Transperineal sonography of a large vulvar hematoma following blunt perineal trauma

Vulvar hematomas may result from puerperal or nonpuerperal-related trauma. These perineal injuries, especially the puerperal type, may be life-threatening and require surgical exploration, evacuation, and hemostasis. In the absence of acute hematoma expansion, expectant management may suffice. Experience with transperineal sonography in the assessment of female perineal trauma has been limited to a single case report pertaining to a puerperal vulvar hematoma. We present an unusual case in which the transperineal sonographic appearance of a large vulvar hematoma following a straddle injury to the perineum assisted in the expectant management of this condition.     

Transabdominal impalement: absence of visceral or vascular injury a rare possibility

Background: Abdominal impalement injuries are usually associated with visceral and vascular injury, causing significant morbidity and mortality. The management of these injuries poses specific challenges in prehospital care, transport, and management strategies. Objective: We report a case of transabdominal impalement with no injury to intra-abdominal visceral or vascular structures, demonstrating a chance occurrence. The literature regarding abdominal impalement injury is reviewed and the management of these injuries is discussed. Case Report: A 35-year-old man with a transabdominal impalement injury after an accidental fall from a tree on to a wooden fence was brought to the Accident and Emergency Department. The wooden fence piece was impaled and in situ. Laparotomy revealed no intra-abdominal visceral or vascular injury. Conclusion: Transabdominal impalement injuries pose peculiar challenges in prehospital care, transport to hospital, and management. Operative intervention is required in all cases for a conclusive and safe management, as the possibility of escaping intra-abdominal injury is very rare.     

Fracture of the humeral neck with intrathoracic dislocation of the humeral head

Intrathoracic fracture-dislocation of the humeral neck is a rare and easily overlooked clinical entity. We present a case and review of the literature. The objective of this study was to summarize the clinical presentation of this injury and to provide recommendations for initial diagnostic imaging and management. A 68-year-old man presented to the Emergency Department after a fall onto an abducted arm with moderate respiratory distress, mild left shoulder pain, and palpable crepitus over the shoulder and chest wall. Radiographic examination demonstrated the humeral head to be lying within the left hemithorax, devoid of any attachments to the remaining proximal humerus. After initial stabilization, the patient underwent surgical excision of the humeral head and delayed hemiarthroplasty. Careful attention to radiographic studies is required to recognize this injury. Initial management centers on airway management, adjunctive imaging, and treatment of any associated injuries followed by surgical excision and proximal humeral reconstruction.     

孕产妇会阴管理的方法与效果

目的探讨对孕产妇实施会阴管理的方法与效果。方法将定期产检、自愿自然分娩的非高危孕产妇166例随机分为观察组85例和对照组81例,对照组孕产妇采用传统的产前健康教育,观察组在此基础上接受系统化的会阴管理培训,即在孕28~32周开始参加培训,采用多媒体教学和模拟演练等多种培训方式指导孕产妇盆底肌训练及分娩配合训练,并通过电话随访监督孕产妇坚持练习。结果产妇会阴裂伤率、会阴切开率降低,第二产程时间缩短(P0.01)。结论对孕产妇实施会阴管理可有效减轻会阴损伤、缩短第二产程。     

Delayed pseudoaneurysm formation of the carotid artery following the oral cavity injury in a child: A case report

BACKGROUNDAn impalement injury of the oral cavity is a common traumatic injury in children. In most cases, it is not accompanied by sequelae, but if foreign body residues are not found due to a minor injury, they may result in inflammatory responses and delayed vascular injuries in the surrounding tissues. Without early diagnosis and appropriate initial management, residual foreign bodies can cause serious complications and even mortality in some cases. CASE SUMMARYA 9-year-old boy suffered an intra-oral injury by a wooden chopstick, and the patient was discharged from the hospital after receiving conservative treatment for the injury. However, the patient was readmitted to the hospital due to intra-oral bleeding, and since neck hematoma and right internal carotid artery pseudoaneurysm formation were detected on computed tomography, emergency surgery was performed. A remnant fragment of a wooden chopstick was found during the operation, and a delayed rupture of the internal carotid artery caused by the foreign body was also found.CONCLUSIONThe failure of early detection and diagnosis of a residual foreign body may result in delayed vascular rupture.     

Successful endovascular therapy of a penetrating zone III jugular bulb injury. A case report

Penetrating venous injuries via Zone III of the neck extended over jugular bulb are rare. The optimal strategies for these venous injuries are currently unknown because many of the vital structures in this region are poorly accessible to the surgeon and therefore it is difficult to control bleeding. A 76-year-old man got drunk and fell down onto a paper door. The wooden framework of the paper door was broken and got stuck deep in the right side of his neck. Enhanced computed tomography showed the wood stick had penetrated through the right jugular foramen and injured the jugular bulb. We successfully performed right sigmoid and jugular vein occlusion via an endovascular approach using Guglielmi detachable coils at first and then to draw out the wood stick in order to avoid venous bleeding. To our best knowledge, these venous injuries have reported in only four cases. Only one case was performed by endovascular approach using n-butyl cyanoacrylate (NBCA). Coil embolization is much better than NBCA in the light of reducing complications due to adhesion to the inserted wood stick and embolization of unintended vessels. Venous occlusion using coil embolization is the best way to treat a penetrating jugular bulb injury via zone III because of reducing the hemorrhage and air embolism.     

闭合性肾损伤的诊断和治疗

目的：探讨闭合性肾损伤的诊断和治疗。方法：1993年－2001年收治闭合性肾损伤80例，行B超、IVU、CT等检查。保守治疗66例（82．5％），手术治疗14例（17．5％），其中包括2例选择性肾动脉栓塞术。结果：78例痊愈出院，肾功能正常。2例（2．5％）死亡，均为多器官损伤合并休克的患者。68例（85．0％）随访1－5年。结论：CT平扫及增强扫描检查可较准确地诊断肾损伤程度，并可同时了解腹腔脏器损伤情况，应作为重度以上肾损伤的首选检查，B超可用以轻伤者筛选诊断。肾损伤的治疗应最大程度保留肾组织，防止并发症及后遗症，除了对严重肾实质碎裂伤，肾血管严重损伤应积极进行手术治疗，以挽救患者生命；对严重肾挫伤、肾裂伤、部分肾破裂伤所致肾出血患者可选择超选择性肾动脉栓塞术。脾破裂合并左肾损伤在临床的多发性损伤中并不少，且有其特殊性，诊治得当则能迅速转危为安，反之则会延误病情。     

Non-operative management of a high-pressure water injection injury to the hand

High-pressure injection injuries to the hand are work-related injuries that can take a devastating toll on the functionality of the affected extremity. Chemical injections are a surgical emergency. Injuries involving only water injection are rarer and have variable management strategies. We report a case of high-pressure injection hand injury due to water only. The patient was managed non-operatively with parenteral antibiotics, narcotics and elevation, with good outcome. We present a review of the literature on high-pressure injection injury.     

Necrotizing fasciitis in a renal transplant patient

We have described a 28-year-old diabetic woman who had necrotizing fasciitis of the perineum three years after receiving a living related renal transplant. The diagnosis of necrotizing fasciitis was made early and she was referred to a tertiary care center where she received radical perineal debridement and aggressive medical and surgical follow-up. Necrotizing fasciitis in a transplant patient is rare; review of the literature shows few cases and no survivors. Our patient has returned to a normal life despite continuation of all immunosuppressive therapy throughout the entire hospital course. In addition, she had a good cosmetic result despite the large necrotic perineal infection. Her survival can be attributed to early diagnosis and referral, immediate and extensive debridement, and aggressive protein replacement.     

182 例低危初产妇行无保护会阴接生技术的临床效果

目的探讨无保护会阴接生技术对低危阴道分娩初产妇会阴裂伤程度及分娩期并发症的影响。方法选择 2015 年 1~3 月, 阴道分娩且无会阴侧切指征的初产妇 182 例,随机分为 2 组,观察组 86 例,对照组 96 例,观察组在胎头着冠后实行无保护会阴接生技术;对照组则按照传统会阴保护接生技术,比较两组产妇的会阴完整率及裂伤程度、会阴水肿情况、产后 2 h 出血量及新生儿窒息情况。结果观察组的会阴完整率高于对照组（χ²=5.419,P＜0.05）,会阴水肿发生率低于观察组（Z=-2.377,P＜0.05）,差异有统计学意义,两组会阴裂伤程度（Z=-0.647,P＞0.05）、产后 2 h 出血量（Z=-0.423,P＞0.05）及新生儿窒息率（Z=-0.486,P＞0.05）, 差异无统计学意义。结论无保护会阴接生技术减轻了产妇会阴损伤程度,没有造成明显的分娩并发症,值得在临床推广。     

探讨两种会阴保护时机选择的效果

目的：探讨两种会阴保护时机的选择对会阴水肿程度、会阴裂伤的影响。方法：选择2012年5月~2013年5月在本院住院选择自然分娩的初产妇300例为研究对象,随机将其分为观察组与对照组各150例,两组均给予常规护理,对照组在胎头拨露使阴唇后联合紧张时保护会阴,观察组在胎头着冠时保护会阴。比较两组产妇的产后会阴水肿情况、会阴裂伤情况。结果：两组产妇会阴裂伤情况比较,观察组优于对照组,差异具有统计学意义（P〈0.05）;观察组产后会阴水肿发生率低于对照组,差异具有统计学意义（P〈0.05）。结论：胎头着冠时保护会阴,可提高会阴完整率,降低会阴裂伤及会阴水肿程度,提高母亲舒适度,促进自然分娩,值得推广。     

High-voltage electrical burn of the genitalia, perineum, and upper extremities: the importance of a multidisciplinary approach

High-voltage electrical burns on genitalia and perineal areas are very rare and only sporadic reports are available in the literature with often confusing diagnoses and inconspicuous treatment protocols. Although the surgical treatment of extremities lesions is well established and includes appropriate debridement, temporary wounds coverage, and final adequate soft-tissue reconstruction, management of genital lesions remains controversial and challenging. The authors present a rare case of severe high-voltage electrical injury with involvement of upper extremities and complex lesions localized to the genitalia and perineal region. Treatment required a multidisciplinary approach including the plastic surgery and the urologic and andrologic teams.     

Case report of perineal hernia after laparoscopic abdominoperineal resection

Perineal hernia (PH) is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present a case report of perineal hernia after laparoscopic APR and discuss its management. The patient was a 77‐year‐old man who was diagnosed with lower rectal cancer. He underwent laparoscopic APR and bilateral lateral lymph node dissection. Two months after the surgery, pain and bulging in the perineal region developed, and PH was diagnosed by CT. Repair with a polypropylene mesh was performed using a combination of laparoscopic abdominal and transperineal approaches. Reportedly, the incidence of secondary PH after APR has increased along with the rate of laparoscopic surgery. Treatment of secondary PH with transperineal repair alone may cause injuries to other organs because of adhesion of the pelvic viscera. In the present case, we safely repaired the hernia repair using a laparoscopy‐assisted perineal approach.     

Rectal “oven mitt”: the importance of considering a serious underlying injury

A 20-year-old man presented with a rectal “oven mitt,” which was removed transanally. Rigid proctosigmoidoscopy revealed no apparent perforation, but subsequent contrast enema using meglumine diatrizoate demonstrated an extraperitoneal rectal perforation, which was probably caused by a wooden stick used to forcefully introduce the glove through the patient’s anus. Thus, rectal injuries may be caused not by the foreign object itself, but by another object used as an introducer.     

The management of stab wounds to the heart with laceration of the left anterior descending coronary artery.

Penetrating cardiac injuries are an increasing cause of traumatic deaths in urban areas. The management of these injuries has undergone a transition from simple pericardiocentesis to cardiac ultrasound evaluation in the stable patient, and emergency thoracotomy and repair of myocardial wounds in the unstable patient in extremes. The incidence of traumatic coronary artery injury is not accurately known because not all victims are examined. With the improvement in emergency medical services, including speed of transportation of these patients, better resuscitation, and knowledgeable use of cardiac ultrasound or emergency room thoracotomy, more patients with coronary artery injuries will survive and reach the operating room. The operative management of the injured coronary artery is dependant on the location of the injury and whether there is myocardial dysfunction. Distal injuries with small myocardial infarction should be treated by ligation alone. Proximal injury and those injuries associate with larger area of ischaemia or infarction are best treated with coronary artery bypass. The role of cardiopulmonary bypass pump in these patients should be evaluated depending on the homodynamic stability of the patient. We present two cases of cardiac stab wounds with transection of the left anterior descending (LAD), which were successfully managed. A literature review regarding the management of combined cardiac and coronary artery injuries is also provided.     

B型超声在腹内脏器损伤诊断中的应用

目的 探讨腹内脏器损伤的声像图特点以及超声诊断价值。方法 应用二维超声对１８０例腹内脏器损伤患者进行超声检查,并与手术及临床诊断结果对照。结果 １８０例患者中裨性脏器损伤９６例,空腔脏器损伤３１例,脏器损伤伴腹腔积液１３９例,占７７．２％,腹膜后血肿２８例。Ｂ超诊断完全符合占６７．２％（１２１／１８０）,部分符合占１５％（４５／１８０）,不符合占７．８％（１４／１８０）。结论 腹内脏器损伤的声像图表现与损伤部分、程度和时间密切相关、腹腔积液是判断有无脏器损伤最敏感的指标。据此超声能对脏器损伤分型和程度判断,能为手术抉择提供重要依据。     

Aplicación de termoterapia en el periné durante el parto para reducir las lesiones que precisan sutura posparto

ObjectiveEvaluate the effectiveness of heat, moist or dry to the perineum during delivery in order to reduce injuries requiring perineal suturing after birth, and to assess its safety in relation to the adaptation of the newborn to extrauterine life.MethodAn open multicentre clinical trial directed from the School of Nursing at the University of Barcelona was carried out between 2009 and 2010 in 5 Catalan Hospitals. The sample consisted of 198 pregnant women subjected to the natural protocol for normal delivery assistance. The pregnant women were randomized to three study groups: moist heat (MHG), dry heat (DHG), and control (CG). Usual care of the perineum was performed during labour in all groups and MHG or GCS was also applied in the perineum in the intervention groups. The Apgar score in the newborn and perineum postpartum was then assessed. Statistical tests were performed using a 95% confidence interval. Statistical analyses were performed using the SPSS version 17.ResultsPerinea that required no suturing: MHG 71% (47) versus CG 56% (37), OR: 1.803; (95% CI: 0.881-3.687); DHG 62% (41) versus CG 56% (37), OR:1.285 (95% CI: 0.641-2.577); MHG 71% (47) versus DHG 62% (41), OR:1.402 (95% CI: 0.680-2.890).MeanApgar score 5’, MHG: 9.91; DHG: 9.98, CG: 9.98. p = 0.431.ConclusionsThe application of heat therapy to the perineum during labour did not significantly reduce perineal suturing after birth. However, better perineal results were observed with moist heat. Heat therapy does not alter neonatal outcomes measured by Apgar score.     

Management of pediatric perineal and genital burns: twenty-year review

Between 1966 and 1986, fifty-seven pediatric patients with partial and/or full-thickness perineal and genital burns with a minimum of 1-year follow-up were identified. Fifty percent of the patients with genital burns and 20% of the patients with perineal and/or buttock burns required skin grafting in the acute stage. No patient required suprapubic cystostomies, diverting colostomies, or local flap coverage of exposed testicles. Burn scar contractures were the most frequent complications. Thirty-two patients (56%) required contracture release of the perineum and coverage with either skin grafts or local skin flaps. In three patients (6%) contracture required release of the penis and scrotum. One patient lost a testicle. Three patients developed rectal prolapse and were treated without surgery. Four patients developed rectal stenosis with fecal incontinence because of burn scar contracture and were treated by anal dilatation, local transposition flaps, and/or excision of the scar and primary closure. Acute management of pediatric patients with such injuries can be conservative. Delayed complications of contractures of the perineum and genitals can be easily corrected with scar excisions, skin grafts, or the use of local skin flaps.     

扩张阴道联合改良会阴保护法在接产中的临床应用

目的探讨扩张阴道联合改良会阴保护法在接产中的应用效果。方法选择2012年1月~12月在我科分娩的300例初产妇,随机分为观察组168例和对照组132例。观察组在接产过程中采用扩张阴道联合改良会阴保护法保护会阴;对照组采用传统式保护会阴法。并比较两组会阴裂伤及产后出血情况。结果观察组会阴裂伤88例,占52.38%,对照组会阴裂伤101例,占76.52%,两组比较有显著性差异(P<0.01);两组会阴裂伤程度、产后出血情况比较有显著性差异(P<0.01)。结论在接产过程中采用扩张阴道联合改良会阴保护法保护会阴,可降低会阴裂伤发生率,减轻会阴裂伤程度,保持会阴完整性,,以减轻产妇的痛苦。同时也减少产后出血的发生。     

对分娩中产妇应用会阴评估量表指导会阴切开的效果观察

目的探讨在分娩中的产妇应用会阴评估量表指导会阴切开的应用效果。方法选取我院符合经阴道分娩条件的孕产妇400例,根据入院时间顺序依次编号,单号为观察组,双号为对照组,每组各200例。对照组采用传统会阴保护方式接产,观察组对分娩中的产妇应用会阴评估量表指导会阴切开。观察比较2组产妇在分娩时的会阴切开率会阴损伤情况和母婴结局。结果观察组产妇会阴切开率低于对照组,观察组产妇会阴损伤发生率低于对照组,差异有统计学意(P<0.05)。观察组伤口愈合不良低于对照组(P<0.05)。结论应用会阴评估量表评估有助于规范限制性使用会阴切开术,能够降低自然分娩中产妇的会阴切开率,保持产妇会阴完整,降低母婴不良结局。