Thoracoabdominal injuries in the athlete

Although thoracoabdominal injuries are uncommon in the athlete, they can be catastrophic if unrecognized or if diagnosis and treatment are delayed. This article reviews thoracic, intrathoracic, abdominal, and groin injuries in the athlete, and how they can be diagnosed and managed.

Serious and fatal air gun injuries: more than meets the eye

OBJECTIVE

To describe the epidemiology of air gun injuries to children that required hospitalization.

DESIGN

A consecutive series of children with air gun injuries.

SETTING

Urban pediatric teaching hospitals in Cincinnati, OH; Kansas City, MO; and Seattle, WA.

METHODS

A retrospective chart review.

RESULTS

A total of 101 children were studied: 81% were male; 80% were white, 18% were black, and 2% were other races. The median age was 10.9 years (range, 0.5 to 18.8). Victims were most commonly shot by a friend (30%) or sibling (21%). A total of 34% occurred at the victim's home, and 36% occurred at the home of a friend or relative. Although 71% of shootings were unintentional, 5% were assaults, and 1% were suicides. The median hospital stay was 3 days (range, 1 to 17 days). Fifteen children (15%) required treatment in intensive care. A total of 56% required at least one surgical procedure. Forty-nine had injuries to the head, including 38 with injuries to the eye, 10 with intracranial injuries, and 1 with a skull injury. Fourteen children were shot in the neck; 15 were shot in the chest, with 2 patients sustaining lacerations of the pericardium and 1 having a right ventricular foreign body. Another child had a laceration of the innominate artery. Nineteen had abdominal injuries, including laceration of the stomach (N = 3), small bowel (N = 4), colon (N = 2), and liver (N = 3). Three of 10 children with intracranial injuries died. Two had long-term neurologic deficits. Of children with eye injuries, 25 (66%) had permanent visual loss and 15 (39%) of these were blind.

CONCLUSION

Air guns are associated with serious and fatal injuries. Families should be counseled that air guns may cause serious injuries and even death. Furthermore, pediatric care givers should advocate for increased regulation of air guns and expansion of safety standards.

[Ultrasound scanning of abdominal contusions in children: experience at the Yopougon CHU (Ivory Coast)]

Ultrasound scans were used to study 23 cases of abdominal contusion in children, between January 1992 and December 1993. Thirteen boys and 10 girls were studied. They were all aged between 4 and 14 years, with a mean age of 6 years. The main causes of their injuries were road accidents (12 cases) and play (11 cases). Ultrasound scans were normal in 6 patients and pathological in 17 patients. The most frequently observed injuries were visceral effects (12 cases), almost always associated with hemoperitoneum. In three cases, hemoperitoneum was detected in the absence of visceral effects. The spleen (4 cases) and the liver (4 cases) were the most frequently injured organs. The other injuries detected included renal hematoma, bladder rupture and parietal hematoma. Diagnosis on the basis of ultrasound scans was found to be incorrect in three cases where diagnosis was repeated after the scan. One case involved a blocked perforation of the rectum, one a benign cyst and the other a mesenteric cyst. Despite these misdiagnoses, ultrasound scanning is a highly sensitive and specific method for examination of contusions in children. It is very useful and often sufficient for accurate diagnosis, particularly in units with only modest technical support.

Comparison of computed tomography and ultrasonographic imaging in the assessment of blunt abdominal trauma in children

BACKGROUND

Computed tomography (CT) has become established in the assessment of paediatric blunt abdominal trauma. However, advances in diagnostic imaging necessitate reassessment of the role of available diagnostic modalities.

METHODS

Experience at a paediatric teaching hospital over a 5-year period was reviewed, with direct comparison of CT against ultrasonographic imaging in 26 children presenting with acute blunt abdominal trauma.

RESULTS

Intra-abdominal injury was diagnosed by CT in 23 of 24 patients compared with 21 on ultrasonography, although ultrasonography identified organ-specific injury in only 12 of 24 patients. CT was superior in the assessment of the multiply injured child, and identified spinal and pelvic injuries in three patients. CT augmented plain chest radiography in ten patients with associated thoracic injuries.

CONCLUSION

CT is the imaging modality of choice in children with severe abdominal trauma but ultrasonography is a reasonable technique to arouse diagnostic suspicion in less severe injuries or where CT is unavailable or delayed.

Hepatic venous injury; a case report of atriocaval shunt by a centrifugal pump

Injury of hepatic vein confluence and retrohepatic vena cava is serious and often fatal. We report one such case that was successfully treated by the Biopump (Medtronic Bio-Medicus, Inc., Eden Prairie, Minn). A 21-year-old man was admitted due to a steering-wheel injury in a motor vehicle accident. CT scan showed extravasated contrast material around the right hepatic lobe, and a large low density area in the right hepatic lobe adjacent to the inferior vena cava, suggesting injury of the hepatic vein confluence or the retrohepatic vena cava. The patient underwent surgical treatment. Laceration of the liver was extended to the hepatic vein confluence. Right hepatic lobectomy and repair of the middle hepatic vein was successfully performed under atriocaval shunting by the Biopump.

Handlebar injuries in children: patterns and prevention

BACKGROUND

Bicycle handlebar injuries in children are a significant cause of abdominal trauma. The present study documents 32 children with handlebar injuries who were managed at the Royal Children's Hospital over a 5-year period, and suggests a design change to bicycle handlebars which may reduce the severity of injury.

METHODS

A retrospective review of all the children admitted to the Royal Children's Hospital with handlebar injuries between January 1990 and January 1995 was undertaken. The age, sex, nature of injury, length of hospital stay and management were recorded.

RESULTS

Thirty-two children with blunt abdominal trauma or lacerations resulting from handlebar injuries were identified. Injuries included: splenic trauma (9); liver trauma (4); traumatic pancreatitis (3); transection of the pancreas (2); renal contusions (2); duodenal haematoma (1); and bowel perforation (3). In addition, there were three urethral injuries and five lacerations involving the abdominal wall and inguino-scrotal region. The presence of external bruising was a poor indicator of underlying brgan damage. Thirteen operations were performed and the mean hospital stay for the series was 9 days.

CONCLUSIONS

Handlebar injuries are a significant cause of both blunt abdominal trauma and lacerations to the contact area. The infrequent finding of external bruising in the presence of major organ damage suggests that, although the velocity at impact may be relatively low, the small cross-sectional area of the end of the handlebar is a major factor contributing to organ damage. Moreover, we suspect that the high proportion of lacerations observed in this type of trauma result from the sharp metallic end of the handlebar cutting through the soft rubber handle. Manufacturers of bicycles should be made aware of these findings and should adjust the design of the handlebars accordingly.

[Duodenopancreatic injuries. Apropos of 30 cases]

We present a retrospective study of 30 cases of duodenopancreatic injuries seen between 1985 and 1995. All injuries were due to blunt trauma mostly in traffic accidents. They include 16 duodenal injuries, 7 pancreatic injuries and 7 combined duodenopancreatic trauma. All patient were operated for peritonitis or state of shock. Preoperative diagnosis was evoked in two cases (6%). Isolated duodenal trauma (30%) were treated by primary repair and drainage, while pyloric exclusion was performed for five patients (17%), distal pancreatectomy in one case (3%), duodenojejunostomy with pancreatic jejunostomy in one patient (3%). In three patients (10%) isolated pancreatic trauma were treated by drainage, cystogastrocotomy in two cases (6.6%). There were nine deaths (30%) due to the severity of associated injuries, a false diagnosis, or incomplete initial treatment. Poor outcome was mostly due to delay in the diagnosis and associated intra-abdominal injuries. A precise diagnosis of the duodenopancreatic trauma allows an appropriate therapeutic strategy avoiding subsequent complications.

Single rope tree swing injuries among children

OBJECTIVE

To examine the scope and severity of injuries sustained from falls from single rope tree swings among children.

METHODS

Twenty-six children formed the basis of this retrospective study. Patients were divided into three groups based on the estimated distance of their fall (one, two, or three stories). Data were analyzed with respect to mechanism of injury, age, gender, length of hospital stay, injury severity score, number and type of injuries, and mortality.

RESULTS

Eighteen patients fell from ropes, and 8 from vines (all onto packed dirt). Fourteen falls occurred from one story or less, 8 from two stories, and 4 from three stories. One death occurred from intracranial injury following a two-story fall. No difference in age, gender, injury severity score, or length of hospital stay with respect to the height of the fall was observed. Falls from lower heights resulted in equally severe injuries as falls from higher heights. Overall, head trauma was the most common injury (58%) followed by long bone fractures (42%), axial skeletal fractures (23%), and intra-abdominal visceral injuries (8%).

CONCLUSIONS

The present study demonstrated that recreational single rope tree swing injuries among children resulted in significant morbidity regardless of the height of the fall. This activity carries a substantial risk for serious injury. The mechanism of injury, clinical data, and the importance of medical awareness and patient education are emphasized.

Gunshot wounds to the buttocks: predicting the need for operation

BACKGROUND

Gunshot wounds to the buttocks may cause significant intra-abdominal injuries. Policies of aggressive abdominal exploration or extensive diagnostic testing have been suggested to avoid delays in treatment and consequent morbidity. Our group has recently suggested that clinical examination is a safe and reliable tool for triaging patients with anterior and posterior abdominal gunshot wounds.

OBJECTIVE

This study was undertaken to test the hypothesis that patients with gunshot wounds to the buttocks can be managed selectively on the basis of clinical findings.

SETTING

A large academic Level I trauma center was the setting for this study.

PATIENTS AND METHODS

Fifty-nine consecutive patients, suffering from gunshot wounds to the buttocks with potential retroperitoneal trajectories, were managed during a 12-month period in our center.

RESULTS

Based on clinical findings, 19 (32.2 percent) patients were operated on, with significant intra-abdominal injuries in 17 (28.8 percent). The remaining 40 (67.8 percent) patients were successfully observed. There were no missed injuries or delays in diagnosis. Sensitivity and specificity of clinical examination for identifying significant intra-abdominal injury was 100 percent and 95.3 percent, respectively.

CONCLUSION

Clinical examination is a safe method for selecting patients with gunshot wounds to the buttocks for nonoperative treatment.

Traumatic uterine prolapse

The rare complication of complete uterine prolapse can occur after a motor vehicle accident. One could speculate that a sudden increase in intra-abdominal pressure related to the trauma and seat belt position lead to this condition.

Diagnosis of injuries after stab wounds to the back and flank

BACKGROUND

Historically, patients with deep posterior wounds underwent a formal celiotomy to rule out injury. Currently, we use a policy of selective management. The purpose of this review is to evaluate our experience with selective management to identify potential areas of further improvement.

METHODS AND RESULTS

This study includes 203 patients over a 10-year period. By changing from a policy of mandatory exploration to selective management the total celiotomy rate decreased from 100 to 24% and the therapeutic celiotomy rate increased from 15 to 80%.

CONCLUSIONS

In stable patients, a diagnostic peritoneal lavage should be performed as the initial diagnostic study. When diagnostic peritoneal lavage is negative, triple contrast computed tomography should be performed to evaluate the remaining retroperitoneal structures. Any suggestion of pericolonic extravasation of contrast or air, edema, or hemorrhage must be interpreted as a positive study and prompt consideration for operative exploration.

Seat belt-induced intestinal perforation

OBJECTIVE

To determine whether a relationship exists between bowel perforation and seat belt use in patients presenting abdominal trauma after traffic accidents.

EXPERIMENTAL DESIGN

We prospectively studied every patient admitted to the emergency room with abdominal trauma after a traffic accident.

PATIENTS AND METHODS

We included every patient diagnosed (clinically, by ultrasound or computerized tomography or at laparotomy) as suffering intraabdominal injury. The degree of trauma was classified according to the Injury Severity Score, taking into account the number of abdominal injuries associated with mortality and seat belt use.

RESULTS

A total of 146 patients were studied. The spleen was the most frequently injured organ (n = 56). The mean Injury Severity Score was 19. Head injuries were more common among patients not wearing the seat belt. Thirteen cases of bowel perforation in patients who had been using the seat belt (p < 0.0001) were observed.

CONCLUSION

Seat belt use can decrease the mortality rate associated with traffic accidents. However, a significant increase exists in the incidence of bowel perforations among seat belt wearers, probably as a result of improper use.

A nationwide analysis of laparoscopic complications

OBJECTIVE

To evaluate the nationwide incidence of laparoscopic complications, as the number of demanding gynecologic laparoscopic procedures increases worldwide.

METHODS

The National Patient Insurance Association was founded in 1987 in Finland. All major complications are reported to the Association because it handles financial compensation for patients' injuries without proof of malpractice. We analyzed 256 complications following laparoscopic procedures occurring in 1990-1994. There were 160 minor complications, which were defined as mild infections, mild hemorrhages, and failed sterilization. In all, 96 major complications occurred, including intestinal, urinary tract, and vascular injuries. The number of gynecologic laparoscopies (70,607 procedures) was obtained from the Finnish Hospital Discharge Register.

RESULTS

The total complication rate was 3.6/1000 procedures, and the rate of major complications was 1.4/1000 procedures. In diagnostic laparoscopies, the annual major complication rate was constantly below 0.6/1000, and in sterilization, it was below 0.8/1000. In operative laparoscopies, major complications increased from 0/1000 in 1990 to 10.5/1000 in 1993 and leveled to 10.1/1000 in 1994. In all, intestinal injuries occurred in 0.6/1000, ureteral injuries in 0.3/1000, bladder injuries in 0.3/1000, and vascular injuries in 0.1/1000 laparoscopic procedures.

CONCLUSIONS

Diagnostic and sterilization laparoscopies appear to be safe, but more complex laparoscopies are associated with an unacceptably high number of serious complications requiring continuous follow-up and expertise.

Monkey bites: a public health problem in urban setting

Animal bites constitute an important public health problem. Monkey bites accounted for 8.8% of total animal bites (1987-1991) treated in Postgraduate institute of Medical Sciences, Rohtak. It was noted that monkeys are becoming the second most common animal to inflict bites. The hospital data revealed that 63.5% of the total animal bites belonged to class-III type. The article also details two case studies of monkey bites.

Multiple impalement with survival

An unusual case of multiple impalement by chain-link fence posts is presented in which facial, thoracic, and abdominal injuries were sustained following a rollover motor vehicle crash. Torso impalement injuries are briefly reviewed and guidelines for the management of such injuries are described.

Laparoscopy in pediatric abdominal trauma

BACKGROUND

The use and indications for laparoscopy have been increasing. As part of this trend, a new algorithm may emerge for pediatric trauma in which laparoscopic techniques are used in hemodynamically stable patients with suspected hollow viscus perforation.

CASE REPORT

We present a case in which laparoscopy was successfully used in a pediatric trauma patient as a diagnostic and therapeutic modality. A 4-year-old boy was a back-seat passenger in a head-on collision motor vehicle accident. He was restrained by a lap seat belt. He sustained a concussion, a large forehead laceration and a seat belt abdominal injury. On admission, he complained of abdominal pain. Physical examination revealed a soft, non-distended abdomen with moderate diffuse tenderness. He was hemodynamically stable. Computerized tomography of the abdomen revealed free fluid in the pelvis. No abnormalities were detected in the liver or spleen. Because of clinical deterioration and suspected intestinal perforation, diagnostic laparoscopy was utilized instead of proceeding directly to celiotomy. At laparoscopy a jejunal perforation was found and successfully repaired laparoscopically. Large hematomas were seen in the mesentery, as well as an unsuspected splenic laceration. No active bleeding was found. The patient recovered uneventfully and was discharged 5 days following the surgical procedure.

CONCLUSION

This case illustrates the efficacy of using early laparoscopy in children with abdominal trauma when diagnosis is difficult and hollow viscus injury is suspected.

[The surgical procedure in left-sided thoracoabdominal knife wounds]

An experience with surgical treatment of 136 patients with left-side thoracoabdominal knife wounds has shown that all the patients can be divided into two groups: transpleural wounds (111 cases or 81.7%) and extrapleural wounds (25 cases or 18.3%). Symptoms of extrapleural wounds (medial and lateral) are described. Injuries to organs of the abdominal cavity were shown to depend on the localization of the diaphragm wound. It was found that in patients with wounds to the posterior cupula there were only injuries of organs fixed in the subdiaphragmatic space.

Abdominal wounds in war

The reported mortality rate associated with abdominal wounds sustained in war varies considerably because of the heterogeneity of wounds and the different circumstances under which figures have been collected rather than different treatment strategies. This review draws together a personal experience, reports from ten wars, and information from a database for war wounded into an analysis of abdominal wounds. The analysis attempts to bring understanding to why people die with abdominal wounds in war and so clarifies logistic and treatment issues.

Air-powered guns: too much firepower to be a toy

OBJECTIVE

This study reviews our experience and calls attention to the potential danger of air-powered guns.

DESIGN

Retrospective analysis.

MATERIALS AND METHODS

Review of patients with air-powered gun-injuries admitted to a Level I trauma center and air gun deaths reported to the United States Consumer Product Safety Commission over a 5-year period ending July 1994.

RESULTS

Sixteen children (median age 10) were admitted after sustaining BB or pellet gun injuries. Three children had cranial penetration; one remains severely brain impaired. One of two thoracic injuries required left ventriculorrhaphy. All five children sustaining abdominal wounds underwent laparotomy for enteric perforations; one was complicated by an intra-arterial pellet embolus. Three of five children with neck wounds had penetrating tracheal injury. Overall nine children required operative intervention. No deaths occurred in our series, but there were 33 air gun deaths reported to the United States Consumer Product Safety Commission during this period.

CONCLUSION

Our data demonstrate that injuries from air-powered guns should be treated in a manner similar to those from low velocity powder firearms. We can no longer continue to underestimate the potential for life-threatening injury from these weapons.