Pre-season screening of the upper body and trunk in Australian football players: A prospective study.

OBJECTIVE: To determine whether screening tests of upper body, trunk region, and of whole-body function could prospectively identify community AFL players who sustain in-season shoulder/head/neck injuries. Additionally, to present screening test reference values. DESIGN: Prospective cohort; SETTING: Community sport; PARTICIPANTS: 142 male community AFL players (range 15-37 years). MAIN OUTCOME MEASURES: (i) isometric shoulder external and internal rotation (ER/IR) strength; (ii) upper body combined elevation functional ROM; (iii/iv) whole-body functional jump ROM; (v) static thoracic spine angle; (vi) cervical joint proprioception, and (vii) trunk muscle size and function. Results were compared among players with (n = 21) and without (n = 121) an in-season shoulder, head, or neck injury. ROC analysis and odds ratios were used to determine the predictive values. RESULTS: Two screening tests predicted an in-season shoulder, head, or neck injury; dominant and non-dominant isometric ER strength (AUC 0.629, 95%CI 0.51-0.74; optimal cut point 182 N and AUC 0.619, 95%CI 0.50-0.74; optimal cut point 184 N, respectively). The adjusted odds ratio for the strongest predictor: dominant ER muscle strength was 6.02 (95%CI 1.8-19.9). CONCLUSION: Greater ER strength was associated with in-season shoulder/head/neck injuries in community AFL players; however, further research is required to determine the clinical significance of this finding.

Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study.

INTRODUCTION: Burns affecting the head and neck (H&N) can lead to significant changes in appearance. It is postulated that such injuries have a negative impact on patients' social functioning, quality of life, physical health, and satisfaction with appearance, but there has been little investigation of these effects using patient reported outcome measures. This study evaluates the effect of H&N burns on long-term patient reported outcomes compared to patients who sustained burns to other areas. METHODS: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Database collected between 1996 and 2015 were used to investigate differences in outcomes between those with and without H&N burns. Demographic and clinical characteristics for adult burn survivors with and without H&N burns were compared. The following patient-reported outcome measures, collected at 6, 12, and 24 months after injury, were examined: satisfaction with life (SWL), community integration questionnaire (CIQ), satisfaction with appearance (SWAP), short form-12 physical component score (SF-12 PCS), and short form-12 mental component score (SF-12 MCS). Mixed regression model analyses were used to examine the associations between H&N burns and each outcome measure, controlling for medical and demographic characteristics. RESULTS: A total of 697 adults (373 with H&N burns; 324 without H&N burns) were included in the analyses. Over 75% of H&N injuries resulted from a fire/flame burn and those with H&N burns had significantly larger burn size (p<0.001). In the mixed model regression analyses, SWAP and SF-12 MCS were significantly worse for adults with H&N burns compared to those with non-H&N burns (p<0.01). There were no significant differences between SWL, CIQ, and SF-12 PCS. CONCLUSIONS: Survivors with H&N burns demonstrated community integration, physical health, and satisfaction with life outcomes similar to those of survivors with non-H&N burns. Scores in these domains improved over time. However, survivors with H&N burns demonstrated worse satisfaction with their appearance. These results suggest that strategies to address satisfaction with appearance, such as reconstructive surgery, cognitive behavior therapy, and social skills training, are an area of need for survivors with H&N burns.

Assessment of quality-of-life in patients with face-and-neck burns: The Burn-Specific Health Scale for Face and Neck (BSHS-FN).

INTRODUCTION: Burns to the cephalic extremities are particularly implicated in problems of self-image and alterations to personal social relations. The aim of this study was to objectively assess the quality-of-life (QoL) of patients suffering from face-and-neck burns through our newly created scale: The Burn-Specific Health Scale for Face and Neck (BSHS-FN). METHODS: After constructing the BSHS-FN, we compared QoL of patients with or without face-and-neck burns. SF-36, the French version of the BSHS-B (Burn Specific Health Scale-Brief), and the BSHS-FN were administrated to 53 patients divided into two groups: GB group (general burns, 26 patients) and FN group (face-neck burns, 27 patients). RESULTS: QoL evaluated using the SF-36 had a higher average total score in GB patients compared to FN patients, but there were no significant difference between the two groups (54.3±18.5 vs. 47.0±17.3, respectively, p=0.11). In contrast, in BSHS-B the total score was significantly different between the two groups with a higher score recorded for the GB group (71.9±13.4 [median: 72.8] in the GB group vs. 62.2±14.4 [median: 64.4] in the FN group). In percentage terms, total score of BSHS-FN for GB group was 79.1±10.1, while total score for FN group was 53.6±13.1 (p<0.001), with the highest score for the Face and Neck domain in GB group (99.7±1.1, p<0.001) CONCLUSION: The BSHS-FN seemed to be more appropriate to assess QoL for FN burn patients. This study supports its application in routine clinical practice and in international studies.

Helmet Clasp Cracks Larynx? A Case Series and Literature Review.

INTRODUCTION: Helmet use is well known to greatly reduce the risk of head injury in both bicycle and motorcycle riding. However, helmet buckle position may increase the risk of injury to the neck cartilages. We present a series of cases in which thyroid cartilage fracture is presumed to arise from the position of the helmet buckle during a crash. Our objective with this case series is to outline an unusual series of cases and review the literature regarding laryngeal injuries secondary to helmet impact. DESIGN: Single institution case series. MATERIALS AND METHODS: We present 3 adult patients with laryngeal fractures following bicycle and motorcycle accidents. Medical records were reviewed for history. RESULTS: All patients in this series presented with voice or swallowing complaints and were found to have thyroid cartilage fractures. It was determined that the buckle of the helmet was positioned overlying the larynx during these accidents, so the impact and flexion of the head and neck may have produced sufficient force against it to fracture the cartilage. A literature search yielded works supporting helmet use for head and brain protection but only a single report of laryngeal injuries secondary to helmet use. CONCLUSIONS: Though wearing a helmet is protective against head injuries, it may create serious risk to the neck cartilages when the buckle is positioned adjacent to the larynx. Rare but serious, neck cartilage fracture should be considered in helmeted cycling accidents. It may be reasonable to advance a helmet design that positions the buckle and other nonpliable components laterally, away from neck cartilages.

POSTERIOR PENETRATING INJURY OF THE NECK: A CASE REPORT.

- A 45-year-old male patient was admitted to the emergency unit due to posterior stab wound of the neck. The knife was directed diagonally from the left to the right side of the neck in the dorsoventral axis. The patient was fully conscious upon admission with pain and paresthesia along the upper right extremity. The patient underwent computed tomography (CT) and CT angiography scan of the neck, which revealed the knife blade piercing the left sided neck muscles and through the intervertebral ligaments of the C IV/C V in direction to the contralateral internal carotid artery, vertebral artery and the C5 nerve root. The patient underwent an urgent surgery according to the radiographs. Electromyography was performed during the early postoperative care and revealed an acute lesion of the right-sided C5 nerve root. Postoperative follow-up magnetic resonance imaging revealed intact brachial plexus bundles at the site of injury. Symptoms of reduced muscle strength and limited range of motion of the upper right extremity prevailed. Penetrating neck injuries represent a rare entity of all trauma injuries. Meticulous preoperative radiographs revealed close proximity of the knife blade tip to the right-sided vertebral artery and common carotid artery. Limited abduction at the right shoulder during postoperative period correlated to the C5 nerve root injury.

Computed Tomography Angiography is the Definitive Vascular Imaging Modality for Penetrating Neck Injury: A South African Experience.

BACKGROUND AND AIMS: Computed tomography angiography has become central to the diagnostic algorithm for penetrating neck injury, but despite its widespread use the literature to support this adoption is limited. We reviewed our experience with computed tomography angiography for the identification of vascular trauma in hemodynamically stable patients with penetrating neck injury at a major trauma center in South Africa. MATERIALS AND METHODS: A prospectively kept trauma registry capturing data in real time was retrospectively reviewed. All patients with penetrating neck injury investigated with computed tomography angiography as the initial vascular investigation during a 47-month period were included. RESULTS: A total of 380 patients were included. Indications for computed tomography angiography were as follows: hard signs (13), soft signs (201), no signs but proximity/zone I or III wounds (141), and undefined signs of vascular injury (25). Of the 380 scans, 7 (1.8%) were indeterminate, 299 (78.7%) negative, and 74 (19.5%) positive for a vascular injury (54 arterial and 20 isolated venous injury). Eight were false positive and 4 false negative. The sensitivity, specificity, positive, and negative predictive values for detecting arterial injury were 93.9%, 97.5%, 85.2%, and 99.1%, respectively. Overall, the yield for demonstrating "true arterial injury" was 12.1% (46/380); hard signs: 76.9% (10/13), soft signs: 16.4% (33/201), and no signs: 2.1% (3/141) which all were secondary to gunshot wounds). Only 8.4% (32/380) required intervention for arterial injury and none for isolated venous injury (hard signs: 62.0%, soft signs: 11.4%, and no signs: 0.7%). No serious complications resulted from computed tomography angiography. CONCLUSION: Computed tomography angiography is a safe and effective imaging modality for the investigation of vascular trauma post penetrating neck injury. Asymptomatic patients with stab wounds do not need to be imaged regardless of proximity concerns. Symptomatic stable patients including a subgroup with hard signs should be imaged rather than explored. Computed tomography angiography provides an interventional road map and can identify injuries amenable to endovascular or conservative management.

A 10-Year Analysis of Head and Neck Injuries Involving Nonpowder Firearms.

Objectives Firearms have an enduring and visible presence within American culture. However, the public health impact of nonpowder firearms and other "toy" guns has not been fully studied. These guns-including BB guns (ie, ball bearing), paintball guns, and pellet guns-are typically marketed to a younger audience. The objective of this study is to analyze head and neck injuries related to nonpowder firearms. Study Design Cross-sectional analysis of a national database. Setting Academic medical center. Subjects and Methods The National Electronic Injury Surveillance System was queried for head and neck injuries involving nonpowder guns, including air, BB, and pellet guns, and associated ammunition. Analysis of age, sex, incidence, injury location, and diagnosis was performed. Results From 2005 to 2014, there were 1695 cases recorded, or 55,060 estimated emergency room visits, due to injuries related to nonpowder guns and fired ammunition. The majority of patients were male (80.9%). These injuries were most common in children 6 to 12 years of age (37.9%), followed by those 13 to 18 years old (27.1%) and adults (≥19 years old; 17.8%), while preschool children (0-5 years) represented 17.2%. The most common injury diagnosis was penetrating foreign body (34.9%), followed by lacerations (24.3%) and contusions/abrasions (13.7%). Conclusion Nonpowder and other nonlethal firearm-related injuries to the head and neck region are a frequent source of emergency room visits nationally. Safety measures and public education on a mainstream level are required.

Laryngeal Injury and Pneumomediastinum Due to Minor Blunt Neck Trauma: Case Report.

BACKGROUND: Serious isolated laryngeal injuries are uncommon in children. CASE REPORT: We describe the case of an 8-year-old boy with laryngeal injury and pneumomediastinum due to minor blunt neck trauma. He presented to the emergency department complaining of odynophagia and hoarseness, but without respiratory distress. Emphysema was seen between the trachea and vertebral body on initial cervical spine x-ray study, and flexible laryngoscopy revealed erythema and mild edema of both the right vocal cord and the arytenoid region. He recovered with conservative management only. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We conclude that it is important to recognize subtle evidence of laryngeal injury secondary to blunt neck trauma to ensure early diagnosis. Initial cervical spine x-ray assessment should exclude both cervical spine fracture and local emphysema after blunt neck trauma. If patients with blunt neck trauma have evidence of a pneumomediastinum, the clinician should consider the possibility of aerodigestive injury.

Airway management in a patient with nuchal, interspinous, and flavum ligament rupture by a sickle: a case report.

BACKGROUND: Penetrating neck injury is an important trauma subset but is relatively rare, especially when involving the posterior cervical column. Rupture of the neck restraints, including the interspinous and flavum ligaments, can create serious cervical instability that requires special consideration when managing the airway. However, no detailed information regarding airway management in patients with profound posterior neck muscle laceration and direct cervical ligament disruption by an edged weapon is yet available in the literature. CASE PRESENTATION: A 63-year-old Japanese man attempted to cut off his head using a sickle after drinking a copious amount of alcohol. On admission, his posterior vertebral column was grossly exposed and the lacerated tissues were actively bleeding, resulting in severe hypovolemic shock. We used a rapid-sequence intubation technique with direct laryngoscopy while manual in-line stabilization of his head and neck was maintained by several people. Surgical exploration revealed nuchal, interspinous, and flavum ligament rupture between his fourth and fifth cervical vertebrae, but no injury to the great vessels was present. The major source of bleeding was a site of oozing from his trapezius and splenius muscles. After surgical hemostasis, wound repair, and subsequent intensive care, our patient was discharged home without any neurological sequelae. CONCLUSIONS: Deficits of the neck restraints can cause cervical spine subluxation and dislocation secondary to neck movement. Thus, the key to successful airway management in such a scenario is minimization of neck movement to prevent further neurological impairment. We successfully managed an airway using a conventional but trusted endotracheal intubation strategy in a patient with multiple traumas and a suspected spinal cord injury. This case also illustrates that, even when great vessel injury is absent, severe hypovolemic shock may occur after profound neck muscle laceration, requiring immediate surgical intervention.

Cervical spine injuries in civilian victims of explosions: Should cervical collars be used?

BACKGROUND: Semirigid cervical collars (SRCCs) are routinely applied to victims of explosions as part of the prehospital trauma protocols. Previous studies have shown that the use of SRCC in penetrating injuries is not justified because of the scarcity of unstable cervical spine injuries and the risk of obscuring other neck injuries. Explosion can inflict injuries by fragments penetration, blast injury, blunt force, and burns. The purpose of the study was to determine the occurrence of cervical spine instability without irreversible neurologic deficit and other potentially life-threatening nonskeletal neck injuries among victims of explosions. The potential benefits and risks of SRCC application in explosion-related injuries were evaluated. METHODS: This is a retrospective cohort study of all explosion civilian victims admitted to Israeli hospitals during the years 1998 to 2010. Data collection was based on the Israeli national trauma registry and the hospital records and included demographic, clinical, and radiologic details of all patients with documented cervical spine injuries. RESULTS: The cohort included 2,267 patients. All of them were secondary to terrorist attacks. SRCC was applied to all the patients at the scene. Nineteen patients (0.83%) had cervical spine fractures. Nine patients (0.088%) had unstable cervical spine injury. All but one had irreversible neurologic deficit on admission. A total of 151 patients (6.6%) had potentially life-threatening penetrating nonskeletal neck injuries. CONCLUSION: Unstable cervical spine injuries secondary to explosion are extremely rare. The majority of unstable cervical spine fractures were secondary to penetrating injuries, with irreversible neurologic deficits on admission. The application of SRCC did not seem to be of any benefit in these patients and might pose a risk of obscuring other neck injuries. We recommend that SRCC will not be used in the prehospital management of victims of explosions. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Thermal shell fragment craniofacial injury: biophysics, pathophysiology, and management.

This article aims to bring attention to unique risks and burns by thermal shell fragment craniofacial soft tissue injury. Hot shrapnel may inflict burns to major vessel walls and lead to life-threatening hemorrhaging or death, which adds a new challenge for craniofacial surgeons. Morbidity of thermal deep tissue may lead to deep tissue necrosis and infection.Thermal energy (TE) physics, biophysics, and pathophysiological effects relate directly to the amount of heat generated from shell casing detonation, which transfers to skin, deep tissue, as well as brain and leads to life-threatening burning of organs; this is different from shrapnel kinetic energy injury.The unprecedented increase in using a large range of explosives and high-heat thermobaric weapons contributes to the superfluous and unnecessary suffering caused by thermal injury wounds.Surgeons and medics should recognize that a surprising amount of TE can be found in an explosion or detonation of a steel-encased explosive, resulting in TEs ranging from 400 F up to 1000 F.

Preflight screening techniques for centrifuge-simulated suborbital spaceflight.

INTRODUCTION: Historically, space has been the venue of the healthy individual. With the advent of commercial spaceflight, we face the novel prospect of routinely exposing spaceflight participants (SPFs) with multiple comorbidities to the space environment. Preflight screening procedures must be developed to identify those individuals at increased risk during flight. We examined the responses of volunteers to centrifuge accelerations mimicking commercial suborbital spaceflight profiles to evaluate how potential SFPs might tolerate such forces. We evaluated our screening process for medical approval of subjects for centrifuge participation for applicability to commercial spaceflight operations. METHODS: All registered subjects completed a medical questionnaire, physical examination, and electrocardiogram. Subjects with identified concerns including cardiopulmonary disease, hypertension, and diabetes were required to provide documentation of their conditions. RESULTS: There were 335 subjects who registered for the study, 124 who completed all prescreening, and 86 subjects who participated in centrifuge trials. Due to prior medical history, five subjects were disqualified, most commonly for psychiatric reasons or uncontrolled medical conditions. Of the subjects approved, four individuals experienced abnormal physiological responses to centrifuge profiles, including one back strain and three with anxiety reactions. DISCUSSION: The screening methods used were judged to be sufficient to identify individuals physically capable of tolerating simulated suborbital flight. Improved methods will be needed to identify susceptibility to anxiety reactions. While severe or uncontrolled disease was excluded, many subjects successfully participated in centrifuge trials despite medical histories of disease that are disqualifying under historical spaceflight screening regimes. Such screening techniques are applicable for use in future commercial spaceflight operations.

[Diagnosis and treatment of cervicothoracic injuries].

It analyzed the diagnosis and treatment results of 123 patients with cervicothoracic injuries for 21 years. The frequency of cervicothoracic injuries among all patients with cervical injuries was 5.7%. Preoperative and postoperative diagnosis included radial and endoscopic methods. The complications rate was 43.6%. The most severe complications were observed in patients with delayed diagnosis of trachea and esophagus injuries.

Pre-expanded thoracodorsal artery perforator-based flaps for repair of severe scarring in cervicofacial regions.

BACKGROUND: Reconstruction of cervicofacial scarring continues to present challenges for surgical treatment. Here we present our clinical experience in repairing cervicofacial scarring using pre-expanded thoracodorsal artery perforator flaps. METHODS: From January 2007 to December 2012, 15 patients were treated for severe cervicofacial scarring. In the first surgical stage, expanders were implanted subcutaneously in the zone nourished by thoracodorsal artery perforators. The expansion generally took 3 to 6 months. In the second surgical stage, the cervicofacial cicatricial contracture was released and the secondary defect was covered with local flaps. The remaining wound was covered by the free thoracodorsal artery perforator expanded flap, which was anastomosed to the facial vascular bundle. The donor site was closed directly in all the patients. RESULTS: The postoperative follow-up time ranged from 1 to 5 years. The deformities were corrected, all flaps survived completely and none were bulky. The maximum length of the flaps was 32 cm (mean, 22.4 ± 4.2 cm), and the maximum width was 17 cm (mean, 14.4 ± 2.2 cm). All patients exhibited recovery of neck movement, and there was no recurrence of neck contracture. CONCLUSION: The pre-expanded thoracodorsal artery perforator flap is an ideal method for reconstruction of severe cervicofacial cicatricial contracture.

Cardiac inhibitory reflex as a cause/mechanism of death.

The role of cardiac inhibitory reflex as a potential cause of death is still a matter of debate. This study reports two cases of death under unusual circumstances. Case 1 corresponds to a man found hanging where the role of ligature compression of the carotid sinus became relevant as a possible explanation of death. In Case 2, the participation of a vasovagal syncope was clearly triggered by the laryngoscopic procedure. It is proposed that cardiac inhibitory reflex should be taken into account in those cases of unexpected death, which fulfills the following three criteria: (i) The investigation of the circumstances of the death is consistent with a hypothesis of cardiac arrest. (ii) A typical triggering peripheral stimulus is present. (iii) The performance of a complete autopsy cannot rule out the participation of a cardiac inhibitory reflex in the cause of death.

Sagittal alignment of the cervical spine after neck injury.

The normal sagittal alignment of the cervical spine is lordotic and is affected by the posture of the head and neck. The question of whether loss of cervical lordosis is the result of muscle spasm after injury or a normal variation, and the clinical significance of such changes in sagittal profile of the cervical spine has been an issue of several studies. The purpose of this paper is to study the incidence of normal cervical lordosis and its changes after neck injury compared to the healthy population. We studied the lateral radiographs of the cervical spine of 60 patients with neck injury compared to 100 patients without a neck injury. Lateral radiographs were obtained in the standing or sitting position, and the curvature of the cervical spine was measured using the angle formed between the inferior end plates of the C2 and C7 vertebrae. In the patients without neck injury, lordotic and straight cervical spine sagittal alignment was observed in 36.5% each, double curvature in 17%, and kyphotic in 10%. In the patients with neck injury, lordotic sagittal alignment was observed in 36%, straight in 34%, double curvature in 26% and kyphotic in 4%. No significant difference between the two groups regarding all types of sagittal alignment of the cervical spine was found (p > 0.100). The alterations in normal cervical lordosis in patients with neck injury must be considered coincidental. These alterations should not be associated with muscle spasm caused by neck pain.

Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars.

BACKGROUND: Many studies have compared the restriction of motion that immobilization collars provide to the injured victim. No previous investigation has assessed the amount of motion that is generated during the fitting and removal process. The purpose of this study was to compare the three-dimensional motion generated when one-piece and two-piece cervical collars are applied and removed from cadavers intact and with unstable cervical spine injuries. METHODS: Five fresh, lightly embalmed cadavers were tested three times each with either a one-piece or two-piece cervical collar in the supine position. Testing was performed in the intact state, following creation of a global ligamentous instability at C5-C6. The amount of angular motion resulting from the collar application and removal was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The measurements recorded in this investigation included maximum values for flexion/extension, axial rotation, medial/lateral flexion, anterior/posterior displacement, axial distraction, and medial/lateral displacement at the level of instability. RESULTS: There was statistically more motion observed with application or removal of either collar following the creation of a global instability. During application, there was a statistically significant difference in flexion/extension between the one-piece (1.8 degrees) and two-piece (2.6 degrees) collars, p = 0.009. There was also a statistically significant difference in anterior/posterior translation between the one-piece (3.6 mm) and two-piece (3.4 mm) collars, p = 0.015. The maximum angulation and displacement during the application of either collar was 3.4 degrees and 4.4 mm. Statistical analysis revealed no significant differences between the one-piece and two-piece collars during the removal process. The maximum angulation and displacement during removal of either collar type was 1.6 degrees and 2.9 mm. CONCLUSIONS: There were statistically significant differences in motion between the one-piece and two-piece collars during the application process, but it was only 1.2 degrees in flexion/extension and 0.2 mm in anterior/posterior translation. Overall, the greatest amount of angulation and displacement observed during collar application was 3.4 degrees and 4.4 mm. Although the exact amount of motion that could be deleterious to a cervical spine-injured patient is unknown, collars can be placed and removed with manual in-line stabilization without large displacements. Only trained practitioners should do so and with great care given that some motion in all planes does occur during the process.