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.     

Chemical injuries from assaults: An increasing trend in a developing country

Objective:

This paper describes chemical injuries, which presented to us and were managed at a burn unit in Nigeria. The purpose of this paper is to highlight the etiologies of these injuries, the extent of the injuries as well as to suggest possible ways to prevent chemical injuries in our environment.

Materials and Methods:

We carried out a retrospective review of chemical burns treated at our center. Our sources of information were the burn unit admission registers, case notes of the patients and operation registers. The results were collated and then analyzed.

Results:

Twenty eight patients presented with chemical burn injuries during the study period between January 2000 and December 2003, constituting 5.7% of all patients with burns treated within that period. Seventeen (60.7%) of the patients were males while 11 (29.3%) were females with a mean age of 20.6 years. The injuries were sustained from assault in 21 (75%), armed robbery attacks in five (17.8%) and suicide attempts in two (7.1%). The agents were usually unknown. Late presentation was observed in all the patients. Raw eggs, palm oil, gentian violet and engine oil were the substances applied immediately after the injuries. Complications observed included septicemia, respiratory distress, blindness, renal failure, mentosternal contractures, ectropion, axillary contractures, hypertrophic scars, keloids and skin depigmentation.

Conclusion:

Chemical burn injuries are mainly due to assaults in Nigeria and are usually extensive and presented late. Education of the people and penalty for any offender will reduce the current spate of such injuries.     

胸腹联合伤的AIS-ISS评分及外科治疗

目的总结胸腹联合伤创伤评分与临床诊断和治疗方法的关系,旨在提高该病的诊断及治疗水平。方法回顾分析83例胸腹联合伤患者临床资料,并对其进行简明创伤分级（AIS）及损伤严重程度评分（ISS）。其中交通事故伤38例,刀刺伤24例,坠落伤8例,挤压伤8例,重物砸伤5例。患者手术治疗43例,胸腔闭式引流28例,保守治疗12例。结果治愈73例,死亡10例,死亡率12．1％。结论详细询问病史及查体,胸、腹部X平片,CT、胸腹部B超、消化道钡剂造影及钡灌肠造影检查有助胸腹联合伤的诊断。对诊断明确的胸腹合并伤,首先改善呼吸功能,恢复有效循环量,对ISS评分大于26的患者,应积极做好手术准备。     

严重胰腺损伤的诊断与手术策略

目的 探讨胰腺损伤的诊断,提高严重胰腺损伤的救治水平。方法 对1986年1月－1998年12月我院收治的14例胰腺横断及胰头毁损患者的临床资料进行回顾性分析。结果 本组胰体尾横断5例、胰颈部横断6例、胰头毁损3例,11例有腹内合并伤。术前诊断4例,开腹探查诊断9例,首次手术漏诊、再次开腹诊断1例。手术方式：远端胰腺切除5例,近端缝合加远端胰腺空肠吻合5例,胰头部切除加远端胰腺空肠吻合3例,单纯外引流1例。本组发生胰瘘5例,死亡3例。结论 早期诊断胰腺损伤仍有困难,多数需靠术中发现;根据胰腺损伤的部位和程度选择恰当的手术方式可有效地减少并发症、降低死亡率。     

Functional outcome after surgical treatment of perilunate injuries: A series of 12 cases

PurposePerilunate injuries (PLIS) are complex injuries, which are frequently missed in the initial setting, and delayed presentation leads to poor functional outcomes. In this study, we are presenting our experience of treating these injuries by surgical treatment and the effect of neglect on their outcome.Materials and methodsIn this retrospective study, 11 patients with 12 PLIS, which presented to our center from January 1, 2000 to December 31, 2012 were included. They were managed surgically as open reduction and internal fixation. Function was documented by using Mayo score. To ascertain the effect of the delay/neglect on the outcome, the patients were divided into two groups according to time between day of injury and final surgery (group I – operated within 6 weeks of injury and group II – treated after 6 weeks of injury).ResultsAverage postoperative Mayo score was 76.4. Average Mayo score in group I was 93.7 (90–95). Average Mayo score in group II was 67.1 (60–75). Although functional result as Mayo score was significantly better in group I (p value <0.5) even chronic or delayed group patients also had good to fair results.ConclusionEarly diagnosis and treatment of such injuries should be emphasized as delay in treatment leads to progressive poor results. Well-planned surgical management gives good functional results even in delayed cases.     

Pitfalls in the surgical management of cervical spine injuries

Records of 69 cervical spine injury patients referred to the authors' institution over a 3-year period were reviewed. The senior author documented definite and probable pitfalls occurring in the pre-, intra-, and postoperative management. Diagnosis, traction, bracing, surgical timing, intraoperative technical errors, and incorrect surgical decisions were noted. Of the 69 patients, 39 (56%) suffered a pitfall of management. Twenty-seven patients (39%) accumulated 49 definite pitfalls between them and 12 patients (17%) suffered a total of 20 probable pitfalls. Of the 49 definite pitfalls, 7 (14%) were preoperative, 17 (34%) were those of surgical decision making, 21 (43%) were operative, and 4 (9%) postoperative. Diagnostic errors and incorrect bracing and traction led to neurological worsening. Intraoperatively, technical errors (30%), wrong timing of surgery (24%), and incorrect choice of operation (16%) were the common pitfalls. Postoperative pitfalls consisted of inappropriate bracing (17%). A Cervical Spine Research Society review (1989) rated complications of cervical spine surgery at 6.3% (63/992). In this study, a sizeable portion (56%) of cervical spine injury patients requiring surgery were at a risk of complications. Short of complications, there are areas of management where errors may have less well-documented undesirable effects or increase the potential for morbidity. An awareness of these pitfalls and increased use of non-operative treatment may eliminate up to 73% of the pitfalls and thereby decrease the morbidity associated with the management of cervical spine injuries.     

Causes of hand injuries in a developing country

Background

In emerging economies such as Nigeria, trauma and hand injuries in particular are on the rise. The aim of this study was to document the causes of hand injuries in Nigeria.

Methods

This was a prospective study conducted between Aug. 1, 2006, and July 31, 2007. We obtained objective information about patient demographic data, occupation, dominant and injured hand, and place and cause of injury. We assessed injury severity using the Hand Injury Severity Score (HISS).

Results

A total of 74 patients with hand injuries were included. The male:female ratio was 1.8:1, and the average age was 26.9 years. Most patients were right-hand dominant, and 56.8% of injuries affected the dominant hand. Engineers and technicians represented 27% of patients with hand injuries, which was the largest group encountered during the study. Most cases occurred because of road traffic injuries, followed by machine injuries. Injuries commonly occurred at the work place and on the road. In total, 57.1% of patients with mechanical injuries were admitted to hospital. The majority received minor surgical treatment, and 16.2% had a digit amputated. The average HISS was 54.35. In total, 64.8% of the injuries were classified as minor or moderate. Sixty percent of admissions were patients with a HISS of severe or major injury.

Conclusion

Hand injury in this part of the world is commonly due to road traffic collisions and machine accidents, and the injuries are usually severe. Hand injuries are commonly seen among technicians and civil or public servants; these people constitute the economic work force.     

Craniocerebral injuries in war against terrorism a contemporary series from Pakistan

Objective: Terrorism-related bomb attacks on civilian population have increased dramaticallyover the last decade. Craniocerebral injuries secondary to improvised explosive devices have not been widely reported in the context of unarmored civilians. This series intends to report the spectrum of these injuries secondary to suicidal and implanted bombs as encountered at the Aga Khan University Hospital, Pakistan (AKUH). Further, a few pertinent management guidelines have also been discussed. Methods: The hospital database and clinical coding during a 5-year period were examined for head injuries secondary to terrorism-associated blasts. In addition to patient demographics, data analysis for our series included initial Glasgow Coma Scale, presenting neurological complaints, associated non-neurological injuries, management (conservative or operative) to associated complications, and discharge neurological status. Results: A total of 16 patients were included in this series. Among them 9 were victims of suicidal blasts while 7 were exposed to implanted devices. The patients presented with diverse patterns of injury secondary to a variety of shrapnel. A follow-up record was available for 12 of the 16 patients (mean follow-up: 7.8 months), with most patients having no active complaints. Conclusion: The results of this series show that civilian victims of suicidal and improvised bombings present with a wide range of neurological symptoms and injury patterns, which often differ from the neurological injuries incurred by military personnel in similar situations, and thereby often require individualized care.     

Primary repair of colon injuries in a developing country

Because there are several specific disadvantages to a colostomy in a developing country, primary repair for colon injury was electively performed. Sixty-one consecutive patients with colon injury were seen between 1978 and 1989 and 57 of these (93 per cent) underwent primary repair. In four a colostomy was constructed. Emergency repair was carried out regardless of site or mode of injury, presence of hypotension or peritoneal contamination. There was one death unrelated to anastomotic complications and one anastomotic leakage. The faecal fistula closed spontaneously in 4 weeks. The wound infection rate was 10 per cent. These data support the emerging view that primary repair of colon injury is the management of choice.     

胆囊切除术胆管损伤的原因分析与处理

目的探讨胆囊切除术导致胆管损伤的原因及损伤后的处理方式。方法对21例胆囊切除术引起胆管损伤的损伤原因及处理方式的临床资料进行回顾性分析。结果损伤原因主要有：（1）胆囊急性炎症期进行手术8例,（2）经验不足5例,（3）Calot三角结构不清3例和解剖变异3例,（4）术中出血导致损伤2例。在处理方式上,本组有3例在术中发现胆管损伤后即时进行修复,12例在术后14d内修复,均取得良好的效果。另外6例在损伤后15d-95d之间进行修复,其中4例恢复良好,1例术后存在慢性胆管炎,死亡1例。绝大部分17例的病例采用胆管空肠Roux-en-Y吻合术,恢复良好15例。结论胆囊切除术导致的胆管损伤应由有经验的肝胆外科专科医生进行修复．早期修复是可行的,胆管空肠吻合术是首选的手术方式。     

Diagnosis and management of major tracheobronchial injuries

From 1968 to 1978, 14 patients were treated for major tracheal or bronchial injury. Five injuries resulted from blunt trauma and nine from penetrating injury. Of the 5 patients with injury due to blunt trauma, three had avulsions of the right main bronchus from the trachea. In 2 of them, the injury was associated with stellate tears of the distal trachea and bronchus. The simple avulsion was repaired by a primary anastomosis of the right main bronchus to the distal trachea. For the other 2 patients, treatment consisted of right pneumonectomy. The remaining 2 patients in this group had complete transection of the trachea and underwent primary repair. Of the 9 patients with a penetrating injury, 4 had lacerations of the cervical trachea which were treated with neck exploration and tracheostomy. Three patients with partial transections of the cervical or upper mediastinal trachea were treated by primary closure. The other 2 patients had gunshot wounds to the distal right lateral trachea, which were treated by right thoracotomy and primary closure. There were no deaths, and the subsequent course was generally good in all patients.     

Finger injuries in a developing sport: cachibol (Newcomb Ball)

Background

Cachibol (also known as Newcomb ball) is a team ball game with characteristics similar to volleyball. Cachibol is becoming increasingly popular, particularly among middle-age women, and is now the fastest growing female sport in our country. Despite its growing popularity, there is a lack of information about the epidemiology of injuries incurred from this activity. The purpose of this study is to describe the incidence and pattern of finger injuries among female cachibol players competing in a 3-day tournament.

Methods

We conducted a cross-sectional survey and an observational cohort study of 612 amateur female cachibol players participating in a 3-day national tournament; 355 players completed questionnaires (58 % response rate). All injuries sustained during the tournament were reported.

Results

Fingers were the most commonly injured part of the body; 148 of 355 respondents reported sustaining a finger injury. During the tournament, 26 players reported a total of 27 injuries, 15 to the fingers. Most finger injuries resulted from a direct hit by the ball. Finger injuries, though considered “mild,” have long-term implications; over 50 % of injured players reported long-term discomfort.

Conclusions

Finger injuries are more prevalent in cachibol than volleyball due to the unique characteristics of the game. Cachibol-related injuries are a growing cause for concern due to the growing number of cachibol players. This study may be useful in developing effective treatment protocols and injury prevention programs for cachibol players.     

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目的探讨非手术治疗脾外伤的可行性及其适应证选择。方法回顾性分析1995年1月至2003年6月间上海仁和医院非手术治疗38例脾外伤的临床资料及其治疗结果。结果38例均经CT检查明确诊断，其中Ⅰ级损伤15例，Ⅱ级损伤19例，Ⅲ级损伤3例，Ⅳ级损伤1例。12例有合并伤。结论选择性非手术治疗脾外伤是一种安全有效的治疗手段，腹腔外器官合并伤及病人的年龄并不影响非手术治疗的疗效。     

Profile of pediatric abdominal surgical emergencies in a developing country

We aim to determine the profile and determinants of outcome of pediatric abdominal surgical emergencies in southeastern Nigeria. We prospectively analyzed 115 children with abdominal surgical emergencies managed at the University of Nigeria Teaching Hospital, Enugu, Nigeria, from January 2008 to June 2009. The emergencies were typhoid intestinal perforation (TIP) 22 (19.1%), intussusception 20 (17.4%), obstructed hernia 17 (14.8%), neonatal intestinal obstruction 11 (9.6%), appendicitis 11 (9.6%), trauma 8 (6.9%), ruptured omphalocele/gastroschisis 8 (6.9%), Hirschsprung's disease 7 (6.1%), adhesive bowel obstruction 7 (6.1%), and malrotation 4 (3.5%). The mean time to diagnosis was 3.5 days (range, 4 hours to 12 days). Ninety-three cases had an emergency operation, while 22 were managed nonoperatively. After a mean hospital stay of 10.8 days (range, 2-38 days), 35 (37.6%) of the operated patients had one or more postoperative complications. There were 10 (8.7%) deaths. Overall, TIP had a higher postoperative complication rate (P < 0.001), while neonates had a higher mortality (P < 0.001). Delayed presentation and lack of neonatal and pediatric intensive care facilities were daunting challenges. A pediatric abdominal surgical emergency in our setting has high morbidity and mortality. Efforts geared towards improvement in time to diagnosis and perioperative care may result in better outcomes.     

拇指缺损的全形再造

目的探讨拇指缺损再造的修复方法。方法应用同一血管蒂的第二足趾趾骨皮瓣和躅甲皮瓣瓦合移植修复再造拇指30例。结果30例再造拇指全部成活,术后随访3月～1年,再造指体均获得满意外形和良好功能。结论拇指缺损全形再造能够一次性满意恢复再造指体外形和功能,供区创面修复也能获得满意的外形和有效愈合保障。     

Complications in surgical treatment of thoracolumbar injuries

The range of surgical methods for operative treatment of thoracolumbar injuries, with their different ways of approach, grafts and techniques, remains wide. The authors present sources of error and specific complications based on their own experience and on the results of a multicenter study of the Spine Study Group of the German Trauma Association (DGU). A systematic overview of possible mistakes and complications is first presented in anatomical order. A detailed analysis is then presented of the complications reported in a multicenter study, carried out prospectively between 1994 and 1996, on 682 patients operated for acute traumatic injuries of the thoracolumbar spine. In 101 cases (15%) at least one complication occurred intra- or postoperatively. In 41 patients (6%) a revision was performed, and in 60 patients (9%) complications without operative revision were observed. These complications were analysed according to the chosen method of initial treatment.     

手部套脱伤的分型与程序化治疗临床应用研究

目的 探讨手部皮肤套脱伤的分型与治疗方式.方法 依据不同的伤情与手术治疗方法,将手部套脱伤分为六种类型.针对不同分型,提出程序化治疗的概念,采取点对点的应对措施,并使用了阶梯式修复血管、交替式切口清创、局限性缝合固定、区域性加压包扎及散在性切口引流等技术.结果 本组共144例,获得10年以上随访49例,5年42例,3年24例,1年20例,5个月9例.15例全手套脱伤中仅1例手背部分皮肤作了游离植皮治疗,小指部分坏死作了截指;其他类型的皮肤撕脱和手指套脱伤经治疗全部存活.皮肤外形美观,耐磨擦能力强,基本恢复了原来的手功能.结论 手部套脱伤六型分类法切合临床实际,程序化治疗采用点对点的应对措施,便于临床迅速展开救治.其中的关键技术解决了手部套脱伤手术中的技术难题,术中、术后相关辅助措施进一步提高了手部皮肤套脱伤治疗的成活率.程序化治疗为临床手部套脱伤的救治开辟了一条全新的途径.