Early management of war missile spine and spinal cord injuries: experience with 21 cases

Between 1991 and 1994, 21 patients with war missile injuries of the spine and spinal cord were treated; there were 17 men and four women, with a mean age 30.7 years; 52.4 per cent were civilians. The wounds were caused by shells (54.6 per cent) and bullets (45.4 per cent). The thoracic and lumbar spines were most commonly injured, and the injuries were frequently associated with lesions of other organs (47.6 per cent). There was extensive initial neurological deficit (tetraplegia, paraplegia) in 47.6 per cent of cases in whom there was no postoperative neurological recovery. All patients were treated operatively and associated injuries of other organs received priority management. A decompressive laminectomy was performed in 80.9 per cent of patients. Penetrating injuries of the dura were recorded in 61.9 per cent, while the spinal cord was injured in 28.5 per cent of patients. The dural defect was reconstructed in these patients. There was a low incidence of postoperative complications (14.5 per cent) which emphasizes the importance of early surgery.     

1086 Consecutive injuries caused by glass

A prospective study of 1086 consecutive injuries caused by glass showed that the mean age of the patients was 15 years and there was a 7: 3 male to female ratio. The home (35 per cent), public places (31.3 per cent) and places of work (21.1 per cent) were the main locations where these accidents occurred. Although most of the injuries were mild, 3 case histories illustrate that some of them were extremely serious, 4.6 per cent of patients requiring immediate admission to hospital. Extrapolation of the figures indicates that approximately 210 000 people attend hospital each year in England and Wales for treatment of an injury caused by glass. The annual cost to the National Health Service is about £7 500 000 but the full financial implications of these injuries in terms of compensation and insurance payments must be much greater. Suggestions are made of ways to reduce the incidence of these injuries from road traffic accidents and accidents with plate glass and glass containers.     

Pilot study of injured patients seen in the University of Port Harcourt Teaching Hospital, Nigeria

A 12-month pilot study of injured patients seen in the Emergency Department of the University of Port Harcourt Teaching Hospital was carried out. Trauma (28.8 per cent) was the main reason for emergency visits; 82.1 per cent of the patients were under 31 years of age. Domestic accidents were the commonest cause of trauma (42.5 per cent), followed by criminally motivated injuries (30.4 per cent), road traffic accidents (26.0 per cent), industrial (0.5 per cent) and other accidents (0.6 per cent). The overall mortality rate due to trauma was 5.4 per cent and within the period of study, trauma was the most common cause of deaths in hospital (10.1 per cent). Road traffic accidents were responsible for 67.9 per cent of these deaths, followed by criminally motivated injuries (16.1 per cent). Domestic, industrial and boat accidents caused 7.6 per cent, 5.4 per cent and 3.1 per cent deaths, respectively. Injury Severity Scores (ISS) among 419 patients showed a 100 per cent mortality for those with scores above 35. There were 48 prehospital, 19 emergency room and 14 in-hospital deaths among patients with an ISS below 35. The deaths resulted largely from delayed transportation of victims to the hospital and partly from inadequate emergency medical services. To reduce the current high rate of preventable deaths from injury, we recommend (i) ambulance services for early transportation of victims to the hospital and (ii) improved emergency medical care.     

Work-related burns: a 6-year retrospective study

During the 6 years from July 1984 to May 1990, 193 patients (30.2 per cent of all patients) were admitted to our regional adult burn centre, for treatment of work-related burn injuries. The median age of patients was 32.5 years (range 18-64 per cent), and 94 per cent were males. Fifty-nine per cent of the patients came from metropolitan Toronto, and 40 per cent from rural Ontario. Most of the patients (97.3 per cent) were referred to the burn centre within 24 h of their injury. The most common aetiology was electrical injury (29.5 per cent), followed by flame (24.4 per cent), contact (10.4 per cent), flash (9.8 per cent), tar and asphalt (9.3 per cent), scald (7.8 per cent), chemical (5.1 per cent), steam (4.7 per cent) and grease (1 per cent). Within the electrical burn group, about one-half were flash burns, one-quarter were clothing fire injuries, and one-quarter were contact injuries. These occupational burns tended to be extensive injuries. The median body surface area (BSA) was 16.5 per cent, with a median full thickness (FT) component of 5.0 per cent. The average length of stay was 20.0 days. Inhalation injury requiring intubation occurred in 14.8 per cent of patients. Sepsis--confirmed by positive blood cultures--developed in 14 per cent of the patients, at an average time of 8.8 days postburn. Staphylococcus aureus was the commonest organism isolated from blood cultures. Pneumonia occurred in 6.3 per cent of patients. A total of 207 surgical procedures was performed on 113 of the 193 patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.     

Hand injuries as an indicator of other associated severe injuries

The purpose of this study was to investigate the incidence of disabling or life-threatening injuries in patients with hand injuries. Retrospective data were collected from a level 1 trauma center registry. A total of 472 patients with hand injuries were admitted to the trauma unit between January 2000 and March 2004. Forty-four per cent of patients with hand injuries had life-threatening injuries. Fifty-one per cent of them had motor vehicle crash-related injuries. Motorcycle crashes were the next most common cause followed by explosions, falls, gunshots, machinery, stabs, bites, crushes, and so on. Frequency of associated injuries was as follows: head injuries, 31 per cent, including skull fractures, 22 per cent; spine injuries, 18 per cent, including spine fractures 18 per cent; chest injuries, 36 per cent, including rib fractures, 15 per cent; and abdominal injuries, 13 per cent. The authors focused on the incidence of disabling or life-threatening injuries in patients with hand injuries. Motor vehicle crashes were most common cause of hand injuries. The most common organs to be injured were chest and head. The most common head injury was skull fracture. Other injuries in decreasing order were spine and rib fractures. These data may be helpful in assessing ambulatory patients in the emergency room, in those hand injuries maybe indicative of other simultaneous life-threatening or disabling injuries.     

Urethral injury due to external trauma

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.     

Has nonoperative management of solid visceral injuries adversely affected resident operative experience?

The purpose of this study was to assess the impact of increased use of nonoperative management of blunt injuries to the spleen or liver on surgical residents' operative experience with solid visceral injuries. We conducted a 10-year retrospective study of blunt spleen and liver injuries at a state-designated Level I trauma center and a survey of chief residents' operative experience with splenic and hepatic injuries from blunt trauma during the same time period. From 1990 through 1999, 431 patients were admitted with splenic injuries and 634 patients were admitted with liver injuries; 350 splenic injuries (81%) were due to blunt trauma; 317 liver injuries (50%) were caused by blunt mechanisms. In 1990 100 per cent of patients with splenic injuries and 93 per cent of those with liver injuries underwent surgery for those injuries. These rates were 19 and 28 per cent respectively in 1999. The number of patients with blunt solid visceral injuries increased more than fourfold from 1990 through 1999. The number of operations for splenic and hepatic injuries performed by chief residents did not decline significantly during this time period (5.5 cases per chief resident in 1990; 4.6 cases per chief resident in 1999). The increased numbers of patients with solid visceral injuries were due to two factors: increased proportion of blunt trauma admissions especially from motor vehicle collisions and improved recognition of spleen and liver injuries by expanded use of CT scans. We conclude that nonoperative management of blunt solid visceral injuries does not necessarily lead to a diminution of operations nor jeopardize resident education. However, trauma volumes must be high enough to support adequate operative experience.     

Management of proximal axillary and subclavian artery injuries

BACKGROUND: The aim of this study was to review the management and outcome of proximal axillary and subclavian artery injuries, and to estimate the prehospital mortality rate for subclavian injury through forensic pathology autopsy data. METHODS: Data were collected prospectively for 260 patients who presented between 1977 and 1996 with trauma to the proximal axillary and subclavian arteries. RESULTS: The majority of victims (214, 82 per cent) were admitted following stab injury. Some 154 patients (59 per cent) presented within 24 h of sustaining an injury and, of these, 59 (38 per cent) required immediate surgery. An additional 67 patients (26 per cent) attended 2 days or more after injury. Comparison of these data with those from forensic autopsy reports suggests that the prehospital mortality rate for penetrating subclavian trauma was approximately 75 per cent. CONCLUSION: Approximately 25 per cent of subclavian artery injuries caused minimal initial symptoms but delayed complications prompted attendance for medical attention. The majority of patients who survived subclavian artery injury and attended for medical attention were haemodynamically stable on admission; selective arteriography provided valuable information in these patients. Supraclavicular and infraclavicular incisions avoided clavicular division and reduced the postoperative morbidity associated with distal subclavian artery injuries.     

Epidemiological pattern of adult burn injuries

An epidemiological survey of 411 patients over a period of five and a half years is analysed. There were no yearly trends but there was a slight increase in the number of female burns during the survey. There were 293 males, 71.3 per cent and 118 females, 28.7 per cent. The majority of the burns occurred in the younger age groups and reflect the cause of the injury. Approximately one-half of the injuries were burns of less than 10 per cent and three-quarters were of less than 20 per cent. The most extensive burns were caused by petrol and clothes fires. Predisposing conditions were present in 23.8 per cent of the patients, with alcohol abuse figuring prominently. Epilepsy was present in 2.7 per cent of the patients. The major predisposing conditions, causes and complications of the burn injuries are discussed. Burn infection occurred in 18.2 per cent of the patients and septicaemia in 3.5 per cent. There was a mortality rate of 8.3 per cent and the average length of hospital stay was 22.9 days. While these burns are mainly preventable it is difficult to see how this can be fully achieved.     

Assessment for additional spinal trauma in patients with cervical spine injury

An institutional review board-approved 8-year retrospective trauma registry analysis of cervical spine injuries (CSIs) was done in a Level 1 trauma center. This analysis includes 129 CSI patients (1.3% of trauma admissions). Cervical spine radiographs diagnosed injuries in 71 per cent of CSI patients. Cervical spine radiographs were false negative in 29 per cent of patients, who were found to have CSI on spine CT. Spine CT had 98 per cent sensitivity and detected 45 per cent additional injuries in cervical spine radiograph-positive patients. Spine CT scans were false negative in two patients with soft tissue injury. Cervical spine fractures were isolated in 45 per cent (n = 58) and multilevel in 55 per cent (n = 71) with contiguous fractures in 43 per cent (n = 55) of patients. Injuries involved two adjoining vertebrae in 38 patients and three or more adjoining vertebrae in 7 patients. C1-2 and C5-6 comprised 26 per cent and 20 per cent of all contiguous fractures. The least common was C7-T1, diagnosed in 2 per cent. The most common contiguous fractures were C1-2 in the elderly and C5-6 in children, comprising half of contiguous cervical injuries in the respective age groups. There were 26 (20.2%) noncontiguous injuries: 15 cervical and 11 cervicothoracolumbar. Multiple regions of the vertebral column were involved in 7.8 per cent of CSI patients. Spine CT is the preferred modality to assess CSI. Injuries were isolated in 45 per cent and were multilevel in the remaining CSI patients. Contiguous and noncontiguous injuries involving the cervical and thoracolumbar spine are common. Assessment of the entire spinal column should be done in patients with CSI.     

The role of primary repair for colonic injuries in wartime

BACKGROUND: The study reviewed an experience of selective primary repair for penetrating colonic injuries incorporating a number of procedures during the 1992-1995 Bosnia-Herzegovina conflict. METHODS: Of 5370 casualties, 259 (4.8 per cent) had injuries to the colon. The patients were divided into two groups: those who had primary repair and those who needed a colostomy. The patients' records were reviewed to determine the cause of injury (explosive weapons or bullets), the position and type of colon injury, associated injuries, the surgical procedure(s) done, complications related to the colonic wound or its management, and mortality. RESULTS: Some 122 (47.1 per cent) patients had primary colonic repair and 137 (52.9 per cent) had a colostomy. One hundred and fifty (57.9 per cent) were injured by explosive weapons, 108 (41.7 per cent) had bullet wounds and one (0.4 per cent) a stab injury. Associated injuries were seen in 249 (96.1 per cent) patients. Complications related to the colonic wound or its management developed in 27 per cent of patients after primary repair and 30 per cent after colostomy. Mortality rates were 8.2 per cent and 7.2 per cent, respectively. CONCLUSION: Primary repair was a safe and effective treatment for penetrating colonic injuries during war.     

Diagnostic and treatment problems in renal injuries

The case records of 112 patients with 116 renal injuries seen at Detroit Receiving Hospital (July 1980 to June 1985) were reviewed. Eighty-three (74%) of the injuries were caused by gunshot wounds, 18 (16%) by stab wounds, and 11 (10%) by blunt trauma. Of 102 patients who had a urinalysis (U/A) in the Emergency Department (ED), 12 had a normal U/A. Five of these 12 patients had severe renal pedicle injuries. Of 75 excretory urograms (IVPs) performed preoperatively, 21 (28%) were normal including seven in patients with major renal injuries requiring surgical treatment. The incidence of shock was 38 per cent in patients with injuries not requiring renal explorations, 69 per cent in patients with renal parenchymal injuries requiring surgery, and 93 per cent in patients with pedicle injuries requiring repair or nephrectomy. Although it is generally believed that traumatic perirenal hematomas should not be explored, there was an increased incidence of complications with this approach in this series. Of 65 stable renal injuries treated conservatively (without exploration of the renal parenchyma), there were nine (14%) complications including three reoperation for missed injuries and three perinephric abscesses. In 46 injuries that were explored (38 for bleeding and eight without bleeding), there were only two complications (5%), including a perinephric abscess.     

Mortality of burn injuries in Jordan

Three hundred and ninety patients who died following fire burns and scalds between 1973 and 1982 were subjected to autopsy examination at the departments of Forensic Medicine in the Ministry of Health and Jordan University Hospital. Flame burns caused 82 per cent of the deaths. Most of the burn injuries occurred at home and most of the accidents may have been avoidable. Seventy-six per cent of the patients were children and young adults (0–29 years). Suicide caused 13·5 per cent of the deaths. The most common causes of death were septicaemia and hypovolaemia.     

Electrical burns--incidence and prognosis in Western Scotland

A 10-year review of all patients admitted to the West of Scotland Regional Burns Unit with serious electrical burns indicated an incidence of only 2.6 cases per million of the population served by the Unit per year. Injuries following electrocution or electric flash, but excluding injuries caused by grasping the hot heating element of an electric fire, were suffered by 70 patients, 52 of whom sustained electrocution which was not immediately fatal. Ninety-one per cent of the patients were male. The patients who died in hospital did so as a result of sepsis rather than as a direct result of the electrical injury. All those patients who had ECG changes on admission recovered completely. In view of the very deep injuries, the amputation rate was high with 12 out of 52 patients (23 per cent) with electrocution injury requiring one or more amputations. The events preceding the serious electrical injury in our patients suggest that, 57 per cent of all the injuries could have been prevented, and in patients under 20 years of age this percentage rose to 91.     

Injuries caused by personal violence

Injury is the leading cause of death for Americans from infancy to middle age. Thirty-seven per cent of injuries admitted to this faculty are the result of personal violence. A prospective pilot study sought to elucidate the circumstances of such injuries. Medical records of all admissions for gunshot wounds, stab wounds or assault during a 30-day period were reviewed (N = 105). A subset (N = 32) were interviewed and given psychometric tests. Distribution by mode of injury was assault, 46 per cent; stabbing, 42 per cent; shooting, 12 per cent. Single, black males aged 18-44 dominated the sample. Injuries tended to occur in or near bars (82 per cent), between 1800 and 0600 hours (79 per cent) and were accompanied by alcoholic intoxication (63 per cent). Un- or underemployment was prevalent (56 per cent). Thirty-eight per cent of incomes were below the official poverty level. Some victims were illiterate. Histories of previous violent encounters (mean number = 22) during the year before the injury and hospital treatment for previous injury were common (56 per cent). Those interviewed reported high frequencies of recent and developmental stresses. The yearly cost of the acute care of patients with injuries caused by violence and treated at this hospital is estimated to be $8,000,000. Of this 80 per cent is paid for with public funds. Personal violence is a serious but neglected part of public health.     

Missile-induced vascular trauma

During seven and a half years of serious hostilities amidst the civilian population of Northern Ireland, a wide variety of vascular injuries inflicted by low and high velocity missiles and bomb explosions were observed. One hundred and thirteen patients, 96.5 per cent males of average age 26.8 years, sustained 191 vascular injuries and were treated at the Royal Victoria Hospital. Treatment commenced within one hour in 87 per cent of patients. Reduced limb ischaemia time, early bleeding control and vascular repair with restoration of flow within 6 hours of injury in 94.4 per cent of patients contributed to an excellent result in 85.5 per cent of survivors. Despite rapid admission, the mortality rate within 3 days of injury was 12.4 per cent, these patients sustaining trauma to major vessel trunks and vital organs. Associated nerve injuries (25 per cent) and skeletal injuries (30 per cent) were treated appropriately. A special group of 38 patients were ‘knee-capping’ victims and contributed to the majority of popliteal vessel trauma. A total of 14.9 per cent of primary arterial and 3 per cent of primary venous reconstructions failed due to thrombotic occlusion, but early postoperative revision was successful in every case. The overall amputation rate for lower limb injuries was 6.9 per cent; of these 5 cases, 4 had popliteal vessel injuries, in 2 of which infection (acute clostridial and chronic osteomyelitis) was partly responsible. Significant wound infection was otherwise absent. The pathophysiological aspects pertinent to the range of weaponry and methods of assault are presented. The operative and postoperative management and results are discussed in the light of documented military and civilian experience.     

Analysis of 153 gunshot wounds of the liver

BACKGROUND: Gunshot wounds of the liver may result in substantial morbidity and death, and optimal management of complex injuries is controversial. METHODS: One hundred and fifty-three patients with civilian gunshot liver injuries were treated during the 10-year period 1986-1995. Demographic, clinical and operative data were recorded. Factors influencing postoperative complications and death were analysed. RESULTS: One hundred and forty-two patients (93 per cent) had single missile injuries and 11 (7 per cent) had shotgun injuries. Three patients were treated non-operatively and 150 patients underwent operation. In 105 patients (70 per cent) the injuries to the liver were minor and required either no treatment (93) or simple suture of bleeding vessels (12). Forty-five patients (30 per cent) had major injuries which were either packed only (26) or required more complex surgical intervention (19). This included resectional debridement (ten), major venous repair (eight) and hepatotomy (one); eight of these patients required packing combined with the procedure. Associated intra-abdominal injuries occurred in 115 patients (77 per cent). The overall mortality rate was 17 per cent (26 patients). Death was directly attributable to the liver injury in 13 patients (8 per cent), 12 of whom died from uncontrolled bleeding. Complications occurred in 63 (51 per cent) of 124 survivors, and correlated with the type and severity of the liver injury and the number of associated injuries. CONCLUSION: Most gunshot liver injuries can be managed by simple surgical techniques. In complex injuries control of major haemorrhage is vital and perihepatic packing may be life saving before undertaking definitive repair of the injury under controlled conditions.     

Splenectomy versus splenic salvage for spleens ruptured by blunt trauma

Of 339 patients treated in three Charlotte hospitals from January 1960 through March 1983 for splenic rupture caused by blunt trauma, 317 (93.5%) underwent splenectomy, and 22 (6.5%) underwent splenic salvage operations. Perioperative mortality for splenectomized patients was 7.9 per cent, and that for those who received splenic salvage operations was 22.7 per cent. Perioperative sepsis occurred in 4.4 per cent of the splenectomized patients and in 9 per cent of those whose spleens were salvaged. Perioperative deaths and sepsis in both groups were related to associated injuries, not to splenic injuries. Follow-ups from 5 months to 22.4 years (mean, 9.5 years) of the 292 splenectomized patients who survived their injuries show that 252 (86.3%) are living, 22 (7.5%) have died of causes unrelated to splenic injuries, 18 (6.1%) could not be found, and none of the patients traced has died of sepsis. One patient (0.34%) experienced an episode of sepsis i.e., a nonfatal septicemia 7 years postsplenectomy, that may be related to splenectomy. These data suggest that the importance of splenic salvage for prevention of postsplenectomy sepsis has been overemphasized and that expeditious splenectomy remains the procedure of choice for patients with ruptured spleens, especially for those with hypovolemic hypotension, anemia from hemorrhage, or multiple injuries. Data to substantiate these views will be presented.     

The effects of administration of drugs influencing haemostasis during treatment of patients with burns

The administration of drugs influencing disordered haemostasis (heparin, nicotinic acid, thrental, phytin and alpha-tocopherol) to patients with burn injuries caused a 43 per cent shortening of the period of treatment. Necrotic eschar separated 7-9 days earlier and the periods necessary to prepare the burn wounds for surgical repair were shortened by 5 days. The success of skin grafting was enhanced with an increased percentage of attachment of the grafts. Necrotic changes of the mucosa of the gastrointestinal tract were found in 35 per cent of patients treated with the drugs as compared with 60 per cent of patients treated by the usual methods.