Trauma calls: role of the general surgeon and CT scanning

Background and objective: General surgeons are required in only a minority of trauma call cases to assess for abdominal injuries. Computed tomography (CT) accurately detects blunt abdominal injuries and may have replaced the need for general surgeons at trauma calls. This study evaluated the role of general surgeons at trauma calls and assessed use of CT in cases of suspected abdominal trauma.

Methods: (a) Eighteen month analysis of trauma calls at a district general hospital and (b) three month prospective study of all trauma cases presenting to A&E.

Results: (a) There were 73 trauma calls and the mechanism of injury in most cases was a road traffic accident (RTA). Most patients had orthopaedic and/or neurosurgical injuries. The general surgeons assessed 22 trauma call patients. Abdominal injury was excluded in 13 (four by clinical examination and nine following CT). (b) Forty three patients fulfilled the criteria for a trauma call and 14 trauma calls were made. The mechanism of injury in most was RTA and most had orthopaedic and/or neurosurgical injuries. The general surgeons assessed 10/43 potential trauma call patients, and abdominal injury was excluded in five (one by clinical examination and four following CT).

Conclusion: A&E staff managed most trauma calls. Most patients did not require general surgical intervention. For penetrating injuries, presence of a general surgeon remained crucial. For blunt injuries CT was an important adjunct. These data suggest that general surgeons do not routinely have to attend all trauma calls but can be called if abdominal and/or vascular injuries are specifically suspected.

     

Patient Positioning for Proximal Femur Fracture Fixation: a Review of Best Practices

Purpose of ReviewProximal femur fractures are common traumatic injuries treated by orthopedic surgeons. Preparation and positioning for surgical intervention are critical in the proper management of proximal femur fractures. The purpose of this study was to review the current evidence on the various positioning options for patients and to highlight the principles and emerging techniques to help orthopedic surgeons treat this common injury.Recent FindingsStrategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications. The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table. The fracture table should be used when surgeons are facile with its use to avoid significant complications. Recent best available evidence has suggested increased risk of malrotation associated with the use of the fracture table. The use of the radiolucent table offers the most flexibility, but limits surgeons as multiple assistants are needed to maintain reduction during fixation.SummaryPositioning for proximal femur fractures is an important technique for general and trauma orthopedic surgeons. Surgeons need to be aware of the various techniques for positioning of proximal femur fractures due to the diversity of injury patterns and patient characteristics. Each positioning technique has it benefits and potential complications that every orthopaedic surgeon should be familiar with while treating these injuries.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12178-021-09710-x.     

Strains and sprains in athletes

Although often considered "minor" injuries, strains and sprains are the leading cause of time lost from athletics due to injury. Trainers, coaches, and physicians other than orthopedic surgeons are usually called on to manage these injuries and thus need to be aware of proper methods of diagnosis and treatment. Because of the tendency of these injuries to recur, treatment must be followed by adequate rehabilitation. Muscle sprains, in particular, require strengthening exercises to prevent recurrences.     

Arthroscopy in the treatment of injuries and knee disorders in children and adolescents

Background. In children and young adolescents, like in adults the knee joint is the most exposed joint to the injuries and pathologies of various ethiology. Injuries of the knee joint in children and young adolescents have their own specificity and they are characterized by some differences. Therefore the diagnostics and management are difficult even for the experienced surgeons. Material and methods. The study is a retrospective analysis of 1552 arthroscopies of the knee joint in children and young adolescents performed in the years 1986-2001. These arthroscopies accounted for 14,4% of all 10770 arthroscopies. Conclusions. Arthroscopy is a decisive diagnostic examination in many cases of diseases of unknown ethiology. Particularly in acute injuries it allows for choosing a further method of treatment. In these conditions also operative arthroscopy is performed. The arthroscopy in children is restricted not by the size of the joint which is very elastic but by the surgeons experience.     

Upper extremity arterial combat injury management

Traumatic hemorrhage and vascular injury management have been concerns for both civilian and military physicians. During the 20th century, advances in technique allowed surgeons to focus on vascular repair, restoration of perfusion, limb salvage, and life preservation. Military surgeons such as Makins, DeBakey, Hughes, Rich, and others made significant contributions to the field of surgery in general and vascular surgery in particular. Casualties from combat in Afghanistan and Iraq confront physicians and surgeons with devastating injuries. The current generation of providers is challenged with applying contemporary care while expanding upon the lessons taught by our predecessors. The objective of this report is to review the historical experience with managing military upper extremity arterial injuries and compare that experience with current management.     

Sports injuries of the wrist

Sports injuries involving the hand and wrist are common and, as a result, many different practitioners (athletic trainers, physical therapists, primary care physicians, general orthopedic surgeons) will encounter these injuries. In addition to thorough evaluation, an understanding of typical pathologies seen in the athlete enhances diagnosis and facilitates appropriate, expedient management. These injuries are complex because they can be either acute traumatic or repetitive in origin and often involve both the bony skeleton and soft tissues. This article provides a review of athletic injuries to the wrist with particular focus on physical evaluation and management of the most common and challenging fractures and soft tissue injuries.     

The perils of bungee jumping

Bungee jumping is a relatively new recreational sport. Most emergency physicians and trauma surgeons have limited experience with its associated injuries. We report the case of a bungee cord attachment apparatus malfunctioning, resulting in a free fall of the jumper of approximately 240 feet. The presence of an air cushion on the ground prevented significant injury. Knowledge of the potential injuries of this new sport is crucial for effective management.     

Blurred front lines: triage and initial management of blast injuries

Recent armed conflicts and the expanded reach of international terror groups has resulted in an increased incidence of blast-related injuries in both military and civilian populations. Mass-casualty incidents may require both on-scene and in-hospital triage to maximize survival rates and conserve limited resources. Initial evaluation should focus on the identification and control of potentially life-threatening conditions, especially life-threatening hemorrhage. Early operative priorities for musculoskeletal injuries focus on the principles of damage-control orthopaedics, with early and aggressive debridement of soft-tissue wounds, vascular shunting or grafting to restore limb perfusion, and long-bone fracture stabilization via external fixation. Special considerations such as patient transport, infection control and prevention, and amputation management are also discussed. All orthopedic surgeons, regardless of practice setting, should be familiar with the basic principles of evaluation, resuscitation, and initial management of explosive blast injuries.     

Emerging techniques in orthopaedics: platelet-rich plasma

Platelet-rich plasma (PRP), a portion of autologous blood containing concentrated platelets above baseline values, has gained recent popularity in the field of orthopaedics. Many orthopaedic surgeons feel that PRP plays an influential role in enhancing the healing process following soft-issue injuries in patients who have failed conservative management or in patients requiring surgical intervention. Platelet-rich plasma is currently being used to treat acute and chronic tendinopathies in the clinical and surgical settings. For clinicians to fully understand the role of PRP, it is imperative that they have a general understanding of the body's healing process. Clinicians should also be aware of the various commercial systems available that may be utilized to produce PRP and the basis behind the performance of these systems. The presence of PRP provides additional treatment options when managing and treating soft-tissue injuries. However, clinicians must realize that little clinical evidence exists supporting the efficacy of PRP and more well-designed, controlled, clinical trials are needed.     

Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation

Background

The operating room is a high-risk setting for occupational sharps injuries and bloodborne pathogen exposure. The requirement to provide safety-engineered devices, mandated by the Needlestick Safety and Prevention Act of 2000, has received scant attention in surgical settings.

Study Design

We analyzed percutaneous injury surveillance data from 87 hospitals in the United States from 1993 through 2006, comparing injury rates in surgical and nonsurgical settings before and after passage of the law. We identified devices and circumstances associated with injuries among surgical team members.

Results

Of 31,324 total sharps injuries, 7,186 were to surgical personnel. After the legislation, injury rates in nonsurgical settings dropped 31.6%, but increased 6.5% in surgical settings. Most injuries were caused by suture needles (43.4%), scalpel blades (17%), and syringes (12%). Three-quarters of injuries occurred during use or passing of devices. Surgeons and residents were most often original users of the injury-causing devices; nurses and surgical technicians were typically injured by devices originally used by others.

Conclusions

Despite legislation and advances in sharps safety technology, surgical injuries continued to increase during the period that nonsurgical injuries decreased significantly. Hospitals should comply with requirements for the adoption of safer surgical technologies, and promote policies and practices shown to substantially reduce blood exposures to surgeons, their coworkers, and patients. Although decisions affecting the safety of the surgical team lie primarily in the surgeon's hands, there are also roles for administrators, educators, and policy makers.     

Inter-professional differences in compliance with standard precautions in operating theatres: a multi-site, mixed methods study

BackgroundOccupational acquisition of blood-borne infections has been reported following exposure to blood or body fluids. Consistent adherence to standard precautions will reduce the risk of infection.ObjectivesTo identify: the frequency of self-reported adverse exposure to blood and body fluids among surgeons and scrub nurses during surgical procedures; contributory factors to such injuries; the extent of compliance with standard precautions; and factors influencing compliance with precautions.DesignA multi-site mixed methods study incorporating a cross-sectional survey and interviews.SettingsSix NHS trusts in Wales between January 2006 and August 2008.ParticipantsSurgeons and scrub nurses and Senior Infection Control Nurses.MethodsA postal survey to all surgeons and scrub nurses, who engaged in exposure prone procedures, followed by face to face interviews with surgeons and scrub nurses, and telephone interviews with Infection Control Nurses.ResultsResponse rate was 51.47% (315/612). Most 219/315 (69.5%) respondents reported sustaining an inoculation injury in the last five years: 183/315 (58.1%) reported sharps’ injuries and 40/315 (12.7%) splashes. Being a surgeon and believing injuries to be an occupational hazard were significantly associated with increased risk of sharps’ injuries (adjusted odds ratio 1.73, 95% confidence interval 1.04–2.88 and adjusted odds ratio 2.0, 1.11–3.5, respectively). Compliance was incomplete: 31/315 (10%) respondents always complied with all available precautions, 1/315 (0.003%) claimed never to comply with any precautions; 64/293 (21.8%) always used safety devices, 141/310 (45.5%) eye protection, 72 (23.2%) double gloves, and 259/307 (84.4%) avoided passing sharps from hand to hand. Others selected precautions according to their own assessment of risk. Surgeons were less likely to adopt eye protection (adjusted odds ratio 0.28, 0.11–0.71) and to attend training sessions (odds ratio 0.111, 0.061–0.19). The professions viewed the risks associated with their roles differently, with nurses being more willing to follow protocols.ConclusionInter-professional differences in experiencing adverse exposures must be addressed to improve safety and reduce infection risks. This requires new training initiatives to alter risk perception and promote compliance with policies and procedures.     

Patient-Reported Outcome Measures Following Surgical Intervention for Pediatric Sports-Related Injuries to the Knee: a Systematic Review

Purpose of ReviewIncreased sports participation and early specialization has contributed to an increase in surgically managed musculoskeletal injuries to the knee in youth athletes. Established patient-reported outcome (PRO) measures have been extensively reported in adult patients to assess outcomes following sports-related knee surgery. However, current PRO measures for pediatric patients undergoing surgery for sports-related injuries have not been well-described.Recent FindingsStrong emphasis has been placed on patient-reported outcomes in recent years, and surgeons have identified many different scoring systems that could be used for sports-related knee injuries in children and adolescents. Recent research has shown that substantial variability exists in the reporting of PRO measures assessing outcomes following surgical management of sports-related knee injuries in pediatric patients.SummaryWith a paucity of studies using PRO measures in surgically managed pediatric knee injuries, only procedures involving the anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) showed preference for particular systems. Pediatric ACL procedures predominantly use the International Knee Documentation Committee (IKDC) scoring system, while MPFL procedures predominantly use the Kujala scoring system. Further studies are necessary to determine preferred and appropriate patient-reported outcome measures for specific sports-related knee procedures in pediatric patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12178-022-09756-5.     

Transthecal digital block: an underutilized technique in the ED

The transthecal digital block is a simple, safe, and effective anesthesia technique that can be used in many digital injuries. It is contraindicated only in cases of infection. The purposes of this article are to (1) discuss the indications for the transthecal digital block, (2) describe the technique, and (3) review the literature. The transthecal technique is used on appropriate patients almost to the exclusion of more traditional digital blocks by many hand surgeons. The advantages of this method are that it requires only a single injection, has a rapid onset of action, and requires only a small amount of anesthetic. It also has virtually no risk of direct mechanical trauma to the neurovascular bundles. This technique has been shown to be exceptionally effective. We encourage emergency physicians to use the transthecal technique when indicated.     

The military upper extremity amputee

Throughout the course of military history, soldiers have continued to sustain amputation injuries during war times and during peacetime and training missions. What has changed over time is the etiology of, indication for, and management of the amputations. Technology has advanced significantly, often with some military connection. More work still needs to be done, especially in the areas of greater prosthetic limb function and usage as well as phantom pain and sensation management. Collaborative efforts among physiatrists, surgeons, prosthetists, and therapists can only benefit the patient.     

Fire and smoke injuries

The successful management of burns and related injuries requires a comprehensive team approach at a designated burn center. This team should consist of burn surgeons, burn nurses, respiratory therapists, physical therapists, occupational therapists, clinical nutritionists, social workers, chaplains, and other clinical consultants. This article focuses specifically on the management of thermal burns and inhalational injuries, with an emphasis on assessment, resuscitation, and critical care management. It also discusses special considerations related to burned trauma patients.     

Easily missed trauma of bones and ligaments.

While most fractures and dislocations are easily detected by radiographic and physical examination, some traumatic events are overlooked because the normal radiographic anatomy is not appreciated. Furthermore, certain routine radiographic views are inadequate to detect specific injuries. "Chip" or "sprain" fractures are often considered minor injuries when they actually connote significant injury to ligaments and capsules. These injuries are usually dismissed by the primary care physician, who does not believe them serious enough to warrant consulting an orthopedic surgeon. However, some are also overlooked by radiologists and orthopedic surgeons. If these injuries are not treated adequately, permanent loss of function or death may result. With these thoughts in mind, we will describe some of these injuries and discuss the radiographic anatomy, the knowledge of which should preclude some of the serious mistakes of diagnosis.     

Orthopedic trauma: office management of major joint injury

Orthopedic injuries are common reasons for visits to primary care physicians. Careful history and physical examination with intelligent use of imaging technology will arrive at the correct diagnosis in most patients. Many conditions may be definitively managed by the office internist. Others maybe initially stabilized and referred to orthopedic surgeons for definitive care. Nondisplaced fractures, tendon injuries, sprains, and overuse syndromes are entities within the purview of the primary care physician. Familiarity and confidence with diagnosis and management of these conditions in the office is optimal for the care of the adult patient.     

Improved Response in Angina Pectoris to a New Drug Combination

Reconstructive surgery offers hope to many victims of trauma. An innovative technique called tissue expansion allows plastic surgeons to generate the tissue needed for ideal reconstruction of injuries due to trauma, burns, or ablative surgery, and its results are more aesthetically successful than reconstruction with other methods. In this article, Drs LeWinn and Ruetschi describe the development of tissue expansion techniques and current uses and offer insight into possibilities for the future.     

The relationship of the level of training and area of medical specialization with registrant performance in an advanced trauma life-support course

Approved advanced trauma life-support (ATLS) programs were given to 160 residents and practitioners of various specialties, utilizing a standardized 50-item, multiple-choice posttest. Level of training (practitioner ν resident) and area of medical specialization with registrant performance on total score and in specific subcontent areas of ATLS were evaluated by subjecting total and subcontent percent scores to a two-way analysis of variance and Newman-Keuls pairwise comparisons.Practitioners outperformed the residents in the subcontent area of abdominal injuries, P<.05. In specialization, emergency medicine outperformed internal medicine specialists, P< .05. Pairwise differences among specialists were not statistically significant. In airway problems, surgeons and internists were outperformed by emergency medicine, whereas in burns, emergency medicine and family practitioners significantly outperformed the surgeons. Emergency medicine outperformed internal medicine, P<.05, in subcontent area of extremity injuries.We conclude that registrants are likely to benefit from an ATLS course, but preliminary evidence would seem to justify some “tailoring” of the ATLS curriculum for different registrant specialty groups.     

Surgeon-performed point-of-care ultrasound in severe eye trauma: Report of two cases

The indications of point-of-care ultrasound (POCUS) in the management of multiple trauma patients have been expanding. Although computed tomography (CT) scan of the orbit remains the gold standard for imaging orbital trauma, ultrasound is a quick, safe, and portable tool that can be performed bedside. Here we report two patients who had severe eye injuries with major visual impairment where surgeon-performed POCUS was very useful. One had a foreign body injury while the other had blunt trauma. POCUS was done using a linear probe under sterile conditions with minimum pressure on the eyes. Ultrasound showed a foreign body at the back of the left eye globe touching the eye globe in the first patient, and was normal in the second patient. Workup using CT scan, fundsocopy, optical coherence tomography, and magnetic resonance imaging of the orbits confirmed these findings. The first patient had vitreous and sub retinal haemorrhage and a full thickness macular hole of the left eye, while the second had traumatic optic neuropathy. POCUS gave accurate information concerning severe eye injuries. Trauma surgeons and emergency physicians should be trained in performing ocular ultrasound for eye injuries.