Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion.

BACKGROUND: Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS: We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS: We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION: These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.

Demographics, presentation, and clinical outcomes after traumatic bifrontal contusions: a systematic review.

Traumatic bifrontal contusions (TBC) form a recognised clinical entity among patients with traumatic brain injury (TBI). This study aims to systematically review current literature on demographics, management, and predictors of outcomes of patients with TBC. A multi-database literature search (PubMed, Cochrane, OVID Medline/Embase) was performed using PRISMA as a search strategy. Studies were selected by predefined selection criteria (PROSPERO: CRD42018055390), and risk of bias was assessed using an adapted form of ROBINS-I tool. Of the 275 studies yielded by the literature search, seven articles met the criteria for inclusion, all of which were level III evidence. Total cohort consisted of 468 patients; predominantly male (n = 5; 303/417 patients) with average age 44.3 years (range, 7-81). Falls (44.9%) and road traffic accidents (46.6%) were the commonest mechanisms of injury with an average presentation GCS of 9.2 (n = 3, 119 patients). GCS on admission of ≤ 13.1 and contusion volume at day 2 post-injury of ≥ 62.9cm3 were associated with increased risk of deterioration needing surgical interventions (n = 1, 7 patients). The majority of patients underwent surgery; the average GOS was 4, at an average follow-up duration of 11.7 months (n = 6, 356 patients). The currently available evidence on the management of TBC is scarce. Larger multicentre well-designed studies are needed to further delineate the factors behind acute deterioration, the effectiveness of management options. Once in place, this can be used to develop and test an algorithmic approach to management of TBC resulting in consistently improved outcomes.

Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries: A CARE-compliant case report.

RATIONALE: Damage control is a staged surgical approach to manage polytraumatized patients. The damage control approach comprises three steps. First, bleeding is controlled and fractures are stabilized temporarily; second, vital parameters are stabilized and the child is rewarmed in the intensive care unit; and third, the child is reoperated for definitive repair of injuries. We aimed to describe the feasibility of the damage control orthopedic approach in a child. PATIENT CONCERNS: An 8-year-old girl fell from the balcony of the 5th floor onto concrete pavement and was admitted to our accident and emergency ward in a stable cardiorespiratory state, but with gross deformity of the lower limbs, left thigh, and forearm. DIAGNOSES: The child had sustained multiple injuries with severe bilateral lung contusion, pneumothorax, fracture of first rib, liver laceration, stable spine fractures, transforaminal fracture of sacrum, pelvic ring fracture, displaced baso-cervical femoral neck fracture, displaced bilateral multifragmental growth plate fractures of both tibiae, fractures of both fibulae, displaced fracture of left forearm, and displaced supracondylar fracture of the humerus. INTERVENTION: In the initial operation, we performed closed reduction and K-wire fixation of the right tibia, closed reduction and external fixation of the left tibia, open reduction and screw osteosynthesis of the femoral neck fracture, closed reduction and K-wire fixation of the radius, and closed reduction of the supracondylar fracture. Subsequently, we transferred the girl to the pediatric intensive care unit for hemodynamic stabilization, respiratory therapy, rewarming, and treatment of crush syndrome. In a third step, 10 days after the injury, we managed the supracondylar fracture of the humerus by closed reduction and K-wire fixation. OUTCOMES: Growth arrest of the left distal tibial growth plate and osteonecrosis of the femoral head and neck, slipped capital femoris epiphysis (SCFE), and coxa vara of the right femur led to balanced leg length inequality 2 years after the injury. The lesion of the left sciatic nerve improved over time and the girl walked without walking aids and took part in school sports but avoided jumping exercises. LESSONS: We emphasize the importance of damage control principles when managing polytraumatized children.

Decompressive Craniectomy With Bifrontal Coronal Incision in the Management of Fronto-Temporal Contusion and Laceration for Early Cranioplasty.

The present study aims to explore the effectiveness of decompressive craniectomy with bifrontal coronal incision in the management of severe contusion and laceration of bilateral fronto-temporal lobes, as well as the outcomes of early cranioplasty. The authors performed the bifrontal decompressive craniectomy on 56 patients with contusion and laceration of bilateral frontal and temporal lobes, and their follow-up treatment outcomes were tracked within 6 months using Glasgow Outcome Scale. The results showed that 33 patients (out of 56, 58.9%) have recovered, 12 patients (out of 56, 21.4%) have moderate defects, 5 patients (out of 56, 8.9%) have severe defects, 3 patients (out of 56, 5.3%) stayed in persistent vegetative status, and the remaining 3 patients (out of 56, 5.3%) have been dead. There was no persistent temporal hollowing. No patients required revision surgery with modified titanium mesh in this study. Particularly, 28 patients have successfully accepted the early cranioplasty with bone flap or computer-assisted design titanium mesh, and showed good recovery. These results together indicated that the decompressive craniectomy with bifrontal coronal incision in the management of severe contusion and laceration of bilateral fronto-temporal lobes can significantly relieve the comorbidity of intracranial hypertension, and improve the prognosis obviously, thus finally increasing the probability of successful rescue and decreasing the probability of mortality and disability.

Seizure After Cranioplasty: Incidence and Risk Factors.

BACKGROUND: To investigate clinical characteristics of postcranioplasty seizures (PCS) first observed after cranioplasty after decompressive craniectomy (DC) to treat traumatic brain injury and to define factors that increase PCS risk. METHODS: This retrospective study, covering the period between January 2008 and July 2015, compared PCS in postcranioplasty patients. Postcranioplasty seizures risk factors included diabetes mellitus, hypertension, time between DC and cranioplasty, duraplasty material, cranioplasty contusion location, electrocautery method, PCS type, and infection. Multivariate logistic regression analysis was performed and confidence intervals (CIs) were calculated (95% CI). RESULTS: Of 270 patients, 32 exhibited initial PCS onset postcranioplasty with 11.9% incidence (32/270). Patients fell into immediate (within 24 hours), early (from 1 to 7 days), and late (after 7 days) PCS groups with frequencies of 12, 5, and 15 patients, respectively. Generalized, partial, and mixed seizure types were observed in 13, 13, and 6 patients, respectively. Multivariate logistic regression analysis showed increased risk with increasing age (>50 years). Cranioplasty contusion location, precranioplasty deficits, duraplasty material, and monopolar electrocautery were predictive of PCS onset (P < 0.05). Increased DC to cranioplasty interval increased risk but was not statistically significant (P = 0.062). CONCLUSIONS: Understanding risk factors for PCS will benefit the management of cranioplasty patients.

Contusional Cerebellar Hemorrhage Related to Placement in the Protrusion Position After Atlantoaxial Fusion.

BACKGROUND: Various complications after C1 lateral mass and C2 pedicle screw fusion surgery (C1LM-C2PSFS) have been reported. However, to our knowledge, this is the first report of contusional cerebellar hemorrhage caused by placement in the protrusion (chin-out) position after C1LM-2PSFS. CASE DESCRIPTION: An 81-year-old woman complaining of gait disturbance and clumsiness of both hands was diagnosed with cervical myelopathy with atlantoaxial subluxation. After we performed C1LM-C2PSFS, her neurologic deficits gradually improved, and there was no radiologic evidence of construct failure. One month after surgery, she had severe headache and vomiting immediately after taking some medications while in the protrusion position. Head computerized tomography scan showed left cerebellar hemorrhage, and titanium rods penetrated the occipital bone on both sides. Flexion/extension radiography showed no loosening of any screws or rods. However, protrusion radiography showed that the tip of the left titanium rod intruded into the intracranial region. We considered that the penetration of the occipital bone by the left titanium rod caused the contusional left cerebellar hemorrhage. We immediately performed revision surgery to replace the titanium rods on each side with shorter rods, and no cerebrospinal fluid leakage was observed. The headache disappeared after the revision surgery. CONCLUSIONS: We report a case of contusional cerebellar hemorrhage caused by the intrusion of a rod into the occipital bone when the patient was placed in the protrusion position. The rod length on the cranial side must be as short as possible, with careful consideration of placing the head in the protrusion position after C1LM-2PSFS surgery.

Creation of an intramedullary cavity by hemorrhagic necrosis removal 24 h after spinal cord contusion in rats for eventual intralesional implantation of restorative materials.

Intramedullary hemorrhagic necrosis occurs early after spinal cord injury at the site of injury and adjacent segments. It is considered harmful because of its potential to aggravate secondary injury, and to interfere with axonal regeneration; it might also lead to an unfavorable environment for intralesional implants. Removal of hemorrhagic necrosis has been attempted before with variable results. The invasive nature of these procedures carries the risk of exacerbating damage to the injured cord. The overall objective for this study was to test several strategies for non-damaging removal of hemorrhagic necrosis and characterize the resulting cavity looking for a space for future intralesional therapeutic implants in rats with acute cord injury. Rats were subjected to graded cord contusion, and hemorrhagic necrosis was removed after 24h. Three grades of myelotomy (extensive, medium sized, and small) were tested. Using the small surgical approach to debridement, early and late effects of the intervention were determined by histology and by analytical and behavioral analysis. Appearance and capacity of the resulting cavity were characterized. Satisfactory removal of hemorrhagic necrosis was achieved with all three surgical approaches to debridement. However, bleeding in spared cord tissue was excessive after medium sized and extensive myelotomies but similar to control injured rats after small cord surgery. Small surgical approach to debridement produced no swelling nor acute inflammation changes, nor did it affect long-term spontaneous locomotor recovery, but resulted in modest improvement of myelination in rats subjected to both moderate and severe injuries. Cavity created after intervention was filled with 10 to 15 µL of hydrogel. In conclusion, by small surgical approach to debridement, removal of hemorrhagic necrosis was achieved after acute cord contusion thereby creating intramedullary spaces without further damaging the injured spinal cord. Resulting cavities appear suitable for future intralesional placement of pro-reparative cells or other regenerative biomaterials in a clinically relevant model of spinal cord injury.

Anterolateral thigh free flap for simultaneous reconstruction of digital extensor tendon and defect of the dorsal hand: A case report.

This paper describes a new technique in the repair of the hand defect with digital extensor tendon injury. The anterolateral thigh flap with the thick femoral fascia has been used in the reconstruction of the composite defect of the dorsal hand, especially the defect of tendon. This technique requires short period of treatment and hence causes less damage to the donor site but shows a better recovery of the hand function. A favorable curative effect has been obtained in this patient.

Preliminary Result of Percutaneous Screw Fixation for Bone Bruise of the Tibial Plateau.

This study reports the preliminary results of surgical treatment of bone bruise of the tibial plateau. Twelve patients underwent percutaneous screw fixation with a mean follow-up of 15 months. The mean duration of surgery was 15 minutes. Preoperatively, 1 week postoperatively, 1 month postoperatively, 6 months postoperatively, and 12 months postoperatively, the mean visual analog scale scores were 7.3, 2.6, 1.2, 0.6, and 0.5, respectively. The mean Hospital for Special Surgery scores were 56, 78, 89, 95, and 98, respectively. In selective patients with bone bruise, the percutaneous screw fixation is feasible to resolve pain and prevent compression of the articular surface.

[A Case of Liver Contusion during Spinal Operation for Idiopathic Scoliosis].

A 20-year-old man diagnosed as idiopathic scoliosis with Cobb angle 146 degrees was scheduled for two-stage operations. Anterior dissection of the thoracic vertebra in the left lateral decubitus position, and the placement of pedicle screws in the prone position were performed as the first-stage operation. During surgery, the patient developed liver contusion with ascites, probably due to hepatic compression placed between vertebrae and operating table in the prone position. In the second operation for posterior spinal fusion, the occurrence of liver contusion was prevented by performing abdominal ultrasonography before and after surgery, and monitoring AST/ALT during anesthesia as the indicators of liver contusion. Intraoperative management for organ protection is required during anesthesia in patients with idiopathic scoliosis associated with thoracic deformity.

Delayed splenic rupture presenting 70 days following blunt abdominal trauma.

Delayed splenic rupture following conservative management of splenic injury is an extremely rare complication. We report a case of an adult patient who presented with delayed splenic rupture necessitating splenectomy, 2 months following blunt abdominal trauma. Imaging at the initial presentation demonstrated only minimal splenic contusion and the patient was discharge following 24 hours of observation.

Role of bone marrow and mesenchymal stem cells in healing after traumatic injury.

BACKGROUND: The role of bone marrow-derived cells (BMDCs) and mesenchymal stem cells (MSC) in healing of traumatic-induced injury remains poorly understood. Mesenteric lymph duct ligation (LDL) results in decreased BMDC mobilization and impaired healing. We hypothesized that LDL-mediated impaired healing would be abrogated by reinjection of BMDC or MSC. METHODS: Sprague-Dawley rats were subjected to LDL + lung contusion (LC+LDL) with or without injection of BMDCs or MSCs. Unmanipulated control (UC) and lung contusion alone (LC) served as controls. BMDC and MSC homing was assessed by hematopoietic progenitor cell (HPC [granulocyte-, erythrocyte-, monocyte-, and megakaryocyte colony-forming units; erythroid burst-forming units; and erythroid colony-forming units]) colony growth and immunofluorescent microscopic tracking of tagged MSC, respectively. Histologic lung injury score (LIS) was used to grade injury. Data are mean ± SD. *P < .05/Student t test. RESULTS: Lung HPC growth was decreased in LC+LDL versus LC alone (HPC colonies: 2 ± 2, 4 ± 3, 4 ± 2 vs. 11 ± 2, 20 ± 6, 22 ± 9. *P < .05). LC+LDL had greater degree of lung injury on days 5 and 7 LC alone (LIS: 5 ± 1, 4 ± 1 vs. 3 ± 1, 1 ± 0.4. *P < .05). BMDC injection into rats with LC + LDL increased lung HPC growth to LC level (HPC colonies: 12 ± 2, 19 ± 5, 17 ± 4 vs 11 ± 2, 20 ± 6, 22 ± 9. P > .05). Injected MSCs into LC+LDL rats homed preferentially to contused versus noncontused lung (MSC/high-powered field: 6 ± 4 vs. 2 ± 2 *P < .05). Either BMDC or MSC injection into LC+LDL rats returned lung injury to LC level on day 7 (LIS: 1 ± 0.4 and 1 ± 1 vs. 1 ± 0.4. P > .05). CONCLUSION: LDL-mediated impaired tissue healing is abrogated by either whole BMDC or MSC injection. This highlights the critical role of BMDC and MSC on healing of trauma-induced injury.

Modified tenodesis method for treatment of mallet fractures.

INTRODUCTION: Mallet fractures are avulsions of the terminal extensor tendon from the base of the distal phalangeal bone with a bony fragment. Surgical treatment, which provides accurate anatomical reduction and rigid fixation, is recommended for mallet fractures with involvement of more than one third of the base of the distal phalangeal bone. Various surgical methods have been reported, but there is still no standard treatment modality. The purpose of this investigation was to assess the results of our modified tenodesis method for mallet fractures. MATERIALS AND METHODS: Using our method, the dorsal fracture fragment was reduced and fixed to the main part of the distal phalangeal bone by 2 stitches of "figure-of-eight" 4-0 Prolene sutures. We reviewed 12 consecutive patients with 13 mallet fractures treated with our modified tenodesis method between January 2009 and March 2012. This retrospective study was composed of 7 male and 5 female patients, with a mean age of 35.7 years (range, 25-56 years). All patients underwent surgical treatment and sequent 3-week finger splinting. Patient follow-up lasted 3 to 6 months, with a mean period of 5.2 months. RESULTS: The modified tenodesis method allowed accurate anatomical reconstruction of the injured extensor mechanism. Grading by Crawford criteria showed that the outcome was "excellent" in 8 of 13 digits and "good" in 5 of 13 digits. The follow-up hand x-rays also revealed congruent joint surfaces of distal interphalangeal joints with no evidence of joint space narrowing. No wound complications were encountered, and all the patients returned to normal activities without any disability. CONCLUSIONS: The modified tenodesis method is simple and effective to provide accurate anatomical reduction and fixation for treatment of type I mallet fractures. No device penetration of the small bony fragment or pinning through the distal interphalangeal joint is required, and the surgical complication rate is low. We recommend this treatment modality for all but chronic cases.

Endoscopy-assisted cerebral falx incision via unilateral approach in treatment of dissymmetric bilateral frontal contusion.

BACKGROUND: Dissymmetric bilateral frontal contusion (DBFC) is relatively frequent in the clinic. In this study, we aimed to investigate the development tendency, clinical features, and treatment experience of DBFC and to summarize out experience in treating these patients via minimally invasive means-endoscopy. METHODS: Over the past 3 years, we have treated a total of 31 patients with DBFC using endoscopy-assisted unilateral cerebral falx incision. We used a 30-degree endoscope to observe the involvement of brain contusion and whether the brain contusions have been cleaned thoroughly. Another 30 patients treated by routine bilateral approach within the same period were taken as controls. RESULTS: Seventeen cases (54.8%) in the unilateral-operation group survived and were in good condition, 8 cases (25.8%) had moderate disability, and 4 cases (12.9%) had severe disability; 1 case (3.2%) was in vegetable state, and 1 case (3.2%) died. Compared with the control group, the GOS score was not significantly different in the unilateral-operation group, but the operation time, blood transfusion volume, length of hospital stay, incidence of mental disorder, and incidence of olfactory nerve injury were greatly reduced in the unilateral-operation group. CONCLUSIONS: Endoscopy-assisted unilateral cerebral falx incision can shorten the operation time and reduce surgical trauma and complications when used for treatment of patients with DBFC.

Management outcome of peroneal nerve injury at knee level: experience of a single military institution.

BACKGROUND AND PURPOSE: We investigated the management outcome of common peroneal nerve decompression at the knee level between the years 2005 and 2009. MATERIAL AND METHODS: Thirty consecutive patients with knee-level peroneal nerve injury who underwent decompression surgery and external neurolysis at our institution were evaluated preoperatively and postoperatively by electrophysiological studies and motor examination (Medical Research Council grading). RESULTS: Twenty-eight of the cases were male and 2 were female. Mean age was 31.1 for males and 57.5 for females. Physical activity during military training (overstretch/contusion) was the cause of nerve lesion in the majority of the patients (n = 28, 93%). Mean time interval between the diagnosis and the surgery was 5 months. Follow-up time ranged from 3 to 48 months (mean: 14 months). Twenty-nine of 30 (97%) patients recovered totally or near totally in foot/toe dorsiflexion. CONCLUSIONS: Early decompression and neurolysis of the common peroneal nerve (CPN) at knee level after strenuous physical activity offers excellent functional recovery. Additionally, for knee-level CPN injuries, in order to minimize the postoperative scar, pain and delay in wound healing, we strictly advocate short 'lazy S-shaped incision' around the fibular head in supine position unlike the classical extensive opening up to the superior border of the popliteal fossa in prone position.

[Diagnostic assessment and treatment concepts for thoracic trauma]. / Diagnostik und Behandlungskonzepte beim Thoraxtrauma.

Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. An appropriate structured network of surgical centers guarantees sufficient and efficient care of patients with severe chest trauma. In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.

Intramuscular transplantation of muscle-derived stem cells accelerates skeletal muscle healing after contusion injury via enhancement of angiogenesis.

BACKGROUND: Muscle contusions are common muscle injuries. Although these injuries are capable of healing, incomplete functional recovery often occurs. Muscle-derived stem cells (MDSCs) are likely derived from blood vessel cells and have a multilineage differentiation potential. PURPOSE: The aims of this study are (1) to find optimal timing of MDSC transplantation to enhance muscle healing by stimulating muscle regeneration and preventing scar tissue (fibrosis) formation after skeletal muscle contusion injury, and (2) to investigate the role of angiogenesis in the muscle-healing process after MDSC transplantation. STUDY DESIGN: Controlled laboratory study. METHODS: Muscle-derived stem cells were injected directly into injured tibialis anterior muscles of mice at various time points (1, 4, and 7 days) after the muscle contusion injury. Muscle regeneration, angiogenesis, and fibrosis formation were evaluated by histology and real-time polymerase chain reaction analysis, and functional recovery was measured by physiologic testing. RESULTS: Transplantation of MDSCs at 4 days after injury significantly promoted angiogenesis, which was induced by high levels of vascular endothelial growth factor expression at week 1, and significantly increased muscle regeneration and muscle strength by week 2, when compared with the other groups. A decrease in fibrosis formation was observed at week 4, when compared with the other groups, after the transplantation of MDSCs at 4 and 7 days after injury. CONCLUSION: Intramuscular injection of MDSCs at 4 days after injury improved and accelerated skeletal muscle healing by increasing angiogenesis and decreasing scar tissue formation. CLINICAL RELEVANCE: These findings could contribute to the development of biologic treatments to aid in muscle healing after muscle injury.