Post-traumatic Setting Research Articles

Incidental Detection of a Rare Pediatric High-Grade Fibrosarcoma in a Post-traumatic Setting: The Conundrum of Intra-Abdominal Hematoma versus Neoplasia

Infantile fibrosarcoma (IF) is a rare malignant fibroblastic tumor that affects infants and young children, occurring most commonly in the extremities. Here, we present a 14-year-old patient with an abdominal mass incidentally detected after a blunt injury to the abdomen. The initial trauma protocol CT revealed a high attenuation mesenteric lesion in the left central abdomen suggestive of mesenteric hematoma. However, the possibility of a solid neoplastic mass lesion could not be excluded. Further evaluation with dynamic contrast-enhanced serial MRI showed a progressive enhancing mass and excluded a hyperacute hematoma with active bleeding. The mass was resected, and histopathological examination and molecular analysis of tumor cells were consistent with a high-grade fibrosarcoma with KMT2D : BCOR fusion.

Elbow Soft Tissue Coverage after Trauma

Traumatic injuries involving the elbow can result in soft tissue defects with exposed critical structures including bone, joint, nerve, tendons or implants.1 Additionally, wounds about the elbow are subject to significant motion and tension, limiting the success of local wound care.2 In these clinical settings, soft tissue reconstruction is often indicated. The goal of reconstruction is elbow wound coverage with pliable, thin, and durable tissue that allows for repetitive motion without limiting range of motion.3 In the post-traumatic setting, optimal function is achieved if the soft tissue reconstruction allows for early return to active motion of the elbow joint.4

Defining the region of interest of the knee for perioperative volumetric assessment with a portable 3D scanner in orthopedic and trauma surgery.

BackgroundThe aim of this study was to characterize three regions of interest (ROI) around the knee with a portable 3D scanner (Artec 3D scanner EVA). Soft tissue topography assessment with an optimized, precise, and reproducible method may assist surgeons when managing soft tissue swelling in the post traumatic setting.Methods12 healthy volunteers (24 legs, 7 women, 5 man) were included in this study. The patient cohort showed a mean age of 27.1 years (SD±3), a mean weight of 70 kg (SD±13) and a mean height of 171 cm (SD±8.8). All scans were recorded by the same examiner in the same room and with the same scanner (Artec, 3 D scanner EVA). Three volume regions of interest (ROI) were defined: the distal femur (circumference measured between the of superior extent of the patella to 10 cm proximal), the knee joint (measured from the top of the patella to the tibial tuberosity) and the proximal tibia (tibial tuberosity to 10 cm distal).ResultsThe mean volume of the right leg was 3.901 l (I. distal femur: 1.63 l, knee joint: 1.33 l, proximal tibia: 1.10 l) and mean volume of the left leg was 3.910 l (I. distal femur: 1.66 l, knee joint: 1.34 l, proximal tibia: 1.12 l). The volume difference between the right and left leg was 0.094 l (SD ± 0.083 l) The Wilcoxon-Mann-Whitney test showed no significant differences of the volumes between the right and left leg.ConclusionsThis study demonstrates that portable 3D scanning could be an accurate and reliable tool for orthopedics and trauma surgeons. Based on the ROIs of this pilot study, further studies are needed to test the significance for clinical applications for patients with an injured knee.

Paenibacillus wound infection in a pediatric trauma patient

We report a case of Paenibacillus wound infection in an immunocompetent and otherwise healthy nine-year-old boy who sustained a laceration following an all-terrain vehicle crash. During his course, he failed non-operative management and required multiple wound washouts and a thirty-six-day course of antibiotics. While this pathogen is most known for causing honeybee disease known as American Foulbrood (AFB), Paenibacillus has been implicated in a handful of human wound complications in the post-traumatic setting. This is a rare, opportunistic bacteria that is resistant to many commonly prescribed antibiotics. Less than twenty cases of human Paenibacillus wound infections have been reported in the literature and when they do occur, they often affect immunocompromised patients or those with chronic medical co-morbidities. In the last ten years, there have been four case reports of neonatal sepsis caused by this pathogen. This appears to be the first pediatric Paenibacillus wound infection reported.

Post-traumatic peripheral vestibular disorders (excluding positional vertigo) in workers following head injury

Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience. The UHN WSIB Neurotology database (n = 4291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI. Based on a database of 4291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere’s disease in the post-traumatic setting did not appear greater than found in the general population. The clinical spectrum pertaining to recurrent vestibulopathy, Meniere’s disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

Trauma to a Hepatoblastoma: A Case Report

We are reporting a case of previously undiagnosed hepatoblastoma in a healthy child, who presented acutely in a post-traumatic setting. We reported a 7-year-old boy, with no previous medical history, presented with gradual worsening abdominal pain following an episode of trivial trauma to the abdomen two weeks prior. He was anaemic at presentation, and had a distended abdomen with a tender enlarged liver. Computed tomography (CT) of the abdomen showed a grossly enlarged left lobe of the liver, within which was an organized hematoma. Serum alphafetoprotein (α-FP) was raised significantly. The liver injury was managed conservatively and the child recovered well. He is set to undergo staging scans and further workup, in anticipation of subsequent systemic therapy. Though exceedingly unlikely in older children, the diagnosis of hepatoblastoma should be entertained in those with an enlarged liver with a clinical presentation masquerading as a ‘straightforward’ liver injury.

Proximal Interphalangeal Joint Arthroplasty in Young Patients.

This investigation compares the outcomes of proximal interphalangeal (PIP) arthroplasty in patients older than and younger than 60 years. Overall, 299 consecutive, primary PIP arthroplasties were performed over a 14-year period, including 126 arthroplasties performed in patients younger than 60 years. In younger patients group, a higher rate of posttraumatic and inflammatory arthritis was observed. In patients younger than 60 years, 32 (25%) revision surgeries occurred. Risk of revision surgery was associated with younger age. The 10-year implant survival rate was 72% for the patients younger than 60 years versus 86% for those older than 60 years. Silicone implants decreased the risk of revision surgery, although it was increased in posttraumatic arthritis. The most common complication in young patients was dislocation (n = 21). At a mean follow-up of 6.4 years, pain levels had significantly improved in patients younger than 60 years, and PIP range of motion and pinch strength were maintained. However, older patients had improved PIP motion compared with younger patients. Younger age leads higher revision rates after PIP arthroplasty, particularly in the posttraumatic setting. Therapeutic, level III.

Instability after reverse total shoulder arthroplasty

This study evaluated patients with and without a prosthetic dislocation after reverse total shoulder arthroplasty (RTSA) to identify risk factors for instability. Dislocation and nondislocation cohorts were established for analysis in 119 patients who had undergone RTSA at our institution between 2011 and 2014. Preoperative history and parameters pertaining to RTSA design were evaluated for correlation with instability. A logistic regression model was used to analyze independent predictors. Eleven patients (9.2%) demonstrated instability in the early postoperative period. Dislocations occurred at an average of 8 weeks postoperatively (range, 3 days-5 months). The mean follow-up of all patients was 28 months (range, 6-106 months). Postoperative instability was associated with male gender, history of prior open shoulder surgery, and preoperative diagnoses of fracture sequelae, particularly proximal humeral or tuberosity nonunion. Absence of subscapularis repair was an independent predictor of instability. In addition, 5 of the 11 patients (45%) in the instability cohort sustained a second dislocation requiring another operation. Redislocation after revision surgery for the initial dislocation was an unexpected and alarming finding. Treatment for the initial dislocation event by placement of a thicker polyethylene insert was inadequate in 45% of patients of our cohort and required another revision with a larger glenosphere and thicker humeral inserts. Initial instability after RTSA must be carefully managed, especially in the revision and post-traumatic setting. Exchange to a thicker polyethylene insert only carries a higher risk of recurrent instability.

Clinical Contribution of Wrist and Hand Sonography: Pilot Study.

The purpose of this study was to evaluate the clinical contribution of wrist and hand sonography. This study was performed in a tertiary academic medical center. Institutional review board approval was obtained. Data collection was done retrospectively from January 2012 to December 2016 and prospectively from January 2017 to July 2017. The study included 112 consecutive patients (52 men and 60 women; mean age, 47 ± 16 years; range, 15-87 years). A total of 126 examinations were performed. All ultrasound examinations were done with high-resolution probes with up-to-date protocols. The clinical contribution of wrist and hand sonography was assessed (ultrasound examinations contributive/noncontributive). Descriptive statistic and nonparametric tests were used. In 96 of 126 (76%) examinations, sonography proved to be contributive, and in 30 of 126 (24%) examinations, sonography proved to be noncontributive. The contributive/noncontributive ratio was 3.2 (96/30). A total of 51 of 126 (40%) examinations were performed in patients with a history of previous trauma. Sonography proved to be significantly more contributive in a posttraumatic setting (chi-square, 9.2; P = .0023). Wrist and hand sonography significantly influences the diagnostic and therapeutic path, especially in a posttraumatic setting.

Preoperative Diagnosis Can Predict Conversion Total Knee Arthroplasty Outcomes

BackgroundCompared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA. MethodsSeventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes. ResultsThe postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042). ConclusionPatients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.

Moderate Depression Promotes Posttraumatic Growth (Ptg): A Young Population Survey 2 Years after the 2009 L'Aquila Earthquake.

Background:Earthquakes can result in a range of psychopathology and in negative and positive consequences for survivors.Objective:To examine the association between clinical aftereffects (anxiety and depressive symptoms) and post-traumatic growth (PTG) among young survivors of the 2009 L’Aquila earthquake, Italy.Method:316 young earthquake survivors enrolled in the University of L’Aquila were evaluated two years after the natural disaster. Participants completed three main questionnaires, including Patient Health Questionnaire-9 items (PHQ-9), Self-Rating Anxiety Scale (SAS), and Posttraumatic Growth Inventory (PTGI).Results:59.6% of the student sample showed different levels of depression, whereas 13.3% reported anxiety symptoms. In both clinical dimensions (anxiety and depression), gender differences were found: female gender was confirmed risk factor for a clinical post-traumatic response. Personal PTG, demonstrated by 18% of the L’Aquila youths included in our sample, was predicted by moderate levels of depression (O.R. 2.7). In our model, gender, age, and anxiety did not show any predictive value.Conclusion:In a post-traumatic setting, the development of individual cognitive strategies is crucial, whereas after a natural disaster, paradoxically, a moderate depressive condition and the related distress could promote the drive to overcome the psychological consequences of the traumatic event.

Abstract No. 462 - Lymphatic intervention for various kinds of lymphorrhea

tion has been shown to be effective in the treatment of recurrent chylous effusions. Many embolic agents have been described in the successful occlusion of the thoracic duct. In this study, we evaluate the role and efficacy of using EVOH copolymer (Onyx) in the treatment of traumatic chylous pleural effusions. Background: A retrospective review was performed of consecutive patients with post-operative chylous pleural effusions treated with thoracic duct embolization using EVOH copolymer at a single institution from 2012-2014. Demographic data, surgical history, procedure details, and toxicities were systematically reviewed. Clinical Findings/Procedure Details: 4 patients (M1⁄42) were identified that met inclusion criteria. Median age at treatment was 67. Median follow was 125 days (range 24-246). Two patients had undergone robotic assisted surgery and 2 had undergone open thoracotomy. 3 patients had thoracic duct ligation performed at the time of their initial surgery. Median time from surgery to embolization was 7 days (range 3-15). Daily chest tube drainage range was 150 -2000 ml. All patients underwent bilateral ultrasound guided inguinal nodal lymphangiogram. The thoracic duct was then accessed using a 21 or 22 gauge Chiba needle. A thoracic duct leak was identified in 3 patients. Coils were placed initially in the central duct prior to embolization of the leak limit potential systemic flow. Onyx 34 (ev3 Neurovascular, Irvine, California) was used in 4 patients with additional Onyx 18 in 1 patient for embolization. Volume used was 1-2 ml in all patients. All patients had resolution of the chylous effusion within 1 day of embolization. The subjects were discharged from the hospital between 4-7 days post-procedure. 30 days post-procedure complications included an abdominal wall hematoma in 1 patient who was subsequently started on anticoagulation. No patients developed recurrent chyle leaks during the follow up period. Conclusion and/or Teaching Points: EVOH copolymer is a safe and effective agent for percutaneous thoracic duct embolization. This is the largest reported series to date demonstrating the efficacy of this embolic agent in treating chylous effusions in the post-traumatic setting.

Acute pain therapy in surgery

Pain is no fundamental illness nor should it be a concomitant handicap in any medical treatment. Nevertheless there still is a huge discrepancy between the fundamentally existing medical options of an adequate pain therapy and the actual everyday care of affected patients. An adequate pain therapy in the perioperative or posttraumatic setting represents a basic prerequisite for a rapid recovery and a reduction of any postinterventional risk of morbidity and mortality. An immediate improvement in quality of life secondary to an adequate acute pain therapy increases the chances of an early mobilization, reduces the duration of hospitalization, and thus supports the physical and social rehabilitation of patients. Above that an adequate acute pain therapy will reduce the risk of the development of any chronic pain syndrome as secondary or late effect following operative interventions. These complex interrelations finally also lead to a direct means of cost reduction in the health care system.

Peroneal artery perforator‐based flaps for reconstruction of middle and lower third post‐traumatic defects of the leg

Grade IIIb open tibial fractures require local or free flaps for cover of the fracture site. Perforator flap surgery is an innovative method for wound cover in this setting. The anatomy of perforating vessels of the peroneal artery is well described. All patients who underwent peroneal artery perforator-based flap cover for acute Grade IIIb fracture tibia between December 2011 and March 2013 were prospectively studied. The wounds were located either in middle or in lower third of the tibia. Flaps were performed under loupe magnification after identifying perforators preoperatively with handheld Doppler. All flaps were of a hockey stick or J design, incorporating the peroneal skin territory and completely islanded. Patients were followed up until all wounds were epithelialized. Eleven patients were identified. Eleven flaps were performed, out of which 10 survived entirely and served the purpose of stable wound cover. One patient sustained partial flap necrosis, which was debrided, and another local flap was performed. More than one perforator could be identified and retained in six of these 11 patients. The peroneal artery perforator-based flap is reliable and reproducible in an acute post-traumatic setting. It should be considered as a suitable alternative for reconstruction for limited defects with exposed fractured tibia over the middle and lower third of the leg.

Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis

Nonsteroidal anti-inflammatory drugs (NSAIDs) play an essential part in our approach to control pain in the posttraumatic setting. Over the last decades, several studies suggested that NSAIDs interfere with bone healing while others contradict these findings. Although their analgesic potency is well proven, clinicians remain puzzled over the potential safety issues. We have systematically reviewed the available literature, analyzing and presenting the available in vitro animal and clinical studies on this field. Our comprehensive review reveals the great diversity of the presented data in all groups of studies. Animal and in vitro studies present so conflicting data that even studies with identical parameters have opposing results. Basic science research defining the exact mechanism with which NSAIDs could interfere with bone cells and also the conduction of well-randomized prospective clinical trials are warranted. In the absence of robust clinical or scientific evidence, clinicians should treat NSAIDs as a risk factor for bone healing impairment, and their administration should be avoided in high-risk patients.

Endophthalmitis following open-globe injuries.

The incidence of traumatic endophthalmitis may be decreasing due to earlier wound closure and prompt initiation of antibiotics. Risk factors for endophthalmitis include retained intraocular foreign body, rural setting of injury, disruption of the crystalline lens, and a delay in primary wound closure. The microbiology in the post-traumatic setting includes a higher frequency of virulent organisms such as Bacillus species. Recognizing early clinical signs of endophthalmitis, including pain, hypopyon, vitritis, or retinal periphlebitis may prompt early treatment with intravitreal antibiotics. Prophylaxis of endophthalmitis in high-risk open-globe injuries may include systemic broad-spectrum antibiotics, topical antibiotics, and intravitreal antibiotics to cover both Gram-positive and Gram-negative bacteria. For clinically diagnosed post-traumatic endophthalmitis, intravitreal vancomycin, and ceftazidime are routinely used. Concurrent retinal detachment with endophthalmitis can be successfully managed with vitrectomy and use of intravitreal antibiotics along with a long acting gas or silicone oil tamponade. Endophthalmitis is a visually significant complication of open-globe injuries but early wound closure as well as comprehensive prophylactic antibiotic treatment at the time of injury repair may improve visual acuity outcomes.

Free Tissue Transfer for Lower Extremity Reconstruction: A Study of the Role of Computed Angiography in the Planning of Free Tissue Transfer in the Posttraumatic Setting

Computed tomographic angiography can be used as a means of assessing lower leg vasculature before performing free tissue transfer, but its reliability within a trauma setting has not been evaluated. The aim of this study was to examine the findings of preoperative computed tomographic angiography and correlate these findings to flap survival and limb salvage. Seventy-six consecutive lower extremity trauma patients underwent preoperative computed tomographic angiography before free flap reconstruction. Arterial inflow, venous outflow, and the incidence of traumatic occlusion were recorded. Flap survival rates, limb salvage, and postoperative complications were noted. There were no complications associated with the computed tomographic angiography procedure. Computed tomographic angiography demonstrated normal vascular anatomy in 40 patients (52.6 percent), anatomical variants in seven patients, and atherosclerotic occlusive disease in six patients. Traumatic arterial occlusion was identified in 22 patients (28.9 percent). Flap failure was seen in five patients and the limb salvage rate was 94.7 percent. All four of the limbs amputated had at least a single artery occluded on preoperative computed tomographic angiography; preoperative arterial occlusion was found to be a significant predictor of limb loss (p < 0.05). The incidence of single-vessel traumatic arterial occlusion within traumatized lower limbs undergoing free tissue transfer may be as high as 29 percent. Computed tomographic angiography provided excellent visualization of lower extremity vasculature, and its routine use for trauma patients is safe. Flap failure rates were low when using this technique for preoperative planning. Flap failure occurred only in patients with evidence of arterial injury. Evidence of arterial occlusion on computed tomographic angiography may be a risk factor for limb loss.

Revisional Total Ankle Arthroplasty Because of a Large Tibial Bone Cyst

Osteoarthritis of the ankle can occur secondary to alteration of the articular surfaces, such as in the posttraumatic setting, or because of gradual degeneration as a result of biomechanical dysfunction. Although primary inflammatory ankle arthritis rarely occurs, the majority of cases of ankle osteoarthritis occur after bony trauma, ligamentous injury, congenital deformity, or previous surgical intervention. Although ankle arthrodesis was shown to be successful and reliable, and although it remains the gold standard for surgical intervention after nonsurgical care of the arthritic ankle has been exhausted, a reasonable return to a dynamic lifestyle can be limited by fusion of the ankle. With the ever-increasing prevalence of favorable objective outcomes after implantation of late-model ankle endoprostheses, total ankle arthroplasty has become a popular alternative to arthrodesis. As the number of total ankle replacements increases in the population, particularly in cases involving younger and more active patients, surgeons will encounter more cases that require revisional total ankle replacement. We describe a patient who underwent the exchange of one total ankle endoprosthesis for another, in the presence of a large cyst about the tibial component of the implant. 4.

Traumatic injuries: imaging of peripheral musculoskeletal injuries.

The current dominant role of conventional radiography must be reassessed at increasingly shorter intervals in view of the continuing emergence of new imaging modalities that are available to diagnose peripheral musculoskeletal injuries. In comparison with conventional radiography, digital radiographic techniques offer advantages for optimization of image quality and dose, such as a wider dynamic range and post-processing of images. Currently, digital luminescence radiography (storage phosphor radiography) is the most commonly used digital method for obtaining radiographs, using the established positioning projections and routines of the film-screen technique. A new process, radiography with flat-panel amorphous silicon detectors, is still under development. Computed tomography is a valuable tool for diagnosing injuries of the peripheral musculoskeletal system, especially when three-dimensional data sets are acquired; these allow reformating images in all planes desired (2D technique) or in a volumetric format (3D technique). Established indications for CT in the peripheral skeleton are hip fractures, wrist injuries and calcaneal fractures; however, CT may be used as a supplement to radiography in every region of the body. Sonography is beginning to play an increasingly important role in trauma. Muscle and tendon injuries are the most common indications, but worthwhile information can be gained of the shoulder, elbow, hip, and knee joints, supplementing conventional or digital radiography. Magnetic resonance imaging effectively visualizes traumatic changes of the skeleton and the peripheral soft tissues. It is the method of choice to detect occult fractures. It can be used to diagnose muscle and tendon injuries. Joint injuries, especially in the knee and the shoulder joint, are common indications for MRI in the posttraumatic setting.

POSTTRAUMATIC ARTHRITIS

The surgical management of posttraumatic arthritis is one of the most difficult problems encountered in shoulder surgery. Bone and soft tissue abnormalities resulting from the initial injury and from any subsequent surgery must be addressed to achieve the best outcome possible. A review of the literature reveals distinctly inferior results and a higher rate of complications following surgical treatment of posttraumatic sequelae compared with the surgical treatment of acute proximal humeral fractures. The authors present helpful hints for dealing with the complex problems encountered in the posttraumatic setting.