Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma

PURPOSE: We determined the use of scrotal ultrasonography in the initial diagnosis and management of testicular injuries due to blunt scrotal trauma. MATERIALS AND METHODS: We performed a retrospective review of 65 patients presenting to our Emergency Department with blunt scrotal trauma in the last 25 years. In 47 patients an inconclusive clinical examination prompted scrotal ultrasonography. A heterogeneous echo pattern of the testicular parenchyma with loss of contour definition was the basis for diagnosis of testicular rupture. The sensitivity and specificity of scrotal ultrasonography were determined by comparing this radiographic criterion with definitive intraoperative findings and the need for delayed orchiectomy due to undiagnosed testicular rupture. RESULTS: Of the 65 patients sustaining blunt scrotal trauma 44 (68%) underwent scrotal exploration, and 30 (46%) of these injuries involved rupture of the tunica albuginea. Among the 47 scrotal ultrasounds performed to supplement a nondiagnostic clinic examination, there were 32 suspected testicular ruptures. Thus, the 2 false-positives resulted in a specificity of 93.5% in those patients explored. No delayed orchiectomies were performed for missed testicular ruptures, resulting in 100% sensitivity. The majority of testicular ruptures were salvaged (83%), with only 5 of the 30 (17%) requiring orchiectomy (4 of these patients had delayed presentation greater than 48 hours). CONCLUSIONS: Scrotal ultrasonography, with the single radiographic finding of a heterogeneous echo pattern of the testicular parenchyma with loss of contour definition, is highly sensitive and specific in the diagnosis of testicular rupture in an otherwise equivocal scrotal examination. Accurate diagnosis and prompt repair led to a salvage rate for testicular rupture specifically of 83% and overall of 92%, with preservation of the testicular parenchyma and hormonal function, and avoidance of the delayed complications of chronic pain, atrophy and orchiectomy associated with missed testicular rupture.     

Trauma as the cause of Peyronie's disease: penile fracture as a model of trauma

PURPOSE: This study was performed to determine whether patients with penile fracture or a long history of forcefully bending the erect penis (taqaandan), as models of acute and chronic penile trauma, had an increased rate of Peyronie's disease (PD). MATERIALS AND METHODS: The study included 193 surgical cases of penile fracture (average followup 85 months), 150 cases of long history of taqaandan, and 50 cases of PD. All 3 groups of patients were interviewed and physically examined. RESULTS: Signs of PD were found in only 1 case of long-term taqaandan and in no case of penile fracture. None of the 50 cases of PD had a history of penile fracture. CONCLUSIONS: Severe, acute trauma of penile fracture and moderate, chronic buckling injury of taqaandan are not associated with later development of PD. These findings question whether the hypothesis that trauma, trauma-induced smoldering inflammatory cascade and aberrant wound healing are the main causes of PD. Alternative, plausible, evidence based explanations should be sought for the etiology of PD. Any theory on the etiology of PD should provide an explanation for total lack of occurrence of PD following the trauma of penile fracture.     

Curvature correction in patients with tunical rupture: a necessary adjunct to repair

PURPOSE: We review our experience with traumatic tunical rupture repair with and without simultaneous penile curvature correction. MATERIALS AND METHODS: Since November 1987, 11 men 23 to 39 years old have presented to us with tunical rupture, of whom 10 underwent surgical repair. All except 1 of the 8 men injured during sexual activity reported a curved penile appearance during erection. After patient 3 in our series sustained repeat rupture 5 months postoperatively due to penile curvature the next 7 underwent simultaneous curvature correction, which since 1996 has been done using 6-zero nylon. RESULTS: Recovery was uneventful in 2 of the 3 men who underwent simple tunical repair with 4-zero polyglactin or polyglycolic acid. All 7 of subsequent patients in whom curvature correction was performed simultaneously recovered satisfactorily with resumed erectile capability. CONCLUSIONS: Although coital position may be an important factor in tunical rupture during sexual activity, penile curvature may be contributory and should be corrected simultaneously with tunical repair.     

钝性伤致支气管断裂的外科诊治(附33例报告)

目的探讨钝性伤致支气管断裂的外科诊疗体会。方法33例支气管断裂病人确诊后均行手术治疗，其中全肺切除5例，支气管袖状成形术4例，支气管董建术24例。结果本组治愈29例，死亡4例；随访24例，时间6月-2年，除2例吻合口周围出现肉芽组织予以剪除外，余22例吻合口通畅良好。结论支气管断裂多有特定的临床表现，CT及纤维支气管镜检查在诊断中起重要作用。一经确诊即应手术治疗，首选支气管重建术。     

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.     

Nonoperative treatment of patients with presumed penile fracture

PURPOSE: Immediate surgical intervention is the basis for treatment of penile fractures due to the high risk of complications associated with conservative management. Unfortunately, patient refusal to undergo surgery has led to conservative treatment of a small group of patients with presumed penile fractures at our institution. We followed these patients in regard to clinical outcome. MATERIALS AND METHODS: Between 1992 and 1999, 5 patients were evaluated after blunt trauma to an erect penis. Patient age at presentation ranged from 19 to 31 years (mean 25). The interval from time of injury to presentation was 24 to 72 hours. Of these patients 4 had been injured during sexual intercourse, while 1 had been injured during masturbation. All 5 patients refused immediate surgical exploration for presumed penile fracture. RESULTS: No patient had any immediate complications. At 6 and 12-month followup all patients reported erections adequate for intercourse without associated pain. One patient reported only mild curvature for which he did not seek treatment. CONCLUSIONS: We report on a subset of young males with presumed penile fracture who refused diagnostic evaluation and therapy, and were able to maintain normal erectile and voiding function. However, longer followup and radiographic evidence will be necessary to corroborate or refute these initial observations.     

Cat bites of the hand

BACKGROUND: Cat bites are the second most common mammalian bites. Cat bites of the hand in particular represent a potentially devastating problem in terms of wound infection and long-term disability if not treated appropriately. The purpose of the present study is to give an overview of demographics, management and follow up of the patients with cat bite injuries of the hand treated at the Royal Hobart Hospital. METHODS: Retrospective and prospective data of all patients with cat bites of the hand seen at the Royal Hobart Hospital for a period of 3 years (January 2000 to April 2003) were collected. Demographics, anatomical site, presentation, assessment, investigations, management and follow up of the patients with this type of injury were analysed. The accuracy of the obtained data was checked by analysing questionnaires returned by our patients. RESULTS: Forty-one patients were treated for cat bites of the hand. Twenty-six were managed in the department of emergency medicine and 15 were admitted and managed by the department of plastic and reconstructive surgery. Five of 15 admitted patients required surgery. Compliance was not a major problem in our study as very few patients were lost to follow up. Almost all patients had close follow up and extensive hand physiotherapy achieving overall good long-term results. Out of 39 patients who were sent questionnaires only one indicated long-term problems with the hand (response rate 46%). CONCLUSION: Appropriate early treatment of cat bites of the hand is the key to success. Treatment with antibiotics, surgical drainage, debridement and copious irrigation, and use of corticosteroids in some cases, proved to be effective. Hand elevation and intensive physiotherapy after a short period of immobilization is critical. We believe that prophylactic antibiotics should be given even in case of a minor infection following cat bites of the hand. Clear guidelines for clinical recognition of infection, hospital admission and management are provided in our study.     

Long-term experience with surgical and conservative treatment of penile fracture

PURPOSE: Immediate surgical repair is widely accepted as the therapy of choice in penile fracture. As recent reports show, good results can also be achieved in some patients with conservative management. It is unclear which patients will truly benefit from an operation. We retrospectively compared the long-term outcomes of surgical and conservative treatment in patients with penile fracture. MATERIALS AND METHODS: In 22 years we treated 29 patients with penile fracture. A total of 12 patients were treated with immediate surgical repair and 17 patients were treated conservatively. Patient charts were reviewed and all patients had followup by interview with an additional clinical evaluation if the result was not completely satisfactory. Outcome was rated good, moderate or poor. RESULTS: Mean followup was 67 months. There was no statistical difference between patients in the surgery group and patients in the conservative group in regard to length of followup, age at presentation or length of hospital stay. In the surgery group and the conservative group 11 (92%) and 10 (59%) patients showed good outcome, respectively. Poor outcome was seen in 3 patients from the conservative group. CONCLUSIONS: Overall, immediate surgery yields excellent results and is superior to nonoperative treatment in the management of penile fracture. However, conservative therapy restricted to uncomplicated cases can lead to an equally good outcome.     

肝脏损伤的诊治分析

目的:总结肝损伤的诊治经验.方法:回顾分析78例肝损伤资料.结果:轻型肝损伤56例,重型肝损伤22例;治愈72例,死亡6例;病死率为7.7%;失血为主要的死亡原因.结论:血流动力学稳定的Ⅰ~Ⅲ级肝损伤可试行非手术治疗;严重肝损伤应在抗休克的同时尽快手术;手术方式应根据术中情况合理选择;肝切除术是治疗严重肝损伤的有效方法;术中胆道减压或术后ENBD可有效地减少术后并发症.     

男性性有关损伤的诊断与治疗

目的探讨男性性行为损伤(SRT)的病因和临床治疗效果。方法对223例SRT患者中,185例采用急诊手术治疗,其余38例分别采取抗炎、止血、镇静、止痛等治疗。结果手术治疗的185例SRT患者,术后3～7d恢复晨间勃起;保守治疗的38例SRT患者,治愈后1～3d恢复晨间勃起,排尿通畅,全部患者3～4周后恢复正常性生活。结论男性性行为损伤属高度个性化疾病,治疗及时,愈后良好,能防止严重并发症的发生。     

睾丸损伤的诊断和治疗(附47例报告)

目的提高睾丸损伤的诊断和治疗水平。方法回顾分析我院47例睾丸损伤患者保守和手术治疗的临床资料。结果闭合性损伤42例,开放性损伤5例。手术探查36例(3例睾丸切除),保守治疗11例。随访3个月～3年,手术组除1例睾丸再植失败外,32例睾丸形态正常。保守治疗组3例出现睾丸萎缩。结论B超检查应属首选,CT检查的阳性率高,对诊断和损伤分级、治疗方案的选择非常重要,睾丸损伤后及时正确的治疗是关键。     

Functional evaluation by quantitative dimercaptosuccinic Acid scintigraphy after kidney trauma in children

PURPOSE: Most pediatric surgical teams have adopted nonoperative treatment for a traumatic kidney lesion in children. In the emergency setting and at long-term followup dimercaptosuccinic acid (DMSA) scintigraphy enables us to identify the consequences on global renal function as well as on the function of each individual kidney. MATERIALS AND METHODS: Eight boys and 12 girls between 0.6 and 15.9 years old (average age 9.7) were evaluated after including renal trauma, minor and major injury in 10 each. Scintigraphy was performed 8 days and 6 months after injury. The tracer used was 2 MBq./kg. Tc-DMSA. Semiquantitative analysis of the images consisted of determining 2 parameters, namely relative renal function, corresponding to the fraction of activity of a single kidney compared to the activity of the 2 kidneys, and the calculated renal activity fraction, corresponding to the function of each kidney compared with the activity of a theoretical kidney in a child of the same age. The posttraumatic renal scintigraphy series was paired with a series of healthy children matched by age, weight, height, sex and affected side of function as a control group. Global renal function was also measured using a formula based on ethylenediaminetetraacetic acid scintigraphy with the height, weight and increased serum creatinine in each patient. RESULTS: For minor injuries the quantitative functional evaluation revealed a significant average loss of renal function +/- SD on the side of the lesion (12.8% +/- 3.1% versus 18.3% +/- 2%, p = 0.001). For major injuries on relative renal function evaluation we noted an average 36-point difference in the damaged and contralateral kidneys 8 days after the accident. Six months after trauma we noted a definitive loss of 48% in the calculated renal activity fraction on the side of the lesion. There was no compensatory hypertrophy on the noninjured side when the calculated renal activity fraction was compared with that of a normal kidney in a control patient (mean 19.1% +/- 4.2% versus 19.5% +/- 3.7%, not significant). Creatinine clearance was normal in each patient.DISCUSSION A renal contusion always induces parenchymal loss. Major kidney trauma has significant consequences on the opposite side. At 6 months the presumably uninjured contralateral kidney may be limited in its ability to compensate through hypertrophy, which worsens the global renal functional prognosis of a traumatic but initially unilateral lesion. CONCLUSIONS: Posttraumatic functional evaluation by DMSA scintigraphy, which measures the nephron capital of each kidney and the 2 together, seems essential to inform patients about the seriousness of the lesion and lead them to an eventual long-term nephrological followup with regular blood pressure assessment.     

Scrotal dog bites

PURPOSE: Dog bites to the scrotum are rare but they potentially result in morbidity if improperly managed. MATERIALS AND METHODS: Between 1991 and 1999 we treated 4 men and 3 boys with dog bites to the scrotum. All 7 patients presented to the emergency department shortly after the injury. Of the 4 adults 3 were ingesting alcohol and 2 were obviously intoxicated, and 1 had a T4 spinal cord injury and was bitten during sleep. Of the children 2 were apparently bitten without provocation, while a 5-year-old boy was bitten when the family dog was disturbed while eating. RESULTS: All wounds were explored, irrigated and débrided. There was no involvement of the testes or spermatic cord. Each wound was closed primarily and 5 healed without sequelae. The spinal cord injured man had partial dehiscence of the incision and in another man superficial hematoma required drainage. Each patient received antibiotics and tetanus prophylaxis but none required rabies inoculation. CONCLUSIONS: Although there are reports of devastating scrotal injuries from dog bites, most such wounds may be treated by careful inspection for intrascrotal injuries followed by débridement and closure. Antimicrobial prophylaxis should be administered, as for any bite wound.