Double penile fracture without urethral injury presenting after 7 days.

Penile fracture is the sudden rupture of the tunica albuginea of an erect penis due to blunt trauma. It is an uncommon uropathology which characteristically occurs when one or both of the turgid penile corpora cavernosa forcefully snap under an abrupt blunt trauma, usually during an aggressive sexual intercourse or noncoital manipulation. In the majority of cases, diagnosis is clinical. Surgical repair irrespective of the time of presentation results in accelerated recovery, reduced morbidity, and fewer short and long-term complication rates. We report the case of a 35-year-old banker who sustained a bilateral rupture of the tunica albuginea without urethral injury during a heterosexual intercourse. He presented 7 days after the trauma to our facility following the persistence of symptoms despite conservative management with herbal medicine. Following a clinical diagnosis of penile fracture, he had penile exploration under regional anesthesia using a degloving subcoronal incision. He subsequently had repair of both corporal tear after clot evacuation. The postoperative period was uneventful, and he was discharged on the 3rd day after the surgery. He had been followed up for 2 years with good erectile and functional outcomes. This case report reiterates the fact that late presentation is not a barrier to surgical management and good outcome.

Résumé La fracture pénile est la rupture soudaine de l'albuginea tunica d'un pénis en érection en raison d'un traumatisme contondant. C'est une uropathologie rare qui se produit typiquement quand un ou les deux de la cavernosa penile turgid de corpora s'enclenchent avec force sous un trauma émoussé brusque, habituellement pendant un rapport sexuel agressif ou une manipulation noncoital. Dans la majorité des cas, le diagnostic est clinique. La réparation chirurgicale indépendamment du temps de présentation a comme résultat le rétablissement accéléré, la morbidité réduite, et moins de taux à court et à long terme de complication. Nous rapportons le cas d'un banquier de 35 ans qui a soutenu une rupture bilatérale de l'albuginea de tunica sans blessure urétrale pendant des rapports hétérosexuels. Il s'est présenté 7 jours après le trauma à notre établissement suivant la persistance des symptômes en dépit de la gestion conservatrice avec la médecine de fines herbes. Après un diagnostic clinique de rupture pénienne, il a eu l'exploration pénienne sous l'anesthésie régionale utilisant une incision subcoronal degloving. Il a par la suite subi la réparation des deux déchirures corporelles après l'évacuation du caillot. La période postopératoire était calme, et il a été déchargé le 3ème jour après l'opération. Il avait été suivi pendant 2 années avec de bons résultats érectiles et fonctionnels. Ce rapport de cas réitère le fait que la présentation tardive n'est pas un obstacle à la gestion chirurgicale et au bon résultat. Mots-clés: Traumatisme contondant, fracture du pénis, rupture, tunica albuginea.

Five-Year Management of Vascular Injuries of the Extremities in the "Real-World" Setting in Northeastern Greece: The Role of Iatrogenic Traumas.

BACKGROUND: Vascular trauma comprises a diagnostic and surgical challenge. Aim of this study was to present the vascular traumas treated in our Tertiary Hospital during the last 5 years. METHODS: We retrospectively reviewed the surgical records of our vascular department and documented the site and type of vascular injuries of the extremities along with the concurrence of musculoskeletal injuries. The type and outcome of surgical interventions were also recorded. RESULTS: Fifty-eight cases of vascular trauma were recorded (39 in the upper and 19 in the lower extremities). Overall, iatrogenic traumas accounted for 41.3% of cases. The arterial injuries of the upper limb were blunt and penetrating in 27% and 67%, respectively. The most affected artery in the upper limb was the radial artery (37.8%), followed by the ulnar artery (27%) and the brachial artery (24.3%). Orthopedic injuries were recorded in 19% of patients. Management involved simple revascularization, bypass operations, patch arterioplasty and endovascular management in 48.7%, 33.3%, 5.1%, and 5.1%, respectively. The most affected site in the lower extremity was the common femoral artery (36.8%) followed by the popliteal artery (21%). Bone fractures were reported in 5 cases (26.3%). The surgical management involved bypass, simple revascularization, patch arterioplasty in 42.1%, 26.3%, and 21%, respectively. Endovascular management was performed in 10.5%. CONCLUSIONS: A considerable percentage of iatrogenic vascular injuries was recorded, affecting both the upper and lower limbs. Despite the trend toward centralization of vascular services, a basic service of vascular surgery should be available in most sites to ensure that patients with vascular injuries receive fast and appropriate care.

Incidence of Hypocalcemia and Role of Calcium Replacement in Major Trauma Patients Requiring Operative Intervention.

Traumatic injury is a major cause of morbidity and mortality, and hemorrhage is a primary factor. Evidence exists that major trauma patients are at high risk of hypocalcemia. The purpose of this study was to determine the incidence and rate of calcium replacement in major trauma patients requiring operative intervention, and to investigate the impact of hypocalcemia on rate of transfusion and mortality. A retrospective analysis was conducted of all top-tier trauma activations presenting to our institution during a 12-month period. A total of 638 activations were identified; 441 were excluded, primarily because of lack of operative intervention. Patients were predominantly male following blunt trauma. The mean initial calcium level was 8.11 mg/dL and 8.64 mg/dL, correcting for albumin levels. An acute decline was noted when initial serum calcium levels and intraoperative calcium levels were compared (7.51 mg/dL). Intraoperative ionized calcium levels were on the low end of the normal range, and 28.42% received supplemental calcium. Patients in our cohort arrived hypocalcemic, which has been previously associated with increased mortality. Patients requiring operative intervention are at increased risk of hypocalcemia. Recognition of this potential is key for improved outcomes.

"Mixed" trauma to the carotid artery in a mixed martial arts injury - A case report and review of the literature.

We present the case of a mixed martial arts (MMA) cage fighter who presented to the emergency department with a right sided common carotid artery pseudoaneurysm as a result of a neck trauma at an MMA event. We discuss the management of blunt force neck trauma, differential diagnosis, imaging findings and review the literature on blunt cerebrovascular injury following blunt force injury to the neck.

[Coronary artery dissection following blunt chest trauma]. / Koronararteriedissektion er en sjælden komplikationi forbindelse med et stumpt thoraxtraume

A previously healthy 38-year-old man was admitted to hospital with chest pain. The day before the patient had been to a karate session and had received multiple punches and kicks to the chest region. An ECG showed Q-waves in V1 and V2 and flattening of the T-waves in V1-V6. Levels of cardiac enzyme markers were elevated. The patient subsequently underwent coronary angiography with supplemental optical coherence tomography that revealed a bifurcate dissection involving the proximal parts of left ramus interventricularis anterior and circumflex coronary artery. Two drug-eluting stents were implanted with good angiographic result.

[A case of blunt common carotid artery injury following minor trauma].

Cervical major blood vessel injuries often produce acute ingravescence of the circulatory dynamics. Therefore, if immediate treatment is not given, fatal complications can occur, resulting in death. Common carotid artery (CCA) injuries in particular are often associated with fatal outcomes. Moreover, most CCA injuries with hemorrhage producing hematoma are the result penetrating trauma, and there are few reports of blunt injuries. We report herein on a case of blunt CCA injury producing acute hematoma due to minor trauma. A 35-year-old man who was gently punched on his jaw when he was training with his child visited emergency room in our hospital complaining of swelling and pain of his neck soon after that. When we examined his neck, the larynx was displaced to the left by right neck swelling. Flexible transnasal laryngoscopic examination revealed constriction of the suffocating airway by a hematoma, so an emergency tracheotomy was performed. Enhanced CT of the neck showed active bleeding, so emergency surgical removal of the hematoma and hemostasis was carried out. We found a laceration (approximately 2 cm) of the CCA, and arrested hemorrhage with sutures. No postoperative neurologic deficit occurred. His postoperative course was good, and discharged 22 days after the operation.

Embolization for pediatric blunt splenic injury is an alternative to splenectomy when observation fails.

BACKGROUND: Management of splenic injury has shifted from operative to nonoperative management in both children and adults with reports of high success rates. Benefits of splenic conservation include decreased hospital stay, blood transfusion, and mortality, as well as avoidance of infectious complications. Angiography with embolization is an innovative adjunct to nonoperative management and has resulted in increased splenic salvage in adults; however, data in the pediatric population are scant. METHODS: A retrospective comparative study of a single-hospital trauma registry reviewed from 1999 to 2009. Patients 18 years and younger admitted with injury to the spleen were included. Children with penetrating injury were excluded. Children were divided into three categories by initial treatment: observation, embolization, or splenectomy. Data recorded include age, radiographic grade of injury, and Injury Severity Score (ISS). Groups were analyzed for success of initial treatment, requirement for transfusion of packed red blood cells, splenic salvage, and mortality. RESULTS: Registry review identified 259 children with blunt splenic injury. Initial treatment was observation in 227, embolization in 15, and splenectomy in 17. In the observation group, 9 (4%) of 227 children failed initial treatment; 8 of these underwent embolization, while 1 unerwent splenectomy. In the embolization group, 1 (7%) of 15 failed initial treatment and underwent splenectomy. Blood transfusion was required by 38 (17%) of 227 in the observation group, 6 (40%) of 15 (p = 0.02) in the embolization group, and 15 (88%) of 17 (p < 0.01) in the splenectomy group. Overall splenic salvage rate was 237 (92%) of 259. Three children died in the observation group, and four children died in the splenectomy group. There was no death in the embolization group. CONCLUSION: Splenic artery embolization for blunt trauma in children is associated with a higher blood transfusion rate compared with observation but offers a safe, intermediate alternative to splenectomy when observation fails. LEVEL OF EVIDENCE: Therapeutic study, level IV.

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).

Magnet-assisted capsular bag fixation to manage limited zonular weakness during phacoemulsification.

A new technique to manage limited zonular weakness during phacoemulsification is presented in this report. The technique, called magnet-assisted capsular bag fixation, uses the magnetic implant to stretch and fixate the capsular bag over the zonular dehiscence area for patients with limited zonular disruption, which stabilizes the capsular bag and facilitates cataract extraction.

[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.

Traumatic cataract formation after vigorous ocular massage.

We report a case of traumatic anterior subcapsular cataract that occurred after vigorous ocular massage with a massaging device.

Diaphragmatic injuries in childhood.

The early detection and surgical repair of diaphragmatic injury is vital for saving the life of symptomatic children suffering from trauma. Furthermore, an accurate diagnosis may be difficult, particularly in right-sided diaphragmatic injuries. Fifteen children with diaphragmatic injury treated at our department between 1977 and 1998 were evaluated retrospectively. They included 9 boys and 6 girls, and consisted of 8 left- and 6 right-sided injuries, and 1 midline retrosternal injury, due to a blunt (n = 13) or penetrating (n = 2) trauma. The most frequent symptoms were dyspnea (86.6%), and abdominal pain and vomiting (13.4%). The diagnosis was confirmed preoperatively in 13 patients based on chest X-ray (n = 7), gastrointestinal series (n = 3), barium enema (n = 1), and computed tomography and/or ultrasonography findings (n = 2). Among these, a diagnostic delay occurred in 3 patients with right-sided injuries. A primary repair was performed through a laparotomy (n = 14) or thoracotomy (n = 1). Postoperative intussusception was the most frequent complication (n = 2). Diaphragmatic injury must be considered in any child who has sustained a thoracoabdominal trauma. Serial chest X-rays should be taken especially in right-sided injuries in which a considerable diagnostic delay may occur. Further radiological methods may be necessary to confirm the diagnosis. In addition, postoperative intussusception may be encountered following diaphragmatic repair.

Multimodality management in severe pediatric spleen trauma.

BACKGROUND: Trauma is the leading cause of death in children. In abdominal lesions the spleen is the most commonly involved organ. During the last two decades much effort has focused on spleen tissue conservation. OBJECTIVES: To analyze the rationale of a multimodality management policy that includes autotransfusion and mesh wrapping. METHODS: Data gathered over 14 years illustrate the introduction of new techniques and their impact on cases of severe spleen rupture. RESULTS: A total of 122 children were treated during the 14 year period, 1985-98. In 16 children an absorbable mesh wrapping, alone or in combination with other techniques, was used to obtain hemostatis and save spleen tissue. CONCLUSIONS: Mesh wrapping, partial splenectomy and autotransfusion can be used, alone or in combination, to preserve severely injured spleens. According to our records, all children survived with a functional spleen. There were no cases of rebleeding. In only one case of prolonged postoperative fever could the cause be traced to an infected spleen hematoma that was drained transcutaneously. Autotransfusion is performed simply and without the use of a "cell saver." Its use can be crucial in small or field hospitals or in a situation of mass casualty.

Topical capsaicin as an adjuvant analgesic for the treatment of traumatic amputee neurogenic residual limb pain.

The treatment of amputee residual limb pain can at times be a challenge for the physician. Occasionally, traditional analgesic medication regimens cannot be used or are ineffective in relieving the pain. Topical capsaicin cream has been a beneficial adjuvant medication in the treatment of some painful conditions. The authors present three patients with traumatic upper limb amputations where topical capsaicin cream was of benefit in the treatment of neurogenic residual limb pain. The hope is that these cases will increase awareness of the potential use of capsaicin cream as an adjuvant analgesic in patients with residual limb pain. Common causes of residual limb pain and the pharmacology of capsaicin cream are discussed.

The role of barium enema in colostomy closure in trauma patients.

Recently, the routine use of barium enema preceding colostomy closure in trauma patients has been challenged. It has been argued that the nature of the injury should be apparent from the initial laparotomy and that the likelihood of finding an unsuspected colonic lesion in the young, previously healthy patients who constitute the majority of trauma patients is very small. We retrospectively reviewed 124 consecutive cases of patients who received colostomy takedowns for trauma. One hundred six of the patients had preoperative barium enema evaluation. 87.1 per cent of the examinations were negative, with a subsequent stoma closure complication rate of 20.4 per cent. Of the 13 positive barium enemas, 9 were falsely positive. These patients had a higher stoma closure complication rate of 39 per cent, a fact that could not be explained on the basis of their abnormal studies. The 18 patients who did not have barium enema performed did not have an increase in complications (17.6%). Barium enema failed to uncover unsuspected pertinent diagnoses, often added unnecessary delays and expense, and in no case changed the operative management. Contrast studies were found to be useful in defining anatomy in cases of known fistulas and when the takedowns were performed without the benefit of operative reports from the previous surgery.

[Diaphragmatic injuries--classification, diagnosis and therapy]. / Zwerchfellverletzungen--Klassifikation, Diagnostik und Therapie.

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.

Blunt injury to the internal carotid artery at the base of the skull: six cases of venous graft restoration.

PURPOSE: Blunt injuries to the internal carotid artery (ICA) at the base of the skull are uncommon but potentially dangerous lesions whose management remains unclear. We report a new surgical approach of the intrapetrosal portion of the ICA that was used in six patients with the help of an ear, nose, and throat surgeon. METHODS: During a 70-month period, seven consecutive patients (four women, three men; mean age, 35.7 years; range, 21 to 59 years) were admitted, six after a motor vehicle accident and one after a cervical manipulation. All patients had a neurologic deficit. An arteriographic scan revealed four unilateral ICA lesions: two false aneurysms, one tight stenosis, and one dissection; two cases of bilateral ICA dissection were mentioned, and one case of ICA dissection was associated with a contralateral ICA thrombosis. RESULTS: One patient died before surgery, and six patients underwent a unilateral venous graft restoration, reaching the vertical portion of the intrapetrosal ICA in two patients and the horizontal portion in four. A shunt was used in one patient. Failure to recognize the end of the ICA lesion was responsible for one postoperative asymptomatic graft thrombosis (17%), but this difficulty was overcome by using intraoperative angioscopy in the other patients. No deaths and no new strokes were noted during postoperative and midterm follow-up (mean follow-up, 34 months). Five postoperative facial pareses occurred and were totally regressive within 3 to 6 months in four patients; one total deafness was recorded. CONCLUSION: Venous graft restoration of traumatic ICA lesions at the base of the skull can safely be performed with such an approach, thus producing highly satisfactory results. Before undergoing surgery, the patient must be aware of the risk of facial and auditive disorders, which are generally temporary.