Severe Concomitant Injuries Research Articles

Imaging of the midfacial and orbital trauma.

The severity of midfacial and orbital injuries depends on the one hand on cause, force vector, load point, or area and on the other hand on the bony and soft tissue resistance as well as individual anatomy. These variables result in a variety of possible injuries of the midfacial and orbital complex. The time critical choice of an adequate imaging modality of these injuries is influenced by the possible severity of concomitant injuries. Besides the confirmation of a clinical diagnosis, the need for high-resolution three-dimensional imaging for preoperative planning of facial reconstruction using intraoperative navigation has become more and more important in the past years. To achieve optimal functional and esthetic outcomes, the anatomical complexity of the midface has to be addressed and the adequate imaging modality has to be chosen keeping the upcoming surgical treatment in mind. The current imaging modalities for midfacial and orbital trauma are presented and critically evaluated depending on the indications. Furthermore, new strategies to support surgeons in achieving best possible midfacial reconstructions are discussed. An algorithm to choose the adequate imaging modality in midfacial and orbital traumatology is provided.

The Diagnostic and Therapeutic Challenges of Degloving Soft-Tissue Injuries

Degloving soft-tissue injuries are a form of avulsion of soft tissue, in which an extensive portion of skin and subcutaneous tissue detaches from the underlying fascia and muscles. Such injuries can affect every part of the body, but in particular the limbs (both upper and lower), trunk, face, and genitalia (Wojcicki, P., Wojtkiewicz, W. and Drozdowski, P., (2011)); [1,2,3] and can be associated with severe concomitant injuries and massive blood losses. Prompt recognition of degloving soft-tissue injuries is essential, yet treatment is time-consuming and often delayed. Thus, the injuries frequently progress to infection or even to necrotizing fasciitis. The severity of complications depends on the mechanism, the concomitant injuries, and the anatomic side affected and whether the degloving injuries are open or closed.

Complications associated with military spine injuries

To assess the presence of complications associated with spine injuries in the Global War on Terror. To characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009. Retrospective study. American servicemembers sustaining spine injury during combat. Extracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma. Major complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord-injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005). Patients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.

Occurrence and Severity of Concomitant Injuries in Other Areas Than the Face in Children With Mandibular and Midfacial Fractures

To clarify the occurrence, causes, severity, and predictors of concomitant injuries in pediatric patients with facial fractures. Files of 339 pediatric patients who had sustained facial fractures at age 15 years or younger were reviewed. Outcome variables were injured organ systems other than the face, types of injuries in areas other than the face, and severity of injuries in areas other than the face. Explanatory variables were gender, age, mechanism of trauma, and type of facial fracture. Concomitant injuries in organ systems other than the face were observed in 11.0%. Limb injuries occurred in 9.1%, head and neck injuries in 5.6%, and chest injuries in 1.8%. The most common injury types were upper limb injury (8.0%), brain injury (3.2%), and lower limb injury (2.9%). Severe head and neck injuries occurred in 3.5% and severe chest injuries in 1.2%. Concomitant injuries occurred more frequently after motor vehicle accidents and falls from height compared with other etiologies (P < .001) and more frequently in association with combined mandibular and midfacial fractures than in association with other fracture types (P < .001). Concomitant injuries in areas other than the face should be expected first and foremost after high-speed trauma mechanisms and in association with severe facial fractures. Concomitant injuries in general occur most frequently in the limbs, with severe concomitant injuries in particular occurring most often in the head and neck region and chest, emphasizing the importance of multiprofessional teamwork in the diagnosis of pediatric patients who have sustained facial fractures.

Endovascular Treatment of Blunt Traumatic Thoracic Aortic Injury

Blunt traumatic thoracic aortic injury (BTTAI) is a lethal injury associated with a prehospital mortality of 80% to 90%. Patients arriving in the emergency room and considered appropriate to undergo emergency open surgical repair still have a mortality rate of 15% to 30% because of severe associated injuries. Conventional open surgical repair requires a left thoracotomy, single lung ventilation, aortic-cross clamping and unclamping, with or without the adjunct use of partial or full cardiopulmonary bypass and systemic heparinization. All this leads to significant physiological stress and surgical trauma resulting in perioperative complications such as major blood loss, coagulopathy, myocardial infarction, stroke, respiratory failure, renal failure, bowel infarction, and paraplegia. Despite advances in anesthesia, critical care medicine, and surgical techniques, a recent meta-analysis showed no definite improvement in operative mortality over the past decade, following open surgical repair in patients with BTTAI. Endovascular repair of BTTAI does not require a thoracotomy, single lung ventilation, aorticcross clamping and unclamping, or systemic heparinization. As a result, endovascular repair of BTTAI has emerged as an effective, minimally invasive treatment alternative, especially in patients with severe concomitant injuries, which may be prohibitive to open surgical repair. Recent published studies have shown that endovascular repair of BTTAI is associated with lower morbidity, mortality, stroke, and paraplegia/paraparesis rates, when compared with open surgical repair of BTTAI.

Immediate endovascular repair for acute traumatic injuries of the thoracic aorta: A multicenter analysis of 28 cases

Endovascular repair of injured thoracic aorta offers a new minimal invasive therapeutic option that could be beneficial in the urgent management of polytrauma patients. The aim of this study was to assess our multicenter experience of immediate endovascular repair for acute traumatic injuries of the thoracic aorta. Between April 2002 and October 2007, all patients treated for an acute traumatic injury of the thoracic aorta, in a less than 12-hour delay, by endovascular repair, were reviewed retrospectively in three Parisian trauma centers. Collected data included age, sex, associated comorbidities, and traumatic lesions to determine the Traumatic Injury Severity Score (TRISS), the type of aortic lesion assessed by computed tomography (CT)-scan and transesophageal ultrasonography, technical aspects of endovascular repair, length of hospital stay, and postoperative mortality. Patients were regularly followed by clinical examination, chest radiographs, and thoracic CT-scan. Twenty-eight patients (20 males, mean age 45 +/- 18.8 years) were treated in a median delay of 5 hours (range 2 to 10 hours) after initial trauma. They all experienced severe traumatic injuries with a mean predictive mortality of 55.6% +/- 33.1% according to TRISS. Aortic lesions were associated with aortic parietal hematoma (71%), hemomediastinum (86%), and hemothorax (68%). All endovascular procedures were technically successful through femoral (n = 24) or iliac access (n = 4), in a mean operating time of 94 +/- 35.8 minutes. Proximal sealing of the endografts required the coverage of the origin of the left subclavian artery in 13 cases and of the left common carotid in one case. The median of hospital stay was 27 days (range 9 to 127 days), with an overall hospital mortality of 17.9% (n = 5). All deaths were unrelated to the aortic rupture or the stent placement, and no intervention-related morbidity or mortality was recorded during a median follow-up of 24 months (range 5 to 73 months). Endovascular stent grafting allows an immediate efficient repair for acute traumatic injuries of the thoracic aorta. This early management is, however, associated with a high in-hospital mortality, related to the severe concomitant injuries of such unselected multitrauma patients.

Clinical Outcome and Quality of Life after Upper Extremity Arterial Trauma

We assessed the long-term clinical outcome of 33 patients treated for arterial trauma of the upper extremity at the Regensburg University Medical Center between 1996 and 2004. Along with clinical parameters, the Disabilities of Arm, Shoulder, and Hand (DASH) score and the Short Form-36 Health Survey (SF-36) score of each patient were collected at the time of follow-up. Findings of the clinical assessment were compared to results obtained with the DASH score and the SF-36 questionnaire. The median follow-up time was 42 months. All arterial injuries had been reconstructed and were open at the time of follow-up. The prevalence of concomitant neural and/or orthopedic injuries was high (24/33, 72%). The influence of neural injury was by far greater than the impact of other factors on the long-term functional outcome. Furthermore, blunt trauma and the need for immediate fasciotomy were further markers for deficient functional recovery. Both the DASH and the SF-36 scores correlated with the clinical assessment of the severity of functional deficits. Upper extremity vascular trauma is almost always associated with severe concomitant orthopedic and/or neural injuries. The involvement of the brachial plexus and the peripheral nerves of the upper extremity is a predictor of worse long-term functional outcome.

Selective primary suture of the battle-injured colon: An experience of the Nigerian Civil War

During the 1967-9 phase of the Nigerian Civil War, 38 primary sutures of battle-injured colons were carried out, with 3 deaths, all in patients with severe concomitant injuries to the liver, diaphragm and right iliac crest. In carefully selected cases--one-third of the total--primary suture was a safe and reliable technique for dealing with battle-lacerated colons. Although there was a substantial morbidity (71 per cent) from wound sepsis, there was also a considerable reduction in the period spent in hospital.

The Need for Multidisciplinary Management of Patients with Upper Thoracic Spine Fractures Caused by High-Velocity Impact: A Review of 32 Surgically Stabilised Cases

To analyse the characteristics of patients who underwent surgery for fractures of the upper thoracic spine (T1-T6) in our institution. The thoracic spine is supported by the rib cage and associated ligaments; therefore, displacement and fracture of the upper thoracic spine in healthy young adults require a great force. The relatively narrow spinal canal around the spinal cord in this area could result in severe neurological deficit should fractures occur. The treatment course of 32 patients (26 men and 6 women) who underwent surgery for fractures of the upper thoracic spine between February 1995 and March 2001 was retrospectively reviewed. Parameters of injuries and treatment methods were evaluated. Of the 32 patients, 29 were injured in traffic accidents (15 motorcycle and 14 vehicle), 2 in falls, and one by a heavy door falling on his back. 29 patients had spinal fractures at more than one level. 23 patients had complete, 7 had incomplete, and 2 had no neurological deficit. 30 patients required multiple modalities of radiological imaging (in addition to plain radiography) for diagnosis. 20 patients sustained other injuries apart from spinal fractures, 15 of them had associated chest injuries. High-velocity fractures of the upper thoracic spine are injuries with devastating consequences, and can result in severe neurological deficit and concomitant injuries. These patients are best treated by a multidisciplinary approach.

THE TREATMENT OF POSTERIOR URETHRAL DISRUPTION ASSOCIATED WITH PELVIC FRACTURES: COMPARATIVE EXPERIENCE OF EARLY REALIGNMENT VERSUS DELAYED URETHROPLASTY

Urological treatment of the patient with severe mechanical trauma and urethral disruption remains controversial. Debate continues regarding the advisability of early realignment vs delayed open urethroplasty. We analyzed our experience with 96 patients to determine the long-term results of the 2 approaches. We retrospectively reviewed the records of 191 men with posterior urethral disruption after severe blunt pelvic injury between 1984 and 2001, of whom 96 survived. Data on 57 patients who underwent early realignment were compared to those on 39 treated with delayed urethroplasty with an average 8.8-year followup (range 1 to 22). All patients were evaluated postoperatively for incontinence, impotence and urethral strictures. The majority of patients had severe concomitant organ injuries (78%) and severe pelvic fractures (76%). The overall mortality rate was 51%. Diagnosis of urethral rupture was based on clinical findings and retrograde urethrography. Strictures developed in 49% of the early realignment group and in 100% of the suprapubic tube group. Impotence (33.6%) and incontinence (17.7%) were less frequent in the early realignment group than in the delayed reconstruction group (42.1% and 24.9%, respectively). Patients with delayed reconstruction underwent an average of 3.1 procedures compared with an average of 1.6 in the early realignment group. Early realignment may provide better outcomes than delayed open urethroplasty after posterior urethral disruption. Increased complications are not seen and, although it can be inconvenient in the massively injured patient, it appears to be a worthwhile maneuver.

Klinische Relevanz von Nebenmilzen nach elektiven und notfallmäßigen Splenektomien

Clinical Relevance of Accessory Spleens Following Elective and Emergency Splenectomies Background: With respect to the various functions of the spleen, a careful risk-benefit analysis must be done before splenectomy. Methods: During 10 years, 211 splenectomies were carried out in our hospital. In 185 of these clinical cases the documents were complete for an analysis. Results: The most frequent indications for surgical treatment were immunothrombocytopenia (22.2%) and lymphogranulomatosis (18.9%) followed by spleen bleedings (24.3%) of traumatically, iatrogenic or spontaneous origin. Postoperative complications such as pulmonary and cardiological disorders, disorders in wound healing, and abscesses could be found in 31.3% of the elective and in 80.4% of the emergency cases. 5.2 and 21.9% of the patients died after elective treatment and emergency surgery, respectively, resulting in an overall mortality of 10.8%. In the latter group death was mostly related to the severe concomitant injuries. The main problem during the postoperative period is the high rate of infections which could be attributed to the loss of an immunologically active organ. Postoperative thrombocytosis was temporary in most cases. A sepsis developed in 4.9% of the patients with a lethal outcome in 2.7% of the cases. 13.5% of the patients showed accessory spleens. In those patients suffering from immunothrombocytopenia and lymphogranulomatosis, they were even found in 22 and 20% of the cases, respectively. 12.1% of the 58 reinspected patients showed accessory spleens; some of them even had multiple accessory spleens. Mostly, solitary accessory spleens were found. They were located in the neighborhood of the spleen or – after splenectomy – in the former spleenic area. The size of accessory spleens ranged between some millimeters and 5 cm with an average length of about 1–2 cm. Accessory spleens were either completely unobtrusive with no function at all, or they can take over some spleenic functions, regardless of their size and location. Especially in combination with immunothrombocytopenia, they may be responsible for the failure of an otherwise successful splenectomy. However, relapses after splenectomy could not generally be attributed to accessory spleens since relapses also occurred after additional exstirpation of accessory spleens. Conclusion: As some accessory spleens take over specialized functions of the spleen while others remain unobtrusive, the benefit of splenectomy for the treatment of blood-related malignancies is hardly foreseeable.

Injuries to the duodenum and pancreas

Background: Blunt or penetrating-perforating severe abdominal trauma involves the duodenum in of 3.7 to 5% of cases and the pancreas in 3 to 12%. In our geographical area, the great majority of injuries to the duodenum and pancreas result from traffic accidents. More than 90% of accident victims have severe concomitant injuries to the liver, spleen and large vessels. The clinical symptoms of pancreatic-duodenal injuries are often inversely proportional to the severity of those injuries and are usually obscured by the other injuries.

Surgical Tactics at Severe Concomitant Injury of the Chest in Early Stage of Traumatic Disease: Diagnosis, Treatment, Outcomes

Long-term experience in treatment of patient with concomitant chest injuries is presented. The authors distinguish two main types of severe concomitant injuries of the chest - monoconcomitant (49.7%) and polyconcomitant (50.3%). In such injuries the difficulty of the clinical picture is caused by the syndrome of mutual aggravation and depression of immune system. Thus, in 62% of cases clinical manifestations are inadequate to the pattern and severity of the separate organs injury. Under modern clinical conditions the difficulty of diagnosis are overcome by means of objective instrumental methods of examination. Surgical tactics consists of a single general complex of measures on elimination of critical states as well as specific tactical activities depending on the peculiarities of the injury. Maximum possible accuracy of the choice of surgical tactics depends on the dominant injury detection.

Surgical treatment of uncomplicated instable injuries of lower thoracic and lumbar spine.

In 87 patients with uncomplicated instable injuries of lower thoracic and lumbar spine the examination data and results of surgical treatment were assessed. Autopsy data were analyzed in 17 patients who were lost due to severe concomitant and multiple injuries. According to clinical manifestations, anatomic and radiologic data the patients were divided into 3 groups: 1) victims with injuries of bone structures only; 2) victims with injuries of bone structures of the posterior supporting complex only; 3) victims with simultaneous injuries of the anterior and posterior supporting complexes. In every group the treatment was based on the peculiarities of the anatomic injuries and included the prevention of secondary complications. Authors consider that the posterior fusion with bone plasty is well justified in compression fractures but puncture method and posterior fixation by metallic devices are preferable in burst fractures. Long term good results were achieved in 67 victims (77%), satisfactory results - in 18 victims (22%) and unsatisfactory results - in 2 victims.

Prevention of taumatic dsease complications at prehospital stage (experience of resuscitation-traumatologic team of first aid)

Protracted systemic disorders of homeostasis of traumatic disease may cause such severe and often lifeincompatible complications as acute respiratory and acute renal failure, sepsis, fat embolism. The effective way of their prevention is as early as possible rendering of qualified medical care to the injured. Under the Moscow First Aid Station there is a resuscitation-traumatologic CITO team. During 2,5 years the team rendered medical care to 1480 patients with severe multiorgan and concomitant injuries, 6,7% of patients had a severe degree of traumatic shock. Authors suggested the algorithms for diagnosis and prehospital management of severely injured. Use of those algorithms allowed to lower the rate of fat embolism and acute respiratory failure, to shorten the terms of assisted ventilation, duration of resuscitation and hospitalization. Twenty two patients (0,87%) with life incompatible injuries were lost.

Preservation of Renal Function After Reconstruction for Trauma: Quantitative Assessment with Radionuclide Scintigraphy

Purpose We quantified the degree of preservation of renal function after reconstruction of traumatic renal injuries and identified the factors that influence preservation. Materials and Methods We reviewed the records of 52 patients between 1977 and 1995 who underwent radionuclide scintigraphy an average of 11.4 days after renal reconstruction for trauma. Of the injuries (75% penetrating and 25% blunt) 6% were grade 2, 43% grade 3, 49% grade 4 and 2% grade 5. Results On the reconstructed side mean renal function was 39.3%. Adequate preservation was possible in 42 patients (81% overall), while 10 (19%) had less than a third function on the injured side. Conclusions Our results provide quantitative evidence that renal reconstruction successfully preserves functioning renal tissue and is an appropriate method of treating major renal trauma. Preservation of functioning renal parenchyma is less successful in patients with renovascular trauma and severe concomitant injuries with shock and extensive blood loss.

Fractures of the pelvis in children.

Pelvic bony injuries are uncommon in children except for avulsion fractures. Medical records and radiographs of 54 children, in whom pelvic fractures were diagnosed from 1974 to 1993, were reviewed. Children 16 years of age and younger who were treated as inpatients were included in this study. Thirty-two patients were boys (59.3%) and 22 were girls (40.7%). In 47 (87.0%) patients, trauma was caused by motor vehicle accidents. The fractures were classified according to the Torode and Zieg classification and the Tile AO/Association for the Study of Internal Fixation classification. Forty-seven (87.0%) children had associated pelvic or extrapelvic injuries. The mean Injury Severity Score was 30.5 (range, 4-66). The AO classification correlated well with the severity of the injury. Eight children (14.8%) died. In most (38 patients = 70.4%) patients, the pelvic bony injury was treated by conservative means. External or internal fixation of the fracture was performed in 16 (29.6%) patients. A followup examination was conducted in 35 of 44 survivors (79.5%; 2 other patients died of unknown causes) with a mean followup of 135 months (range, 18-235 months); 1 additional patient was interviewed by telephone. In this series, long term morbidity was rare and was attributed to severe pelvic ring disruptions, acetabular fractures, or concomitant injuries. It is concluded that in unstable pelvic ring disruptions and acetabular fractures, the principles of management in children should not differ greatly from those in adults. Serious associated pelvic or extrapelvic injuries may pose more management problems than does the pelvic fracture.

Unilateral Thoracic Facet Dislocation

A unilateral facet dislocation is an injury classically localized to the cervical spine. A series of 3 unilateral thoracic facet dislocations are reported in 2 adults and 1 child. Each had severe concomitant injuries to the thorax, which caused respiratory compromise. On lateral radiographs, all had anterior vertebral body translation of less than 20% of the vertebral body width with minor degrees of kyphosis. Axial computed tomographic images showed a unilateral empty facet sign. All patients were neurologically intact and none had any mechanical pain at last followup. The mechanism of injury is flexion distraction with rotational force that disrupts the rib cage.

Management of pancreatic injuries : Stone H. H., Fabian T. C., Satiani B. et al. (1981) Experiences in the management of pancreatic trauma. J. Trauma21, 257

With the aim of aiding the accurate diagnosis and treatment of patients with pancreatic injuries, we reviewed the medical records of all those patients, treated for traumatic pancreatic lesions at our hospital in the period between 1971 and 1987. For all twenty-four male patients the mechanism of the injury, the diagnostic methods employed, associated injuries, location of the pancreatic injury, the presence of pancreatic duct lesion, treatment, the final outcome, and complications are described. In our view, the high mortality rate of patients with pancreatic trauma is due not to the pancreatic injury per se, but to the severe concomitant injuries resulting from a high-energy trauma. On the basis of the literature and our own experience we designed a flow chart for the management of pancreatic injuries. If the history and physical examination indicate that intra-abdominal injury might be present, radiographic and ultrasound investigation are the diagnostic methods of choice. Patients without pancreatic duct injury can be treated with debridement and external suction drainage. If pancreatic duct lesion is presented and is located to the right of the superior mesenteric vessels, treatment should consist of partial pancreatic resection and pancreatico-jejunostomy or a Whipple procedure. If the pancreatic duct lesion is located to the left of the superior mesenteric vessels, distal pancreatectomy and splenectomy with pancreatico-jejunostomy, should be performed.

Prognostic value of the level of lymphocytes in the blood in retroperitoneal hemorrhage

To determine the reaction of the lymphatic system, taking into account its damage in severe concomitant injuries with retroperitoneal hemorrhages, we studied the case histories of 62 patients who were treated in the surgical department for closed abdominal trauma.