Fatal intracerebral gas gangrene in a 10-month-old child

Today, intracerebral infections by gas forming bacteria are very rare. They are mostly seen after penetrating injuries and more rarely after trivial trauma. Although prognosis of this kind of infection is severe, the general outcome of these patients after surgical and antibiotic treatment is good. We report a ten months old boy suffering a pecking injury just above the left ear with perforation of the temporal bone and dura. In between 48 hrs he developed a rapidly progressive gas gangrene encephalitis due to infection with C. perfringens and died despite of surgical and antibiotic treatment due to massive brain swelling and cardio-pulmonary failure.     

早期诊断双层缝合持续冲洗治疗十二指肠破裂

目的:总结十二指肠损伤的早期诊断双层缝合持续冲洗治疗经验。方法:对36例十二指肠损伤患者采用双层缝合持续冲洗等综合治疗。结果:全组36例,死亡1例,死亡率为2.7％。结论:采用早期诊断、及时手术、双层缝合、持续冲洗引流治疗是防治十二指肠破裂患者术后肠瘘、感染等并发症的有效方法。     

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.     

An unusual penetrating craniocerebral injury due to landmine explosion: a case report

Penetrating landmine injuries are the unavoidable consequences of military conflicts. They are potentially life-threatening. The mortality rates in the literature range from 23% to 92% and are considerably higher in patients admitted with poor neurologic state. Penetrating craniocerebral injuries require early surgical management designated to prevent infection and remove foreign objects, necrotic tissue and complicating blood clots, as well as to minimalize post-traumatic sequelae. We report herein an interesting case of penetrating intracerebral injury with giant shrapnel due to landmine in a 20-year-old young man.     

Can Open Hand Injuries Wait for Their Surgery in a Tertiary Hospital?

Objective  Open hand injuries are routinely admitted and planned for surgery acutely, competing with other surgical emergencies. This retrospective study aims to evaluate if a delay in timing to surgery for open hand injuries led to an increased rate of infection. Materials and Methods  All patients who sustained open hand injuries and underwent semi-emergent day surgery from January 1, 2015 to December 31, 2016 were included. Outcome of postoperative infection was analyzed against demographic data, injury details, and delay from trauma to therapy. Results  There were 232 cases (91% males) included, with 92.0% performed under local anesthesia. Deep seated postoperative infection was seen in 1.3%, which was not significantly associated with delay to surgery. Conclusion  We had comparable infection rates as compared with published literature. Delayed timing of surgical treatment in open hand injuries was not associated with increased rates of deep-seated infection. Managing open hand injuries as semi-emergent surgeries may be acceptable given the low infection rates.     

A treatment concept using external transfixation in unstable defect trauma of the knee joint

The main problems in the treatment of severe knee injuries with extensive soft tissue damage, ligamentary lesions and compound fractures consist in the high risk of infection and complex instability of the joint. 20 patients suffering such type of trauma were treated by a schedule comprising an extensive debridement and a combination of minimal internal osteosynthesis and external transfixation. Secondary operations were always performed as a second look in all patients and various surgical reconstructions of the soft tissue coverage under continuous protection of the external fixation. Most patients obtained satisfactory functional results, only 2 cases ended up with arthrodesis due to deep infection.     

四肢主干血管急性损伤的诊治

目的 对３０８例四肢主干血管急性损伤进行回顾分析。方法 本组共３０８例,其中开放性损伤１８１例,闭合性损伤１２７例。男２９９例,女９例。年龄最大６２岁,最小６岁,平均２４．５岁。对该种损伤患者尽早施行手术清创、探查。具体修复方法为：（１）单纯修补缝合受损的血管。（２）血管端端吻合术。（３）血管移植。结果 ３例因吻合口血栓形成发现较晚而截肢。１例因肢体血循环重建时间较长,术后出现骨筋膜室综合征肾功能     

Civilian Extraperitoneal Rectal Gunshot Wounds: Surgical Management Made Simpler

Background Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. Methods The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. Results Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. Conclusions Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.     

Complications of regional anesthesia and acute pain management

Perioperative nerve injuries are recognized as a complication of regional anesthesia. Although rare, studies suggest the frequency of complications is increasing. Risk factors include neural, traumatic injury during needle or catheter placement, infection, and choice of local anesthetic solution. Neurologic injury due to pressure from improper patient positioning, tightly applied casts or surgical dressings, and surgical trauma are often attributed to regional anesthetic. Body habitus and preexisting neurologic dysfunction may also contribute. The safe conduct of regional anesthesia involves knowledge of patient, anesthetic, and surgical risk factors. Early diagnosis and treatment of reversible etiologies are critical to optimizing neurologic outcome.     

Classification and management of acute wounds and open fractures

Open fractures and traumatic wounds represent a surgical challenge due to the risk of infection that can, at the extreme threaten life and limb but more commonly limit options for reconstruction. The treatment of these wounds requires removal of contamination and non-viable tissue in a way that minimizes further tissue damage, because healthy tissue in the wound bed is essential for microbial eradication. In more high-energy and complex wounds, particularly those associated with fractures, treatment requires a combined approach from both orthopaedic and plastic surgical teams. Initial surgical treatment is an urgent priority and must involve senior surgeons from both specialities. This combined approach can maximize potential for reconstruction and rehabilitation while minimizing risk of complications like infection and amputation. However, this combined approach requires significant resources and therefore these injuries should be managed in specialist centres appropriately staffed and resourced.     

Surgical management of complex fractures of the distal femur

Fractures of the distal femur are often complex injuries presenting numerous potential complications. The surgical management of these difficult injuries is based on classification, patient selection, and preoperative planning. The surgical approach and modified extensile approach include four fixation devices. The results with 63 patients and 68 injuries reviewed over a ten-year period consisted of 76% good to excellent results, five malunions, and a 4.4% infection rate.     

Classification and management of acute wounds and open fractures

Open fractures and traumatic wounds represent a surgical challenge due to the risk of infection. At the extreme this is life and limb threatening but, more commonly, this limits options for reconstruction - which can have severe functional implications for a patient's rehabilitation. The treatment of these wounds requires removal of contamination and non-viable tissue in order to minimize further tissue damage, which has been covered by a series of guidelines developed by the British Orthopaedic Association. In high energy and complex wounds that are associated with fractures, treatment requires a combined Orthopaedic and Plastic Surgery approach. Initial surgical treatment is a priority and must involve senior surgeons from both specialties. This combined approach maximizes potential for reconstruction and rehabilitation while minimizing risk of infection and amputation; however, this combined approach also requires significant resources. These injuries should be managed in specialist centres, appropriately staffed and resourced, as facilitated by Major Trauma Centres.     

The microbiology and risk of infection following open, agricultural upper extremity injuries

PURPOSE: This study was designed to determine the microbiology and risk of infection following open, agricultural, upper extremity injuries. Specifically, we sought to evaluate the microbiology of the wounds at the time of initial treatment and the development of any subsequent infections, determine whether the development of subsequent infection was related to injury severity, and clarify whether the microorganisms isolated at the time of initial treatment and development of subsequent infection were susceptible to the initial antibiotic prophylaxis. METHODS: A retrospective chart review of 214 patients was conducted. RESULTS: The initial injuries were classified into 1 of 3 groups, with 1 being the least severe and 3 being the most severe. Twenty-six were type 1 injuries, 94 type 2, and 94 type 3 injuries. Forty patients developed infection following the injury. Seventeen had superficial wound infection, 16 had deep soft tissue infections, and 7 developed osteomyelitis. Six went on to an amputation due to infection. Fifteen of the infections were polymicrobial. The number of patients who developed infection in the first 6 months following injury was 2, 14, and 24 for type 1, 2, and 3 injuries respectively (p=.07). CONCLUSIONS: Empiric antimicrobial regimens for the management of infection requiring surgical debridement following open upper extremity agricultural injury should be active against staphylococci, aerobic gram-negative bacilli, and anaerobes, but not necessarily against fungi. These antibiotics ideally should be administered on initial presentation of the patient to the emergency department. Prospective studies with emphasis on timely acquisition of cultures and sensitivities are needed to determine optimal prophylactic antimicrobial therapy for these injuries and directed antibiotic regimens for the infections that may develop. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.     

A case of brain abscess due to Entamoeba species, Eikenella corrodens and Prevotella species

We report a case of brain abscess due to multiple pathogens including Entamoeba species, Eikenella corrodens and Prevotella species. Patient had odontogenic infection without any site of amoebic infestation. Complete recovery was achieved with surgical treatment and antimicrobial therapy.     

Classification and management of acute wounds and open fractures

Open fractures and traumatic wounds represent a surgical challenge due to the risk of infection. At the extreme this is life and limb threating, but more commonly, it limits the options for reconstructions which can have functional implications for a patient. The treatment of these wounds requires removal of contamination and non-viable tissue in order to minimize further tissue damage. A wound bed of healthy tissue is essential for microbial eradication. In high energy and complex wounds associated with fractures, treatment requires a combined orthoplastic approach. Initial surgical treatment is an urgent priority and must involve senior surgeons from both specialties. This combined approach maximizes potential for reconstruction and rehabilitation while minimizing risk infection and amputation. However, this combined approach requires significant resources. Therefore, these injuries should be managed in appropriately staffed and resourced specialist centres, in practice this normally means treatment in a major trauma centre.     

四肢主干血管急性损伤的外科处理

目的 探讨四肢主干血管急性损伤的外科治疗方法。方法 回顾性分析我院收治四肢主干血管急性损伤患者100例。共行手术106次,其中行血管移植58条(人造血管移植40条,大隐静脉移植18条),血管断端直接吻合44条,血管裂口修复28条,单纯动脉结扎2条。结果 治愈94例,无血栓形成及肢体缺血。1例大隐静脉移植术后移植段静脉血栓形成,1例切口感染,3例下肢因挤压伤致大面积肌肉坏死,均治愈,另1例右小腿远端缺血截肢。结论 正确的现场处理、精细的血管外科技术、血管移植材料的合理选择是提高治疗效果的关键。     

Digital nerve injuries in orthopaedic surgeons

Accidents during a surgical procedure can occur to both the surgeon and the patient. In order to assess the occurrence of hand injuries amongst surgeons a survey of digital nerve injuries was carried out. The incidence (15%) was disappointingly high and the majority of penetrating injuries occurred during surgery. The risk of infection to both patient and surgeon is emphasized.     

The impact of violent injuries on an NHS plastic surgery unit

BACKGROUND: Violence and injuries caused by violence appear to be increasing. PATIENTS AND METHODS: A prospective study of violent injuries treated in our unit. RESULTS: Over a 5-month period, 148 (21%) of 704 acute admission patients aged 14 years or more and 11 children had injuries due to violence. The head, neck and hands were the commonest sites of injury. Of the 148 patients, 144 (91%) underwent surgery for their injuries. CONCLUSIONS: Injuries due to violence have a significant effect on the resources of our NHS hospital and probably of all NHS hospitals with acute surgical services.     

Kriegschirurgische Versorgung von Gef??verletzungen der Extremit?ten

Delivery of combat health support means a challenge for personnel and material. Past military conflicts have provided lessons for civilian surgical practice, whereas nowadays civilian experiences influence military surgical practice in the austere environment of today??s battlefield. Due to high explosives, ammunition and high-velocity missiles and also improved body armor, military surgeons have to deal with devasting extremity trauma, which has not been seen routinely in former conflicts because survival was not possible due to core injuries. Extremity injuries represent 50?C75% of all injuries sustained by soldiers and 15% of wounded soldiers die of exsanguination from extremity wounds. The bleeding from some of these injuries can be arrested by a tourniquet, direct pressure and/or hemostatic dressing application in the field allowing for casualty evacuation. Nevertheless, 4.4?C7% of all injuries need definitive vascular surgical treatment because of ongoing life and limb-threatening hemorrhaging and ischemia. From routine ligation of vascular injuries in World Wars I and II surgeons adapted to principles of in-theater repair of arterial and venous injuries in Korea and Vietnam. Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) provided the first opportunities since Vietnam for the development of a registry of vascular injuries, the re-evaluation of established vascular surgical principles under austere conditions and adaptation where necessary. The aim of the following article is to provide information on the current management of wartime vascular injuries on the basis of U.S. experiences in the on-going conflicts OIF/OEF.     

Management of soft tissue injury.

The fate of a surgical wound is held in a delicate balance between the host's resistance to infection and the causal factors of infection. Considerable insight into this relationship between the host and pathogen can be gained from the results of quantitative bacteriologic measurements. Newer rapid slide techniques have been developed which provide the surgeon with this information within 20 minutes. In most soft tissue injuries, the wound bacterial count gives an accurate prediction of subsequent infection. Wounds combining greater than 10(5) bacteria per gram of tissue are destined to develop infection. When the bacterial count is below that level, the wounds will usually heal per primam without infection. This large number of bacteria required to elicit infection reflects the remarkable ability of soft tissues to resist infection. This state of high resistance to infection can be reduced by several factors which include circulatory embarrassment, tissue injury, dead space, and the presence of foreign bodies (dirt, sutures, drains, etc.). When treating soft tissue injuries, the surgeon must employ specific therapeutic modalities that allow the wound to heal per primam without infection. On the basis of experimental studies supported by clinical experience, the following treatment protocol for soft tissue injuries is recommended. Using strict aseptic technique, the wound must be first anesthetized with 1 per cent Xylocaine to permit painless sound cleansing. All wounds should be subjected to high pressure syringe irrigation to remove bacteria, foreign bodies, and blood clots. When necessary, debridement of all devitalized tissue should be performed with a stainless steel scalpel. Many wounds caused by sharp wounding agents contain no foreign bodies and few bacteria and exhibit considerable resistance to infection. In these wounds, primary closure can be initiated after irrigation without the development of infection. Wounds resulting from impact forces have a diminished resistance to infection and are susceptible to infection by low level of bacterial contamination. Immediate antibiotic treatment of patients with impact injuries subjected to meticulous debridement and cleansing will permit a safe primary closure. In wounds contacted by pus or feces, open wound management followed by delayed primary closure is usually indicated. Antimicrobial prophylaxis is also recommended for patients with such wounds. Ideal postoperative care of all traumatic wounds includes a surgical dressing and immobilization and elevation of the site of injury.