Traumatic skull fractures in children and adolescents: A retrospective observational study

ObjectiveTo investigate the epidemiological features of child and adolescent (≤18 years old) patients managed for traumatic skull fractures (TSKFs) and associated traumatic brain injury (TBI).Design393 Patients who were children and adolescent who had TSKFs admitted to our university affiliated hospitals between January 2003 and December 2010. The incidence and patterns were summarized with respect to different age group, admission time and etiology.SettingTwo university-affiliated hospitals from January 2003 to May 2010.ResultsThe most common etiologies were motor vehicle collisions (MVCs) (166, 42.2%) and high fall (101, 25.7%). The most common skull fracture sites were parietal fractures (n = 111, 28.2%) and basilar skull fracture (n = 111, 28.2%). A total of 300 (76.3%) patients suffered TBI and 23 (5.9%) patients suffered OCI. The most common intracranial hemorrhage was epidural hemorrhage (n = 94, 23.9%). The frequencies of emergency admission, medical insurance and associated injuries were 56.2% (n = 221), 22.4% (n = 88) and 37.2% (n = 146). The frequencies of TBI and associated injuries were significantly increased from 53.45% to 76.3% and from 6.9% to 41.6% with age, respectively.ConclusionsMVCs were the most common etiologies. Parietal and basilar skull fractures, epidural hemorrhages were the most common fracture sites and intracranial hemorrhage.     

Traumatic extrathoracic pulmonary hernia

Traumatic extra thoracic pulmonary hernia is a rare and uncommon observation. An important factor is relative lack of muscular support afforded by anterior chest wall. We report a case of 45 year old man who presented with severe breathlessness following assault with iron rod. He had with herniation of right lung, fractured clavicle, first rib and hemothorax. He underwent surgical reduction of the herniated lung with prolene mesh repair of the defect. The postoperative course was uneventful.     

Traumatic pancreatic duct injury in children: minimally invasive approach to management

Background

The management of children with main pancreatic duct injuries is controversial. We report a series of patients with pancreatic trauma who were treated using minimally invasive techniques.

Methods

Retrospective review of children with pancreatic trauma treated at a UK tertiary referral institution between 1999 and 2004.

Results

Fifteen children (11 boys) were admitted with pancreatic trauma. Twelve (80%) were less than 50th centile for body weight. Contrast-enhanced computed tomography (CT) scans were used to define organ injury, supplemented by magnetic resonance cholangiopancreatography (MRCP) in 7. Twelve (80%) underwent diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with a median time after injury of 11 (range, 6-29) days. The degree of pancreatic injury was defined by ERCP and CT/MRCP as grade II (n = 2), grade III (n = 4), grade IV (n = 9) (American Association for the Surgery of Trauma grades). Nine children had a transductal pancreatic stent inserted endoscopically. Computed tomography/ultrasound-guided drainage was performed in 4 children for acute fluid collections. Two children later underwent endoscopic cyst-gastrostomy, one of whom later required conversion to an open cyst-gastrostomy.

Conclusion

Body habitus may predispose to pancreatic duct trauma. Contrast-enhanced CT scan (and MRCP) should dictate the need for ERCP. Transductal pancreatic stenting allows internal drainage of peripancreatic collections and may reestablish duct continuity, although a proportion still requires percutaneous or endoscopic cyst-gastrostomy drainage. Open surgery for pancreatic trauma should now be an exception.     

Traumatic intraspinal pneumocele

Traumatic intraspinal pneumocele (TIP) is a radiologic finding in which air is visualized within the spinal canal on routine cervical spine x-rays following a head injury. TIP may be the initial radiologic evidence of a severe central nervous system injury. The presence of TIP will alert a physician to the severity of the head injury, as well as the need for further radiologic investigations.     

Brain death

Summary Following the research of Giessen Neurosurgery on primary and secondary lesions of the hypothalamo-pituitary system and the brainstem over a period of more than 30 years, cerebral failure and death does not represent a uniform syndrome but consists of several, well characterized syndromes of irreversible hypothalamo-pituitary, mesencephalic and bulbar failure. The specific syndromes are described in detail. The diagnosis is based on establishing complete irreversible damage of specific vital basal functions such as hypothalamo-pituitary transmission, water-and electrolyte metabolism, temperature regulation, circulation and respiration. The common feature of all types is the irreversible break-down of the complex central neurogenous and/or neurohumoral regulatory system. The permanent and irreversible loss of central regulation and modulation means at the same time the complete cessation of the specific human cortical function, the death of the whole brain. Only in bulbar failure with primary irreversible cessation of respiration artificial respiration can maintain the autonomous functions of the heart for a limited time. It is indicated when organ explantation is to be considered. Complete and irreversible isolated loss of cortical function abolishes the normal human life, but does not mean death of the remaining vegetating human being.Presented at the meeting of the Working Group of the Pontificia Academia Scientiarum on The artificial prolongation of life and the exact determination of the moment of death, Vatican City, October 19–21, 1985.Dedicated to Prof. Dr. Jean Brihaye at the occasion of his 65th anniversary.     

不同方法治疗外伤性耳廓缺损

目的探讨根据耳廓缺损部位和耳后乳突区皮肤损伤程度的不同,选择不同的手术方式治疗外伤性耳廓缺损的可行性并评价手术效果。方法本组108例外伤性耳廓缺损患者,采用两种耳廓再造的方法,72例运用耳后皮肤软组织扩张术行耳廓再造,36例运用Brent技术行耳廓再造,耳支架均采用自体肋软骨雕刻。结果 108例再造外耳均愈合良好,外形满意,双侧耳对称。有4例出现耳软骨支架外露,经治疗后愈合。结论根据患者自身情况,制定个性化治疗方案,可以在提高手术安全性前提下,达到最佳的效果。     

Management of Traumatic Diaphragmatic Rupture

Purpose Diaphragmatic rupture following trauma is often an associated and missed injury. This report documents our experience of treating traumatic diaphragmatic rupture (TDR).Methods We retrospectively analyzed 18 patients who presented between 1993 and 2000 with TDR, caused by blunt injuries in 14 and by penetrating injuries in 4.Results The average age of the patients was 32 years and the female to male ratio was 4:14. The TDR was right-sided in 5 patients and left-sided in 13. The diagnosis was made by chest X-ray, thorax and upper abdominal computed tomography, and upper gastrointestinal contrast studies. The most common herniated organs were the omentum (n = 11), stomach (n = 10), spleen and colon (n = 9), and liver (n = 2). Sixteen diaphragmatic injuries were repaired primarily, and two were repaired using a prolene mesh graft. The mortality rate was 5.5% (n = 1).Conclusions A high index of suspicion and early surgical treatment determine the successful management of TDR, with or without the herniation of abdominal organs. The surgical approach to TDR is individualized. Acute left-sided injuries are best approached through the abdomen, although we prefer the chest approach, adding laparotomy when necessary. Acute right-sided injuries and chronic injuries should be approached through the chest.Nispetiye cad. Profesorler Sitesi C3 Blok, A-kapisi No: 66/8, Etiler 34337, Istanbul, TurkeyPresented in part at the 8th European Conference on General Thoracic Surgery, London, UK, November 1–3, 2000     

创伤性膈疝的X线及CT诊断

目的总结创伤性膈疝的X线及CT表现,提高对该病的认识。方法搜集2002年1月至2005年12月间经手术、病理证实的创伤性膈疝18例,回顾性分析其X线及CT表现。结果18例创伤性膈疝中,X线平片表现膈肌上抬、轮廓模糊消失、液气胸、创伤性湿肺等。胃肠造影可直接显示膈上疝囊等结构。CT可显示疝入胸腔的软组织肿块,提供补充信息。结论创伤性膈疝有较典型的影像学表现,平片、胃肠造影、CT等多种影像检查手段的结合,可提高其诊断率。     

Traumatic pulmonary pseudocyst: An underreported entity

BackgroundTraumatic pulmonary pseudocysts (TPP) are underreported cavitary lesions of the pulmonary parenchyma that can develop following blunt chest trauma. Although the occurrence of traumatic pulmonary pseudocyst is rare, this condition should be considered in the differential diagnosis of any cavitary lesion. Awareness of this injury and its clinical significance is important for successful management in order to avoid medical errors in the course of treatment.MethodsA literature search was conducted through Medline using the key phrases “traumatic pulmonary pseudocyst” and “traumatic pneumatocele.” Relevant articles, especially those with focus on diagnosis and management of traumatic pneumatocele in adults, were selected. Due to the scarcity of literature and lack of Level I evidence on this subject, studies published in any year were considered.ResultsA search of “traumatic pulmonary pseudocyst” and “traumatic pneumatocele” yielded 114 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were reviewed. The majority of these were individual case studies; only eight articles were considered large case studies (greater than eight patients).ConclusionTraumatic pulmonary pseudocysts are lesions that occur secondary to blunt chest trauma. Diagnosis is based on a history of trauma and appearance of a cystic lesion on CT. Accurate diagnosis of traumatic pulmonary pseudocyst is imperative to achieve successful outcomes. Failure to do so may lead to unnecessary procedures and complications.     

Traumatic rupture of choledochal cyst in a child

Traumatic rupture of choledochal cyst is an extremely rare disorder. The current patient is a 4-year-old boy who fell in a bathroom and suffered a blow to the abdomen. Percutaneous transhepatic cholangiography revealed pancreaticobiliary maljunction. Inflammation of the peritoneal cavity was moderate. At first look, the choledochal cyst was excised and hepaticojejunostomy was performed. At this time, a rupture approximately 2 mm in diameter was recognized at the rear surface of the inferior part of the common bile duct.     

Traumatic aneurysms of the descending thoracic aorta

From July 1979 to December 1985 we observed 51 patients with traumatic lesions of the descending thoracic aorta. Twenty-nine had acute ruptures, mostly accompanied by multiple injuries, and 27 had to be operated upon immediately. Twenty-two patients (19 males, 3 females) had chronic traumatic aneurysms of the descending thoracic aorta (more than six weeks after trauma). Mean age at the time of trauma was 24 years. Mean age at time of surgery was 36.5 years. Twelve patients were symptomatic. All were treated surgically. At surgery, complete aortic disruption was found in 15 patients and partial rupture in seven. We did not use aortic shunting of any kind, only aortic cross-clamping. Hypertension was controlled by intravenous drug infusion. The ruptured aortic segment was replaced in all cases by prosthetic Dacron graft. There were no operative deaths. One patient (age 77) died 11 weeks after surgery from multiple organ failure. One case of postoperative paraplegia was observed. This patient recovered almost completely from his neurological deficit.     

Mortality and causes of death after traumatic spinal cord injury in Estonia

Abstract

Study design

Retrospective population-based study with mortality follow-up.

Objective

To study mortality, causes and risk factors for death in Estonian patients with traumatic spinal cord injury (TSCI).

Setting

All Estonian hospitals.

Methods

Medical records of patients with TSCI from all regional, central, general, and rehabilitation hospitals in Estonia from 1997 to 2007, were retrospectively reviewed. Mortality status was ascertained as of 31 December 2011. Causes of death were collected from the Estonian Causes of Death Registry. Standardized mortality ratios (SMRs) were calculated for the entire sample and for causes of death. A Cox proportional hazards modeling was used to identify the risk indicators for death.

Results

During the observation period (1997–2011) 162 patients of 595 died. Nearly half of the patients (n = 76) died during the first year after TSCI. The main causes of death were external causes (30%), cardiovascular disease (29%). and suicide (8%). The overall SMR was 2.81 (95% confidence interval 2.40–3.28) and SMR was higher for women than for men (3.80 vs. 2.70). Cause-specific SMRs were markedly elevated for sepsis and suicide. Mortality was significantly affected by the age at the time of injury, neurological level, and extent of the injury as well as the year of TSCI and complications.

Conclusion

Life expectancy is significantly decreased in patients with TSCI in Estonia compared with the general population. Deaths during the first year after the injury have an important impact on statistics. Treatment of cardiovascular diseases, infections, and prevention of suicide are useful for reducing mortality in patients with TSCI.     

Traumatic abdominal wall hernia: A reappraisal

Traumatic abdominal wall hernia, a rare cause of hernia, has a confusing clinical picture and requires a high index of suspicion for prompt diagnosis and management. Such hernias, if missed, can result in high morbidity and may prove fatal. Distinction from a pre-existing hernia is important as well. We report our experience in two such cases, which had presented in a span of 9 months, and submit a brief analysis of 50 reviewed cases.     

Mckay手术在儿童创伤性马蹄内翻足矫形中的应用

目的：寻求儿童创伤性马蹄内翻足的理想矫形方法。方法：对6例患儿施行矫形术。结果：6例畸形足均获矫正。随访1．5－4年,显示踝关节恢复功能位,运动无明显受限。结论：Mckay手术能最大限度地矫正踝关节畸形,不影响骨、关节、软组织发育,操作不复杂,适宜于不同程度的儿童创伤性马蹄内翻足。     

Traumatic Anterior Dislocation of the Shoulder: Factors Affecting the Progress of the Traumatic Anterior Dislocation

Background

The aim of this study was to identify the factors that affect the progress of a traumatic anterior dislocation of the shoulder.

Methods

Two hundred and thirty-eight patients (246 shoulders) with a traumatic anterior dislocation were enrolled in this study. The mean age at the time of surgery was 25 years (range, 14 to 47 years). There were 214 men and 24 women.

Results

One hundred and sixty-four shoulders (67%) were younger than 20 years at the time of the first dislocation. Patients younger than 20 years showed a shorter interval of redislocation (p = 0.001) and a higher frequency of dislocation (p = 0.001). Athletic patients experienced their first dislocation at a younger age (p = 0.023) and showed a shorter interval of redislocation (p = 0.001) than their non-athetic counterparts. The incidence of classic and non-classic Bankart lesions was unaffected by age at the time of the first dislocation, interval between the first and second dislocation or the frequency of dislocation. Patients with bony Bankart lesions had a higher frequency of dislocation (p = 0.043).

Conclusions

The age at the time of the first dislocation and athletic activity were related to early redislocation and a high frequency of dislocation. Bony Bankart lesions were observed more often in patients with a higher frequency of dislocation. Early surgical treatment is a good option for young athletic patients with a bony Bankart lesion and a short interval between the first and second dislocation.     

Brain stem death

The concept of brain and brain stem death developed from the observation of apnoeic comatose patients. In the UK, the diagnosis of brain stem death is made by clinically testing brain stem function once specific pre-conditions have been met. The exact definition of brain death and some details regarding the tests required to make this diagnosis vary across the globe. However, the majority of tests carried out are similar to those in the UK. In this review we define brain stem death and the clinical tests used to confirm it. The use of ancillary testing can have a role in patients where clinical tests are not possible and this is also discussed.