Plaster cast immobilisation during air travel-analysis of current practice and aircraft-simulated experimental study

BACKGROUND: There is an increase in aircraft transportation of patients with lower limb fractures. Current practice is variable. Our aim was to study current practice and to analyse the situation in an experimental simulated aircraft flight. METHODS: Current advice supplied by commercial airline offices in the UK was noted. Postal questionnaires were sent to Orthopaedic Consultants in the UK to obtain their current practice. Experimental aircraft travel was simulated in a decompression chamber with five medically fit volunteers with no fracture, immobilised in an above knee plaster cast. Compartment pressure and venous return was documented and the results analysed in two different positions with the leg elevated and dependant. RESULTS: Airlines do not have any formal guidelines. Orthopaedic consultants in the UK note variable advise in this situation. Experimental study in the aircraft simulation showed that two volunteers developed significant increase in compartmental pressure with the leg elevated to 90 degrees , which settled after the plaster cast was split. There was no increase in compartment pressure noted with leg dependant on the floor with 45 degrees of flexion at hip. CONCLUSION: The literature on this issue is limited. With our analysis we feel that patients can be transported with the plaster cast split with limb dependant on the floor i.e. hip flexion less than 45 degrees . Our volunteers had no fractures so direct comparison with pathological changes in acute fracture is problematical. Further studies into this problem are recommended.     

Thigh compartment syndrome in urban trauma: bullets to blame,not collisions

Background

Compartment syndrome of the thigh is a surgical emergency rarely reported in the literature. The most common etiologies include blunt trauma, vascular injuries from penetrating trauma, and hematoma formation. Thigh compartment syndrome (TCS) is important as it is often associated with concomitant severe injury with mortality rates as high as 47%. This study aims to identify mechanisms of injury, clinical presentation, and outcomes associated with TCS in the urban trauma patient population.

Methods

Demographic and clinical information for all patients with a diagnosis of TCS at a level 1 urban trauma center over a 10.5-y period were reviewed. Collected data included age, sex, mechanism of injury, method of diagnosis, time taken for diagnosis and management, methods of decompression, wound management, lengths of stay in the intensive care unit and hospital, amputation rate, and hospital disposition.

Results

Ten patients were identified with diagnosis of TCS. The mechanism of injury was penetrating in six patients and blunt in four. The mean time from injury to diagnosis was 23.4 h. Intensive care unit and hospital lengths of stay were significantly increased among patients sustaining penetrating injuries compared with blunt injuries. Two of the six penetrating injury patients underwent an amputation. Eight of 10 patients were ambulatory on discharge. There were no mortalities.

Conclusions

Among urban trauma patients, penetrating injuries of the thigh and adjacent vascular structures and the need for decompressive fasciotomy of the lower leg are the major risk factors for TCS. Clinical diagnosis and early intervention with fasciotomy remain the mainstay of treatment.     

Surgical site infection in tibial plateau fractures with ipsilateral compartment syndrome

AimThe aim of this study was to investigate the effects of compartment syndrome and timing of fasciotomy wound closure on surgical site infection (SSI) after surgical fixation of tibial plateau fractures. Our primary hypothesis was that SSI rate is increased for fractures with compartment syndrome versus those without, even accounting for confounders associated with infection. Our secondary hypothesis was that infection rates are unrelated to timing of fasciotomy closure or fixation.Materials and methodsWe conducted a retrospective cohort study of operative tibial plateau fractures with ipsilateral compartment syndrome (n = 71) treated with fasciotomy at our level I trauma center from 2003 through 2011. A control group consisted of 602 patients with 625 operatively treated tibial plateau fractures without diagnosis of compartment syndrome. The primary outcome measure was deep SSI after ORIF.ResultsFractures with compartment syndrome had a higher rate of SSI (25% versus 8%, p < 0.001). The difference remained significant in our multivariate model (odds ratio, 7.27; 95% confidence interval, 3.8–13.9). Delay in timing of fasciotomy closure was associated with a 7% increase per day in odds of infection (95% confidence interval, 0.2–13; p < 0.05).ConclusionsTibial plateau fractures with ipsilateral compartment syndrome have a significant increase in rates of SSI compared with those without compartment syndrome (p < 0.001). Delays in fasciotomy wound closure were also associated with increased odds of SSI (p < 0.05).     

Experimental evaluation of the effect of raised pressure in a single compartment in the lower leg on neighbouring compartments using fresh above knee amputated legs-a study of interstitial pressures with two case reports

STUDY DESIGN: Experimental evaluation of intracompartmental pressures in a fresh above knee amputated human leg. OBJECTIVES: To determine what effect raised pressure in one compartment of the lower leg had upon its neighbour. SUMMARY OF BACKGROUND DATA: There has been no previous reports of isolated compartment pathology, following low velocity trauma, causing a compartment syndrome in all four compartments of the lower leg. METHODS: Immediately after leg amputation, the intracompartmental pressure in the deep posterior compartment was artificially raised to 100 mmHg with infused 0.9% sodium chloride solution. The resultant pressure changes in remaining compartments were recorded over 30 min. RESULTS: Five legs were evaluated. After 30 min, the mean maximum intracompartmental pressure increase found in the superficial posterior, anterior and peroneal compartments was 78.4 mmHg (range 65-94 mmHg), 25.2 mmHg (range 14-31 mmHg) and 24.8 mmHg (range 15-31 mmHg), respectively. CONCLUSIONS: This experimental data and case reports show that a compartment in which there is raised pressure may exert external pressure on a neighbouring compartment that can result in physiological changes to induce a compartment syndrome within that neighbour. The importance of assessing all compartments within a limb segment, even when associated with low velocity trauma, remains paramount.     

Arterial injury associated with acute compartment syndrome of the thigh following blunt trauma

BACKGROUND: Acute compartment syndrome of the thigh is a rare condition, and the basic causes of high pressure within a muscle compartment have been considered to be intramuscular haematoma and soft-tissue oedema. However, the importance of arterial injury has not been well recognized. METHODS: Among 3658 blunt trauma patients admitted to our Level 1 Trauma Centre between 1994 and 2001, there were eight patients (nine thighs) who had undergone emergency fasciotomy and these were the subjects of the present study. Arteriography of the proximal lower limb had been performed after the fasciotomy in patients with prolonged hypotension and persistent bleeding from the fasciotomy wound. RESULTS: All the patients had sustained high-energy trauma, systemic hypotension and local trauma to the proximal lower limb. Among them, four (five thighs) had undergone arteriography and four (four thighs) were confirmed as having sustained arterial injuries. In those patients with definitive arterial injuries, the time from injury to the onset of the compartment syndrome was less than 5 h. CONCLUSIONS: Acute compartment syndrome of the thigh in blunt trauma patients may be the result of associated arterial injuries. It is suggested that patients with local trauma to the proximal lower limb who exhibit an acute compartment syndrome together with haemodynamic instability should undergo arteriography soon after fasciotomy.     

Hostile Abdomen Index Risk Stratification and Laparoscopic Complications

Background:

Common life-threatening complications associated with laparoscopy, including bleeding and inadvertent enterotomy, are described in the literature. We investigated the application of the Hostile Abdomen Index related to these complications. We hypothesize that the preoperative score may guide a surgeon in risk stratification.

Methods:

We used data from Monmouth Medical Center morbidity and mortality conferences and reviewed bleeding and enterotomy complications in laparoscopic abdominal surgery. Complications were tracked using the Hostile Abdomen Index compared between 2 periods: published early experience with laparoscopic surgery (1998–2003) and unpublished late experience (2004–2010). The index ascribes a number (1–4) before a laparoscope is inserted and another number (1–4) after the laparoscope is inserted into the abdomen.

Results:

From 1998 to 2010, 43 patients had bleeding complications (0.45%) and 28 had inadvertent enterotomies (0.29%). There was no difference in bleeding between the early and late experiences. Enterotomy complications decreased in the late experience (P < .001). Our rescue success was 97.2% over 13 years. Those laparoscopic cases with high preoperative scores (3–4) had a higher rate of conversion to open procedures.

Conclusions:

The Hostile Abdomen Index can be used to track 2 potentially life-threatening laparoscopic complications. The index score has been explained to our surgeons on numerous occasions. A higher chance of bleeding and enterotomy or risk stratification correlates with a preoperative 3 or 4 score and may lead to a more cautious approach toward initial laparotomy or earlier conversion.     

Complications and revision amputation following trauma-related lower limb loss

IntroductionTrauma-related amputations are a common cause of limb loss in the United States. Despite the military and public health impact of trauma-related amputations, distributions of various lower limb amputations and the relative frequency of complications and revision amputations have not been well described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of trauma-related lower extremity amputations among civilians in U.S. trauma centers.Materials and methodsWe conducted a secondary data analysis of the 2011–2012 NTDB research data sets, using means and frequencies to characterize the patient population and describe the distribution of major lower extremity amputations. Multivariable regression models were fit to identify predictors of major post-surgical complications, revision amputation, length of hospitalization, and in-hospital mortality.ResultsA total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4% were male and 67.6% were white. The three most frequent definitive amputations preformed included trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for all amputees was 22.7 days. Patients with at least one revision amputation stayed in the hospital approximately 5.5 days longer than patients not needing a revision amputation. 1204 patients (41.8%) required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical complication. African Americans experienced a 49% higher major post-surgical complication incidence and stayed, on average, 2.5 days longer in the hospital compared to whites. Injury severity score, age, hospital teaching status, presence of a crush injury, fracture location, presence of compartment syndrome, and experiencing a major post-surgical complication were all significant predictors of revision amputation.ConclusionWe report a high rate of complications and revision amputations among trauma-related lower limb amputees, and identify predictors of surgical outcomes that have not been described in the literature including African American race. Compartment syndrome is a significant predictor of major post-surgical complications, revision amputation, and length of hospitalization.     

Management of soft-tissue injuries in distal radius fractures

Distal radius fractures account for approximately 15% of all fractures in adults, and are the most common fractures seen in the emergency department. Soft-tissue injuries associated with distal radius fractures may influence strategies for the acute management of the fracture, but also may be a source of persisting pain and/or disability despite fracture healing. This article describes soft-tissue injuries and considerations for treatment associated with distal radius fractures, including injuries to the skin, tendon and muscle, ligaments, the triangular fibrocartilage complex, neurovascular structures, and related conditions such as compartment syndrome and complex regional pain syndrome.     

Acute compartment syndrome of the limb

In this review the aetiology, clinical signs, diagnosis and therapy of the acute compartment syndrome of the limb is discussed. It is a limb- and untreated life threatening emergency. For good results, early detection is necessary. It is important to educate those taking care of patients of risk, especially in the early symptoms and signs. In uncooperative, unconscious and sedated patients pressure monitoring is recommended. The critical level of the absolute intracompartmental pressure is unclear. It is recommended to use a delta p pressure of 30 mm Hg. Below this pressure in the presence of clinical signs a fasciotomy of all compartments is the treatment of choice.     

浮动肘合并伤及并发症的处理和预防

浮动肘是指同一侧肱骨、尺桡骨同时发生骨折的一类损伤。这是一种少见的严重的高能量损伤，常常同时伴有血管、神经、肌腱、以及身体其他部位的损伤。我们自１９５７～１９９５年期间共收治了４２例浮动肘病人，其中２８例伴有合并伤，占６６．７％。获得随访３２例，随访时间为伤后３个月～３０年，平均６．８年。其中１５例出现并发症，占４６．９％，主要为骨折畸形愈合，延迟愈合，骨不连，感染，关节功能障碍，肘内翻等。我们分析了其产生原因，并提出了相应的处理和预防措施。     

Analyses of possible risk factors for subacromial impingement syndrome

AIM: To evaluate the association between various risk factors, including sleeping position, and impingement syndrome. Impingement syndrome is the most common cause of shoulder problems. The pathogenesis of this problem is still debated these days.METHODS: This was a case control study conducted at the outpatient clinic of Songklanakarind hospital. Data regarding history, physical examination and radiographic evaluations using supraspinatous outlet views were obtained from all patients with clinically suspected impingement syndrome. The diagnoses of impingement syndrome were confirmed by a xylocaine subacromial injection test. All patients were interviewed concerning their usual sleeping position, which was categorized into supine, decubitus, prone and undetermined. Radiographs were evaluated to determine the shape of the acromion, which was divided into 3 types: flat, curved and hook. We used logistic regression analysis to determine the association between risk factors and outcome.RESULTS: The study group included 111 patients with impingement syndrome and 191 healthy volunteers as a control group. The mean age was about 50 years with a body mass index (BMI) of 24 kg/m² in both groups. The most common shape of the acromion was flat (84.5%), followed by curved (10.7%) and hook (4.8%). We found the 4 independent risk factors affecting impingement syndrome were smoking status, occupation, acromion shape and sleeping position. Patients who currently smoked had a 6.8 times greater risk of impingement syndrome compared to non-smokers (OR 6.8, 95% CI: 1.2-39) and government officers had a 6.3 times increased risk compared to rubber tappers (OR 6.3, 95% CI: 1.3-30.3). Patients with a hook type acromion had 6.2 times the risk of flat type (OR 6.2, 95% CI: 1.1-35) and patients who slept in the decubitus position had 3.7 times the risk of those who slept in the supine position (OR 3.7, 95% CI: 1.2-11.6). No significant associations were found between age, sex, BMI, sports activity and impingement syndrome.CONCLUSION: Independent risk factors affecting impingement syndrome are current smoker, government officer, a hook-type acromion and the decubitus sleeping position.     

Exercise Induced Chronic Compartment Syndrome of the First Dorsal Interosseous Compartment of the Hand: A Case Report

Exercise-induced chronic compartment syndrome in the first dorsal compartment is an uncommon entity and relatively rare condition which is not very well understood. It is a usually activity-related condition and is associated with decreased function of muscle with intracompartmental swelling. We present a case with proven exercise-induced raised compartment pressure that responded well to surgical fasciotomy.     

Complications of the upper urinary tract in patients with spinal cord injury: a long-term follow-up study

The aim of this study was to establish hazard ratios for the risk of complications of the upper urinary tract in relation to bladder management methods in patients with spinal cord injury. A total of 179 male patients were eligible for this investigation which was followed-up on a yearly basis until 2003. The average age at which the lesion occurred was 25.2 years (range 18–57). The average duration of follow-up since SCI was 29.3 years (range 10–53). During follow-up, the incidence of vesicoureteral reflux (VUR) was 15.1%. A total of 61 (34.1%) and 44 (24.6%) patients were diagnosed with pyelonephritis and renal stones, respectively. There were no significant differences in these complications among groups. Upper tract deterioration (UTD) was observed in 58 patients (32.4%). The incidence of UTD in the urethral catheter group (51.7%) was higher than that in other groups (P=0.008). Using multivariate analysis, patients with VUR were shown to have a higher risk of pyelonephritis (odds ratio 2.78; 95% confidence interval 1.16–6.68), and UTD (odds ratio 22.10; 95% confidence interval 6.92–70.56). We also found that UTD was more common for patients with an indwelling urethral catheter than for patients using other methods. For other variables, no positive association was observed. In cases which cannot undergo intermittent catheterization, or when the bladder cannot empty spontaneously, a suprapubic catheter is better than a urethral catheter for reducing UTD in this population. These findings suggest that even at a late stage post injury, bladder management methods are still important.     

胰十二指肠切除术围手术期并发症临床分析

目的探讨胰十二指肠切除术围手术期并发症的发生情况及其预防。方法回顾性分析111例胰十二指肠切除术患者的临床资料,分析并发症发生的可能因素。结果 111例患者中术后出现并发症48例（43.2%）,其中发生1种并发症者25例,2种者15例,3种者及以上者8例;死亡4例（3.6%）。结论胰十二指肠切除术是腹部外科中有较高风险的手术,加强围手术期预防及处理是降低胰十二指肠切除术后并发症发生率和死亡率的重要措施。