High-pressure injection injuries

High-pressure injection injuries are potentially disabling forms of trauma. Three cases are presented of patients who sustained high-pressure injuries from paint, air and water. Injuries from paint require emergency surgical débridement and exploration because of the extreme tissue toxicity of the injected material. The patient in this study had a favourable outcome after delayed closure of his wound and extensive physiotherapy. High-pressure injuries resulting from air and water can be managed conservatively, as in the two patients reported in this paper. Their treatment included tetanus prophylaxis, irrigation, dressings, splinting, admission to hospital, intravenous broad-spectrum antibiotics, radiologic assessment and careful neurovascular evaluation. Surgical débridement and exploration were not necessary.     

Blast and fragment injuries of the musculoskeletal system

Blast and fragment injuries of the musculoskeletal system are the most frequently encountered wounds in modern warfare. Most injuries to the musculoskeletal system involve so-called secondary blast injuries in which casing fragments and other debris become flying projectiles. Nonoperative treatment of selected wounds caused by small-fragment debris has been successful but remains controversial. Successful surgical treatment depends on meticulous wound débridement, with excision of nonviable tissue and foreign material likely to cause infection; adequate drainage; and delayed closure. Advanced internal fixation techniques used in modern trauma centers to treat predominantly blunt trauma may not be appropriate for care of orthopaedic war wounds in a field setting.     

Percutaneous management of Morel-Lavallee lesions

BACKGROUND: Previous recommendations for treatment of Morel-Lavallee soft-tissue degloving lesions have included open débridement with packing or delayed closure. The purpose of this study was to review the use of percutaneous drainage for the initial management of these lesions. METHODS: Nineteen patients with a Morel-Lavallee lesion were managed with percutaneous drainage and débridement of the lesion within three days after the injury. Drainage was usually completed through two 2-cm incisions: one over the distal aspect of the lesion and one over the most superior and posterior extent of the lesion. A plastic brush was used to débride the injured fatty tissue, which was washed from the wound with pulsed lavage. A medium Hemovac drain was placed within the lesion and was removed when drainage was <30 mL over twenty-four hours. RESULTS: Fifteen of the nineteen patients had surgery for an associated pelvic or acetabular fracture. Seven of the nine patients in whom a pelvic fracture was treated surgically had percutaneous fixation of the posterior part of the pelvic ring as well as treatment of the Morel-Lavallee lesion during the same operative setting. Fixation of the remaining two pelvic fractures and the six acetabular fractures was deferred until at least twenty-four hours after the drain was removed. Three of sixteen cultures of specimens taken from the wounds were positive. None of the patients with percutaneous fixation of the pelvis had wound complications. One wound required surgical exploration because of persistent drainage, but the culture was negative and the wound healed with no sequelae. No patient required débridement of skin and, at a minimum of six months, no deep infection had occurred. CONCLUSIONS: Early percutaneous drainage with débridement, irrigation, and suction drainage for the treatment of Morel-Lavallee lesions appears to be safe and effective. Percutaneous procedures for pelvic fixation were well tolerated by the small number of patients in this series, and open procedures appeared to be safe when performed in a delayed fashion.     

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.     

Infected total knee arthroplasty treated by arthroscopic irrigation and débridement

Sixteen patients with infected total knee arthroplasties (4 postoperative and 12 late hematogenous) were treated by arthroscopic irrigation and débridement. All patients had < or = 7 days of knee symptoms, and there were no radiographic signs of osteitis or prosthetic loosening. Six of the 16 original total knee arthroplasties (38%) did not need prosthesis removal at a mean follow-up of 64 months (range, 36-151 months). Ten other knees were treated with irrigation, débridement, and hardware removal within 7 weeks of the latest procedure used to try to retain components. Two (13%) of these cases ultimately required an arthrodesis for persistent infection. Although we still believe that this method is preferable to resorting immediately to implant removal for acute infections, arthroscopic débridement was less efficacious for most situations when compared with open treatment. We would use arthroscopic irrigation and débridement only under selected circumstances (medically unstable or anticoagulated patients).     

Effect of delayed treatment on open tibial shaft fractures

Open tibial shaft fractures were analyzed retrospectively to determine the effect of treatment timing on infection and nonunion rates. The cases of 77 patients with 81 open tibial shaft fractures were reviewed. Patients were treated with initial wound cleansing and splinting in the emergency department and then formally with operative irrigation and débridement and stabilization, which included intramedullary (IM) nailing, external fixation, open reduction and internal fixation, or splinting. All tibial shaft components ultimately were treated with IM nailing. Mean time to operative treatment was 12.97 hours (SD, 10.8 hours). There were 7 infections (8.6%) and 3 nonunions (3.7%). Time was found not to be a significant factor in predicting either infection or nonunion. Increased severity of fracture was a significant factor in predicting infection rate. The infection rate for fractures treated first with external fixation and then with IM nailing was significantly higher than that for fractures treated with IM nailing alone. In addition, a relation was found between patients who received multiple débridements and development of infection. These results show that infection and nonunion rates were not adversely affected by longer time to operative treatment (up to 48 hours) when adequate trauma department open fracture care and early initiation of antibiotics were coupled with standardized and thorough débridement in the operative theater.     

Débridement and primary closure of nonhealing foot wounds

Fifty-eight chronic nonhealing foot wounds (51 patients) were treated with irrigation, aggressive débridement, and primary tension-free closure. Factors such as wound location, wound size, presence of infection, and healing outcome were recorded. In addition, medical comorbidities and preoperative laboratory test results were reviewed. Thirty-seven (64%) of the 58 wounds healed after primary closure. Of the other 21 wounds, 16 healed after repeat irrigation, debridement, and closure or local wound care; 2 patients were lost to follow-up after initial failed wound healing, 1 patient died after initial failed wound healing, and 2 cases were salvaged with amputation. Failed primary closures were thought not to increase wound size; all but 3 of these closures decreased wound size significantly. Differences between the wounds that healed primarily and the wounds that failed healing were not statistically significant. Diabetes was present in 46% of the patients whose wounds healed primarily versus 71% of the patients whose wounds failed healing (P = .06). Irrigation, débridement, and primary closure of nonhealing foot wounds can be a useful treatment option for most such patients. Complete healing or reduced wound size occurs in 95% of cases.     

Treatment strategies for gunshot wounds of the extremities

The incidence of gunshot wounds is increasing also in Europe and surgeons in urban trauma centers are more frequently confronted with this type of injury. Since there is no established treatment algorithm for gunshot injuries to the extremities, the surgeon should rely on established soft tissue injury and fracture protocols. Gunshot fractures with minor soft tissue destruction should be treated as closed fractures. The treatment of choice for unstable fractures is early internal stabilization, whereas stable fractures may be treated by functional bracing. The administration of an antibiotic prophylaxis for fractures with minor soft tissue injury is controversial. Gunshot fractures with major soft tissue injury should be treated as open fractures. Debridement of nonviable tissue and external fixation are recommended. Prophylactic intravenous antibiotics are mandatory and prophylactic fasciotomy is often required. Upon definitive internal stabilization, bone grafting should be considered since gunshot fractures are usually associated with a high degree of comminution. Articular gunshot injuries are treated as open joint injuries and require irrigation, debridement, foreign body removal and antibiotic prophylaxis.     

Management of low velocity gunshot-induced fractures

Bullets fired from civilian weapons are usually of low velocity, resulting in minimal tissue cavitation as compared to high-velocity weapons. A prospective protocol was initiated for patients sustaining a low-velocity gunshot to the extremity resulting in a stable, nonoperative fracture configuration. Treatment consisted of local irrigation and débridement, tetanus prophylaxis as required, a long acting cephalosporin intramuscularly, and splinting or casting of the fractured extremity. Twenty-five patients were managed by this protocol. This patient population was compared to a random retrospective sample of 25 patients with similar ballistic induced fractures and wounds managed by local débridement and 48 h of intravenous antibiotics. One infection occurred in each group, requiring further therapy. We conclude that the patient with a low-velocity gunshot induced fracture can be managed without the use of short-term intravenous antibiotics with no increased risk of infection.     

Indications for surgical débridement in 125 human bites to the hand

Indications for operative intervention following human bites to the hand were determined based on physical examination and time elapsed since injury. One hundred twenty-four patients admitted to Charity Hospital of New Orleans, La, were stratified according to time elapsed from injury to treatment (early, less than 24 hours; delayed, 1 to 7 days; and late, greater than 7 days). Patients in the early group were mainly treated with conservative wound care, consisting of local wound exploration and irrigation in the emergency department, while those in the late group underwent surgical débridement. Patients in the delayed group either received conservative wound care or underwent débridement in the operating room. The early and late groups recovered excellent hand function while results within the delayed group were variable with improved results depending on rapid surgical débridement or drainage.     

Versorgungsstrategien bei Schussverletzungen der Extremität

The incidence of gunshot wounds is increasing also in Europe and surgeons in urban trauma centers are more frequently confronted with this type of injury. Since there is no established treatment algorithm for gunshot injuries to the extremities, the surgeon should rely on established soft tissue injury and fracture protocols. Gunshot fractures with minor soft tissue destruction should be treated as closed fractures. The treatment of choice for unstable fractures is early internal stabilization, whereas stable fractures may be treated by functional bracing. The administration of an antibiotic prophylaxis for fractures with minor soft tissue injury is controversial. Gunshot fractures with major soft tissue injury should be treated as open fractures. Debridement of nonviable tissue and external fixation are recommended. Prophylactic intravenous antibiotics are mandatory and prophylactic fasciotomy is often required. Upon definitive internal stabilization, bone grafting should be considered since gunshot fractures are usually associated with a high degree of comminution. Articular gunshot injuries are treated as open joint injuries and require irrigation, debridement, foreign body removal and antibiotic prophylaxis.     

Orthopaedic injuries among survivors of USS COLE attack

The objective of this article is to describe the range of orthopaedic injuries and outcomes of acute treatment regimens among survivors of the USS COLE terrorist attack and to reemphasize basic treatment principles for blast injuries. With the current geopolitical environment, the average community orthopaedic surgeon may be involved in treating injuries due to an explosive terrorist attack. This is a retrospective review of a consecutive series of the 39 patients who were injured during the USS COLE attack on October 12, 2000, and were received at Naval Medical Center, Portsmouth, Virginia, from the MEDEVAC (Medical Evacuation) system. The 17 casualties from the attack were not included in this study. Data were retrospectively collected from patient charts for all patients who survived the USS COLE attack. The 39 patients who survived the USS COLE attack sustained 81 injuries. Fourteen patients sustained 32 orthopaedic injuries, of which 61% were lower extremity injuries. Of the 10 patients who required hospitalization, 6 had orthopaedic injuries (60%). Three of five open fractures (60%) became infected, and two of two (100%) open fracture wounds treated with primary closure in the initial setting were infected. Lower extremity orthopaedic injuries may predominate in a shipboard blast scenario. Even minor injuries require prolonged time before patients return to active duty. Complex wounds have high infection rates and should be treated according to previously established protocols for wartime injuries. Principles of provisional fracture stabilization prior to transport, adequate wound débridement, and delayed wound closure are reviewed.     

The practical management of Fournier''s gangrene.

Effective early treatment of this serious condition is necessary to prevent death. Urgent exploration by the most experienced surgeon available should include wide excision of all necrotic or dubious tissue, and adequate drainage of deep fascial planes. Deep and apparently healthy tissues must be exposed and the surgeon must be prepared to proceed to laparotomy, and even diverting colostomy and/or suprapubic cystotomy when necessary. Cross matched blood must be available, and we have found hydrogen peroxide irrigation useful. Pus, tissues, and blood samples for bacteriological culture and sensitivity should always be sent, but broad spectrum antibiotics should be started without delay to prevent systemic complications. In addition to the urgent initial surgery, repeated daily examination of all wounds is necessary, usually under general anaesthesia to allow full inspection, further débridement, irrigation and change of dressings, until the infective process is halted. This is a serious condition with a high mortality which we believe may be reduced by early diagnosis and appropriate aggressive surgery.     

Open fractures of the tibia: a review of one hundred and two cases

One hundred and two consecutive open fractures of the tibial shaft were treated from 1970 to 1976. Four required primary amputation. The remainder received standardized wound care, consisting of surgical débridement and delayed primary wound closure. Soft-tissue injuries were classified according to severity, because the initial injury was the most important prognostic factor. All patients received a seventy-two-hour course of parenteral antibiotics. Fifty-six fractures were managed with cast immobilization, thirty-five with rigid internal fixation, and seven with rigid external pin fixation. The over-all rates of infection (15 per cent) and delayed union (13 per cent) are not directly comparable to other series because one must consider the severity of each injury when analyzing results. Management of the fracture itself should be individualized. The risk of primary wound closure does not appear to be warranted.     

Effect of semiquantitative culture results from complex host surgical wounds on dehiscence rates

The primary aim of this study was to determine the effect of positive bacterial cultures at the time of closure on dehiscence rates. Pre‐ and post‐débridement wound cultures from patients undergoing serial surgical débridement of infected wounds were compared with outcomes 30 days postoperatively. One‐hundred patients were enrolled; 35 were excluded for incomplete culture data. Sixty‐five patients were evaluated for species counts, including Coagulase negative Staphylococcus (CoNS), and semiquantitative culture data for each débridement. The post‐débridement cultures on the date of closure had no growth in 42 patients (64.6%) of which 6 dehisced (14.3%), and 36 remained closed; with no statistically significant difference in dehiscence rates (p = 0.0664). Pre‐débridement cultures from the 1st débridement of the 65 patients showed 8 patients had no growth, 29 grew 1 species, 19 grew 2 species, and 9 had 3–5 species. There was a reduction in the number of species and improvement of semiquantitative cultures with each subsequent débridement. The dehiscence rate for those who had 2 débridements (n = 42) was 21.4% at 30 day follow‐up and 21.7% in those who had 3 débridements (n = 23). The number of débridements had no statistical significance on dehiscence rates. The presence of CoNS on the day of closure was a statistically significant risk for dehiscence within 30 days (p = 0.0091) postoperatively. This data demonstrates: (1) positive post‐débridement cultures (scant/rare, growth in enrichment broth) at the time of closure did not affect overall dehiscence rates (p = 0.0664), (2) the number of species and semiquantitative culture results both improved with each subsequent débridement, (3) the number of surgical débridement did not influence postclosure dehiscence rates. (4) Positive cultures containing CoNS at the time of closure is a risk factor for dehiscence (p = 0.0091).     

A case report of pleural empyema treated by video-assisted thoracoscopic surgery in an elder patient receiving hemodialysis

A 79-year-old male who had the treatment of renal failure with hemodialysis was admitted to our hospital for the management of right pleural empyema. We performed thoracoscopic débridement and pleural irrigation in the management of empyema thoracis, because both chest tube drainage and antibiotic therapy had failed. Postoperatively pleural irrigation was performed for three weeks and the chest drains were removed after four weeks. He was successfully transferred to our department of internal medicine at four weeks after the operation. Thoracoscopic débridement and pleural irrigation for the elder patient with pleural empyema is safe, effective and minimally invasive surgical procedure.     

Closed fractures complicated by peripheral nerve injury

Closed fractures may be complicated by associated peripheral nerve injury. However, because clinical information is limited, determining the best course of treatment is difficult. Most patients with closed fractures have a local nerve injury without nerve division; their prognosis for recovery is favorable. In the acute setting, immediate surgery is usually unwarranted because of the difficulty in accurately defining the severity and extent of nerve injury. When débridement of an open fracture or repair is not required, peripheral nerve injuries are best observed and the extremity treated with splinting and exercise to prevent loss of joint motion. Patients who fail to demonstrate signs of recovery at 6 months, either clinically or with electrodiagnostic testing, should undergo exploration to maximize the likelihood for return of function. When, during exploration, the nerve is in continuity, intraoperative measurement of nerve action potentials should be done. Measuring nerve action potentials will determine whether nerve grafting, local neurolysis, or excision of the injured segment, accompanied by primary repair, is the most appropriate treatment.     

Débridement of the burn wound with sutilains ointment

Twenty-one patients with fresh full-thickness burns received a course of two daily applications of sutilains ointment to an area of their burn wound not exceeding 9 per cent of the body surface. Twelve had a mirror-image control burn site of equivalent depth and extent, which was treated identically except sutilains applications were omitted. Good débridement, defined as a wound free of adherent eschar, was observed in 9 patients (43 per cent). The remaining patients' wounds had adherent eschar at the end of the test, or demonstrated equal débridement of both the test and control site. Good débridement was not promoted by increasing the frequency of wet dressings between sutilains applications. Débridement was better in patients receiving more than 8 days of applications. A higher percentage of patients receiving silver sulphadiazine demonstrated good débridement than those receiving gentamicin or no topical antibacterial agent. Burn wound bacterial colonization pattern in sutilainstreated patients did not vary from that observed in those patients receiving only topical antibacterial agents alone.Histological examination revealed that areas with good débridement showed an intense inflammatory cell response and dissolution of the elastic fibres. Control sites and areas with poor débridement showed a lesser inflammatory response and preservation of elastic fibres. No explanation for the variable response to sutilains was apparent histologically. Because of pain associated with application, cost and the unpredictability, sutilains should not be used indiscriminately without monitoring its response carefully and should be used only in conjunction with a topical antibacterial.     

Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections.

BACKGROUND: The clinical presentation of an infection at the site of a total knee arthroplasty can be used as a guide to treatment, including the decision as to whether the prosthesis should be retained or removed. We reviewed the results of treatment of infection after total knee arthroplasty to evaluate the effectiveness of four treatment protocols based on the clinical setting of the infection. METHODS: We retrospectively evaluated the results of treatment of eighty-one infections in seventy-six consecutive patients who either had an infection after a total knee arthroplasty or had multiple positive intraoperative cultures of specimens of periprosthetic tissue obtained during a revision total knee arthroplasty performed because of presumed aseptic loosening. The patients were managed according to one of four protocols. Five infections in five patients who had positive intraoperative cultures were treated with antibiotic therapy alone. Twenty-three early postoperative infections in twenty-one patients were treated with débridement, antibiotic therapy, and retention of the prosthesis. Twenty-nine late chronic infections in twenty-eight patients were treated with a delayed-exchange arthroplasty after a course of antibiotics. Seven acute hematogenous infections in six patients were treated with débridement, antibiotic therapy, and retention of the prosthesis. Seventeen infections in seventeen patients were not treated according to one of the four protocols. Sixteen late chronic infections were treated either with an arthrodesis (five infections) or with débridement, antibiotic therapy, and retention of the prosthesis (eleven infections). One acute hematogenous infection was treated with resection arthroplasty because of life-threatening sepsis. RESULTS: The mean duration of follow-up was 4.0 years (range, 0.3 to 14.0 years). Eleven patients who had an arthrodesis, a resection arthroplasty, or an above-the-knee amputation after less than two years of follow-up were included in the study as individuals who had a failure of treatment. In the group of patients who were managed according to protocol, the initial course of treatment was successful for all five infections that were diagnosed on the basis of positive intraoperative cultures, five of the ten deep early infections, all thirteen superficial early infections, twenty-four of the twenty-nine late chronic infections, and five of the seven acute hematogenous infections. Only one of eleven prostheses in patients who had a late chronic infection that was not treated according to protocol was successfully retained after débridement. CONCLUSIONS: Our treatment protocols, which were based on the clinical setting of the infection, were successful for most patients. A major factor associated with treatment failure was a compromised immune status. Bone loss and necrosis of the soft tissues around the joint also complicated the treatment of these infections.     

Ballistics for physicians: myths about wound ballistics and gunshot injuries

PURPOSE: Wound ballistics is a difficult subject. The behavior of all bullets is unpredictable but the specific effect of high velocity projectiles has been a particular source of confusion in the literature. This confusion has resulted in the likely incorrect conclusion that all high velocity wounds require massive débridement. We reviewed the entirety of the literature on this subject and concluded that high velocity weapons do not reliably create massive wounds, and judicious débridement and staged explorations may be the best treatment method for these patients. MATERIALS AND METHODS: A MEDLINE search and retrieval were done of all pertinent references from 1966 to May 2003 concerning the field of wound ballistics. Articles initially missed in this search were obtained from the bibliography of retrieved studies. More than 70 articles and book chapters were reviewed. RESULTS: Five common myths about the tissue effects of gunshot wounds were reviewed as well as the data that dispel these myths. Information on the effects of different bullet types, and the intended and actual effect of military rifle wounds were assessed. CONCLUSIONS: For the majority of high velocity gunshot wounds, especially military rifles that generally fire a projectile that is meant to stay intact after impact, wound severity can be limited, even much less than that from a civilian rifle, shotgun or handgun. Judicious use of débridement during surgical exploration limits the extent of iatrogenic injury in the surgical care of these patients.