High-speed Motor Vehicle Collision Research Articles

Iliac transposition technique for reconstruction of aortic bifurcation in pediatric blunt abdominal aortic injury

Blunt abdominal aortic injuries, especially in pediatric patients, represents a rare and critical challenge. We report a unique case of a 10-year-old boy who presented after a high-speed motor vehicle collision resulting in injury to the aortic bifurcation, alongside other intra-abdominal trauma. A novel surgical approach for aortoiliac reconstruction in a contaminated field was used. This technique consisted of the mobilization of the distal aorta and common iliac arteries, ligation of right internal iliac artery, and creation of aortoiliac and common to internal iliac artery anastomoses. This method demonstrates a potentially lifesaving technique in select patients.

The epidemiology of pelvic ring fractures in Qatar

PurposeThis study aimed to determine the incidence of pelvic ring fractures and their associated epidemiological profile in Qatar.MethodsA retrospective cross-sectional study was performed at the only level I trauma centre in Qatar for patients diagnosed with pelvic ring fractures between January 2016 and December 2018. Age, sex, mechanism of injury, fracture classification and associated characteristics, mode of treatment, associated nerve injuries, and other complications were analyzed.ResultsA total of 327 consecutive patients were included, with an average age of 32.6 years. Most of the included patients were males, 85% (279), with a male: female ratio of 6:1. The incidence of pelvic fractures was 3.887/100,000 across the three years. High-speed motor vehicle collisions (MVC) were the most common mechanism of injury (108, 33%), followed by falling from height (105, 32%). Young-Burgess lateral compression (LC) fracture type was the most frequent (224, 68.5%) and was associated with 25% of the entire mortalities. Nine (2.8%) cases were open fractures, and 12% (39) were deemed unstable. Around 29% of cases had associated injuries, with an overall mortality rate of 4.9% (16) observed. Most fractures were treated nonoperatively(n = 283,86.5%).ConclusionThis study demonstrated the epidemiology of pelvic fractures in Qatar. MVC and work-related injuries were predominant in a younger cohort compared to the literature. Also, the mortality rate was lower than those reported in the literature. Therefore, well-trained surgeons and specialized trauma centres for treating these injuries are recommended.

Costoclavicular Brachial Plexus Block Facilitates Painless Upper Extremity Reduction: A Case Report.

The costoclavicular brachial plexus block (CCBPB) has emerged as a more effective approach to regional anesthesia of the upper extremity. The costoclavicular space is the anterior portion of the superior thoracic aperture, located between the clavicle and first rib. The brachial plexus cords traverse this space clustered together in a superficial location lateral to the axillary artery and share a consistent topographical relationship to one another. By targeting the brachial plexus at this specific anatomical location, the CCBPB offers a powerful, single-shot, sensorimotor block of the upper extremity below the shoulder. We present a novel application of the CCBPB to facilitate emergency department (ED) analgesia and closed reduction of an upper extremity fracture. A 25-year-old male presented to the ED with a traumatic Colles fracture sustained during a high-speed motor vehicle collision. Despite multimodal analgesia, the patient reported intractable severe pain with intolerance of radial manipulation. An ultrasound-guided CCBPB was performed to augment pain control and avoid procedural sedation, resulting in dense, surgical anesthesia of the upper extremity, and painless fracture reduction. Regional anesthesia is an effective component of multimodal pain management and another tool in the emergency physician's analgesic armamentarium. In acute orthopedic traumas necessitating emergent reduction, regional blocks serve as rescue pain control and can obviate the need for procedural sedation. In terms of targeted upper extremity analgesia, the CCBPB offers effective, single-shot, sensorimotor blockade below the shoulder, mitigating use of opioids and their deleterious side effects, while simultaneously avoiding incomplete blockade or phrenic nerve palsy associated with other approaches to brachial plexus blockade.

Costoclavicular Brachial Plexus Block Facilitates Painless Upper Extremity Reduction: A Case Report

Introduction: The costoclavicular brachial plexus block (CCBPB) has emerged as a more effective approach to regional anesthesia of the upper extremity. The costoclavicular space is the anterior portion of the superior thoracic aperture, located between the clavicle and first rib. The brachial plexus cords traverse this space clustered together in a superficial location lateral to the axillary artery and share a consistent topographical relationship to one another. By targeting the brachial plexus at this specific anatomical location, the CCBPB offers a powerful, single-shot, sensorimotor block of the upper extremity below the shoulder. We present a novel application of the CCBPB to facilitate emergency department (ED) analgesia and closed reduction of an upper extremity fracture.Case Report: A 25-year-old male presented to the ED with a traumatic Colles fracture sustained during a high-speed motor vehicle collision. Despite multimodal analgesia, the patient reported intractable severe pain with intolerance of radial manipulation. An ultrasound-guided CCBPB was performed to augment pain control and avoid procedural sedation, resulting in dense, surgical anesthesia of the upper extremity, and painless fracture reduction.Conclusion: Regional anesthesia is an effective component of multimodal pain management and another tool in the emergency physician’s analgesic armamentarium. In acute orthopedic traumas necessitating emergent reduction, regional blocks serve as rescue pain control and can obviate the need for procedural sedation. In terms of targeted upper extremity analgesia, the CCBPB offers effective, single-shot, sensorimotor blockade below the shoulder, mitigating use of opioids and their deleterious side effects, while simultaneously avoiding incomplete blockade or phrenic nerve palsy associated with other approaches to brachial plexus blockade.

Reduction of cervicothoracic spondyloptosis in an ambulatory patient: when traction fails.

Cervical spondyloptosis is a rare complication of high-energy trauma which often results in significant patient morbidity and mortality. The authors present a case of spondyloptosis of C7 over T1 with minimal radicular symptoms and otherwise complete spinal cord sparing. This case highlights the surgical challenges faced with cervical spondyloptosis and the techniques used when traction fails. A 21-year-old man with no significant past medical history presented after a high-speed motor vehicle collision with cervicothoracic pain and mild hand grip weakness in addition to numbness of the fourth and fifth digits bilaterally (American Spinal Injury Association Impairment Scale Grade D). Computed tomography imaging revealed spondyloptosis of C7 over T1, a fracture of the C2 vertebral body, and a burst fracture of C3. To relieve spinal cord compression and restore sagittal realignment, closed reduction was attempted, however this resulted in perching of the bilateral C7-T1 facets, leading to an open posterior approach. The patient underwent C7 laminectomy, bilateral C7-T1 facetectomy, and manual reduction using a Mayfield skull clamp followed by C2-T3 fixation. Postoperatively, pain was diminished, sensory disturbances were resolved and the patient was otherwise neurologically stable. There is a role for closed traction for reduction of cervical spondyloptosis, however, its role is debated especially when the patient is predominately neurologically intact. In this setting, the spine surgeon may be required to change traction and operative strategies in order to minimize potentially harmful manipulation while restoring sagittal realignment and stabilizing the spine for preservation of neurological function.

Traumatic bilateral lumbosacral facet dislocation without fracture: illustrative case.

Traumatic bilateral lumbosacral facet dislocations without fractures are extremely rare. Only 7 cases have been documented since the first description by Watson-Jones in 1974. Although various treatment strategies have been reported, no consensus has been reached regarding the best surgical approach. A 35-year-old female presented for medical attention following a high-speed motor vehicle collision. She sustained multiple injuries, including an abdominal aortic injury requiring emergent thoracic endovascular aortic repair. She was found to have bilateral lumbosacral dislocation without fracture (L5-S1) and was noted to be neurologically intact. Once medically stabilized, the patient was taken to the operating room for minimally invasive reduction and stabilization of her lumbosacral spine. Postoperatively, the patient was neurologically intact and remained stable with no deficits and appropriate lumbosacral alignment throughout her 2-year follow-up. The authors report a minimally invasive approach to the management of bilateral lumbosacral facet dislocation without fracture. Although conventional open approaches have been described previously, consideration should be given to minimally invasive strategies in select patients to facilitate their rehabilitative postoperative course.

Endovascular Repair of Traumatic Infrarenal Aortic Injury in an 8-Year-Old.

The patient is an 8 year-old male presenting to outside facility following high-speed motor vehicle collision in which he was a restrained passenger. CT imaging at that time demonstrated a traumatic infrarenal aortic pseudoaneurysm, extensive pneumoperitoneum and free fluid, and an unstable L2 vertebral body fracture. He underwent exploratory laparotomy with small bowel resection prior to transfer. The patient was left in discontinuity and temporary closed. Vascular surgery was consulted upon arrival to tertiary care children's hospital. The decision was made to proceed with emergent endovascular repair. An aortogram confirmed the location of the aortic disruption well below the renal arteries, superior to the bifurcation. An 11 mm × 5 cm Viabahn covered stent was placed across the injury with adequate proximal and distal seal. This is a case of seatbelt-related pediatric infrarenal aortic injury in the setting of polytrauma. Endovascular repair was pursued in this damage-control setting.

Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture

After a high-speed motor vehicle collision, a man presents with a laterally dislocated ankle and pulseless foot. Dr. Michael Weaver proceeds to perform an

Cervicothoracic Morel-Lavallée Lesion After a High-Speed Motor Vehicle Crash

The Morel-Lavallée (ML) lesion occurs as a result of a shearing force that separates the subcutaneous tissue from fascia, with no discontinuity with the dermis to the environment. Although most commonly occurring in the proximal lower extremity and pelvis, awareness of the injury has led to recognition of ML lesion in other regions of the body such as the thoracolumbar and lumbar spine. Late or misdiagnoses can lead to complications and increased morbidity. Awareness and early recognition of these lesions, which can occur anywhere in the spine posteriorly, often lead to successful conservative management. A complete physical examination during patient follow-up will likely lead to increased diagnoses of these lesions in a subacute setting. We present a unique case of a patient with 2 ML lesions a first report of this, with one ML lesion involving the cervicothoracic junction, previously unreported, and the other involving the thigh, the most common site for ML lesions, in the patient after a high-speed rollover motor vehicle collision. The etiology and pathophysiology of these lesions are discussed.

Blunt Traumatic Innominate Artery Pseudoaneurysm Endografting without Heparin Due to Severe Brain Injury.

Blunt traumatic innominate artery injuries occur in polytrauma victims who have suffered high-speed motor vehicle collisions. Their associated injuries may preclude the use of heparin and affect surgical management and perioperative neurological risk. The uniqueness of this case is combining the arterial injury repair with a severe progressive neurological injury that prohibited standard perioperative antiplatelet or anticoagulent use.

Case Report: Delayed Presentation of Bowel Obstruction Caused by Blunt Abdominal Trauma.

IntroductionBowel obstruction is a rare but well reported complication of blunt abdominal trauma (BAT). Obstruction is most often seen acutely caused by bowel wall hematomas and chronically as a result of post-traumatic strictures. Here, we present a novel case of BAT causing a subacute obstructing bowel wall hematoma.Case ReportA healthy, 32-year-old male presented to our emergency department with three days of nausea and vomiting. Chart review revealed he had been seen two weeks prior after a high-speed motor vehicle collision. During that initial visit, the patient had a benign abdominal exam and was discharged without imaging. On this return visit, the patient was found to have a large, obstructing colonic hematoma.ConclusionBecause emergency physicians care for patients in both the acute and subacute phases of trauma, clinicians should recognize the more subtle sequelae of BAT.

Blunt Transection of the Entire Anterolateral Abdominal Wall Musculature Following Seatbelt-Related Injury

Traumatic abdominal wall hernias (TAWHs) are uncommon and the incidence of this, which is rarely encountered in clinical practice, has been estimated at 1%. Furthermore, blunt transection of the entire abdominal wall musculature caused by seatbelt is a very rare complication. We report a case of adult with a complete disruption of the entire anterolateral abdominal wall muscle following the seatbelt injury. A 32-year-old male was wearing a seat belt in a high speed motor vehicle collision. Abdominal computed tomography (CT) scan revealed the complete disruption of bilateral abdominal wall musculatures including TAWH without visceral injury. However, injuries of small bowel and sigmoid colon were observed in the intra-operative field. The patient underwent the repair by primary closure of the defect with absorbable monofilament sutures. This case suggests that especially in TAWH patients, even if a CT scan is normal, clinicians should keep the possibility of bowel injury in mind, and choose a treatment based on the clinical findings. Keywords: Hernia, Abdominal; Seat belts; Abdominal muscles; Herniorrhaphy; Multiple trauma

Delayed presentation of blunt inferior vena cava injury following high-speed motor vehicle collision

This is a report of a case of acute-on-chronic inferior vena cava thrombosis 10 years following blunt abdominal trauma from a motor vehicle collision. Although more common risk factors for this pathology include anatomical variation or the long-standing presence of an inferior vena cava filter, history of blunt abdominal trauma serves as a rare etiology. Fewer than 20 cases of inferior vena cava thrombosis following blunt abdominal trauma have been reported in the literature, and most describe a presentation within weeks of inciting trauma. The lengthy time to diagnosis and acute-on-chronic presentation given substantial reconstitution of circulation by collateral veins make this case unique in the literature.

Evaluation of the Post-Traumatic Red Eye.

An 11-year-old male presented with 2 months of intermittent headache, left eye pain, and diplopia following a high-speed motor-vehicle collision (MVC) 2 months prior. During his initial evaluation for his MVC, no orbital or ocular trauma had been noted. He had been evaluated previously by his pediatrician, who was concerned for retinal detachment and recommended ophthalmology follow-up. He came to the emergency department due to continued and worsening symptoms. Physical examination showed mild proptosis, ptosis, as well as dilated and tortuous episcleral veins most prominent laterally (Figure 1).

Intra-Testicular Papaverine Injection for Testicular Salvage after Blunt Testicular Trauma: A Case Report

Blunt trauma is the most common mechanism of injury to the scrotum and testicle. Surgical exploration with primary repair, hematoma evacuation, and de-torsion are common surgical interventions. A 20-year-old male with no previous medical history presented after a high-speed motor vehicle collision. Ultrasonography demonstrated heterogeneous changes of the tunica albuginea and decreased arterial flow to bilateral testicles. He was subsequently taken to the operating room for surgical exploration, which revealed bilateral mottled testes with questionable viability. Papaverine was injected into each testicle, which resulted in visibly increased perfusion and subsequent preservation of the testicles. Conclusion: Current evidence on the use of papaverine is isolated to testicular torsion. Additional research should be conducted on the use of papaverine in blunt testicular trauma. Papaverine injection may be a valuable treatment option when inadequate perfusion is observed intra-operatively.

To fix or not to fix: Delayed repair of anterior flail in the frail and multiply injured

A 72-year-old male with a history of atrial fibrillation, remote stroke, hypertension, and chronic obstructive pulmonary disease presented following a high-speed motor vehicle collision. Injuries included bilateral segmental rib fractures with radiographic anterior flail and a right acetabular fracture. Secondary to thoracic trauma, mechanical ventilation was required and the patient underwent surgical stabilization of left-sided fractures utilizing by 75, 75, 115, and 50 mm plates for ribs 3, 4, 5, and 6, respectively, early in his hospital course followed by fixation of the right hemipelvis. A trial of extubation was unsuccessful. During reintubation, he developed marked abdominal distension and large volume pneumoperitoneum with signs of compartment syndrome. Emergent decompressive laparotomy revealed a perforated posterior prepyloric gastric ulcer that was repaired. Intensive care unit course was complicated by 72 h of multisystem organ failure; however, he recovered and was again nearing the point of ventilator liberation. Right-sided rib stabilization, albeit it delayed, was performed with fixation of 3, 4, 5, and 6 accomplished with long-segment plates bridging to costal cartilage in order to achieve stability. Dense inflammation and callous formation were encountered prolonging operative time. Tracheostomy was performed 3 days postoperatively, despite minimal ventilator requirements, given ongoing secretions and development of pseudomonal pneumonia. The patient was weaned to tracheostomy collar with in-line speaking valve within 2 weeks. This case highlights surgical rib stabilization in a frail, multiply injured patient through which ventilator wean was expedited and rehabilitation potential was optimized.

Case reports of atrial and pericardial rupture from blunt cardiac trauma

BackgroundBlunt cardiac trauma is diagnosed in less than 10% of trauma patients and covers the range of severity from clinically insignificant myocardial contusions to lethal multi-chamber cardiac rupture. The most common mechanisms of injury include: motor vehicle collisions (MVC), pedestrians struck by motor vehicles and falls from significant heights. A severe complication from blunt cardiac trauma is cardiac chamber rupture with pericardial tear. It is an exceedingly rare diagnosis. A retrospective review identified only 0.002% of all trauma patients presented with this condition. Most patients with atrial rupture do not survive transport to the hospital and upon arrival diagnosis remains difficult.Case presentationWe present two cases of atrial and pericardial rupture. The first case is a 33-year-old female involved in a MVC, who presented unresponsive, hypotensive and tachycardic. A left sided hemothorax was diagnosed and a chest tube placed with 1200 mL of bloody output. The patient was taken to the OR emergently. Intraoperatively, a laceration in the right pericardium and a 3 cm defect in the anterior, right atrium were identified. Despite measures to control hemorrhage and resuscitate the patient, the patient did not survive.The second case is a 58-year-old male involved in a high-speed MVC. Similar to the first case, the patient presented unresponsive, hypotensive and tachycardic with a left sided hemothorax. A chest tube was placed with 900 mL of bloody output. Based on the output and ongoing resuscitation requirements, the patient was taken to the OR. Intraoperatively, a 15 cm anterior pericardial laceration was identified. Through the defect, there was brisk bleeding from a 1 cm laceration on the left atrial appendage. The injury was debrided and repaired using a running 3–0 polypropylene suture over a Satinsky clamp. The patient eventually recovered and was discharged home.ConclusionsWe present two cases of uncontained atrial and pericardial rupture from blunt cardiac trauma. Contained ruptures with an intact pericardium present as a cardiac tamponade while uncontained ruptures present with hemomediastinum or hemothorax. A high degree of suspicion is required to rapidly diagnose and perform the cardiorrhaphy to offer the best chance at survival.

Bilateral distal ureteral transection in the setting of blunt trauma

A 69-year-old obese man was involved in a high-speed head-on motor vehicle collision. He was tachycardic and normotensive on arrival. He subsequently developed hemodynamic instability requiring blood transfusion. On examination...

Occult Spinal Cord Injury after Blunt Force Trauma in a Patient with Achondroplasia: A Case Report and Review of Trauma Management Strategy

BackgroundAchondroplastic dwarfism is associated with anatomic abnormalities that can predispose to occult injury and challenges in trauma management. Airway anatomy is problematic due to macrocephaly, midface hypoplasia, and a narrow nasopharynx. Manipulation of the neck is very dangerous due to the high likelihood of preexisting cervicomedullary stenosis. Restrictive lung disease and obstructive sleep apnea may complicate respiratory status. Peripheral and central venous access can be difficult to obtain. Orthopedic and metabolic comorbidities can lead to a prolonged hospital course. Case ReportA 17-year-old male patient with achondroplasia presented to the Emergency Department after a high-speed motor vehicle collision. Despite a negative computed tomography scan of the cervical spine and absence of neck pain, a magnetic resonance imaging evaluation was obtained due to severe neurologic deficits; it revealed disruption of the anterior longitudinal ligament at C2/3 and spinal cord contusion from C3–C6. The patient had a difficult intubation and prolonged weaning from the ventilator after his operation. Why Should an Emergency Physician Be Aware of This?Emergency physicians must maintain preparedness for all patients and situations, no matter how rare. Prior knowledge of key differences in management of the ABCDs (airway, breathing, circulation, neurological deficit) in patients with achondroplasia will reduce morbidity and mortality.

Vertebral Artery Transection in Non-Penetrating Cervical Spine Injury: A Case Report

Introduction: Vertebral artery injury associated with blunt cervical trauma has been infrequently reported. The prevalence of traumatic vertebral artery injury is approximately 0.5-2.0% to overall trauma patients, usually occurs in the setting of high-energy trauma. The most common mechanism of injury was high-speed motor vehicle collisions and pedestrian-versus-automobile collision. Here, we would like to report a case of cervical spine fracture with cord injury and left vertebral artery transection after a slipping down event that was successfully managed by endovascular intervention with favourable outcome. Case report: A 42-year-old man having medical history of alcoholic liver disease and hepatitis C was sent to our ER in December 2016 in a conscious disturbance and hypotension state after suffering a slipping down event at a slope in a market after drinking. After resuscitation, a series of trauma imaging survey was arranged. Results: His CT scan of brain showed essentially negative finding; his CT scan of C-spine demonstrated fracture of right transverse process and transverse foramen of C3, avulsion fracture of left transverse process of C4; his MRI of C-spine disclosed a large hematoma at pre-vertebral space, cord contusion and hemorrhage at C3/C4 without significant compressive lesion and loss of flow void at left upper vertebral artery at the level of C3-C4. Angiography was arranged to identify his vascular injury and it showed the interruption of left vertebral artery at C4 with formation of arteriovenous fistula draining into adjacent venous plexus. After evaluating his vital signs, liver function, and family discussion, endovascular intervention was preferred to manage his left vertebral artery injury. After the detachable coils were approved, successful trapping of the left vertebral artery was done by endovascular embolization. The angiography performed just before coiling showed the newly development of pseudoaneurysm closed to the injured site. 27 days after admission, he was discharged with stable vital signs, clear consciousness, but the muscle power of his right upper limb was grade 2/5 while the muscle power of his other extremities was grade 4/5 and he had no sphincter problem. Conclusion: There is a particularly high risk for vertebral artery injury in the setting of cervical spine fractures with subluxation, and/or extension to the foramen transversarium. Under such circumstances, the vascular injury most likely occurs when tensile or shear strain exceeds the mechanical limits of arterial tissue during hyperflexion, hyperextension, anteroposterior translation, and/or forcible rotation. Displaced bone fragments can injure the artery directly especially when the foramen transversarium is disrupted. The clinician must be aware of the presence of vertebral artery injury in cases of cervical spine trauma.