Severity of traumatic adrenal injury does not meaningfully affect clinical outcomes.

PURPOSE: There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury. METHODS: After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded. RESULTS: A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p < 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10 days vs. 16 days, p = 0.03). CONCLUSION: The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

Ultrasound-guided Procedures Allow Delay of Definitive Treatment for Core Muscle Injuries.

INTRODUCTION: Core muscle injuries (CMI) are common in every sport. To minimize lost playing time, providers apply various nonsurgical treatments, including platelet-rich plasma, corticosteroids, ultrasound (US)-guided percutaneous tenotomy, and prolotherapy. Limited data exist with regard to their effectiveness. We chose to review a cohort of consecutive professional and collegiate athletes who sustained CMI at various points within their seasons and underwent a combination of US-guided percutaneous needle "tenotomy" and corticosteroid injections to complete the remainder of their seasons. METHODS: Twenty-five consecutive collegiate or professional athletes with CMI involving the rectus abdominis-adductor aponeurotic plate were included in this retrospective study. Athletes with concomitant symptomatic hip femoroacetabular impingement were included in the study. The primary outcome measure was whether athletes completed their seasons. Secondary measures were weeks played after the procedures (delay until surgery), need for repeat procedures, and outcomes after eventual surgery. Postoperative performance was assessed via interviews at 6 wk and 6 months postoperatively. RESULTS: Twenty-one of 25 (84%) athletes completed their seasons. On average, athletes returned to play 3 d (range, 1-9 d) after the procedures. Surgical repair was delayed a mean of 18 wk (range, 2-44 wk). Seven athletes had concomitant symptomatic femoroacetabular impingement and six underwent combined hip arthroscopy and core muscle repairs. Among 17 patients who eventually had core muscle surgery alone (no hip surgery), 82% (14 of 17) reported performing at their preinjury level at 6 wk. At 6 months, 96% of postop athletes (22 of 23) reported performing at their preinjury level. CONCLUSIONS: Temporizing CMI with US-guided percutaneous tenotomy and corticosteroid injections is effective in allowing continued sport participation among high-level athletes and does not negatively affect postoperative outcomes.

CT-guided tractography is a safe and complementary diagnostic tool in the management of penetrating abdominal trauma.

BACKGROUND/OBJECTIVE: Despite extensive published research, the surgical approach to penetrating abdominal trauma patients is still under debate. Computed tomography-guided tractography (CTT) is an imaging modality in which water soluble iodinated contrast medium is administered into the site of the injury in the CT unit. The aim of this study was to determine the diagnostic accuracy of the CTT. METHODS: A retrospective evaluation was made of patients admitted to the Emergency Department with penetrating abdominal trauma and who underwent CTT. Contrast enhanced abdominal CT and CTT reports, surgical findings and clinical results were examined. RESULTS: Evaluation was made of a total of 101 patients comprising 89 males (88.1%) and 12 females (11.9%). CTT was determined to have 92.8% sensitivity, 93.6% specificity, 97% positive predictive value, and 85.5% negative predictive value. In 27 patients (26.7%) where the CTT indicated passage through the peritoneum, no parenchymal organ injury was present. Only one patient (2.9%) without peritoneal penetration on CTT had organ injury at exploration. No procedure-related morbidities developed. CONCLUSION: CTT is a safe imaging modality for the evaluation of hemodynamically stable patients. Compared to other imaging modalities, there is clearer demonstration of whether or not the peritoneum is intact. However penetration on CTT does not exactly correlate with organ injury.

CT with coronal reconstruction identifies previously missed smaller diaphragmatic injuries after blunt trauma.

Diaphragmatic injuries (DIs) are difficult to diagnose and often go unrecognized after blunt trauma. We proposed that CT scan with coronal reconstruction (CTCR) improves the detection of small DIs missed by chest x-ray (CXR) and CT scan with axial views (CTAX). We performed a retrospective review at a Level I trauma center from 2001 to 2006 and identified 35 patients who underwent operative repair of DI after blunt trauma. The size of the DI and the radiographic test (CXR, CTAX, and CTCR) that identified the defect was compared. Results were analyzed using mean, Mann-Whitney U test, and Fisher exact test. Of the 35 DI repairs, nine were performed after CXR alone and 12 after identification by both a CXR and CTAX. There was no significant difference between the mean DI size identified by CXR with and without CTAX (10.6 vs 9.7, P = 0.88). The remaining 14 DIs were undetected by CXR and CTAX. Seven of these (before CTCR) were found during exploratory laparotomy and seven were identified by CTCR (4.6 cm vs 3.5 cm, P = 0.33). The mean DI size identified by CTCR was significantly smaller than that identified by CXR alone (4.6 cm vs 9.7 cm, P < 0.05) and by CXR and CTAX (4.6 cm vs 10.6 cm, P < 0.0005). CTCR improves the ability to detect smaller DI defects (4 to 8 cm) that were previously missed by CXR and CTAX. CTAX adds little to CXR alone for the diagnosis of large defects (greater than 8 cm).

Jujitsu kick to the abdomen: a case of blunt abdominal trauma resulting in hematochezia and transient ischemic colitis.

Blunt abdominal trauma is a common presentation to the emergency department. Ischemic colitis is a rare complication of this and its possible sequelae are important for an emergency physician to recognize. A 21-year-old man presented to the emergency department with abdominal pain and hourly episodes of bright red blood per rectum shortly after being kicked in the stomach at his jujitsu class. He had no significant medical history, and results of his systems review were otherwise unremarkable. On examination, he appeared well, with normal vital signs. He had mild lower abdominal tenderness, but there were no peritoneal signs present. There was blood on the digital rectal examination. His hemoglobin, platelet, and international normalized ratio levels were normal and his abdominal radiograph was unremarkable. The gastroenterology service was contacted because of the hematochezia and a flexible sigmoidoscopy was performed. The sigmoidoscopy showed erythema, ulceration, and edema of a segment in the left colon, consistent with ischemic colitis. This was later confirmed on biopsy. A computed tomography (CT) scan of the abdomen was conducted, which revealed left colonic inflammation consistent with colonic ischemia. There was no mesenteric vascular thrombosis or mesenteric hematoma found on CT. His hematochezia and abdominal pain subsided spontaneously, and he was discharged home. This case illustrates transient ischemic colitis as a potential presentation of blunt abdominal trauma, and emergency physicians should consider this uncommon diagnosis in the differential diagnosis of patients presenting after abdominal trauma.

[Radiofrequency coagulation for splenic resection--a case report]. / Die Radiofrequenz-Koagulation bei der nicht-anatomischen Resektion der Mil--Ein Fallbericht.

Radiofrequency ablation is used in our Department of Surgery in cases of unresectable liver tumors. The case of a 22-year old male, who underwent nonanatomical resection of the spleen for trauma, is briefly reported. Splenic resection with the use of the radiofrequency needle could be performed safely and easily without complications. We use radiofrequency coagulation routinely in cases of blunt trauma of the spleen and liver.

Sigmoid colon obstruction due to blunt abdominal trauma: a case report.

Post-traumatic colonic stenosis (obstruction) is rare. We experienced a case of sigmoid obstruction due to blunt abdominal trauma. A 75-year-old man was hit on the lower abdomen 3 days before admission and gradually developed abdominal pain and distension. Laboratory data showed severe inflammation and a barium enema disclosed obstruction of the sigmoid colon. Conservative treatment was carefully carried out, because there was no sign of peritoneal irritation and there were passages of normal stool and flatus. The sigmoid obstruction gradually improved and the stenosis was almost undetectable on a barium enema on the 51st hospital day. An abdominal contusion is the most likely causal factor in this case. Compression of the sigmoid colon between the abdominal wall and the promontory of the pelvis is the most possible explanation.

Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest.

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eight-five patients with penetrating injury (Group 1) and 9 with blunt injury (Group 2) required emergency laparotomy. In the remaining 15 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 18 hours to 15 years (mean, 8 months) after injury. The vast majority of the Group 1 and all Group 2 patients had injury to other organs, and the diagnosis of the diaphragmatic injury was made in almost all of them during the emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or with an upper gastrointestinal series or barium enema. All diaphragmatic injuries were repaired primarily except one which was repaired with Prolene mesh. Four of the Group 1 patients died, a mortality of 2.2%, and 2 of the Group 2 patients died, a mortality of 22.2%. All Group 3 patients recovered. This study suggests that diaphragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen and particularly of the epigastrium and lower chest. The presence of such an injury should be excluded before the termination of the exploratory procedure. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm or lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.