Penetrating visceral injuries of the neck: results of a conservative management policy

A study of the conservative treatment of 109 patients with penetrating neck injuries was carried out over 3 years. Patients with clinical or radiological evidence of injury to the oesophagus or trachea were included in the study while nine patients with major vascular trauma were explored immediately and excluded. Three late vascular operations were performed. The remaining 106 patients were treated conservatively. There were two deaths, both from associated injuries. The remaining 104 patients were treated successfully with only three cases of minor wound sepsis. We conclude that oesophageal and tracheal injuries after stab injuries and low velocity gunshot wounds can be treated successfully by non-operative treatment.     

Selection criteria for non-surgical treatment of liver injury in adult polytraumatized patients

Conservative treatment of hepatic trauma is currently implemented in 80-90% of cases with a success rate of 92.5% and is mainly based on the haemodynamic status of the patients. We conducted a retrospective study of 71 patients with hepatic trauma from January 1993 to April 2001 and reviewed our experience with surgical and conservative treatment, also considering associated extrahepatic lesions. Fifty-three (74.6%) patients with liver trauma underwent celiotomy and 18 (25.3%) were treated conservatively. Haemodynamic instability was the most common indication for surgery (34 patients). Eighteen (52.9%) patients required an extrahepatic surgical procedure. Nineteen (35.8%) patients were haemodynamically stable and the indications for surgery in these cases were penetrating trauma in 6, large haemoperitoneum in 12, and diaphragmatic rupture in 1. The overall mortality in the operated group was 15%, but the liver-related mortality rate was 7.5%. The success rate for conservative management was 88.8%, with mortality 0% and morbidity 11%. The patients managed conservatively had grades of injury (I-III) similar to the haemodynamically stable operated patients (94.4% vs 94.7%), whereas the haemoperitoneum was larger in the operated group (63.1% vs 11.1%). Non-operative management is the preferred treatment option in haemodynamically stable patients with limited haemoperitoneum, regardless of the grade of the hepatic lesion, and without severe intra-abdominal injuries.     

Diagnosis and treatment of the cruciate ligament injury of knee joint

During 1959 to 1986, 62 Cases with cruciate ligament injury of the knee joint were treated in our hospital. Thirty of these cases were anterior cruciate ligament injuries and 32 cases were posterior The diagnosis of the cruciate ligament injuries was made by stability tests of the cruciate ligament. When the knee was greatly swollen with multiple ligament injuries, a series of X-ray films should be taken to test the knee stability under local or nerve block anesthesia. Fresh tear of the cruciate ligament (33 cases) was treated with immediate surgical repair except in one. Old ligament injuries (28 cases) were treated by conservative method (10 cases) or surgical reconstruction (18 cases). All patients were followed for 2 to 18 years (mean 6 years). The results showed that the fresh tear of the cruciate ligament treated surgically had excellent and good rates in 87.9% (29/33). In the conservative treatment group, only 27.3% (3/11) obtained good result, and most of them were complicated with meniscal lesions and osteoarthritis. Eighteen cases treated by ligament reconstruction gave 34.5% (8/18) good result.     

Outcomes of surgical management of tracheobronchial injuries a case series from a developing country

Objective: Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma.Methods: A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries.Results: The average age was 31 years with most of the patients being male (14:1). Among them,11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma (blunt and penetrating trauma). Eight patients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% (1 patient). Most patients survived with no sequelae (10 patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management.Conclusions: Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.     

Neurosurgical intervention in penetrating spinal trauma with associated visceral injury

Associated injuries to the neck, chest, or abdomen are found in approximately one-quarter of all civilians with penetrating spinal cord or cauda equina injuries. While the value of and indications for general surgical exploration and repair of these injuries are fairly self-evident, the value of neurosurgical intervention in terms of neurological outcome and infection prophylaxis remains the subject of debate. To study this issue, 160 civilian patients with penetrating spinal injuries and neurological deficits were retrospectively reviewed. Associated injuries of the esophagus, trachea, bronchi, or bowel were seen in 107 individuals (67%); 33 (31%) of these patients had abdominal injuries, 25 (23%) had neck injuries, 23 (21%) had thoracic injuries, and 26 (24%) had injuries occurring at multiple sites. Of these 107 patients, 67 (63%) had complete neurological injuries and the remaining 40 (37%) demonstrated incomplete deficits. All 107 patients underwent surgical exploration and repair of their visceral injuries; in 19 of them a neurosurgical procedure was also performed for decompression of the neural elements and/or debridement of the wound. Regardless of the presence of associated visceral injuries, the mechanism of injury, and the extent of the neurological deficit, no statistically significant difference in neurological outcome was found in patients with or without neurosurgical intervention. Complications associated with neurological injury were reported in 17 (11%) of the total group of 160 patients. Four (21%) of the 19 patients who had neurosurgical intervention suffered a related complication, compared to only six (7%) of the 88 patients who were managed conservatively (p less than 0.05). Within the limitations of a retrospective review, the results of this study do not clearly support the value of routine neurosurgical intervention as an adjunct to general surgical repair in cases of spinal injury associated with penetrating visceral trauma.     

Management of airway trauma. I: Tracheobronchial injuries

One hundred six consecutive patients with injuries to the tracheobronchial tree who were admitted to the emergency room of the Tulane Medical Center Hospital or the Charity Hospital of Louisiana at New Orleans over a period of almost 20 years were analyzed retrospectively. Penetrating trauma of the neck or chest was reported in 100 of the patients, and only 6 had blunt trauma to the neck or thorax as the cause of injury. There were 18 deaths among the 106 patients (16.98%), including 11 (13.75%) of 80 with injuries of the cervical trachea. Seven (53.8%) of 13 with principal injuries of the thoracic trachea died; all 13 patients with major bronchial injuries survived. On admission to the emergency room, all patients had signs of airway compromise such as tachypnea, dyspnea, cyanosis, subcutaneous emphysema, or an abnormal respiratory pattern. Severe airway compromise was evident in 46 patients; 24 (23%) were treated with oral or nasal intubation, 19 (18%) with emergency tracheostomy, and 3 (2%) with intubation of a tracheal injury. Hemoptysis was an unreliable signal of serious injury, being present in only 28 of the patients. Patients who had major vascular injuries combined with trachea involvement were generally not salvageable. In regard to morbidity and mortality, the most common preventable errors were delay in diagnosis and treatment of tracheobronchial injuries, missed esophageal injuries, massive aspiration of blood, and abdominal vascular injuries.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis and treatment of renal trauma in 298 patients

OBJECTIVE: To investigate the diagnosis and treatment of renal trauma. METHODS: Retrospective analysis of 298 patients with renal trauma was carried out. Among them, 272 (91.3%) had blunt renal injuries and 26 (8.7%) had penetrating injuries; 123 (41.3%) had multiple complicated intraabdominal injuries and 56 (18.8%) had concomitant shock. Normal-dose-IVU examination was used in 39 patients and double-dose-IVU in 44 patients, ultrasonography in 109 patients, and CT in 45 patients. Conservative and supportive therapy was done in 193 patients (64.8%) and operation in 105 patients (35.2%). RESULTS: The positive rate was 48.7% by the normal-dose-I VU examination and 90.9% by double-dose-IVU, 78.8% by ultrasonography, and 95.6% by CT. One hundred and eighty-three patients were cured by conservative therapy and 101 by operation. Fourteen patients died. CONCLUSIONS: B-ultrasound can be conveniently used for primary assessment of renal injuries, while CT shows rapid, accurate and proper condition of a renal trauma patient. The treatment depends on the severity of the injury. The conservative therapy is employed in most cases which present slight or moderate injury and no evident massive bleeding. Severe injury requires surgical exploration. The operative approach is by using a transabdominal incision, which makes it relatively easy to explore intraabdominal organs and control the injured kidney. It is also very important to control shock and prevent other severe complications in the early stage of the treatment.     

Outcomes of surgical management of tracheobronchial injuries---a case series from a developing country

Objective

Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma.

Methods

A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004 to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries.

Results

The average age was 31 years with most of the patients being male (14:1). Among them, 11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma (blunt and penetrating trauma). Eight patients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% (1 patient). Most patients survived with no sequelae (10 patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management.

Conclusions

Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.     

Management of airway trauma. II: Combined injuries of the trachea and esophagus

Twenty-four consecutive patients with combined injuries of the trachea and esophagus were operated on at the Tulane University Hospital and the Charity Hospital of New Orleans between 1967 and 1983. Only 3 of the injuries resulted from blunt trauma, and 1 of these patients had a total transection of both the trachea and esophagus; the remaining injuries were due to penetrating trauma (20 gunshot wounds; 1 stab wound). The combined lesions involved the cervical region in 20 patients and the thoracic esophagus and trachea or bronchus in 4. All patients underwent bronchoscopy; in recent years all have had esophagoscopy, because our experience indicates that esophagrams, which patients also underwent, have a high rate (12.5%) of false negative results. Operative techniques included a two-layer closure of all esophageal injuries, closure of the trachea with non-absorbable monofilament suture, and transthoracic or cervical drainage. Muscle flaps were used for suture line reinforcement. Associated operative procedures included tracheostomy (5), laparotomy (4), vascular procedures (5), neurologic procedures (2), and closed-tube thoracostomy (6). Five patients (21%) died in the perioperative period, 4 of 20 with combined cervical injuries, and 1 of the 4 with combined thoracic injuries. Deaths resulted from missed injuries to the esophagus (2 patients), a missed tracheal injury (1), associated vascular injury (1), and associated thoracoabdominal injury (1). Two patients experienced cervical esophageal suture line leaks, both of which sealed with conservative therapy. Clinical follow-up showed good results in 90% of the patients who survived.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nonoperative treatment of liver superficial injuries

The study is based on the results of conservative and operative surgical treatment of 184 victims with open and closed, isolated and combined injuries of the liver. The patients' age was from 15 to 80 years. All patients were examined and treated in 1991 to 1996 in Moscow clinical hospital No 67. Conservative treatment for superficial injuries of the liver were carried out in 72 patients. 112 patients underwent urgent operations. Conservative treatment included: examination, control diagnostic laparoscopy and introduction of control drainage followed by dynamic laparoscopy. Operative treatment included: laparotomy, revision of the abdominal cavity, sutures or resection of the liver, surgical treatment of the other abdominal organs. Comparative analysis of two methods of treatment demonstrated possibility and necessity of the use of conservative treatment for superficial injuries of the liver, especially in combined traumas.     

Tracheobronchiale Verletzungen

BACKGROUND: Tracheobronchial ruptures are rare surgical emergencies with significant mortality. We present management and outcome of such ruptures treated at the University of Leipzig in Germany and propose a novel therapeutic algorithm-a new classification system for stratifying treatment of patients with tracheobronchial ruptures. METHODS: We retrospectively studied 24 patients 19 to 88 years old who were treated in our institution for tracheobronchial injury. RESULTS: Eighty-seven percent of the injuries were caused iatrogenically. Fifty-four percent were type I injuries (isolated tracheal lesions), 38% type II (involvement of carina or main stem bronchi), and 8% type III (distal lesions of lobar or segmental bronchi). Seventy-five percent of the patients were operated via right-sided dorsolateral thoracotomy. In four (22%), insufficiency of the tracheal closure occurred, with mediastinitis possibly being a significant risk factor for this event (P<0.001). In surgically treated patients, rupture-related and overall mortality were 5.5% and 28%, respectively, whereas in medically treated patients, mortality was 33%. CONCLUSION: The proposed classification of tracheobronchial injuries enables stratifying the treatment of patients with tracheobronchial ruptures. Type I lesions can be surgically closed either by a right-sided thoracotomy or transcervical-transtracheal approach. In contrast, surgical management of type II and III injuries always requires thoracotomy.     

医源性神经损伤及显微外科修复

目的：阐述医源性神经损伤的伤因、治疗和预防要点。方法：分析１９８２—１９９５年间，收治的１８例医源性神经损伤的病史及随访记录。结果：伤因分为手术误伤，石膏或小夹板压迫，止血带伤和药物性损伤４类。１２例采用神经松解，神经吻合，神经移植等手术治疗。疗效优者６例，良３例，优良率为７５％（９／１２）。６例采用保守治疗而愈。结论：医务工作者只要具有高度的责任感、严谨的工作作风和细致的操作技术，医源性神经损伤是可以避免的。     

Non-missile penetrating injuries of the spine

Summary Non-missile penetrating injuries of the spine accounted for 7% of all spinal injuries admitted to this Institute during the last 10 years. Young males were most commonly affected and 73% of the injuries involved the upper dorsal und cervical spine. They presented with varying degrees of neurological deficit. Plains x-rays revealed the bony injury and/or the retained foreign body satisfactorily. Myelography (with or without CT scan) was performed in patients with progressive neurological deterioration and those not responding to conservative therapy. Surgery remained the mainstay of treatment and improved neurological function in 7 out of 9 cases. Conservative management resulted in complications such as persistent CSF fistula, uncontrolled fulminant meningitis and septicaemia, with 100% mortality. Early surgical intervention is, therefore, recommended in all penetrating injuries of the spine.     

Management of enterocutaneous fistulae: A 10 years experience

AIM: To compare the outcomes of conservative vs surgical treatment of enterocutaneous fistulae (ECF) in a community teaching hospital over a decade.METHODS: All cases of ECF between 1997 and 2007 were reviewed for management strategy.RESULTS: Of the 83 patients with ECF, 60 (72%) were postoperative. Sixty-six patients (79.5%) were treated initially with conservative measures. Eighteen patients failed to respond to conservative treatment and required later (secondary) exploration; this group consisted of an equal number of low vs high output fistulae. Seventeen (20.5%) patients underwent initial (primary) definitive-surgery secondary to anastomotic leak and peritonitis. Surgical procedures included resection of ECF with anastomosis (24), exclusion (6) and direct-drainage (4). No significant difference was seen in the recurrence rate for conservative (10%) vs operative-treatment (20%).CONCLUSION: Conservative treatment plays a pivotal role as an initial management in both low and high output fistulae. In selective cases only, early primary exploration is recommended.     

Bronchoscopic methods in complex diagnosis and treatment of burned patients with inhalation injuries]

Chromobronchoscopy was first used in treatment of 37 burned patients with inhalation injuries for better visual manifestation of the injuries of the tracheobronchial tree mucosa. The trachea and bronchi mucosa was irrigated with a viral stain--0.25% aqueous solution of methylene blue. The intensity of staining the mucosa in light blue colour showed the true limits and depth of the injury. Resulting from the clinico-endoscopic examinations supplemented with findings of chromobronchoscopy, cytological and bacteriological analyses, a working classification of inhalation injuries in burned people was developed which allowed the adequate methods of local treatment during fiber bronchoscopy to be worked out taking into account the degree of thermochemical injuries of the respiratory pathways. It resulted in 19.7% lower lethality of burned patients.     

Renal pedicle injury in patients with multiple injuries

In a study of 41 patients seen over 24 years, renal pedicle injuries were associated with life-threatening multiple system injuries and the immediate surgical management of these associated injuries by general surgeons took precedence over that of the renal pedicle injury. The result was the delayed diagnosis of the renal pedicle injury with loss of function of the kidney. In an effort to improve the renal salvage rate aggressive management of renal pedicle injuries with immediate radiologic evaluation and early surgical treatment was instituted in 1969. The records of 41 renal pedicle injuries from 1959 to 1983 were evaluated. Blunt external trauma was the cause in 76%. All 41 patients had multiple system injuries, averaging 3.7 associated injuries per patient, with 35 (85%) having a laparotomy for intra-abdominal injuries and an overall mortality rate of 44%. Conservative management was followed in 13 patients, with injury to the renal artery in nine and a branch of the renal artery in four, with a renal loss/delayed nephrectomy rate of nine of nine (100%) renal artery injuries. Immediate surgical management was performed in 23 patients, with injury to the renal artery in nine, the renal artery and renal vein in four, a branch of the renal artery in two, and the renal vein in eight, with a renal salvage rate of seven of 21 (33%) renal artery and/or vein injuries. Five patients died on admission or on the operating room table. A significant renal salvage rate resulted from immediate radiologic evaluation and early surgical treatment of renal artery/vein injuries compared to zero salvage rate with conservative management.     

Treatment of abdominal injuries: a report of 522 cases

OBJECTIVE: To make a summary of the experiences in the treatment of abdominal injuries. METHODS: A retrospective study was done on 522 cases of abdominal injuries in our department from January 1986 to December 2004. RESULTS: Of all,382 cases were treated by surgery and 140 by conservative method. Among the surgically treated cases, 347 patients (90.8%) recovered, 35(9.2%) died and 21 had postoperative complications (5.6%). For patients undergoing conservative treatment, 139(99.3%) recovered but one (0.7%) died. CONCLUSIONS: The severity of abdominal injury and delayed treatment are two key factors leading to death. Surgical procedure is still the main method against alternative abdominal injuries. It is necessary to strictly control the indications in conservative treatment.     

Undisplaced subtle ligamentous Lisfranc injuries, conservative or surgical treatment with percutaneous position screws?

Purpose: Undisplaced subtle ligamentous Lisfranc injuries are easy to miss or underestimate, and many cases are treated without surgical fixation. It has not yet widely known whether conservative treatment for undisplaced subtle ligamentous Lisfranc injuries may lead to a poor outcome. The purpose of this study is to compare the outcomes of conservative versus surgical management (percutaneous position screw) of undisplaced subtle ligamentous Lisfranc injury. Methods: We analysed 61 cases in this retrospective study, including 38 males and 23 females. Forty-one patients were managed conservatively, while 20 patients received surgical treatment involving minimal invasive percutaneous position screw. American orthopaedic foot &ankle society (AOFAS), foot function index (FFI, including FFI disability, FFI pain score and activity limitation scale) scores, Maryland foot score and short form-36 (SF-36) were recorded and compared after a follow-up of 10e16 months (average 12.3). Results: Patients in the surgical management group had higher scores in all evaluation methods (p < 0.05). The complications in the conservative management group had higher incidence, mainly including secondary diastasis (34.1% vs. 5.0%), joint stiffness after 3 months (82.9% vs. 0%), and secondary arthrodesis (12.2% vs. 0%). The highest rate of complication in surgical management group was temporary forefoot pain (55.0%). Conclusion: The results of this study suggest that the outcomes of the surgical management with percutaneous position screw fixation are better than the conservative management to treat undisplaced subtle ligamentous Lisfranc injuries. This study can serve as a resource for orthopaedic surgeons in recognizing and managing such injuries.     

Conservative treatment of fingertip injuries

In a prospective investigation of 81 consecutive patients with fingertip injuries conservative treatment was evaluated. Fingertip injuries were defined as lesions greater than or equal to 1 cm2 in the terminal phalanx without injury to the tendons or joints. All fingertip injuries were cleaned and covered by Vaseline gauze and left to heal. If less than 2 mm of soft tissue covered the bone a few millimetres of bone were nibbled away to allow good cover with soft tissue. The majority of injuries (64 per cent) occurred at work. The average healing time was 25 days. The main later complaints were intolerance of cold (36 per cent), numbness (36 per cent) and tenderness (26 per cent). None of the patients had stiff joints. On average, the two-point discrimination had increased by 1 mm in the injured fingertip. Conservative treatment is recommended as a safe and simple treatment of fingertip injuries, even when bone is exposed in the wound.     

Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

BACKGROUND: Geriatric trauma patients have a worse outcome than the young with comparable injuries. The contribution of traumatic brain injury (TBI) to this increased mortality is unknown and has been confounded by the presence of other injuries. The purpose of this study was to investigate the role of age in the mortality and early outcome from isolated TBI. METHODS: This was a retrospective analysis of all adult patients with isolated TBI (Abbreviated Injury Scale score > or = 3) admitted during a 5-year period to two Level I trauma centers. Mortality, Glasgow Outcome Scale score at discharge, therapy, and complications were compared for elderly (age > or = 65 years) and younger patients. RESULTS: Of 694 patients, 22% were defined as elderly. The mortality for the elderly group was twice that of their younger counterparts (30% vs. 14%, p < 0.001), even for those with mild to moderate TBI (Glasgow Coma Scale score of 9-15). Thirteen percent of elderly survivors had a poor functional outcome (Glasgow Outcome Scale score of 2 or 3) at hospital discharge versus 5% in the young group (p < 0.01). Independent factors associated with a high mortality were age and Glasgow Coma Scale score. CONCLUSION: The mortality from TBI is higher in the geriatric population at all levels of head injury. In addition, functional outcome at hospital discharge is worse. Although some of this increased mortality may be explained by complications or type of head injury, age itself is an independent predictor for mortality in TBI.