Surgical management of traumatic spondyloptosis: a case series.

BACKGROUND: Traumatic spondyloptosis is a rare and severe spinal injury characterized by complete anterior translation of one vertebra over another, often resulting in debilitating neurological deficits. CASE PRESENTATION: We present two cases of traumatic spondyloptosis and elaborate on the clinical presentation, management, and follow-up improvement. The first case is a 30-year-old Nepalese man who sustained traumatic spondyloptosis following a blunt force injury to his back while engaged in tree-cutting activities. The patient presented with severe back pain, left lower limb paralysis, and neurological deficits (consistent with American Spinal Injury Association grade C). Radiographic evaluation revealed total anterior dislocation of the L4 vertebral body over L5, accompanied by fractures of the superior endplates of both vertebrae. The second case is a 35-year-old Nepalese female who presented with back pain and lower limb paralysis following a fall from a 300-m cliff, exhibiting tenderness and ecchymosis in the mid-back region. Radiological examination revealed D12 vertebra translation over L1 with fracture, categorized as American Spinal Injury Association grade A. Both cases were surgically managed and stabilized. CONCLUSION: These cases emphasize the importance of a comprehensive approach to trauma management as well as prompt recognition, and early surgical management in optimizing outcomes for patients with traumatic spondyloptosis.

Clinical prediction models for the management of blunt chest trauma in the emergency department: a systematic review.

BACKGROUND: The aim of this systematic review was to investigate how clinical prediction models compare in terms of their methodological development, validation, and predictive capabilities, for patients with blunt chest trauma presenting to the Emergency Department. METHODS: A systematic review was conducted across databases from 1st Jan 2000 until 1st April 2024. Studies were categorised into three types of multivariable prediction research and data extracted regarding methodological issues and the predictive capabilities of each model. Risk of bias and applicability were assessed. RESULTS: 41 studies were included that discussed 22 different models. The most commonly observed study design was a single-centre, retrospective, chart review. The most widely externally validated clinical prediction models with moderate to good discrimination were the Thoracic Trauma Severity Score and the STUMBL Score. DISCUSSION: This review demonstrates that the predictive ability of some of the existing clinical prediction models is acceptable, but high risk of bias and lack of subsequent external validation limits the extensive application of the models. The Thoracic Trauma Severity Score and STUMBL Score demonstrate better predictive accuracy in both development and external validation studies than the other models, but require recalibration and / or update and evaluation of their clinical and cost effectiveness. REVIEW REGISTRATION: PROSPERO database ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=351638 ).

Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study.

BACKGROUND: Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation. METHODS: We conducted a post hoc analysis of a multicenter, prospective observational study (2019-2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs. RESULTS: From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673-5.643; p = 0.219). CONCLUSION: Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

No benefit from the addition of low-dose ketamine infusion to standard evidence-based care of patients with multiple rib fractures.

BACKGROUND: Multiple rib fractures from blunt thoracic trauma cause significant morbidity. Optimal current management includes multimodal analgesia, pulmonary hygiene, and early mobilization. Low-dose ketamine infusion (LDKI) has been proposed as an adjunctive analgesic in this setting. A prior study reported decreased pain scores with LDKI in patients with multiple rib fractures. We hypothesized that LDKI would decrease morphine milligram equivalents (MMEs) in patients with multiple rib fractures. METHODS: A prospective randomized placebo-controlled trial was performed in adult (18 years or older) patients with three or more rib fractures. A prestudy power analysis calculated an 80% chance of identifying a 15% decrease in MMEs with 50 subjects. The study was approved by the institutional review board and informed consent obtained in all subjects. Demographic (age, sex) and injury specific information (Injury Severity Score, number of rib fractures) were obtained. Subjects were randomized 1:1 to receive continuous LDKI (0.1 mg/kg/h) or placebo infusion (0.9% NaCl) for ≤48 hours. All patients received a standard evidence-based multidisciplinary protocol for rib fractures management. Primary outcome measure was MME use or pulmonary complications. Statistical comparison of LDKI versus placebo was performed using the Mann-Whitney U test. RESULTS: All 50 enrolled subjects (placebo, 25; LDKI, 25) received study drug infusion. The two groups were well matched for age, Injury Severity Score, and number of rib fractures. We observed no differences in the Day 1 (p = 0.961), Day 2 (p = 0.373), or total MMEs (p = 0.946) between groups. Similar total MME use was observed when subjects who received ≥40 hours of study drug and were compared (p = 0.924). Use of LDKI did not alter subsequent need for opiate analgesics postinfusion, hospital length of stay, pulmonary complications, or need for readmission. CONCLUSION: The addition of LDKI to an established multimodal, evidence-based protocol for management of multiple rib fractures did not decrease opiate usage or impact pulmonary complications. LEVEL OF EVIDENCE: Therapeutic/Care Managaement; Level I.

Follow-up strategies after non-operative treatment of traumatic splenic injuries: a systematic review.

PURPOSE: Blunt trauma often results in splenic injuries, with non-operative management (NOM) being the preferred approach for stable patients. Following NOM, splenic vascular injuries, such as pseudoaneurysms, may arise, prompting radiological follow-up. However, a consensus on optimal radiological follow-up strategies is lacking. This systematic review evaluates existing evidence on radiological follow-up post-NOM for traumatic splenic injuries. METHODS: Conducting a systematic review following updated PRISMA guidelines, we searched MEDLINE, Embase, The Cochrane Library, and trial registries from January 2010 to March 2023. Inclusion criteria covered studies on radiological follow-up for blunt splenic injuries. RESULTS: Out of 5794 studies, 17 were included involving 3392 patients. Various radiological modalities were used, with computed tomography (CT) being the most common. Vascular injuries occurred in 4.5% of patients, with most pseudoaneurysms diagnosed on day 2-6 post-trauma, and leading to intervention in 60% of these cases. Thirteen studies recommended routine follow-up, with six favouring CT, and seven supporting radiation-free modalities. Four studies proposed follow-up based on clinical indications, initial findings, or symptoms. Recommendations for specific timing of radiological follow-up ranged from 48 h to seven days post-injury. Regarding AAST grading, nine studies recommended follow-up for injury grade III and higher. CONCLUSION: Limited high-quality evidence exists on radiological follow-up in isolated blunt splenic injuries, causing uncertainty in clinical practice. However, our review suggests a reasonable need for follow-up, with contrast-enhanced ultrasound emerging as a promising alternative to CT. Specific timing and criteria for follow-up remain unresolved, highlighting the need for high-quality prospective studies to address these knowledge gaps.

Traumatic Tympanic Membrane Perforation in Children: A Descriptive Cross-sectional Study.

INTRODUCTION:   TTraumatic perforation of the tympanic membrane in pediatric population is often encountered in primary  otolaryngologic clinics or in the emergency department. The objective of the  study was to find out the clinical presentation of traumatic tympanic membrane perforation in the pediatric population. METHODS: A cross-sectional study was done from February, 2023 to February, 2024 after obtaining the ethical approval from the Institutional Review Board (2023/114). All the patients aged less than 18 years and presenting with traumatic tympanic membrane perforation were included in the study. Collected data was entered and analysed using Microsoft Excel. Patients were evaluated for demographics, mechanism of trauma and clinical characteristics of ear drum perforation in children. RESULTS: A total of 384 children aged less than 18 years were included in the study among which 267 (69.53%) were males. Physical assault 109 (28.39%) was the most common cause of tympanic membrane perforation. The most common symptom at the time of presentation was ear block/hearing loss 208 (54.16%). Conductive hearing loss was present in 214 (55.73%) children. CONCLUSION: Traumatic perforation of the tympanic membrane resulted mostly from the blunt force trauma especially in male children.

[Thoracic Endovascular Aneurysm Repair Using the Concomitant Chimney Technique for Blunt Thoracic Aortic Injury:Report of a Case].

Blunt thoracic aortic injury (BTAI) is associated with high morbidity and mortality. Recently, minimally invasive thoracic endovascular aortic repair (TEVAR) has been reported to be a safe surgical treatment for acute BTAI. Here, we report the success of TEVAR using the concomitant chimney technique for BTAI. A 70-year-old man in shock was referred to our emergency room following a traffic accident. Computed tomography( CT) scan demonstrated multiple rib fractures, hemothorax, and BTAI. According to the severity of BTAI as classified by the Society for Vascular Surgery( SVS) guidelines, the patient was diagnosed with grade 4 free rupture. We performed TEVAR twice because of the endoleak; however, this method saved the patient's life. The use of the chimney technique to preserve the patency of the left subclavian artery is beneficial because the majority of BTAI cases occur in the aortic isthmus from a pathophysiological perspective.

[Extracorporeal membrane oxygenation (ECMO) in severe acute respiratory distress syndrome due to blunt chest trauma: A case report]. / Oxigenación por membrana extracorpórea (ECMO) en síndrome de dificultad respiratoria aguda grave por traumatismo torácico contuso. Caso clínico.

We report a case of a patient with chest trauma (TT) complicated with severe acute respiratory distress syndrome (ARDS) who required extracorporeal membrane oxygenation (ECMO) as ventilatory support. Clinical case: A 48-year-old man, with no relevant history, after a high-energy vehicle collision admitted with severe TT. He evolved with respiratory failure that required intubation and connection to mechanical ventilation (MV). He persisted with high ventilatory requirements, requiring rescue ECMO and transfer to our center. He evolved with gasometric and ventilatory improvement that allowed disconnection on the ten day. There were no bleeding or thrombotic complications during ECMO. Discussion: ECMO support is complex, expensive, and is performed in high-risk patients. The use of this resource requires trained health workers. Its use must be highly selective, constituting a valuable support tool in some patients with severe ARDS secondary to TT.

Leukocytosis and thrombocytosis after splenectomy: expected finding, infection, or something else: a case report.

BACKGROUND: Leukocytosis and thrombocytosis often follow splenectomy in blunt trauma patients, complicating the postoperative identification of infection. While the platelet count to white blood cell ratio provides diagnostic assistance to discern between expected laboratory alterations and infection, diagnoses such as leukemia are often overlooked. CASE PRESENTATION: A 53-year-old Hispanic male presented with abdominal pain, nausea, tachycardia, and focal peritonitis 4 days after being assaulted and struck multiple times in the abdomen. Initial white blood cell count was 38.4 × 109/L, platelet count was 691 × 109/L, and lipase was 55 U/L. Computed tomography abdomen/pelvis demonstrated a hematoma encasing the distal pancreas and abutting the stomach and colon. Emergent laparotomy revealed a nearly transected pancreas and devascularized colon, necessitating a distal pancreatectomy, splenectomy, and colonic resection with primary anastomosis. Postoperatively, he had a persistently elevated leukocytosis, thrombocytosis, segmented neutrophils, eosinophilia, and basophilia (peak at 70, 2293, 64, 1.1, and 1.2 × 109/L, respectively). Despite sepsis workup, including repeat computed tomography, no source was identified. Hematology/oncology was consulted for concern for hematologic etiology, with genetic testing and bone marrow biopsy performed. The diagnosis of breakpoint cluster-Abelson gene-positive chronic myeloid leukemia was made based on genetic tests, including polymerase chain reaction and fluorescence in situ hybridization analysis, which confirmed the presence of the Philadelphia chromosome. Bone marrow biopsy suggested a chronic phase. The patient was treated with hydroxyurea and transitioned to imatinib. CONCLUSIONS: Thrombocytosis following splenectomy is a common complication and a plate count to white blood cell count ratio < 20 indicates infectious etiology. A significantly elevated white blood cell count (> 50 × 109/L) and thrombocytosis (> 2000 × 109/L) may suggest something more ominous, including chronic myeloid leukemia , particularly when elevated granulocyte counts are present. Chronic myeloid leukemia workup includes peripheral smear, bone marrow aspiration, and determination of Philadelphia chromosome. Post-splenectomy vaccines are still indicated within 14 days; however, the timing of immunization with cancer treatment must be considered. Tyrosine kinase inhibitors are the first-line therapy and benefits of pretreatment with hydroxyurea for cytoreduction remain under investigation. Additionally, tyrosine kinase inhibitors have been associated with gastrointestinal perforation and impaired wound healing, necessitating heightened attention in patients with a new bowel anastomosis.

The optimal management of blunt aortic injury in the young.

BACKGROUND: Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset. METHODS: Patients (1-19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1-9] and adolescents [ages 10-19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI. RESULTS: Adolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 â€‹%, p â€‹= â€‹0.057) and significantly reduced mortality (2.1 vs 14.4 â€‹%, p â€‹< â€‹0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059-0.324, p â€‹< â€‹0.0001). CONCLUSIONS: BAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.

Between blunt, sharp and hacking trauma: Observing the characteristics of pickaxe injuries.

Pickaxe injuries have never been thoroughly investigated in forensic science. This case, involving the fatal wounding of a 28-year-old individual by pickaxe blows to the head, abdomen, and hand, highlights the unique injury patterns associated with such an instrument. The injuries observed in the frontal skull exhibited characteristics akin to typical chop wounds, while those on the parietal skull bore similarities to blunt force trauma. The pickaxe penetrated the hands and the abdomen, with the depth of penetration directly correlating to the force applied. Consequently, pickaxe injuries can be considered a hybrid of different injury mechanisms, a fact that should be carefully considered in forensic analysis.

Infrared thermography for detection of blunt-force trauma injuries during animal abuse investigations.

Detection of bruising in living animal victims of abuse can be challenging due to animal temperament and anatomy. Visual assessment, combined with physical and serum biochemical evaluation, can fail to detect injuries. However, development and validation of a noninvasive, antemortem method for detecting bruising in domestic species could have important medicolegal implications. Key clinical message: Thermal imaging utilizing infrared wavelengths can assist in detection of trauma in cases of animal abuse where no visible injuries are apparent, aiding in providing appropriate medical treatment and guidance for the legal system.

Thermographie infrarouge pour la détection de traumatismes contondants lors d'enquêtes sur la maltraitance des animauxLa détection des ecchymoses chez les animaux vivants victimes de maltraitance peut s'avérer difficile en raison du tempérament et de l'anatomie de l'animal. L'évaluation visuelle, combinée à l'évaluation physique et une analyse biochimique sérique, peut ne pas détecter les blessures. Cependant, le développement et la validation d'une méthode ante-mortem non invasive pour détecter les meurtrissures chez les espèces domestiques pourraient avoir d'importantes implications médico-légales.Message clinique clé :L'imagerie thermique utilisant des longueurs d'onde infrarouges peut aider à détecter les traumatismes dans les cas de maltraitance animale où aucune blessure visible n'est apparente, contribuant ainsi à fournir un traitement médical approprié et à guider le système judiciaire.(Traduit par Dr Serge Messier).

Scrotal Trauma Treatment and Outcomes.

INTRODUCTION: Genitourinary tract injuries have been reported to account for 3% to 10% of trauma patients, and scrotal injuries have been reported to comprise 71% of male genital trauma. Scrotal trauma is particularly prevalent in males 10 to 30 years of age, thus posing a potential threat to fertility. Scrotal trauma can be blunt or penetrating in nature, and the mechanism of trauma can have an impact on the management and outcomes of this type of injury. METHODS: A retrospective chart review of adult patients who presented with scrotal trauma to a single large level I trauma center from January 1, 2000, to June 1, 2022, was conducted to assess the relative occurrence and type of trauma (blunt vs penetrating), as well as differences in the management, duration of hospital stay, and need for orchiectomy between these 2 types of injury. RESULTS: There were 102 patients included in this study, with an average age of 39.5 years (18.7-77.2 years). Fifty-six patients had blunt scrotal trauma, and 46 had penetrating scrotal injury. There was not a statistically significant difference in the percentages of blunt versus penetrating trauma (P < = 0.3729). Patients with penetrating trauma were more likely to be inpatient than those with blunt trauma (69.6% vs 42.9%; P < = 0.013; 95% CI, 0.062-0.473). A total of 61 patients were treated conservatively (44 and 17 patients in the blunt and penetrating trauma groups, respectively). Overall, 41 patients required surgical intervention: 12 who had blunt trauma and 29 who suffered penetrating injury. Surgical treatment was more common for penetrating trauma than for blunt trauma (63.0% vs 21.4%; P <0.0001; 95% CI, 0.220-0.612). Eleven patients underwent orchiectomy - 4 from the blunt trauma group and 7 from the penetrating trauma group; the rate of orchiectomy was not significantly different between the 2 groups. CONCLUSIONS: In this study, blunt scrotal trauma was slightly more common than penetrating injury, but the difference did not reach statistical significance. Blunt scrotal trauma was associated with a higher rate of conservative treatment. Further study is needed to better understand the impact of scrotal trauma on future fertility.

Pediatric Pyloric Transection: An Unusual Injury Following Blunt Abdominal Trauma.

BACKGROUND The pediatric population, due to its distinct anatomy and physiology, often presents with unique mechanisms of trauma, leading clinicians to encounter diverse and sometimes unexpected injuries. Whether these injuries result from blunt or penetrating trauma, they may involve intra-abdominal organs in pediatric patients. Additionally, there are occasional occurrences where injuries affect rare sites such as the pylorus in an isolated manner within this age group. Clinicians must be prepared to address a wide range of injury patterns to ensure optimal outcomes for pediatric patients experiencing trauma to intra-abdominal structures such as the pylorus. CASE REPORT We report a 19-month-old boy who presented with abdominal pain, crying, and repeated vomiting of gastric contents after a wardrobe fell on his upper torso. His vital signs were stable except that he was tachycardiac. Upon investigation, abdominal computed tomography (CT) revealed pneumoperitoneum, free peritoneal fluid, and inflammatory changes in the intestinal wall, suggesting hollow viscus injury. Exploratory laparotomy was performed, and complete transection of the pyloric area of the stomach was identified. The pancreatic and biliary ducts were intact. On postoperative day 5, an upper gastrointestinal (UGI) contrast study prior to initiating oral feeding was done and showed normal findings with no contrast leakage. His postoperative course was unremarkable. CONCLUSIONS Isolated pyloric injuries following blunt trauma are rare with no known case reports in pediatric age group. High morbidity and mortality rates can result from traumatic gastrointestinal injuries including the involvement of pylorus. Therefore, accurate diagnosis and prompt management are essential for an improved outcome.

Wolf in sheep's clothing: a case of primary lung adenosquamous carcinoma mimicking traumatic pulmonary pseudocyst.

BACKGROUND: Traumatic pulmonary pseudocyst is a rare "cystlike" lung lesion that typically develops following blunt chest trauma. It differs from lung cancer associated with cystic airspaces in terms of pathogenic mechanisms, clinical manifestations, and radiological features. Furthermore, there are few reports of the diagnostic bias between traumatic pulmonary pseudocyst and lung cancer associated with cystic airspaces. Here, we present a rare case of lung cancer associated with cystic airspaces that mimicks traumatic pulmonary pseudocyst. CASE PRESENTATION: A 61-year-old man with no chest medical or surgical history, no chest radiologic examination within the last five years, and no smoking history had an air-filled "cystlike" lesion surrounded by solid components and ground-glass opacities in the middle third of the right upper lobe of the lung during a computed tomography evaluation following blunt chest trauma. He was initially diagnosed with traumatic pulmonary pseudocyst and treated conservatively. On the third post-trauma day, he experienced hemoptysis, which was successfully treated with intravenous hemostatic medication. On the ninth post-trauma day, he exhibited a significant hemoptysis and a moderate dyspnea. A subsequent chest computed tomography scan demonstrated that the solid components had entered the lesion's cavity and significantly expanded, and the surrounding ground-glass opacities had slightly enlarged. A contrast-enhanced chest computed tomography scan and a three-dimensional reconstruction computed tomography image confirmed that the solid components were a hematoma caused by damage to the right upper pulmonary vein. A right upper lobectomy was performed based on the concern about severe intrapulmonary bleeding. An intraoperative frozen section analysis showed significant bleeding in the lung parenchyma. Adenosquamous carcinoma was unexpectedly identified during the postoperative pathological examination of the resected specimen. A diagnosis of primary lung adenosquamous carcinoma was made. He was discharged on the seventh postoperative day and followed up for two years without any recurrence. CONCLUSIONS: The potential of lung cancer associated with cystic airspaces should be considered for "cystlike" lung lesions discovered in elderly patients after blunt chest trauma. A comprehensive review of the medical history, meticulous analysis of the radiological findings, and close monitoring can help clinicians reduce the risk of diagnostic bias.

Airway management in a child with complete tracheal transection following blunt laryngotracheal trauma.

Blunt injury to the neck following high-impact trauma can be associated with airway injury. The anaesthesiologist should have a high index of suspicion for the same when the patient presents for any surgical intervention for trauma. A complete evaluation of the tracheobronchial tree using a flexible bronchoscope is essential before instrumenting the airway in a child with suspected laryngotracheal trauma because blind intubation can convert a lesser grade airway trauma into a significant one. We report the airway management in a child belonging to middle childhood, who presented with complete tracheal transection after a blunt laryngotracheal trauma.

[Blunt force trauma in forensic radiology]. / Stumpfe Gewalt in der forensischen Radiologie.

OBJECTIVE: Description of the main forensic radiological examination modalities and findings in blunt force trauma in living and deceased adults. METHODS: Elaboration of the essential points based on the authors' own experiences and relevant literature. RESULTS AND CONCLUSION: Injury-related consequences of blunt force are frequently observed in forensic radiological diagnostics, especially in the context of accidents and suicides, and less frequently in homicides. The method of choice for radiological imaging of blunt force in deceased persons is native postmortem computed tomography (PMCT). In principle, the radiological effects of blunt force in PMCT do not differ significantly from those in living persons. Postmortem magnetic resonance imaging (PMMRI) is very suitable for imaging blunt soft tissue injuries in the shorter postmortem interval. In the case of living individuals with the consequences of blunt force trauma, imaging is primarily indicated for clinical diagnostic reasons. Common indications are domestic violence, violence against the elderly, and disputes in public spaces. The choice of radiological examination method depends on the clinical history and symptoms, and the radiological examinations can be subjected to a forensic assessment.