Magnitude and outcomes of complex perineal injury - A retrospective analysis of five years' data from a Level 1 trauma centre.

Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.

The utility of adding symptoms and signs to the management of injury-related pain.

OBJECTIVE: Improved pain assessment and management in the emergency department (ED) is warranted. We aimed to determine the impact on pain management, of adding symptoms and signs to pain assessment. PATIENTS AND METHODS: A single center before-and-after study was conducted, supplemented by an interrupted time series analysis. The intervention included the addition of clinical presentation (CP) of the injury and facial expression (FE) of the patient to pain assessment scales of patients with soft tissue injures. Pain intensity was categorized as: mild, moderate, and severe. We compared types of pain relief medications, use of strong opioids, and pain relief efficacy between pre and post intervention phases. RESULTS: Before-and-after analysis revealed a significant reduction in the use of strong opioids. The adjusted relative ratio for the use of strong opioids in the post intervention phase was 0.63 (95% CI: 0.48-0.82). This reduction was mostly driven by less use of strong opioids in patients reporting severe pain (from 17.3%-7.9%) (P < 0.0001). A larger proportion of patients in the post intervention phase than in the pre intervention phase received weak opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) (27.4% vs 19.1%, P = 0.002), and a larger proportion did not receive any pain relief medication (19.8% vs 10.5%, p < 0.0001). The use of strong opioids increased with higher levels of FE and CP. Among patients with mild injury and reporting severe pain, the odds of receiving a strong opioid was nearly 9 times (OR = 8.9, 95% CI: 4.0-19.6) higher among those who were with an unrelaxed FE and showed pain behavior than those with relaxed FE. Interrupted time-series analysis showed that the mean ΔVAS (VAS score at entry minus VAS score at discharge) in the post intervention phase compared with the pre intervention phase was not statistically significant (P = 0.073). The use of strong opioids in the post intervention phase was significantly reduced (P = 0.017). CONCLUSION: Adding symptoms and signs to pain assessment of patients admitted with soft tissue injuries decreased the use of strong opioids, without affecting pain relief efficacy.

One-stage reconstruction of complex soft tissue defects in the hands using multidigit, chimeric, lateral arm, perforator flaps.

PURPOSE: To describe our experience using microsurgically fabricated, multilobed, chimeric, lateral arm (LA) flaps to reconstruct hand injuries with complex, multidigit, soft tissue defects and to evaluate the morbidity and esthetic and functional outcomes of the donor sites. METHODS: We performed a single center, retrospective analysis of 21 patients with hand wounds treated from October 2013 to February 2016. All patients underwent reconstruction using multilobed, chimeric, free, LA flaps. A self-reported questionnaire was used to assess donor site morbidity and satisfaction with the esthetic and overall functional result. Outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) score, static 2-point discrimination score, and visual analogue scale. RESULTS: The study included 21 patients (20 males and 1 female), with an average age of 32.14 years (range 18-45 years), who sustained traumatic injuries in road traffic accidents (n = 2) or industrial devices (n = 19). The average DASH score was 28.25 ±â€¯2.3, the average 2-PD score was 7.20 ±â€¯1.30, and the average visual analogue scale (VAS) was 0.38 ±â€¯0.40. All 21 patients had sensory disorders at the donor site. Postoperative donor site complications comprised wound dehiscence (n = 1) and hematoma (n = 3). The patient-rated satisfaction score for the donor site was 5.40 ±â€¯0.90, and 70% of the patients would undergo the same surgery again. CONCLUSION: Microsurgical fabrication of multilobed, chimeric, LA flaps can exhibit sensory recovery and minimal pain but may cause hematoma and sensory disorders at the donor site. The flaps are a viable alternative for the reconstruction of complex, multidigit, soft tissue defects of the hands.

Patient-Reported Outcome Measures for Soft-Tissue Facial Reconstruction: A Systematic Review and Evaluation of the Quality of Their Measurement Properties.

BACKGROUND: A patient's health-related quality of life can be significantly impacted by facial scarring and disfigurement. Facial soft-tissue reconstruction should aim to improve this, with outcomes measured from the patient's perspective using patient-reported outcome measures. This systematic review identifies patient-reported outcome measures for soft-tissue facial reconstruction and appraises their methodologic and psychometric properties using up-to-date methods. METHODS: A systematic search of the MEDLINE, Embase, PsychINFO, and Cochrane databases was performed. Identified patient-reported outcome measures were assessed using the updated Consensus-Based Standards for the Selection of Health Measurement Instruments checklist. Psychometric properties were also assessed and a modified Grading of Recommendation Assessment, Development and Evaluation analysis was performed to aid in recommendations for future questionnaire use. RESULTS: Thirty-four studies covering nine patient-reported outcome measures were included. Methodologic quality and psychometric evidence were variable. FACE-Q, Skin Cancer Index, Patient Outcome of Surgery-Head/Neck, and the Derriford Appearance Scale 59/24 all demonstrated high enough evidence to be recommended as having potential for inclusion in future studies. CONCLUSIONS: This is the first systematic review to identify and critically appraise patient-reported outcome measures for soft-tissue facial reconstruction using internationally accepted criteria. Four questionnaires were deemed to have adequate levels of methodologic and psychometric evidence, although further studies should be conducted before they are used routinely in patients undergoing facial reconstruction. Through the use of psychometrically well-validated questionnaires, it is hoped that patients' concerns can be truly appreciated, the level of care improved, and the quality of reconstructive options offered advanced.

Abrasion injuries on artificial turf: A systematic review.

OBJECTIVES: To review the incidence of abrasion injuries sustained on artificial turf playing fields and the level of evidence existing on player perceptions of abrasion injuries on these surfaces. DESIGN: Systematic review. METHOD: A systematic search was performed using SPORTDiscus, Medline, Web of Science, Scopus and Science Direct databases. Inclusion criteria included: abrasion type injuries measured; conducted on artificial/synthetic turf; type of sport reported; peer-reviewed original research; English language search terms, but no language restrictions. A quality assessment was conducted using the Newcastle-Ottawa quality scale. RESULTS: The search yielded 76 potential articles, with 25 meeting all inclusion criteria. Twenty articles were injury-based and five were perception-based. The differences in injury definition and the lack of details of the playing surfaces produced varying results on the rate of injuries on artificial turf. Regardless of the condition of the surface, the level of play, or the sport, players perceived the fear of abrasion injuries as a major disadvantage of artificial turf surfaces. CONCLUSIONS: The review highlighted the current disparity that exists between players' perceptions of abrasion injuries and the level of evidence of abrasion injury risk on artificial turf playing surfaces. There is a need for the inclusion of greater detail of playing surfaces' specifications and condition, and an injury definition sufficiently sensitive to better measure abrasion injury incidence and severity. Without this more detailed information, it is likely that the strongly perceived risk of abrasion injuries will continue as a barrier to the adoption of artificial playing surfaces.

Pain after ortho-plastic reconstruction of lower limb injuries: A snapshot study.

INTRODUCTION: The incidence of pain after flap reconstruction of complex lower limb injury is poorly reported in the literature, and yet represents a significant source of morbidity in these patients. In our centre (Southmead Hospital, Bristol, England) patients who have had flap reconstruction for complex lower limb injury are followed up at a joint ortho-plastics lower limb clinic run weekly. The aim of this study was to report the incidence of pain in such patients at follow-up in the specialist clinic. The impact of the experience of pain upon the quality of life, and the efficacy of analgesia was assessed these cases. PATIENTS AND METHODS: This was a cross sectional snapshot study of a cohort of complex lower limb patients attending our lower limb ortho-plastics outpatient clinic between the dates of: 17/5/16 and 28/6/16. Any patient attending clinic with previous flap reconstruction for lower limb injury was asked to complete the BPI (Brief Pain Index) questionnaire, and details regarding their injury and surgery were collected. RESULTS: There was a 100% response rate, with 33 patients completing the questionnaire. 28 out of the 33 patients (85%) reported ongoing pain. There was no significant relationship between time post operatively and average pain scores (Spearman's Rank R = 0.077), nor was there significant difference by age or gender. Over 25% of the patients with pain were not taking analgesia, however those using simple analgesia (paracetamol, NSAIDS) derived on average over 70% pain relief. CONCLUSIONS: Pain in a common complication following flap reconstruction for complex lower limb injury reported in 85% of our cohort. This pain does not seem to be correlated with time, gender or age, and responds well to simple analgesia in most cases. This emphasises the importance of asking about pain at follow up, and taking simple measures to improve pain outcomes.

A structural MRI study of excoriation (skin-picking) disorder and its relationship to clinical severity.

Excoriation (skin-picking) disorder (SPD) shares symptomology with other obsessive-compulsive and related disorders. Few studies, however, have examined the neurological profile of patients with SPD. This study examined differences in cortical thickness and basal ganglia structural volumes between 20 individuals with SPD and 16 healthy controls using magnetic resonance imaging (MRI). There were no significant differences in demographic variables (age, gender, education and race) between groups. All subjects completed a structural MRI scan and completed a battery of clinical assessments focusing on SPD symptom severity, depression and anxiety symptoms, and quality of life. No statistically significant differences in basal ganglia (caudate, putamen, and nucleus accumbens) structural volumes were found between groups. In individuals with SPD, increasing impulsiveness correlated positively with increased cortical thickness in the left insula, and skin picking severity correlated negatively with cortical thickness in the left supramarginal gyrus and a region encompassing the right inferior parietal, right temporal and right supramarginal gyrus. This study suggests similarities and differences exist in symptomology between SPD and the other obsessive-compulsive and related disorders. Additional neuroimaging research is needed to better delineate the underlying neurobiology of SPD.

Predicting pain outcomes after traumatic musculoskeletal injury.

Traumatic musculoskeletal injury results in a high incidence of chronic pain; however, there is little evidence about the nature, quality, and severity of the pain. This study uses a prospective, observational, longitudinal design to (1) examine neuropathic pain symptoms, pain severity, pain interference, and pain management at hospital admission and 4 months after traumatic musculoskeletal injury (n = 205), and (2) to identify predictors of group membership for patients with differing moderate-to-severe putative neuropathic pain trajectories. Data were collected on mechanism of injury, injury severity, pain (intensity, interference, neuropathic quality), anxiety (anxiety sensitivity, general anxiety, pain catastrophizing, pain anxiety), depression, and posttraumatic stress while patients were in-hospital and 4 months after injury. A third of patients had chronic moderate-to-severe neuropathic pain 4 months after injury. Specifically, 11% of patients developed moderate-to-severe pain by 4 months and 21% had symptoms immediately after injury that persisted over time. Significant predictors of the development and maintenance of moderate-to-severe neuropathic pain included high levels of general anxiety while in-hospital immediately after injury (P < 0.001) and symptoms of posttraumatic stress 4 months after injury (P < 0.001). Few patients had adequate pharmacological, physical, or psychological pain management in-hospital and at 4 months. Future research is needed among trauma patients to better understand the development of chronic pain and to determine the best treatment approaches.

An application of the health action process approach to physiotherapy rehabilitation adherence.

This study tested the utility of an extended version of the health action process approach (HAPA) to explain the attitudinal and behavioural processes contributing to rehabilitation adherence and ultimately rehabilitation outcomes in physiotherapy patients. The HAPA focuses on self-efficacy, action and coping planning and their relationships to behavioural intentions and actual behaviour. A one group prospective design was employed in which 20 participants with soft tissue injuries of the shoulder were followed for the first four weeks of their clinic- and home-based physiotherapy. Participants enrolled in the study after their first physiotherapy clinic appointment, at which time they completed questionnaires measuring the motivational HAPA constructs and shoulder function. Action and coping plans were then made with assistance of the researcher. Adherence behaviours were measured throughout the study, and at the end the volitional stage HAPA constructs, action self-efficacy and shoulder function were assessed. Moderate to strong correlations occurred between the self-efficacies and behavioural intentions, behavioural intentions and adherence behaviours, and adherence behaviours and post-study shoulder function. These findings support the extension of the HAPA model to include the functional outcomes for soft tissue injuries of the shoulder. Its true value will nevertheless only be realized in a longer duration study with a larger sample size.

[Treatment of severe tibial fractures with extensive soft tissue damage and/or contamination. Quality of life after use of the Ilizarov external fixator]. / Behandlung schwerster Tibiafrakturen mit gefährdetem Weichteilmantel und/oder Kontamination. Lebensqualität nach Einsatz des Ilizarov-Fixateur externe.

BACKGROUND: The Ilizarov external fixator (IF) is an immediate and definitive treatment option for severe tibial fractures compromised by extensive soft tissue damage. The aim of this study was to assess the general performance of the IF and especially the impact on patient quality of life. METHOD: A postal questionnaire including an SF-12 health survey and questions about various other aspects of quality of life was sent to all patients who received an IF for primary fracture treatment at a level 1 trauma centre between January 2000 and June 2009. RESULTS: A total of 48 completed questionnaires were received from patients treated with IF for severe tibial fractures. The median time to removal of the IF was 154 days (range 70-614 days). The mean SF-12 mental component score (MCS) was 52 (SD±12) and the mean physical component score (PCS) was 38 (SD±11). Of the patients 100 % answered that they were either satisfied or very satisfied with the treatment and 91 % would choose the same method of treatment under similar circumstances. CONCLUSIONS: This study demonstrates a high performance of IF in the treatment of severe tibial fractures with compromised soft tissue where more standard forms of treatment are contraindicated.

Negative pressure wound therapy: improving the patient experience part 3 of 3.

Negative pressure wound therapy (NPWT) is considered to be an effective wound treatment, yet research has highlighted a clear need for its improvement, particularly in reducing pain. This is important not only for patient well-being and treatment satisfaction but also for the healing process. In parts 1 and 2, wound care clinicians were invited to share their views on patients' experiences of NPWT. Part 3, presented here, explores the views of patients who have had NPWT, through use of a questionnaire survey and interview (n = 50). Findings show that the majority of patients felt that NPWT had a positive impact on their wound (94%) and that their overall experience was positive (88%). However, respondents identified a number of challenges associated with NPWT, such as reduced mobility, noise issues, and sleep disturbance. Respondents also identified a number of areas for improvement with NPWT, including greater training for nurses, practical alterations to the equipment, and methods of minimising pain and skin damage during NPWT. Taken together with the findings from part one and two, this study highlights several key considerations for future research and clinical practice with NPWT.

Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in eastern France.

OBJECTIVE: To estimate: (1) the association between executive function (EF) impairment and falls; and (2) the association of EF impairment on tests of physical function used in the evaluation of fall risk. DESIGN: Cross-sectional study. SETTING: Thirteen health examination centres in Eastern France. PARTICIPANTS: Four thousand four hundred and eighty one community-dwelling older adults without dementia aged 65 to 97 years (mean age 71.8±5.4, women 47.6%). MEASUREMENTS: Participants underwent a comprehensive medical assessment that included evaluations of EF using the Clock Drawing Test and of physical performance using the Timed Up and Go Test (TUG). Analysis used multivariable modified Poisson regression to evaluate the association between impaired EF and each of the fall outcomes (any fall, recurrent falls, fall-related injuries). Multivariable linear regression was used to evaluate the association between EF impairment and performance on the TUG and grip strength. RESULTS: EF impairment, assessed using the clock drawing test, was present in 24.9% of participants. EF impairment was independently associated with an increased risk of any fall (RR=1.13, 95% CI (1.03, 1.25)) and major soft tissue fall-related injury (RR= 2.42, 95% CI (1.47, 4.00)). Additionally, EF impairment was associated with worse performance on the TUG (p<0.0001). CONCLUSIONS: EF impairment among older adults without dementia was highly prevalent and was independently associated with an increased risk for falls, fall-related injuries and with decreased physical function. The use of the Clock Drawing Test is an easy to administer measure of EF that can be used routinely in comprehensive fall risk evaluations.

Self-reported and performance-based functional outcomes after surgical repair of proximal hamstring avulsions.

BACKGROUND: Because a proximal hamstring avulsion results in residual loss of function, surgical repair is recommended. Few studies have investigated postoperative function with validated outcomes. PURPOSE: To examine lower extremity function after surgical repair of proximal hamstring avulsions using validated self-reported and performance-based functional outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Operative records from 2006 to 2010 were retrospectively reviewed in 3 hospitals. A total of 39 patients who had undergone surgical repair of a proximal hamstring avulsion were identified, and 36 met the inclusion criteria. Thirty-one patients completed questionnaires with demographic background data and quality of life-related questions: the Lower Extremity Functional Scale (LEFS) and the Proximal Hamstring Injury Questionnaire (PHIQ). Thirty patients were evaluated using a Biodex dynamometer for isokinetic quadriceps and hamstring strength measurements at a velocity of 60 deg/s, and 27 patients performed 4 single-legged hop tests. RESULTS: Twenty-eight repairs were acute (<4 weeks), and 3 were chronic. There were complete ruptures of all 3 tendons in 17 (55%) cases. The mean follow-up was 30 months. Most patients experienced little or no pain or limitations during activities of daily living. The mean LEFS score was 89%, and 29 (94%) of the 31 patients were satisfied with the result after surgery. Eighteen (58%) of the 31 patients had returned to their preinjury activity level. Significant differences in the mean hamstring strength (peak torque) (P < .001) and single-legged hop test (P = .01) between the uninvolved and involved leg were found. Twenty-two (71%) of the 31 patients did not fully trust their operated leg during physical activities and feared sustaining a hamstring injury. Return to activity significantly correlated with the single-legged hop test, the LEFS score, and the questions regarding trust and fear. CONCLUSION: In this study, using both validated self-reported and performance-based outcome measures after surgical repair of proximal hamstring avulsions, minor pain and limitations to activities of daily living were seen. Isokinetic hamstring strength in the operated leg was significantly lower compared with the nonoperated leg, and a majority of the patients did not trust the operated leg completely during physical activity.

Cytokine levels as potential biomarkers for predicting the development of posttraumatic stress symptoms in casualties of accidents.

BACKGROUND: Traumatic injuries are usually associated with increased secretion of pro-inflammatory cytokines, and are sometimes followed by the development of acute stress symptoms (ASS) and posttraumatic stress symptoms (PTSS). AIMS: To measure serum pro- and anti-inflammatory cytokines in accident casualties and to associate it with ASS at hospitalization, and with PTSS 1 month later. METHODS: Participants were 48 patients, aged 20-60, hospitalized following various orthopedic injuries including bone fractures, and 13 healthy volunteers matched for gender. At hospitalization (Time 1), 30 ml heparinized venous blood were drawn and cytokines levels in serum were assessed; participants filled out the Acute Stress Disorder Inventory (ASDI), COPE, and injury-related questionnaires. One month later (Time 2), 26 participants filled out the Posttraumatic Disorder Symptom Scale (PDS). RESULTS: High serum levels of IL-6, IL-8, and TGF-beta and low levels of serum IL-4 and IL-10 were found in injured patients as compared with controls, When controlling for age and severity of injury in the regression analysis, higher levels of IL-6 and IL-8 and lower TGF-beta were predicted by higher ASS and higher use of and emotion-focused coping. Higher PTSS scores at Time 2 were predicted by higher levels of IL-8, lower levels of TGF-beta, and higher ASS measured at Time 1. CONCLUSIONS: High levels of the pro-inflammatory cytokine IL-6 and IL-8 and lower levels of the regulatory cytokine TGF-beta should be further assessed as a possible risk factor or a bio-marker of PTSS in accident casualties.

Novel treatment for massive lower extremity avulsion injuries in children: slow, but effective with good cosmesis.

BACKGROUND: Extended avulsion injuries are associated with significant loss of skin and subcutaneous fat, leaving the reconstructive surgeon with the challenge of substituting all tissues lost in the best possible way. We wanted to test whether the combined use of a Vacuum Assisted Closure system (VAC) and Integra Dermal Regeneration Template (IDRT) matched the required treatment profile encompassing initial control of infection, remodeling of body contours, and reconstruction of near normal skin. MATERIALS AND METHODS: 4 children with massive lower extremity avulsion injuries were treated with early necrosectomy, VAC application for 3-5 weeks for wound cleansing and wound bed conditioning, subsequent implantation of IDRT, and finally autologous split thickness skin grafting (STSG) for definitive wound closure. Thereafter, a standard rehabilitation program was used. The key parameters of VAC and IDRT application, take rates of IDRT and STSG, complications, length of stay, and final outcome were recorded. RESULTS: In all patients, early removal of necrosis and infection control was successfully achieved. Continuous VAC application fostered the formation of a several millimeters thick new tissue layer partly compensating for the lost hypodermis. IDRT implantation and subsequent STSG yielded take rates of nearly 100% and both functionally and cosmetically excellent long-term results. There were no major complications. CONCLUSION: The combination of VAC and IDRT in children with massive leg avulsion injuries is feasible, safe, and delivers high-quality long-term outcomes that appear to justify the multiple operative procedures, the long hospitalization times, and the comparatively high costs entailed.

[Psychological comparison of patients with soft tissue injuries in oral and maxillofacial region by different kinds of suturing].

OBJECTIVE: To evaluate the psychological situations of patients with soft tissue injuries in oral and maxillofacial region by different kinds of suturing. METHODS: A total of 200 patients were selected and randomly divided into two groups. Group A received intradermic suture while group B underwent para-position suture. All patients were evaluated by hospital anxiety and depression (HAD) scales pre-suture, after one week, one month and three months. RESULTS: The HAD total scores of group B were significantly high compared with group A (P < 0.05) after one week and one month, while there was no difference between group A and group B pre-suture and three months later. CONCLUSIONS: Intradermic suture results in less psychological influence in patients with soft tissue injuries in oral and maxillofacial region.

Perceived cognitive deficits, emotional distress and disability following whiplash injury.

OBJECTIVES: To describe the pattern of perceived cognitive deficits in patients with whiplash injury, to examine the relation between perceived cognitive deficits and disability, and to examine the determinants of perceived cognitive deficits in patients with whiplash injury. PARTICIPANTS: A total of 81 individuals participated in the study. There were 29 patients (13 men, 16 women) with a diagnosis of whiplash, grade I or II. Patients with work-related soft-tissue injuries (n=24) and nonclinical controls (n=28) were included as comparison groups. METHODS: Participants completed measures of perceived cognitive deficits, pain severity, depression, anxiety and pain-related disability. RESULTS: Both patient groups scored significantly higher than the nonpatient control group on the measure of perceived cognitive deficits, but did not differ significantly from each other. Perceptions of cognitive deficits were significantly correlated with pain-related disability. A hierarchical regression examining the relative contribution of anxiety, depression and pain showed that only anxiety and depression contributed significant unique variance to the prediction of perceived cognitive deficits. DISCUSSION: The potential benefits of focusing interventions on the management of anxiety and depression in the rehabilitation of patients with whiplash injuries are discussed.

Salvaged limbs after tibial shaft fractures with extensive soft-tissue injury: a biopsychosocial function analysis.

BACKGROUND: The purpose of this study was to perform a biopsychosocial function analysis of the outcome in patients with a salvaged leg after tibial shaft fractures associated with extensive soft-tissue injury. METHODS: A retrospective review of 18 consecutive patients with tibial shaft fractures and extensive soft-tissue damage with a mean Injury Severity Score of 31 was undertaken. All patients were assessed for their physical function, psychological status, and general function. RESULTS: The range of motion and torque of the ankle joint were severely affected. The knee joint was affected, but only with regard to the torque during concentric muscular activities. Nottingham Health Profile scores showed that the general and social function for these patients were significantly affected. Five of 18 patients suffered from depression. CONCLUSION: Salvage procedures should be advocated if possible, but careful selection of patients on the basis of mental and social factors is crucial for the outcome.