[Specialized surgical aid in peace-time firearm wounds of thorax and abdomen]

The experience with 504 cases of fire-arm wounds of the thorax and the abdomen in peace-time, peculiarities of organization of surgical aid and management of victims in conditions of a big city are reviewed. Principal difference with war-field tactics of surgeons is shown.

[Rare intra-abdominal complications of a ventriculoperitoneal shunt: report of three cases]

Three cases of rare intra-abdominal complications of ventriculoperitoneal shunt (VPS) surgery are reported. Case 1 was a 32-year-old male who had undergone VPS surgery for hydrocephalus following meningitis on July 10, 1980. Two weeks later he developed fever and a cystic mass about 10 cm in diameter in the right hypochondrium. Shuntography and a barium enema study demonstrated a pseudocyst at the distal end of the shunt. The cyst wall was excised, the peritoneal tube removed, and VPS converted to a ventriculoatrial route following which the pseudocyst resolved. Case 2 was a 49-year-old female who developed hydrocephalus following subarachnoid hemorrhage, and VPS surgery was performed on March 10, 1989. Two weeks later, she developed fever and right upper abdominal pain. Abdominal x-ray and CT scan revealed a right subdiaphragmatic abscess. The abscess was drained and the shunt system was removed on April 4. VPS was placed again on April 21 without further complications. She was symptom free for the next 7 years. Case 3 was a 57-year-old female who presented in a semicomatose state after falling from bed on May 5, 1995. CT scan showed left-sided acute subdural hematoma (ASDH) for which surgery was performed. Her neurological status improved postoperatively. She eventually developed hydrocephalus and left-sided subdural effusion for which right VPS and left subduroperitoneal shunt (SPS) surgery was performed on January 25, 1996. The peritoneal end of the tube of the SPS protruded out of the anus one and a half year after shunt placement. The entire SPS system was removed as there was no more collection in the subdural space. We reviewed the literature and discussed the pathophysiology involved in the development of intraabdominal complications following VPS.

Fatal intra-abdominal injury associated with incorrect use of a seat belt

Images

[Posttraumatic duodenal lesions in children. The therapeutic considerations]

The posttraumatic lesions of the duodenum in children represent rare cases in the surgical field. 4 cases of duodenal lesions were registered and operated upon in the Pediatric Surgery and Orthopedic Clinic, in cooperation with the ICU Clinic, 2 of them having postoperative complications (duodenal fistulae), these cases being initially situated in a retroperitoneal position (lateral and posterior). The ICU therapy was directed in the first step towards the traumatic and septic shock, in the second one to the immediate postoperative care and in the third step towards late complications. For the 2 cases having postoperative complications, the care was directed towards the elements of local complications (retroperitoneal abscess, fistulae), MSOF, sustaining the immune system correcting the nutritional deficiencies. Surgical methods used for sustaining the ICU therapy were: endovenous catheterisation, gastro-duodenal aspiration, solving the fistulae through catheters and suture. The results, using the methods described above, were good.

[Management of combined thoracoabdominal wounds]

Last years in the country gace rise to the problem of treatment of fire-arm's wounds in civil population. The results of treatment of victims with firearm thoracoabdominal wounds have evidenced unprepareness of surgeons for rendering specialized aid in conditions of "military-urban" surgery. The study performed by the authors has shown that there are substantial and principal differences between many postulates of war-field surgery and "military-urban" surgery. It consists in early hospitalization of victims with combined thoraco-abdominal injuries, prevalence of bullet wounds over fire-mine explosive injuries which have an effect on the extent of surgical intervention, results of treatment and development of complications. The proposed treatment modalities in victims with combined penetrated thoracoabdominal injuries in great measure may contribute to optimization of surgical aid in conditions of "military-urban" surgery.

Patterns of injury in belted and unbelted individuals presenting to a trauma center after motor vehicle crash: seat belt syndrome revisited

STUDY OBJECTIVE

Investigators have described a "seat belt syndrome" consisting variously of injuries to the lumbar or cervical spine, abdominal contents, or all 3. In this study we sought to identify these and any other patterns of injury associated with seat belt use in patients who presented to a trauma center after a motor vehicle crash.

METHODS

The charts of all patients involved in motor vehicle crashes who presented as trauma alerts to the study institution between January 1, 1991, and December 31, 1993, were retrospectively reviewed for data regarding belt use and 35 specific injuries in 7 body regions. We calculated the positive likelihood ratio of injury between belted and unbelted patients, along with 95% confidence intervals.

RESULTS

We identified 1,124 patients involved in motor vehicle crashes. Of these subjects, 376 were belted and 544 unbelted; in 204 belt status was unknown. Belted patients were more likely to have sustained sternal fracture than were unbelted patients (4% versus .7%; positive likelihood ratio, 1.97; 95% confidence interval, 1.09 to 3.29) but were less likely to have sustained head injury (30.6% versus 46.0%; positive likelihood ratio, .67; 95% confidence interval, .53 to .83). We noted no statistically significant differences in the rates of other specific injuries, including cervical and lumbar fractures and the need for abdominal surgery.

CONCLUSION

Severe injuries of all types occur in both belted and unbelted individuals involved in motor vehicle crashes who present to a typical trauma center. With the exception of sternal fractures, injuries previously associated with the seat belt syndrome occurred in similar proportions of belted and unbelted patients. Head injuries were less frequent. Seat belt use cannot serve as a discriminator for specific injury. A diligent search of all body regions is indicated in both belted and unbelted patients.

Hidden spears: handlebars as injury hazards to children

OBJECTIVES

To delineate the mechanism of serious bicycle handlebar-related injuries in children and make recommendations for preventive strategies.

METHODS

Prospective cross-sectional surveillance system of seriously injured child bicyclists supplemented by in-depth, on-site crash investigation to delineate specific injury mechanisms. Interdisciplinary analyses involved engineers, clinicians, epidemiologists, and biostatisticians.

SETTING

The emergency department and in-patient trauma service of an urban level one pediatric trauma center between October 1995 and September 1997.

PARTICIPANTS

Patients under 18 years of age who were treated for serious bicycle-related injuries (Abbreviated Injury Scale scores of 2 or greater).

RESULTS

The surveillance system identified two distinct circumstances for serious child bicyclist injury: 1) handlebar-related injuries associated with minor incidents (falls from bicycles) and 2) nonhandlebar-related injuries associated with severe incidents (bicycle-motor vehicle crashes). Crash investigations explored the minor incidents that resulted in serious handlebar-associated injuries. In the typical mechanism, as the child lost control of the bicycle and began to fall, the front wheel rotated into a plane perpendicular to the child's body. The child then landed on the end of the handlebar resulting in serious truncal injuries.

CONCLUSIONS

A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. Recognition of the mechanism of handlebar-related injuries might aid the practitioner in early diagnosis of serious abdominal injuries in child bicyclists. This injury mechanism may be avoided through bicycle redesign that would involve both limiting rotation of the front wheel and modifying the ends of handlebars. An integrated approach involving a surveillance system to identify an injury hazard supplemented by in-depth, on-site crash investigations effectively provided the detailed mechanism of injury needed to develop interventions.

Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse)

Rib fractures are a common skeletal manifestation of non-accidental injury (NAI) in infants and young children and are generally considered to be highly specific for abuse. There are, however, relatively few descriptions of fractures involving the costochondral junctions in NAI. We present three children (two boys, one girl; 7, 18, and 36 months of age) with anterior rib fractures which involved the sixth to ninth costochondral junctions. The fractures were bilateral in two children and symmetrical in one. They had appearances analogous to 'bucket handle' metaphyseal fractures of long bones. They were difficult to visualise and healed with minimal callus formation. These fractures were associated with major abdominal visceral injuries, which in themselves carry a significant morbidity and mortality. The importance of recognising such fractures is highlighted.

Computed tomography for blunt abdominal trauma in the ED: a prospective study

A study was undertaken to determine the criteria for ordering abdominal computed tomography (CT) in the emergency department (ED) for stable patients who sustained blunt trauma and to identify a patient population at high risk for having intra-abdominal injury (IAI) utilizing physical examination, decrease in hematocrit, and hematuria. Patients in a university ED who had abdominal CT from April 1995 to October 1995 were evaluated prospectively. Before the scan, the examining physician completed an entry form that included physical findings, hematocrit, hematuria, Glasgow Coma Scale score, intoxication, distracting injuries, reasons for obtaining the scan, and planned disposition. Patients were followed until discharge. A total of 196 patients were evaluated. Abdominal tenderness was present in 120 patients. Twenty-two patients had IAI. Eight required surgical intervention, and all 8 had abdominal tenderness. A total of 40 potential trauma admissions were averted by obtaining CT within the ED. The combined abnormal abdomen examination and presence of hematuria had a sensitivity of 64%, specificity of 94%, positive predictive value of 56%, and negative predictive value of 95%. Decrease of > or = 5 in hematocrit was not statistically significant for detection of IAI. CT had no false negatives in this cohort. These results show that early CT scanning of stable patients who have sustained blunt trauma is an effective screen for IAI and may result in fewer total admissions, but has potential for overuse. Patients with abdominal pain and hematuria should be scanned. The benefit of a CT scan for patients without tenderness or with an isolated decrease in hematocrit is questionable.

The use of laparoscopy in the diagnosis and treatment of abdominal complications of ventriculo-peritoneal shunts in children

Ventriculo-peritoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. Abdominal complications of VPS are now a rare event; however, their frequency varies from 5% to 47% according to reports. Anything that causes an obstruction or impediment of the VP derivation system will lead to intracranial hypertension, which requires immediate surgery. From 1985 to 1995 at the Division of Pediatric Surgery of the Federico II University of Naples, ten laparoscopies were performed in ten children with VPS complications. Cerebrospinal fluid pseudocysts were found in four infants. There was one case of abdominal wall perforation by the tip of the catheter at the umbilical level, two bowel obstructions, and one catheter was lost in the abdominal cavity. Finally, two children had malfunctioning of the peritoneal limb of the catheter. The laparoscopic technique was curative in all ten cases, thus avoiding a conventional laparotomy and the consequent risk of adhesions, which could cause further complications.

An unusual domestic accident: a penetrating abdominal wound with intestinal evisceration in a child

We report a penetrating abdominal injury due to a piece of glass, a very unusual domestic accident, in a 2-year-old boy who was admitted to the emergency department with an evisceration through the umbilicus. His mother reported that she was asleep when the boy came to her room, and did not know how it had happened. We primarily suspected child abuse, but the presence of a piece of glass in the boy's heel led us to think of a domestic accident. He had poured himself a glass of water, and then fell on the glass. We could not find a similar case in the literature on domestic accidents.

Hollow visceral injury and blunt trauma

BACKGROUND

The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis.

METHODS

A 9-year trauma registry review of all patients with HVI.

RESULTS

A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05).

CONCLUSION

HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.

Utility and cost-savings of diagnostic laparoscopy in low-probability gunshot wounds of the abdomen

Gunshot wounds of the abdomen are associated with a 90% or greater incidence of intra-abdominal injury, prompting many trauma centers to routinely explore these patients via laparotomy. Increasingly, diagnostic laparoscopy has been used to evaluated the abdomen to exclude peritoneal violation by the missile. Retrospective analysis of the experience at a Level I Trauma Center with 20 isolated abdominal gunshot wound patients who did not have obvious indications for laparotomy such as peritonitis or shock is detailed. Outcome and cost analysis were compared in patients who had diagnostic laparoscopy or laparotomy. Patients who underwent diagnostic laparoscopy instead of laparotomy had a 42% reduction in operative time, a 33% reduction in hospital charges, and a reduction in hospital length of stay from an average of 3.5 days to less than one day. The only operative complication noted was in a patient who underwent laparotomy. Diagnostic laparoscopy may be used in select patients to exclude significant intra-abdominal injuries following gunshot wounds of the abdomen with reduction in health care costs and morbidity.

[A case of perforating bullet wound of the neck]

We report here a rare case of perforating bullet wound of the neck and abdomen. No injury of the neck's internal organs was found. The patient required surgical debridement of the enterance and exit of the wound only.

[Ischemic stenosis of the small intestine after blunt abdominal trauma]

A case of posttraumatic ischaemic stenosis is presented. The patient, a five year-old girl, was admitted to hospital with physical and radiological signs of small bowel obstruction about two weeks after sustaining blunt abdominal trauma in a car accident. At laparotomy two lesions of the distal jejunum were found. Proximal to this the small intestine was dilated. A segment of 25 cms. of small bowel including the two lesions was resected. Microscopic examination showed two ulcers with adjacent fibrosis consistent with ischaemic stenosis. The patient recovered completely after the operation. The entity of "seat belt syndrome" is presented.

Seatbelt injury to the common iliac artery: case report

In traffic accident victims, the seat belt syndrome is a well known injury which rarely involves the common iliac artery due to its posterior anatomical position and to protection by the pelvis. We report a case of blunt abdominal trauma related to the type of seat belt worn. The trauma provoked subintimal haemorrhaging of the left common iliac artery, without skeletal lesions or other visceral injuries. Correct diagnosis was delayed for three months after the crash, when an angiogram was performed to investigate disabling claudication and vascular pulse change in the left leg. This arterial injury could have been related to the association of two different types of force created during the crash ("compression/deceleration-type mechanism") that might have produced shearing forces causing a vascular wall discontinuity and/or an intimal flap. The authors speculate that the vascular lesion was observed on the same (left) side as the fastening point of the seat belt (a lap-and-shoulder belt with a three-point attachment) where the shearing forces may have been most intense due to the junction between the lap strap and the diagonal shoulder belt.

Spiral computed tomography demonstration of active haemorrhage in blunt abdominal trauma

In blunt abdominal trauma, patients may still be actively bleeding despite being physiologically stable. Fast computed tomography scanning permits the detection of active haemorrhage by localising the site of extravasation of contrast enhanced blood. Though a specific sign of active bleeding, particularly arterial haemorrhage, it is insensitive to the slow, continuous venous oozing associated with retroperitoneal and pelvic skeletal injuries. However, its presence will have a critical influence on further surgical intervention. The imaging features of this uncommon entity are demonstrated in our case report.

Blunt and penetrating trauma--has anything changed?

Management of abdominal trauma has changed significantly in the last decade. The next decade will also see significant change as imaging and minimally invasive surgical techniques evolve and more approaches are examined in well-designed prospective studies.