[A retrospective evaluation of genitourinary system trauma in pediatric patients]

In the present study, 34 pediatric patients who were hospitalized and maintained with urogenital trauma in our department last ten years, were reviewed, retrospectively. Six of them (17.6%) were girls and 28 (82.4%) were boys, and the mean age was 10.1 years (ranged between 2.5-17 years). The causes of injuries were traffic accident in 24 cases (70.6%), full from a height in 9 cases (26.4%) and gun-shot in one case (3%). Traumas involving the kidney, urethra, bladder and, testis were encountered in 13 (38.2%), 13 (38.2%), 4 (11.7%), 3 (8.8%) and 1 (2.9%), respectively. The mean duration of follow up was 11.2 months (6-12 months). The encountered complications were urethral stricture in 2 cases with urethral trauma and bladder neck stricture in 1 case with bladder trauma. In conclusion, the most common pediatric genito-urinary injuries we observed in this study, were blunt trauma resulted from traffic accidents and falls, and were more frequent in boys similar to the literature. The most common injured organs were kidney, urethra and bladder and the complications were rare. But the importance of follow up in pediatric patients should be kept in mind.

Surgical experience with management of vascular injuries

To highlight the problems that are associated with the causes, diagnosis and management of vascular injuries.

MATERIALS AND METHODS

A retrospective study of 52 cases of vascular injuries managed at the Jos University Teaching Hospital (JUTH) during a ten year period.

RESULTS

The sex ratio M:F was 6:1 and the mean age at presentation was 23 years. The most common causes of vascular injuries were road traffic accidents in 44 per cent, iatrogenic 27 per cent and industrial in 13 per cent. These resulted in 50 cases (96 percent) of penetrating vascular injuries and 2 (4 percent) of blunt injury to vessels. Fifty-four percent of patients presented in shock. Active bleeding was recorded in 81 percent, pulse deficit in 65 percent and frank gangrene in 16 per cent. Aneurysms of various types occurred in 14 percent. Associated injuries were fractures in 60 percent, soft tissue injuries in 56 per cent and peripheral nerve injuries in 10 per cent. Overall, 52 arteries and 51 veins were injured, resulting in 15 lacerations, 74 complete transactions and 2 vascular blunt injuries with intimal tears and intraluminal thrombosis. Direct lateral suture of vessels was employed in 13 vessels, anastomosis in 12 vessels, graft interposition in 4 cases, ligation in 49 cases and aneurysmectomy in 3 cases. Three primary amputations were performed versus 7 secondary amputations. Hospital mortality was 16 percent and was mainly due to hypovolaemic shock, acute renal failure and sepsis.

Contact geometry at the undersurface of the acromion with and without a rotator cuff tear

PURPOSE

The purpose of this study was to investigate the difference in contact geometry at the undersurface of acromion in shoulders with and without a rotator cuff (RC) tear.

TYPE OF STUDY

Case-control study.

METHODS

Forty fresh cadaveric shoulders (average age at death, 61 years) without gross osteoarthritic changes were divided into the intact RC group (n = 20) and the RC tear group (n = 20). Clinical impingement was simulated by compressing the humeral head and the intact portion of the RC against the coracoacromial arch with an axial compressive force of 25 kg while the humerus was held abducted 20 degrees in the scapular plane. The contact pattern between the acromion and the RC was measured with Fuji Prescale super low-pressure-sensitive film (Fuji Photo Film Co, Ltd, Tokyo, Japan). The imprint image was analyzed using Global Lab image software (Automatix, Marlboro, MA).

RESULTS

The percentage of the maximum anteroposterior dimension of the imprint on Fuji film to the anteroposterior diameter of the acromial undersurface was 29% +/- 9% in intact RC shoulders, and 39% +/- 13% in shoulders with an RC tear (P >.05). The percentage of the maximum mediolateral dimension of the imprint to the mediolateral diameter of the corresponding part of the acromial undersurface was 27% +/- 12% in intact RC shoulders, and 48% +/- 11% in shoulders with an RC tear. This difference was statistically significant (P <.005).

CONCLUSIONS

The contact geometry of the acromial undersurface with the underlying RC in the anteroposterior dimension, which might be related to the appearance in supraspinatus outlet view, was not significantly different between shoulders with and without an RC tear. These findings suggest that factors other than acromial shape play a significant role in the pathogenesis of RC tears. The implication regarding the role of acromioplasty remains to be clarified.

Viscoelastic material as an adjunct to dissections and to treat microperforations during nonpenetrating filtering surgery

A case is described in which viscoelastic material was used in the anterior chamber to minimize or prevent fluid flow through the area of the trabecular meshwork and Schlemm's canal during nonpenetrating filtering surgery. In cases with or without small perforations, the technique minimizes or decreases fluid flow so that the surgeon has a clearer view of these tissues and can perform more thorough and accurate stripping of deeper layers of tissue.

Routine cervical spine radiography for trauma victims: Does everybody need it?

OBJECTIVE

The purpose of this study was to evaluate the indication for routine cervical spine radiography in trauma patients.

METHODS

Prospective analysis of radiologic and clinical findings was performed during a 5-year period. Patients suitable for a clinical decision rule were reviewed separately.

RESULTS

Of the 1,757 consecutive patients included in the study, 38 were diagnosed with a cervical spine injury. Of the 599 patients suitable for the clinical decision rule, 62 had midline cervical tenderness, including 2 with cervical spine injury. No additional cervical spine injuries were found during follow-up.

CONCLUSION

It is within good practice, and it is also cost-effective, to obtain a cervical spine radiograph only on clinical parameters in trauma patients with no apparent bodily trauma and optimal parameters. With this clinical decision rule, 30.6% of all cervical spine series were redundant, and no (occult) spinal fractures would have been undetected.

Concomitant blunt enteric injuries with injuries of the liver and spleen: a dilemma for trauma surgeons

Prompt identification of enteric injuries after blunt trauma remains problematic. With the increased utilization of nonoperative management of blunt abdominal trauma gastrointestinal disruptions may escape timely detection and repair. The purpose of this study was to evaluate blunt enteric injuries requiring operative repair in adult patients and the association of concomitant hepatic and/or splenic injuries. Over a 10-year period (January 1990 through December 1999) 1648 patients suffered blunt liver, spleen, and/or enteric injuries, with 87 (5.3%) of these requiring operative repairs of the enteric injury. These patients had enteric injury only (EI) (60.9%; 53 of 87), concomitant enteric/splenic injury (ESI) (10.3%; 9 of 87), concomitant enteric/hepatic injury (EHI) (13.8%; 12 of 87), and enteric/hepatic/splenic injury (EHSI) 14.9% (13 of 87). A delay in treatment of >8 hours from presentation of EI compared with either EHI or ESI was not significantly different between the two groups. EHSI had exploratory laparotomy more expeditiously related to hemodynamic instability. Mortality rates were higher with EHI related to hemorrhagic shock and/or severe traumatic brain injury. Morbidity was not related to a delay in diagnosis until the period of delay was greater than 24 hours. The nonoperative management of blunt solid organ injury does not delay the detection and treatment of concomitant bowel injuries compared with isolated blunt enteric injuries. Occult enteric injury with solid organ injury has a low incidence and represents a continuing challenge to the clinical acumen of the trauma surgeon.

Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome

BACKGROUND

The potential for ligamentous injury of the cervical spine (C-spine) may mandate prolonged neck immobilization via a hard cervical collar in the blunt trauma victim (BTV) with altered sensorium. We investigated the incidence of ligamentous C-spine injuries, and whether applying (post hoc) the practice management guidelines from the Eastern Association for the Surgery of Trauma (three radiograph views plus computed tomographic scan of C1-C2) would have detected the injuries.

METHODS

The study was a 3-year retrospective review of BTVs admitted to the state's Primary Adult Resource Center for trauma from 1996 to 1998. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. A rigorous algorithm to clear the C-spine was used. Pure ligamentous C-spine injury was defined as a C-spine having abnormal anatomic alignment, dislocation, subluxation, or listhesis, but without fracture. Demographics, diagnostic studies, presence of neurologic deficit, therapy, survival, and disposition were analyzed.

RESULTS

There were 14,577 BTVs with 614 (4.2%) patients having C-spine injury. There were 2,605 (18%) unreliable patients, with 143 (5.5%) of these having C-spine injury, 129 (90%) having fracture and 14 (10% of BTVs; 0.5% of unreliable patients) having no fracture. Of the 14 unreliable patients with pure ligamentous C-spine injury, 13 had initial diagnosis by supine cross-table lateral radiograph. The one exception had a normal three-view radiographic series, but atlanto-occipital dislocation was diagnosed by computed tomographic scan. Eight patients had upper level injury (C0-C4) and six were lower (C4-C7). Four patients died within 30 minutes after admission, 4 underwent cervical fusion, and 6 were treated with collar only. Five (50%) of the survivors had no apparent neurologic deficit attributed to the C-spine at admission. Nine patients remained institutionalized after discharge and one was discharged home.

CONCLUSION

Ligamentous injuries without fracture of the C-spine are rare. Application of the practice management guidelines developed by the Eastern Association for the Surgery of Trauma for identifying C-spine instability is effective and should facilitate early removal of the cervical collar in unreliable patients.

Maxillary double lip: report of two cases

Two cases of double lip malformation, an uncommon oral anomaly, are presented, and the factors involved in the development, pathogenesis, diagnosis, and treatment of these uncommon lesions are reviewed. Double lip is usually associated with Ascher's syndrome, which is a rare disease with three more or less consistently associated abnormalities: double upper lip, blepharochalasis and enlargement of the thyroid. Two cases of double lip are reported; one of which was related with Ascher's syndrome, while the other had a traumatic origin.

Heimlich trauma: a violent maneuver

The Heimlich maneuver is a life-saving technique for dislodging foreign material from the respiratory tract. This report illustrates intraabdominal injuries, including a large mesenteric laceration, mesenteric contusions, and intraperitoneal hemorrhage, that occurred in a recipient of a vigorously applied Heimlich maneuver. The potential for confusing such injuries with homicidally inflicted injuries is emphasized.

Soccer ball-related retinal injuries: a report of 13 cases

PURPOSE

To describe the clinical characteristics and management of retinal injuries caused by soccer ball impact as well as the mechanism of injury, prognostic features, risk factors, and possible prevention strategies.

METHODS

Thirteen cases of soccer ball injuries from retina referral practices were retrospectively reviewed, with attention to the mechanism of associated ocular complications and the anatomic and visual outcomes.

RESULTS

Soccer ball injuries occurred in both male and female patients (9 male, 4 female) with ages ranging from 8 to 21 years (median 14 years). These patients were observed from 0 to 64 months (median follow-up, 8 months). Four patients had traumatic macular holes, two eyes had retinal detachment associated with retinal dialysis, two had retinal tears associated with hemorrhage, one had a choroidal rupture, and one had only vitreous hemorrhage and Berlin's edema. Although six eyes had some degree of traumatic retinal pigment epitheliopathy, it was the primary diagnosis in only three. Visual acuity at presentation ranged from 20/20 to count fingers, with 7/13 (54%) having 20/200 or worse vision. Seven eyes underwent surgical procedures; the remainder were observed. Final visions ranged from 20/20 to count fingers, with 3/13 (23%) having 20/200 or worse vision. Six eyes (46%) improved by two or more lines by the last follow-up.

CONCLUSION

Soccer ball-related ocular injuries disproportionately affect young players, are more frequent in females than previously reported, and have more severe visual consequences than previously recognized. Injury prevention strategies to minimize contact between the eye and the soccer ball may reduce the incidence and severity of eye injuries.

The clinical presentation of pediatric pelvic fractures

BACKGROUND

Few studies have addressed the presentation and clinical impact of pediatric pelvic fractures. We sought to describe pediatric blunt trauma patients with pelvic fracture (PF) and to evaluate the sensitivity and specificity of physical examination at presentation for diagnosis.

METHODS

Retrospective analysis of all PF and control (NPF) patients from our pediatric institution over an 8-year period.

RESULTS

A total of 174 patients (88 PF, 86 NPF) were included. Median patient age was 8 years (range, 3 months to 18 years), with 54% males. The most common mechanisms of injury for PF patients were automobile-related accidents (75%). There were 140 patients (87%) who were transported by air or ground medical services. At presentation, approximately 16% of PF patients had a Glasgow Coma score of <15, a mean Revised Trauma Score of 7.49, and a median Injury Severity Score (ISS) of 9. Thirty-one PF patients (35%) had an ISS of >15 indicating severe, multiple injuries. Sixty-eight PF patients (77%) had severe isolated injuries (Abbreviated Injury Scale 1990 value of >3); 11% of PF patients required transfusions, and 2% died. Fifteen PF patients (17% ) had no pelvic ring disruption; 39 (43%) had a single pelvic ring fracture, 22 (2%) had two pelvic ring fractures, 2 (2%) had acetabular fractures, and 10 (11%) had a combination of pelvic fractures. An abnormal physical examination of the pelvis was noted in 81 patients with PF (92% sensitivity, 95% confidence interval [CI] = 0.89-0.95), 15 NPF patients had an abnormal examination (79% specificity, 95% CI = 0.74-0.84). The positive predictive value of the pelvis examination was 0.84, and the negative predictive value was 0.89. The most common abnormal pelvis examination finding was pelvic tenderness in 65 PF patients (73%). A total of seven PF patients had a normal examination of the pelvis; four had a depressed level of consciousness (defined as GCS <15), and six patients had a distracting injury.

CONCLUSIONS

Pediatric blunt trauma patients with pelvic fracture represent a severely injured population but generally have lower transfusion rates and mortality than noted in adult studies. The pelvis examination appears to be sensitive and specific in this retrospective study. However, an altered level of consciousness and/or distracting injuries may affect examination sensitivity and specificity. Based on this retrospective study, we cannot advocate eliminating pelvic radiographs in the severely injured, blunt trauma patient. Prospective studies are recommended.

Delayed diagnosis in pediatric blunt trauma

OBJECTIVE

Identification of injuries of a traumatized patient is a mandate for the emergency department (ED) and the trauma team. Delayed diagnosis of injury in trauma patients leads to increased morbidity, mortality, dissatisfaction, and risk of litigation. Comparing children admitted for blunt trauma, with and without delay, this study examines risk factors for delayed diagnosis.

METHODS

Delays in diagnosis from 1991 to 1996 were identified during prospective collection of trauma registry data. Controls were randomly selected from the trauma registry. Charts from both groups were retrospectively reviewed.

RESULTS

Fifty-eight patients had 65 delays in diagnosis. Significant independent delay variables included: female, motor vehicle crash (MVC)-related mechanism, altered consciousness, higher injury severity score, and multiple injuries (P < 0.05). Trauma team activation, documentation of tertiary survey, and length of hospitalization were greater in patients with delay injuries (P < 0.05). Logistic regression identified MVC-related mechanism, female, facial, and extremity injuries as a combination of predictors.

CONCLUSIONS

Delays occurred in 1% of patients. Trauma team care itself did not protect all patients from delay. Injury severity at presentation alone is not an adequate predictor of delayed diagnosis in the pediatric patient. A combination of variables was identified as negative predictors of delay. Further study is needed to validate these criteria, and determine if earlier diagnosis would effect quality.

Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma

The objective of this study was to determine prospectively which risk factors require cardiac monitoring for blunt cardiac injury (BCI) following blunt chest trauma. All patients who sustained blunt chest trauma had an electrocardiogram (ECG) on admission to our urban level I trauma center. Those with ST segment changes, dysrhythmias, hemodynamic instability, history of cardiac disease, age > 55 years, or a need for general anesthesia within 24 hours (group 1) were admitted to the intensive care unit (ICU) for 24 hours where they were subjected to serial ECGs, creatinine phosphokinase (CPK) assays, and echocardiography (ECHO). Those with only mechanism for BCI, i.e., none of the above risk factors (group 2), were admitted to a nonmonitored bed and had a follow-up ECG 24 hours later. A series of 315 patients were admitted with blunt chest trauma during a 17-month period; 144 patients were in group 1 and 171 in group 2. Overall, 22 patients were diagnosed as BCI (+BCI), defined as evolving ST segment changes, dysrhythmias, a CPK-MB index of > 2.5, or hemodynamic instability. Of the 18 +BCI patients in group 1, all were symptomatic (i.e., none was included solely for a cardiac history, age, or need for general anesthesia). Six of these patients required treatment for dysrhythmias, hypotension, or pulmonary edema; one of whom died. Four patients with +BCI were in group 2 and had ECG changes at 24 hours; none of these four had any sequelae from their +BCI. None of the ECHOs demonstrated abnormal wall motion. Patients who sustain blunt chest trauma with a normal ECG, normal blood pressure, and no dysrhythmias on admission require no further intervention for BCI. Patients with ST segment changes, dysrhythmias, or hypotension following blunt chest trauma should be monitored for 24 hours, as this subgroup occasionally requires further treatment for complications of BCI. ECHO adds nothing as a screening test.

Subclavian arterial injury associated with blunt trauma

Blunt subclavian artery trauma is an uncommon but challenging surgical problem. The purpose of this study was to retrospectively review the management of blunt subclavian artery injuries treated by the Trauma and Vascular Surgery Services at the East Tennessee State University-affiliated hospitals between 1992 and 1998. Six patients with seven blunt subclavian artery injuries were identified. Physical signs indicating blunt subclavian artery injury were pain or contusion around the shoulder joint; fractures of the clavicle, scapula, or ribs; periclavicular hematomas; and ipsilateral pulse or neurologic deficits. Seven subclavian artery injuries were treated-two arterial transections, two pseudoaneurysms, and three intimal dissections. Associated injuries included four clavicle fractures, one humerus fracture, one combined rib and scapular fractures, and two pneumothoraxes. Vascular surgical treatment included three primary arterial repairs, two saphenous vein interposition grafts, and one polytetrafluoroethylene (PTFE) graft. One patient was treated nonoperatively with anticoagulation. No deaths occurred. Morbidity occurred in two patients with chronic upper extremity neuropathy producing prolonged disability from pain and weakness; one patient had reflex sympathetic dystrophy, and the other had a brachial plexus injury. In conclusion, blunt subclavian artery trauma can be successfully managed with early use of arteriography and prompt surgical correction by a variety of vascular techniques. Vascular morbidity is usually low, but long-term disability because of chronic neuropathy may result from associated brachial plexus nerve injury despite a successful arterial repair.

Triangular transchamber suture

A 64-year-old woman with a fibrous membrane at the lens plane after traumatic loss of all the iris and massive intraocular hemorrhage had posterior chamber intraocular lens (PCIOL) implantation anterior to the fibrous membrane with a triangular transchamber suture to prevent possible PCIOL-corneal touch and enhance the stability of the PCIOL. After 3 years, the PCIOL remained in a good position and visual rehabilitation was satisfactory and without complications.

Late traumatic dislocation of laser in situ keratomileusis corneal flaps

PURPOSE

To report the management and outcome of late-onset traumatic dislocation of laser in situ keratomileusis (LASIK) flaps.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Four patients with late-onset LASIK flap dislocation occurring after mechanical trauma at various intervals (10 days-2 months) after the procedure.

INTERVENTION

In all cases of postoperative traumatic LASIK flap dislocation, the flap was refloated with scraping and irrigation of the underlying stromal bed within 12 hours of the injury. A bandage contact lens was placed, and a regimen including topical antibiotics and corticosteroids was instituted in all cases.

MAIN OUTCOME MEASURES

Best spectacle-corrected visual acuity and complications associated with the surgery were monitored.

RESULTS

Postoperative follow-up ranged from 4 to 21 months. Nonprogressive epithelial ingrowth was noted in one patient and diffuse lamellar keratitis developed in another patient. All patients recovered pretrauma spectacle-corrected visual acuity.

CONCLUSIONS

Corneal LASIK flaps are prone to mechanical dislocation as late as 2 months after the procedure. Appropriate management results in recovery of optimal visual outcomes.

Liver fracture and bleeding

At laparotomy for blunt abdominal trauma a surgeon in a district general hospital encounters a fractured bleeding liver. How should the problem be handled? Professor J. E. J. Krige of Cape Town, South Africa, replies.

Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children

Defendants accused of inflicting fatal abdominal injuries to children occasionally raise the defense that the injuries were caused by cardiopulmonary resuscitation (CPR). The purpose of this study is to answer the question: Does closed chest CPR result in fatal blunt abdominal injuries that can be mistaken for homicidal assault? To that end, a retrospective study was conducted of all homicidal blunt abdominal injuries in children 10 years and younger from the Dade, Broward, and Palm Beach Medical Examiner's Offices from 1981 through 1997. These were compared to cases of children who died of natural causes during the same time period in Broward County who had CPR (control group 1) and to children who died of nonvehicular accidental blunt abdominal trauma (control group 2). Children with life-threatening head injuries were excluded. Medical examiner records, autopsy reports, documenting photographs, and clinical records were reviewed. The data analyzed included subject demographics, whether CPR was performed and by whom, and autopsy findings. Thirty-three child homicides with fatal abdominal injuries were reviewed. Twenty-four (73%) of the homicides received CPR. There was no difference in the nature and severity of injuries between the 24 children who received CPR and the 9 who did not. Three hundred and twenty-four cases of pediatric natural deaths were reviewed, all of which had CPR. No traumatic abdominal injuries were found in any of the children who died of natural causes. Only four children who died of natural causes had evidence of extraabdominal trauma related to CPR. No cases of nonvehicular accidental blunt abdominal trauma were identified during the 17-year period, although there were nonvehicular accidental fatalities due to extraabdominal injuries. The likelihood of CPR-related primary abdominal trauma in child homicides is very low.

[Blindness caused by an airbag in a minor accident]

PURPOSE

Installation of airbags has reduced the rate of fatal injuries in severe automobile accidents. We report, however, severe ocular injuries in a minor accident as the result of an airbag.

CASE REPORT

A front passenger suffered a blunt ocular trauma of her right eye during a collision. The approaching speed was about 31 km/h. The maximum change of velocity in direction of the impact was 19 km/h. Color traces were found on the upper rim of the airbag, apparently from the patient's eye shadow.

RESULTS

In the emergency room, visual acuity was reduced to light perception. There was endothelial contusion, traumatic mydriasis, and lens subluxation. A sclopetarian retinopathy developed with a chorioretinal scar. Eight months after the accident visual acuity remained at light projection only.

CONCLUSIONS

The eye injuries had very probably been caused by the deploying airbag. Improvements are a better geometry of deployment (e.g., tethered airbags), release at higher impacts only, and "intelligent systems" with additional sensors to avoid potentially hazardous airbag inflation in minor accidents.

Duodenal injuries

BACKGROUND

The worldwide increase in road traffic accidents and use of firearms has increased the incidence of duodenal trauma.

METHODS

The English language literature on duodenal trauma over the period 1970-1999 was reviewed.

RESULTS AND CONCLUSION

Upper gastrointestinal radiological studies and computed tomography may lead to the diagnosis of blunt duodenal trauma. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. The majority of duodenal injuries may be managed by simple repair. More complicated injuries require more sophisticated techniques. High-risk duodenal injuries are followed by a high incidence of suture line dehiscence and they should be treated by duodenal diversion. Pancreaticoduodenectomy should be considered only if no alternative is available. 'Damage control' should precede definitive reconstruction.

Consequences of nonpenetrating projectile impact on a protected head: study of rear effects of protections

BACKGROUND

Police and armed forces have helmets that can now stop handgun bullets and even a certain category of rifle bullets. The trend is to increase the ballistic limits of helmets, but injuries caused by nonpenetrating impacts are not well understood. The helmet defeats the projectile and creates a local cone of deformation that impacts the head a second time. The term "rear effects" describes the behind-armor blunt trauma caused by the nonpenetrating impact.

METHODS

To analyze rear effects on the skull, an experimental study was associated with parametric simulations on a three-dimensional finite element model. Transfer of energy throughout the head was tested on 30 human skulls filled with a silicone gel. The magnitude of contact forces on the skull surface and the pressure levels in the skull were recorded during a reference impact.

RESULTS

A biomedical approach by pathologic findings and radiographs showed very localized fractures. The protection brought by the diploe in the multilayered bone was confirmed and characterized by numerical simulations.

CONCLUSION

This first step toward a better understanding of the rear effect phenomenon in relation to its consequences on brain tissue will lead to the design of more efficient protections.

The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures

In order to identify the prognostic factors and to evaluate the impact of associated injuries in the outcome of patients with pelvic fractures, a retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. Demographic data, the mechanism of injury, the physiologic status on admission, associated injuries, pelvic fracture classification, complications and mortality were analysed. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to "shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. No correlation between pelvic fracture classification or fracture stability with mortality was observed. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture.

Conservative management of major liver trauma

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Ocular injuries by elastic cords in children

BACKGROUND

Elastic cords hitting the eyeball as high-speed projectiles can severely damage ocular structures and can produce permanent visual function impairment.

OBJECTIVES

To evaluate the frequency, mechanics, and severity of eye injuries caused by elastic cords in children to adopt the most appropriate preventive measures.

METHODS

A retrospective medical records review of hospital admissions secondary to ocular trauma between 1991 and 1997 in a pediatric ophthalmology unit at an urban tertiary care pediatric hospital was performed to select all children admitted for ocular injury caused by an elastic cord.

RESULTS

Eight children fulfilled the inclusion criteria; the prevalence ratio was 2% of all pediatric trauma admissions. In all cases the mechanics of trauma was a combination of blunt and high-speed projectile injury. The mechanism of trauma in younger patients was typically a cord that was misused during unsupervised playtime, whereas cord slipping from car roof racks was noted in older patients. One patient suffered a severe permanent visual impairment caused by retinal detachment. All other children regained full visual acuity at the time of discharge and maintained it through a mean follow-up of 22 months (range: 18-29).

CONCLUSION

Circumstances of injury in younger children are different from those found in older children, the latter being similar to those reported for adults. Prevention is the primary measure to be taken to reduce the prevalence of this injury and to lower the risk for ocular severe anatomic damage as much as possible. This can be achieved primarily by modifying the design of the hooks, intensifying educational campaigns, and keeping elastic cords out of children's reach.