Assault by burning--a reappraisal

Assault by burning is a serious form of trauma that often results in higher incidence of inhalation injury, longer intensive care unit (ICU) and hospital stay, and higher mortality rate than is observed in the general burn population. We evaluated the epidemiology and outcome of assault burn victims treated in a tertiary burn center over a 6-year period. Among the 1063 acute burn patients who had been admitted to the Burns Unit between March 1993 and February 1999, 28 (2.6%) had assault burn injuries either by scald, chemical or fire. The mean extent of burn was 21.9%+/-20.8% (range 2-90%) total body surface area and the mean length of hospital stay was 65.2+/-107.3 days (range 1-565). Nineteen out of 25 patients (67.9%) underwent 76 operations. Nine patients had inhalation injuries requiring intubation and ICU admission. Three patients died in the series, which yielded a mortality rate of 10.7%. Compared to the general burn population, the assault burn group had significantly larger burn size (P<0.001), higher incidence of inhalation injury (P<0.001), longer ICU and hospital stay (P<0.001), and higher mortality rate (P<0.005). When these 28 victims were grouped according to the type of assault burn injury into a fire group, chemical group and scald group, all the 9 ICU admission and the 3 mortalities belonged to the fire group. Assault by fire resulted in larger burn size (P=0.03), more inhalation injury (P<0.001) and longer ICU stay (P=0.02). Although the fire group had a longer hospital stay and higher mortality rate, this was statistically insignificant.

Seat belt use before and after motor vehicle trauma

BACKGROUND

Motor vehicle crashes cause significant morbidity and mortality annually. Seat belt use has partially been associated with a decreased risk of morbidity and mortality among those involved in motor vehicle crashes. Persons injured in motor vehicle crashes and not wearing seat belts have an increased risk of admission to trauma centers for motor vehicle crash-related injury. The purpose of this study was to measure changes in seat belt use after discharge among patients admitted to a Level I trauma center for injuries sustained in motor vehicle crashes.

METHODS

Patients admitted to a Level I trauma center for injuries sustained in motor vehicle crashes during 1998 were eligible for participation. A telephone interview was conducted with a random sample of 136 eligible patients regarding patterns of seat belt use before and after their collision. Demographic data and clinical characteristics were also collected. The frequency of seat belt use before and after crash involvement was compared for all patients and stratified by age, gender, race, and Injury Severity Score (ISS).

RESULTS

Slightly over half (54%) of patients reported "always" wearing a seat belt before their collision compared with 85% afterward. Younger age groups, male subjects, and whites had the largest increases in the frequency of seat belt use after collision (45%, 37%, and 44% increases, respectively). With respect to injury severity, the largest increase in the frequency of seat belt use was among those with ISS of 15 to 25 (82% increase). Significant concordance between patient- and emergency medical service-reported use of seat belts was observed. Among subjects reported by emergency medical service personnel to have been restrained, nearly 90% reported belt use at the time of the telephone interview. The most frequently cited occasion for failure to use seat belts (30%) was when taking short trips. Other reported reasons were forgetting to fasten belts (29%), discomfort (10%), being in a rush (8%), riding in the back seat (4%), and that seat belts were unnecessary when riding with a good driver (3%).

CONCLUSION

Involvement in a motor vehicle crash results in increased seat belt use. Prevention efforts should be directed toward those patients who report infrequent use. Patient "converts" to seat belt use after collisions may be useful in public awareness and prevention campaigns.

[Development of a standardized instrument for quantitative and reproducible rehabilitation data assessment after polytrauma (HASPOC)]

INTRODUCTION

Previous scoring systems for measurement of the quality of outcome are based on scores regarding injuries to individual body regions. Known scores which describe several organ regions are of no importance for trauma patients. Therefore a new rehabilitation outcome evaluation score was developed at our hospital.

METHODS

Based on a prospective reinvestigation, a score system was developed that allows a quantitative appraisal of the subjective and objective outcome. A complete physical examination was performed, including ROM, neurologic examination and strength analysis. Part I (113 questions) is to be filled out by the patient; part II (191 questions) focusses on different body regions, physical examination and functional scoring. Included are the MFA, FIM, GCO and Frankel score. A final score (HASPOC) was developed to give a quantitative result of the outcome.

RESULTS

The new score has a range from 5 to 411 points. One hundred and fifty patients were re-examined. The mean follow-up time was 2.2 +/- 0.1 years. The SF 12 indicated an outcome more than satisfactory in 63% of cases. The MFA demonstrated moderate or severe restrictions in 41%, in the case of injuries of the lower extremity in 52% of patients. The HASPOC indicated a mean of 44.5 points.

CONCLUSION

This paper describes the development, structure, and the quantitative outcome of rehabilitation in polytrauma patients. This standardized rehabilitation instrument deals with a very heterogeneous patient population and shows the rehabilitation deficits accurately. Implemented recognized evaluations allow comparison of these results with those of other scoring systems.

Antegrade intramedullary nailing of the humerus complicated by heterotopic ossification of the deltoid: a case report

A case of antegrade nailing of the humeral shaft in a polytrauma patient was complicated by heterotopic ossification of the lateral deltoid muscle and severe loss of shoulder motion. The patient did not respond to physiotherapy alone and was successfully managed by excision of the heterotopic bone and adjunctive radiation therapy.

[Fall from high altitude]

BACKGROUND

It is controversial in which way the human body can tolerate mechanical stress and later develop sequelae after deceleration trauma.

MATERIAL AND METHODS

A report on a 26-year-old male who survived a free fall of 28 metres from a building.

RESULTS

It is accounted for an achieved velocity of 81 kph and accumulated energy of 21,000 Joule. The incident lead to multiple complicated fractures, nerve injuries and an acute head injury. The patient's cognitive function was restored after a few months, and he is satisfied with the outcome.

[Determinants of the global quality of life after polytrauma]

This study investigated multiple trauma patients, who were injured between 1991 and 1995 and treated in our department. The aim of this study was to identify the determinants of quality of life after multiple trauma. From a total of 186 patients 173 (93%) were examined. The patients were asked to rate their quality of life according to the Nottingham Health Profile (NHP) and to a visual analogue scale (VAS). The VAS and the NHP isolated the age of the patients, the duration of artificial respiration, and the duration of rehabilitation as the predictors for a reduced overall quality of life. These results show that quality of life after multiple trauma not only depends on the severity of injury but also on demographic and psychosocial factors.

Hospitals without walls: a journey through the health-care system

The paper describes aspects of a journey through the health-care system following a domestic accident. The journey commenced in the accident and emergency department and, over a 3 month period, traversed the operating theatre, intensive care and an orthopaedic ward before moving into a Hospital in the Home programme and community health and district nursing services. The paper explores the experiences of the accident victim, a 56-year-old man, and his wife who is an experienced nurse and university lecturer. The paper supports the 'seamless delivery' concept of integrated care while, at the same time, sounding notes of caution. The principal messages in this paper are about the relationships that nurses build with patients and their families over long periods of care, the paradoxical sense of 'outsideness' that can occur when the home becomes medicalized and the importance of the home as a healing environment.

Catecholamine-induced hypertension in lumbosacral paraplegia: five case reports

Hypertension in the patient with SCI is relatively rare and generally restricted to patients with high-level injuries where autonomic dysreflexia can occur. Resting blood pressure in individuals with SCI has been described as lower than that in the normal population. This report describes five previously normotensive teenagers with subsequent paraplegia as a result of gunshot wounds who presented with hypertension secondary to idiopathic elevation of plasma or urinary catecholamine levels. A clonidine suppression test was used as a neuroprobe to inhibit centrally mediated sympathetic outflow, excluding the probability of an extra-axial autonomous catecholamine-secreting tumor as the possible source of hypertension. Positive suppression was achieved in four patients (41%, 37.2%, 4.8%, and 37.2% decreases). One patient had values corresponding to orthostatic changes (an increase of 63%) because of poor compliance with the test. This patient was lost to follow-up; in the remaining four, hypertension resolved at 12, 8, 9, and 6 weeks postinjury. The increased circulating catecholamine level appears to be promoted by a centrally mediated response to the SCI. Elevated blood pressure probably results from an upgraded receptor regulation or an increased receptor sensitivity on the affected cells in the absence of restraining spinal reflexes. The pathophysiology of such hypertension seems to be secondary to autonomic dysfunction and, although it may be transient, it should be treated promptly and reevaluated periodically until stabilization is achieved.

[ReIntra--a model for rehabilitation of severely injured accident victims]

ReIntra is a medical/occupational counselling and reintegration service launched in 1997 with the aim of supporting seriously injured accident victims along their path towards, hopefully, social and professional rehabilitation. We have analysed 109 patients with severe injuries for whom previous attempts at reintegration left something to be desired. ReIntra's findings, collated after an average period in care of around 17 months, show that the patients' main problems have less to do with the system of medical care than with the reintegration process. Problems seem to occur, in particular, at the interface between the various care centres involved. Following numerous interventions on the part of ReIntra, initial signs of success are now apparent. In 9% of cases, reintegration was no longer possible owing to the severity of the injuries sustained. 17% of the patients were still undergoing medical rehabilitation preventing any observations with regard to the likelihood of full vocational rehabilitation. 58% of accident victims were in the vocational reorientation phase. A further 16% had been fully integrated into professional life.

Long term results after multiple injuries including severe head injury

OBJECTIVE

To describe the long term results in patients with multiple injuries including severe head injury.

DESIGN

Retrospective and prospective clinical study.

SETTING

Level I trauma centre, Germany.

PATIENTS

Patients aged 16-60 years who had been injured more than 2 years before, whose Injury Severity Score was over 20 and whose cranial Abbreviated Injury Score (AIS) was over 3.

MAIN OUTCOME MEASURES

Glasgow Outcome Scale (GOS), functional, neuropsychological, vocational and social outcomes.

RESULTS

58 patients, median age 24 (range 16-53, interquartile range (IQR) 21-32) years were investigated 5 (3-9; IQR 4-7) years after their injury. Median ISS was 34 (21-57; IQR 26-41) and GCS 6 (3-8; IQR 4-7). Duration of coma was 10 (2-51; IQR 7-22) days and neurological rehabilitation lasted 169 (10-830; IQR 80-300) days. Movements of the elbow and ankle was most impaired by injury. All psychometric tests showed deficits, particularly in speed of processing, concentration, recent memory, and learning performance. The social environment had been changed in half and vocational rehabilitation was dependent on age. 24 (42%) returned to their former profession, 18 (31%) were retrained to another profession, 16 (27%) were unemployed or retired on a pension. 31 (53%) made a good recovery with moderate disability, 19 (33%) had severe disability, and 8 (14%) remained in a persistent vegetative state assessed by the GOS.

CONCLUSION

Early and concentrated rehabilitation facilitates functional, social, and neuropsychological reintegration.

Amputated lower limbs as a bank of organs for other organ salvage

Aggressive modern technologies have made it possible to attempt limb salvage in even the most extreme cases. However, it is imperative to remember that prolonged salvage attempts may lead to devastating complications. The decision-making is more problematic in patients with bilateral severely injured mangled lower limbs. In such a case, protocols like the MESS are no longer valid because of the implications of bilateral amputation. In these rare cases, we use a multi-team approach and modern micro-surgical reconstructive techniques in attempting to salvage at least one of the lower limbs. We present here our experience in six patients with bilateral mangled lower limbs where an amputated limb was the source of "spare parts" for the salvage of the contralateral limb. In each of the cases, after evaluation and planning, the harvesting of the required tissues (including skin, muscle, bone, nerve and blood vessels) from the amputated leg was performed and simultaneously, a reconstruction of the contralateral severely injured limb was done. These cases emphasize the importance of modern trauma care, not only the ability to treat multiply traumatized patients, but also the capability to execute sophisticated techniques during the acute phase of treatment with maximal cooperation between teams from different disciplines.

Mangling upper limb injuries in industry

The salvage of upper limbs mangled by industrial machinery became possible with the development of predictable techniques of vascular and microvascular anastamosis. Unfortunately, many of these salvaged limbs are associated with fair and poor functional outcomes. The quality of the skeletal fixation can have a substantial effect on the functional outcome and should be a major focus of the limb repair process. Internal plate fixation facilitates wound care and limb mobilization without tethering muscle-tendon units and is safe in the majority of severe upper limb injuries provided that all devitalized tissue is debrided and, if necessary, reconstructed using microvascular tissue transfers. Injury patterns, especially those which involve associated injury of the elbow or forearm ligaments, must be identified and treated appropriately. Internal fixation should restore anatomical alignment and provide sufficient stability to allow immediate active mobilization of the limb without contributing to devascularization of the soft tissues or skeleton.

[Reconstruction of hip joint function: old fracture-dislocation of hip joint complicated with deformed healing of upper 1/3 of fractured femur--a case report]

OBJECTIVE

To explore a method of reconstruction of hip joint function after deformed healing of the upper 1/3 of fractured femur as a complication of old fracture dislocation of hip joint.

METHODS

A patient with loss of function in hip joint and fusion of knee joint was treated with lock for femur intra-medullary fixation in April 1997.

RESULTS

Before operation, the diseased hip joint lost its most functions and the entire lower extremity was disabled because the knee joint had been fused. One year after operation, the follow-up examination revealed that the patient could walk by crutches without discomfort, his daily life and work recovered to normal.

CONCLUSION

It is effective to treat a patient suffering old fracture-dislocation of hip joint complicated with deformed healing of the upper 1/3 of fractured femur by means of individualized artificial joint replacement and a prosthesis body with lock for femur intra-medullary fixation, and it is helpful for the development of a new clinical idea to reconstruct functions in the management of some particular cases.

Combined injuries of the medial collateral ligament and the anterior cruciate ligament. Early ACL reconstruction versus late ACL reconstruction

Aim of this retrospective study is to evaluate the effect of acute and late anterior cruciate ligament (ACL) reconstruction in patients with a combined injury of the ACL and the medial collateral ligament (MCL). All MCL injuries were treated non-operatively. In 27 patients (group I) we performed early ACL reconstruction (within the first 3 weeks after injury). The postoperative rehabilitation protocol included brace treatment for all patients over a period of 6 weeks. In 37 patients we performed late ACL reconstruction (after a minimum of 10 weeks). In this group initial non-operative MCL treatment (6 weeks brace treatment) was followed by a period of accelerated rehabilitation. Patients with late ACL reconstruction had a lower rate of loss of motion after finishing the postoperative rehabilitation programme and a lower rate of re-arthroscopies for a loss of extension (group I: 4 patients, group II: 1 patient). The difference in the mean quadriceps muscle strength (group I: 83.3%, group II: 86.3%) was not statistically significant. After a mean interval of 22 months, we saw no difference in the frequency of anterior or medial instabilities or in the loss of motion. The Lysholm score was significantly better in the group with late ACL reconstruction (group I: 85.3, group II: 89.9). The position on the Tegner activity scale decreased in both groups, to 5.5 in group I (preoperatively: 6.0) and to 5.6 in group II (preoperatively: 5.9). With regard to the lower rate of motion complications in the early postoperative period, the lower rate of re-arthroscopies, and the significantly better results in the Lysholm score, we prefer late ACL reconstruction in the treatment of combined injuries of the ACL and the MCL.

Functional outcome in children with multiple trauma without significant head injury

OBJECTIVE

To assess functional outcome and describe disability at discharge in children who have had trauma without significant head injury.

DESIGN

Retrospective cohort.

SETTING

National Pediatric Trauma Registry, 1988-1994.

PARTICIPANTS

Patients of ages 7 to 18 years with Glasgow Coma Scale (GCS) 13 to 15 without significant anatomic head inJury.

RESULTS

Functional Independence Measure (FIM) at discharge was used to assess patient outcome. There were 13,649 children meeting study criteria who had sustained 34,254 injuries. Fractures constituted 30% of all injuries. As measured by FIM, 1,522 (11.2%) patients had mild disability at discharge; 1,983 (14.5%) had moderate disability. After adjustment for age and injury severity, children with lower extremity fractures were more likely to be discharged with functional limitations than those without (relative risk, 5.43; 95% confidence interval: 5.06, 5.84). Of children with moderate disability at discharge, less than 50% were referred for rehabilitation evaluation and less than 25% for physical therapy.

CONCLUSION

Functional dependence is present in a large proportion of injured children, even without significant head injury. Rehabilitation and other services may be underused in this population. Further study is required to fully assess the degree and duration of disability in these patients.

[The rehabilitative treatment of victims with multiple and combined trauma]

Traditional methods of rehabilitation period treatment are not always possible with poly-trauma patients due to the presence of several fractures in association with internal injuries, bed-rest regime, hypokinesia of long duration and other factors. The author offers a complex approach to treatment with the provision for individual state of the patient. A consistent and gradual application of individual rehabilitation programmes together with physiotherapy, physical exercises, acupuncture, reflexotherapy and psychotherapy often helped to obtain good results.

[Effect of kinetic therapy on the course of treatment of patients with post-traumatic lung failure]

This study was conducted to investigate the effects of intermittent prone positioning of patients with post-traumatic respiratory failure (paO2/FiO2 < 280 mm Hg) in comparison with conventional therapy in a supine position. Although the severity of injury of the prone-positioned patients was much higher (ISS 35.8 vs 24.5), the ventilation time (32 vs 31 days) and ICU stay (39 vs 36 days) were similar to patients treated in the supine position. Besides the beneficial effect of prone positioning on oxygenation, for the first time we have evidence that prone positioning improves the outcome of patients with post-traumatic respiratory failure.

[Radon baths and laser therapy in the rehabilitation of patients with the late sequelae of joint trauma to the head and neck]

The study of combined effects of radon baths and laser irradiation of some cranial zones in therapy of 60 patients with late sequelae of craniocervical trauma has shown that the highest response can be achieved in vegetovascular dystonia, asthenoneurotic syndrome, vestibulopathy, spinal artery syndrome. Pathogenetic therapy with laser radiation and radon baths is validated in management of late sequelae of craniocervical trauma.