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PubMedDate not supplied

Reduction of posterior hip dislocations in the lateral position using traction-countertraction: safer for the surgeon?

Closed reduction of a hip dislocation is a physically demanding task for the orthopaedic surgeon. The most commonly used methods for reduction of the hip involve vigorous axial traction on the lower extremity with the patient in the supine position, using an assistant who attempts to hold the pelvis down. The surgeon generally stands over the patient to pull up on the bent knee, which puts the surgeon at risk for a low back injury and, if done while the patient remains on a stretcher, can put the surgeon at risk for a fall from a height. Reduction in the prone position is advocated by some, but caring for the sedated patient in the prone position can be difficult and the patient's pelvis tends to roll off the edge of the stretcher, preventing the achievement of hip flexion, which is desirable in achieving reduction. We describe a traction-countertraction technique that appears to be significantly less dangerous for the surgeon. In this technique the hip is reduced with the patient remaining on the stretcher in the lateral position. In addition, fluoroscopy can be carried out during the reduction maneuver, and the images can be quite helpful in adjusting the direction of manipulative forces.

Hip Dislocation↗

PubMed1983

Intra-articular fractures of the distal tibia: the pilon fracture.

Forty-two patients with pilon fractures were followed 24 to 96 (mean, 53) months post-fracture. Fractures were classified as Type I (26%), Type II (29%), or Type III (45%) as defined by Ruedi and Allgower. Type I fractures were usually torsional in nature whereas Type II and III injures were usually the result of a fall from a height or motor vehicle accident. Type I and II pilon fractures were amenable to anatomic open reduction and stable internal fixation and 80% or more had satisfactory results. Only 44% of Type III fractures treated by open reduction and internal fixation produced a satisfactory outcome. Nonanatomic reduction, unstable fixation, infection, nonunion, and/or angulation were the usual causes of failure of this form of treatment.

Adult↗

PubMed1993

Lisfranc joint injuries: trauma mechanisms and associated injuries.

A retrospective review of the roentgenograms of 750 patients treated in our institution for tarsometatarsal joint injuries or metatarsal fractures over a 10-year-period was performed. Injuries of the Lisfranc joint were found in 66 patients (9%). Twelve patients (19%) had a total dislocation, 47 patients (71%) a partial dislocation, and seven patients (11%) a subtle injury of the Lisfranc joint. Four main groups of trauma mechanisms were identified (low-energy injuries, falls from a height, direct crush injuries, and high-energy vehicular crashes). Lisfranc joint injuries caused by low-energy injuries (21 patients) were as frequent as those caused by high-energy vehicular crashes (22 patients). There was no apparent relationship between the mechanism of injury and the type of Lisfranc joint dislocation. All patients except three had associated metatarsal fractures, most commonly in the second metatarsal. The location of associated metatarsal fractures was different from that in patients with metatarsal fractures alone (p < 0.001). Fractures, dislocations, or fracture-dislocations of midtarsal bones (cuneiforms, cuboid, navicular) occurred in 26 patients (39%). Multiple metatarsal fractures and midtarsal bone injuries were more frequent in high-energy vehicular crashes than in low-energy injuries (p = 0.016 and p = 0.033, respectively). In 23 patients (35%), the treatment had been focused on multiple metatarsal fractures or midtarsal bone injuries without full appreciation of the concomitant Lisfranc joint incongruity. Increasing the knowledge of normal foot anatomy and the appreciation of the risk of Lisfranc joint injury even in seemingly trivial stumbling accidents obviously may improve the diagnosis and treatment of these potentially disabling injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1999

Posttraumatic hypertension secondary to adrenal hemorrhage mimicking pheochromocytoma: case report.

We report the case of a 68-year-old man who presented with a mass 3 x 4 cm in size located in the right adrenal gland together with extreme hypertension, tripled urine levels for normetanephrine, and normal plasmatic levels of metanephrines. The patient had suffered a fall from a height of 2.5 meters before hospitalization. [123I]MIBG-scan was repeatedly positive in the area of the right adrenal gland. At laparotomy under alpha-adrenergic blocking agents, the suspected pheochromocytoma was histologically confirmed as hematoma. After resection of the adrenal gland, blood pressure returned to normal without drug therapy as did metanephrine levels in urine. Although adrenal insufficiency after distension of the gland caused by hemorrhage has been reported, there are no data available regarding the mimicking of a hormonally active pheochromocytoma. We conclude that intra-adrenal pressure rise caused by hematoma may cause partial ischemic necrosis to the gland but may also induce reactive hyperplasia with periodic excessive secretion of catecholamines. This interpretation is consistent with the finding that plasma levels of catecholamines were normal in contrast to the urinary normetanephrines in the presented case. It might be worthwhile to investigate patients with intra-adrenal hemorrhage immediately after sustaining multiple injuries and in the posttraumatic course of several months up to 1 or more years together with verification of abnormal urinary excretion of metanephrines as a sign of impaired adrenal function.

Adrenal Gland Diseases↗

PubMed1983

Segmental spinal instrumentation in the management of fractures of the thoracic and lumbar spine.

Eleven cases of fracture of the thoracic and lumbar spine were treated with segmental spinal instrumentation (Luque rods). The majority of these injuries occurred in motor vehicular accidents or falls from a height and were usually associated with multisystem trauma. This method of instrumentation provided immediate rigid internal fixation, which obviated the need for postoperative orthoses, allowed easier nursing care and early ambulation, and facilitated rehabilitation of patients with spinal cord injury. At 13 months' average follow-up, there have been no instances of wire breakage, rod deformation, or deterioration of neurologic status. This favorable experience suggests that segmental spinal instrumentation should be considered as an alternative mode of spinal instrumentation in fractures of the thoracic and lumbar spine.

Accidents, Traffic↗

PubMed1985

Transverse fracture of the upper sacrum. Suicidal jumper's fracture.

Thirteen patients with transverse fractures of the upper sacrum were studied to determine fracture anatomy, clinical presentation, and therapeutic approaches. The injury results from falls from a height and is usually associated with suicidal attempts by jumping. The position of the lumbar spine in lordosis or kyphosis at the time of impact determines which of three types of morbid anatomy will result. Because of associated polytrauma, fracture of the upper sacrum is often not recognized in the acute stage, and awareness of the possibility of such injury, especially in the presence of perineal neurologic deficit should result in securing good quality radiographic study, including tomograms. Surgical treatment is often required.

Adult↗

PubMed1989

Traumatic cervical spine injuries in childhood and adolescence.

Of 84 consecutive children and adolescents with traumatic cervical spine injuries treated over a 10-year period, 61 (73%) were available for review. Age ranged from the newborn period to 17 years. Analysis of injury type revealed four groups of roughly equal incidence: atlantoaxial rotary subluxation, upper cervical fracture or dislocation, lower cervical injury, and spinal cord injury without radiographic abnormality. Forty-four percent of patients incurred a neurologic injury. Falling from a height was the most common mechanism of injury. Apart from patients with complete neurologic deficits, the prognosis for these injuries is good.

Adolescent↗

PubMed2000

Pediatric spinal injury.

Spine injury in children thankfully is still a relatively rare injury. The incidence of pediatric spine injuries has been reported as 2% to 5% of all spine injuries. The biological differences of children make differences in fracture patterns and alter the management necessary for successful treatment. The other factors that affect fracture production and associated injuries are head size relative to the body size, flexibility of the spine and supporting structures, the growth plates, and the elasticity and compressibility of the bone. The majority of compression injuries in children are made up of falls from a height. Spinal injuries in children remain a challenge despite some technical changes in assessment and treatment.

Child↗

PubMed2003

Quality of multiple trauma care in 33 German and Swiss trauma centers during a 5-year period: regular versus on-call service.

BACKGROUND: The purpose of this study was to evaluate process and outcome quality of severely injured patients admitted during on-call (OC) versus regular trauma service (RS). METHODS: This was a prospective and multicentric analysis of the Trauma Registry of the German Trauma Society. Patients were evaluated if directly admitted from the scene of accident with an Injury Severity Score of > 15 and if alive on arrival at the emergency department. RESULTS: Seventy percent of patients were admitted during OC; these patients were significantly younger. Blunt trauma predominated, with a 95% incidence. Falls from great heights were significantly more frequent during RS, whereas motor vehicle crashes predominated during OC. No differences were found for emergency department management (e.g., time to abdominal ultrasound, chest radiograph, or cranial computed tomography). However, time to admission to the intensive care unit was substantially longer during RS. No significant differences were found for outcome parameters such as length of intensive care unit stay, hospitalization time, incidence of organ failure, or mortality. CONCLUSION: This study demonstrates a constant quality of care provided 24 hours per day, 7 days per week in the participating hospitals. Differences within individual trauma centers were not compared and need to be assessed by internal quality management.

Germany↗

PubMed2004

Late renal functional and morphological evaluation after non-operative treatment of high-grade renal injuries in children.

OBJECTIVE: To assess the long-term results in children with high-grade renal trauma who were managed without surgery, as such treatment was initially successful but little is known about the late ipsilateral renal function and morphology. PATIENTS AND METHODS: The study included 13 children (nine boys and four girls; mean age 8 years, sd 5) with high-grade renal injury who were managed without surgery between 1997 and 2001, and followed for a mean (sd, range) of 3 (2, 0.5-7) years. The trauma was caused by a motor-car accident in five and falling from a height in eight children, and was on the right in 10 and on the left in three. There was gross and microscopic haematuria in 10 and three patients, respectively. The trauma was graded according to the American Association for Surgery of Trauma, with grades III, IV and V renal injury in six, four and three children, respectively. All patients were treated initially by observation; one required super-selective embolization because of continuing haemorrhage. Three children with progressive urinary extravasation were treated with a percutaneous tube drain and JJ stent for 6 weeks. Patients were discharged after a mean (sd) hospital stay of 9 (6) days. Ultrasonography then showed resolving haematoma in all patients with a mean (sd) size of 7 (2) cm(2). At the last follow-up patients were re-evaluated by a clinical examination, renal scintigraphy and computed tomography angiography. RESULTS: None of the children was hypertensive nor had any abnormality on urine analysis; all had normal serum creatinine levels, and scintigraphy and angiography showed normal contralateral kidneys in all. Ipsilateral abnormalities were detected in 12 patients, and included a single scar in five, multiple scars in six and a cystic lesion with multiple septa in one. There was no vascular complication or hydronephrosis, and no significant functional loss, with all affected kidneys having a split function of 41-50% at the last follow-up. CONCLUSION: Although there is no late functional loss there are residual morphological changes in almost all children with high-grade renal injury. This study provides objective support for the non-operative management of high-grade renal injury in children, but a prolonged follow-up is warranted to assess the risk of progression of these abnormalities.

Child↗

PubMed1998

Paramedic judgment of the need for trauma team activation for pediatric patients.

OBJECTIVE: To determine the value of paramedic judgment in determining the need for trauma team activation (TA) for pediatric blunt trauma patients. METHODS: A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28, 1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of >10 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. RESULTS: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric blunt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. CONCLUSION: Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly after injury. However, if a pediatric patient appears injured, transport from the scene and examination by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.

Adolescent↗

PubMed2005

The clinical significance of spinal cord injuries in patients older than 60 years of age.

OBJECTIVES: To study the causes and the rehabilitation outcome of traumatic spinal cord injury (SCI) in patients older than 60 years at the time of injury. MATERIAL: Forty-four patients were included. METHODS: The American Spinal Injury Association Motor Impairment Scale on admission and at discharge and the Functional Independence Measure Motor subscale at discharge were calculated retrospectively according to the patient records. The causes of injury and treatment were obtained. The MRI-scans in patients with cervical injuries during the last 5 years were evaluated. RESULTS: Thirty-four patients (77%) were injured after falling from a height, 24 with cervical lesions. Thirty-five patients (80%) had incomplete lesions and they had the best outcome with regard to functional level. MR images of 15 patients with cervical lesions revealed preexisting cervical stenosis in 80%. CONCLUSIONS: A high proportion of the patients had a cervical spinal stenosis and incomplete SCI; most of them regained good function.

Age Factors↗

PubMed1992

Diffuse axonal injury caused by assault.

The case reports of 50 fatal head injuries caused by assault and managed at the Institute of Neurological Sciences, Glasgow, were reviewed. Fifteen cases had diffuse axonal injury. Diffuse axonal injury is a well recognised type of brain damage brought about by a head injury, usually as a result of a road traffic accident or fall from a height. It does not seem to be widely appreciated that it may also occur as a result of an assault. This has important medicolegal implications.

Adolescent↗

PubMed1987

Alcohol associated deaths in British soldiers.

In the decade 1968-77, 203 (12%) of the 1723 deaths in off duty British Army males were associated with a blood alcohol concentration (BAC) in excess of 80 mgs/100 mls. These deaths occurred in road traffic accidents (49%), acute alcohol poisoning (23%), suicide (9%), drowning (8%), falling from a height (7%), burns (3%), and interpersonal violence (1%). The mean BAC was similar in all of these categories (180 mgs/100 mls) except in acute alcohol poisoning where it was double this figure. The mean age at death was similar, approximately 24 years, for all categories except suicide, where it was 28 years. The mean age at death of those with raised alcohol levels was not significantly different from that of the total number in the same group. Alcohol associated death is generally more common abroad than in the United Kingdom, with the notable exception that, in the British Army of the Rhine (BAOR), the incidence of alcohol associated road traffic deaths is no higher than that in the United Kingdom. BAC above 80 mgs % is much less common in soldiers whose deaths occur on duty (1.6%).

Accidents↗

PubMed2006

Non-fatal occupational injuries in British agriculture.

OBJECTIVES: To investigate the incidence, nature and determinants of non-fatal occupational injuries in British agriculture. METHODS: As part of a postal survey, data on lifetime histories of work in agriculture and occupational accidents were obtained from men born between 1933 and 1977 and residing in three rural areas of England and Wales. Incidence rates for different categories of accident were compared with those derived from statutory reporting. Associations with risk factors were explored by Poisson regression, and summarised by incidence rate ratios (IRRs). RESULTS: Of the 10 765 responders (response rate = 31%), 3238 (30%) reported at least one occupational accident at the ages of 14-64 years, leading to absence from work for >or=3 days, including 1492 accidents that could be linked to a specific job listed in the history of agricultural work. The reported incidence of injuries in agriculture was markedly higher than that derived from statutory reporting, particularly for self-employed farmers. During 1996-2003, the highest rates of agricultural accidents were from handling, lifting or carrying (4.9/1000 person-years), falls from a height (4.6/1000 person-years) and injury by animals (3.4/1000 person-years). After adjustment for calendar period and age, the risk of accidents was elevated in men who had only recently entered agricultural work (IRR 3.7, 95% CI 2.7 to 5.1 for men who had worked in agriculture for up to 1 year relative to those who had entered the industry >25 years earlier), and in those who carried out forestry (IRR 1.7, 95% CI 1.5 to 1.9). CONCLUSION: Our findings confirm the substantial underascertainment of serious accidental injuries in agriculture through statutory reporting, particularly for the self-employed. The risk of accidents is highest in new recruits to the industry and in those undertaking forestry, and these groups should be a target for further preventive action.

Accidents, Occupational↗

PubMed1984

Intracellular potential changes following coronary occlusion in isolated perfused rat hearts.

A method of perfusing rat ventricles has been developed which permits the recording of intracellular potentials from up to 10 cell layers below the endocardial surface. Intracellular potentials from all layers remained the same for up to 1.5 h before occlusion. Regional occlusion of flow was produced by occluding the left anterior descending coronary artery and then intracellular potentials were recorded from normal and occluded cells for up to 2 h after occlusion. Immediately after occlusion, marked changes in potentials were recorded from occluded tissue. The greatest change was in the duration of the action potential which showed a marked shortening. There was also a reduction in the maximum rise rate and action potential height with smaller falls in resting membrane potential. Changes were greatest in the deeper cells (layers 6-10) and least in superficial subendocardial cells which were always superfused with perfusion fluid. Occlusion increased the number of quiescent cells (no action potential) as well as the number of cells showing aberrant action potential configurations (e.g., double peaks). Similar changes in intracellular potentials following occlusion were also recorded from the subepicardial surface of anaesthetized rats in situ. Arrhythmias induced by occlusion were similar to those seen in conscious rats following occlusion of a coronary artery.

Action Potentials↗

PubMed1975

In vitro measurement of margin of safety of neuromuscular transmission.

The margin of safety of neuromuscular transmission was measured in isolated guinea pig lumbrical muscles. Twitch height of an indirectly stimulated muscle was reduced stepwise by suitable concentrations of tubocurarine for comparison with the associated occlusion of receptors by the drug. Receptor occlusion was estimated from the effect of tubocurarine on carbachol depolarization measured extracellularly by the moving-fluid electrode technique. Roughly 75-80% of the receptor pool had to be blocked before the twitch height began to fall, and 90-95% had to be blocked before the twitch response was completely abolished. These results agree well with those found previously in vivo. Thus, the present results add further support to the earlier measurements. In particular, artifacts that might have been present because of the complex pharmacokinetic situation in vivo have been ruled out.

Animals↗

PubMed1993

Traumatic optic neuropathy in children: a prospective study.

Fifty children with indirect optic nerve injury were prospectively studied over an 8-year period. They constituted 20% of all patients with optic nerve injury managed on a slightly different protocol. Half of these children were injured due to fall from a height, followed by road traffic accidents in 40% of the cases. Forty-three children had unilateral and 7 children had bilateral visual impairment. Five children had definite history of delayed-onset visual involvement, which ranged from 12 to 72 h following injury. Fifty percent of these children had fractured skulls and 14% had optic canal fracture. Visual evoked potentials were performed in 43 patients of which wave formation was normal in 7 and abnormal in 14 patients. The remaining 22 patients had no wave formation. All the patients were managed conservatively and received corticosteroids for a period of 3 weeks. In 7 children an optic nerve decompression was performed between 4 and 6 weeks following injury. Spontaneous visual improvement was observed in 20 (40%) children. In all the patients onset of visual recovery was noticed within 3 weeks. Of the 7 children who had optic nerve decompression, 4 had minimal spontaneous recovery and their vision remained static. All these 4 children benefited by surgery and the vision improved further following the decompression. Three children had no perception of light prior to surgery and none of these patients showed visual improvement following surgery. The present study brings out the clinical profile of children with optic nerve injury and the indications of surgery in these patients.

Adolescent↗