Traumatic Soft Tissue Injuries Research Articles

Paired maxillary and smaller mandibular mouthguard for rugby player with malalignment

A rugby player who had frequently experienced soft tissue injuries while playing rugby and wearing a conventional custom-made mouthguard came to the hospital clinic. The patient had suffered traumatic soft tissue injuries such as lip lacerations and bite trauma. Severe crowding due to ectopic maxillary and mandibular canines was observed. In response to the patient's request for better protection, a set of maxillary and mandibular mouthguards was designed: one covering the entire maxillary dentition and the other the mandibular front teeth only. The mouthguards were to be worn simultaneously. In this paper, we describe how these mouthguards were fabricated and discuss the results. The patient has experienced no injury to the stomatognathic system, including the lips, for five seasons since he began wearing this set of mouthguards. This new pairing of mouthguards appears to offer sufficient protection against injury, despite severe malalignment. We believe that this new type of paired maxillary and mandibular mouthguards has the potential to reduce sports-related dental injuries.

Antithrombin Reduces Inflammation and Microcirculatory Perfusion Failure in Closed Soft-Tissue Injury and Endotoxemia

Closed soft-tissue trauma leads to activation of the coagulation cascade and is often complicated by systemic inflammation and infection. Previous investigations have shown potent anti-inflammatory properties of antithrombin. We herein report on the action of antithrombin on skeletal muscle injury in experimental endotoxemia. By using a pneumatically driven computer-controlled impact device, closed soft-tissue trauma was applied on the left hind limb of pentobarbital-anesthetized rats. Six hours later, endotoxemia was induced by intraperitoneal injection of Escherichia coli lipopolysaccharide. An equivalent volume of physiological saline was given in controls. At the same time point, treatment of animals was started by intravenous injection of antithrombin (250 IU/kg body weight) or vehicle solution. Twenty-four hours after trauma, the extensor digitorum longus muscle was microsurgically exposed and analyzed by means of high-resolution multifluorescence microscopy. Traumatic soft-tissue injury with additional endotoxemia was characterized by nutritive perfusion failure (functional capillary density: 379±20cm/cm;), tissue hypoxia (nicotinamide adenine dinucleotide autofluorescence: 77±4 aU), and enhanced leukocyte-endothelial cell interaction (773±35 cells/mm;). Therapeutic intervention with antithrombin 6 hrs after trauma restored nutritive perfusion and tissue oxygenation (functional capillary density: 469±22cm/cm; nicotinamide adenine dinucleotide autofluorescence: 61±5 aU [p < 0.05]) and reduced inflammatory leukocyte adherence (237±20 cells/mm; [p < 0.05]) toward values found in nontraumatized controls (functional capillary density: 573±13cm/cm; nicotinamide adenine dinucleotide autofluorescence: 56±2 aU; leukocyte adherence: 204±20 cells/mm;). Antithrombin ameliorates microcirculatory dysfunction and tissue injury in traumatized animals during endotoxemia. Furthermore, a reduced inflammatory cell response helps to prevent leukocyte-dependent secondary tissue injury.

Detection and characterization of traumatic scalp injuries for forensic evaluation using computed tomography

The purpose of this prospective study was to evaluate the rate of detection and correct classification of traumatic soft tissue injuries of the head using clinical multislice computed tomography (MSCT) compared with an external forensic examination. Thirty-one patients with soft tissue injuries after head trauma and clinically indicated cerebral MSCT scan underwent an external forensic examination with documentation of the morphological appearance and the exact localization of scalp and facial injuries. MSCT data were evaluated by a radiologist blinded to the results of the external examination using axial images as well as multiplanar reconstruction tools. The results of the radiological and forensic report were compared and analyzed. The main finding was that clinical MSCT data of the head detected 55 % of all external lesions and diagnosed the correct morphological type of lesion in 30 %. All lacerations and 44 % of the hematomas were correctly identified in the radiological report, whereas the diagnosis of swellings and abrasions was difficult. MSCT showed a high specificity for all types of soft tissue lesions. Additionally, a substantial number of internal lesions such as fractures or intracerebral bleedings were revealed which were not detected in the external examination. The results demonstrate that the forensic-radiologic evaluation of clinical MSCT data has a good diagnostic performance and is a valuable method to retrospectively supplement external forensic examination in living crime victims. It also might-to a certain extent-be used as the only source in cases where no forensic external examination has taken place within due time.

Biomarkers to Predict Wound Healing: The Future of Complex War Wound Management

Currently, no biological assay exists to objectively assess wounds to aid in timing of wound closure and guide therapy. In this article, the authors review military investigations in biomarkers as a method of objectively determining acute traumatic wound physiology and their applicability in predicting healing of complex soft-tissue wounds. The civilian literature related to biomarkers and wound physiology related to chronic and acute wounds was reviewed as a basis for current research into acute traumatic soft-tissue wounds. Analysis of serum and wound effluent from traumatic extremity soft-tissue combat wounds revealed changes in specific proinflammatory matrix metalloproteinases associated with impaired wound healing. Forsberg et al. analyzed serum and wound effluent for chemokines and cytokines. An increase in serum procalcitonin levels correlated with wound dehiscence. Lastly, serum, wound effluent, and wound bed tissue biopsy specimens were analyzed by Hawksworth et al. Consistent with previous studies, elevation in proinflammatory cytokines was associated with wound dehiscence. Changes in levels of proteases, protease inhibitors, and inflammatory markers have been correlated with wound healing. These findings further support the idea that inflammatory dysregulation and a persistent inflammatory state leads to failure of wound healing in the acute setting. These findings highlight potential targets for the development of a biological assay to individualize management of complex soft-tissue wounds, based on patient physiology and response, that would be applicable to not only military trauma but also civilian trauma. Ultimately, this would result in earlier wound closure, reduction in the number of operating room trips, and reduced health care costs.

Extent and time course of pain intensity upon treatment with a topical diclofenac sodium patch versus placebo in acute traumatic injury based on a validated end point: post hoc analysis of a randomized placebo-controlled trial

Objective: To investigate the extent and time course of pain intensity upon treatment with a topical diclofenac patch compared with placebo in acute traumatic sport injury based on a validated and established end point. Methods: Post hoc analysis of a randomized, placebo-controlled, double-blind, multicentre, 1-week study in 120 patients with traumatic blunt soft tissue injury. Visual analogue scale (VAS) scores (in millimetres) for pain on movement were analysed. The mean absolute VAS changes in pain intensity from baseline over the study course were calculated for the diclofenac patch formulation (active) and placebo; mean differences between active and placebo were assessed twice daily during the first 3 days after enrolment and then once daily up to day 7. Results: The diclofenac patch was consistently superior to placebo in relieving pain. The mean differences compared with placebo were greatest on day 2 (23.6 – 30.6 mm, p < 0.0001) and day 3 (24.5 – 24.6 mm, p < 0.0001). Diminishing differences were observed over the study course. Conclusion: The investigated diclofenac sodium patch provides clinically relevant pain relief in patients with acute traumatic injuries. Maximum effects versus placebo are detected at 2 – 3 days post-injury. This analysis may serve as useful information for the planning of clinical trials in acute traumatic injury.

Ultrathin Oblique Volar-to-Dorsal Reverse Turnover Radial Artery Perforator-Based Adipofascial Flap

Adipofascial flaps used in reconstruction of various tissue defects have been described by many authors and have several advantages. A clinical report of an extensive dorsal hand traumatic soft tissue injury where a new ultrathin oblique volar-to-dorsal adipofascial reverse turnover flap based on radial artery distal perforators is presented. Its width-to-length ratio was 1:4 (the longest ever reported), designed to cover primary free tendon grafts and exposed metacarpal bones. The technique has provided very good hand function and cosmetic outcome, minimum donor site morbidity, shortened rehabilitation, and no complications. Adipofascial flaps constitute a functional and an aesthetic refinement in the reconstructive surgical techniques managing complex tissue defects of the dorsum of the hand, a new surgical strategy reported here.

Failure of Fracture Plate Fixation

Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft-tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjunction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full-length constructs should be considered for osteoporotic fractures.

Versatile use of vacuum-assisted healing in fifty patients

Context:Wound management can often be a challenging experience, especially in the presence of diabetes mellitus, vascular or immunological compromise. While no single technique can be considered by itself to be ideal, vacuum-assisted healing, which is a recent innovation, is fast becoming a necessary addition as adjuvant therapy to hasten wound healing.Aims:To determine the efficacy of vacuum-assisted healing.Settings and Design:Plastic surgery centre. Ministry of Health Hospital, Kuwait.Materials and Methods:Patients from Kuwait in a wide variety of clinical situations were chosen for study: Patients (n=50) were classified by diagnosis: Group 1: pressure sore- sacral (n= 3), trochanteric (n=6), ischial (n= 2); Group 2: ulcers (n= 11); Group 3: traumatic soft tissue wounds (n =15); Group 4: extensive tissue loss from the abdominal wall perineum, thigh and axilla (n =5); Group 5: sternal dehiscence wounds (n =4) and Group 6: wounds from flap necrosis (n =4). All wounds were subjected to vacuum by wall unit or portable unit, using pressure of 100-125 mm - continuous or intermittent. Closure of wounds, significant reduction in size and refusal by patient for continuation of vacuum-assisted closure therapy were end points of vacuum application.Results:Sixteen per cent of patients showed complete healing of the wound. Seventy per cent of patients showed 20-78% reduction in wound size. In 14% of patients treatment had to be discontinued. All patients showed improvement in granulation tissue and reduction in bacterial isolates and tissue oedema.Conclusions:The application of subatmospheric pressure or negative pressure promotes healing in a wide range of clinical settings and is an advanced wound healing therapy that can optimize patient care, promote rapid wound healing and help manage costs. It may be used in most instances in both hospital and community settings.

MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament

The objective of this study was to assess the utility of MRI in diagnosing injury to the first interosseous cuneometatarsal (Lisfranc) ligament and to additionally determine the associated patterns of traumatic soft tissue and osseous injury. Fifteen patients (16 feet) who were referred for MRI evaluation of the Lisfranc ligament, and had operative exploration or examination under anesthesia, were included for analysis. Standard non-contrast MRI foot imaging was performed in all cases. Evaluation of the following components was performed: the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal metatarsal ligaments, soft tissue edema and fluid, and bone marrow edema and fractures. Surgical reports were regarded as the reference standard in all cases. Seven of 10 cases of grade 3 Lisfranc ligament injuries at surgery were correctly graded at MRI. No cases of surgically proven complete Lisfranc ligament tears (grade 3) were interpreted as normal at MRI. All Lisfranc ligament sprains (grade 2 or 3) at surgery were detected at MRI. Two of six cases reported as grade 1 injuries at MRI were normal at surgery. No cases of surgically proven normal or sprained Lisfranc ligaments were interpreted as grade 3 tears on MRI. Four of six of our cases of normal or sprained Lisfranc ligaments demonstrated fractures; while the minority of complete Lisfranc ligament tears (3/10) contained fractures. MRI is reasonably accurate at detecting traumatic injury to the Lisfranc ligament. However, in clinically suspected cases of traumatic Lisfranc ligament injury, true positive rate for sprain is low.

Trigger finger: etiology, evaluation, and treatment

Trigger finger is a common finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. Although it can occur in anyone, it is seen more frequently in the diabetic population and in women, typically in the fifth to sixth decade of life. The diagnosis is usually fairly straightforward, as most patients complain of clicking or locking of the finger, but other pathological processes such as fracture, tumor, or other traumatic soft tissue injuries must be excluded. Treatment modalities, including splinting, corticosteroid injection, or surgical release, are very effective and are tailored to the severity and duration of symptoms.

Damage control orthopaedics

Damage control orthopaedics (DCO) describes a philosophy for the management of the patient with multiple bony injuries. The fundamental principles are that fractures and traumatic soft tissue injuries (the `wound organ') should be stabilised promptly with the minimum physiological insult to the patient, and that initial surgery should be regarded as a staged part of the resuscitation process. This article discusses the history of DCO; the scientific basis behind DCO principles; patient selection for DCO; the principles of resuscitation in the multiply injured; the evidence for and against DCO; and possible future advances.

Topical Ketoprofen Patch (100 mg) for the Treatment of Ankle Sprain: A Randomized, Double-Blind, Placebo-Controlled Study

Background Topical nonsteroidal anti-inflammatory drugs offer the advantage of enhanced drug delivery to local affected tissues with low plasma levels and an expected reduced incidence of systemic adverse events (mainly peptic ulcer disease and gastrointestinal hemorrhage). Hypothesis To test the efficacy and tolerability of a 100-mg patch of ketoprofen applied once a day. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods The 2-week trial included patients suffering painful (spontaneous pain ≥50 mm on a 0- to 100-mm visual analog scale), benign (grade I or II), recent (<2 days) ankle sprains as a model of general traumatic soft tissue injuries. The primary efficacy criterion was spontaneous pain change after 7 days of treatment in the intention-to-treat population. One hundred sixty-three patients were randomized (ketoprofen, 81; placebo, 82). Results After 1 week of treatment, the decrease in spontaneous pain was -50 ± 20 mm for ketoprofen and -38 ± 24 mm for the placebo, showing a statistically significant intergroup difference (P =. 0007). The majority of the secondary criteria were also statistically significant in favor of the ketoprofen patch. Tolerance was good in both groups, adverse events being mostly local. Conclusion This trial suggested that a 7-day course of treatment with a ketoprofen patch is useful in benign ankle sprain, without revealing unexpected adverse events.

Wound management with vacuum-assisted closure: experience in 51 pediatric patients

Background/Purpose Soft tissue loss from infectious, vascular, and traumatic disorders often results in poor healing, painful wound care, and the need for repeated operations. This retrospective study evaluates a single-institutional experience with negative pressure therapy (NPT), using the vacuum-assisted closure (VAC) device in a group of children with diverse soft tissue problems. Methods The medical records of 51 patients treated with NPT from January 2000 to July 2003 were reviewed for demographics, diagnosis, duration of VAC therapy, wound closure, recurrent disease, and complications. Results Patients were classified by diagnosis: group 1: pilonidal disease (n = 21, primary = 6 and recurrent = 15); group 2: sacral and extremity ulcers (n = 9); group 3: traumatic soft tissue wounds (n = 9); and group 4: extensive tissue loss (n = 12) from the abdominal wall (n = 7), perineum (n = 2), thigh (n = 2), and axilla (n = 1). Group 1 had an average age of 16 years (range, 10-20 years), 67% were obese, and had an average length of follow-up of 13 months (range, 8-36 months). VAC was placed in the operating room in 95% with subsequent outpatient care that included dressing change 3 times weekly. Healing occurred in all patients with primary disease at an average of 37 days. For patients with recurrent disease, 12 healed at an average of 48 days and 3 developed recurrent sinuses. Group 2 was treated with VAC as a bridge to skin grafting or flap closure. All children in group 3 achieved healing without skin grafting at an average of 10 days and with acceptable cosmesis. Negative pressure therapy in group 4 was the only wound treatment in 10 patients and adjunctive to operative closure in 2. Complications from VAC occurred in 5 patients: retained sponge in 2 and device malfunction in 3. Conclusions Negative pressure therapy offers a safe, cost-effective alternative to traditional complex wound care in children. Its advantages are less frequent dressing changes, outpatient management, resumption of daily activities including return to school, and a high degree of patient tolerance.

Boxer’s Knuckle: A Single Case Study

AbstractDirect trauma to the dorsal aspect of the MCP joint of the fingers is a common occurrence in sports. Boxers and martial artists sustain repetitive forceful trauma to the clenched fist. The MCP joint may sustain contusions, ynovitis, articular fractures, collateral ligament damage, or extensor mechanism disruption (Arai 2002, Hame 2000). Traumatic soft tissue injury to the extensor mechanism have been coined “boxer’s knuckle” and can be a devastating injury to the elite athlete (Posner 1989). This case study examines the anatomy of the extensor mechanism and relates this to an injury seen in clinic in a patient who did not participate in any sport.

Tap water or normal saline for cleansing traumatic wounds?

The aim of this review was to identify whether cleansing with tap water results in higher rates of wound infection or delayed healing compared with other cleansing solutions in adults or children with acute uncomplicated traumatic soft tissue wounds. The review utilized a systematic search of key databases (Cochrane Library, Medline, Embase, Cinahl, British Nursing Index and PubMed), bibliographies, and internet resources. Three controlled trials were found which studied 1281 people. One further study reported outcomes but could not be fully examined as only an abstract was available. Based on the studies reviewed, results suggest no clinically significant increase in the risk of wound infection in wounds irrigated with tap water when compared to sterile normal saline in uncomplicated soft tissue injury. However, the available evidence lacks strength because of the relatively low power and poor quality of studies.

Acute pasteurella multocida in total knee arthroplasty

Pasturella multocida is a rare cause of joint sepsis in total joint arthroplasty, and all case reports have identified a distant source of infection from an animal bite that has caused potential hematogenous seeding of the prosthesis. We report a case in which no potential distal wound source was found and the only likely etiology was local wound seeding from an old injury. In that injury, a saddle stirrup had caused a severe traumatic soft tissue injury as a horse had rolled over the patient. We draw attention to the fact that this particular bacteria is virulent in producing septic contamination of a total joint prosthesis, and aggressive treatment is indicated when such infection is identified.

Traumatic soft tissue injuries of the shoulder girdle

As the major hinge of motion of the upper extremity, the shoulder girdle is prone to soft tissue injuries associated with trauma or overuse. Most soft tissue injuries are tendon injuries, joint sprains or dislocations. The trauma mechanism, position of the arm, the anatomic location of pain and presence of referred pain should be investigated. A detailed history and careful physical examination will lead to the diagnosis of specific disorders in most cases. A wide selection of imaging studies is available for shoulder problems. The imaging of choice should be chosen based on the working diagnosis and cost. This review focuses on the diagnosis and management of acute and chronic soft tissue injuries and pathologies involving the adult shoulder.

TREATMENT OF SOFT TISSUE INJURIES TO THE DORSUM OF THE METACARPOPHALANGEAL JOINT (BOXER'S KNUCKLE)

We retrospectively reviewed the surgical treatment for 16 cases of traumatic soft tissue injury to the metacarpophalangeal joint (Boxer's knuckle). A history of trauma was present in all cases and there was an associated extensor tendon dislocation in seven cases. Eight cases were initially treated conservatively, but their symptoms persisted. Intraoperative findings included rupture of the extensor hood or joint capsule in all cases. Surgical closure of the rupture of the joint capsule resulted in a successful outcome in all cases. We consider that conservative treatment of this injury may not be effective when the joint capsule of the metacarpophalangeal joint is ruptured. We recommend arthrography of the metacarpophalangeal joint to assist in the decision as to whether to proceed with surgical or conservative treatment.

Normal Ranges of Scapholunate Distance in Children 6 to 14 Years Old

The purpose of this study was to determine the normal ranges of scapholunate distance (SLD) applicable to children. Bone age radiographs of 85 children (36 boys, 49 girls) 6 to 14 years of age were used to establish the normal ranges. Repeated-measures analysis of variance revealed significant age and gender differences. Therefore, linear regression was used to determine normal SLD ranges separately for girls and boys based on chronologic age and bone age. SLD normal ranges were similar for chronologic age and bone age. Interobserver and intraobserver agreement was excellent. There was no significant age by gender interaction found, indicating that although boys had significantly longer distances than girls, both showed a similar rate of decreasing SLD distance with age. These results provide age-and gender-based normal ranges of SLD in young children. These results may be useful in assessing traumatic soft tissue injuries about the pediatric wrist. Of note, only three girls and two boys (all 12 years or older) met the adult criterion of normal SLD of ≤2 mm.

Normal ranges of scapholunate distance in children 6 to 14 years old.

The purpose of this study was to determine the normal ranges of scapholunate distance (SLD) applicable to children. Bone age radiographs of 85 children (36 boys, 49 girls) 6 to 14 years of age were used to establish the normal ranges. Repeated-measures analysis of variance revealed significant age and gender differences. Therefore, linear regression was used to determine normal SLD ranges separately for girls and boys based on chronologic age and bone age. SLD normal ranges were similar for chronologic age and bone age. Interobserver and intraobserver agreement was excellent. There was no significant age by gender interaction found, indicating that although boys had significantly longer distances than girls, both showed a similar rate of decreasing SLD distance with age. These results provide age-and gender-based normal ranges of SLD in young children. These results may be useful in assessing traumatic soft tissue injuries about the pediatric wrist. Of note, only three girls and two boys (all 12 years or older) met the adult criterion of normal SLD of < or = 2 mm.