四肢多发骨折并发胸腔积液的危险因素分析

目的:探讨四肢骨折合并胸腔积液的危险因素,为预防胸腔积液的发生提供参考。方法：自2010年1月至2019年12月采用手术治疗的137例四肢多发骨折患者,男102例,女35例,年龄16~92（48.34±15.85）岁。四肢多发骨折定义为全身有两处以上的四肢骨折,所有入选患者术前具有完整的临床,影像及实验室检查资料,包括术前胸部CT,性别,年龄,体质量指数（body mass index,BMI）,红细胞压积（hematocrit,HCT）,美国麻醉医师协会（American Society of Anesthesiologists,ASA）分级,创伤严重度评分（injury severity score,ISS）,吸烟史,手术史,糖尿病史,高血压史,入院至手术时间,骨折部位,血小板计数,白蛋白,C-反应蛋白和D-二聚体等因素。记录患者是否合并胸腔积液,计算胸腔积液量,并对相关危险因素进行统计学分析。结果：四肢骨折均接受了手术治疗,术后患者切口愈合良好,无伤口感染和急性肺损伤或急性呼吸窘迫综合征等并发症出现。通过多因素回归分析示：ISS>16分（P=0.000）、吸烟史（P=0.001）和肋骨骨折（P=0.000）是四肢多发骨折合并胸腔积液的危险因素。多因素线性回归分析显示：吸烟史,ISS及肋骨骨折是四肢多发骨折胸腔积液量增多的危险因素。结论：四肢多发骨折合并胸腔积液与ISS、吸烟史以及肋骨骨折相关;胸腔积液量与吸烟史、ISS及肋骨骨折有关。对ISS>16分,有吸烟史或合并肋骨骨折的多发骨折患者应提高警惕,尽早干预,降低合并胸腔积液量的风险。     

Pelvic injuries in childhood and adolescence: Retrospective analysis of 5-year data from a national trauma centre

Background

Pelvic fractures are uncommon injuries in paediatric trauma patients because of specific anatomical features. Due to the low incidence there is no standardized therapeutic algorithm.

Material and methods

This retrospective review evaluates paediatric pelvic fractures of a Level I Trauma Centre over 5 years. In addition, we compared the data with adult pelvic fractures and reviewed the literature. A total of 37 pelvic fractures (??16 years) were documented, with an incidence of 9.9% in the child with multiple injuries. The most common injury mechanisms were traffic accidents, followed by falls from heights.

Results

Type A injuries occurred in 50% (type B: 16%, type C: 27%, acetabular injuries: 11%). Osteosynthesis was performed in nine cases. Therapeutic intervention was necessary in three cases of haemodynamically relevant bleeding; 97% of all children had associated injuries (mean ISS: 38).

Conclusion

Our data showed some differences to the literature. Pelvic fractures are predictors for high injury severity. Despite similar fracture pattern, in contrast to adults most injuries could be treated non-operatively. In unstable or dislocated fractures open reduction and stabilization must be performed.     

Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients

BACKGROUND: Despite the lack of evidence, traditional trauma teaching has suggested that low rib fractures increase the risk of abdominal solid organ injury (ASOI). This study was designed to assess if in fact this is true, and to try and define other factors that increased the risk of ASOI in rib fracture patients. METHODS: The charts of 476 hospitalized rib fracture trauma patients were reviewed. Data were collected for age; sex; Injury Severity Score (ISS); rib fracture location; and the presence or absence of injuries to the abdominal organs, head, neck, face, thorax, great vessel, heart, thoracolumbar spine, pelvis, and extremities. RESULTS: The probability of liver injury increased with the presence of any right-sided rib fracture, any low rib fracture, female gender, young age, and an elevated ISS. The probability of splenic injury increased with the presence of left-sided rib fractures only, any low rib fracture, young age, and an elevated ISS. CONCLUSION: In hospitalized trauma patients, low rib fractures, right-sided rib fractures, female gender, young age, and an elevated ISS increased the probability of liver injury; and low rib fractures, left-sided only rib fractures, young age, and an elevated ISS increased the probability of splenic injury. Associated pelvic fractures and long bone fractures did not increase the likelihood of ASOI in this cohort.     

Management and outcome of open pelvic fractures: a retrospective study of 41 cases

Background

Open pelvic fractures occur uncommonly. Despite serious sequelae, they have been infrequently reviewed.

Methods

We conducted a retrospective review of all patients with open pelvic fractures in our department from January 2001 to April 2010.

Results

Forty-one patients (32 men, 9 women) with these injuries were identified. The average Injury Severity Score (ISS) was 31.4, with 80% of patients having a score ≥16. The average blood transfusion in the first 24 h was 17.2 units, and the average hospital stay was 60 days. Overall mortality was 24%(n = 10): 3 early deaths and 7 late deaths. Factors associated with overall mortality by univariate analysis were ISS, RTS, GCS, age, pelvic sepsis, Gustilo classification of soft-tissue injury, and Young classification of bony fracture. Factors associated with late mortality by univariate analysis were: ISS, RTS, pelvic sepsis, Gustilo classification of soft-tissue injury, and blood transfusion in the first 24 h. Moreover, multivariate analysis showed that only RTS was independently associated with both overall and late mortality.

Conclusion

Despite treatment advances, mortality rates remain high in patients with open pelvic fractures. The urogenital and/or intra-abdominal injuries are not associated with mortality. RTS ≤ 8 might be a predictor of poor outcome in open pelvic fractures patients. Open reduction and internal fixation might be used in those unstable pelvic fractures without gross contamination in the fracture region after extensive cleansing and lavage. More emphasis needs to be placed on this injury complex.     

Clinical outcomes of multiple rib fractures: does age matter?

Purpose

To evaluate the clinical outcomes of multiple rib fracture due to blunt trauma in young patients, a 3-year retrospective study was conducted. Patients with ≥3 rib fractures were divided into two groups (group I: <45 years old and group II: ≥45 years old). Mortality, hospital stay, ventilatory support, chest tubes insertion and associated injuries were studied.

Results

Of the 902 patients admitted with blunt chest trauma, 240 (27 %) met the inclusion criteria and 72.5 % patients were <45 years old. The most common causes of injury were motor vehicle crash (59 %) and fall (29 %). The Injury Severity Score (ISS) was higher in group I (16 ± 9 vs. 13 ± 6; p = 0.04). Hospital mortality was higher in group II (6 vs. 2 %; p = 0.18). Pneumothorax, haemothorax and ventilatory support were comparable. Patients in group II were more likely to undergo chest tubes insertion (26 vs. 14 %; p = 0.04), while group I had a significantly higher incidence of associated abdominal injuries (25 vs. 12 %; p = 0.03).

Conclusion

Old age presenting with rib fractures is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture.     

A review of upper limb injuries in bear maul victims: Consistent pattern and inverse relation in severity with facial and scalp injuries

Purpose

Bear maul injuries are the most common wild animal inflicted injuries in India. More than 300 bear maul injuries report to our hospital per year.

Paediatric pelvic ring fractures and associated injuries

Introduction

Paediatric pelvic fractures have been infrequently reviewed. The study was performed to highlight the unique features of pelvic fractures in children.

Patients and methods

A 14-year retrospective study was undertaken of all patients treated for a pelvic fracture at our institute.

Results

Thirty-nine children were included. The mean Injury Severity Score (ISS) was 17.1 (range 4–75). Simple ring fractures were the most common type (46%), dominated by pedestrian versus motor vehicle trauma (58.9%). A pelvic fracture was evident on the initial plain radiographs of all 39 children. Further radiographic investigations (12 CTs and 1 MRI) were undertaken in 13 (33%) of the children. Additional posterior ring fractures were identified in 9. A total of 32 children (82%) sustained one or more associated injuries. Head injuries accounted for 25% and orthopaedic/skeletal injuries for 33% of all associated injuries. Fourteen children required a total of 24 acute surgical procedures. Mean out-pateint clinical follow-up was for 27 months (range 3–85). There was one mortality in this series. Eight children (20%) suffered long term sequale.

Conclusion

Paediatric pelvic fractures differ from their adult counterpart in aetiology, fracture type, and associated injury pattern. They represent a reliable marker for severe trauma. Prospective studies are required to define optimal treatment guidelines, particularly in older children.     

Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures

Background

The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures.

Methods

We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] ≥ 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and χ² tests, followed by logistic regression analysis.

Results

Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12.9%; overall mortality 15.1%). The laparotomy group had higher mean ISS (36.9 v. 24.9), higher mean abbreviated injury scores (AIS) for the abdomen (2.6 v. 0.9) and chest (3.4 v. 1.6), lower mean initial hemoglobin levels (105.2 v. 127.0 g/L), higher mean crystalloid (4249 v. 3436 mL) and blood transfusion volumes over 4 hours (12.1 v. 3.9 units), more frequent hypotension (44.6 v. 18.0%) and a higher percentage of positive CT scans (67.9% v. 28.4%) and FAST examination results (42.9% v. 3.3%) than the nonlaparotomy group. Age (mean 53.7 v. 41.5 yr); ISS (mean 39.0 v. 24.4); AIS for the head (mean 3.2 v. 1.7), abdomen (mean 1.6 v. 1.1), chest (mean 2.7 v. 1.8) and pelvis (mean 3.1 v. 2.6); crystalloid (mean 5157.3 v. 3266.4 mL) and blood transfusion volumes over 4 hours (mean 13.1 v. 3.7) and initial hypotension (61% v. 14.8%) were all greater among patients who died than those who survived. Mean initial hemoglobin levels were lower among patients who died than among those who survived (111.1 v. 126.2 g/L). Age, the AIS for the head, initial hypotension and low initial hemoglobin levels were highly predictive of mortality, whereas low initial hemoglobin levels, a positive FAST examination and high AIS for the abdomen and chest were all highly predictive of laparotomy.

Conclusion

Among the polytrauma patients with pelvic fractures, 14.3% underwent laparotomy, and mortality was higher among these patients than among those who did not have the procedure. The predictors of laparotomy and mortality are similar to those anticipated in patients without pelvic fractures.     

Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer

INTRODUCTION

Rib plating is becoming increasingly common as a method for stabilizing a flail chest resulting from multiple rib fractures. Recent guidelines recommend surgical stabilization of a flail chest based on consistent evidence of its efficacy and lack of major safety concerns. But complications of this procedure can occur and are wide ranging.

PRESENTATION OF CASE

We report an interesting case of a 58-year-old male patient that worked as a long-distance truck driver and had a flail chest from multiple bilateral rib fractures that occurred when his vehicle was blown over in a wind storm. He underwent open reduction with internal fixation (ORIF) of the bilateral rib fractures and they successfully healed. However, he had permanent long thoracic nerve injury on the side with the most severe trauma. This resulted in symptomatic scapular winging that impeded him from long-distance truck driving. The scapular winging was surgically corrected nearly two years later with a pectoralis major transfer augmented with fascia lata graft. The patient had an excellent final result.

DISCUSSION

We report this case to alert surgeons who perform rib fracture ORIF that long thoracic nerve injury is a potential iatrogenic complication of that procedure or might be a result of the chest wall trauma.

CONCLUSION

Although the specific cause of the long thoracic nerve injury could not be determined in our patient, it was associated with chest wall trauma in the setting of rib fracture ORIF. The scapular winging was surgically corrected with a pectoralis major transfer.     

Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care

BACKGROUND: To determine the role of pelvic fractures in auditing mortality resulting from trauma. STUDY DESIGN: This retrospective case-control study based on autopsy-evaluated circumstances of the deaths of patients with pelvic fractures. RESULTS: Of 2,583 patients injured in motor-vehicle collisions, 655 (25.4%) constituted the pelvic fracture (PFx) group, and 1,928 (74.6%) constituted the control group. One-third of the PFx group's fatalities had an Injury Severity Score (ISS) of 75 and were not preventable. The PFx group had a substantially higher median ISS than the control group (50 versus 34; p < 0.0001). Four hundred fifty-four patients (69.3%) in the PFx group with ISS 16 to 74 had substantially higher rates of associated injuries. Nearly half of the PFx group patients with ISS 相似文献   

Impact of rib fixation on quality of life after major trauma with multiple rib fractures

Introduction

Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life.

Rib fracture as a predictor of future fractures in young and older postmenopausal women: National Osteoporosis Risk Assessment (NORA)

Summary  

A rib fracture history after age 45 was associated with a 5.4-fold increase in new rib fracture risk and a 2.4-fold increase in risk of any new clinical fracture in 155,031 postmenopausal women. A rib fracture history suggests osteoporosis and should be considered when evaluating patients for interventions to prevent fractures.     

Polytrauma mit Beckenfraktur und schwerem Thoraxtrauma

Background

The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function.

Methods

A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay.

Results

The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01).

Conclusions

In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.     

Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung

Objective

Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding.

Method

Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch®) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding.

Results

Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14–80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3–5) and a total severity of injury with the ISS of 37 points (21–66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2–12.4) and an average transfusion requirement of 6 red blood cell units (4–13). The time until the TAE was started was on average 62 min (25–115) with a duration period of the TAE of 25 min (15–67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%.

Conclusion

Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.     

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND: The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS: Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION: Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.     

The significance of first rib fractures in children

Purpose

The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients.

Methods

The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed.

Results

Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%.

Conclusions

Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.     

Use of ketorolac is associated with decreased pneumonia following rib fractures

Background

The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown.

Methods

A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not.

Results

Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit–free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different.

Conclusions

Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks.     

The Value of Lung Injury Score in Assessing the Outcome of Patients with Rib Fracture

Background and Purpose:   

Management of rib fractures constitutes a major part of the trauma workload of any unit. Rib fractures result in disrupted chest wall mechanics and ventilatory insufficiency. The ability of a lung injury scoring system to predict the degree of respiratory dysfunction after rib fractures was evaluated.