Post-injury Complications Research Articles

Craniomaxillofacial injuries: experience in Tehran.

This is a retrospective study of 1,608 patients (1,575 males and 33 females) who were treated in two university hospitals in Tehran, Iran from 1984 to 1990. The injuries were classified into three types: soft tissue injuries (132 patients), bony fractures (356 patients), and mixed injuries (1,120 patients). The craniofacial injuries were classified into seven anatomical levels: lower third; middle third; upper third; lower and middle third; lower and upper third; middle and upper third; and lower, middle, and upper third). The lower third craniofacial injuries were the most common (69%, n = 1,110) followed by the middle third (42%, n = 677). Injuries to the upper third were the least common (28%, n = 452). In the lower third injuries the mandible was the most common site; lateral midface injuries were the most common site in the middle third region; and frontal bone was the most common site in upper third injuries. Most of these injuries were caused by firearms (71%, n = 1,135) during the Iraq-Iran conflict; the least common cause was assault (0.80%, n = 13). There were many associated noncraniofacial injuries, such as head and ocular injuries and abdominal injuries. The head injuries were classified into five grades according to the clinical and computed tomography findings. Treatment of the craniofacial injuries ranged from minor repair or closed reduction to major soft tissue and bony reconstruction. The postinjury complication rate was very high, especially for firearm injuries. The follow-up period ranged from 3 months to 3 years.

Interleukin-6 Delays Neutrophil Apoptosis via a Mechanism Involving Platelet-Activating Factor

Interleukin (IL)-6, an integral mediator of the physiologic acute phase response to injury, has been associated with adverse postinjury complications when present in excessive concentrations. The precise role of IL-6 is unclear, but may involve exacerbation of polymorphonuclear neutrophil leukocytes (PMN)-mediated hyperinflammation. We have shown that IL-6 delays PMN apoptosis, thereby inhibiting the resolution of inflammation. More recently we have found that IL-6 stimulates PMNs to generate platelet-activating factor (PAF). Given the evidence for PAF involvement in postinjury hyperinflammation, we hypothesized that IL-6 delayed apoptosis via a mechanism involving PAF. PMNs were isolated from healthy human donors using plasma-Percoll gradients and were cultured in enriched RPMI 1640 media at 2 x 10(7) PMNs/mL for 24 hours (37 degrees C, 5% CO2). Subgroups were treated with IL-6 (0.1-10 ng/mL) or PAF (0.1-10 ng/mL) or pretreated with the PAF receptor antagonist WEB 2170 (20 microM) before IL-6 or PAF. Morphologic assessment and quantitation of apoptosis was performed with acridine orange/ethidium bromide stain. Both IL-6 and PAF suppressed PMN apoptosis. Pretreating PMNs with WEB 2170 abrogated the effects IL-6 as well as PAF. Interleukin-6 delays PMN apoptosis via a mechanism involving PAF. These observations may help elucidate the mechanisms of IL-6 and PAF in mediating postinjury hyperinflammation and secondary organ dysfunction, ultimately leading to effective therapeutic targets in patients at risk for multiple organ failure.

Reconstruction of extensor mechanism after trauma and infection by transposition of the Achilles tendon: report of technique and four cases.

High-energy injuries to the knee often involve extensive soft tissue loss as well as fractures. In certain situations, the patellar tendon may be lost due to initial injury or post-injury complications such as infection. Use of the gastrocnemius flap is a popular method of covering the defect as well as controlling infection and promoting healing by increasing local vascularity. We present a method of reconstructing the patellar tendon by extending the use of the gastrocnemius flaps using its Achilles tendon and calcaneal insertion. The distal insertion of the Achilles tendon is fixed to the tibial tuberosity with a cancellous screw, and the proximal end is sutured to the quadriceps muscles. The knee is immobilized for 1 week, after which the knee is mobilized in a hinged brace. Three of the four cases had good results, one a moderate result (the initial injury was extensive, with dislocation of the knee).

CAUSES AND COSTS OF INJURIES IN MULTIPLE TRAUMA PATIENTS REQUIRING EXTRICATION FROM MOTOR VEHICLE CRASHES

Prospective and contemporaneous medical and economic cost studies of 144 victims of motor vehicle crashes admitted to a regional level I trauma center with multiple injuries (ISS > or = 16) revealed 122 non-ejected patients, of whom 102 required extrication (EXTRIC) from the vehicle for physical or medical reasons and 20 who did not (N group). There were no differences in age (EXTRIC, 34 +/- 17 years; N, 41 +/- 24 years), type of crash (Frontal: 57% EXTRIC, 60% N; Lateral: 32% EXTRIC, 35% N) restraint use (35% EXTRIC, 35% N), or mortality (29% EXTRIC, 30% N). However, the estimated maximum speed before the crash was higher in EXTRIC patients (50 +/- 16 mph vs. 46 +/- 18 mph N, p < 0.04), as was the change in velocity (delta V) on impact (EXTRIC 30 +/- 15 mph; N, 24 +/- 8 mph, p < 0.01). Brain injuries (51% EXTRIC vs. 35% N) and lower extremity injuries were more numerous in EXTRIC patients (59% vs. 20% N, p < 0.003) and the number of splenic, lower extremity, and pelvic injuries associated with shock was greater in EXTRIC patients, p < 0.02; as were postinjury complications. As a result, operating room costs from orthopedic and plastic surgery increased professional charges in the EXTRIC group versus the N group ($20,000, EXTRIC; $17,000, N) and critical care costs ($13,000, EXTRIC; $4,000, N) with total costs of $72,000 and $77,000, respectively. The lower extremity injuries in EXTRIC patients were primarily a result of body part contacts with intrusions (CIs) of the car occupant compartment structures [73% with vs. 24% without (p < 0.0001)]. In lateral MVCs, brain injuries were also more commonly associated with CIs of the side window frame or A pillar (72% CI vs. 25% no CI; p < 0.035); but as a whole in MVCs in which extrication was necessary, lower extremity injuries from instrument panel or toepan CIs appeared more frequent than those resulting from contacts only (p < 0.0001). In EXTRIC patients, 69% of those in shock had CI injuries, and 80% of the deaths in the EXTRIC group were associated with CI injury. These data suggest that measures designed to prevent CIs by strengthening car passenger compartment structures may reduce the incidence of severe brain and lower extremity injuries and may reduce the need for extrication after MVCs.

Management and Complications of Middle- and Upper-Third Facial Compound Injuries: An Iranian Experience

Surgery for 772 patients with middle- or upper-third facial injuries was carried out between 1984 and 1990 in two university hospitals in Tehran. The most common etiological factor was firearm injuries (69.04%; n = 533), followed by road traffic accidents (24.44%; n = 189). The most common associated nonfacial injuries were head injuries (36.97%; n = 285 followed by ocular injuries (23.18%; n = 179). Treatment of middle- or upper-third facial injuries ranged from minor repair to major surgery with autogenous or allogenous grafts. The complications associated with middle- or upper-third facial injuries were either postinjury complications or postoperative complications and ranged from minor infection to loss of vision.

The management of splenic injury.

Increased concern over the potential immunologic consequences of splenectomy has prompted surgeons to attempt salvage of traumatized spleens. We report a retrospective study of 172 consecutive patients with documented splenic injury treated over a 2-year period: 107 patients underwent splenectomy; 65 were managed without total splenectomy; 32 were not explored. The overall mortality rate was 27%; the overall complications were 30%, including a 13% incidence of post-splenectomy subphrenic abscess. The incidence of infectious complications after splenectomy was 36%, while the incidence in nonsplenectomized patients was 9%. The Injury Severity Scores (ISS) in the two groups were significantly different (p less than or equal to 0.05). When the group whose spleens were salvaged was compared to an equivalent group matched for ISS, age, and sex, there was no significant difference in sepsis rates (23% vs. 10.7%; 0.10 greater than or equal to p greater than or equal to 0.05). Survival in those with postinjury infectious complications was significantly improved in patients with a remaining spleen (p less than or equal to 0.01). Abdominal computerized tomography was used successfully as a method of following injured and repaired spleens in order to predict return to full activity.

Laryngotracheal trauma: Recognition and management

In 23 patients with laryngotracheal trauma at the Louisville General Hospital during a ten-year period, 19 survived. One death was directly atributable to the airway injury. The most common postinjury complication was hoarsensess attributable to direct injury to the cords or recurrent nerve paralysis. One patient had further operation for subglottic stenosis. In general, blunt injuries were more severe than penetrating injuries. Subcutaneous emphysema, aphonia or dyshonia, hemoptysis, signs of injuries, a sucking wound, are presumptive findings of laryngotracheal injury. Appropriate endoscopy and radiographic studies should confirm the diagnosis. Control of the airway is achieved by emergency tracheostomy or intubation followed by tracheostomy. Prompt operative intervention and primary repair follow.

Frontal sinus fractures.

AbstractOpinions vary regarding the treatment of fractures of the frontal bone with frontal sinus extension. Each surgeon bases his therapeutic approach on his teachings and experience, but he may fail to recognize significant residuals be unaware of related complications that occur after the patient is released from his care. The treatment criteria may furthermore be shaded by the experiences of a surgeon who recognizes an occasional post injury complication and proposes treatment of the acute injury which is unnecessarily radical.Clearly, such divergence of opinion can be unified only through critical long‐term follow‐up of patients whose acute frontal sinus injury is carefully analyzed, categorized and systematically treated.The purpose of this discussion is to share a 10‐year experience in the acute management of 63 frontal sinus fractures, treated at the University of Michigan Medical Center Hospitals between 1961 and 1971. The case summaries have been divided into three groups based on the site or sites of sinus fracture, as assessed at the time of the initial injury. Of the 63 total cases, 30 involved fractures of the anterior wall of the frontal sinus; 16 fractures included injury to the nasofrontal duct, and 17 cases involved the posterior wall of the frontal sinus.

Treatment of Acromioclavicular Separations

1. Trauma to the shoulder joint in athletes not inf requently results in separation of the acromioclavicular joint. These separations may be classified into grades I, II, and III. 2. In general, grade I and grade II separations may be treated symptomatically and with protection for a limited time. Pain with use and restriction of full shoulder girdle motion may persist for periods of three to six weeks. 3. Grade III or complete acromioclavicular separations require reduction and maintenance of reduction until healing occurs. Various methods of treatment, both open and closed, have been used. One method is described. 4. It is essential to restore the preinjury state of the acromioclavicular joint as nearly as possible in order to assure the athlete of full uninhibited use of the shoulder girdle. Postoperative and postinjury complications are infrequent and treatment programs for these are outlined.