Thoracic trauma in polo: two cases and a review of the literature

Background

The traditional sport of polo has been played for centuries and has been deemed one of the most dangerous sports due to its high speed and the uncertainty of what might happen as directions change and contact occurs between horses and riders as well as with balls and mallets. Despite its longevity, there is very little in the medical literature about the sport of polo.

Objectives

Two cases of thoracic trauma after falls from horses while playing polo are presented. Both falls resulted in similar injury patterns to the riders. A discussion follows that reviews the medical literature on equestrian injuries in general and polo injuries in particular.

Discussion

Both cases show a similar injury pattern of clavicle fracture, multiple rib fractures, and lung injury (pulmonary contusion and pneumothorax). Literature review reveals severe injury including head and spinal trauma to be disproportionately represented in the equestrian sports.

Conclusion

Emergency physicians should look for significant injuries when evaluating victims of polo accidents, as the forces generated can be quite high. Protective equipment, although potentially helpful, has not been studied and may not prevent these high-velocity injuries.     

A novel fixation system for sacroiliac dislocation fracture: Internal fixation system design and biomechanics analysis

Background

Although there were many different types of fixation techniques for sacroiliac dislocation fracture, the treat remained challenging in posterior pelvic ring injury. The purpose of this study was to evaluate the biomechanical effects of a novel fixation system we designed.

Methods

12 human cadavers (L3–pelvic–femora) were used to compare biomechanical stability after reconstruction on the same specimens in four conditions: (1) intact, (2) cable system, (3) plate–pedicle screw system, and (4) cable system and plate–pedicle screw combination system (combination system). Biomechanical testing was performed on a material testing machine for evaluating the stiffness of the pelvic fixation construct in compression and torsion.

Finding

The cable system and plate–pedicle screw system alone may be insufficient to resist vertical shearing and rotational loads; however the combination system for unstable sacroiliac dislocation fractures provided significantly greater stability than single plate–pedicle or cable fixation system.

Interpretation

The novel fixation system for unstable sacroiliac dislocation fractures produced sufficient stability in axial compression and axial rotation test in type C pelvic ring injuries. It may also offer a better solution for sacroiliac dislocation fractures.     

Frequency and Cost of Claims by Injury Type From a State Workers' Compensation Fund From 1998 Through 2008

Objective

To determine which work-related injuries are the most frequent and costly.

Design

Secondary analysis of workers' compensation claims data.

Setting

Data were provided by a large, Maryland workers' compensation insurer from 1998 through 2008.

Participants

Not applicable.

Interventions

None.

Main Outcomes Measures

For 45 injury types, the number of claims and compensation amount was calculated for total compensation and for medical and indemnity compensation separately.

Results

Back and knee injuries were the most frequently occurring single injury types, whereas heart attack and occupational disease were the most expensive in terms of mean compensation. When taking into account both the frequency and cost of injury (mean cost × number occurrences), back, knee, and shoulder injuries were the most expensive single injury types.

Conclusions

Successful prevention and management of back, knee, and shoulder injuries could lead to a substantial reduction in the burden associated with work-related injuries.     

Skin Dimpling after a Closed Proximal Humerus Fracture

Background

Skin dimpling, also known as skin puckering, is a rare occurrence after closed proximal humerus fractures. This finding is suggestive of incarceration of the skin at the fracture site and may lead to necrosis and conversion to an open fracture.

Objectives

Our goal is to describe our experience with skin dimpling after a proximal humerus fracture to increase awareness and recognition of this clinical presentation in the Emergency Department (ED).

Case Report

We report a case of a 46-year-old woman who presented to the ED with left shoulder pain and swelling after a fall. She was found to have skin dimpling over the anterior aspect of the shoulder on further examination and was diagnosed with a proximal humerus fracture after imaging.

Conclusion

Skin dimpling is an uncommon sign associated with proximal humerus fractures that can help in diagnosis and determining course of treatment. Devastating soft tissue injury can occur if the fracture is not immediately reduced. Therefore, it is imperative that physicians be able to promptly identify the clinical presentation to prevent unwanted sequelae.     

Deeper chest compression – More complications for cardiac arrest patients?

Aim of the study

Sternal and rib fractures are frequent complications caused by chest compressions during cardiopulmonary resuscitation (CPR). This study aimed to investigate the potential association of CPR-related thoracic and abdominal injuries and compression depth measured with an accelerometer.

Methods

We analysed the autopsy records, CT scans or chest radiographs of 170 adult patients, suffering in-hospital cardiac arrest at the Tampere University Hospital during the period 2009–2011 to investigate possible association of chest compressions and iatrogenic injuries. The quality of manual compressions during CPR was recorded on a Philips, HeartStart MRx Q-CPR™-defibrillator.

Results

Patients were 110 males and 60 females. Injuries were found in 36% of male and 23% of female patients. Among male patients CPR-related injuries were associated with deeper mean – and peak compression depths (p < 0.05). No such association was observed in women. The frequency of injuries in mean compression depth categories <5, 5–6 and >6 cm, was 28%, 27% and 49% (p = 0.06). Of all patients 27% sustained rib fractures, 11% sternal fracture and eight patients had haematomas/ruptures in the myocardium. In addition, we observed one laceration of the stomach without bleeding, one ruptured spleen, one mediastinal haemorrhage and two pneumothoraxes.

Conclusion

The number of iatrogenic injuries in male patients was associated with chest compressions during cardiopulmonary resuscitation increased as the measured compression depth exceeded 6 cm. While there is an increased risk of complications with deeper compressions it is important to realize that the injuries were by and large not fatal.     

Irreducible Fracture of the Proximal Interphalangeal Joint of the Fifth Toe

Background

Interphalangeal joint dislocations of toes are relatively rare and can generally be treated by closed reduction.

Objectives

This case presentation intends to emphasize that irreducible lesser toe fractures may represent significant injuries. The minimal external injury and the infrequent presentation of these injuries entail the risk of remaining undiagnosed.

Case Report

We present a case of a persistent proximal interphalangeal joint fracture-dislocation of the fifth toe. Open reduction was performed because closed reduction remained unsuccessful as a result of interposition of both the flexor tendon and the volar plate into the fracture line.

Conclusions

Even such a minor trauma as a lesser toe injury deserves thorough physical examination, and when indicated on radiological imaging, as significant injuries can easily be overlooked.     

The effect of experimental shortening of the clavicle on shoulder kinematics

Background

Malunion after mid shaft clavicle fractures has recently been recognized as a cause of pain and dysfunction of the shoulder. The mechanism that causes these complaints is however yet unclear. In this study we describe the kinematic changes that occur in the shoulder girdle due to clavicle shortening.

Methods

An experimental cadaveric study was performed on five shoulders of three fresh frozen specimens. The specimens were fixed in an upright position that allowed free motion of the shoulder girdle. We measured position of the bony structures with an opto-electronic system (Northern Digital Inc., Waterloo, Ontario Canada) in rest and during in a series of motions. Measurements were done with a normal clavicle and after shortening of the clavicle by 1.2, 2.4 and 3.6 cm. The shoulders were moved manually by one of the researchers. We examined for changes in resting position and during movement that resulted from the experimental shortening of the clavicle.

Findings

In the resting position, winging of the scapula increased with resultant changes in the orientation of the glenoid, acromio-clavicular and sterno-clavicular joints and an altered position of the clavicle. On average protraction increased by 20°, lateral rotation changed 12° and posterior tilt decreased by 7°. Clavicle shortening affected sterno-clavicular joint rotations but did not do so in the acromio-clavicular joint. In arm elevation the offset in scapula orientation at resting position stayed relatively constant over the full range of motion but the amount of disposition is progressive in relation to the amount of shortening.

Interpretation

Shortening of the clavicle leads to significant changes in the shoulder girdle in resting position and in movement.     

Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries

Purpose

The purpose of the study was to document prehospital analgesia (PA) for children with extremity injuries at home or en route to the hospital, as assessed by research personnel at the pediatric emergency department.

Methods

Two parallel groups of patients with fractures or soft-tissue injuries (STIs) were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. Parents or children were interviewed, pain assessed, and data from the emergency department charts collected.

Results

A total of 310 patients were recruited; their mean age was 10.2 years, and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and STI. Of the patients, 78% had PA, 73% received first aid (icing, immobilization), and 37% had medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures.

Conclusion

Most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.     

Acutely Irreducible Ankle Fracture Dislocation: A Report of a Bosworth Fracture and its Management

Background

Acutely irreducible ankle fractures are uncommon. Irreducibility caused by interposition of soft tissue and entrapment of fracture fragments has been well described. An irreducible ankle fracture due to a locked fibular shaft fragment behind the tibia, a Bosworth fracture, is a rare injury.

Case Report

We describe a Bosworth fracture in a 19-year-old man subsequent to a fall.

Conclusion

The Bosworth fracture dislocation is a rare injury to the ankle, the correct diagnosis of which depends on awareness of the variant and careful evaluation of the initial clinical and radiographic features. As with our patient, a good outcome is achievable despite the severe nature of these injuries.     

Thiazide Use Is Associated With Reduced Risk for Incident Lower Extremity Fractures in Men With Spinal Cord Injury

Objective

To determine the association between thiazide use and lower extremity fractures in patients who are men with a spinal cord injury (SCI).

Design

Cohort study from fiscal years 2002 to 2007.

Setting

Medical centers.

Participants

Men (N=6969) with an SCI from the Veterans Affairs (VA) Spinal Cord Dysfunction (SCD) Registry, including 1433 users of thiazides and 5536 nonusers of thiazides.

Intervention

Thiazide use versus nonuse.

Main Outcome Measure

Incident lower extremity fractures.

Results

Among the men, 21% in the VA SCD Registry (fiscal years 2002–2007) included in these analyses used thiazide diuretics. There were 832 incident lower extremity fractures over the time period of this study: 110 fractures (7.7%) in 1433 thiazide users and 722 fractures (13%) in 5536 nonusers of thiazides. In unadjusted and adjusted models alike, thiazide use was associated with at least a one-quarter risk reduction in lower extremity fracture at any given point in time (unadjusted: hazard ratio (HR)=.75; 95% confidence interval (CI), .59–.94; adjusted: HR=.74; 95% CI, .58–.95).

Conclusions

Thiazide use is common in men with SCI and is associated with a decreased likelihood for lower extremity fractures.     

The effect of clavicle malunion on shoulder biomechanics; a computational study

Background

Clavicle malunion affects the biomechanics of the shoulder joint. The purpose of this study is to establish the abduction, flexion, and internal (medial) rotation biomechanics of the shoulder after clavicle malunion.

Methods

A computational study was performed utilizing a three-dimensional, validated computational model of the upper extremity. Sequential shortening of the clavicle up to 20% was simulated. Muscle forces, moment arms, and moments were calculated for the surrounding musculature through a range of flexion, abduction, and internal rotation during the simulated shortening.

Findings

Shortening of the clavicle decreases the shoulder elevation moments of the upper extremity muscles during abduction. Internal rotation moments are also decreased with shortening. Flexion moments were affected less through physiologic range of motion. The observed effects are due to a combination of changes in moment arms of the individual muscles as well as a decrease in the force generating capacity of the muscles. Additionally, shortening of the clavicle increases coronal angulation of the clavicle at the sternoclavicular joint.

Interpretation

Shortening causes a decrease in the moment generating capacity as well as the total force generating capacity of the shoulder girdle muscles. The clinical significance of these computational results, which are consistent with recent clinical studies, is validation of the proposed functional deficit caused by clavicle malunion.     

Emergency Department Management and Follow-up of Children with Bicycle Spoke Injuries

Background

Evidence for a standard x-ray study and cast immobilization in emergency department (ED) management and follow-up of children with bicycle spoke injury (BSI) is absent.

Objective

To describe the injury pattern and outpatient follow-up and care of ED patients with BSI. In addition, patient characteristics predicting the presence of a fracture and long-term follow-up were assessed.

Methods

This was a retrospective study including BSI patients < 9 years of age. Kruskal-Wallis test was used to compare groups with a fracture, soft tissue injury, and mild skin abrasion. Multivariable logistic regression analysis was used to identify independent predictors of a fracture and long-term outpatient follow-up.

Results

Twenty-three percent of 141 included patients had a fracture, with a median (interquartile range) follow-up of 27 (23–40) days. For soft tissue injury and mild abrasions this was 9 (6–14) and 7 (5–9) days, respectively (p < 0.001). No clinical variables could predict a fracture. Fifty-six (40%) patients required no further care after the first outpatient visit at ∼1 week. Triage category yellow and swelling were independent predictors for more than one outpatient visit, besides presence of fracture. Corrected odds ratios (95% confidence interval) were 2.42 (0.99–5.88) and 4.76 (1.38–16.39), respectively. Only 12% of 141 patients had none of these predictors at ED presentation.

Conclusions

A quarter of ED patients with BSI have a fracture with no clinical signs that could predict the presence of a fracture, justifying a standard x-ray study in ED management. Only 12% of ED patients with BSI have no fracture and no signs that predict long-term follow-up. In this group, further studies are warranted to investigate the benefit of cast immobilization for fractures and soft tissue injury.     

Chest injury following cardiopulmonary resuscitation: A prospective computed tomography evaluation

Introduction

Traumatic chest injuries may occur following cardiopulmonary resuscitation (CPR). The aim of this study was to address the frequency of injuries, especially rib and sternal fractures, and also to identify factors that contribute to post-CPR trauma.

Methods

This study was a prospective cross-sectional study conducted in the emergency departments (ED) of eight academic tertiary care centers. To evaluate injuries secondary to CPR, we performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest. Contributing factors that might be related to injuries were also investigated.

Results

We enrolled 71 patients between 1 January 2011 and 30 June 2011. Rib and sternal fractures were diagnosed in 22 and 3 patients, respectively. Females were more susceptible to rib fracture (p = 0.036). When non-physicians participated as chest compressors in the ED, more ribs were fractured (p = 0.048). The duration of CPR and number of compressors were not contributing factors to trauma secondary to CPR. There was a wide variation in the frequency of rib fractures from hospital to hospital (0–83.3%). In high-risk hospitals (in which more than 50% of patients had rib fractures), the average age of the patients was higher, and non-physicians took part in ED CPR more often than they did at low-risk hospitals.

Conclusion

The incidence of rib fracture following CPR was different in various hospitals. The presence of non-physician chest compressors in the ED was one of the contributing factors to rib fracture. Further studies on the influence of resuscitators and relation between quality of chest compression and CPR-induced injuries are warranted to reduce complications following CPR.     

Cardiac Injury Due to Accidental Discharge of Nail Gun

Background

Since 1991, the incidence of injuries associated with pneumatic and explosive powered nail guns has steadily been rising due to increasing use of these devices by the untrained consumer. The vast majority of injuries involve the extremities, but injuries have been reported to occur in virtually every area of the body.

Objective

Discuss the epidemiology, pathophysiology, and management of penetrating cardiac nail gun injuries.

Case Report

A 33-year-old man sustained a penetrating cardiac injury from accidental discharge of a nail gun. The patient had successful repair of a laceration to his right ventricle.

Conclusions

Penetrating cardiac injuries from pneumatic nail guns are rare and have mortality similar to stab wounds. Improved safety mechanisms and training are the keys to prevention. Consideration also should be given to implementing legislation restricting the sale of nail guns.     

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective,Observational Study

Background

Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.

Objectives

Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.

Methods

We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.

Results

Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.

Conclusions

Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.     

Massive hemothorax after blunt transverse cervical artery injury

Background

Blunt injuries to the thyrocervical trunk or its branches are rare because these vessels are well protected and located deep in the neck. To the best of our knowledge, we describe the first case of a massive hemothorax after blunt injury to the transverse cervical artery.

Case Report

A 42-year-old man was brought to our Emergency Department after he fell from a height of 10 meters. On work-up, a massive left hemothorax with extravasation from the left transverse cervical artery and pelvic fractures were detected. Endovascular embolization was successfully performed. There was no evidence of direct injury to the neck, lung laceration, or significant vascular injury that might have caused the massive hemothorax. A shearing mechanism associated with sudden deceleration caused by the 10-meter fall might have caused the transverse cervical artery injury in our patient.

Conclusion

Consideration of injury to the thyrocervical trunk or its branches by the emergency physician will result in more frequent consideration and more timely diagnosis when there is no chest injury and massive hemothorax.     

Patterns of Injury and Management of Children With Pelvic Fractures at a Non−Trauma Center

Background

Pelvic injuries in young children are rare, and it has been difficult to establish clinical guidelines to assist providers in managing blunt pelvic trauma, especially in non−Level 1 trauma centers.

Objective

Our aim was to describe the relationship among clinical findings, mechanism of injury, and the radiographic resources utilized in children with pelvic fractures presenting to a non−Level 1 trauma center.

Methods

A retrospective review of patients with a pelvic fracture treated in two urban pediatric Level 3 emergency departments was performed.

Results

Between 2001 and 2010, a total of 208 patients were identified. Avulsion/iliac wing fractures were the most common fractures (58.7%), and sports-related injuries were the most common mechanism of injury (50.0%). Children with sports-related injuries were more likely to sustain an avulsion fracture (p < 0.001), less likely to have a computed tomography scan obtained in the emergency department (p < 0.001), and less likely to have an associated injury (p < 0.001) than other children. Children struck by a motor vehicle (p < 0.001) or involved in a motor vehicle accident (p < 0.001) were more likely to receive a computed tomography scan (p < 0.001) and have associated head and extremity injuries (p < 0.001). Mechanism of injury was associated with abnormal computed tomography scans. Nearly all patients were treated nonoperatively (98.1%) and no deaths were reported in this study.

Conclusions

Patterns of injury, based on mechanism of injury, have been reported to assist the assessment and management of children with minor pelvic injuries.     

Childhood Death Attributable to Trauma: Is There a Difference Between Accidental and Abusive Fatal Injuries?

Background

Trauma is a leading cause of death among children worldwide. Detailed knowledge of the epidemiology of childhood fatal injuries is necessary for preventing injuries.

Objective

To determine clinical differences between children who were treated in an emergency department for accidental or abusive injuries.

Methods

A retrospective review of all deceased patients who were treated in two urban pediatric emergency departments between 1998 and 2010 was performed. Patients were categorized into two groups, accidental and abusive, for comparison.

Results

A total of 1498 patients died during the study period, with 124 deaths being attributable to injury for a rate of 9.5 injury-related deaths per year. Most fatal injuries were accidental. Children with abusive fatal injuries were younger and more likely to have been seen for an injury in a clinic or emergency department within 2 months of their death. Eighty-two percent of abusive fatal injuries had documented subdural hematomas, whereas only 7.2% of accidental fatal injuries had a subdural hematoma documented. Nearly 50% of abusive fatal injuries had retinal hemorrhages reported, although no child with an accidental fatal injury had this type of injury documented.

Conclusion

Younger children, especially those previously seen in an emergency department or clinic for injury, are more likely to sustain an abusive fatal injury. Sentinel physical findings associated with abusive fatal injuries include subdural hematomas and retinal hemorrhages, and the presence of these findings should prompt an investigation into the circumstances of injury.     

The comminuted midshaft clavicle fracture: a biomechanical evaluation of plating methods

Background

The optimal plate location and fixation method for midshaft fractures of the clavicle remains undetermined. The objective of this study was to develop a realistic biomechanical model with which to compare superior with inferior-medial plate placement, and the failure resistance of locked and against non-locked constructs.

Methods

We estimated implant loads for operated patients in early rehabilitation utilising 3-D mathematical model of the shoulder. During simulation of upper limb motion associated with eating, the fracture opened in an inferior and frontal direction. The peak X, Y, and Z loads from the simulation were reproduced using a materials testing machine. A one centimetre transverse osteectomy was created at the midshaft of forty composite clavicles. Each specimen was then fixed with either (1) non-locked superior plating (n = 10), (2) locked superior plating (n = 10), (3) non-locked inferior-medial plating (n = 10), or (4) locked inferior-medial plating (n = 10). Specimens were loaded at 20 N/s in four-point bending for 50 cycles to the peak X, Y, Z moment obtained from the computational model (− 3.50, 2.46, and − 1.00 Nm), then loaded to failure at 20 N/s.

Findings

Inferior-medial unlocked plates were significantly stiffer than superior locked plates (P = 0.046).

Interpretation

Operative fixation of midshaft clavicle fractures is controversial, though becoming more widely accepted. Few biomechanical data are available to assist surgical decision-making. Inferior plates may be better equipped to resist the in vivo loads experienced by the clavicle during early rehabilitation after internal fixation, particularly during the shoulder flexion motions associated with eating.     

Motorized Dirt Bike Injuries in Children

Background

The number of dirt bike injuries in children in the United States is increasing and poses a public health problem.

Objective

The purpose of our study was to identify the imaging patterns of dirt bike injuries in children and associations with morbidity and mortality.

Methods

The study included 85 children (83 boys, 2 girls) <18 year of age (mean age 12.3 years, standard deviation 3 years) with dirt bike injury treated at a tertiary care pediatric hospital. Imaging studies and hospital medical records were reviewed. Outcomes were classified into the following categories: short-term disability, long-term disability or no follow-up available. Imaging studies were reviewed for head, torso, and extremity injuries. One-tailed z test for two proportions was used to determine significant differences between various proportions. Chi-square test with Yates correction was used to determine the significance of long-term disability with injury type.

Results

Long bone fractures were the most common injuries. Lower extremity fractures accounted for 79% of extremity fractures and were significantly more common than upper extremity fractures (p = 0.001). Head injuries included fractures (n = 9), brain contusion (n = 5), and meningeal hemorrhage (n = 2). Head injury was associated with long-term disability (p < 0.0001). All torso injuries were solitary.

Conclusions

Long-term disability was associated with head injuries but not with torso or extremity injuries. Lower extremity injuries were significantly more common than upper extremity injuries. Torso solid organ injuries were uniformly solitary.