Mortality in patients with bilateral femoral fractures.

OBJECTIVES: To determine and compare the mortality rates of patients with bilateral versus unilateral femoral fractures and to determine the contribution of the femoral fracture to, and identify risk factors for, such mortality. STUDY DESIGN: Retrospective analysis using trauma registry data on consecutive blunt trauma patients with unilateral (800 patients, group I) or bilateral (eighty-five patients, group II) femoral fractures. METHODS: Univariate data analysis was performed to compare the groups' ages, Injury Severity Scores, Glasgow Coma Scale values, mortality, and the presence of adult respiratory distress syndrome (ARDS). Logistic regression analysis was performed to determine variables statistically associated with mortality. RESULTS: Group II patients had a significantly higher Injury Severity Score (30.2 versus 24.5, p < 0.001), lower Glasgow Coma Scale value (12.3 versus 13.1, p = 0.05), higher mortality rate (25.9 vs 11.7%, p < 0.001), and higher incidence of ARDS (15.7 versus 7.27%, p = 0.014) than group I patients. Group II patients also had significantly more closed head injuries, open skull fractures, intraabdominal injuries requiring surgical intervention, and pelvic fractures; the rates of thoracic injury were similar. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures and death; however, other factors (shock, closed head injury, and thoracic injury) had much stronger correlations with mortality. CONCLUSIONS: Patients with bilateral femoral fractures have a significantly higher risk of death, ARDS, and associated injuries than patients with unilateral femoral fractures. This increase in mortality is more closely related to associated injuries and physiologic parameters than to the presence of bilateral femoral fractures. The presence of bilateral femoral fractures should alert the clinician to the likelihood of associated injuries, a higher Injury Severity Score, and the potential for a more serious prognosis.

Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of a pelvic fracture on a woman's physical, sexual, and reproductive functioning. DESIGN: Retrospective review. SETTING: Level one trauma center. PATIENTS: Two groups of female multitrauma patients: those with pelvic fractures (subjects) and those with extremity fractures but no pelvic fracture (controls). MAIN OUTCOME MEASUREMENTS: Of the 302 women eligible for participation in this study, 255 (80%; 123 subjects, 118 controls) were interviewed by blinded professional interviewers regarding genitourinary symptoms, sexual function, and reproductive history. RESULTS: Urinary complaints occurred significantly more frequently in subjects than in controls (21 versus 7%, respectively; p = 0.003), in subjects with residual pelvic fracture displacement > or = 5 mm than in those without displacement (33 versus 14%, respectively; p = 0.018), and in subjects with residual lateral (60%) or vertical (67%) displacement than in those with medially displaced fractures (21.4%) (p = 0.04). Although both groups reported increased rates of cesarean section, this increase was statistically significant only in the subject group: 14.5% preinjury versus 48% postinjury (p < 0.0001). Adjusting for previous cesarean sections, cesarean section was significantly more frequent in subjects with fractures initially displaced > or = 5 mm (80%) than in those with fractures initially displaced < 5 mm (15%) (p = 0.02). There was no difference in the incidence of miscarriage or infertility between the groups. Problems with physiologic arousal or orgasm were rare. Pain during sex (dyspareunia) was more common in subjects with fractures displaced > or = 5 mm than in those with nondisplaced fractures (43 versus 25%, respectively; p = 0.04). CONCLUSIONS: We found that pelvic trauma negatively affected the genitourinary and reproductive function of female patients. The increased rate of cesarean section in women after pelvic trauma may be multifactorial in origin and warrants further investigation.

Functional status following orthopedic trauma in young women.

OBJECTIVE: To evaluate the general health status and sexual function of women following serious orthopedic injury. METHODS: Women aged 16-44 who were treated at a level I trauma center between 1986 and 1992 for a fracture to the pelvis or lower extremity were interviewed by telephone. The interview included the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) supplemented by questions about sexual function. The SF-36 is a measure of outcome from the respondent's point of view and consists of 36 items representing eight health concepts. RESULTS: Of 289 eligible women, 233 (81%) were interviewed (123 pelvic fracture; 110 lower extremity fracture). Their mean Injury Severity Score was 17.9. Compared to age- and gender-standardized norms, study patients as a group scored significantly worse (lower scores) on all dimensions of the SF-36 except mental health (p < 0.05). Of the women interviewed, 45% reported feeling less sexually attractive due to their injury, and 39% reported a decrease in sexual pleasure. Women who reported arthritis that was attributed to their fracture had significantly poorer health outcomes than study subjects who did not. The most significant predictor of deviations from SF-36 norms was the presence of one or more comorbid chronic conditions. CONCLUSION: The results underscore the importance of considering comorbidities when evaluating health outcomes following major trauma. In addition, the relatively high rates of reported change in sexual function after injury argue for more attention to these issues in both clinical practice and outcomes research.

Blunt rupture of both atrioventricular valves.

Younger patients are surviving extensive damage to the heart and supporting structures, often associated with multiple systems injuries. A 23-year-old patient who sustained blunt trauma to the chest resulting in a pericardial laceration, injury to tricuspid and mitral valves, myocardial contusion, and paresis of the left phrenic nerve is reported. Porcine bioprosthetic valve replacement of both atrioventricular valves was necessary. Prompt diagnosis and aggressive intervention of such injuries can lead to successful repair of complex cardiac trauma.

Burns in motor vehicle accidents.

Burns received as a result of motor vehicle accidents (MVA's) create special problems in their care, as they are frequently severe and are often associated with other injuries. One hundred seventy-eight consecutive patients with burns sustained in an MVA were studied. The mean TBSA burn was 33.9%. The mortality was 24.7%, but the mean burn size in this fatal group was almost doubled at 63.9%. The injury most commonly associated with death was inhalation injury (in 36.3%). Thirty-six per cent of the patients sustained other injuries in addition to their burn, the most frequent of which was to the musculoskeletal system (67 injuries). Multiple trauma had little effect on mortality unless severe, but fractures especially complicated burn wound care unless surgically stabilized. Current methods of management are presented along with our approach to multiply injured burn patients.

Cold injury complicating burn therapy.

The immediate application of cool water to a burn provides prompt relief of pain; however, we must become aware of the complications associated with the use of ice and ice water in this regard. Two cases of extremity ischemia secondary to burn wound therapy are reported with a discussion of patient care. The most important aspect of this injury is prevention.

In vitro penetration of topical antiseptics through eschar of burn patients.

The ability of topical antiseptics to penetrate eschar of burn patients was determined by the agar diffusion technique. Gentamicin sulfate, mafenide acetate, nitrofurazone, povidone-iodine, silver nitrate, and silver sulfadiazine were tested against clinical isolates of Candida albicans, Staphylococcus, Streptococcus, and gram-negative bacilli including Pseudomonas aeruginosa. In practically all instances, the diameters of the zones of inhibition observed using eschar were comparable to those obtained with filter-paper discs. This finding showed that the antimicrobial agents could penetrate eschar and retain their effectiveness after penetration.

Introduction of Pseudomonas aeruginosa into a hospital via vegetables.

Pseudomonas aeruginosa was isolated from tomatoes, radishes, celery, carrots, endive, cabbage, cucumbers, onions, and lettuce obtained from the kitchen of a general hospital, with tomatoes yielding both highest frequencies of isolation and highest counts. Presence of P. aeruginosa on the hands of kitchen personnel and cutting boards and knives which they used suggests acquisition of the organism through contact with these vegetables. It is estimated that a patient consuming an average portion of tomato salad might ingest as many as 5 x 10(3) colony-forming units of P. aeruginosa. Pyocine types of P. aeruginosa isolated from clinical specimens were frequently identical to those recovered from vegetables, thus implicating tomatoes and other vegetables as an important source and vehicle by which P. aeruginosa colonizes the intestinal tract of patients.

Mode of transmission of Pseudomonas aeruginosa in a burn unit and an intensive care unit in a general hospital.

The transmission of Pseudomonas aeruginosa was studied in the burn unit and the intensive care unit of a 650-bed hospital. There was a tendency among patients in the burn unit to yield more than one type of P. aeruginosa, and several patients shared the same types at a particular point in time, suggesting cross-contamination among patients. Similar observations were made in the intensive care unit. Cultures from the hands of nurses caring for these patients yielded the same types of P. aeruginosa, suggesting the direct handling of patients by the nursing personnel to be the principal mode of transmission.