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PubMed2003

Influence of a standardized closed soft tissue trauma on resistance to local infection. An experimental study in rats.

PURPOSE: The etiology of local posttraumatic infection in the locomotor system depends on the amount, virulence and pathogenicity of the inoculated microorganisms and the local/systemic host damage due to the type and extent of the accident or iatrogenic trauma. The relative effect of these factors remains unclear. In particular, it is still unclear today whether--in presence of microorganisms--soft tissue damage and its pathophysiological consequences lead to infection after soft tissue trauma, or whether the bacterial contamination is the primarily cause for posttraumatic infection. The aim of the project was to gain information on the consequences of a soft tissue injury in terms of resistance to local infection. Since clinical populations are too heterogeneous, the problem was investigated in a standardized, reduced (no surgery or implants) experimental in vivo model. METHOD: In female Sprague-Dawley-rats with a standardized closed soft tissue trauma to the tibialis anterior muscle (group I: n=13) or without (group II: n=13), we compared the incidence of local infection after a pairwise local, percutaneously injected bacterial challenge with various concentrations of Staphylococcus aureus (2 x 10(4)-2 x 10(6) colony forming units, CFU). The standardized closed soft tissue trauma was created by application of a specially designed, computer controlled impact device. The contaminated soft tissue and the underlying bone were removed under sterile conditions after five days and quantitatively evaluated for bacterial growths. Infection was defined as positive bacterial growth at the soft tissue and/or bone. A stepwise experimental design with an "up-and-down" dosage technique was used to adjust the bacterial challenge in the area of the ID50 (50% infection dose). Statistical evaluation of the difference between the infection rates of both groups was performed by two-sided fisher exact test (p<0.05). RESULTS: The overall infection rate was 46%. For the group with soft tissue trauma the ID50 was 1.32 x 10(5) CFU and 1.05 x 10(6) CFU for the group without soft tissue trauma. The infection rate was 69% (9 of 13 animals) for the group with soft tissue trauma and 23% (3 of 13 animals) for the group without soft tissue trauma. This difference is statistically significant (p=0.047). CONCLUSIONS: The infection rate after a standardized closed soft tissue injury was significantly higher and the ID50 lower than without soft tissue trauma. Our results demonstrate that in presence of microorganisms it is not primarily the bacterial contamination but rather the soft tissue damage and its pathophysiological consequences resulting in decreased infection resistance that secondarily lead to infection.

Animals↗

PubMed2001

Disability evaluation of extremity fractures.

Most fractures heal with restoration of bone and joint function. Disability is generally temporary in these instances, and there is no permanent impairment to be rated in the majority of cases. However, multiple complications can occur that can lead to loss of skeletal function, restricted range of motion, and associated soft tissue injuries, and neurovascular damage can dramatically and severely compromise function and performance. Clearly, not all fractures heal within the timeframes as outlined in Table 2, and determination of the point of maximum medical improvement, which must be achieved in order to declare an impairment as permanent, can be challenging in these cases. Some individuals with fractures that demonstrate bone union radiologically may develop long-term disability; nearly 30% of individuals with a unilateral lower extremity fracture will not return to work within 12 months of injury. In the absence of a complicating soft tissue injury, the explanation for this discrepancy between impairment and disability can be elusive. During the past 10 years, improved systems of trauma care have reduced mortality rates in the United States. As greater numbers of persons survive motor vehicle accidents and other major trauma, the possibility exists that increasing numbers of fractures leading to impairment or disability may be seen. Recognition of how and when fractures heal, possible complications that may arise, risk factors for long-term disability, and the correlation of vocational and avocational physical demands with the resultant outcome will enable the clinician to appropriately and accurately assess disability status, design a rehabilitation program, and assign an impairment rating.

Adult↗

PubMed2000

A randomized trial of preexercise stretching for prevention of lower-limb injury.

PURPOSE: This study investigated the effect of muscle stretching during warm-up on the risk of exercise-related injury. METHODS: 1538 male army recruits were randomly allocated to stretch or control groups. During the ensuing 12 wk of training, both groups performed active warm-up exercises before physical training sessions. In addition, the stretch group performed one 20-s static stretch under supervision for each of six major leg muscle groups during every warm-up. The control group did not stretch. RESULTS: 333 lower-limb injuries were recorded during the training period, including 214 soft-tissue injuries. There were 158 injuries in the stretch group and 175 in the control group. There was no significant effect of preexercise stretching on all-injuries risk (hazard ratio [HR] = 0.95, 95% CI 0.77-1.18), soft-tissue injury risk (HR = 0.83, 95% CI 0.63-1.09), or bone injury risk (HR = 1.22, 95% CI 0.86-1.76). Fitness (20-m progressive shuttle run test score), age, and enlistment date all significantly predicted injury risk (P < 0.01 for each), but height, weight, and body mass index did not. CONCLUSION: A typical muscle stretching protocol performed during preexercise warm-ups does not produce clinically meaningful reductions in risk of exercise-related injury in army recruits. Fitness may be an important, modifiable risk factor.

Adolescent↗

PubMed2003

Hemorrhagic shock induces an S 100 B increase associated with shock severity.

S 100 B is a glial marker of cerebral Injury. In a previous clinical study, we found an S 100 B increase within the first 24 h in patients with multiple trauma and hemorrhagic shock but without cerebral trauma. The aim of our current experimental study was to determine whether this posttraumatic S 100 B increase is caused by extracerebral soft tissue injury or by hemorrhagic shock and whether it is associated with the severity of hemorrhagic shock. Hemorrhagic shock was achieved by bleeding anesthetized rats to a mean arterial pressure (MAP) of 30-35 mmHg through a femoral catheter and maintaining this MAP until incipient decompensation. At incipient decompensation, MAP was either increased immediately to 40-45 mmHg (moderate shock) or was maintained until 40% of shed blood had been returned (severe shock), and then increased to 40-45 mmHg. Resuscitation was provided after 40-45 mmHg MAP had been maintained for 40 min. Soft tissue injury was achieved by midline laparotomy performed at the onset of hemorrhagic shock or without shock and was maintained for 30 min. Hemorrhagic shock caused an early S 100 B increase at the onset of decompensation. S 100 B remained increased for 24 h and was significantly higher after severe than after moderate shock. In contrast, soft tissue injury without hemorrhagic shock caused no S 100 B increase. The data presented demonstrate for the first time that the S 100 B increase is induced by hemorrhagic shock and is associated with the severity of shock.

Acidosis↗

PubMed1990

Infections in frail and vulnerable elderly patients.

Frail and vulnerable elderly patients, recognized primarily by the presence of such disabilities as immobility, incontinence, and dementia, are at particularly high risk for the development of infectious diseases, which are the leading cause of hospitalization in this population. The infectious diseases most often observed in the debilitated elderly are pneumonias, urinary tract infections, skin infections, and gastroenteritis, with fever a common manifestation. Some of the factors identified as contributing to their increased susceptibility include diminishing physiologic functioning; compromised host-defense mechanisms; increased incidence of mechanical risk factors, such as pressure ulcers, indwelling or condom catheters, feeding tubes, and soft tissue injuries; and comorbidities such as soft tissue or pulmonary edema. In addition to the common infecting pathogens found in the general population, these unique compromising factors increase the risk of elderly patients for aerobic gram-negative bacillary infection. Further increasing the therapeutic dilemma are ethical considerations involved in prolonging treatment that might be considered medical intervention beyond what is routine and necessary. Although the decision to treat must be made on an individual basis, studies have not always shown treatment to provide benefits in terms of quality of life. Once it is decided to treat, however, appropriate therapy is crucial. One of the most important considerations is renal function, which impacts on effectiveness, toxicity, and cost of therapy and is likely to be diminished in elderly patients. A non-nephrotoxic agent, such as aztreonam, may be a more appropriate therapeutic choice than an aminoglycoside antibiotic in this patient population.

Aged↗

PubMed1999

An indirect method for the estimation of osteoporotic fractures from injury and fracture profiles.

Study objective was to develop a valid epidemiological method for the estimation of osteoporotic fracture risk, using administrative databases and accounting for variable baseline risks of injury. Design is the secondary analysis of inpatient and outpatient utilization data. A baseline injury risk was estimated by the incidence of primary utilization of medical services for soft tissue injuries (ICD-9 diagnostic codes 910-929), and the risk profile was compared after normalization with the overall primary utilization rate for fractures (ICD-9 diagnostic codes 800-829). The setting is a county with approximately 100,000 inhabitants in the former East Germany. Participants were all inhabitants of the county who had a physician contact (inpatient or outpatient) during 1987-1988, as well as hospital inpatients for all of Germany in 1989. The number of fractures increased with age, especially in women, when compared to the number of fractures expected from the incidence of soft tissue injury. Similar patterns were identified in hospitalization data from East and West Germany. Estimating the prevalence of osteoporosis directly from certain "osteoporotic" fracture types associated with higher age is potentially biased, since it neglects the underlying risk of injury. Our model distinguished the osteoporotic fracture risk as the excess risk over an expected injury-related fracture risk for a given age and sex, and may allow a more valid quantification of osteoporotic fractures in different populations.

Adolescent↗

PubMed2001

Walk-through injuries: glass door facial injuries.

During 1998, 13 patients were treated in the Tel-Aviv Sourasky Medical Center for complex facial soft-tissue injuries caused by passing through large, clear glass doors. All epidemiological details were gathered and analyzed. Of 1,100 soft-tissue facial injury admissions in 1 year, 13 patients had a substantial soft-tissue facial injury after passing through a glass barrier. Nine were injured during leisure time activity, five in a shopping mall, and four in their residence. Interestingly, the authors found a common pattern of facial injuries in all patients. It consisted of large, irregular, composite skin and soft-tissue flaps as well as large, tom, irregular skin lacerations. The nose was injured predominantly, and the injury was particularly complex. Their recommended management of these injuries is a thorough and careful evaluation of flap viability. Surgical management of avulsed, viable flaps includes margin debridement and repositioning. If the flap is narrow enough, it can be debrided and the margins adapted primarily. If viability of part of the flap is in doubt, that part should be debrided and used as a composite graft. When this graft dies, a full-thickness graft is taken from another facial site. The cosmesis of such a graft is better than using the debrided, thin segment as a skin graft that is too thin. The authors emphasize that there is a need to encourage authorities to reinforce regulations relating to injury prevention from architectural glass. The first is to use special glazing, either tempered glass, laminated glass, or both. The other method of improving safety is by indicating glass using decorations or warning stickers, or by making it partly translucent. Unless these regulations are obeyed, fatal or complex trauma may occur.

Adult↗

PubMed1996

Clinical assessment of scaphoid injuries and the detection of fractures.

Difficulty in interpreting X-rays following carpal injury emphasizes the importance of clinical assessment in diagnosing scaphoid fractures. The classical sign of tenderness in the anatomical snuffbox is not specific and leads to many unnecessary out-patient reviews. A prospective comparison was made between anatomical snuffbox, scaphoid tubercle and scaphoid compression tenderness as indicators of scaphoid fracture in 221 patients with suspected scaphoid injury. Swelling was determined by measuring the difference in circumference at the wrist joint to compare between fracture and soft tissue injury. Scaphoid compression tenderness was found to be the most accurate test with a sensitivity of 100% and a specificity of 80%. Swelling of the wrist joint was significantly greater when there was a fracture, compared to soft tissue injury alone, even when the initial X-ray was normal. This was independent of any physiological variation in circumference between dominant and non-dominant sides. Scaphoid compression tenderness is therefore suggested as the most accurate indicator of scaphoid fracture and marked swelling should raise suspicion even if the X-ray is normal.

Adolescent↗

PubMed2005

Ballistic fractures--the limited value of existing classifications.

We have assessed a number of ballistic fracture classifications but were unable to identify one that could adequately grade the severity of the injury, assist in determining the optimal treatment or predict outcome. Many of the existing classifications are based on experimental studies or radiological appearance and do not take into account the soft tissue injury, which is usually the main prognostic indicator. In addition few differentiated between different bones, and some were specific to only one bone. We would suggest that ballistic fractures are treated on an individual basis, specifically considering the soft tissue injury, the anatomical location of the injury and any involvement of joints. The specific weapon or muzzle velocity are not of prime importance, and classifications should not be based on these.

Fractures, Bone↗

PubMed1964

THE DYNAMIC TREATMENT OF THE LOW BACK STRAIN SYNDROME.

The modalities at present in use for the treatment of soft-tissue injuries responsible for the low back strain syndrome are predominantly passive, yet similar soft-tissue injuries elsewhere in the body receive and respond to an early program of active movement. To assess the feasibility of such an approach to the low back strain syndrome, a program of therapeutic exercises with and without the addition of heat and massage was employed for the treatment of this condition. Exercises alone were found to be as effective as a program of "heat, massage and exercises" in resolving the presenting complaints. At the same time this dynamic approach served to reduce the undesirable effects, both local and general, of the enforced inactivity of the patient.

Exercise↗

PubMed1998

Genital injuries following sexual assault of women with and without prior sexual intercourse experience.

BACKGROUND: The literature on sexual assault has not directly addressed the question of genital injuries in women without prior sexual intercourse experience. Given the paucity of research and the current importance of physical evidence in the criminal justice system, this study was designed to document the type and site of genital injuries from sexual assault in women without and with prior sexual intercourse experience. METHODS: The charts were reviewed of 132 women who had been sexually assaulted and had sought medical treatment at the Sexual Assault Care Centre (SACC), Women's College Hospital, Toronto, within 10 days after the assault. Half (66) of the women reported that, at the time of the assault, they had no prior sexual intercourse experience. The Sexual Assault Evidence Kit in each patient's file was reviewed to ascertain the type and location of genital injuries. Types of injuries were classified into 3 categories (nonperforating soft-tissue injuries, lacerations or current bleeding) and locations into 6 categories (labia majora and minora, posterior fourchette and introitus, hymen, vagina, cervix, and anus). RESULTS: Significantly more women without than with prior sexual intercourse experience had visible genital injuries (65.2% v. 25.8%, p < 0.01). However, of the women without prior experience, only 9.1% had hymenal perforation. Analyses of the data for only women with genital injuries indicated no difference between those without and those with prior sexual intercourse experience in the overall mean number of injured sites (1.65 and 1.47 respectively) or in the mean number of sites with nonperforating soft-tissue injuries (0.349 and 0.706), lacerations (0.953 and 0.471) and bleeding (0.279 and 0.294). INTERPRETATION: The results suggest that genital injuries are more common in women without prior sexual intercourse experience but that substantial proportions of all women, regardless of their prior sexual experience at the time of assault, will not have visible genital injuries. Emergency department staff and members of the criminal justice system need to be aware of the variable presentation of genital trauma related to sexual assault in women with and without prior sexual intercourse experience.

Adolescent↗

PubMed1997

A high-frequency shear device for testing soft biological tissues.

Accurate mechanical property data obtained at large shear deformations and high frequencies are a fundamental component of realistic numerical simulations of soft tissue injury. Although many commercial systems exist for testing shear properties of viscoelastic materials with properties similar to soft biological tissue, none are capable of determining properties at high loading rates necessary for modeling soft tissue injury. Previous custom shear testing systems, though capable of high-frequency loading, indirectly measure tissue properties by using analytical corrections for inertial effects. To address these limitations, a new custom designed oscillatory shear testing apparatus (STA) capable of testing soft biological tissues in simple shear has been constructed and validated. Through a proper selection of sample thickness, direct measurement of material properties at high frequencies is achieved mechanically without analytical inertial adjustments. The complex shear modulus of three mixtures of silicone gel with viscoelastic properties in a range similar to soft biological tissue was characterized in the STA over a dynamic frequency range of 20-200 Hz and validated with a commercially available solids rheometer. The frequency-dependent complex shear modulus measurements of the STA were within 10% of the rheometer measurements for all mixtures over the entire frequency range tested. The STA represents substantive improvement over current shear testing methods by providing direct measurement of the shear behavior of soft viscoelastic material at high frequencies. Mechanical property data gained from this device will provide a more realistic basis for numerical simulations of biological structures.

Brain↗

PubMed1996

[Complex trauma of the knee joint. Diagnosis--management--therapeutic principles].

The complex nature of combined fractures and soft tissue injuries of the distal femur and proximal tibia needs special attention and specific management. Distal femoral and proximal tibial fractures in young patients are usually caused by high-energy trauma. They are complicated by a high rate of systemic and local injuries to cartilage, ligaments and skin. This small but important group with severe injuries needs a detailed treatment algorithm, because despite the treating surgeon's skill, enthusiasm and wishful thinking, these injuries frequently lead to unsatisfactory results. The combination of distal femoral fractures and proximal tibial fractures was defined as complex knee injury type 1; the combination of distal femoral fractures or proximal tibial fractures with second or third degree open or closed soft-tissue injury was defined as complex knee injury type 2; knee dislocations were defined as complex knee injury type 3. A decision-making scheme is presented specifically addressing timing and treatment modalities. Out of 116 type 1 and 2 complex knee injuries, 8 had a deep infection, in 6 cases an amputation was carried out and in 4 cases a knee arthrodesis was performed. In 81 isolated distal femoral fractures, only 4 had a deep infection, none needed amputation, and in only 1 case did a knee arthrodesis have to be performed. The average Neer Score in 90 followed-up complex knee injuries, types 1 and 2, was 76.5 +/- 13.5 compared with 82.8 +/- 10 (out of 54 isolated distal femoral fractures). Out of 37 cases with knee dislocation, 22 (60%) had an poor result according to the Lysholm Score (average Lysholm Score 60.7 +/- 28).

External Fixators↗

PubMed1993

Tibial plateau fractures. Management and expected results.

The objective of treatment of tibial plateau fractures is precise reconstruction of the articular surfaces, stable fragment fixation allowing early motion, and repair of all concomitant lesions. A classification scheme is employed to include the high incidence of concomitant lesions in specific fracture types. The term "complex trauma" is used for extensive injuries involving multiple structural elements of the knee joint. Exact grading of the soft-tissue injury is crucial for the treatment plan. The authors suggest a four-grade classification system of closed and open soft-tissue injury. Preferred treatment is open reduction and internal fixation (ORIF) in all displaced and unstable tibial plateau fractures. A stepwise approach is used in complex knee trauma. Primary treatment includes closed reduction, wound debridement, if necessary, and external fixation of the femur and lower leg ("transfixation"). Open reduction and internal fixation and complex bone and soft-tissue reconstructions are performed in a second operation after recovery of the soft tissues. A follow-up study of 190 of 244 cases of tibial plateau fractures treated in the authors' institution from 1981 to 1987 showed good results after operative treatment, even in extensive fractures, with a tolerable complication rate. The functional recovery was relatively impaired in multiple injured patients and in complex knee trauma.

External Fixators↗

PubMed2000

Mechanism-based pattern approach to classification of complex injuries of the knee depicted at MR imaging.

Complex knee injuries are common, often resulting from multiple forces: varus, valgus, hyperextension, hyperflexion, internal rotation, external rotation, anterior or posterior translation, and axial load. Certain combinations of forces are known to cause specific injury patterns. After a review of the literature, the authors developed a mechanism-based classification system based on patterns of bone marrow edema and ligament injury for complex knee injuries depicted at magnetic resonance imaging. The classification system takes into account knee position and forces and recognition of patterns of bone injury and complementary soft-tissue injury. Ten mechanism-based injury patterns were recognized: (a) pure hyperextension, (b) hyperextension with varus, (c) hyperextension with valgus, (d) pure valgus, (e) pure varus, (f) flexion with valgus and external rotation, (g) flexion with varus and internal rotation, (h) flexion with posterior tibial translation, (i) patellar dislocation (flexion, valgus, and internal rotation of femur on fixed tibia), and (j) direct trauma. Recognition of these patterns may help assess the full extent of knee injury, particularly at the posterolateral and posteromedial corners of the knee.

Anterior Cruciate Ligament Injuries↗

PubMed1998

[Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures].

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.

Adolescent↗

PubMed2003

Intramedullary transmetatarsal Kirschner wire fixation of Lisfranc fracture-dislocations.

Lisfranc joint injuries are frequently the result of high-energy accidents. The usual method of treatment is open reduction and internal fixation or closed reduction with percutaneous pinning. In cases in which soft tissue injury may compromise open reduction and internal fixation or traditional pinning techniques, transmetatarsal Kirschner wire fixation may be performed, allowing the placement of temporary hardware away from the site of soft tissue injury. The following report details this technique as it has been used in 3 patients.

Adult↗

PubMed2001

Skateboarding injuries of today.

BACKGROUND: Skateboarding injuries have increased with the rise in popularity of the sport, and the injury pattern can be expected to have changed with the development of both skateboard tricks and the materials used for skateboard construction. OBJECTIVE: To describe the injury pattern of today. METHODS: The pattern of injuries, circumstances, and severity were investigated in a study of all 139 people injured in skateboarding accidents during the period 1995-1998 inclusive and admitted to the University Hospital of Umeå. This is the only hospital in the area, serving a population of 135 000. RESULTS: Three of the 139 injured were pedestrians hit by a skateboard rider; the rest were riders. The age range was 7-47 years (mean 16). The severity of the injuries was minor (AIS 1) to moderate (AIS 2); fractures were classified as moderate. The annual number of injuries increased during the study period. Fractures were found in 29% of the casualties, and four children had concussion. The most common fractures were of the ankle and wrist. Older patients had less severe injuries, mainly sprains and soft tissue injuries. Most children were injured while skateboarding on ramps and at arenas; only 12 (9%) were injured while skateboarding on roads. Some 37% of the injuries occurred because of a loss of balance, and 26% because of a failed trick attempt. Falls caused by surface irregularities resulted in the highest proportion of the moderate injuries. CONCLUSIONS: Skateboarding should be restricted to supervised skateboard parks, and skateboarders should be required to wear protective gear. These measures would reduce the number of skateboarders injured in motor vehicle collisions, reduce the personal injuries among skateboarders, and reduce the number of pedestrians injured in collisions with skateboarders.

Adolescent↗