Multiple Concomitant Injuries Research Articles

Survival Secrets: Unmasking the Factors Predicting Failure of Non-operative Management (NOM) in Splenic Injuries.

Splenic injuries are common solid organ injuries resulting from blunt abdominal trauma in road traffic accidents. Very often, splenic injuries can be life-threatening. Earlier, splenic injuries were often dealt with surgical intervention, such as splenectomy. With the recognition of the immunological function of the spleen and possible complications of splenectomy surgery, such as overwhelming post-splenectomy infections (OPSI), there has been a recent trend for non-operative management (NOM). To study the variables predicting failure of NOM in blunt abdominal trauma patients with splenic injury. This is a retrospective study that includes 235 patients who presented to the Safdarjung Hospital emergency room (New Delhi, India) with blunt trauma abdomen and splenic injuries with or without associated injuries between January 2019 and December 2021. The data was entered in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Categorical variables were expressed as frequencies and percentages. Pearson's chi-square test of association was used to determine if there is a relationship between two variables. A p-value of <0.05 was considered statistically significant. Out of 235 patients with blunt abdominal trauma and splenic injuries, 82 were hemodynamically unstable despite resuscitation and were taken up for emergency laparotomy. The remaining 153 patients, who were either hemodynamically stable or stabilized after adequate resuscitation, were managed on the lines of NOM. The number of patients with splenic injury in AAST grades 1, 2, 3, 4, and 5 was 36, 50, 40, 24, and three, respectively. Out of 153 patients, 130 (85%) were successfully managed by NOM, while eight (5%) had to discontinue NOM as they required surgical intervention. The failure of NOM (fNOM) is seen mostly with grade 5 injuries (2/2, 100%, p<0.01), followed by grade 4 (4/20, 20%) and grade 3 (2/37, 5.7%). The mean age in fNOM was 58.3 years, as compared to 42.2 years in the success of NOM (sNOM). All eight patients had multiple concomitant injuries, with femur fracture being the most common association in up to six patients (p<0.01), followed by liver injury in four patients. There were 15 mortalities, irrespective of AAST severity grade. All of these patients had associated concomitant injuries, with intracranial bleeding (n = 10, 32%, p<0.01) being the most common association, followed by femur fracture (n = 6, 20%) and liver injury (n = 5, 16%). Also, the cause of death was unrelated to splenic trauma (p = 0.67), with pulmonary embolism (n = 6, 40%, p<0.01) being the most common cause, followed by brain stem herniation (n = 5, 34%). Non-operative management is a safe and efficient method for treating patients with splenic injuries who are hemodynamically stable or stabilized. The factors associated with fNOM include elderly age, a higher American Association for the Surgery of Trauma(AAST) grade of splenic injury, and associated concomitant injuries. Femur fracture was the most common concomitant injury present in cases where NOM failed, followed by liver injury. The presence of intracranial bleeds in these patients was a common association with mortality, irrespective of the grade of splenic injury.

Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play

This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes. NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded. There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position. Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. Prognostic IV.

Classifying and standardizing panfacial trauma according to anatomic categories and Facial Injury Severity Scale: a 10-year retrospective study

BackgroundThe purpose of this study was to identify the epidemiologic factors of panfacial fractures (PFs), and to evaluate the significance of anatomic PF categories and the Facial Injury Severity Scale (FISS) in classifying and standardizing panfacial injuries.MethodsA retrospective review of all patients treated with PFs at our institution between June 2010 and April 2021 was performed. PF was defined as a concurrent fracture in at least 3 of 4 facial subunits (frontal, upper midface, lower midface, and mandible). Data regarding patient demographics, causes of injury, location of fractures, major concomitant injuries, and postinjury complications were collected, and the FISS score was collected from each patient. Statistical analysis was performed using IBM SPSS Statistics version 22.0.ResultsA total of 227 patients were enrolled. The most commonly fractured bones were the maxillary sinus wall (92.1%), mandible (82.8%), and zygomatic arch (75.3%), and the most common fracture sites in PFs were graphically presented. Four PF patterns were defined: FULM (n = 60), FUL (n = 39), ULM (n = 127), and FUM (n = 1). There was a significant association between PF patterns and sex (p = 0.018), the number of concomitant injuries (p = 0.014), and early surgical airway management (p = 0.003). Different PF patterns were significantly correlated with different types of concomitant injuries and complications. The FISS score showed a significant difference with PF patterns (p = 0.000) and sex (p = 0.007), and a FISS value of 11 or more is the appropriate cutoff for the prediction of multiple concomitant injuries and complications.ConclusionsBoth the anatomic PF categories and FISS were significantly correlated with various concomitant injuries and complications. The combination of PF categories and FISS provided a better positive and negative prediction of concomitant injuries and complications for PF patients. Patients with FULM and FISS > 11 had an obviously higher proportion of the need for multiprofessional treatment.

Cost Utility of Splenic Artery Angioembolization for High-Grade Splenic Injury

Abstract Background: Management of blunt spleen injuries has evolved from mandatory splenectomy to non-operative man-agement (NOM) allowing for splenic salvage, Splenic artery embolization (SAE) has been shown to be an effective treat-ment for hemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. Aim of Study: The aim of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma with splenic injury and to determine if the costs of an added, preventative procedure (SAE) early in management of blunt splenic injury would be offset by added utility by avoiding splenectomy. Patients and Methods: This study was a retrospective cohort study from a tertiary institution (50 patients in King Khaled Hospital Trauma Center, Hail, KSA and 9 patients in Al Hussein University Hospital, Cairo, Egypt). A total of 59 patients were treated with embolization in this period for blunt trauma, and however 39 cases were excluded given the presence of multiple concomitant injuries. Isolated splenic injury treated with SAE were identified in 20 patients and included for final analysis. Of these 10 patients, none required subsequent splenectomy following SAE. Results: The mean total angiography costs were 1837.94± 405.368 $, the costs of post-procedure management of patients including all hospital costs prior to discharge with associated length of stay. Conclusion: Splenic embolization is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our center was much lower than previously modelled data from overseas studies. Further research is advised to directly compare the cost of SAE and splenectomy in other countries.

Younger age increases the risk of sustaining multiple concomitant injuries with an ACL rupture.

Anterior cruciate ligament (ACL) tears have a major impact on the individual and society. Long term effects may be mediated by injuries that occur concurrently to the ACL tear. The purpose of this study was to describe in a nationwide cohort the traumatic meniscal injuries and bone marrow lesions concomitant to ACL tears, their age and sex distribution and the rate any association with ACL reconstruction. All ACL tears in Iceland from 2006 to 2011 and their concomitant bone marrow lesions and meniscal injuries were identified from MRI reports. These injuries were further classified by location, sex and age. The cohort was divided into under 17, 17-29, 30-49 and above 50 to reflect likely differences in the mechanisms of injury and risk factors that may vary with age. Data from the Icelandic Social Insurance Administration were used identify all those who were operated. Descriptive analysis was performed to show the proportion of ACL injured knees sustaining concomitant injuries and how these injuries varied with age, sex, and subsequent treatment RESULTS: 1365 knees with ACL ruptures were included. Only 13% of knees had no concomitant injury identified. Overall, 57% of knees had a bone marrow lesion in at least one location and 70% of knees had at least one traumatic meniscal injury. A greater number of combined lateral tibial and femoral bone marrow lesion was seen in younger age groups (χ2 (3) = 113.32, p < 0.0001). Bruises in the medial compartment were the least common concomitant injuries. More injuries were related to higher chances of ACL reconstruction (OR 1.6, 95% CI 1.4-1.7). Age was associated with risk of all injury types and locations with older age generally being associated with fewer injuries. In an ACL ruptured cohort, the overall incidence of BMLs may be lower and meniscus injuries higher than previously reported. However, these injuries are more prevalent in the younger cohort potentially resulting in a poorer long-term prognosis. Knowledge of the association between age and concomitant injuries will help guide rehabilitation. II.

Posterior pelvic plating in the treatment of tile type C unstable pelvic injuries: a prospective study

Introduction Unstable pelvic ring disruptions result from high-energy trauma and are often associated with multiple concomitant injuries. Internal fixation has become the preferred treatment for unstable posterior pelvic ring injuries. Several methods of fixation of posterior pelvic injuries have been described, including anterior pelvic plating, posterior sacroiliac plating, lumbopelvic fixation, and percutaneous fixation with iliosacral screws. Aim The aim of this study was to report on the clinical and radiological results of plate osteosynthesis for fixing posterior pelvic injuries in Tile’s C completely unstable pelvic ring injuries. Patients and methods This study involved 21 patients with Tile type C pelvic injuries who had their posterior injuries fixed by plate osteosynthesis. The mean duration of postoperative follow-up was 25.29±9.93 (13–48) months. The clinical outcome was assessed with postoperative Majeed’s score and the rate of postoperative complications. The radiological outcome was assessed through the measurement of posterior displacement as per the method of Matta and Tornetta. Results The mean±SD postoperative Majeed score was 76.57±11.21. There was a statistically significant improvement in the postoperative vertical displacement of the posterior injury (P Conclusion Pelvic plating is an effective procedure in the management of completely unstable posterior pelvic ring injuries. The treatment of these complex injuries is associated with a relatively high incidence of postoperative complications.

Traumatic and non-traumatic adrenal emergencies.

Multiple traumatic and non-traumatic adrenal emergencies are occasionally encountered during the cross-sectional imaging of emergency department patients. Traumatic adrenal hematomas are markers of severe polytrauma, and can be easily overlooked due to multiple concomitant injuries. Patients with non-traumatic adrenal emergencies usually present to an emergency department with a non-specific clinical picture. The detection and management of adrenal emergencies is based on cross-sectional imaging. Adrenal hemorrhage, adrenal infection, or rupture of adrenal neoplasm require immediate detection to avoid dire consequences. More often however, adrenal emergencies are detected incidentally in patients being investigated for non-specific acute abdominal pain. A high index of suspicion is required for the establishment of timely diagnosis and to avert potentially life-threatening complications. We describe cross-sectional imaging findings in patients with traumatic and non-traumatic adrenal hemorrhage, adrenal infarctions, adrenal infections, and complications of adrenal masses.

A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction.

War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury with multiple concomitant injuries that can contribute to limited coverage options. Thus, flap availability and choice can become critical in the reconstruction algorithm of these severely traumatized patients. The authors' purpose was to analyze the outcomes of muscle and fasciocutaneous flaps during their extremity reconstructive experience to determine which option had better flap and limb salvage outcomes. A retrospective review of servicemembers treated with flap-based limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Patients were divided into cohorts of patients who underwent muscle or fasciocutaneous flaps. Three hundred fifty-nine flap procedures were performed. Of these procedures, 197 were muscle (55 percent) and 152 were fasciocutaneous flaps (42 percent). There was no difference in overall flap complications between groups (30 percent versus 26 percent; p = 0.475). However, there was a significantly higher flap failure rate in the muscle compared with the fasciocutaneous group (13 percent versus 6 percent; p = 0.030). Although there were more overall extremity complications in the muscle group (59 percent versus 47 percent; p = 0.030), there were no significant differences in soft-tissue infection, osteomyelitis, or amputation rates. There are many flap options that provide adequate coverage in extremity salvage. Complication rates did not differ significantly between muscle and fasciocutaneous flaps, with one exception--flap failure rates were significantly higher in our muscle-based flap cohort of patients. Nonetheless, each of these flap types has utility in our patients based on individual wounding patterns, flap availability for reconstruction, and rehabilitation goals. Therapeutic, III.

Surgical Treatment of Complicated Sacrum Fractures in Unstable Pelvic Injuries. Treatment Experience

The majority of unstable pelvic injuries are accompanied by sacrum fractures of different localization. Experience in treatment of 8 patients with multiple concomitant injuries and sacrum fractures at the level of sacrum canal (Denis 3) is presented. All patients with acute condition were admitted into intensive care unit and underwent complex examination. At this step of intensive care the complexity of sacrum fractures and nerve injuries diagnosis is conditioned by the severity of patient’s condition. Patients with pelvic injuries require careful examination for detection of sacrum and nerve injuries in this region. However taking into account the multiplicity of injuries the emergency operation for nerve roots revision is not expedient. At rendering care to such patients the basic principles should be the conception of injuries control with preference given to stable and functional methods of fracture fixation. In our opinion all Denis 3 fractures with neurologic disorders require decompression-stabilizing operations that enable to mobilize patients, to determine and probably to improve the prognosis of neurologic pathology.

Surgical Treatment of Complicated Sacrum Fractures in Unstable Pelvic Injuries. Treatment Experience

The majority of unstable pelvic injuries are accompanied by sacrum fractures of different localization. Experience in treatment of 8 patients with multiple concomitant injuries and sacrum fractures at the level of sacrum canal (Denis 3) is presented. All patients with acute condition were admitted into intensive care unit and underwent complex examination. At this step of intensive care the complexity of sacrum fractures and nerve injuries diagnosis is conditioned by the severity of patient’s condition. Patients with pelvic injuries require careful examination for detection of sacrum and nerve injuries in this region. However taking into account the multiplicity of injuries the emergency operation for nerve roots revision is not expedient. At rendering care to such patients the basic principles should be the conception of injuries control with preference given to stable and functional methods of fracture fixation. In our opinion all Denis 3 fractures with neurologic disorders require decompression-stabilizing operations that enable to mobilize patients, to determine and probably to improve the prognosis of neurologic pathology.

Percutaneous Minimally Invasive Management of Iatrogenic Ureteral Injuries

To present experience with the percutaneous management of iatrogenic ureteral injuries. Eighteen women and six men with a mean age of 59.3 years (range 33-80 years) received a diagnosis of ureteral injury sustained during gynecologic, urologic, and general surgical procedures. In a total of 25 injured ureters, 12 had interruption of continuity of their lumen, 10 were associated with contrast extravasation, and 3 were related to both. A standard percutaneous nephrostomy tract was established on the side of the afflicted kidney. Combined use of hydrophilic guidewires and balloon dilations were performed to achieve antegrade recanalization of the ureteral lesion. Then, a ureteral stent was inserted to assure patency. Average stricture length was 1.21 (range 0.5-1.9 cm). Success of the aforementioned technique was possible in 18 ureters. Successful management in one session took place in 14 ureters. Average hospitalization time was 1.8 days (range 0-5 d). The follow-up period ranged between 12 and 18 months, with mean follow-up time of 12.9 months. Ureteral patency was evident at 1 week follow-up in six patients with obstructed ureters. In the remaining patients, balloon dilation of the stricture was repeated, and another stent was placed. Extravasation of contrast was observed in two patients with extravasating ureters in the same period. Nephrostomy tubes were removed after a mean indwelling period of 5.9 weeks (range 1-12 wks). Two patients treated by the described method died during their hospitalization in the intensive care unit because of sepsis from peritonitis that was related to colon injury and multiple concomitant injuries. Major complications were not observed in the remaining 22 patients during the follow-up period. The minimally invasive management of ureteral injuries is a safe and efficient method for both ureteral obstruction and/or laceration in a wide range of iatrogenic ureteral injuries.

Sepsis Caused by Peripelvic Soft Tissue Infections in Critically Injured Patients With Multiple Injuries and Unstable Pelvic Fracture

In critically injured patients with multiple injuries and unstable pelvic fracture, late mortality almost invariably results from sepsis. We analyzed the clinical features of 11 patients with sepsis caused by soft tissue infections surrounding the fractured pelvis, of 830 patients with pelvic fracture after blunt trauma treated at our level I trauma center over the past 25 years. Soft tissue infection was defined as abscess formation in subcutaneous tissue or muscle diagnosed by computed tomography or an operation. Mean injury severity score was 48, and mean systolic blood pressure on arrival was 66 mm Hg. All patients had multiple concomitant injuries and prolonged hemorrhagic shock. Open pelvic fracture was present in five patients. Mean blood transfusion volume within 24 hours was 12,611 mL. Intra-aortic balloon occlusion was performed in three patients and transcatheter angiographic embolization in nine patients. Embolic sites of transcatheter angiographic embolization were bilateral internal iliac arteries (n = 9), lumbar artery (n = 5), median sacral artery (n = 2), and circumflex femoral artery (n = 2). Infection sites included the gluteal (n = 11), femoral (n = 6), sacral (n = 4), lumbar (n = 4), anterior iliac (n = 2), inguinal (n = 1), and perineal (n = 1) regions. Necrotic changes of infected soft tissue were found in all patients. They underwent open drainage and daily debridement with pulsatile irrigation followed by intravenous antibiotics. All patients developed severe sepsis, five of whom subsequently died of multiple organ failure. In critically injured patients with multiple injuries and unstable pelvic fracture, peripelvic soft tissue infections occasionally cause sepsis. Peripelvic infections are often accompanied by necrotic changes and easily develop into severe sepsis or multiple organ failure. Identifying high-risk patients and early diagnosis with prompt surgical treatment are indispensable for the patients' survival.

Distal radius fractures and concomitant injuries: experimental studies concerning pathomechanisms

Since Colles’ description of the distal radius fracture (1814) and the publication by Dupuytren (1834), the frequency of this fracture, and the problems associated with it, have been increasingly recognized. Not only the treatment but also the mechanism of injury of the different types of fracture have been analysed repeatedly. The various theories concerning the pathomechanism have led to names such as “sprain fracture”, “bent fracture”, “thrust fracture”, “compression fracture”, “snap fracture” and others. In our experimental studies, we attempted to simulate the pathomechanics of distal radius fractures, and to represent it illustratively. With the aid of a materials testing machine, 63 prepared cadaver parts were hyperextended at the wrist joint until distal radial fracture occurred. Accompanying injuries were identified radiologically and by dissection. Furthermore, the cadaver parts were deep-frozen and examined by means of computer tomography and cryo-section, using Kathrein's method. Through experimental hyperextension, it was possible to generate dorsal, central and palmar types of fracture. We produced 42 dorsal, 14 central and seven palmar fractures. The extent to which the carpal bones of the proximal row were pressed against the dorsal or palmar edge; or the centre of the distal radial articular surface, was fundamental. Subsequent dissection showed multiple concomitant injuries in 40 cases (63%), and none in 23 cases (37%). One reason for the occurrence of such concomitant injuries may be the relative strengths of the bone and ligaments. Most frequently (27 cases, or 43%), we found a destabilization of the triangular fibrocartilage, with or without a bony avulsion fragment (fracture of the ulmar styloid process), followed by ruptures of the interosseous ligaments between the scaphoid and the lunate (20 cases, or 32%) and between the lunate and triquetrum (11 cases, or 18%). The application of knowledge gained from experimental studies carried out on fixed cadaver parts to clinical cases is problematic. This holds true for both concomitant injuries and fracture types. The lack of physiological defence reflexes as well as the deliberately slowed experimental procedure must be taken into account. On the other hand, in this series of experiments it was possible to generate experimentally many of the radius fractures found in clinical practice, together with their concomitant injuries. Distale Radiusfrakturen and Begleitverletzungen: Experimentelle Untersuchungen zum Pathomechanisms Received: 6 June 2000; Accepted: 25 January 2002 Handchir Mikrochir Plast Chir 34 (2002) 150–157 © Georg Thieme Verlag Stuttgart, New York ISSN 0722-1819 English Translation:

Penetrating injuries of the subclavian artery

Background Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. Methods A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. Results The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. Conclusions Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.

Endovascular Management of Blunt Traumatic Renal Artery Dissection

To describe the importance of accurate diagnosis and successful emergent endovascular repair of intimal injury to the renal artery from sudden deceleration. A 22-year-old man was evaluated after jumping head first out of a fourth floor window. Gross hematuria was detected at the initial assessment. Contrast-enhanced computed tomography (CT) revealed diminished uptake in the right kidney. Arteriographic examination of the renal artery demonstrated 2 areas of intimal disruption, which a team of physicians decided to treat with angioplasty and stent placement owing to the associated intracranial injuries. Two balloon-expandable stents were successfully deployed to exclude the intimal defects. Once the associated injuries were also addressed, the patient made an uneventful recovery. CONCLUSIONS; Management of blunt traumatic injuries to the renal vasculature involves timely assessment to maximize preservation of renal function. In the setting of multiple concomitant injuries, recent experience supports the consideration of endoluminal intervention for traumatic renal artery dissections.

Endovascular Management of Blunt Traumatic Renal Artery Dissection

Purpose:To describe the importance of accurate diagnosis and successful emergent endovascular repair of intimal injury to the renal artery from sudden deceleration.Case Report:A 22-year-old man was evaluated after jumping head first out of a fourth floor window. Gross hematuria was detected at the initial assessment. Contrast-enhanced computed tomography (CT) revealed diminished uptake in the right kidney. Arteriographic examination of the renal artery demonstrated 2 areas of intimal disruption, which a team of physicians decided to treat with angioplasty and stent placement owing to the associated intracranial injuries. Two balloon-expandable stents were successfully deployed to exclude the intimal defects. Once the associated injuries were also addressed, the patient made an uneventful recovery.Conclusions:Management of blunt traumatic injuries to the renal vasculature involves timely assessment to maximize preservation of renal function. In the setting of multiple concomitant injuries, recent experienc...

Non-penetrating abdominal trauma: With special reference to lesions of the duodenum and pancreas

1. 1. A series of sixty-seven cases of non-penetrating trauma of the abdomen has been reviewed with over-all mortality of 19.4 per cent. 2. 2. Occurrence of subcutaneous abdominal trauma is relatively rare in hospital admissions. Injury to the liver, spleen, kidney and the fixed solid viscera are most common. 3. 3. The high mortality lies in the frequency of multiple concomitant injuries not only intra-abdominal but also those of the head, chest and diaphragm and pelvis. Lesions of the liver, spleen, stomach and diaphragm show the highest mortality. 4. 4. There were thirty-four operative and thirty-three non-operative cases. The non-operative cases were largely those of mild trauma, contusion of the kidney, those in extremis and those with delayed or concealed hemorrhage in the multiple-injured. 5. 5. Nine of the eighteen cases of splenic rupture were associated with multiple injuries; four survived splenectomy. All patients in whom splenic laceration was the only trauma recovered following splenectomy. 6. 6. A case of retroperitoneal complete rupture of the duodenum between the second and third portions is reported. The diagnosis was aided by gas outlining the psoas muscle shadow, demonstrated in flat abdominal x-ray. Likewise, retroperitoneal crepitation lateral to a peculiar gray-black hematoma in mesentery of the ascending colon was present. For full exposure of ruptured segments not only mobilization of the ascending colon and duodenum, but also division of lateral margin of the gastrocolic omen-turn was required. 7. 7. The reported characteristics of retroperitoneal duodenal rupture are reviewed. 8. 8. The relatively high incidence of pancreatic lesions in this series is noteworthy. These consisted of a case of complete rupture of the pancreas with rupture of stomach and duodenum, a simple contusion of the head of the pancreas complicated by secondary suppuration of gallbladder and atonic obstruction of duodenum, and two cases of mild pancreatic trauma followed with the development of pseudocysts. 9. 9. The high mortality of pancreatic lesions with concomitant major trauma is discussed. 10. 10. The complications of pancreatic injury are reviewed, particularly pseudocyst and fistula, and their treatment described. For pseudocyst resection with partial pancreatectomy, cyst gastrostomy or cyst enterostomy is the treatment of choice.