Traumatic urethral injuries: Does the digital rectal examination really help us?

Introduction

The digital rectal examination (DRE) has been commonly employed as a trauma screening tool since the inception of the ATLS program. Because of weak evidence, its utility as a screening test has recently been questioned. The primary goal of this study was to identify the sensitivity of the DRE for detecting blunt urethral injuries in a level 1 trauma center. The secondary goal was to evaluate the interaction of DRE with additional clinical indices of urethral trauma.

Methods

A retrospective review of all blunt injured patients diagnosed with a urethral disruption at an urban level 1 trauma center from 1995 to 2008 was performed. Urethral injuries were diagnosed by retrograde urethrogram, urethroscopy and operative exploration. Demographics and injury data were collected. The value of the DRE in diagnosing urethral trauma was assessed (p = 0.05).

Results

Urethral injuries were diagnosed in 41 male patients (mean age = 39 years), 34 (83%) of whom were injured via a motor vehicle (median ISS = 21). Associated injuries were present in 40 (95%) patients, including 39 (95%) pelvic fractures. No clinical signs of urethral injury were evident on initial examination in 25 (61%) patients. All patients had hematuria after catheter insertion. An abnormal prostate on DRE, blood at the urethral meatus, and hematuria prior to catheter insertion was present in 1 (2%), 8 (20%) and 7 (17%) patients, respectively. Both meatal blood and hematuria were better screening tests than the DRE (p < 0.05).

Discussion

The sensitivity of the DRE for identifying urethral disruption is 2%. The majority of patients with urethral trauma undergo urinary catheterization prior to diagnosis of the injury. Additional signs of disruption including meatal blood and hematuria detected prior to catheter insertion are also infrequent. While the DRE remains clinically indicated in patients with penetrating trauma in the vicinity of the rectum, pelvic fractures, and spinal cord injuries, it appears to be insensitive for detecting blunt urethral injuries.     

Best poster award: Accuracy of surgery residents' interpretation of computed tomography scans in trauma

Background

We evaluated the accuracy of surgery residents in interpreting computed axial tomography (CT) scans of trauma patients as compared with attending radiologists.

Methods

Residents listed injuries they identified on initial CT scans of trauma patients in a time-stamped computerized system before the official report becoming available. Head, chest, and abdomen/pelvis CT scans were included. We compared the accuracy of these reads with final radiology reports.

Results

There were 84 injuries in 31 patients. Residents correctly identified 25 of 26 (96%) injuries to the head, 28 of 42 (67%) chest injuries, and 15 of 16 (94%) injuries to the abdomen and pelvis. The accuracy of resident reads of chest CT scans was lower (P = .035) than for other body areas. Radiologists' identified 23 of 26 (89%) head injuries, 38 of 42 (90%) chest injuries, and 14 of 16 (88%) injuries in the abdomen and pelvis CT scans. None of the missed injuries were life threatening or required immediate attention.

Conclusions

Surgical residents accurately identify acute injuries on the CT scans of trauma victims.     

Lower genitourinary trauma in modern warfare: The experience from civil violence in Iraq

Background

Reports on genitourinary (GU) trauma during the Iraqi conflict have been limited to battlefield injuries. We sought to characterise the incidence, mechanism of injury, wounding pattern, and management of lower GU injuries sustained in civil violence during the Iraqi war.

Patients and methods

A total of 2800 casualties with penetrating trauma to the abdomen and pelvis were treated at the Yarmouk Hospital, Baghdad from January 2004 to June 2008. Of the casualties 504 (18%) had GU trauma including 217 (43%) with one or more injuries to the lower GU organs.

Results

Among the 217 patients there were 262 lower GU injuries involving the bladder in 128 (48.8%) patients, bulbo-prostatic urethra in 21 (8%), penis in 24 (9.2%), and scrotum in 89 (34%). Injuries to the anterior urethra and genitals were inflicted by Improvised Explosive Devices (IEDs) in 53–67% of cases and by individual firearms in 33–47%, while injuries to the posterior urethra and bladder were inflicted by IEDs in 17–22% of cases and by firearms in 78–83%. All penile wounds were repaired save 3 (12.5%) patients who underwent total penectomy. Of 63 injured testicles 54 (86%) could be salvaged and 9 (14%) required unilateral orchiectomy. The leading cause of death was an associated injury to major blood vessels in 26 (84%) of 31 patients who died.

Conclusions

Injuries to the anterior urethra and genitals were commonly caused by IEDs, while injuries to the posterior urethra and bladder were usually caused by individual firearms. Testis injury was almost always salvageable. Associated trauma to major blood vessels was the leading cause of death in these casualties.     

Patterns of accidental genital trauma in young girls and indications for operative management

Background/purpose

The aim of this study was to define the injury patterns of accidental genital trauma (AGT) in female patients and examine the indications and outcomes of operative intervention.

Methods

Review of patients younger than 16 years with AGT from 1980 to 2007 excluding sexual- and obstetric-related injuries.

Results

One hundred sixty-seven patients met the criteria. Mean (±SEM) age was 6.9 (0.2) years. There were 70.5% straddle injuries, followed by nonstraddle blunt injuries (23.5%) and penetrating injuries (6.0%). Injuries to the labia were most frequent (64.0%). Injuries to the posterior fourchette (7.8%) and hymenal disruption (8.4%) were less frequent. There was 87.9% of AGT that was managed expectantly without further sequelae. Twenty patients (12.1%) were managed operatively. Penetrating injuries were more likely to require operative management (P ≤ .03). The operative group was also more likely to have multiple genital injuries (60% versus 25%, P < .01). Proctoscopy, vaginoscopy, and/or cystoscopy were performed in 55% of patients in the operative group.

Conclusions

Accidental genital trauma is most commonly caused by straddle-type injuries and is usually amenable to nonoperative management. Hymenal disruption and injuries to the posterior fourchette are uncommon with these types of injuries.     

Ureteral trauma: Patterns and mechanisms of injury of an uncommon condition

Background

Traumatic ureteral injuries are uncommon, thus large series are lacking.

Methods

We performed a retrospective analysis of the National Trauma Data Bank (2002-2006).

Results

Of the 22,706 genitourinary injuries, 582 ureteral injury patients were identified (38.5% blunt, 61.5% penetrating). Patients were 84% male, 38% white, and 37% black (mean age, 31 y). Blunt trauma patients had a median Injury Severity Score of 21.5 versus 16.0 for penetrating injury (P < .001). Mortality rates were 9% blunt, and 6% penetrating (P = .166). Penetrating trauma patients had a higher incidence of bowel injuries (small bowel, 46%; large bowel, 44%) and vascular injuries (38%), whereas blunt trauma patients had a higher incidence of bony pelvic injuries (20%) (P < .001).

Conclusions

Ureteral injuries are uncommon, seen in approximately 3 per 10,000 trauma admissions, and occur more in penetrating than in blunt trauma. The most common associated injury for blunt ureteral trauma is pelvic bone fracture, whereas penetrating ureteral trauma patients have more hollow viscus and vascular injuries.     

Modern management of traumatic subclavian artery injuries: a single institution's experience in the evolution of endovascular repair

Background

Subclavian artery injuries traditionally require morbid surgical procedures. Repair by way of an endovascular approach can potentially decrease the morbidity and mortality associated with these injuries.

Methods

A 2-year retrospective review of trauma patients with subclavian artery injuries was performed at our institution. Relevant data were extracted from patient records and analyzed. These results were then used to develop an algorithm for the management of trauma patients with subclavian artery injuries.

Results

Fifteen patients with subclavian artery injuries were identified. Five patients died in the emergency room. Of the 10 surviving patients, 8 had their diagnosis made at arteriogram. Six patients underwent endovascular repair, and 4 of these repairs were successful. Three patients were managed by way of open repair. Two deaths occurred in the endovascular group, and 1 death occurred in the open group.

Conclusions

Our findings suggest that endovascular management of subclavian artery injuries is an acceptable technique in appropriate candidates and compares favorably with open repair. However, as with open repair, the associated morbidity and mortality remains quite high. We propose an algorithm whereby hemodynamically stable patients with hard signs of vascular injury proceed directly to angiography, whereas open repair is reserved for those patients who are unstable or in whom a catheter-based approach has previously failed.     

Outcomes of truncal vascular injuries in children

Background

Pediatric truncal vascular injuries occur infrequently and have a reported mortality rate of 30% to 50%. This report examines the demographics, mechanisms of injury, associated trauma, and outcome of patients presenting for the past 10 years at a single institution with truncal vascular injuries.

Methods

A retrospective review (1997-2006) of a pediatric trauma registry at a single institution was undertaken.

Results

Seventy-five truncal vascular injuries occurred in 57 patients (age, 12 ± 3 years); the injury mechanisms were penetrating in 37%. Concomitant injuries occurred with 76%, 62%, and 43% of abdominal, thoracic, and neck vascular injuries, respectively. Nonvascular complications occurred more frequently in patients with abdominal vascular injuries who were hemodynamically unstable on presentation. All patients with thoracic vascular injuries presenting with hemodynamic instability died. In patients with neck vascular injuries, 1 of 2 patients who were hemodynamically unstable died, compared to 1 of 12 patients who died in those who presented hemodynamically stable. Overall survival was 75%.

Conclusions

Survival and complications of pediatric truncal vascular injury are related to hemodynamic status at the time of presentation. Associated injuries are higher with trauma involving the abdomen.     

Alpine ski and snowboarding traumatic injuries: incidence, injury patterns, and risk factors for 10 years

Background

Alpine skiing and snowboarding are popular winter sports in Canada. Every year participation in these activities results in traumatic injury. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with ski and snowboarding injuries.

Methods

A comprehensive 10-year retrospective review of Alpine ski and snowboarding injuries from 1996 to 2006 was conducted. The Alberta Trauma Registry was used as the primary source of data.

Results

A total of 196 patients (56.6% skiers, 43.4% snowboarders) were identified as having major traumatic injuries (Injury Severity Score, ≥12). Forty-three patients required intensive care unit support. The majority of injuries were related to falls and collisions with natural objects. Head injuries were most common, followed by chest, spinal, and extremity trauma. Seventy-nine patients required emergency surgery.

Conclusions

Skiing and snowboarding represent activities with high potential for traumatic injury. Safety initiatives should be developed to target this population.     

Blunt Urethral Trauma: A Unified, Anatomical Mechanical Classification

Purpose

We propose a simple, anatomically based classification of blunt urethral injury as a replacement for currently used classifications, which are not comprehensive, anatomically inconsistent or based on a mixed anatomical/mechanistic formula. The latter are difficult to learn and use, and have not been universally adopted.

Materials and Methods

We reviewed most of the currently used general uroradiological, emergency radiological and urological textbooks to define the classification of urethral injuries that is most widely accepted. Most authors use the Colapinto and McCallum classification, modifications thereof or the older surgical classification of urethral injuries, which simply divides such injuries anatomically into anterior and posterior. However, there is little consensus about the best classification and none includes all of the blunt injuries of the urethra. To correct these difficulties we devised a comprehensive and anatomically consistent classification.

Results

The proposed classification categorizes blunt urethral trauma as I-posterior urethra intact but stretched (Colapinto and McCallum type I), II-partial or complete pure posterior injury with tear of membranous urethra above the urogenital diaphragm (Colapinto and McCallum type II), III-partial or complete combined anterior/posterior urethral injury with disruption of the urogenital diaphragm (Colapinto and McCallum type III), IV-bladder neck injury with extension into the urethra, IVA-injury of the base of the bladder with periurethral extravasation simulating a true type IV urethral injury and V-partial or complete pure anterior urethral injury.

Conclusions

The proposed classification is anatomically valid and includes all of the common types of blunt urethral injuries. Universal adoption of this system should permit comparison of various management/treatment modalities at various institutions.     

Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination

Background

Cervical spine injuries can occur in as many as 10% of patients with blunt trauma with mental status changes from closed head injuries. Despite normal results on cervical spine computed tomography (CT), magnetic resonance imaging (MRI) is often recommended to exclude ligamentous or soft tissue injury.

Methods

A retrospective review was conducted of trauma patients admitted to a level I trauma center from 2002 to 2006, in whom cervical spine injuries could not be excluded by physical examination. All patients with normal results on cervical spine CT followed by cervical spine MRI were included in the analysis.

Results

One hundred twenty patients underwent MRI to examine their cervical spines. Seven patients had abnormal MRI findings suggestive of acute traumatic injury. No MRI studies led to operative intervention. Screening MRI increased from 1% of comatose patients in 2002 to 18% in 2006.

Conclusions

The use of MRI in patients with normal results on cervical spine CT does not appear to alter treatment.     

Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service

Background

Recent media interest in stabbings and shootings has lead to the general assumption that injury and death secondary to deliberate penetrating trauma are rising. The aim of this study was to establish the prevalence of deliberate penetrating trauma within a London-based physician-led pre-hospital trauma service, and evaluate whether the perceived increase reported by the media translates into a real increase in penetrating trauma caseload.

Method

A retrospective review of a physician-led pre-hospital care trauma database was conducted to identify all patients who sustained stabbing or shooting injuries over a 16-year period. Patients who died in the pre-hospital phase and paediatric patients were included. Other local and national datasets were examined to determine whether similar trends were observed.

Results

1564 penetrating trauma victims were identified, including 92 children. 1358 patients (86.8%) sustained stab wounds; 206 patients were shot (13.2%). Penetrating injury accounted for 9.9% of the overall trauma caseload during the study period. The annual increase in patients sustaining stabbing injuries was 23.2%. Gun shot wounds increased by 11.0% per year.

Conclusion

The study demonstrates a significant annual rise in the number of cases of deliberate penetrating trauma managed by a UK physician-led pre-hospital trauma service.     

Cow-related trauma: A 10-year review of injuries admitted to a single institution

Introduction

Bovine-related injuries to farmers are common in rural communities. Many injuries are significant requiring hospital admission and surgery. We reviewed all cattle-related injuries admitted to a regional trauma centre over 10 years and detail the nature of the injuries.

Method

A retrospective review was undertaken, using hospital inpatient coding system (HIPE) to identify patients admitted following cow-related trauma for the last 10 years. From retrieved charts mechanism of injury was identified, demographics recorded and Injury Severity Score (ISS) and Trauma Injury Severity Score (TRISS) calculated based on the injuries sustained.

Results

47 patients were identified, with a median age of 53 years. 4 injuries occurred in children, and 12 in patients over 65 years old. Three-quarters of those injured were male. Kicking was the most common mechanism of injury (n = 21), but charge/head-butt injuries and trampling injuries were associated with more serious injury scores. 72% of patients were admitted under Orthopaedics as their primary care team, 25% under General Surgeons, with one patient admitted medically. Mean ISS score was 6.9 (range 1-50). 41 operative interventions were performed on 30 patients during their admission. 6.3% of patients required admission to Intensive Care with a mean length of stay of 12.3 days (range 2-21 days). There was no mortality.

Conclusion

Cow-related trauma is a common among farming communities and is a potentially serious mechanism of injury that appears to be under-reported in a hospital context. Bovine-related head-butt and trampling injuries should be considered akin to high-velocity trauma.     

The risk of intra-urethral Foley catheter balloon inflation in spinal cord-injured patients: Lessons learned from a retrospective case series

Background

Inflating the balloon of Foley catheter in urethra is a complication of urethral catheterisation. We report five patients in whom this complication occurred because of unskilled catheterisation. Due to lack of awareness, the problem was not recognised promptly and patients came to harm.

Case series

1. 1.
   A tetraplegic patient developed pain in lower abdomen and became unwell after transurethral catheterisation. CT pelvis revealed full bladder with balloon of Foley catheter in dilated urethra.
    
2. 2.
   Routine ultrasound examination in an asymptomatic tetraplegic patient with urethral catheter drainage, revealed Foley balloon in the urethra. He was advised to get catheterisations done by senior health professionals.
    
3. 3.
   A paraplegic patient developed bleeding and bypassing after transurethral catheterisation. X-ray revealed Foley balloon in urethra; urethral catheter was changed ensuring its correct placement in urinary bladder. Subsequently, balloon of Foley catheter was inflated in urethra several times by community nurses, which resulted in erosion of bulbous urethra and urinary fistula. Suprapubic cystostomy was performed.
    
4. 4.
   A tetraplegic patient developed sweating and increased spasms following urethral catheterisations. CT of abdomen revealed distended bladder with the balloon of Foley catheter located in urethra. Flexible cystoscopy and transurethral catheterisation over a guide-wire were performed. Patient noticed decrease in sweating and spasms.
    
5. 5.
   A paraplegic patient developed lower abdominal pain and nausea following catheterisation. CT abdomen revealed bilateral hydronephrosis and hydroureter and Foley balloon located in urethra. Urehral catheterisation was performed over a guide-wire after cystoscopy. Subsequently suprapubic cystostomy was done.
    

Conclusion

Spinal cord injury patients are at increased risk for intra-urethral Foley catheter balloon inflation because of lack of sensation in urethra, urethral sphincter spasm, and false passage due to previous urethral trauma. Education and training of doctors and nurses in proper technique of catheterisation in spinal cord injury patients is vital to prevent intra-urethral inflation of Foley catheter balloon. If a spinal cord injury patient develops bypassing or symptoms of autonomic dysreflexia following catheterisation, incorrect placement of urethral catheter should be suspected.

     

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

Purpose

We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries.

Methods

All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007.

Results

Overall, 78 patients were identified with an average age of 15.0 ± 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively.

Conclusions

CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma.     

Displaced inferior ramus fractures as a marker of posterior pelvic injury

Introduction

Injuries to the anterior or posterior pelvic ring rarely occur in isolation. Disruption to the anterior pelvic ring, indicated by a fracture of the superior or inferior pubic ramus, or injury to the pubic symphysis, may be indicative of additional pelvic ring disruption. The purpose of this retrospective study was to determine whether displaced inferior pubic ramus fractures warrant a more detailed investigation of the posterior ring in an effort to predict unstable posterior pelvic ring injuries.

Materials and methods

All patients with a displaced inferior ramus fracture on AP pelvic radiograph were identified at a single level I trauma center over a 5-year period. Complete pelvic radiographs and computed tomography scans were then evaluated for additional pelvic ring injuries. The data were analyzed using the chi-square test to determine the association between inferior ramus fractures and posterior pelvic ring injury.

Results

Sixty-three of the 93 patients with a fracture of the inferior ramus (68 %) were found to have a posterior ring injury; 60 % of these injuries were unstable. Patients with concurrent superior ramus fractures were more likely to have a posterior ring injury (p < 0.001) and an unstable pelvis (p = 0.018). Of those with a displaced unilateral inferior ramus fracture, parasymphyseal involvement was associated with higher incidence of posterior ring injury (p = 0.047) and pelvic instability (p = 0.028).

Conclusion

The anterior pelvic ring can be used to help identify unstable injuries to the posterior pelvis. Patients with displaced inferior pubic ramus fractures warrant a detailed examination of their posterior ring to identify additional injuries and instability.     

Is pre-hospital thoracotomy necessary in the military environment?

Introduction

Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest ‘on-scene’ thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries?

Methods

Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome.

Results

Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities—7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring.

Discussion

Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury.

Conclusion

As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.     

Urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome: long-term results

Purpose

The aim of the study was to evaluate the efficacy and safety of urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome (PBS).

Methods

During a 10-year period, 7 infants with PBS and urethral hypoplasia presented either with open urachus or surgically created urinary diversion referred to our hospital. Five milliliters of normal saline was pushed via a 22-gauge plastic angiocatheter into the urethra with simultaneous finger pressure on the perineum to occlude the proximal urethra that was repeated with higher volumes of the solution (up to 20 mL). The procedure was continued until a 6F or 8F feeding tube catheter confirmed the urethral patency. Hydrodistension was repeated in 3-month intervals till complete patency was confirmed by imaging.

Results

Median age of the infants was 6 (1-8) months. All urethral hydrodistension were successful after 1 to 3 sessions. Follow-up imaging studies showed significant improvement in all patients except one. Natural and surgically created urinary diversions were closed in 6 infants.

Conclusions

The hydrodistension create an equal and constant pressure into the urethral wall without any urethral damage. This technique can be considered along with the other available methods for management of urethral hypoplasia in selected cases of PBS.     

Lesiones gastrointestinales y mesentéricas en el paciente politraumatizado: incidencia, demora diagnóstica y pronóstico

Background

Gastrointestinal and mesenteric injuries (GIMI) are uncommon in trauma patients, and their diagnosis are often delayed. Our aims were to determine the reliability of CT scan in our centre, and to assess the clinical significance of a delayed diagnosis.

Materials and method

Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of Gregorio Marañón University General Hospital, between 1993 and 2006.

Results

We found 105 (16.6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1495 severe trauma cases included. A total of 46% had blunt injuries. The mean injury severity score (ISS) and new ISS (NISS) were 20 and 25, respectively. There were 9 (8.5%) deaths, 4 of which were unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 there were signs suggestive of a GIMI. In another 43 (41%) patients an urgent laparotomy was indicated because of positive clinical findings or instability. Surgery was delayed for more than 8 hours in 21 (20%) patients, the most common reason being a false negative result in the CT scan.

Conclusions

The overall incidence of GIMI was high in our centre (31% due to penetration and 10.7% blunt trauma). Several factors, such as the initial lack of symptoms, a low diagnostic sensitivity of the CT scan (34% false negatives), and the non-surgical management of solid organ injuries, have contributed to a delayed diagnosis and treatment in one out of each five patients in our series, but this has not led to a significant increase in septic complications in this group.     

Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria

Background

There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines (‘potential major trauma’) with trauma patients who are identified as ‘confirmed major trauma patients’ at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.

Methods

For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as ‘confirmed major trauma patients’ and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the ‘potential major trauma’ group. Non-major trauma patients (N = 27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.

Results

The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.

Conclusions

While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.     

Locked versus standard unlocked plating of the symphysis pubis in a Type-C pelvic injury: A cadaver biomechanical study

Introduction

The benefits of locked plating for pubic symphyseal disruption have not been established. The purpose of this biomechanical study was to determine whether locked plating offers any advantage over conventional unlocked plating of the pubic symphysis in the vertically unstable, Type-C pelvic injury.

Methods

In each of eight embalmed cadaver pelvis specimens, sectioning of the pubic symphysis in conjunction with a unilateral release of the sacroiliac, sacrospinous, and sacrotuberous ligaments and pelvic floor was performed to simulate a vertically unstable Type-C (Orthopaedic Trauma Association 61-C1.2) pelvic injury. The disrupted SI joint was then reduced and fixed using two 6.5 mm cannulated screws inserted into the S1 body. Using a six-hole 3.5 mm plate specifically designed for the symphysis pubis having both locked and unlocked capability, four pelvises were fixed with locked screws and four pelvises were fixed with standard unlocked bicortical screws. Both groups were similar based on a dual-emission X-ray absorptiometry evaluation (P = 0.69). Each pelvis was then mounted on a servohydraulic materials-testing apparatus using a bilateral stance model to mainly stress the symphyseal fixation and was cycled up to 1 million cycles or failure, whichever occurred first.

Results

Five specimens experienced failure at the jig mounting/S1 vertebral body interface, occurring between 360,000 and 715,000 cycles. Frank failure of the anterior or posterior instrumentation did not occur. However, end-trialing diastasis of the initial pubic symphysis reduction was found in all pelvises. There were no differences between the groups with respect to this loss of symphyseal reduction (P = 0.69) or average cycles to failure (P = 1.0).

Conclusion

Pubic symphyseal locked plating does not appear to offer any advantage over standard unlocked plating for a Type-C (OTA 61-C1.2) pelvic ring injury.