Early Surgical Repair Research Articles

Early and late fixation of ulnar styloid base fractures yields different outcomes

BackgroundThe role of surgical fixation of ulnar styloid fractures remains a subject of debate. The purpose of this study was to compare the surgical outcomes following early and late intervention.MethodsWe retrospectively reviewed 28 patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2014. Surgical fixation was performed within 3 months of injury in 13 patients (group A) and beyond 3 months in 15 patients (group B). Patient characteristics and functional outcomes were compared between the two groups. The outcome survey consisted of QuickDASH score, grip strength, range of motion, pain score based on the visual analog scale, and surgical complications. Descriptive statistics were calculated for key variables. A p value of < 0.01 was considered statistically significant.ResultsPatient characteristics including age, sex, injured side, dominant side injury, and concomitant distal radius fracture showed no significant differences between the two groups. Time to surgery averaged 1.1 months in group A and 12.3 months in group B. Significantly better outcomes were found in group A than in group B, including QuickDASH scores (4.4 ± 5.9 vs. 12.9 ± 9.9) and grip strength (37.4 ± 5.1 vs. 29.1 ± 5.9 kg). Significantly better range of motion was found in group A than in group B with respect to supination (81.9° ± 4.3° vs. 75° ± 8.5°), extension (84.6 ± 4.3 vs. 76.7 ± 6.5), and flexion (80.4° ± 3.8° vs. 72° ± 4.1°). The difference was not significant in case of pronation (78.8° ± 3° vs. 74.3° ± 5.9°) and with respect to pain scores (0.6 ± 0.7 vs. 1.3 ± 1).ConclusionBoth osseous and soft tissue lesions need to be fully addressed in ulnar styloid fractures. Early detection and surgical repair yielded better outcomes. Higher complication rates in late-treated fractures show that surgeons should select surgical candidates and modalities properly.

Isoexpansile sulfur hexafluoride gas to repair near-total iris disinsertion

Iridodialysis is commonly encountered after blunt trauma to the eye. Most iris detachments are small, superior, and asymptomatic and require no surgical intervention. However, large areas of iridodialysis require early surgical repair to prevent the onset of iris necrosis, pigment dispersion, and secondary glaucoma. Suture fixation of iris to the sclera is the most commonly used method for iris repair; however, this technique becomes difficult in cases of near-total iris disinsertion, even in expert hands. We describe a case of posttraumatic near-total iris disinsertion with subluxated cataract managed with phacoemulsification and iris preservation with the help of intracameral injection of isoexpansile sulfur hexafluoride.

P 137 - The effectiveness of dynamic sitting in sedentary workers with low back pain

Proximal hamstring injuries cause buttock pain and may result in significant weakness and sciatic neuralgia. Avulsion ruptures involving 2 or more tendons with >2-cm retraction may benefit from early open surgical repair. More chronic equivalents may benefit from Achilles allograft reconstruction. Chronic proximal hamstring syndrome causing posterior thigh and sit pain may occur from less severe, often repetitive injury to the proximal hamstring origin with secondary sciatic neuralgia from local adhesions or scar entrapment. Recalcitrant cases may benefit from surgical intervention, but the most effective procedure (tenotomy, resection of degenerative tissue with tenotomy vs repair, sciatic neurolysis) has not been established. The role of endoscopic surgery of the proximal hamstring is evolving, but currently may best be indicated for ischial bursectomy, debridement of degenerative tendon tissue, and/or sciatic neurolysis. Although endoscopic proximal hamstring repair is feasible for treating tears with mild retraction, the role of endoscopic (or open) surgery in repair of acute complete tears with <2-cm retraction or less severe injuries (partial tears or complete tears without retraction) is controversial because most of these injuries may respond to nonoperative management. In this setting, perhaps surgical treatment (open or endoscopic) should be reserved for patients who have failed nonsurgical management.

Endoscopic Endonasal Approach to the Growth Hormone–Secreting Pituitary Adenomas: Endocrinologic Outcome in 68 Patients

The endoscopic endonasal approach has recently become an acceptable option for resection of all pituitary adenomas. We assessed biochemical outcome of endoscopic endonasal surgery in growth hormone (GH)-secreting adenomas, including remission rate, predictors of remission, and associated complications. Sixty-eight consecutive patients with acromegaly who underwent endoscopic endonasal surgery were analyzed prospectively. Tumors were classified according to size, Knosp grade, and Hardy-Wilson classification. Biochemical remission was defined as normal serum insulin-like growth factor 1 level and either a suppressed GH serum level less than 0.4 μg/L during an oral glucose tolerance test or a random GH level less than 1.0 μg/L at least 3 months after surgery. Total biochemical remission rate was 64.7%. Gross total resection was achieved in 61 of the 68 patients (89.7%). Remission was achieved in 12 of 16 microadenomas (75%) and 32 of 52 macroadenomas (61.5%). Based on univariate logistic regression analysis, preoperative variables predictive of remission were age (P=0.004), Knosp grade (P= 0.023), and preoperative GH levels (P= 0.042). Three patients (4.4%) experienced postoperative panhypopituitarism, and permanent diabetes insipidus was seen in 4 patients (5.9%). Two patients (2.9%) developed cerebrospinal fluid leaks, which were treated by lumbar puncture in one case and early surgical repair in the other case. Endoscopic endonasal adenoma resection leads to a high rate of endocrinologic remission in GH-secreting adenomas with a low complication rate. Patients with older age, higher preoperative GH levels, and higher Knosp grades are less likely to achieve remission.

Impact of Percutaneous Pulmonary Valve Implantation on the Timing of Reintervention for Right Ventricular Outflow Tract Dysfunction

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Early surgical repair has dramatically improved the outcome of this condition. However, despite the success of contemporary approaches with early complete repair, these are far from being curative and late complications are frequent. The most common complication is right ventricle outflow tract (RVOT) dysfunction, affecting most patients in the form of pulmonary regurgitation, pulmonary stenosis, or both, and can lead to development of symptoms of exercise intolerance, arrhythmias, and sudden cardiac death. Optimal timing of restoration of RVOT functionality in asymptomatic patients with RVOT dysfunction after TOF repair is still a matter of debate. Percutaneous pulmonary valve implantation, introduced almost 2 decades ago, has become a major game-changer in the treatment of RVOT dysfunction. In this article we review the pathophysiology, the current indications, and treatment options for RVOT dysfunction in patients after TOF repair with a focus on the role of percutaneous pulmonary valve implantation in the therapeutic approach to these patients.

Blunt bowel and mesenteric trauma: role of clinical signs along with CT findings in patients' management.

Bowel and/or mesentery injuries represent the third most common injury among patients with blunt abdominal trauma. Delayed diagnosis increases morbidity and mortality. The aim of our study was to evaluate the role of clinical signs along with CT findings as predictors of early surgical repair. Between March 2014 and February 2017, charts and CT scans of consecutive patients treated for blunt abdominal trauma in two different trauma centers were reread by two experienced radiologists. We included all adult patients who underwent contrast-enhanced CT of the abdomen and pelvis with CT findings of blunt bowel and/or mesenteric injury (BBMI). We divided CT findings into two groups: the first included three highly specific CT signs and the second included six less specific CT signs indicated as "minor CT findings." The presence of abdominal guarding and/or abdominal pain was considered as "clinical signs." Reference standards included surgically proven BBMI and clinical follow-up. Association was evaluated by the chi-square test. A logistic regression model was used to estimate odds ratio (OR) and confidence intervals (CI). Thirty-four (4.1%) out of 831 patients who sustained blunt abdominal trauma had BBMI at CT. Twenty-one out of thirty-four patients (61.8%) underwent surgical repair; the remaining 13 were treated conservatively. Free fluid had a significant statistical association with surgery (p = 0.0044). The presence of three or more minor CT findings was statistically associated with surgery (OR = 8.1; 95% CI, 1.2-53.7). Abdominal guarding along with bowel wall discontinuity and extraluminal air had the highest positive predictive value (100 and 83.3%, respectively). In patients without solid organ injury (SOI), the presence of free fluid along with abdominal guarding and three or more "minor CT findings" is a significant predictor of early surgical repair. The association of bowel wall discontinuity with extraluminal air warrants exploratory laparotomy.

Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios.

The facial disfigurement and functional debility resulting from craniomaxillofacial injuries in low-intensity conflict scenarios can physically and psychologically traumatize the afflicted personnel. Efficient and definitive management, with complete esthetic restoration and functional rehabilitation, is not only an organizational obligation, but also a tactical necessity to maintain a high state of morale among the troops. There exist two schools of thought on principles of management of such injuries. The older, three-phased approach consists of initial debridement and suturing, followed by conservative closed reduction in maxillofacial fractures using splints and ligatures, thereafter followed by delayed repair and late reconstruction of residual bone defects and deformities after the soft tissue healing is complete. The newer trend involves early and aggressive open surgical reduction and craniomaxillofacial fixation techniques along with reconstructive procedures carried out hand in hand with the soft tissue debridement and closure. The aim was to compare the efficacy of the two management protocols, namely the contemporary approach of early aggressive surgical intervention, versus the conservative approach of initial debridement, closed reduction and delayed repair, as the definitive treatment modality of maxillofacial injuries sustained in low-intensity conflicts. This retrospective analytical study included 40 patients with maxillofacial injuries sustained in combat scenarios treated over a period of 3years. These patients who had been treated for ballistic maxillofacial injuries were divided into two groups: The first group of 20 patients (Group 1) included those who had undergone an early, aggressive, surgical intervention, and the second group of 20 patients (Group 2) included those who had undergone resuscitation and primary soft tissue closure followed by conservative, closed reduction techniques, delayed repair (including open reduction and internal fixation (ORIF) procedures), and late reconstruction of bone soft tissue defects (which included utilization of various grafts and flaps). Both groups were evaluated and compared for postoperative recovery and early and late complications such as impaired esthetic results and impaired functional recovery. Early, definitive, and aggressive maxillofacial surgical techniques proved superior to the conservative approach by bringing about primary bone healing and minimizing residual deformities and subsequent scar contractures, thus yielding improved functional as well as superior esthetic outcomes. In today's low-intensity conflict scenario, the emphasis in management of maxillofacial injury victims should be on an early, definitive, and aggressive surgical repair and reconstruction of the facial skeleton, thus restoring quality of life to these soldiers, sparing them life-long indignity after a potentially severe esthetically and functionally debilitating injury.

Penile fracture; three years’ experience from a tertiary care centre

Background: To study cause, presentation, diagnosis and early management of penile fracture and to prevent the complications.Methods: In this study 48 patients of penile fracture were included in the study who were admitted in general surgery department at Government Medical College Srinagar from May 2007 to May 2010. All patients were evaluated with detailed history, clinical examination and baseline investigations followed by immediate surgical repair.Results: Age range of patients was 21-75 years. Youngest being 21 years and eldest being 75 years (median-30 years). 38(79.1%) patients were married while as 10(20.9%) patients were unmarried. Sexual intercourse was main cause, seen in 41(85.4%) of patients, aggressive masturbation in 5(10.4%) patients and rolling over in bed during erection was seen in 3(6.2%) patients. All patients presented in general surgery department with complaints of pain and swelling in penile region. Time interval between injury and presentation to the department ranged from 4-24 hours (mean 11 hours). Isolated cavernosa injury was seen in 43 (89.6%) patients, while as 5 (10.4%) patients were having associated urethral injury (3 were having partial injury and 2 complete urethral disruption). There was a ventral rent in 31(64.6%) patients and lateral rent in17 (35.4%). Size of tear in tunica albuginea was less than 1cms in 19(39.6%) patients, 1-2cm in 17(35.4) patients and more than 2cms in 12 (25%) patients. Patients were discharged on 2-5 days (mean 3.1 days). There were no immediate postoperative complications. 2 (4.1%) patients had pricking sensation at repair site, 1(2.05%) patient had pain during erection and 2 (4.01%) patients had mild deviation during erection on follow up.Conclusions: Penile fracture is a relatively rare urological emergency which mostly occurs during sexual intercourse or aggressive masturbation and is usually a clinical diagnosis. Early surgical repair avoids complications and preserves both sexual and voiding functions.

Growing Skull Fracture: Case Report after Rottweiler Bite and Review of the Literature.

Growing skull fracture remains a rare but clinically significant complication of traumatic skull fractures in children less than 3 years of age. Dog attacks on children commonly cause head and neck injuries. We report the first case of growing skull fracture caused by a Rottweiler bite in a 21 days old neonate. Early diagnosis and surgical repair resulted in excellent outcome.

Omphalocele: 15-years experience from a single center in developing country

Background: Omphalocele is one of the most common anterior abdominal wall defects and still remains a management challenge in developing countries. A multidisciplinary team approach involving various prenatal and postnatal interventions is required to have a favorable outcome. In this study, we had analyzed the clinical profile and outcome of the neonates with omphalocele in a developing country. Materials and Methods: We had done a retrospective analysis of medical records of neonates who were admitted with omphalocele at our center from 2002 to 2016. Results: A total of 65 neonates were enrolled in the study with a male-to-female ratio of 1.6:1. Mean birth weight was 2550 ± 670 g and mean gestational age was 37.2 ± 3.4 weeks. Polyhydramnios was present in 40% pregnancies and only 30% (20/65) were diagnosed on prenatal ultrasound screening. Nearly 31 neonates (48%) were having omphalocele minor, and 34 (52%) were diagnosed with omphalocele major. The incidence of associated anomalies was 40% (26/65) with cardiac diseases being the most common followed by gut anomalies. Primary closure of defect was done in 78.5% (51/65) neonates, and delayed surgical repair was performed in 21.5% (14/65) neonates. Mean duration of postoperative hospital stay was 15.5 ± 3.5 days. Five patients (7.6%) expired during study period including two with associated congenital anomalies and one with rupture of omphalocele major sac membrane. Conclusion: Despite significant improvements, management of omphalocele still poses a challenge due to variable size of the defect and associated anomalies. Whenever feasible, early primary surgical repair remains the ideal procedure to have a good outcome.

A Tertiary Center Experience of Fracture Penis

Introduction: Fracture penis is uncommon and often a result of sexual trauma. Diagnosis remains clinical and early surgical management is advocated. Herein, we share our experience of 20 such cases. Materials and Methods: Twenty fracture penis patients presented between August 2014 and April 2017 were included. Patients' data were retrieved retrospectively using case sheets and followed by outpatient department visits and telephonically. Eighteen patients had penile exploration while two patients were managed conservatively. Erectile and voiding functions were assessed by asking single question to the patient, which was limited to only two options in the form of normal and abnormal. All patients were followed up for a minimum of up to 6 months. Results: The patients were aged between 20 and 60 years (mean 37.7 years). Mean timing of presentation was 28.8 h (range 2 h to 7 days). Mean follow-up was 22.5 months (6–42 months). There were no long-term postoperative complications. Eighteen patients had coital trauma, one unmarried patient had a history of manipulation of erect penis, while one patient had a fall-on erect penis. Three patients had associated urethral injury. All patients had almost the same potency as preoperatively, but for one who had erectile dysfunction for a short period recovered spontaneously on tablet sildenafil. No patient had long-term voiding dysfunction, penile curvature, or sexual dysfunction. Conclusion: History and clinical examination clinch the diagnosis. Considering it as a urological emergency, radiological imaging is not required routinely. Early surgical repair preserves the potency and voiding functions.

Early versus late repair of rotator cuff tears in rats

In the event of a traumatic rotator cuff tear, patients are routinely advised that early surgical intervention produces an optimal repair, despite a lack of direct evidence to support this recommendation. To address this knowledge gap, massive rotator cuff tears in rats were assessed by biomechanical and bone morphometric analyses after early or late repair. Combined supraspinatus and infraspinatus tendon tears of the left shoulder were created in 21 adult Wistar rats, which were divided into 2 groups. The tendons of the injured shoulder in the animals in group I were surgically repaired 8 weeks after the injury. Under the same anesthesia, the same injury was created on the right shoulder, which was immediately repaired. The rats from group I were euthanized 8 weeks after the repairs. No repair was performed in the rats from group II, which were euthanized 8 weeks after the injury. Tissues from both groups were harvested and biomechanically tested for supraspinatus tendon and bone morphometry analysis of the humeral head. All biomechanical properties were significantly increased in the early repair group compared with the late repair group. No significant differences were observed in bone morphometry of the humeral head when early and late repair groups were compared. Early surgical repair of a massive rotator cuff tear leads to improved biomechanical properties of the tissue after healing. Proximal humerus bone morphometry was unaffected by surgical repair timing.

The Assessment and Management of Simple Elbow Dislocations.

Background:Simple elbow dislocations are a commonly seen joint dislocation involving a sequential disruption of the soft tissue stabilisers without a significant associated fracture.Methods:A selective literature search was performed and personal surgical experiences are reported.Results:The majority of these injuries can be treated with expedient closed reduction, with the intact bony congruency of the elbow joint conferring early stability. Early mobilisation after reduction results in a faster recovery with good functional outcomes. Surgical intervention for persistent instability or stiffness is uncommonly required. Although, early surgical ligamentous repair has been considered, the current evidence does not demonstrate any long-term benefits compared to non-operative treatment.Conclusion:The majority of simple elbow dislocations can be successfully managed non-operatively with good reliable outcomes. Careful follow up is essential, however, to identify patients that may occasionally develop persistent instability or stiffness and require intervention.

Physical therapists as first-line diagnosticians for traumatic acute rotator cuff tears: a prospective study.

Early diagnosis of traumatic acute full-thickness rotator cuff tears (FTRCT) is important to offer early surgical repair. Late repairs following fatty infiltration of the rotator cuff muscles have less favorable results. We think that physical therapists are valuable diagnosticians in a screening process. The objective of this study was to evaluate the usefulness of physical therapists as first-line diagnosticians in detecting acute traumatic FTRCT. Between November 2010 and January 2014, 394 consecutive patients having an age between 18 and 75years who sought medical care because of acute shoulder trauma with acute onset of pain, limited abduction and negative plain radiographs were included in the study. A clinical assessment was conducted by a physical therapist 1week after the trauma. The patients were divided into three groups by the physical therapist according to the findings: FTRCT (Group I, n = 122); sprain (Group II, n = 62); or other specific diagnoses (Group III, n = 210). Group III patients were discharged and excluded from the study. Magnetic Resonance Imaging shoulder was performed for all Group I patients and for all patients with persistent symptoms in Group II. 79/184 patients had FTRCTs documented by MRI in groups I and II. The clinical assessment of the physical therapist had a sensitivity of 85%, specificity of 68%, and usefulness index of 0.45 (> 0.35 considered useful) for diagnosing FTRCT. Physical therapists can be useful as first-line diagnosticians in detecting traumatic FTRCT.

First-time anterior shoulder dislocation natural history and epidemiology: immobilization versus early surgical repair

Traumatic anterior shoulder dislocations are a common problem. There is a high rate of recurrent instability, especially in patients <30 years of age that are involved in high level sports. The purpose of this review is to discuss the natural history after a first-time shoulder dislocation and provide a brief overview of management options. Initial nonoperative management consists of immobilization in internal rotation for 1–3 weeks. The current evidence does not support immobilization in external rotation or for longer periods of time. For those patients who are at a high risk of recurrent instability, the evidence suggests that early surgical repair to address the pathology can be undertaken. This has shown to be clinically and fiscally effective while improving patient outcomes.

Ruptura bilateral total do aparelho extensor do joelho

ObjectiveBilateral extensor tendon ruptures of the knee are rare and have only been published in the form of case reports or small series. MethodsSeven patients corresponding to 14 extensor tendon ruptures of the knee were evaluated by the same examiner after a minimum one year post‐surgery. Clinical and radiographic evaluations were performed; for statistical analysis, the level of significance was set at 0.05. ResultsThe most common injury was patellar tendon rupture (n=9; 64.29%) followed by quadriceps tendon rupture (n=5, 35.71%). The intrasubstance was the most affected location (57.15%), followed by the myotendinous junction (21.43%) and the patellar bone insertions (21.43%). Quadriceps tendon ruptures were more prevalent in patients older than 50 years, while patellar tendon ruptures tended to occur in younger individuals. All but one patient had recognized risk factors for tendinous degeneration and rupture: 75% of the cases suffered from diseases, 50% had history of drug use and/or abuse, and 37.5% had both disease and drug use history. Mean attained values for flexion ROM were 124.64°±9.43 (110–140°) and 89.57±6.02 (78–94) for Kujala score. More than half of the patients complained of residual pain and quadriceps muscular weakness. Mean age was younger in the individuals who complained of residual pain. ConclusionBilateral tendon ruptures of the knee extensor apparatus ruptures are rare and serious injuries, mostly associated with risk factors. Early surgical repair and intensive rehabilitation program for bilateral extensor tendon ruptures of the knee may warrant satisfactory functional outcomes in the medium to long term, despite non‐negligible levels of residual pain, quadriceps muscle weakness, and atrophy.

Nonsurgical Conservative Management of Traumatic Intubation Causing Tracheal Rupture With Pneumomediastinum

SESSION TITLE: Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tracheobronchial rupture is an uncommon serious complication of endotracheal intubation (1). This case is a rare example of a complete posterior wall tracheal rupture with pneumomediastium that was conservatively treated successfully, without surgical intervention. CASE PRESENTATION: 77 year old female with a past medical history of mitral valve replacement, coronary artery disease s/p CABG, breast cancer, VP shunt, systolic congestive heart failure, hypothyroid and hypertension was found unresponsive and cyanotic at home. Emergency medical services were unable to intubate the patient in the field. She was then intubated in the emergency department upon arrival. Initial vitals 156/77, HR 93, RR14, 100% on Fi02 100%, T 36.6. Her physical exam was unremarkable with no crepitus noted. Initial labs showed WBCs of 22, H/H 11.8/39.2, K 5.5, BUN/Cr 21/1.3. Patient was found to have lucencies surrounding the trachea on chest x ray post intubation. Subsequent CT thorax showed (Image 1) moderate to large volume pneumomediastinum surrounding the trachea and extended upward into the neck with disruption of the right posterolateral tracheal wall. Patient was admitted to the medical intensive care unit and bronchoscopy was performed that showed a 5 cm posterior tracheal tear about 2 cm from the carina (Image 2). The tracheal injury most likely occurred due to her difficult intubation. Patient was treated empircally with vancomycin, pipercillin/tazobactam, metronidazole, serial x rays and low PEEP and tidal volume ventilation. She was extubated once her mental status had improved. The patient was successfully treated and repeat bronchoscopy showed complete resolution of the tracheal laceration. DISCUSSION: Early surgical repair is the preferred treatment for large tracheal tears with extensive subcutaneous emphysema however this option may not be feasible for elderly patients with medical comorbidities (2). These patients can be treated with empiric antibiotics, serial imaging, and low pressure mechanical ventilation. CONCLUSIONS: Patients with a large intubation induced tracheal tear with signs of respiratory failure, mediastinitis or esophageal injury can be successfully medically managed conservatively without surgical intervention. Reference #1: Conti M, Pougeoise M, Wurtz A, et al. Management of postintubation tracheobronchial ruptures. Chest 2006;130:412-8. Reference #2: Chang Cheng-Yu et al. Conservative Treatment of Severe Tracheal Laceration After Endotracheal Intubation. Respir Care 2011;56(6):861-862. DISCLOSURE: The following authors have nothing to disclose: Catherine Stadler, Jagadish Akella No Product/Research Disclosure Information

Tracheal Rupture With Extensive Subcutaneous Emphysema Involving the Face

SESSION TITLE: Critical Care SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tracheal rupture is a rare but life-threatening complication that most commonly occurs after blunt trauma of the neck and chest. Iatrogenic rupture is extremely rare and can occur after intubation, bronchoscopy, or esophagectomy. CASE PRESENTATION: A 51-year-old woman with a past medical history of hypertension presented with facial, neck, and chest wall swelling and crepitus. The patient underwent endoscopic gastric balloon removal one day earlier. 2 days after the procedure, the patient complained of discomfort around her face, neck, and chest. On admission, her examination was notable for palpable crepitus around her scalp, face, orbits, neck, and chest. The chest X-ray showed pneumomediastinum and subcutaneous emphysema (Images A and B). Chest computed tomography (CT) scan of the chest revealed extensive severe subcutaneous, fascial plane, and intramuscular emphysema, involving the scalp, face, neck, and chest (Images C-G, arrow). Additionally, there was diffuse pneumomediastinum extending to the thoracoabdominal junction, and a tear at the posterior tracheal wall. Three-dimensional (3D) CT reconstruction revealed a 5 centimeter posterior tracheal wall tear (Image H). The patient was taken emergently for surgical intervention and repair of the tracheal wall, and recovered fully. DISCUSSION: There are multiple factors which can contribute to tracheal rupture, and they can be divided into mechanical factors that include trauma during intubation, overinflation of the cuff and vigorous coughing, manipulation or surgical intervention within the airway, and anatomical factors. Overinflation of the cuff and sudden movement of the endotracheal tube are the most common causes, while a direct tear caused by the tube itself is rare [1]. Published literature on tracheal rupture has shown a female predominance and mean age over 50 years [2]. This is believed to be due to a weaker pars membranosa in women, as well as a smaller tracheal diameter which makes women more vulnerable to cuff overinflation. Male sex is an independent factor adversely influencing mortality [3]. The clinical manifestations of tracheal injury include subcutaneous emphysema, mediastinal emphysema, pneumothorax, and respiratory distress. They usually appear during surgery or in the immediate post-operative period. Subcutaneous emphysema is the most common symptom and also a protective factor, as its presence alerts to the possible existence of tracheal rupture and accelerates the steps towards its definitive diagnosis and treatment. Diagnostic confirmation is usually made by bronchoscopy. Consensus on the management of tracheal rupture has not yet been reached. Early surgical repair has traditionally been the mainstay of treatment. However, there are now more clinicians who opt for conservative treatment in patients with small ruptures (<2cm), and in selected patients with minimal, non-progressive symptoms. CONCLUSIONS: Tracheal rupture is a very rare condition but it carries a high morbidity and mortality. Diagnostic suspicion is essential, with subsequent confirmation by bronchoscopy. The condition is most common in elderly women, although the risk of death is higher in men. Iatrogenic causes occur most commonly after intubation. Reference #1: Conti M, Pougeoise M, Wurtz A, Porte H, Fourrier F, Ramon P, Marquette CH. Management of postintubation tracheobronchial ruptures. Chest. 2006;130:412-418. Reference #2: Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg. 2002;21:649-652. Reference #3: Minambres E, Buron J, Ballestros MA, et al. Tracheal rupture after endotracheal intubation. Eur J Cardiothorac Surg. 2009;3:1056-1062. DISCLOSURE: The following authors have nothing to disclose: Radu Postelnicu, Gaetane Michaud No Product/Research Disclosure Information

Current Management of Penile Fracture: An Up-to-Date Systematic Review.

Because of the low incidence of penile fracture, many aspects of the diagnostic process and of the surgical and functional outcomes are rarely reported. To systematically review the current literature on the surgical management of penile fracture, focusing on etiology, diagnosis, functional outcomes, and postoperative complications. The present review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration standards for systematic reviews. A systematic search for the terms penile fracture, fracture of penis, trauma of penis, rupture of corpora cavernosa, and immediate management of penile fracture was been carried out in the PubMed, EMBASE, Cochrane, SCOPUS, and Science Citation Index databases. Etiology of penile fracture, clinical presentation, types of radiologic investigations and their accuracy, surgical approach, suture material used for tunica repair, timing of surgical exploration, intraoperative findings, surgical complications, and functional outcomes. The total number of patients analyzed was 438, and the patients' an average age was 36 years. The most frequent reported cause of penile fracture was sexual intercourse (80% of cases). The most common finding at examination was a penile hematoma (97.5%). Although operator dependent, in experienced hands, ultrasonography was found to be a useful tool in confirming the location of the albuginea tear and identifying the presence of any concomitant urethral injury, helping the surgeon to choose the best surgical approach. Early surgical repair of a penile fracture was found to be a safe procedure, although long-term complications are not uncommon. Tertiary referral centers that managed a larger number of cases seemed to obtain more satisfactory long-term results with a significantly smaller number of complications. A low incidence of postoperative complications and full satisfactory functional outcomes are reported when early repair is performed in high-volume centers. Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current Management of Penile Fracture: An Up-to-Date Systematic Review. Sex Med Rev 2018;6:253-260.

A Systematic Review of Electromyography Studies in Normal Shoulders to Inform Postoperative Rehabilitation Following Rotator Cuff Repair

Study Design Systematic review. Background Electromyography (EMG) has previously been used to guide postoperative rehabilitation progression following rotator cuff repair to prevent deleterious loading of early surgical repair. Objective To review the current literature investigating EMG during rehabilitation exercises in normal shoulders, and to identify exercises that meet a cut point of 15% maximal voluntary isometric contraction (MVIC) or less and are unlikely to result in excessive loading in the early postoperative stages. Methods An electronic search of MEDLINE via Ovid, Embase, CINAHL, SPORTDiscus, PubMed, and the Cochrane Library for all years up to June 2016 was performed. Studies were selected in relation to predefined selection criteria. Pooled mean MVICs were reported and classified as low (0%-15% MVIC), low to moderate (16%-20% MVIC), moderate (21%-40% MVIC), high (41%-60% MVIC), and very high (greater than 60% MVIC). Results A search identified 2159 studies. After applying the selection criteria, 20 studies were included for quality assessment, data extraction, and data synthesis. In total, 43 exercises spanning passive range of motion, active-assisted range of motion, and strengthening exercises were evaluated. Out of 13 active-assisted exercises, 9 were identified as suitable (15% MVIC or less) to load the supraspinatus and 10 as suitable to load the infraspinatus early after surgery. All exercises were placed in a theoretical-continuum model, by which general recommendations could be made for prescription in patients post rotator cuff repair. Conclusion This review identified passive and active-assisted exercises that may be appropriate in the early stages after rotator cuff repair. J Orthop Sports Phys Ther 2017;47(12):931-944. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7271.