Management of severe pelvic fracture associated with injuries of adjacent viscera.

OBJECTIVE: To investigate the approach of emergency management for severe pelvic fracture associated with injuries of adjacent viscera and evaluate the therapeutic effect. METHODS: The data of 79 patients with severe pelvic fracture associated with injuries of adjacent viscera were retrospectively studied, and the study covered a period of 14 years. RESULTS: To cease massive bleeding due to pelvic fracture, ligation of internal iliac arteries was performed on 33 cases, and angioembolization on 8. Of 42 patients with cystic or/and urethral injury, 35 underwent cystostomy and delayed reconstruction, and 7 received a primary realignment. All of 17 patients with injury of retroperitoneal rectum underwent diverting colostomy of the proximal end of sigmoid with presacral drainage, but 4 received primary repair without colostomy. In 22 patients with intraperitoneal colorectal injury, 19 were managed with primary repair or anastomosis while 3 received a colostomy. The overall mortality rate was 8.86% (7/79); the main causes were hemorrhagic shock and associated injury. The complications included urethro-rectal fistula in 4 cases, thrombosis of right common iliac artery in 1, ARDS following chest trauma in 1, and paraplegia in 1. Except the patient with paraplegia, all of them were cured. CONCLUSIONS: Prompt diagnosis and proper treatment are the key to success. Devascularization of internal iliac arteries with external fixation cage of the pelvis, cystostomy and proximal sigmoidostomy are effective procedures in emergency treatment of the critical patients.

[Management of extensive closed internal degloving injury].

OBJECTIVE: To study the management of extensive closed internal degloving injury (CIDI). METHODS: From September 1987 to October 1999, 18 cases of CIDI were retrospectively reviewed. Of 18 cases, there were 7 cases in thigh, 6 cases in legs and 5 cases in pelvis, ranging from 15 cm x 12 cm to 38 cm x 25 cm in size. Various managements were adopted according to the severity of the injury, including vacuum drainage and adjuvant compression in 5 cases, regrafting of defatting fenestrated full-thickness skin by non-resection in 8 cases, and skin grafting with transfer of myocutaneous flap in 5 cases. Among them, there were 11 cases of bone and articular fixation or repair, 4 cases of principal vessels repair. All of the cases were evaluated clinically and followed up for 6 months to 3 years. RESULTS: In the 8 cases repaired by regrafting of defatting fenestrated full-thickness skin, only one case of skin necrosis, 5 cm x 2 cm in size, recovered after skin grafting; the others healed well. All of the patients recovered normal life and had normal limbs. CONCLUSION: It's crucial to make a careful assessment about the injury severity of CIDI, to stress on importance of management of both CIDI and deep injury, and to choose proper options after comprehensive assessment of the injury.

Penetrating cardiac wounds: principles for surgical management.

Stab wounds are the main type of penetrating cardiac injury in China and they have a fairly good prognosis when the patient receives expeditious and appropriate management. The objective of this study is to present the experience of managing the patients with penetrating cardiac injuries. A retrospective study involving 82 cases with penetrating wounds of the heart in the past 16 years was carried out. Stab wounds accounted for 86.58% of this series (71 of 82 patients). All 82 cases were treated operatively. The amount of preoperative infusion as fluid resuscitation for shock was less than 1,000 ml in 65.85% of the present study. Only in three patients was preoperative pericardiocentesis performed, yielding a false-negative result in one. Six patients sustaining cardiac arrest soon after arrival were subjected to emergency room thoracotomy (ERT), and five of them survived. The overall survival rate was 96.34%. One patient died of exsanguination due to injury of multiple chambers; of the remaining 2 deaths after operation 1 was associated with abdominal injuries and the other with failure of cerebral resuscitation. From the experience reported in this study, early establishment of diagnosis and prompt thoracotomy against time are the fundamental factors affecting the outcome of penetrating cardiac injuries. Preoperative massive transfusion and pericardiocentesis are not advocated.