e., index) was documented between Fiscal Years 2002 and 2021 (index TBI; n = 150,976). Members were excluded from the cohort for a history of a more severe TBI (n = 128,253) and/or a catastrophic injury (e.g., spinal cord injury; n = 3,805). Members were matched with data from completion of the NSI that was contained within the DoD TBI portal. The cohort was further evaluated to determine the frequency of documented NSI administration within one year of the index mTBI date. Among those with an index mTBI meeting inclusion criteria, 3,351 (2.2%) Service Members had an NSI documented within the EMR. When filtered to NSI surveys completed within 1 year of the index mTBI date, 1,182 (0.78%) NSIs were recorded. The prevalence of a matched NSI increased as time went on, with the highest number administered in 2019. Findings suggest relatively infrequent administration and documentation of the NSI following mTBI. System- and individual-level barriers may have played a role in this. Increased understanding regarding barriers and facilitators to administering and documenting the NSI within the EMR are needed to inform future implementation efforts to further measurement-based care among Service Members.

Thermal corneal injuries are uncommon but potentially vision-threatening. Full-thickness corneal perforation caused by monopolar electrocautery during cosmetic blepharoplasty is exceptionally rare and scarcely reported in the literature. We report a 27-year-old healthy man who sustained an accidental central full-thickness corneal perforation during elective upper eyelid blepharoplasty due to inadvertent contact with monopolar cautery. The patient presented with severe ocular pain, markedly reduced vision, and a shallow anterior chamber. Prompt intervention was performed under sterile conditions. The corneal perforation was sealed using N-butyl cyanoacrylate tissue adhesive, followed by placement of a bandage contact lens. Adjunctive topical and systemic medications were administered to prevent infection, control inflammation, and inhibit collagenolysis. At one-week follow-up, the adhesive remained intact with a stable anterior chamber and no evidence of leakage or infection. Visual acuity improved to 20/200, limited by central stromal opacity. Although long-term follow-up was unavailable, immediate tectonic stabilization was successfully achieved. This case highlights a rare but severe ocular complication of cosmetic blepharoplasty. Early recognition and rapid application of cyanoacrylate glue can effectively preserve globe integrity in small corneal perforations. Proper ocular protection is essential during periocular surgical procedures to prevent such catastrophic injuries.

Reduction of Neuro Check Intervals in Traumatic Brain Injury Patients is Associated with Lower Delirium Risk.

Cervical spine injuries in elite rugby union, while infrequent, carry a disproportionately high risk for players. The nature of collisions in rugby creates unique biomechanical stresses on the cervical spine, heightening the risk of catastrophic injury. Injuries vary across a spectrum from transient neuropraxia ('stingers') to structural injuries requiring surgical intervention. Despite the gravity of these injuries, there remains no standardized, evidence-based return to play (RTP) protocol for rugby players after cervical spine surgery. A thorough literature review was undertaken to systematically analyze the existing literature on RTP outcomes for rugby players after surgical intervention for a cervical spine injury, and to clarify deficiencies in clinical practice. The most common procedures undertaken are anterior cervical discectomy and fusion, cervical disc arthroplasty, and posterior foraminotomy. Each procedure has unique biomechanical implications for RTP. A consensus is that caution is urged in multilevel fusions, occipitocervical involvement, and injuries crossing the cervicothoracic junction due to loss of movement and increased strain on adjacent segments. However, there is no consensus about the timeline for safe RTP after surgery. Additionally, considerations of neuromuscular conditioning and the assessment of sarcopenia in determining a safe time to return to play are of the essence. If unaddressed, deconditioning, especially of deep cervical musculature, may predispose athletes to hardware failure or recurrent injury. Thus, a multidisciplinary approach is essential. Rugby has shown leadership in the management of concussion yet lacks a comparable framework for cervical spine injury, a condition with arguably more devastating long-term outcomes. Drawing on consensus guidelines from American football and orthopaedic spinal literature, this paper calls for a multidisciplinary, rugby-specific RTP protocol that integrates surgical, biomechanical, neuromuscular, and imaging criteria. Such guidelines would enhance player safety and provide clarity for clinicians navigating complex decisions about return to play. This is a clinical and fiscal imperative given the potential for career-ending injury and significant economic consequences.

BackgroundWrestling is associated with a substantial risk of injury; however, comparative injury epidemiology between Olympic Wrestling (OW) and Beach Wrestling (BW) remains limited, constraining evidence-informed injury-prevention strategies across formats.MethodsA prospective comparative epidemiological study was conducted during the 2025 Senior Olympic Wrestling World Championships and the 2025 Beach Wrestling World Series. Only competition-related bout injuries requiring on-site medical assessment or treatment were recorded. Injuries were documented using the United World Wrestling (UWW) standardized injury report form and expressed as incidence rates per 1,000 athlete-exposures (AEs). Injuries were classified by severity, anatomical region, and wrestling format. Between-group comparisons were performed using chi-square tests and independent-samples t-tests (p < 0.05).ResultsA total of 53 competition-related injuries were recorded: 29 in BW (20.0 injuries per 1,000 AEs) and 24 in OW (13.3 injuries per 1,000 AEs). Although BW demonstrated a higher overall injury incidence, all BW injuries were classified as mild or moderate, with no severe or catastrophic cases. In contrast, OW demonstrated a significantly higher proportion of moderate-to-severe injuries compared with BW (75% vs. 14%; χ² = 14.73, p < 0.001). The head and face were the most commonly affected regions in both formats (38% in BW; 42% in OW). Secondary injury patterns differed, with OW injuries more frequently involving the knee (25%) and shoulder (17%), whereas BW injuries were more evenly distributed across the upper extremities (34.6%). No catastrophic injuries occurred in either format.ConclusionsBeach Wrestling demonstrated a more favourable injury-severity profile despite a higher overall injury incidence, whereas Olympic Wrestling was associated with a greater proportion of clinically significant injuries. These findings highlight important format-specific differences in injury patterns and support the need for targeted injury-prevention strategies and continued evaluation of competition rules and environments.

Anatomical variations of the cystic duct are uncommon but clinically significant, as unrecognized variants increase the risk of catastrophic bile duct injury during cholecystectomy. We report a case of a 47-year-old woman presenting with biliary colic and transient cholestatic liver enzyme derangement, in whom an aberrant cystic duct draining directly into the right hepatic duct (RHD) was identified intraoperatively during cholangiography. The case highlights operative decision-making and reviews the role of dedicated preoperative imaging in detecting biliary duct anomalies to optimize surgical planning.

Sports medicine epidemiology has advanced considerably over the past two decades, with standardized surveillance systems and consensus statements improving the quality of data collection and reporting. Yet the field continues to face structural challenges, including small cohorts, heterogeneous samples, and rare outcomes that undermine reproducibility and limit generalizability. In practice, researchers and clinicians frequently rely on implicit expert judgment to bridge these gaps, but such judgments are often undocumented and irreproducible. Expert elicitation offers a structured, transparent approach to formalizing this knowledge into quantitative priors that can complement empirical data within Bayesian analyses. This commentary introduces expert elicitation to sports medicine epidemiology, drawing on applications of the Sheffield Elicitation Framework (SHELF) in our ongoing work. We highlight three key areas where elicitation can strengthen research and practice: 1) studies involving small, sport-specific cohorts, such as Paralympic athletes; 2) analyses of rare or severe events, including catastrophic injuries and sudden illnesses; and 3) underpowered intervention trials, where structured priors can improve interpretation and guide future prevention and treatment strategies. We also share practical insights from our pilot work, including strategies for framing questions, conducting warm-up and challenge exercises, and using real-time visualization to improve accuracy and engagement. Expert elicitation is not without challenges, requiring careful facilitation and appropriate expertise, but it provides a rigorous, reproducible method for transforming clinical judgment into usable data. Wider adoption of this methodology could accelerate progress in athlete health research by formalizing knowledge that already shapes practice but remains largely untapped.

Background: Tracheobronchial injuries are rare but life-threatening emergencies that demand rapid and coordinated management. In cases of catastrophic airway disruption, conventional airway techniques may fail, resulting in a “cannot intubate, cannot oxygenate” (CICO) scenario. Extracorporeal membrane oxygenation (ECMO) has emerged as a valuable adjunct to support oxygenation and ventilation in such circumstances. Case Presentation: A 44-year-old male presented with a severe anterior neck injury following a suicide attempt. Initial airway management at a referring hospital involved placement of an endotracheal tube through a tracheal defect, followed by urgent transfer to a tertiary center. On arrival, the patient was profoundly hypoxic (SpO2 40%) with extensive cervical trauma, including multilevel transections of the thyroid and cricoid cartilages and complete tracheal transection below the thyroid cartilage. Severe subcutaneous emphysema and distorted anatomy rendered conventional airway access unfeasible. Management and Outcome: The patient was transferred emergently to the operating theatre, where a multidisciplinary team determined that definitive airway control could not be safely achieved. Veno-venous ECMO (VV ECMO) was rapidly initiated via femoral cannulation, resulting in immediate stabilization of oxygenation and allowing safe surgical exploration. The otolaryngology team performed staged laryngotracheal reconstruction. Postoperatively, imaging demonstrated thyroid cartilage fracture and extensive emphysema. The patient was managed in the intensive care unit with corticosteroids, antibiotics, and tracheostomy. Progressive respiratory and neurological improvement permitted successful VV ECMO decannulation and transition to spontaneous ventilation. The tracheostomy was subsequently downsized, and the patient was discharged from the ICU for psychiatric evaluation and rehabilitation. Conclusion: This case underscores the critical role of VV ECMO as a lifesaving bridge in catastrophic airway trauma when conventional airway management is impossible. Early recognition of CICO physiology, prompt ECMO initiation, and effective multidisciplinary collaboration are key factors in improving outcomes in complex airway emergencies.