Ultrasound in Trauma and Other Acute Conditions in Sports, Part I.

The utility of ultrasound in sports medicine is improving the sports medicine physician's ability to rapidly diagnose and treat a multitude of sports related pathologies. In this article, we clearly outline the current status of the evidence in support of using sports ultrasound in the setting of acute abdominal and thoracic trauma, acute lung illness, limited cardiac evaluation of a collapsed athlete, volume status assessment, and fracture evaluation.

Penetrating chest trauma caused by a blank cartridge actuated rubber ball projectile: case presentation and ballistic investigation of an uncommon weapon type.

Recently, an increasing number of an uncommon weapon type based on a caliber 6-mm Flobert blank cartridge actuated revolver which discharges 10-mm-diameter rubber ball projectiles has been confiscated by police authorities following criminal offenses. A recent trauma case presenting with a penetrating chest injury occasioned an investigation into the basic ballistic parameters of this type of weapon. Kinetic energy E of the test projectiles was calculated between 5.8 and 12.5 J. Energy density ED of the test projectiles was close to or higher than the threshold energy density of human skin. It can be concluded that penetrating skin injuries due to free-flying rubber ball projectiles discharged at close range cannot be ruled out. However, in case of a contact shot, the main injury potential of this weapon type must be attributed to the high energy density of the muzzle gas jet which may, similar to well-known gas or alarm weapons, cause life-threatening or even lethal injuries.

Nuking the radiation: minimizing radiation exposure in the evaluation of pediatric blunt trauma.

PURPOSE OF REVIEW: Our objective is to highlight recent literature investigating low-radiation diagnostic strategies in the evaluation of pediatric trauma. RECENT FINDINGS: In the area of minor head injury, research has focused on implementation of validated clinical decision rules into practice to reduce unnecessary computed tomography scans. Clinical observation may also serve as an adjunct to initial assessment and a potential substitute for computed tomography imaging. Subgroups of children with special needs or severe injury mechanisms may also be safely characterized by the clinical decision rule and spared radiation exposure. Physical examination techniques may be useful in diagnosing mandibular fractures. In addition, evidence suggests that plain radiography for evaluation of blunt thoracic trauma may be sufficient in many cases, and computed tomography could be reserved for those with abnormal radiographs, high-risk mechanisms, or abnormal physical findings. Clinical decision rules are able to predict intra-abdominal injury with high sensitivity. Data suggest that skeletal surveys may be modified to limit radiation exposure in the case of suspected nonaccidental trauma. SUMMARY: More research is needed in development of pediatric-specific clinical decision rules and risk stratification and in testing low-radiation diagnostic modalities in the pediatric trauma population.

[Tricuspidal valve rupture after blunt chest trauma]. / Niewydolnosc zastawki trójdzielnej w wyniku urazowego pekniecia miesnia brodatkowatego.

BACKGROUND: Blunt chest trauma is frequently associated with cardiac contusion and structural damage, most cases only being recognized after death. We report a case of multiple organ trauma, where cardiac failure, caused by tricuspid valve rupture, was markedly delayed. CASE REPORT: A 21 yr old man was admitted to hospital after a car accident. He was suffering from cerebral contusion and oedema, pulmonary contusion, and a left pneumothorax. He also had multiple fractures of the facial bones, orbit, L4 vertebra and left tibia. He was tracheotomised, and a subdural sensor was inserted for continuous monitoring of intracranial pressure. He was sedated and ventilated for two weeks. On the 12th day, his jaw was reconstructed, and immediately after surgery, mild signs of cardiac failure were observed, which were attributed to cardiac contusion. Two weeks after admission, the patient was weaned from the ventilator, and three days later, his facial bones were reconstructed. Four days later, the signs of cardiac failure reappeared. Transoesophageal echocardiography revealed rupture of a head of papillary muscle, with 4th degree tricuspid insufficiency and enlargement of the right ventricle. The ruptured muscle was reconstructed under extracorporeal circulation, and the patient made a satisfactory recovery. DISCUSSION: Acute tricuspid valve insufficiency, albeit rare, may occur in patients with blunt chest trauma. Sedation and lack of physical activity may delay the definite diagnosis, especially when only transthoracic echocardiography is used. Cardiac arrhythmias, diastolic murmur, or signs of congestive cardiac failure in a chest trauma patient may all suggest some structural damage; therefore, transoesophageal echocardiography should be performed as early as possible in such situations.

Bilateral chylothorax after blunt thoracic trauma: a case report.

Traumatic chylothorax other than iatrogenic thoracic duct injury is extremely rare in children. Chylothorax can cause cardiopulmonary abnormalities and significant nutritional, metabolic and immunologic consequences. The management of chylothorax ranges from conservative treatment to surgical intervention. We present a four-year-old boy who presented with respiratory difficulty due to multiple rib fractures and bilateral chylothorax, which developed after a blunt chest trauma. The patient was successfully treated through a conservative approach with total parenteral nutrition, nothing by mouth, and bilateral chest tube drainage. The nature of pleural effusion developed following a blunt thoracic trauma is important in the management of trauma patients.

Early Surgical Reconstruction of Sternum with Longitudinal Rigid Polymer Plating after Acute Chest Trauma.

PURPOSE: The surgical management of the patients with traumatic sternal fractures remains controversial. The aim of this study was to evaluate the effectiveness of an early surgical reconstruction of a displaced sternal fracture utilizing longitudinal rigid polymer fixation in the settings of an acute chest trauma. METHODS: To perform the sternal fixation, we utilized a longitudinal rigid plating system. The plate is made of polyether ether ketone (PEEK), an organic thermoplastic polymer. RESULTS: We used the entire length of the plate on each side of the fracture, secured in multiple places with 6-8 screws. Once the plates have been fully secured we tighten all the screws with a screwdriver. We demonstrated that the method minimizes pain and prevents the development of pulmonary complications. CONCLUSION: This technique provides cosmetically acceptable results, minimizing risk of sternal nonunion, and decreases length of hospitalization.

Mediastinal metastasectomy from a primary germ cell testicular tumour resulting in occult thoracic duct injury and chylothorax.

A 22-year-old man underwent mediastinal metastasectomy for a testicular germ cell tumour via median sternotomy. Intraoperatively, the tumour was massive, measuring 88 mm in anterior-posterior (AP) diameter. It was densely adherent to the trachea and aggressive debulking resulted in tracheal injury. Therefore, the patient was kept nil by mouth for 3 days postoperatively and was discharged uneventfully. He represented only 2 days later with a large right-sided chylothorax. His chylothorax was managed conservatively with insertion of an intercostal catheter (ICC) and a low-fat diet. Over the course of 9 days, the ICC drained approximately 5 L of fluid. His admission was further complicated by severe gastroparesis requiring feeding Nasojejunal (NJ) tube placement. The delayed feeding in this case resulted in late detection of the occult thoracic duct injury. This case illustrates that conservative and multidisciplinary management of a postoperative chylothorax from a suspected thoracic duct injury achieves favourable outcomes avoiding further surgical intervention.

Repair of Tricuspid Valve Leaflet With CardioCel Patch After Traumatic Tricuspid Regurgitation.

Posttraumatic tricuspid valve regurgitation (TR) is a rare entity and is almost always associated with blunt chest trauma. It is usually identified by transthoracic echocardiography after the manifestation of clinical symptoms of heart failure. Treatment varies from long-term medical therapy and observation to surgical correction with tricuspid valve replacement or repair. We describe the case of a 26-year-old man who was involved in a major road traffic accident and was referred for surgical repair a year later because of severe posttraumatic TR. The tricuspid valve was successfully reconstructed with a CardioCel patch, Gore-Tex neochordae, and a tricuspid ring. The patient recovered well.

Penetrating thoracic wounds caused by plastic bullets.

Thoracic penetrating injuries caused by a new plastic bullet were studied to determine the nature of the wounds and the appropriate management. Twenty-six casualties from the Israeli-Palestinian conflict (Intifada) were included. The organs most commonly involved were lung (n = 21), bony chest wall (n = 9), heart (n = 3), and diaphragm. Bleeding was at least moderate in 20 patients, amounting in all patients to an average of 975 ml. Thoracotomy was required in 11 patients (42%) mainly because of cardiac injury (n = 3) and aortic or other arterial bleeding (n = 3). Simple oversewing of severed organs (n = 8) or ligation of bleeding vessels (n = 3) was satisfactory. Two patients died (7.7% mortality); one after major liver resection; the other was dead on arrival. We conclude that plastic bullets have a linear course unless displaced by the bony chest wall, when they tend to fragment and cause simple fractures. Fired from a presumed range of at least 70 m, plastic bullets behave like low-velocity missiles, and tissue destruction is minimal. Management should be similar to that of civilian thoracic penetrating trauma.

[Unusual case of gunshot by self-made firearm]. / Niezwykly przypadek postrzalu z broni palnej samodzialowej.

A case of suicide with the use of a primitive self-made firearm, constructed with a steel tube was presented. Victim standing on a stool, with hanging loop around neck, shot himself to mouth with fourteen steel balls. At this moment the weapon tore apart wounding hand of the victim.

Traumatic fracture of polytetrafluoroethylene axillofemoral bypass graft.

We report traumatic disruption of a ringed polytetrafluorethylene (PTFE) axillofemoral bypass (AFB) graft due to a fall. We also review the literature of previously reported blunt traumatic PTFE graft disruptions. A 75-year-old man with previous bilateral AFB grafting presented with a painful left chest wall mass after a fall from standing height. Chest computed tomography (CT) revealed a large chest wall hematoma. The patient underwent evacuation of the hematoma, resection of the fractured graft, and placement of an interposition PTFE graft. Two prior case reports have documented the midportion PTFE graft disruption from blunt trauma. Our case report demonstrates the potential for disruption of the midportion of ringed PTFE AFB grafts with direct blunt trauma. The diagnosis was confirmed by CT scan and the graft was successfully repaired with an interposition graft.

[Reconstruction of a crushed chest with HI-TEX PARP NT implant]. / Die Rekonstruktion eines zertrümmerten Brustskeletts mithilfe des Implantats HI-TEX PARP NT.

The authors present the case of a 57-year-old man with polytrauma, who was injured in a train accident. Together with other injuries, he also sustained multiple comminuted fractures on the left half of the rib cage. These subsequently required surgical intervention because of thoracic instability and impending lung injury. Extensive damage to the thoracic skeleton was treated by removal of the damaged tissues and replacement by the HI-TEX PARP NT implant. The presented procedure is being discussed as an alternative to metallic fixation in thoracic instability in cases of devastating injury or injury resulting in bone and tissue loss.

Surgical stabilization of traumatic flail chest.

Since 1970 we have stabilized the ribs to correct paradoxical movement of the chest wall in chest injuries, using an original technique, in order to avoid as far as possible the need for long-term chest wall stabilization by intermittent positive pressure respiration (IPPR). The technical details of surgical stabilization are described, and the different types of stainless steel struts are shown. Type I was originally used either as an intramedullary nail or as an external brace. Types II and III were designed for external fixation of the strut to the rib. Treatment of 29 patients with severe flail chest, classified into four groups is shown: group I was treated by IPPR, group II by IPPR plus surgical stabilization, group III by surgical stabilization only, and group IV by surgical stabilization after exploratory thoracotomy. The clinical results are discussed. We conclude that surgical stabilization of the paradoxial movement of the chest wall can avoid the use of the respirator or at least reduce the interval of IPPR to a short period during the initial recovery from trauma. Using type III struts, we have obtained stabilization of the flail chest in all cases even in patients with severe anterior paradoxical movement. The patients' tolerance of surgical stainless steel struts was good.

[Posttraumatic aneurysm of the brachiocephalic trunk: a rare injury]. / Aneurysma des Truncus brachiocephalicus nach stumpfem Thoraxtrauma. Eine seltene Verletzung.

We report on a posttraumatic aneurysm of the brachiocephalic trunk, something which is rather rare. The injury was caused by blunt chest trauma following a car accident. Computed tomography could not find the brachiocephalic lesion. In patients with fractures of the upper ribs after blunt chest trauma, angiography should be done to exclude severe injuries of the aorta and brachiocephalic vessels.

Endovascular repair of an innominate artery false aneurysm following blunt trauma.

PURPOSE: To describe a case of endovascular graft exclusion of an innominate artery pseudoaneurysm arising from blunt trauma. METHODS AND RESULTS: A 21-year-old patient was admitted following a major road accident. Computed tomography (CT) and aortography on admission disclosed an isolated innominate artery pseudoaneurysm. The lesion was stable, so an elective endoluminal repair was undertaken once the patient was treated for his other injuries. The right carotid artery was exposed and controlled, and the aneurysm was excluded by transluminal implantation of a customized stent-graft consisting of predilated polytetrafluoroethylene graft material covering a balloon-expandable Palmaz stent. A CT scan at 1 month and duplex scans at 6-month intervals documented good stent-graft positioning and aneurysm exclusion over a period of 18 months. CONCLUSIONS: This case illustrates the potential durability of endoluminal repair of innominate artery lesions and highlights the potential role of this minimally invasive alternative to surgery in these clinical situations.

Endovascular treatment of penetrating thoracic outlet arterial injuries.

OBJECTIVES: to establish the feasibility of stent-graft treatment of penetrating thoracic outlet arterial injuries. DESIGN: prospective study. MATERIALS AND METHODS: forty-one patients with penetrating injuries to the carotid, subclavian and proximal axillary arteries admitted between August 1998 and May 1999 were studied. Patients requiring urgent surgical exploration for active bleeding (n=26) were excluded. Remaining patients underwent arteriography to assess suitability for stent-graft placement. After successful stent-graft treatment clinical and sonographic follow-up were done at 1 month and thereafter 3-monthly. RESULTS: of the 15 patients considered, 10 patients qualified for stent-graft treatment (seven male, three female, mean age 27 years). The vessels involved were subclavian artery (seven), carotid artery (two) and axillary artery (one). Seven had arteriovenous fistulae and three, pseudoaneurysms. Stent-graft treatment was successful in all 10 patients with no procedure-related complications. On mean follow-up of 7 months no complications were encountered. CONCLUSION: endovascular treatment shows promise as a treatment modality for thoracic outlet arterial injuries. Long-term follow-up is required for comparison to the results of standard surgical repair.

[Vascular injuries in everyday practice]. / Gefässverletzungen in der täglichen Praxis.

BACKGROUND: It was the objective of this retrospective study to analyse the causes of injury, surgical approaches, outcome, and complications in patients with vascular trauma and to report our experience with vein homografts for arterial reconstruction in the upper and lower limbs and cervicothoracic region in patients operated on over a period between 1981-2001. PATIENTS: In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 20 cases. In 4 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were aggravated by concomitant bone fractures, and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%), crural (22.6%), and ulnar and radial (13.2%) arteries. 16 patients with penetrating cervicothoracic arterial injuries were registered during this period. 8 patients underwent emergency exploration and 8 patients angiography prior urgent exploration. RESULTS: Saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene and Dacron grafts were used in eight cases, end to end anastomosis in 12 cases, venous bypasses in 5 cases, venous patches in 7 cases. 17 patients underwent arterial repair and 9 venous repair. Vein homografts as an arterial substitute were implanted in 8 patients. Five secondary amputations were performed and five patients died. The limb salvage rate was 95% and the primary patency rate of vein homografts was 75% (excluded primary amputations). The penetrating cervicothoracic injuries were all repaired with improvement in level of consciousness and neurological deficit when present. CONCLUSIONS: Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues. In the absence of suitable autologous vein grafts, homografts appear to be an interesting alternative for arterial repair. In penetrating cervicothoracic vascular injuries immediate operative repair offers the best chance of recovery.