Surgical tactics in combined intracranial and extracranial injuries

The authors describe results of an analysis of observations of 1872 patients treated for injuries of the brain associated with extracranial traumas. Specific features of clinical manifestations of such traumas and resulting specificity of medical tactics which could be useful for the surgeons dealing with associated injuries.     

Diagnostics and surgical treatment of lymphatic ducts' trauma by abdominal and retroperitoneal trauma

Results of surgical treatment in 14 patients with lymphatic duct traumas of abdominal cavity and retroperitoneal space are presented. Diagnostics and surgical treatment in patients with lymphatic duct injuries and tactics in the presence of chronic lacteal fistula, caused by trauma are described.     

Injuries and foreign bodies of the rectum

Analysis of experience in the treatment of 43 patients with traumas of and foreign bodies in the rectum showed that the mechanism of the trauma and the degree of destruction are criteria of the choice of optimal therapeutic tactics. The authors show that nonoperative treatment is sufficiently adequate in superficial injuries, which account for almost 50% of all traumas. Surgical debridement is absolutely necessary in deep traumas; relieving colostomy is expedient in destruction of the rectal wall. The total mortality rate was 2.8%.     

Treatment of fractures of long tubular bones associated with cranio-cerebral injuries

Based on an analysis of treatment of 166 patients with fractures of long tubular bones associated with cranio-cerebral trauma the authors discuss tactics of treatment of injuries of the locomotor apparatus. In patients with critical cranio-cerebral traumas at the early period of trauma disease of the brain fractures should be treated by sparing methods, Ilizarov's apparatus included. The operations on the bones should be performed on indications not earlier than 3-4 weeks after trauma.     

Injuries of the heart and pericardium

The work presents data of 25 patients with wounds of the heart and pericardium. Clinical diagnostics, tactics and results of treatment are described. Attention is called to the importance of the method of thoracoscopy in determination of the character of injuries. To improve results of the treatment of this group of patients, the work of the emergency aid must use resuscitation-surgical teams, admittance of the patients to specialized departments for thoracal traumas.     

Spinal injuries in accidental falls

The case histories of 247 patients with spinal damages caused by a fall from a height are analysed. In 180 (75.3%) patients the damage to the spine was combined with traumas of other localization. The author emphasizes the specific features of the diagnosis and the tactics of management of patients with trauma attended by multiple and concurrent injuries and calling for physicians of allied specialties to take part in the examination and treatment. The methods of treatment of spinal damages are chosen strictly individually and are combined with nonoperative or operative management of injuries to other parts of the skeleton.     

急诊和亚急诊手术治疗有合并伤的臂丛损伤

目的 在急诊处理锁骨骨折、肩胛骨骨折、锁骨下动脉损伤及肩关节脱位、骨盆骨折等创伤的同时或2～3周内进行臂丛神经离断伤或部分离断伤的手术修复，以提高其术后的优良率。方法 1993年2月～2003年1月，我们对怀疑有臂丛损伤的患者，尽快进行MRI等检查，根据临床表现和检查结果，对其中明确为离断伤或部分离断伤的29例患者，在伤后急诊或2～3周内实施了臂丛探查，神经直接缝接，颈丛、膈神经、副神经移位，臂丛神经交叉移位及侧侧缝合等手术。结果 其中21例患者术后得到6个月～6年(平均3年)的随访，按照顾玉东的臂丛损伤功能评定标准，本组患者观察总体优良率达70.6％。结论 对有合并伤的臂丛神经离断伤或部分离断伤患者，急诊或2～3周内进行手术探查和修复，可减少手术次数和难度，提高臂丛损伤修复术的优良率。     

Injuries of the lumbosacral segments of the spine

Having studied 470 case histories of patients with injuries of the spine the author found traumas of the 5th lumbar vertebra in 23 cases (4.9%). The characteristic injuries were compression wedge-shaped fractures, multiple fractures of the vertebrae, comminuted and traumatic spondylolistheses and dislocation fractures. A typical mechanism of the injury was a blow in the lumbar region or in the back with subsequent bending of the trunk. The tactics of surgical treatment of such lesions is presented, the main tasks of which are the reconstruction of the shape and the volume of the vertebral canal, the stabilization of the basis compartment of the spine and the prevention of subsequent degenerative changes.     

Surgical treatment of patients with injuries of the spine of the thoracic and lumbar localization

Surgical treatment of 276 patients with uncomplicated (71.7%) and complicated (28.3%) injuries of the spine of the thoracic and lumbar localization was taken as the material for the article. The authors propose a rational strategy and tactics of operative treatment of patients with traumas of the spine and also they make an assessment of efficiency of some new surgical technologies. The volume and optimum terms of the decompressive-stabilizing operations on the spine are determined depending on the kind of the vertebral injury and the general state of the patient. The effectiveness of the present-day systems of stabilization of the spine (transpedicular constructions and plates for the frontal fixation of the spine) was demonstrated.     

Evaluation of severity of ischemia after injuries of the major arteries of the extremity]

Experiments were conducted in 32 dogs to study the results of rheography, ultrasonic Dopplerometry, electric excitability of muscles, and tissue pH measurement in various periods of ischemia and after restoration of blood flow in the extremities. Clinical follow-up of 226 patients with injuries to the major arteries of an ischemic extremity confirmed the importance of the results of instrumental methods of examination for appraising the severity of ischemia and predicting its outcomes. The author distinguished four degrees of ischemia in injury to the vessels. Combination of clinical findings and the results of special methods of treatment makes it possible to choose the rational surgical tactics in traumas of the arteries of the extremities.     

Clinical-radiologic diagnostics of cranio-cerebral injuries in polytrauma

A retrospective analysis of clinical-radial examination was made in 1946 patients with polytrauma. In 82% of them severe cranio-cerebral traumas and extracranial injuries were revealed. The diagnosis of fractures of the skull bones on the basis of survey radiography was possible but in 2% of the patients. Cranio-cerebral and craniofacial traumas appeared much more often than injuries of other anatomical areas, reaching 79.4%. Spiral computed tomography was the main method of early diagnosing polytrauma which allowed detecting the character, localization and volume of traumatic injuries of the skull bones, facial skeleton and brain in shorter terms. The information value of the method was 97%.     

Liver trauma: experience in the management of 252 cases

The treatment of liver traumas has evolved considerably over recent decades with the possibility of non-operative management and arteriographic embolisation for selected patients in haemodynamically stable conditions. The aim of the study was to compare two periods with different approaches to the management of blunt or penetrating liver injuries. From January 1989 to October 2004, 252 patients were admitted to the emergency surgery department of Niguarda Hospital in Milan for liver traumas. Hepatic lesions accounted for 66% of abdominal lesions due to trauma and were classified according to the Organ Injury Scaling system. Abdominal ultrasound and CT scans were used to investigate the injuries. The study consisted of two periods: during the first period (1989-1993) surgery was the only treatment for trauma-induced hepatic lesions of any grade. Damage control surgery was employed for unstable patients undergoing laparotomy. From 1994 on, grade 1-2 injuries in patients with haemodynamically stable conditions were treated by non-operative management and grade 3 injuries by embolisation. In this second period only unstable patients with active bleeding or haemoperitoneum >500 ml with grade 3-5 injuries underwent laparotomy. The overall mortality for liver traumas was 27% (68/252) and was intraoperative in 97% of cases (66/68). Deaths were due to liver haemorrhage in 30 cases and to bleeding from extrahepatic or extra-abdominal injuries in the other 38 cases. Liver trauma was therefore directly responsible for mortality in as many as 12% of cases (30/252). The present study analysed two periods characterised by different approaches to the management of liver trauma. In the first period, laparotomy was the only choice, whereas subsequently non-operative management came to play an important role in haemodynamically stable patients and proved to be a safe method in selected cases. Major liver resections are seldom indicated in liver injuries. Damage control surgery has been practised since the first period and, before any surgical manoeuvres are performed, still represents a valuable tool to guarantee haemodynamic stability, which is the crucial factor for the outcome of liver resections for trauma.     

Winter sports injuries of the urogenital tract (author's transl)

During 1964-1974 112 injuries of the urogenital tract caused by winter sports were treated at the University Hospital Innsbruck, Department of Urology. Eighty-eight patients suffered skiing injuries, 20 tobogganing injuries, and one injury each was caused by ski jumping and bobsleighing accidents, two traumas resulted from a fall from a chair lift. On the basis of typical case reports the most common types of trauma of the urogenital tract are demonstrated and the basic mechanisms of the accidents are discussed. Particular attention is paid to the obvious increase of lesions of the external genitalia and the urethra in the last few years caused by the so-called spinning ski, as well as the frequency of kidney traumas, especially in winters with little snow. Tobogganing accidents caused injuries to the kidneys as well as to bladder and urethra. In contrast to traumas caused by skiing, tobogganing injuries were mostly multiple. Analysis of patients records shows an increase of these injuries, which were really not typical for winter sports. The possible reasons as well as their prevention are discussed.     

Clinical management of abdominal trauma

Objective： To improve the prognosis of patients with abdominal trauma.
Methods： Between January 1993 and December 2005, 415 patients were enrolled in this research. The patients consisted of 347 males and 68 females with mean age of 36 years （ranging from 3-82 years）. All abdominal traumas consisted of closed traumas （360 cases, 86.7%） and open traumas （55 cases, 13.3%）.Results： A total of 407 cases （98.1%） were fully recov- ered from trauma and the other 8 cases （1.9%） died of mul- tiple injuries. The mean injury severity score （ISS） of all patients was 22 while the mean ISS of the patients who died in hospital was 42. Postoperative complications were seen in 9 patients such as infection of incisional wounds （6 cases）, pancreatic fistula （2 cases） and intestinal fistula （1 case）. All these postoperative complications were cured by the conservative treatment. Conclusion： Careful case history inquisition and physical examination are the basic methods to diagnose abdominal trauma. Focused abdominal ultrasonography is always the initial imaging examination because it is non-invasive and can be performed repeatedly with high accuracy. The doctors should consider the severity of local injuries and the general status of patients during the assessment of abdominal trauma. The principle of treatment is to save lives at first, then to cure the injuries. Unnecessary laparotomy should be avoided to reduce additional surgical trauma.     

Emergency laparoscopy in closed abdominal injuries]

Results of emergency laparoscopies in 240 patients with closed traumas of the abdomen are presented. No injuries were found in 154 patients when performing laparoscopy. By the authors' data the diagnostic informative value of laparoscopy in closed traumas made up 98%. Wide use of laparoscopy allowed to avoid diagnostic laparotomy in doubtful clinical picture of closed abdominal traumas.     

Non-operative management of blunt abdominal injuries

Over the past three decades, non-operative management has been shown to be an effective therapeutic option in hemodynamically stable patients. We retrospectively reviewed the last 7 years of our experience with the non-operative management of blunt abdominal traumas. From January 1998 to July 2005, 123 patients with blunt abdominal traumas and injuries to the spleen, liver and pancreas were admitted to our hospital. Fifty-eight of them (47.2%) were submitted to non-operative management; 5 (8.6%) presented associated splenic and hepatic injuries. We performed non-operative treatment for 27 splenic injuries (33.7% of all splenic injuries), 32 hepatic injuries (62.7% of all hepatic injuries) and 3 pancreatic injuries (75% of all pancreatic injuries). There was no mortality and no complications. We submitted one haemodynamically stable patient who presented a grade V hepatic injury and "contrast pooling" at abdominal CT scan to angiography and transarterial embolisation; this patient was successfully managed non-operatively. The overall success rate of non-operative management was 98.5%. The only non-operative management failure was a patient with both splenic and hepatic injuries. The success rate for injuries to the spleen was 96.3%, to the liver 96.9% and to the pancreas 100%. We conclude that hemodynamically stable patients suffering intra-abdominal injury can be safely managed non-operatively.     

Isolated and combined abdominal traumas (author's transl)

A group of 89 patients treated for abdominal traumas between 1975 and 1980 is analyzed in respect of type and cause of accident, concomitant traumas and intra-abdominal organ lesion patterns. Isolated abdominal traumas are compared with abdominal traumas within an overall polytrauma. Complications and causes of death among the authors' own patients are reported. The relatively high overall mortality rate of 38% is due to the above-average proportion of multiple traumas amounting to 72%. Multiple intra-abdominal injuries or organs, simultaneous involvement of the thorax and necessary massive transfusions result in particularly unfavourable prognoses.     

The main ways of improving results in treating combined injuries of the major vessels of the extremities

Based on an analysis of the surgical treatment of 240 patients with traumas of the main extremity vessels (147 associated traumas included) the authors show that favorable outcomes of such injuries are due to such factors as timely diagnosis, successful struggle with the traumatic shock and blood loss, adequate and skillful technique of surgical measures, adequate treatment of concomitant injuries and character of therapy in the postoperative period.     

Significance of traumatology in abdominal and vascular surgery

Frequency of polytrauma accounts for the numerous abdominal traumas. Abdominal injuries should be treated by an abdominal surgeon. Three hundred and seventy traumas of the abdomen were checked regarding other injuries and their percentages given. Mortality rate was 16.6 percent. The different steps of diagnosis are shown with special reference to intraperitoneal lavage and sonography. Frequency of possible organ injuries in patients at G?ttingen Medical Center is noted and the special surgical care is explained. The importance and urgency of vascular injuries are discussed with reference to different types of arterial and venous injuries in the abdominal cavity and in retroperitoneal spaces.     

Significance of traumatology in abdominal and vascular surgery

Frequency of polytrauma accounts for the numerous abdominal traumas. Abdominal injuries should be treated by an abdominal surgeon. Three hundred and seventy traumas of the abdomen were checked regarding other injuries and their percentages given. Mortality rate was 16.6 percent. The different steps of diagnosis are shown with special reference to intraperitoneal lavage and sonography. Frequency of possible organ injuries in patients at Göttingen Medical Center is noted and the special surgical care is explained. The importance and urgency of vascular injuries are discussed with reference to different types of arterial and venous injuries in the abdominal cavity and in retroperitoneal spaces.