Rarely Seen Compartment Syndrome of the Shoulder and Back: Diagnosis and Management

Compartment syndrome (CS) is a well-known surgical emergency with high morbidity including potential long-term disability and limb loss. The most important factor determining the degree of morbidity with CS is time to treatment; therefore, early diagnosis and surgery are vital. We present a patient who fell off his bicycle and sustained cervical spine fractures causing near complete quadriplegia. He was found by the road over 12 hours later, so his creatine phosphokinase (CPK) was trended and serial examinations were performed. We identified tight deltoid, trapezius, and latissimus compartments and brought him to the operating room for fasciotomies. Although lab values and compartment pressures can be helpful, they should not guide treatment. It is important to consider atypical sites for CS and complete a head to toe physical examination. Patients should proceed to the operating room if clinical suspicion exists for CS because of the morbidity associated with a missed diagnosis.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience

INTRODUCTION

The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries.

METHODS

A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series.

RESULTS

6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge.

CONCLUSIONS

This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Diabetic Soft Tissue Infections

Diabetes is a systemic illness that can cause a broad range of physiologic effects. Infection rates and wound healing are both affected through multiple mechanisms. Other physiologic changes increase risk for wounds as well as complex soft tissue infections ranging from simple cellulitis to necrotizing soft tissue infections. Clinicians and surgeons need to have a low index of suspicion for severe infection in a patient presenting with diabetes, and even more so in patients with uncontrolled diabetes.

Use of Kaolin-Impregnated Gauze Aids in Hemostasis and Blood Loss Mitigation in a Penetrating Injury to the Bladder and Small Bowel

Hemorrhage control can be technically challenging in penetrating injuries to the pelvis. In an era of decreased availability of blood, rapid hemostasis is critical to minimize blood loss, limit transfusions, and control contamination from hollow viscus injuries. QuikClot Control+® 12x12 Hemostatic Device(C+) (Teleflex Medical OEM, Plymouth, MN), a form of kaolin-impregnated gauze, maybe a helpful adjunct to ebb the flow of hemorrhage from large surface area wounds. We present a case in which C+ was utilized in the preperitoneal packing of a gunshot wound to the pelvis and aided in obtaining hemostasis while simultaneously allowing the team time to complete the remainder of the case. Though further large randomized control trials are required to identify the role of C+ in trauma laparotomy, it remains a tool in the surgeon's armamentarium when dealing with hemorrhage.

Missing Bullets: Bullet Embolization Case Series and Review of the Literature

PURPOSE

Bullet embolization is a rare but dangerous phenomenon. Based on the location of embolization, migration of bullets can cause limb or intra-abdominal ischemia, pulmonary infarction, cardiac valve injury, or cerebrovascular accident. Bullet emboli can present a diagnostic challenge given the varied nature of complications based on location of embolization, which may not coincide with the site of initial injury. The purpose of this study is to present several cases of bullet embolization from our busy urban trauma center and make recommendations for management.

METHODS

We present 3 cases of bullet embolization seen in injured patients at our Level 1 trauma center. We describe our management of these injuries and make recommendations for management in the context of our institutional experience and comment on the available literature regarding bullet embolization.

RESULTS

Two of our patients presented in extremis and required operative intervention to achieve stability. The intravascular missile was discovered intraoperatively in one patient and removed in the operating room, while the missile was discovered on postoperative imaging in another patient and again removed operatively after an unsuccessful attempt at minimally invasive retrieval. Our third patient remained hemodynamically stable throughout his hospitalization and had endovascular management of his bullet embolus.

CONCLUSION

Bullet emboli present a challenging complication of penetrating trauma. We recommend removal of all arterial bullet emboli and those within the pulmonary venous system. In hemodynamically stable patients, we recommend initial attempts of endovascular retrieval followed by open surgical removal. We recommend open removal in cases of hemodynamic instability.

Prevalence of Housing Insecurity in Survivors of Traumatic Injury

BACKGROUND

Almost 20% of the US population are housing insecure (HI) due to inadequate living conditions, imbalanced costs to income, nonsustainable shelter, or overcrowding. Housing insecure and physical trauma share similar risk factors, but their direct association is not well elucidated. The objective of our study was to determine the prevalence of HI in survivors of traumatic injury.

METHODS

We conducted a prospective cohort study at an urban, level 1 trauma center. A survey on social determinants of health was administered to adult patients, and demographic, injury specifics, and clinical outcomes data were collected. HI was defined by affirmative answers to questions related to history of homelessness or concern about sustainable shelter. The cohort was stratified by HI; groups were compared using the Mann-Whitney U and Fisher exact tests, as appropriate.

RESULTS

Of 116 study participants, four were excluded due to missing data. Of the 112, 42 (37.8%) reported HI and most were black (69%) males (73.8%). There were no demographic differences between groups. Conversely, HI patients had a higher rate of penetrating traumatic injury (34.1% vs 14.5%, P-value = .03) and were significantly less educated compared to secure participants (P-value = .03) [no degree (26.2% vs 10.3%), high school degrees (21.4% vs 41.2%)] with concomitant illicit drug use (63.4% vs 27.9%, P < .001), and history of addiction (52.4% vs 7.2%, P < .001).

CONCLUSION

HI far exceeds national averages in our cohort. Although difficult to ascertain a cause-effect relationship, HI may be a modifiable risk factor for trauma that negatively influences outcomes.

Screening, Brief Intervention, and Referral to Treatment to Prevent Post-Traumatic Stress Disorder After Gunshot Wounds

Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)-a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.

Approaches to Repair of Penetrating Injuries of the Proximal, Mid, and Distal Esophagus

INTRODUCTION

Traumatic esophageal injuries represent less than 10% of traumatic injuries. Penetrating injuries represent an even smaller but more lethal percent. Esophageal injuries can be cervical, thoracic, or abdominal with decreasing frequency. Cervical and thoracic esophageal injuries represent >80% of these injuries and are more morbid. Morbidity and mortality are increased with delayed identification. Although diagnosis can be hard, management is similar despite location.

CASES

We present 3 cases of esophageal injuries to the cervical, thoracic, and abdominal esophageal segments with descriptions on diagnosis, repair, and management differences.

DISCUSSION

Despite low incidence of penetrating esophageal injuries, morbidity and mortality are extremely high, especially with associated injuries. Early identification and treatment is paramount. Anatomical knowledge is necessary for successful surgical management. Primary repair in 2 layers should be attempted whenever possible including musical closure with absorbable suture. Flaps, diversions, wide drainage, and feeding tube access should always be key surgical considerations. Flaps can include sternocleidomastoid muscle for cervical injuries, intercostal muscle, diaphragm, and pericardium for thoracic injuries and "Thal" gastric flaps for gastroesophageal junction and abdominal injuries. Successful identification and management can lead to increased survival.

Successful Non-Operative Management of Extensive Pneumatosis Cystoides Intestinalis Due to Graft Versus Host Disease

Graft versus host disease is a serious complication of allogenic stem cell transplants and can manifest with gastrointestinal complications including pneumatosis cystoides intestinali (PCI). A 43-year-old male with a history of acute myeloid leukemia presented to the hospital with abdominal pain and sepsis. The patient was intubated and admitted to the ICU. His CT scan demonstrated extensive colonic pneumatosis. He was high risk for laparotomy so was treated non-operatively. He improved and his abdominal exam remained benign. With aggressive resuscitation, close monitoring, and antibiotics, the patient was able to avoid major abdominal surgery. pneumatosis cystoides intestinali is a concerning finding that often leads to surgical interventions. Concurrent sepsis, gut ischemia, and frank perforation often lead to surgical intervention. In patients with high surgical risk and lack of critical bowel findings, non-operative management can be successful.

Video-Assisted Thoracoscopic Internal Rib Fixation

Rib fractures result in serious morbidity and mortality after trauma. Although there is ongoing debate about surgical rib fixation, it is increasingly important for some patients. Minimally invasive techniques for rib fixation are gaining traction within the trauma community. We present an observational experience at our level 1 trauma center with our first 10 cases of video-assisted thoracoscopic surgery (VATS) internal rib fixation. Video-assisted thoracoscopic surgery internal plates are especially helpful for rib fractures under the scapula, which are difficult to access traditionally. This technique is also excellent at reducing complex segmental fractures as the bridge can span across multiple fractures with a single post on either side. They also work well for posterior fractures where multiple screws cannot be placed. Video-assisted thoracoscopic surgery internal rib fixation is a viable and exciting option for surgical fixation. The plates work particularly well for certain fracture patterns.

Femoral-Femoral Bypass for Limb Salvage to Correct Common Iliac Occlusion after Lower Extremity Trauma

BACKGROUND

Roadway injuries are a leading cause of lower extremity vascular trauma. Treating these injuries involves controlling life-threatening hemorrhage and restoring distal perfusion.

MATERIALS AND METHODS

We describe a unique presentation of chronic iliac artery occlusion in the setting of blunt trauma requiring extra-anatomic bypass for maximal limb salvage.

RESULTS

A 50-year-old male presented after a pedestrian versus auto accident. He had mangled bilateral lower extremities and was taken emergently for lower extremity amputations. He was found to have chronic left common iliac occlusion and a femoral-femoral bypass was performed to assist with healing his left below-the-knee amputation.

DISCUSSION

Lack of adequate perfusion can cause poor outcomes in limb salvage. This case demonstrated that lower extremity trauma can be complicated by chronic vascular disease. Reperfusion and adequate wound healing can be accomplished by using bypass grafting after more traditional reperfusion techniques fail.