Ultrasound biomicroscopic findings in a case of cyclodialysis

Ultrasound biomicroscopy (UBM) with a high frequency can be used to evaluate the structure of the anterior eye segment in vivo. A 24-year-old male was referred to us after 1 month of follow-up by a local ophthalmologist, because of decreased visual acuity and hypotony after a blunt eye injury. A cyclodialysis cleft in the 2- to 4-o'clock position and a cavernous pattern all over the choroid were found using UBM. The patient underwent surgical treatment to close the cleft. Even after the recovery of intraocular pressure (IOP), the peripheral ciliary body around 360 degrees was still separated from the sclera when examined by UBM. Despite the detached ciliary body, keeping IOP within normal levels is an interesting finding. UBM is helpful in the diagnosis and treatment of traumatic cyclodialysis.

Accuracy of administrative data in trauma: splenic injuries as an example

BACKGROUND

Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries.

METHODS

Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. chi2 analysis was used to compare dichotomous data and Student's t test continuous data.

RESULTS

The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 +/- 14.7 vs. 19.52 +/- 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs.17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001)

CONCLUSION

This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.

[Chest trauma: analysis of 126 cases]

To evaluate our experience in chest trauma we review the records of the patients admitted for chest trauma to our service between December 1994 and April 2000. There were 126 patients (113 males, 89.7%), with an age range of 7 to 96 years (mean 35.3). The most frequent cause of chest injury were traffic accidents 48 cases (38%) and 73 cases (57.9%) were victims of blunt trauma. In 36 cases there was a politrauma. Hemo and/or pneumothorax represented the most common thoracic injury (85.7%). Rib fractures were present in 47 cases (36.2% with more than 3 rib fractures). Four patients sustained flail chest and 5 defect of thoracic wall. Six patients were pulmonary contusion and 8 intraparenchymal hematoma. Pleural drainage was performed in 106 cases (8 cases bilateral) and thoracotomy was indicated in 11 (6 cases emergency). Mortality was 6.9% (n:8), of which 4 belonged to politrauma group. Mortality is directly related with politrauma. In the patients of the chest trauma, aggressive diagnostic and therapeutic approaches in association with intensive care follow-up remains one of the most important points to decrease mortality and morbidity rate.

Blunt and penetrating trauma of the thoracic aorta and aortic arch branches: an autopsy study

BACKGROUND

Due to the highly lethal nature of trauma of the thoracic aorta and aortic arch branches (TA-AAB), autopsy studies are essential for the investigation of its epidemiologic characteristics.

METHODS

The reports of 11,446 consecutive medicolegal autopsies were reviewed. Among 1,980 injury-related fatalities, 251 victims (12.7%) with 302 TA-AAB injuries were found. Several trauma variables were recorded and their relations were examined.

RESULTS

Blunt TA-AAB injuries were recorded in 86.4% of the victims. They were located mainly at the aortic isthmus and distal descending thoracic aorta and were accompanied to a great extent by extrathoracic trauma. The vast majority of penetrating lacerations were located at the ascending aorta, arch, and arch branches and were mostly associated with other lethal intrathoracic injuries. All penetrating trauma victims died before reaching the hospital, whereas 5.5% of the blunt trauma victims were admitted to the hospital alive.

CONCLUSION

Major differences between blunt and penetrating TA-AAB injuries were revealed, regarding their location, patterns of concomitant injuries, and victims' survival time. Patients injured in motor vehicle crashes, as opposed to various other causes of trauma, were found to have the best chances of reaching the hospital alive.

A five year study of high falls in Edinburgh

High falls are a common cause of death and disability. The aim of this study was to obtain an epidemiologically complete picture of all high falls over a 5 year period in Edinburgh, Scotland. Prospectively collected data on hospital survivors and hospital deaths was collected from the Scottish Trauma Audit Group (STAG) database. Data on prehospital deaths was obtained from autopsy reports and detailed police enquiry reports. There were 341 patients in the study, of whom 82% were male. Seventy-four percent survived to hospital discharge. Sixty-three percent of the total deaths appeared to be suicides. Head and chest injuries were responsible for the majority of deaths. Pelvis, limb and vertebral injuries predominated in survivors. In conclusion, prevention may be the most effective method of reducing prehospital deaths. Abdominal injuries were associated with a poor outcome, but survival might improve with immediate surgical exploration in haemodynamically unstable patients.

Posterior capsule rupture after a paint-pellet injury

We report a case in which a high-velocity paint pellet injury to the eye ruptured the posterior lens capsule. In the setting of blunt trauma, posterior capsule rupture has rarely been reported. Recognizing such a rupture allows the surgeon to plan the best surgical approach.

Mechanisms of blunt perineal injury in female pediatric patients

BACKGROUND/PURPOSE

Controversy persists regarding the causes of and the morbidity associated with blunt perineal injuries in children. The purpose of this study was to determine the most common mechanisms of blunt perineal trauma in female pediatric patients and to define the subset of patients that may benefit the most from an examination under anesthesia (EUA).

METHODS

Nearly 4,450 female pediatric patients were entered in the Pennsylvania Trauma Outcome Study database between 1993 and 1997. The mechanism and extent of perineal injury, surgical repair, and associated injuries were examined for all girls 0 to 16 years of age with a diagnosis of blunt perineal trauma.

RESULTS

A total of 358 girls experienced blunt perineal trauma. Motor vehicle crashes (MVC) accounted for the majority of injuries in all age groups. Falls and bicycle-related injuries were significantly more prevalent in children less than 9 years of age, and assaults in children 0 to 4 years. Head trauma was the most common associated injury in children less than 15 years. Children less than 10 years of age required surgical repair of their perineal injuries more frequently than their older counterparts. Perineal injuries caused by falls, assaults, or playground-related equipment were more likely to require surgical repair than those caused by other mechanisms.

CONCLUSIONS

Perineal injuries that require surgical repair occur predominantly in patients less than 10 years of age who sustain blunt perineal trauma from a variety of causes, but rarely MVC. Thus, such patients should undergo aggressive evaluation, including EUA, especially if they present with perineal bleeding, hematoma, or swelling. Furthermore, perineal injuries in children under 4 years should raise the suspicion of abuse.

Traumatic hyphema: a critical review of the scientifically catastrophic history of steroid treatment therefore; and A report of 24 additional cases with no rebleeding after treatment with the Yasuna systemic steroid, no touch PLUS protocol

PURPOSE

To establish a detailed history of steroid therapy administered either systemically or topically for traumatic hyphema (TH) over the past 40 years. To this literature, we report and add another 24 TH cases treated with the Yasuna systemic steroid No Touch PLUS protocol.

METHODS

Review of all reports in Medline since its inception in 1966 and such reports not in Medline but retrievable by successive reference and various alternate sources. Retrospective review of charts of all cases of TH at the University of Florida from 1980-1987. Of 135 cases so retrieved, 24 were found who had received this treatment protocol properly. (Ethical, moral and liability aspects prohibited a formal comparative study of a no medical treatment control group since this is unconscionable and abusive at the present state of knowledge.)

RESULTS

The historical review revealed that there is general ignorance of the salutary effect of both topical and systemic steroids in reducing the rebleed rate in TH. This is so marked that at least five experiments reported in the literature are invalidated to a variable degree because all patients, in both the experimental and control groups, had received topical steroids. Further, that the remarkable reduction in the rebleed rates for control groups of theoretically medically untreated TH, from the vicinity of 25% or more to the vicinity of 10-15% appears to be due primarily, if not solely, to this now ubiquitous administration of topical steroids in TH. In addition, in retrospect, there are also a remarkable number (at least 5) of major statistical errors in this literature and another 6 studies of outpatients in which compliance with therapy as outpatients is not even considered. Therefore at least 16 (57%) of the 28 papers reviewed have serious flaws and doubtful or uncertain results or conclusions. Of the 9 papers which lead one to wrongful conclusions, 5 are prejudicial against systemic steroid treatment (and 2 against systemic ACA treatment, and 2 against systemic TXA treatment). All but one of the nine are, as a corollary, prejudicial in favor of non medical treatment of TH. In our 24 cases studied, none suffered a rebleeding episode.

CONCLUSIONS

The "continuing controversy" about medical treatment of TH is the direct result of poor science and poor scientific methods in clinical trials. Because no method has yet been devised to determine which traumatic hyphemas will rebleed, but preventing rebleeding is about all that we can do maximize the outcome, we recommend that all patients with TH receive the Yasuna systemic steroids no touch and/or PLUS protocol in addition to current conventional treatment (bed rest, hospitalization for all patients under 18 years of age)

Evaluation of low-pressure arterial and venous clamps: electron microscopic study and possible clinical applications

These authors report on validating their choice of disposable clamps in arterial and venous microsurgery in a comparative and experimental study using the scanning electron microscope. This appears to be the first evaluation of venous endothelial clamping lesions. Early intimal clamping lesions were studied using three different clamps and two protocols in 18 femoral arteries and veins in rabbits. Results were evaluated using a new classification that can be applied to both arterial and venous lesions: Grade I: cellular disorientation and disorganization; endothelial lamination; and absent or very few platelet deposits; Grade II: alterations of the cytoplasmic membranes in fusiform cells; presence of at least one breach of endothelial continuity; and moderate number of platelet deposits; Grade III: presence of endothelial detachment; and large numbers of platelet deposits. They showed that in arteries, all the clamps tested caused only low-grade lesions. In contrast, in veins, they demonstrated both the very fragile nature of the endothelium, and also the comparative safety of the low-pressure venous clamp. Their choice of specific clamps for venous anastomoses was validated.

Current management of pelvic fractures

Blunt pelvic injuries are becoming more common in this era of high-speed, high-energy collisions. At least 5% of blunt injuries result in pelvic fracture. With mortality rates approaching 55% for severe crush injuries of the pelvis, early stabilization and control of bleeding, as well as assessment for other injuries, requires a focused, multidisciplinary approach. We discuss early management and stabilization of severe pelvic fractures.

Air bag-induced corneal flap folds after laser in situ keratomileusis

PURPOSE

We describe a case of air bag-induced ocular trauma resulting in folds in the corneal flap 3 weeks after laser in situ keratomileusis.

METHODS

Case report. Three weeks after laser in situ keratomileusis, a 20-year-old man was involved in a motor vehicle accident and sustained blunt trauma to the right eye, which caused corneal flap folds, corneal edema, anterior chamber cellular reaction, and Berlin retinal edema.

RESULTS

Six weeks after laser in situ keratomileusis, persistent flap folds necessitated re-operation with lifting of the flap and repositioning. One week after the procedure, the visual acuity improved to 20/20-2, and the folds had cleared.

CONCLUSION

Trauma after laser in situ keratomileusis may produce folds in the corneal flap. With persistence of these folds, management by lifting and repositioning the corneal flap may be necessary to permit recovery of visual acuity.

Can falls on stairs result in small intestine perforations?

OBJECTIVE

Abusive parents often report that a fall on stairs resulted in their children's injuries. This review explores whether there is any evidence in the medical literature that a fall on stairs could be a plausible explanation for a small intestine perforation.

METHODOLOGY

The English-language medical literature was searched by Medline, for a 29-year period (1970-1998), for reports of the types of injuries sustained in falls on stairs and for reports of the types of blunt abdominal trauma that result in small intestine perforations. Articles that exclusively focused on infant walker injuries or the elderly were excluded. Duodenal, jejunal, and ileal perforations were included, whereas intestinal hematomas and undescribed intestinal injuries were excluded. All types of injuries to the stomach, colon, and rectum were excluded.

RESULTS

Falls on stairs were not reported to be a cause for any of the 312 cases of small intestine perforations reviewed. There were no reports of any intraabdominal injuries, including small intestine perforations, in any of the 677 cases of falls on stairs reviewed. Falls on stairs rarely resulted in any type of truncal injury.

CONCLUSIONS

Although falls on stairs have been reported to be the most common cause of injury in childhood, no evidence was found to support the contention that an unobstructed fall on stairs could be consistent with perforation of the small intestine.

Small bowel perforation: an unusual presentation for child abuse

Hollow viscus perforation due to inflicted blunt abdominal injury is uncommon. Diagnosis is frequently delayed because of inaccurate or absent history, nonspecific or delayed physical findings or both, and laboratory tests with low sensitivity. Computed tomographic scanning of the abdomen is the best diagnostic test available. A high index of suspicion is essential to diagnose visceral perforation early, as significant morbidity and mortality results from diagnostic delay.

Shaken baby syndrome

PURPOSE

To examine the comprehensive ophthalmologic experience with the shaken baby syndrome at one medical center, including clinical findings, autopsy findings, and the outcome of survivors.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

One hundred twenty-three children admitted from January 1987 through December 1998 for subdural hematomas of the brain secondary to abuse were included.

METHODS

Clinical features of eye examinations of the patients during their admission and after discharge and histopathologic observations for patients who died were retrieved from medical records and statistically analyzed.

MAIN OUTCOME MEASURES

Visual response and pupillary response on initial examination, fundus findings, final vision, neurologic outcome of survivors, and death.

RESULTS

Ninety percent of the patients had ophthalmologic assessments. Retinal hemorrhages were detected in 83% of the examined children. The retinal hemorrhages were bilateral in 85% of affected children and varied in type and location. Nonophthalmologists missed the hemorrhages in 29% of affected patients. Poor visual response, poor pupillary response, and retinal hemorrhage correlated strongly with the demise of the child. One child who died had pigmented retinal scars from previous abuse, a condition not previously observed histopathologically to our knowledge. One fifth of the survivors had poor vision, largely the result of cerebral visual impairment. Severe neurologic impairment correlated highly with loss of vision.

CONCLUSIONS

Shaken baby syndrome causes devastating injury to the brain and thus to vision. Retinal hemorrhages are extremely common, but vision loss is most often the result of brain injury. The patient's visual reaction and pupillary response on presentation showed a high correlation with survival. Good initial visual reaction was highly correlated with good final vision and neurologic outcome. According to the literature, when retinal hemorrhages are found in young children, the likelihood that abuse occurred is very high. Nonophthalmologists' difficulty in detecting retinal hemorrhages may be an important limiting factor in identifying shaken babies so they can be protected from further abuse.

Traumatic duodenal rupture in a soccer player

Traumatic duodenal rupture resulting from blunt trauma during soccer is an extremely rare occurrence. A case report of this unusual condition is presented together with a review of the literature.

Fracture of the penis--diagnosis and management

Fracture of the penis is an uncommon injury, but it occurs most commonly during over enthusiastic sexual intercourse. Diagnosis is not difficult but serious complications such as urethral rupture and corporo-urethral fistula may occur. Management should be by early surgical exploration, with evacuation of the haematoma and repair of the tear in the tunica albuginea in order to minimize the length of patient's stay in hospital and avoid complications such as penile deformity and painful penile erections.