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Superficial soft-tissue injury.

In 1992, Lee and Opeskin published an article on the little-recognized problem of death related to multiple superficial soft-tissue injuries following an assault. These deaths resulted from an acute assault and were restricted to young aboriginal women with a history of alcoholism. Presented here is a similar case occurring in a 22-year-old Polynesian woman. However, there are some significant differences. Aside from the final acute assault, there was evidence of chronic repeated episodes of superficial soft-tissue injury that resulted in undermining of connections between large areas of different tissue planes. These injuries produced pockets and spaces lined by fibrous tissue and numerous old intramuscular and subcutaneous hematomas, some of which showed secondary infection. There was also dense soft-tissue and subcutaneous fibrosis, and myositis ossificans.

Adult↗

Nabumetone in the treatment of skin and soft tissue injury.

Nabumetone, a new nonsteroidal anti-inflammatory agent, has been evaluated for the treatment of skin and soft tissue injury, including sports injury, in clinical trials involving nearly 1,000 patients. Its efficacy, safety, and tolerance in these patients is reviewed. The efficacy of nabumetone in the treatment of soft tissue injury has been demonstrated to be similar to that of soluble aspirin, ibuprofen, and naproxen. It was not possible in these studies to demonstrate a definite advantage over placebo, and the reasons for this are discussed along with some suggestions for future studies. There were no serious adverse experiences reported, and nabumetone was well tolerated and compared favorably with the other agents used, including placebo. It caused significantly fewer gastrointestinal side effects than soluble aspirin. Nabumetone is an appropriate choice of nonsteroidal anti-inflammatory drug for the treatment of sports injury.

Adolescent↗

Effects of induced hypothermia after soft-tissue injury.

BACKGROUND: Hypothermia is occasionally employed to reduce the metabolic rate and to protect the brain in patients undergoing surgery, but it is controversial whether hypothermia (HT) is beneficial or harmful in trauma victims with soft-tissue injuries. For this purpose, we studied the acute effects of hypothermia induced after infliction of a standardized soft-tissue injury. METHODS: After a standardized high-energy gunshot wound to the right hind leg of 14 anesthetized piglets, the animals were randomized to normothermia or HT (30 degrees C) induced with a HT bed. The cardiovascular and hematological status was monitored for 6 h after the injury. RESULTS: The heart rate, mean arterial pressure, neutrophil count, and plasma adrenaline level were significantly lower in the HT pigs than in the controls (p<0.05). The arterial oxygen tension was significantly elevated in the HT group. Cardiac index and oxygen delivery decreased slightly in both groups, but no difference developed between the groups in these parameters. Serum potassium increased significantly in the controls (p<0.001). CONCLUSION: HT down to 30 degrees C following high-energy penetrating soft-tissue injury had a modest effect on the hemodynamics and oxygen delivery. However, evidence of 'stress' was reduced, and the pigs developed a progressive increase in their serum potassium concentration.

Animals↗

[Should non-steroidal anti-inflammatory agents be used in acute soft tissue injuries?].

Non-steroid anti-inflammatory drugs are often used to treat acute soft-tissue injuries. The results of controlled studies are controversial, however, regarding the effect of non-steroid anti-inflammatory drugs in these conditions. This article refers to a meta-analysis from 1990 by Almekinders, summing up a number of studies on the issue. A Norwegian study by Lereim & Gabor from 1985 is also discussed. The author's conclusion is that soft-tissue injuries should be treated conservatively, perhaps with the addition of mild analgesics such as paracetamol.

Acute Disease↗

The impact of femur fracture with associated soft tissue injury on immune function and intestinal permeability.

Alterations in intestinal permeability and immune function were investigated in a murine femur fracture (FFx) model. We postulated that soft tissue injury associated with closed FFx (crush injury) would result in greater immunosuppression that open FFx (surgical division). AKR mice were randomized to four groups (Normal, Sham, Open FFx, Closed FFx) and studied at 24 and 96 h post-injury. Immune function was assessed by splenocyte blastogenic response and class-specific immunoglobulin production. Intestinal permeability was assessed by measurement of whole blood fluorometry after gavage administration of fluorescein-dextran (FITC-dextran). Closed FFx is associated with increased splenocyte blastogenesis and increased immunoglobulin production at 24 h post-injury. This immunostimulatory response was associated with altered intestinal permeability early after injury (FITC-dextran:.185 +/- .070 Closed FFx vs. .069 +/- .011 Normal, p = .06). Immunosuppression was evident at 96 h post-injury in the closed FFx group, documented by significant reductions in splenocyte blastogenesis to all mitogens studied. The Open FFx group did not demonstrate any reduction in splenocyte blastogenesis at 96 h post-injury. These data suggest that the soft tissue injury associated with Closed FFx is associated with significant immunosuppression and altered gastrointestinal permeability, which may adversely affect the host by increasing the relative risk of post-trauma infection.

Animals↗

Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures.

Arthroscopy was used to assess the soft tissue injuries associated with distal radial fractures in 118 acute intra- and extra-articular fractures. The triangular fibrocartilage complex (TFCC) was torn in 46 of 118 patients--in 35% of intra-articular fractures and in 53% of extra-articular fractures. No correlation between ulnar styloid fractures and TFCC injuries could be found. Scapholunate (SL) ligament injuries with instability were present in 21.5% of intra-articular fractures and in 6.7% of extra-articular fractures. Lunotriquetral (LT) ligament injuries with instability were present in 6.7% of intra-articular fractures. and in 13.3% of extra-articular fractures. Combined SL and LT injuries were present in 5.6% of intra-articular fracture. Preoperative radiographs correlated with TFCC injury. Patients with TFCC tears had greater shortening and dorsal angulation on the preoperative radiographs. Preoperative radiographs had no predictive value for interosseous ligament injury. Ligamentous injuries are commonly associated with both intra-articular and extra-articular distal radial fractures.

Adolescent↗

Hemorrhagic shock abolishes the myelopoietic response to turpentine-induced soft tissue injury.

Hemorrhagic shock has been shown to alter bone marrow (BM) myelopoiesis. Isolated hemorrhagic shock is uncommon after trauma and the combined effect of tissue injury and shock on myelopoiesis is unknown. We studied the growth of BM granulocyte-macrophage colony forming units (CFU-GM) following shock and soft tissue injury. Rats were anesthetized and allocated into one of four groups: CONTROL, sham neck dissection; SHOCK, rats were bled to a mean BP of 45 mmHG for 45 min and resuscitated with shed blood and saline; TURP, soft tissue injury was induced by turpentine 0.5 ml/100 g SQ into the hindquarter; SHOCK + TURP, rats received TURP just before SHOCK as described above. Groups (n = 6) were sacrificed 1, 3, and 5 days after treatment. BM cells plated for CFU-GM and splenic macrophages were cultured for IL-1 production. Unstimulated splenic macrophage production of IL-1 alpha was not different for any group except Day 5 turpentine animals. TURP induced a significant increase in CFU-GM on Day 1 compared to that in control (47 +/- 22 vs 21 +/- 11; P < 0.05). SHOCK completely abolished this response to TURP. Both the SHOCK and TURP alone increased CFU-GM on Day 5 compared to that in CONTROL but there was no additive effect in the SHOCK + TURP group. These data show that the BM response to combined soft tissue injury and shock (TURP + SHOCK) appears similar to that of SHOCK alone and that hemorrhagic shock appears to be a significant immunosuppressive factor in the regulation of myelopoiesis following injury.

Animals↗

Analgesia in soft-tissue injury: current practice in Auckland is not supported by the available evidence.

AIMS: To document current prescribing habits and attitudes of doctors in the Auckland region towards analgesic medication for soft-tissue injury and determine whether the available evidence supports this practice. METHOD: A survey of 573 doctors in the Auckland region was conducted. There was a 71.4% response rate. The clinical and experimental evidence concerning non-steroidal, anti-inflammatory (NSAID) use in soft-tissue injury was reviewed. The side-effect profiles of NSAIDs were reviewed, with emphasis on the incidence of gastrointestinal side-effects when NSAIDs are prescribed for short periods and evidence implicating adverse renal effects on healthy exercising adults. RESULTS: Most doctors ranked NSAIDs more effective than paracetamol (70.4%, p<0.01). NSAIDs were the most prescribed single analgesic agents (47.8%, p<0.0001). Diclofenac was the NSAID of choice for 69.8% of doctors, who used NSAIDs (p<0.001). The incidence of gastrointestinal side-effects for short-term use of NSAIDs in acute soft tissue was 11%. CONCLUSION: The available evidence does not support the belief by the doctors surveyed that NSAIDs are more effective than paracetamol in soft-tissue injury. NSAIDs delay, but do not prevent the inflammatory response in injured tissue and may expose athletes to an increased risk of re-injury by delaying healing. Significant adverse effects do occur in previously healthy patients who receive NSAIDs.

Acetaminophen↗

Soft-tissue injuries of the wrist.

The wide spectrum of athletic activities places demands of different magnitudes, orientations, and degrees of repetition on the wrists of athletes. These demands can result in injuries to the soft tissues of the wrist, which may make optimal athletic performance difficult if not impossible. With the advent of increased awareness of injuries particular to a sport and advances in diagnostic acumen, both technologic and clinical, these once enigmatic pathologic entities can be approached with a treatment plan that often can return the athlete to competition quickly. A number of these injuries and their pathomechanics, diagnosis, and treatment options have been described in this article. Although adequate treatment of the subject of athletic soft-tissue injuries to the wrist requires a more lengthy discussion than is appropriate here, the material presented on dorsal pain disorders, carpal instability, and the triangular fibrocartilage complex should serve as a starting point for increasing cognizance and understanding of the injured wrist in the athlete.

Athletic Injuries↗

Induced hypothermia after high-energy soft-tissue injury and subsequent hemorrhagic shock.

Many cases of hypothermia (HT) occur in trauma victims subjected to soft tissue injury and hemorrhage. The aim of the present study was to study the effects of HT on the combination of these insults. A standardized gunshot wound was inflicted on the right hind leg of 14 anesthetized piglets. They were then exsanguinated of 50% of their blood volume and randomized to normothermia or HT (30 degrees C). The animals were observed for 4 h after the injury with measurements of hemodynamics, oxygen consumption, and of plasma catecholamines and electrolytes. The insults reduced cardiac output and the arterial pressure by approximately 50%, but no further reduction occurred when HT was induced. The oxygen extraction ratio increased from approximately 35% to 75% in both groups. The gradual reduction of oxygen consumption in HT animals (P < 0.05) decreased the oxygen extraction ratio to around 50%. Heart rate, the serum potassium and creatinine concentrations, and the leukocyte counts were all maintained closer to baseline in the presence of HT. Hypothermia tended to decrease oxygen extraction and was associated with less evidence of tissue injury. These effects are potentially beneficial in soft-tissue trauma combined with hypovolemia.

Animals↗

Piezoelectric lithotripsy and soft tissue injury. Safety limits in the experimental and clinical setting.

Controversy surrounds the capacity of extracorporeal shock wave lithotripsy to cause soft tissue injury. This study examines the influence of different dosages of shock waves on the gall bladder in both humans and an animal model. Sixty one guinea pigs were divided into groups and subjected to different numbers of shock waves (6,000, 24,000, and 48,000) at different frequencies (2.5, 5.0, 10, 20 shock waves per second) and sacrificed at different intervals. Soft tissue damage after lithotripsy seemed to be related to the number of shock waves administered. In addition, repeated administration of low dose lithotripsy (at weekly intervals for six weeks) did not seem to produce a cumulative injury. Finally, in the animals sacrificed one month after receiving high dose lithotripsy, no soft tissue damage was evident, indicating satisfactory healing. Thirty patients were subjected to either high dose (36,000 shock waves) or low dose (6,000 shock waves) lithotripsy 24 hours before elective cholecystectomy. Both macroscopic and microscopic evidence of soft tissue injury were detected in a significantly higher percentage of patients who received a high dose in a single treatment (p less than 0.05). The group who received repeated low dose lithotripsy showed no evidence of cumulative injury. We conclude that low dose lithotripsy produces minimal soft tissue injury and is safe when repeated up to six times at weekly intervals.

Animals↗

Double-blind, multicenter evaluation of the efficacy and tolerability of diclofenac dispersible in the treatment of acute soft-tissue injuries.

In a randomized, double-blind, parallel-group, multicenter study, the efficacy and tolerability of diclofenac dispersible were compared with placebo in the treatment of acute soft-tissue injuries. Patients seen within 48 hours of a soft-tissue injury received either diclofenac dispersible 50 mg or placebo three times daily for 3 to 7 days, with paracetamol allowed as a rescue analgesic. Of a total of 253 recruited patients. 247 patients (122 in the diclofenac dispersible group and 125 in the placebo group) were eligible for tolerability assessment and 229 patients (115 diclofenac dispersible and 114 placebo) were eligible for efficacy analysis. In general, median reductions in the intensities of pain at rest, on movement, and on local pressure (as measured on 100-mm analog chromatic continuous scales) were greater with diclofenac dispersible than with placebo after treatment (differences did not reach statistical significance). At the center that recruited the largest number of patients, the initial median levels of pain at rest and on movement were considerably lower than those at the other centers. On reanalysis of the pain data without this center, a significant difference favoring diclofenac dispersible over placebo was noted for pain on movement and on local pressure (P < or = 0.044). With respect to daily assessment of pain severity, more patients in the diclofenac dispersible group had none or mild pain while fewer had moderate or severe pain during the early posttreatment days; this treatment difference versus placebo reached statistical significance on days 3 and 4 (P < or = 0.045).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

External fixation of tibial shaft fractures with severe soft tissue injuries by Hoffmann-Vidal-Adrey osteotaxis.

The operative results in 65 patients with 66 tibial shaft fractures and severe soft tissue injuries, stabilized by an external fixation frame according to Hoffmann or Vidal-Adrey, are reviewed and the treatment principles are discussed. Four patients required secondary amputations. Fifty-three patients could be followed up for an average of 23.2 months. The infection rate was 9.2% and nonunion was found in 11.1% of cases. Two patients had a refracture after removal of the fixation device. Twenty-three patients (42.6%) required one or more secondary operations. Of the 65 patients, 70.4% had very good or good end results, 16.7% acceptable, and 12.9% poor. External fixation according to Hoffmann or Vidal-Adrey affords excellent definitive stabilization in simple fractures of the lower leg with soft tissue injuries. In comminuted fractures of the lower leg with loss of bone fragments and severe tissue damage, external fixation is better used as a means of temporary stabilization until soft tissues permit definitive rigid stabilization.

Accidents, Traffic↗

The prevalence of soft tissue injuries in nonoperative tibial plateau fractures as determined by magnetic resonance imaging.

OBJECTIVE: To determine the incidence of meniscus tears and complete ligament disruption in nondisplaced and minimally displaced tibial plateau fractures, which are otherwise amenable to nonoperative management. DESIGN: Prospective clinical study. SETTING: Level I urban trauma center. INTERVENTION: Magnetic resonance imaging of 20 consecutive nonoperative tibial plateau fractures. RESULTS: Magnetic resonance imaging was performed on 20 consecutive nonoperative (nondisplaced or minimally displaced) tibial plateau fractures to determine the frequency of significant soft tissue injuries. Ninety percent (18 of 20) had magnetic resonance imaging-diagnosed significant injuries to the soft tissues, including 80% (16 of 20) with meniscal tears, and 40% (8 of 20) with complete ligament disruptions. CONCLUSIONS: This study found a high prevalence of soft tissue injuries with nondisplaced fractures of the tibial plateau and cautions the physician and patient with respect to future knee function and possible arthrosis.

Adult↗

Topical ketoprofen TDS patch versus diclofenac gel: efficacy and tolerability in benign sport related soft-tissue injuries.

OBJECTIVE: To compare the ketoprofen TDS patch with diclofenac gel in the treatment of traumatic acute pain in benign sport-related soft-tissue injuries. DESIGN: 7-14 treatment days, prospective, randomised, open study. PATIENTS: Outpatients aged 18-70 years diagnosed for painful benign sport-related soft-tissue injury (sprains, strains and contusions within the prior 48 h), randomised to either ketoprofen patch 100 mg once daily (n = 114) or diclofenac gel 2-4 g three times daily (n = 109). INTERVENTION: 7-14 days of topical non-steroidal anti-inflammatory drugs treatment to assess the pain intensity changes (daily activities and spontaneous at rest) in a daily diary (100-mm Visual Analogue Scale (VAS)). MAIN OUTCOME MEASUREMENT: Pain intensity (VAS). RESULTS: The ketoprofen patch was not inferior to diclofenac gel in reducing the baseline pain during daily activities (difference of -1.17 mm in favour of ketoprofen patch, 95% CI (-5.86 to 3.52), reducing to the baseline VAS 79%. Ketoprofen patch presented also a higher cure rate (64%) than diclofenac gel (46%) at day 7 (p = 0.004). Patient opinions about the treatment comfort (pharmaceutical shape, application and dosage) were also statistically higher for the ketoprofen patch (>80% of the patients rated as good or excellent the patch removal and skin adherence). CONCLUSION: Ketoprofen patches are effective and safe pain relievers for the treatment of sports injury pain with advantages compared with diclofenac gel.

Administration, Topical↗

Assault and facial soft tissue injuries.

A hypothesis that facial wounds are the most common soft tissue injuries resulting from assault has been tested by examining the records of 225 consecutive victims of assault (169 males, median age 22 years; 56 females, median age 24 years) attending the Accident and Emergency Department of the Bristol Royal Infirmary during 1984/85. Demographic factors including age and sex of patients and time, day and month of attendance were recorded. Results supported the hypothesis but significantly more men (72%) than women (57%) had facial injuries (chi 2 = 12.2, p = less than 0.01). Chest, abdominal and limb injuries were proportionately more frequent in women (p = less than 0.001). Middle third wounds were the commonest facial injuries (affecting 59% of patients) followed by upper third (25%) and lower third (16%). Left-sided facial injury was more common than right-sided (chi 2 = 14.6; p = less than 0.01). Young adult males most commonly attended, but very few elderly patients. "Risk" of assault appeared highest at weekends, between 10 pm and 2 am and between July and October. The involvement of plastic and oral surgeons in the treatment of assault victims is likely to be considerable.

Adolescent↗

C-reactive protein levels determine the severity of soft-tissue injuries.

Increased serum levels of C-reactive protein (CRP), a nonspecific indicator of tissue injury, may be valuable in determining the extent of soft-tissue injury. Patients with three types of musculoskeletal injury were included in this study: anterior cruciate ligament tear (n = 11), Achilles tendon tear (n = 7), and intervertebral disc rupture (n = 18). Patients in these three groups and three control groups (n = 37) had serum CRP levels measured immediately after injury and at 48 hours, 1 week, and 2 weeks postinjury. The status of the injury in both patient groups was confirmed through clinical findings, imaging studies, or surgical findings. Mean CRP levels in all three injury groups were highest at 48 hours (anterior cruciate ligament tears [9.2 +/- 2.1 mg/dL], Achilles tendon tears [10.1 +/- 2.2 mg/dL], and acute disc rupture [4.1 +/- 1.0 mg/dL]). In all three groups, CRP levels dropped significantly (P < 0.001) after 1 week and returned to nearly normal levels by 2 weeks. All control patients had normal levels of CRP (< 1.0 mg/dL). In the absence of other causes, an elevation in CRP concentration will aid in determining the severity of acute tissue injury.

Achilles Tendon↗