一期手术治疗合并脊柱损伤的多发伤

目的评价一期手术治疗合并脊柱损伤的多发伤临床效果。方法2002年9月～2004年5月,一期手术治疗合并脊柱损伤的多发伤12例共39处损伤(骨折)。其中颈椎骨折脱位合并四肢骨折4例,颈椎过伸伤合并四肢骨折2例,胸腰椎骨折合并四肢骨折6例。手术体位优先考虑脊柱或骨盆损伤的处理,并尽量兼顾四肢损伤。记录患者手术时间、出血量、并发症情况;神经功能评价以Frankel标准判定。结果本组平均每例患者手术时间(210±50)min,平均输血量(600±200)mL,平均每部位手术时间65min,输血量200mL。术前Frankel评分平均为2.3分,术后3月平均为3.1分。8例获得1年随访时各部位骨折全部愈(融)合,无内固定松脱断裂。结论部分合并脊柱损伤的多发伤在全身情况允许的情况下可考虑一期手术治疗。一期手术有利于全身情况改善及术后早期活动;并能有效降低并发症的发生率。     

不同方式修复全手指脱套伤23例疗效分析

目的 探讨几种修复全手指皮肤套状撕脱伤的手术方式及其疗效. 方法 原位再植一期修复全手指皮肤套状撕脱伤11例23指;游离腹部皮瓣一期修复3例6指,二期l例1指;第二趾甲皮瓣一期修复9例13指,二期修复1例2指. 结果 再植组15指成活,8指坏死.游离腹部皮瓣3指顺利成活,3指坏死.第二趾甲皮瓣13指全部顺利成活.随访6个月～7年,平均随访2.5年.修复手指外形较好,质地良好,感觉和功能恢复满意.足部供区1例植皮处中央出现破溃,经换药后愈合,其余供区一期愈合,无瘢痕挛缩等并发症.所有患者步态正常、无足部疼痛或行走不适感. 结论 根据患者年龄、性别、职业、需求、身体条件、受伤时生命体征和伤情特点等选择合适的术式治疗全手指脱套伤,就能够取得令患者满意效果.     

以胸内脏器伤为主的多发伤早期处理和治疗

目的探讨以胸内脏器伤为主的多发伤早期处理方法。方法回顾性分析本院10年51例以胸内脏器伤为主的多发伤。男33例，女18例，年龄3—89岁，其中20-50岁41例。车祸撞击伤34例，挤压伤3例，坠落伤9例，刀刺伤5例。肺挫伤35例（其中双肺挫伤5例），气管损伤1例，主动脉破裂2例，心脏挫伤10例。合并一侧肋骨骨折34例，双侧肋骨骨折9例（其中浮动胸壁3例），共损伤肋骨153根。伴血气胸35例（其中双侧血气胸3例），合并颅脑伤7例，腹腔脏器15例（其中1例腹主动脉破裂），脊柱伤5例，长骨骨折12例，腹膜后血肿3例，骨盆骨折4例，泌尿系损伤5例，发生休克31例（占60．8％）。穿透性胸伤中，肺裂伤伴膈肌裂伤2例，心包伤并肋间血管破裂1例，心包伤伴脾破裂l例，心脏穿透伤并左股动脉破裂1例，均合并血气胸和休克。51例中，2处伤27例，3处伤14例，4处伤3例，5处伤6例，6处伤1例，共144处伤，损伤脏器81个。ISS：16—24分9例，25—50分34例，51～75分8例。结果7例入院后6h内死亡，ISS均在51.75分（占87．5％），死亡率13．7％。结论理想结果依赖于早期迅速诊断与正确处理和治疗，确定应用液体的量和质以维持合适循环容量。     

摩托车致同侧肢体多处骨关节伤13例报告

自1985年3月～1992年5月,我院共收治摩托车致同侧肢体多处骨关节伤13例,34处伤,全部采用手术治疗,收到良好效果,现报告如下.本组13例均为男性,年龄20～40岁,左侧9例,右侧4例,共有34个伤,28处骨折,闭合骨折23处,开放性髌骨骨折3处.开放性股骨干骨折2处.计有股骨干骨折13例,髌骨骨折13例,髋臼骨折2例,髋关节后脱位5例,合并坐骨神经伤1例.所有伤员均无血管损伤.本组13例均行手术治疗,急诊手术10例,延期手术3例,其中2例并髋白骨折和坐骨神经伤是在伤后20天行内固定术和坐     

中西医结合治疗多发伤伴多发骨关节损伤

我科用中西医结合方法治疗多发伤并多发骨关节损伤73例，取得了较好的临床效果，现报道如下：临床资料本组73例中男64例．女9例；年龄14～SO岁；交通事故伤44例，高处坠落伤12例，重物砸伤1（）例，机器伤3例．其它伤4例；颅脑伤9例．胸部伤3O例，腹部闭合伤26例；骨盆骨折37例，骶骼关节脱位9例．够关节骨折脱位8例；股骨骨折21例，胜味骨粉碎骨折24例，尺挠骨双骨折12例，肋骨骨折3例；脊柱压缩骨折15例，其中截瘫8例；合并休克者问例；损伤部位最多达6处，最少3处。治疗扩容抗体克61例，剖腹探查26冽，胸腔闭式引流术16例，骨折切开复…     

外固定器结合有限内固定在四肢骨盆及多发伤骨折中的应用

目的探讨外固定器结合有限内固定(EFLIF)治疗四肢、骨盆及多发伤骨折的临床应用价值。方法使用EFLIF治疗58例四肢骨盆及多发伤骨折。结果 47例随访5～10年,平均6.3年。39例一期手术患者骨折平均愈合时间4.3个月(2.6～5.7个月),功能优良率83%。针道感染6例、关节活动障碍7例、骨折延迟愈合和不愈合8例。后者行二期皮瓣移植及三期钢板或带锁髓内钉固定(ORIF)并植骨,遗留膝关节僵直1例,膝踝关节活动受限3例,骨不连1例。功能满意率75%。结论 EFLIF适用于四肢、骨盆及多发伤骨折,包括开放和闭合性骨折;EFLIF和ORIF两者在骨折不同时期可交替使用,有利于促进骨折愈合和改善功能。     

四肢多发性骨折及其合并伤的急救与护理

我院近二年来共收治四肢多发性骨折及其合并伤４２例,现将急救及护理报告如下。临床资料本组４２例中,男２３例,女１９例。年龄最小６岁,最大７１岁。交通事故伤２５例,坠落伤５例,塌砸挤压伤１２例。４２例中共有１０８处骨折,其中２处骨折２７例,３处骨折６例,４处骨折９例。合并伤１５例,其中颅脑损伤４例,肋骨骨折并血气胸６例。肝破裂２例,脾破裂３例。并发症２３例,其中休克１９例,脂肪拴塞４例。开放性骨折３８例,闭合性骨折４例。急救与护理一、多发性骨折及其合并伤首先要“全、快、早”。此病伤因复杂,伤情严重。…     

后入路手术治疗肩胛骨骨折14例疗效观察

[目的] 探讨后入路手术治疗肩胛骨骨折的适应证及疗效.[方法] 自2000年5月-2007年11月经后入路手术治疗肩胛骨骨折14例,其中男10例,女4例,平均34.6岁(18～62岁).车祸伤8例,高处坠落伤3例,直接暴力伤2例.刀砍伤1例.闭合性骨折11例,开放性骨折3例.根据Hardegger的分型方法,体部骨折8处,肩胛因骨折9处,肩峰骨折6处,肩胛颈骨折lO处,盂缘骨折6处,盂窝骨折4处.其中混合型骨折10例,合并全身多发伤5例;伴有腋神经损伤1例,肩胛上神经损伤2例.通过后入路手术,对不同类型的肩胛骨骨折使用重建钢板或拉力螺钉和钢丝等固定.[结果] 14例患者获得随访,随访时间6个月～3年,平均18个月.根据Rowe疗效评价标准,优10例,良2例,可2例,差0例,优良率为85.7%.术后并发肩关节不稳1例.[结论] 经后入路内固定肩胛骨骨折操作简单,暴露充分.效果可靠.几乎各种类型的肩胛骨骨折均可通过后入路完成,尤其适用于肩胛骨的体部骨折,外科颈骨折及肩胛因骨折以及多部位复杂骨折,是肩胛骨骨折手术治疗的一种安全有效方法.     

地震伤骨盆骨折的损害控制处理——附一例报告

目的 探讨损害控制在地震伤骨盆骨折中的应用及效果.方法 对1例地震伤致骨盆骨折伤员应用损害控制技术治疗并进行总结回顾,伤员一期行抗休克治疗及骨折临时固定,二期采用导航下微创手术治疗.结果 经过损害控制的分期处理,稳定伤员的生命体征,骨折复位固定满意,无并发症发生.结论 创伤控制应用于地震伤骨盆骨折伤员的救治了提高了伤员的生存率,可减少并发症的发生率.     

83例皮肤软组织撕脱伤的治疗体会

1临床资料与方法 1.1一般资料 2003年9月～2008年4月共收治皮肤肌肉撕脱伤病例83人,男53例,女30例,年龄22～54岁,平均31.4岁.其中车祸伤47例,机器绞伤21例,重物碾压伤15例.合并四肢骨折42例.     

Penetrating injuries of the subclavian artery

BACKGROUND: Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. METHODS: A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. RESULTS: The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. CONCLUSIONS: Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.     

The correlation between stabbing-related upper extremity wounds and survival of stabbing victims with abdominal and thoracic injuries

BackgroundWhen treating patients with stab injuries of the torso, clinicians often lack timely information about the degree and nature of internal organ damage. An externally observable sign significantly associated with characteristics of torso injuries may therefore be useful for practitioners. One such potential sign is the presence of wounds to the hands, sometimes sustained during victims' attempt to defend themselves during the violent altercation. Thus, the primary aim of this study was to evaluate the association between presence of upper extremity wounds and the severity of the thoracic and intra-abdominal injuries due to stabbing.MethodsThis study was carried out retrospectively using data on 8714 patients with stabbing-related injuries from 19 trauma centers that participated in the Israeli National Trauma Registry (INTR) between January 1st1997 and December 31st 2013. Patients with wounds of upper extremities in addition to torso injuries (UE group) were compared to other patients with torso injuries (TO group) in terms of demographics, injury characteristics and clinical outcome.ResultsThe compared groups were found to be homogeneous in terms of age and systolic blood pressure; the number of sustained torso injuries was also identical. The UE group comprised a slightly greater percentage of females, however both groups were predominantly male. Patients with upper extremity injuries had a lower proportion of internal organ damage (36% vs. 38.5%) and lower mortality (0.9% vs. 2%). The higher mortality of patients without upper extremity wounds remained significantly different even when adjusted by other epidemiological parameters (OR 2.46, 95% CI 1.33–5.08).The number of sustained upper extremity injuries was positively associated with deeper penetration of the torso by the stabbing instrument.ConclusionsPatients with stabbing-related upper extremity wounds had a significant survival advantage over patients without such injuries. However, a greater number of sustained upper extremity wounds may be an external sign of greater severity of thoracic and intraabdominal stabbing injuries.     

Gunshot wounds to the head: gang- and non-gang-related injuries and outcomes

Primary objective: This study examined the differences between gang and non-gang-related incidents of penetrative missile injuries in terms of demographics, motivation, intra-cranial pathology, transit time, injury time and clinical outcome. Research design: Retrospective and prospective chart review. Methods and procedures: Between 1985-1992, 349 patients with penetrating missile injuries to the brain presenting to LAC-USC were studied. Experimental interventions: Inclusion criteria were implemented to keep the cohort as homogenous as possible. Patients excluded were those with multiple gunshot wounds, non-penetrating gunshot wounds to the head, systemic injuries and cases in which the motivation for the incident was unknown. Main outcomes and results: Gang-related shooting slightly out-numbered non-gang-related incidents. Demographic analysis showed both a male and Hispanic predominance for both gang- and non-gang-related victims and significant differences in gender, race and age. Occipital entrance sites were more common in the gang-related vs temporal entrance sites in the non-gang-related. Mean transit time to the emergency department for gang-related shootings was less than non-gang-related shootings (24.4 vs 27.8 minutes). Most shooting incidents took place between 6 pm and 3 am. No difference between survival and outcome was noted between gang and non-gang victims. Conclusions: Significant differences were found between gang- and non-gang-related shooting victims in terms of demographics, entrance site and transit time. No difference was found between injury time, survival and outcome between gang and non-gang populations.     

Pancreatic and duodenal injuries: keep it simple

BACKGROUND: The management of pancreatic and duodenal trauma has moved away from complex reconstructive procedures to simpler methods in keeping with the trend towards organ-specific, damage control surgery. METHOD: A retrospective case note review was undertaken over a 30-month period to evaluate a simplified protocol for the management of these injuries. RESULTS: Of 100 consecutive patients there were 51 with pancreatic injury, 30 with a duodenal injury and 19 with combined pancreaticoduodenal trauma. Overall mortality was 18.0%, with a late mortality (after 24 h) of 9.9%. This is comparable to previous studies. Morbidity from abscesses, fistulas and anastomotic breakdown was acceptably low. CONCLUSION: The concept of staged laparotomy can be successfully applied to wounds of the pancreas and duodenum. Debridement of devitalized tissue and drainage can be employed for most cases of pancreatic trauma. Most duodenal injuries can be managed with debridement and primary repair. Temporary exclusion and reoperation should be employed for unstable patients.     

Urethral injuries in the Civil War

PURPOSE: We compiled all cases of urethral injury received in battle during the Civil War to detail their management and determine the outcome of treatment. MATERIALS AND METHODS: Surgeon medical reports of individual cases of urethral injury listed in the Medical and Surgical History of the Civil War, and pension records available in the National Archives and Records Administration were reviewed. RESULTS: A total of 105 cases of urethral injury from gunshot wounds, comprising 7% of all urogenital casualties, were reported during the Civil War between 1861 and 1865. Of them 22 (21%) were fatal and 83 patients (79%) cases survived. Debridement and catheter drainage of urinary extravasation or perineal urethrotomy was initial treatment. The majority of urethral injuries were complicated by troublesome strictures, fistulas, urinary incontinence and erectile impotence. Only 19 patients (23%) recovered fully. CONCLUSIONS: Civil War urethral injuries had devastating long-term consequences.     

Survey of cecal and ascending colon injuries among Vietnam casualties in Japan (1967-1970)

One hundred seventy cases of war injury to the ascending colon were reviewed. The results showed primary closure to be a safe procedure in small wounds (less than 1 cm). They also showed that resection and anastomosis were safe in major wounds without significant associated injuries. More massive wounds of the ascending colon with associated injuries presented the greatest problem and the outcome was comparable with either of the presently employed surgical procedures.     

Abdominal Stab Wounds in Children: an 18-Year Experience

Objective: Evaluation of the diagnosis, management, and the role of selective treatment in children with abdominal stab wounds. Patients and Methods: 59 children (56 male and three female) were included in the study. The patients' median age was 11.8 years (range, 5–14 years). Time between injury and admission was about 3 h. Laparotomy was performed in 44 patients (74%). Solid organ injury was detected in 32 of these patients (73%) and could not be observed in twelve (27%). 15 patients (26%) were treated conservatively, and only one (6.6%) underwent laparotomy during the follow-up. The stomach was the most frequently injured organ (ten patients), followed by the intestines (nine patients). Types of surgical treatment were as follows: primary suture in 28 patients, resection-anastomosis in three, and osteotomy in two. Results: Some prognostic factors such as presence of abdominal organ evisceration and pneumoperitoneum were not significantly correlated with intraabdominal organ injury, whereas some other risk factors such as acute abdomen on admission (p < 0.002) or abdominal clinical and hemodynamic findings (p < 0.001) showed significant correlation with intraabdominal organ injury. The relative risk (odds ratio) of developing an intraabdominal organ injury was > 2 for patients with signs of an acute abdomen on admission. Postoperative complications were observed in five patients with organ injuries. None of our patients died. Conclusions: Conservative treatment can be safely performed in most children with abdominal stab injuries. Signs of major internal hemorrhage or generalized peritonitis are an absolute indication for emergency operation for abdominal stab wounds. Peritoneal penetrations, free air on the abdominal X-ray, and omental or intestinal evisceration are poor indicators of significant organ injuries, and patients presenting these signs shold be closely followed up for developing acute abdominal symptoms. Received: November 2, 2001; revision accepted: February 15, 2002     

Laparotomy for penetrating gastric trauma - A South African experience

IntroductionPenetrating gastric injury (PGI) is common and although primary repair is sufficient for most injuries, several areas surrounding the peri-operative management remain contentious. This study reviews our experience in the management of PGI and review the clinical outcome at a major trauma centre in South Africa.Materials and methodsA retrospective study was conducted from January 2012 to April 2020 at a major trauma centre in South Africa.Results210 cases were included (184 male, median age: 30 years). Mechanism of injury was 59% stab wounds (SWs) and 41% gunshot wounds (GSWs). The AAST grade was predominantly (92%) grade 2 for all cases. 20% (41/210) were isolated gastric injuries. All cases underwent primary repair and there were no cases of suture line failure. Eleven cases (5%) had one or more injuries not identified at the index laparotomy: 7 were unidentified gastric injuries and the remaining 4 were unidentified non gastric injuries. There was no association between unidentified injuries and mechanism of injury or outcome. Fifty-seven (27%) cases experienced one or more complications. Eighty-two cases (39%) required intensive care unit admission. The overall median length of hospital stay was 7 (IQR 4-11) days. The overall mortality was 14%. GSW injuries were more likely to have additional organ injury, higher ISS and PATI scores, longer length of hospitalization, higher likelihood of ICU stay, greater morbidity and mortality than SW injuries. There was a slight increase in the wound sepsis rate as number of associated extra gastric injuries increased but this was not statistically significant. There was no difference in wound overall sepsis rate between SW and GSW injuries (2% vs 8%, p=0.121).ConclusionsPrimary repair alone is sufficient for most PGI, but laparotomy is associated with high incidence of unidentified injury and surgeons must to be cognisant of the likelihood of these occult injuries.     

Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries

PURPOSE: Nonoperative treatment of serious renal injuries has been advocated and yet to our knowledge the optimum level of operative treatment has not been established to date. We report a unique data set, in which patients with severe renal injuries were treated with an ultraconservative nonoperative approach during a period when urological consultation was not available at a major urban trauma center. MATERIALS AND METHODS: We retrospectively reviewed the charts of 51 patients identified with renal trauma in the Detroit Receiving Hospital trauma data base from 1997 to 2001. RESULTS: Injuries were grades I to V in 15, 7, 11, 14 and 4 cases, respectively, and had a tendency toward serious injury. Renorrhaphy was never performed. Nephrectomy was done sparingly, only for grade V renal injuries and only in patients who were exsanguinating from the kidney. Two of the 4 patients with grade V injury died of multiple injuries, including massive head injuries. Only 2 of the patients treated nonoperatively (4%) had complications, including fever and hematuria in 1 each. CONCLUSIONS: This data set seems to support an ultraconservative approach of limiting renal surgery to only patients with active exsanguination. The nephrectomy rate for 14 grade IV injuries, including some gunshot wounds to the kidney, was 0%. When comparing this rate with that in the literature, we would expect it to be 1 patient to as high as 10. This approach was safe and resulted in a low complication rate of 4%. Series in which more aggressive therapy for renal injuries is advocated should compare favorably to ultraconservative therapy if aggressive therapy is to continue to be widely advocated.     

Double jeopardy revisited: Clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

Introduction

In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult. Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.

Methods

All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.

Results

Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18-40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80-90 mm Hg). Median base excess was −6.5 (quartile range −12 to −2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.

Conclusion

Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.