Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement.

BACKGROUND: To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa. METHOD: A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected. RESULTS: Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days. CONCLUSION: Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A followup study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary.

The in vitro effect of xylitol on chronic rhinosinusitis biofilms.

INTRODUCTION: Biofilms have been implicated in chronic rhinosinusitis (CRS) and may explain the limited efficacy of antibiotics. There is a need to find more effective, non-antibiotic based therapies for CRS. This study examines the effects of xylitol on CRS biofilms and planktonic bacteria. METHODS: Crystal violet assay and spectrophotometry were used to quantify the effects of xylitol (5% and 10% solutions) against Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus. The disruption of established biofilms, inhibition of biofilm formation and effects on planktonic bacteria growth were investigated and compared to saline and no treatment. RESULTS: Xylitol 5% and 10% significantly reduced biofilm biomass (S. epidermidis), inhibited biofilm formation (S. aureus and P. aeruginosa) and reduced growth of planktonic bacteria (S. epidermidis, S. aureus, and P. aeruginosa). Xylitol 5% inhibited formation of S. epidermidis biofilms more effectively than xylitol 10%. Xylitol 10% reduced S. epidermidis planktonic bacteria more effectively than xylitol 5%. Saline, xylitol 5% and 10% disrupted established biofilms of S. aureus when compared with no treatment. No solution was effective against established P. aeruginosa biofilm. CONCLUSIONS: Xylitol has variable activity against biofilms and planktonic bacteria in vitro and may have therapeutic efficacy in the management of CRS.

Positron emission tomography/computed tomography scanning for the diagnosis of occult sepsis in the critically injured.

BACKGROUND: Although the site of nosocomial sepsis in the critically ill ventilated patient is usually identifi able, it may remain occult, despite numerous investigations. The rapid results and precise anatomical location of the septic source using positron emission tomography (PET) scanning, in combination with computed tomography (CT), has promoted this modality as the diagnostic tool of choice for pyrexias of unknown origin. METHOD: The objective of this study was to report our experience using PET/CT scanning for the localisation of a septic focus in critically injured patients in whom no source could be identifi ed using conventional investigations. RESULTS: Two patients with gunshot wounds and two who had sustained multiple fractures following motor vehicle collisions developed pyrexias of unknown origin during their stay in the trauma intensive care unit. Routine screening for a septic focus was unrewarding, and 18F-fl uorodeoxyglucose PET/CT scanning was used to identify the possible source. PET/CT scanning identifi ed the septic focus in all patients. Abscesses were drained successfully in those with penetrating trauma and in one with blunt polytrauma. Pulmonary tuberculosis, not apparent on initial radiology, was identifi ed using PET/CT in one patient with blunt thoracic trauma. CONCLUSION: PET/CT scanning appears to both confi rm and localise the source of sepsis in a variety of pathologies in critically ill patients who develop pyrexias for which no source can be identifi ed by conventional screening techniques.

Validation of the mortality prediction equation for damage control surgery in an independent severe trauma population.

BACKGROUND: A prediction model was developed in Cape Town which utilised age, preoperative lowest pH and lowest core body temperature to derive an equation for the purpose of predicting mortality in damage control surgery. It was shown to reliably predict death despite damage control surgery. The equation derivation dataset and the validation set showed the equation to have 100% positive predictive value (PPV) for both datasets and 24% sensitivity. The aim of the study was to validate the prediction model in an independent dataset from a prospective trauma registry. METHOD: Retrospective analysis of an ethics-approved prospectively collected database and electronic medical records was performed on trauma patients undergoing damage control surgery at the Inkosi Albert Luthuli Central Hospital, Durban, between 2007 and 2013. Age, lowest preoperative core body temperature and the pH of the patients were analysed using the previously derived equation. The output from the equation was then classified as a prediction of death, based on the obtained values, and then compared to the actual outcome of whether the patients survived or died. RESULTS: A total of 48 patient records were analysed in the study. Twenty-nine patients in the cohort died. The equation predicted mortality in only four cases, of whom three died and one survived (75% PPV and 10% sensitivity). The unexpected survivor reduced the PPV to 75%, compared to 100% PPV achieved in the original study. CONCLUSION: The results of this study were inconsistent with those of the original study, and the 0.500 cut-off value used in the equation yielded PPV and sensitivity which were relatively non-clinically useful for the average patient in this cohort.

Management of vascular injuries on ICU patients: KZN experience.

BACKGROUND: Vascular injury management remains an extremely challenging task. The fundamental principles of management are bleeding arrest and flow restoration, to avoid death and amputation. With advances in medicine, there has been a shift from ligation to primary repair which has resulted in a fall in amputation rate from 50 % in World War II to less than 2 % in civilian injuries. METHOD: A retrospective cross-sectional study was conducted on ICU requiring polytrauma patients with vascular trauma admitted between January 2013 and December 2021. Additional data were collected prospectively from January 2022 to December 2022. All data was from an ethics approved Trauma Registry. The injury was either confirmed by imaging or via exploration. The pre-designed data proforma acquired the following variables: age, mechanism of injury, injured vessel, associated injury, management of the vessel, and management of the associated injury. The data were analysed using Stata version 17 (StataCorp, College Station TX). Frequencies and percentages were calculated to summarise numerical data An ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the KZN Department of Health. All data were de-identified in the data collection sheet. RESULTS: There were 154 arterial injuries and 39 venous injuries. The majority, 77 (50 %) of arterial injuries were managed via open strategies, and 36 (23 %) were managed via endovascular intervention. The majority, 20 (51 %) of venous injuries underwent open ligation, and 12 (31 %) were managed non-surgically. The highest number of endovascular interventions was observed in aortic injuries. For a total of 25 aortic injuries, 22 (83 %) were managed endovascular (TEVAR) and 2 (8 %) were managed non-operatively. CONCLUSION: The choice between the endovascular and open approach depends on the injured blood vessel. The majority of venous injuries were treated with open ligation in this cohort.

Introductory Editorial.

This is the introduction article and editorial that will address the latest approaches to safe management of snakebite in South Africa and shares the evidence and expert consensus from the recent South African Snakebite Symposium (SASS) meeting held in July 2022.

Interpretation of emergency CT angiograms in vascular trauma - vascular surgeon vs radiologist.

BACKGROUND: This study aims to investigate any discrepancy in interpretation of computed tomography (CT) angiograms (CTA) in suspected traumatic arterial injury by vascular specialists and radiology specialists, and the influence of any discrepancies on patient outcome. METHODS: A prospective observational comparative study of 6-month duration was undertaken at a tertiary hospital in Durban, South Africa. Haemodynamically stable patients with suspected isolated vascular trauma admitted to a tertiary vascular surgery service who underwent a CTA on admission were reviewed. The interpretations of CTAs were compared between vascular surgeons, vascular trainees and radiology trainees with the consultant radiologist report as the gold standard comparator. RESULTS: Of 131 CTA consultant radiologist reports, the radiology registrar concurred with 89%, which was less than the vascular surgeon who correctly interpreted 120 out of 123 negative cases with three false positives. There were no false negatives or descriptive errors. A 100% sensitivity (95% CI 63.06-100) and 97.62% (95% CI 93.20-99.51) specificity was noted for the vascular surgeon. Overall agreement was 97.71 % with Cohen's kappa value = 0.83 (95% CI 0.64-1.00) indicating very good agreement. Apart from three negative direct angiograms, patient management and outcome were not impacted by the vascular surgeons' errors in interpretation. CONCLUSION: There is very good inter-observer agreement in the interpretation of CTAs in trauma between the vascular surgeon and radiologist with no negative impact on patient outcome.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans.

Snake bite management is largely driven by expert opinion and consensus, however there are a few large retrospective studies and RCT's that have improved the quality of medical guidance currently available. South African snakes are different in the venomous potential and it behooves the hospital provider and the average medical practitioner to know the current best practice concepts concerning assessment, treatment and antivenom use. The recent SASS meeting in July 2022 provided an update and national consensus from which this Hospital Care document is derived.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans.

Snakebites occur in the community, not in the Emergency Unit. As such it is important to understand the first-aid concepts and pre-hospital emergency care aspects of this neglected disease. This article will highlight the concepts for emergency care within the context of the current pre-hospital arena and in light of the recent South African Snakebite Symposium consensus meeting held in July 2022, where wilderness rescue, emergency medical services and other medical participants agreed through evidence review and consensus debate on the current best approaches to care of the snakebite victim outside the hospital environment.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans: Special patient groups and surgical aspects.

This article explores the management of snakebite to vulnerable patient groups, namely children and pregnant women as well as providing detail on the current best practice when caring for venom ophthalmia and surgical wounds resulting from snakebite. Finally, the optimal free-to-use medical record for accurate documentation of snakebite incidents is provided for use by South African practitioners.

Variables required for the audit of quality completion of patient report forms by EMS-A scoping review.

Introduction: This review aimed to compile a list of essential variables from the patient assessment, care provided out-of-hospital and the patient handover over process that should be recorded on a Patient Report Form (PRF). A scoping review was conducted to identify articles concerning the recording of medical information on the PRF in the prehospital environment. Methods: A three-step search strategy was used to systemically search published literature. A Boolean method using synonymous phrases related to patient handover variables required for PRF competition was developed based on an initial online search of key phrases. Using the Boolean phrase, a scoping review (guided by a protocol developed a priori) was conducted. The search was conducted using PubMed, CINAHL, Summon and Scopus. A PCC framework was used to guide the inclusion criteria of identified articles. Results: The database search yielded 2461 results. Duplicates (n = 736), articles published prior to the year 2000 (n = 260), and non-English results (n = 30) were removed. The remaining 1435 articles underwent title and abstract screening to determine the relevance to the study topic. This resulted in articles apparently relevant to the study (n = 47) and these underwent full-text review. Following full-text review 25 articles were included in the study. Patient related information and variables detailing the condition of the patient, including, patient demographics, vital signs, patient assessment and treatment initiated and the manner in which this information is transferred during the patient handover are factors that are important during patient hand over. Conclusion: The information on the PRF prevents potential loss of critical patient information and details of the patient's condition and treatment from the prehospital field. The development of an appropriate checklist to quality assure PRF's by ensuring that all vital information is captured on the PRF is proposed.

The spectrum and outcome of paediatric emergency surgical admissions - a regional hospital analysis.

BACKGROUND: Improving emergency surgical care for children requires information on the causes of admissions and the variables affecting outcome. There is a lack of such data in the South African context. METHODS: This retrospective study was conducted from January 2016 to December 2017. Data was collected on all children (< 12 years of age) requiring admission with emergency surgical conditions. Infrastructure and staffing ratios were determined prior to data collection. Information was sourced from admission and discharge books, patient files and theatre registers. Variables of age, sex, referral source, diagnosis, length of stay, surgical treatment and outcome including death were collected. RESULTS: Four hundred and thirty-five of the 1 048 children (42%) admitted were in the 0-2-year age group. Trauma (258), sepsis (564) and burns (226) were the main causes. The median hospital stay was 3 days (IQR 2-5), however, for burns patients, the median stay was 4 days (IQR 2-9). Surgery was performed on 279 (27%) admissions. Eight (0.8%) died, six of which were due to burns. Clinical status prior to death was poorly documented. A dedicated high care unit and burns isolation rooms were lacking. Surgeon/population and child/nurse ratios were respectively 1.48/100 000 and 7-12/1. CONCLUSION: This study found that the emergency paediatric surgical burden is significant. Sepsis and trauma combined are the leading cause of emergency admissions. Burns had the highest mortality. Although mortality was low, improvements of staff to patient ratios and the institution of an early warning system could reduce mortality.

Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format.

BACKGROUND: Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non-trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format. METHODS: Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days. RESULTS: The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p < 0.001), more admissions to ICU (23/56; 41.1%) (p < 0.001), more complications (29/56; 51.8%) (p = 0.039), and higher length of stay > 14 days (16/56; 28.6%) (p = 0.037). CONCLUSION: The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.

Intensive care unit hospitalisation costs associated with road traffic crashes at a central hospital in KwaZulu-Natal for the 2017/18 financial year.

BACKGROUND: The financial and physical impacts of road traffic crashes are borne by the individual, the extended family, society, the health sector and the economy of the country. The main contributors to these costs are the loss of productivity and the accrual of ongoing healthcare costs over a long-term period. There is limited information available on the cost of admitting seriously injured patients post accidents to a central hospital intensive care unit. METHODS: Cost data was obtained from the electronic database for all patients admitted for more than 24 hours to the trauma intensive care unit at Inkosi Albert Luthuli Central Hospital. A mixed costing approach was used. Data was collected on surgical procedures, imaging, laboratory tests, trauma receiving fees, pharmaceuticals, goods and services and compensation of employees. RESULTS: The total cost of treating road traffic crash patients for the 2017/18 financial year equated to R21 140 475.49. The three main cost drivers comprised the compensation of employees (R12 135 848.41; 57.4%), goods and services (R5 083 182.12; 24%) and surgery costs (R1 429 321.00; 6.8%). The average cost per admission was R163 879.65, with the average cost per inpatient day equating to R12 727.56. Male patients admitted from motorcycle crashes had the highest cost per admission, followed by motor vehicle crashes and pedestrian vehicle crashes. CONCLUSION: The cost and burden associated with road traffic crashes is reflective of national and international trends and will require a comprehensive strategy to reduce accidents as well as better management at the scene and at lower levels of care.

Renal replacement therapy in intensive care units in KwaZulu-Natal Province, South Africa.

Background: Renal replacement therapy (RRT) is a scarce resource in southern Africa. Critically ill patients are at risk of developing acute kidney injury (AKI), which may require RRT. There are few data on the utilisation of RRT in southern African intensive care units (ICUs). Objectives: To determine the indications for initiating RRT in critically ill patients in ICUs in KwaZulu-Natal, South Africa (SA) and to describe the methods and dosing of RRT. Methods: A prospective observational study was performed to investigate the indications for initiating, methods and dosing of RRT among patients admitted to four ICUs in KwaZulu-Natal Province, SA. All adult patients were eligible for inclusion. Results: A total of 108 patients who received RRT were included in the study. The most common reasons for initiation of RRT were a high/rising creatinine, high/rising urea, acidosis and fluid balance. The majority of the patients (79.6%; n=86) had three or more indications for RRT. A total of 353 intermittent haemodialysis/slow low-efficiency dialysis (IHD/SLED) sessions and 84 continuous renal replacement therapy (CRRT) sessions were recorded. The median (interquartile range (IQR)) CRRT dose was 25.8 (19.1 - 28.8) mL/kg/h. The median (IQR) urea reduction ratio for IHD/SLED was 32.4% (15.0 - 49.8). Conclusion: Patients in this study had multiple indications for initiating RRT. The dosing of RRT was not optimal, with a wide range shown in CRRT, and the majority of patients did not achieve a urea reduction ratio (URR) >65%. Contributions of the study: Renal replacement therapy is a scarce resource in Africa. Little is known about the current types and dosing of RRT in critical care units in South Africa. We showed that critically ill patients had multiple indications for RRT and the dosing was not optimal.

Establishing a South African national framework for COVID-19 surgical prioritisation.

BACKGROUND: Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. OBJECTIVES: To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculatorfor operative care. METHODS: The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. RESULTS: A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. CONCLUSIONS: This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.

Petrous apex pneumatisation in children: a radiological study.

OBJECTIVE: This study aimed to investigate petrous apex pneumatisation in children, as an understanding of petrous apex pneumatisation is useful in the diagnosis and surgical management of middle-ear disease. METHODS: Computed tomography head scans from 1700 patients aged 0-16 years were assessed. Petrous apex bone and air cell volumes were calculated to determine the degree of petrous apex pneumatisation. Scans were analysed for communicating tracts between the middle ear and petrous apex. RESULTS: Petrous apex pneumatisation was found in 21.0 per cent of patients. Positive relationships were found between age and petrous apex pneumatisation prevalence (rs = 0.990, p < 0.001), and between age and degree of petrous apex pneumatisation (rs = 0.319, p < 0.001). Petrous apex pneumatisation prevalence did not significantly differ by sex or ethnicity. Communicating tracts were identified in 84.3 per cent of patients with petrous apex pneumatisation, most commonly anterior to the otic capsule. CONCLUSION: In children, the prevalence and degree of petrous apex pneumatisation increases with age, but prevalence is not affected by sex or ethnicity.

The value of immediate postoperative radiographs following fluoroscopically-guided orthopaedic surgery in a polytrauma ICU setting in KwaZulu-Natal, South Africa.

BACKGROUND: Radiographic imaging remains a cornerstone of orthopaedic practice. Traditional control X-Rays are routinely requested after procedures. These X-rays may add little value in post-op evaluation of trauma ICU patients, in light of intra-operative screening already performed and reviewed, but has high potential morbidity risk. AIM: The aim is to determine if patients undergoing extra-articular fracture fixation, with fluoroscopic image guidance, require any management change due to immediate check x-rays findings. METHOD: Electronic patient and imaging records from January 2015 to November 2019 at a Trauma-specific ICU at a Trauma Society of South Africa accredited, Level 1 Trauma Unit were reviewed retrospectively. All patients matching the inclusion criteria were evaluated to determine if there were any complications and changes in management after the check X-Rays. RESULTS: There were 103 ICU patients identified with a mean age of 32 years (3 to 94). Fifty-seven percent had fluoroscopy images as well as post-operative check x-rays and 51.5% had only check X-rays. Only two cases needed revision surgery based on the control x-ray findings. The post-operative x-ray did not alter the management of 98.1% of our patients. CONCLUSION: In this study, routine post-op check x-rays did not add significant additional information to warrant early additional surgical intervention especially in ICU patients with adequate intra-operative fluoroscopy images. This investigation should be ordered for individual patients based on clinical grounds. This will help minimize patient exposure to avoidable radiation, labour intensive transfers to the radiology department, and decrease investigations that have financial implications but with limited benefits.

Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: simple, cost-effective and accurate.

AIM: This audit aims to gauge the safety and efficacy of iso-oncotic water-soluble contrast media as the sole imaging evaluation of the distal pharynx and cervical oesophagus after penetrating cervical trauma. METHODS: A retrospective audit was performed over a 4-year period of all patients with penetrating cervical trauma to zones 1 and 2 of the neck who were subjected to imaging evaluation as part of a selective non-operative management policy for penetrating cervical trauma. The outcome was reviewed and the sensitivity, specificity and predictive values of the investigation were determined. The surgical management of identified injuries is also described. RESULTS: Four hundred and sixty-five contrast studies were included with 11 studies positive for pathology (9 injuries, 2 incidental findings). Surgery was undertaken in 4 patients with cervical oesophageal injuries and conservative management was carried out in 5 cases of distal pharyngeal injury. No missed injuries and no significant adverse events were identified during the study period. CONCLUSION: A contrast study of the oesophagus with water-soluble iso-oncotic contrast media as the sole diagnostic imaging modality is safe (avoiding the risk of aspiration pneumonia), reliable (identifying all injuries) and cost-efficient (avoiding the need for additional expensive investigations) in cases of penetrating cervical trauma.

Renal trauma in a Trauma Intensive Care Unit population.

BACKGROUND: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. This study in a dedicated Trauma Intensive Care Unit (TICU) population aimed to assess the outcomes of renal injuries and identify factors that predict the need for nephrectomy. METHODS: Patients, older than 18 years, admitted to TICU from January 2007 to December 2014 who sustained renal injuries had data extracted from the prospectively collected Class Approved Trauma Registry (BCA207-09). Patients who underwent surgical intervention for the renal injury or received non-operative management were compared. The key variables analysed were: patient demographics, mechanism of injury, grade of renal injury, presenting haemoglobin, initial systolic blood pressure, Injury Severity Score and Renal Injury AAST Grade on CT scan in patients who did not necessarily require immediate surgery, or at surgery in those patients who needed emergency laparotomy. RESULTS: There were 74 confirmed renal injuries. There were 42 low grade injuries (grade I-III) and 32 high grade injuries (5 grade IV and 27 grade V). Twenty-six (35%) had a nephrectomy: 24 with grade V injuries and 2 with grade IV injuries required nephrectomy. Six patients in the high injury grade arm had non-operative management. A low haemoglobin, low systolic blood pressure, higher injury severity score, and a high-grade renal injury, as well as increasing age were positive predictors for nephrectomy in trauma patients with renal injury. CONCLUSION: Non-operative management is a viable option with favourable survival rates in lower grade injury; however, complications should be anticipated and managed accordingly. High grade injuries predict the need for surgery.