Specific Injury Patterns Research Articles

Analysis of medial tibial plateau fracture injury patterns using quantitative 3D measurements

BackgroundThe Wahlquist system classifies tibial medial plateau fractures into three types based on the sagittal fracture line location, with type C at highest risk of complications. However, the injury mechanism of tibial medial plateau fractures, especially tibial rotation movement, remains unclear. The purpose of the present study was to determine the injury patterns of medial tibial plateau fractures using 3D model simulation and quantitative 3D measurements. MethodsSeventy-eight consecutive AO/OTA type 41-B tibial plateau fractures were retrospectively analyzed using CT-based 3D models and quantitative 3D measurements. The knee posture at the moment of fracture occurrence was simulated, and various knee angles in the sagittal, coronal, and axial planes were measured to evaluate the mechanism of medial tibial plateau fracture. The mean valgus-varus, hyperextension-flexion, and internal-external rotation angles were determined, and the chi-square test was used for comparisons of categorical varus and valgus force data to determine the main force direction in Wahlquist type C fractures. ResultsAngle measurements in the coronal planes showed that 28 (35.9%) medial tibial plateau fractures resulted from a varus injury pattern, while 50 fractures (64.1%) resulted from a valgus pattern. Valgus force produced significantly more Wahlquist type C fractures (37 of 50 fractures) than varus force (2 of 28 fractures) (p < 0.05). There was no significant difference in the cases of patients with type C fractures between the tibial internal and external rotation injury patterns(P > 0.05). ConclusionsValgus force was the cause of 64.1% of the medial tibia plateau fractures in the present cohort. Furthermore, valgus force produced more Wahlquist type C fractures than varus force. The present findings will help orthopedists understand the injury mechanism of the Wahlquist classification system, and will facilitate the identification of the common features of medial tibial plateau fractures induced by specific injury patterns.

Intussusceptive angiogenesis in Covid-19: hypothesis on the significance and focus on the possible role of FGF2.

The interest on the role of angiogenesis in the pathogenesis and progression of human interstitial lung diseases is growing, with conventional sprouting (SA) and non-sprouting intussusceptive angiogenesis (IA) being differently represented in specific pulmonary injury patterns. The role of viruses as key regulators of angiogenesis is known for several years. A significantly enhanced amount of new vessel growth, through a mechanism of IA, has been reported in lungs of patients who died from Covid-19; among the angiogenesis-related genes, fibroblast growth factor 2 (FGF2) was found to be upregulated. These findings are intriguing. FGF2 plays a role in some viral infections: the upregulation is involved in the MERS-CoV-induced strong apoptotic response crucial for its highly lytic replication cycle in lung cells, whereas FGF2 is protective against the acute lung injury induced by H1N1 influenza virus, improving the lung wet-to-dry weight ratio. FGF2 plays a role also in regulating IA, acting on pericytes (crucial for the formation of intraluminal pillars), and endothelium, and FGF2-induced angiogenesis may be promoted by inflammation and hypoxia. IA is a faster and probably more efficient process than SA, able to modulate vascular remodeling through pruning of redundant or inefficient blood vessels. We can speculate that IA might have the function of restoring a functional vascular plexus consequently to extensive endothelialitis and alveolar capillary micro-thrombosis observed in Covid-19. Anti-Vascular endothelial growth factor (anti-VEGF) strategies are currently investigated for treatment of severe and critically ill Covid-19 patients, but also FGF2, and its expression and/or signaling, might represent a promising target.

Distinct tissue injury patterns in juvenile dermatomyositis auto-antibody subgroups

IntroductionJuvenile dermatomyositis (JDM) can be classified into clinical serological subgroups by distinct myositis-specific antibodies (MSAs). It is incompletely understood whether different MSAs are associated with distinct pathological characteristics, clinical disease activities, or response to treatment.MethodsWe retrospectively reviewed clinicopathological data from consecutive JDM patients followed in the pediatric rheumatology clinic at a single center between October 2016 and November 2018. Demographics, clinical data, and laboratory data were collected and analyzed. Detailed muscle biopsy evaluation of four domains (inflammation, myofiber, vessels, and connective tissue) was performed, followed by statistical analysis.ResultsOf 43 subjects included in the study, 26 (60.5%) had a detectable MSA. The most common MSAs were anti-NXP-2 (13, 30.2%), anti-Mi-2 (7, 16.3%), and anti-MDA-5 (5, 11.6%). High titer anti-Mi-2 positively correlated with serum CK > 10,000 at initial visit (r = 0.96, p = 0.002). Muscle biopsied from subjects with high titer anti-Mi-2 had prominent perifascicular myofiber necrosis and perimysial connective tissue damage that resembled perifascicular necrotizing myopathy, but very little capillary C5b-9 deposition. Conversely, there was no positive correlation between the levels of the anti-NXP-2 titer and serum CK (r = − 0.21, p = 0.49). Muscle biopsies from patients with anti-NXP-2 showed prominent capillary C5b-9 deposition; but limited myofiber necrosis. Only one patient had anti-TIF1γ autoantibody, whose muscle pathology was similar as those with anti-NXP2. All patients with anti-MDA-5 had normal CK and near normal muscle histology.ConclusionsMuscle biopsy from JDM patients had MSA specific tissue injury patterns. These findings may help improve muscle biopsy diagnosis accuracy and inform personalized treatment of JDM.

Pediatric versus adult paradigms for management of adolescent injuries within a regional trauma system

BackgroundWe aimed to examine process and outcome indicators for adolescents with specific injury patterns managed in pediatric versus adult paradigms within the same trauma system. MethodsAdolescents (15–17 years old) admitted to the region's adult trauma center (ATC) or pediatric trauma center (PTC) with an abdominal injury, femur fracture or traumatic brain injury (TBI) were reviewed retrospectively. Global and injury-specific process and outcome indicators were compared. ResultsOf 141 ATC and 69 PTC patients, injury patterns differed significantly with more TBI and abdominal injuries at the ATC and femur fractures at the PTC. Overall injury severity was greater at the ATC. Patients with solid organ injuries appeared more likely to undergo embolization or splenectomy at the ATC; however, higher injury grade and later time period were the only variables significantly associated with this. Computed tomography (CT) was used significantly more frequently at the ATC overall, most notable with panscanning and head CTs for major TBI. Time to operative management did not differ for patients with isolated femur fractures. Neuropsychological follow up after minor TBI was documented more often at the PTC than the ATC; there was no difference for those with more severe TBIs. ConclusionsManagement varies for adolescents between PTCs and ATCs with more exposure to radiation and less neuropsychological follow-up of less severe TBIs at the ATC. This presents distinct opportunities to identify best policies for triage and sharing of management practices within a single regional inclusive trauma system in order to optimize short and long-term outcomes for this population. Type of studyRetrospective cohort. Level of evidenceLevel IV.

Results of Treatment of the Multiple Ligament Injured (Dislocated) Knee.

Knee dislocations leading to multiligament knee injuries are associated with a wide variety of bony, ligamentous, soft tissue, and neurovascular injury patterns. Numerous management strategies have been proposed including nonoperative treatment and surgical repair or reconstruction. In recent years, an emphasis has been placed on anatomic repair and reconstruction principles, which have shown superior outcomes compared with older techniques. However, despite these advances, clinical outcomes continue to vary widely, with many patients experiencing chronic pain, stiffness, loss of range of motion, instability, and failure to return to work or sports. The purpose of this chapter is to review clinical outcomes following combined anterior and posterior cruciate ligament, medial collateral ligament, and posterolateral corner injuries sustained during a knee dislocation. Understanding the available treatment options and reported outcomes will allow surgeons to individualize management to address each patient's specific injury pattern and functional goals.

Common Injuries Associated with Falls from Tree Stands in Iowa

Tree stand falls are a common injury among hunters. This study was designed to identify specific injury patterns and local and regional factors affecting access to and care for this unique trauma cohort in Iowa. The University of Iowa trauma registry was retrospectively queried from 2004 to 2014 for patients with a mechanism of injury of fall from tree stands. Data are presented as mean±SD, median, and range, or raw number and percentages as appropriate. Correlation analyses were performed using the Spearman coefficient. Fifty-three patients were identified. Age was 44±14 (17-78) y. Median fall height was 4.6 m (15 ft), ranging from 1.5 to 12 m (5 to 40 ft). Transport times varied from <1 h to >7 h. Hypothermia was observed in 6 patients (11%). Two patients (4%) tested positive for alcohol. Three patients (6%) tested positive for drugs. Soft tissue injuries (32 [60%]; ie, lacerations and abrasions) were the most common, followed by 30 spine fractures (57%, including 11 lumbar and 10 thoracic fractures), 16 other bone fractures (30%), and 11 rib fractures (21%). Twenty-two patients underwent surgery. Median hospital length of stay was 4 d, ranging from 0 to 20 d. Tree stand falls lead to significant injuries. Hypothermia represents a significant risk for these patients, and remote location resulted in long transportation time. Improper use or poor condition of safety equipment contributed to falls and injuries in a few of our patients.

Die spezifischen Auswirkungen und Merkmale von Trampolinpark-assoziierten Verletzungen

Numerous studies have described indoor trampoline park (ITP)-related injury patterns, but they have shown heterogeneous results. No such study has been performed in Germany to date. The aim of this study was to analyse the specific trampoline-related injury patterns found in our population. This retrospective study included patients suffering from ITP-related injuries between 1 October 2016 and 30April 2018. 258 patients were included in the analysis. Patients were categorised depending on different variables including age, sex, site of injury, diagnosis, length of admission and treatment using SPSS. In the 19-month study period, 258 patients with ITP-related injuries were recruited. Single ITP-related injuries were diagnosed in 250 (96.9 %) patients. The median age of this group was 22 years (IQR 15-28). 126 (50.4 %) injuries were suffered by men and 124 (49.6 %) by women. 168 (67.2 %) injuries occurred in the lower extremity. Sprains (n = 114, 45.6 %) and fractures without joint dislocation (n = 59, 23.6 %) were the most common diagnoses. Males suffered significantly more often from injuries of the upper extremity (26.2 vs. 9.7 %; p = 0.010), while females most commonly suffered from injuries of the lower extremity (79.8 vs. 54.8 %; p < 0.001). 45 (18 %) patients required hospital admission and twenty-five (10.0 %) patients required surgery. Eight (3.1 %) patients suffered from injuries in more than one anatomic location. ITP-related injuries were more prevalent in adults compared with children. The lower limb was the most affected anatomic location in all ages. The pattern of the injuries was heterogeneous, and their respective treatment represents a major challenge for traumatology surgeons.

Orthoplastics, tariffs and the reality of providing complex fracture care

IntroductionThe United Kingdom (UK) Major Trauma Network has encouraged cohorting of significantly injured patients with specific injury patterns. Complex injuries to the limbs is a key area of this patient population. Funding and clinician resource allocation, have not been appropriately adjusted to take account of this approach. We assessed the orthoplastic trauma workload in our unit over a 12 month period, taking into account the resource burden of each admission in comparison to the funding received. Materials and MethodsThe details of admissions requiring orthoplastic care over the period from February 2017-February 2018 were extracted from hospital records. Data regarding patient demographics, admission length, procedures and complications was analysed. Additional data regarding time spent in theatre was obtained from computerised records, as well as detailed coding data regarding clinical events coded for and funding received for the admission. Results24 patients were identified as meeting the criteria for inclusion in this study. Mean length of stay was 23 days (1–98 days) and theatre time 386 min (15–842 min). Average payment per admission was £14,497 (£593-£86,245). ConclusionTariff payments barely cover the cost of a hospital bed and theatre time. Materials costs, as well as the additional costs associated with providing a high quality specialist service mean that our orthoplastic service is currently being run at a significant loss. The benefits for patients in having a well-established orthoplastic unit are numerous and well documented. This study provides evidence to support negotiation for a tariff uplift to allow ongoing provision of a high quality orthoplastic service without detriment to hospital budgets.

Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases

Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls. We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to2014. We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%). Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.

TFCC injuries: How we treat?

The triangular fibrocartilage complex (TFCC) is a well defined anatomical entity located on the ulnar aspect of the wrist joint functioning primarily to stabilize the distal radio –ulnar joint (DRUJ) and also to act as a shock absorber across the ulno-carpal joint.Palmer and Werner were first to explain the anatomic details of the TFCC and to describe its biomechanical role at the wrist. The TFCC comprises of the fibro-cartilagenous disc, the dorsal and palmar ligaments spanning across radius and ulna, the ulno-carpal ligaments, a meniscal homolog, and the sub sheath of ulnar extensor of the wrist. The intricate anatomy of this area and complex load transmission kinematics renders it vulnerable to injury and attrition. Both traumatic and degenerative insults produce specific injury patterns which can present as vague ulnar-sided wrist pain particularly during forearm rotation.These injuries are managed initially by modification of daily activities to avoid aggravation of pain and injury, by complete abstinence from sporting/gym/yoga maneuvers which involve stressing the wrist joints, temporary splint or cast immobilisation are also used along with non-steroidal anti-inflammatory medication.Corticosteriod injection are also used in conjunction with physical therapy in grossly symptomatic patients.Surgical treatment is advocated if conservative management fails to provide relief, or in cases presenting initially with frank instability of the DRUJ or with unstable and displaced fractures. Choice of operative treatment is guided by type and extent of injury and may include debridement, repair and in TFCC injuries associated with degenerative changes, ulnar unloading procedures like shortening or Wafer procedure. With current understanding of arthroscopic anatomy of the wrist, availability of instrumentation as well as familiarity of surgeons with this tool, arthroscopic management can be instituted successfully in most if not all conditions afflicting the TFCC.

Evaluation of blood product transfusion therapies in acute injury care in low- and middle-income countries: a systematic review

BackgroundWorldwide, injuries account for approximately five million mortalities annually, with 90% occurring in low- and middle-income countries (LMICs). Although guidelines characterizing data for blood product transfusion in injury resuscitation have been established for high-income countries (HICs), no such information on use of blood products in LMICs exists. This systematic review evaluated the available literature on the use and associated outcomes of blood product transfusion therapies in LMICs for acute care of patients with injuries. MethodsA systematic search of PubMed, EMBASE, Global Health, CINAHL and Cochrane databases through November 2018 was performed by a health sciences medical librarian. Prospective and cross-sectional reports of injured patients from LMICs involving data on blood product transfusion therapies were included. Two reviewers identified eligible records (κ=0.92); quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Report elements, patient characteristics, injury information, blood transfusion therapies provided and mortality outcomes were extracted and analyzed. ResultsOf 3411 records, 150 full-text reports were reviewed and 17 met inclusion criteria. Identified reports came from the World Health Organization regions of Africa, the Eastern Mediterranean, and South-East Asia. A total of 6535 patients were studied, with the majority from exclusively inpatient hospital settings (52.9%). Data on transfusion therapies demonstrated that packed red blood cells were given to 27.0% of patients, fresh frozen plasma to 13.8%, and unspecified product types to 50.1%. Among patients with blunt and penetrating injuries, 5.8% and 15.7% were treated with blood product transfusions, respectively. Four reports provided data on comparative mortality outcomes, of which two found higher mortality in blood transfusion-treated patients than in untreated patients at 17.4% and 30.4%. The overall quality of evidence was either low (52.9%) or very low (41.2%), with one report of moderate quality by GRADE criteria. ConclusionThere is a paucity of high-quality data to inform appropriate use of blood transfusion therapies in LMIC injury care. Studies were geographically limited and did not include sufficient data on types of therapies and specific injury patterns treated. Future research in more diverse LMIC settings with improved data collection methods is needed to inform injury care globally.

The risk of concomitant injuries of the contralateral side in valgus injured knee by lateral bumper impact – “Windswept injury mechanism”-

PurposeValgus injury of high energy of the lateral bumper impact can lead blows to the inside of the knee that push the knee outwards or indirect injury where a varus force is applied to the contralateral knee, which injury pattern named as “Windswept injury mechanism” in this study. The objective of this study was to establish injury pattern in the contralateral side knee on the basis of this pattern recognition to enhance a diagnosis of interrelated osseous and soft-tissue injuries. MethodsSixteen patients by “Windswept injury mechanism” were identified, who visited a level 1 trauma center between Jan 2007 and Dec 2016. We first evaluated the osseous and soft tissue injuries at primary impacted site by valgus force after checking MRI. Thereby, assessed the contralateral knee which structures were injured. To find any correlation between both knees in ligament injuries, patients were divided into two groups according to coincided anterior cruciate ligament (ACL) rupture. ResultsBy the “Windswept injury mechanism”, MCL total rupture was observed in all primary knees, and the major ligament injuries also were coincided on the contralateral knee. In primary knee, either ACL or PCL was ruptured in all cases. 9 patients (56%) had combined ACL rupture with MCL injury, 12 patients (75%) of combined PCL injury, and 5 patients (31%) had combined injury of both ACL and PCL. In contralateral knee, lateral collateral ligament injury was observed in 69%. 7 patients (44%) was combined with ACL injury, 7 patients (44%) with combined PCL injury, 4 patients (25%) with combined both ACL and PCL injury. In comparison of two groups, significantly higher risk of ACL injury in the contralateral knee was identified when coincided ACL and MCL injury in primary knee (p = 0.003). ConclusionThe specific mechanism-based injury pattern of “Windswept injury mechanism” was the first to identify the mechanism that showed concomitant major ligament injuries in the contralateral knee and to develop validated the higher risk of ACL injury in the contralateral knee when combined ACL and MCL injuries in primary knee, which improving diagnosis of potentially subtle and easily missed knee injuries.

Primary Management of Polytrauma

The management of polytrauma patients is a challenging and dynamic process for the whole multidisciplinary team in the emergency department. Decisions made and measures taken during primary management have the ultimate effect on the prognosis of multiple injured patients. Trauma team leaders and team members benefit from a structured approach to such a complex situation. Hospital-specific interdisciplinary consensus on the workflow can help to optimize the management of trauma patients. All medical specialties involved should therefore have a basic understanding of each other’s approaches and the treatment options of the most important injury patterns. Primary Management of Polytrauma aims to provide a systematic and comprehensive guide on how to identify treatment options of potentially life-threatening injuries. The editors, all 3 themselves experienced surgeons from the Republic of South Korea, gathered authors from several surgical disciplines to cover sections on injuries of all major body regions. These specific sections are preceded by 2 sections on “Initial Assessment and Management” and the “Management of Shock,” which are authored by an emergency physician and 2 acute care surgeons. The book ends with 2 chapters on the role of radiology and a section on when and how to transfer trauma patients from your hospital. Within its 183 pages, the book provides a lot of detailed surgical information on how to diagnose and to classify individual injuries and gives insights into the regional approach of the management of trauma patients. Unfortunately, these sections do not intersect with each other, and there exists no overriding framework. Therefore, the book falls short to be a structured step-to-step guide to the management of polytrauma patients. Especially during the primary management of multiple injured patients, anticipation of injury mechanisms, pathophysiology of injury-related diseases (ie, trauma-associated coagulopathy), and critical injury constellations are crucial points. Unfortunately, none of these problems are substantially discussed in the book. The authors do not mention internationally accepted course concepts like the European Trauma Course (ETC) or Advanced Trauma Life Support (ATLS), both of which offer possibilities to learn trauma management in a structured manner. The views of international guidelines are rarely reflected in the book. In the chapter “Management of Shock,” recommendations on hemostatic resuscitation include the immediate transfusion of packed red blood cells; fresh-frozen plasma; platelets; and the correction of the lethal triad of coagulopathy, hypothermia, and acidosis. Lots of such improvident advice can be found throughout the first 2 chapters. For massive transfusion situations, for example, it is stated that (Chapter 2, page 14) “Current data support a target ratio of plasma:red blood cell:platelet transfusions of 1:1:1.” No advice on how to adjust transfusion on laboratory measures or the potential problems that come with transfusing large amounts of plasma is mentioned. The “current data” cited in the reference list, however, were published between 1982 and 2010, although more recent and high-quality evidence would have been available in most cases.1 Cited references in the short section discussing coagulopathy even go back to 1982–1989 (Chapter 2, page 14). More importantly, the book is lacking high-evidence recommendations from international consensus guidelines, like the early application of tranexamic acid to the bleeding trauma patient to treat or prevent hyperfibrinolysis.2 Specific chapters provide more detailed information on the classification and the surgical approach to the respective injuries. Radiological images and the discussion of relevant clinical scoring systems (as can be found in Chapter 4, “Spinal Injuries”) can support the physician’s individual decision-making. However, in most cases, these decisions would not be made by the leader or a member of the trauma team during the initial management of the patient. This is rather a surgical specialist’s task. In summary, this book allows for detailed insight into parts of the surgical decision-making and the approach to specific injuries and injury patterns of the polytraumatized patient. This can be interesting additional information for the advanced trauma leader or interested members of the trauma team. Due to lack of evidence-based information and missing recommendations from current guidelines, we cannot recommend the book as a guide or a reference for studying the primary management of polytrauma patients. Nils Kunze-Szikszay, MDKonrad Meissner, MDKlinik für AnästhesiologieUniversitätsmedizin GöttingenGöttingen, Germany[email protected]

Multiple Ligament Knee Injuries: Does the Knee Dislocation Classification Predict the Type of Surgical Management?

This study aims to evaluate relationships among multiple ligament knee injury (MLKI) patterns as classified according to the knee dislocation (KD) classification and the types of surgical management pursued. We hypothesized that the KD classification would not be predictive of the types of surgical management, and that categorizing injuries according to additional injury features such as structure, chronicity, grade, and topographic location would be predictive of the types of surgical management. This is a Retrospective cohort study. This study was conducted at a level I trauma center with a 150-mile coverage radius. Query of our billing database was performed using combinations of 43 billing codes (International Classification of Diseases [ICD] 9, ICD-10, and Current Procedural Terminology) to identify patients from 2011 to 2015 who underwent operative management for MLKIs. There were operative or nonoperative treatment for individual ligamentous injuries, repair, or reconstruction of individual ligamentous injuries, and staging or nonstaging or nonstaging of each surgical procedure. The main outcome was the nature and timing of clinical management for specific ligamentous injury patterns. In total, 287 patients were included in this study; there were 199 males (69.3%), the mean age was 30.2 years (SD: 14.0), and the mean BMI was 28.8 kg/m2 (SD: 7.4). There were 212 injuries (73.9%) categorized as either KD-I or KD-V. The KD classification alone was not predictive of surgery timing, staging, or any type of intervention for any injured ligament (p > 0.05). Recategorization of injury patterns according to structure, chronicity, grade, and location revealed the following: partial non-ACL injuries were more frequently repaired primarily (p < 0.001), distal medial-sided injuries were more frequently treated operatively than proximal medial-sided injuries (odds ratio [OR] = 24.7; p <0.0001), and staging was more frequent for combined PCL-lateral injuries (OR = 1.3; p = 0.003) and nonavulsive fractures (OR = 1.2; p = 0.0009). The KD classification in isolation was not predictive of any surgical management strategy. Surgical management was predictable when specifying the grade and topographic location of each ligamentous injury. This is a Level IV, retrospective cohort study.

Immediate Surgery in Acute Type A Dissection and Neurologic Dysfunction: Fighting the Inevitable?

Neurologic dysfunction remains an ongoing challenge in the diagnosis of type A aortic dissection (AAD). Our study analyzed the impact of preoperative neurologic dysfunction (PND) on outcome and assessed a potential link between PND and specific patterns of postoperative neurologic injury. Medical records of 338 patients (70.1% men; mean age, 59.3 ± 13.7 years) undergoing surgical repair for AAD were screened for the presence of PND. Preoperative characteristics, surgical treatment, and hospital and neurologic outcomes were analyzed according to patients with PND (PND+) and without PND (PND-) RESULTS: There were 50 patients (14.8%) admitted with PND. PND+ patients showed significantly higher rates of postoperative neurologic injury (44.4%) than PND- patients (14.3%; P < .001) with a specific pattern of ischemic lesions in accordance with preoperative neurologic status. While PND+ patients suffered mainly from right hemispheric strokes (66.7% vs 32.4% in PND- patients, P= .024), PND- patients more frequently presented with bilateral cerebral ischemia (56.8% vs 13.3% in PND+ patients, P= .004). Multivariable analysis identified presence of PND (odds ratio, 2.977; 95% confidence interval, 1.357-6.545) as an independent predictor for new postoperative neurologic injury. PND was associated with impaired survival (P= .005). This study identified an association of preoperative neurologic status and specific stroke patterns after surgical repair of AAD. Irrespective of timing of surgery and reperfusion strategies, preoperative neurologic dysfunction is strongly associated with impaired neurologic outcome.

An unusual pattern of post-mortem injury caused by Australian fresh water yabbies (Cherax destructor)

A 67-year-old woman with a history of previous cerebrovascular accidents who was confined to a wheel chair drowned in a pond in a public park. Features compatible with drowning included congestion and edema of the lungs with prominent hemolytic staining of the intima of the aortic root. Minor bruises and abrasions were identified. Toxicology was negative. An additional unusual finding was that of patterned symmetrical injuries to the earlobe and pinna of both ears. The injuries consisted of small irregular areas of skin loss that were sometimes linear and parallel and had the appearance of animal nibble marks. Given the presence in the pond of numerous Australian fresh water yabbies (Cherax destructor), and no other predators, it appeared that the injuries had been caused by post mortem feeding by these crustaceans. This case therefore extends the range of animals that may be involved in post mortem predation that may be encountered in cases of freshwater drowning/immersion in an Australian context, with a specific pattern of injury focused on the ear lobes.

Missed Diagnosis and Acute Management of Radial Head Dislocation With Plastic Deformation of Ulna in Children.

Radial head dislocation with ulnar bowing (Monteggia type I equivalent injury) is a frequently missed injury. If not recognized acutely, these missed injuries can lead to serious long-term complications. The purpose of this study was to evaluate the rate of missed diagnosis and to report on the characteristics and early management of this specific injury pattern. A total of 112 patients with Monteggia fracture-dislocation were identified, of which 18 patients had sustained a Monteggia type I equivalent injury. The total duration between injury, diagnosis, and treatment was noted. Medical records were reviewed to identify cases with the initially missed diagnosis. The radiographic assessment included the direction of radial head dislocation and location/displacement of the apex of the ulnar bow. Clinical outcomes were evaluated using Kim elbow performance score. Thirteen of 18 cases with Monteggia equivalent injury were missed at the initial presentation. The diagnosis was established when the patients followed up in the orthopaedic clinic. Of these 18 patients, 11 were treated by closed reduction/cast and 7 patients required surgery. Significant differences were found between the closed reduction/cast and operative group for the mean time from injury to treatment (3.2±2.6 vs. 12.7±13.6 d). For each day of delay in treatment, the odds for surgical intervention increased by a factor of 1.126 (12.6%). There were no significant differences between the location and magnitude of the apex of the ulnar deformity between the 2 groups. Kim elbow score was excellent in all cases at the latest follow-up. Clinical suspicion and careful radiographic assessment are of utmost importance for every child with forearm and elbow injury without an apparent fracture, as there is a high rate of missed diagnosis for this specific Monteggia injury pattern. Prompt treatment would allow for successful closed reduction while even minor delays would increase the need for surgical intervention. Therapeutic, level III.

Bone abrasions due to the dragging force of a moving vehicle: two unusual case reports

Abrasion injuries such as graze abrasions occur due to dragging of the body over a rough surface along the line of force. Such dragging of a body usually occurs when a person is trapped/pinned underneath a moving object like an automobile. Most of such injuries are superficial in nature or are limited to the soft tissues only. However, when the body is dragged for a considerable distance with considerable force then there might be bony involvement causing abrasion injuries to bone, which may be termed as abrasion. The authors present 2 cases having a specific pattern of abrasion injuries due to dragging of the broad body surface area by a moving vehicle for a considerable distance with speed and force in a road traffic accident. With evolving science there is a need to acknowledge injuries which may have specific pattern. Abrasion of bone due to a dragging force comprises such an interesting pattern of injuries, which potentially have forensic significance.

Preterm Lung Exhibits Distinct Spatiotemporal Proteome Expression at Initiation of Lung Injury.

The development of regional lung injury in the preterm lung is not well understood. This study aimed to characterize time-dependent and regionally specific injury patterns associated with early ventilation of the preterm lung using a mass spectrometry-based proteomic approach. Preterm lambs delivered at 124-127 days gestation received 15 or 90 minutes of mechanical ventilation (positive end-expiratory pressure = 8 cm H2O, Vt = 6-8 ml/kg) and were compared with unventilated control lambs. At study completion, lung tissue was taken from standardized nondependent and dependent regions, and assessed for lung injury via histology, quantitative PCR, and proteomic analysis using Orbitrap-mass spectrometry. Ingenuity pathway analysis software was used to identify temporal and region-specific enrichments in pathways and functions. Apoptotic cell numbers were ninefold higher in nondependent lung at 15 and 90 minutes compared with controls, whereas proliferative cells were increased fourfold in the dependent lung at 90 minutes. The relative gene expression of lung injury markers was increased at 90 minutes in nondependent lung and unchanged in gravity-dependent lung. Within the proteome, the number of differentially expressed proteins was fourfold higher in the nondependent lung than the dependent lung. The number of differential proteins increased over time in both lung regions. A total of 95% of enriched canonical pathways and 94% of enriched cellular and molecular functions were identified only in nondependent lung tissue from the 90-minute ventilation group. In conclusion, complex injury pathways are initiated within the preterm lung after 15 minutes of ventilation and amplified by continuing ventilation. Injury development is region specific, with greater alterations within the proteome of nondependent lung.

Assessing the ability of the Sacral Autonomic Standards to document bladder and bowel function based upon the Asia Impairment Scale.

Retrospective review of data. To determine if there is a relationship between the Asia Impairment Scale (AIS) and the bladder and bowel components of the International Standards to Document Remaining Autonomic Function after SCI (ISAFSCI). University-Based Academic Rehabilitation Program. Retrospective cross-sectional study assessing International Standards for Neurologic Classification After SCI (ISNCSCI) examination along with bladder and bowel components of the ISAFSCI. Subjects with AIS A injuries were statistically less likely to have history of bladder control and bowel control per investigator determination and bladder sensation via self-report versus patients categorized with AIS B injuries. Self-reported history of bowel sensation and control of voiding were more likely in subjects with C, D, or E injuries than with B injuries. Bowel and bladder control as determined by investigator and bladder and bowel sensation and control as self-reported were all statistically less likely in persons with AIS A injuries versus CDE. This retrospective study provides initial data regarding components of the bladder and bowel sections of the sacral ISAFSCI and AIS. Further prospective research is needed to further characterize the relationship between retention of bladder and bowel sensation and function and the AIS. We suggest that incorporation of the sacral components of the ISAFSCI into the ISNCSCI may be beneficial to obtain further information about retention of sacral function with specific patterns of injury.