[Ballistic injury, decaying wounds: the nurse at the heart of the long rehabilitation process]. / Lésion balistique, plaies délabrantes : l'infirmier au cœur du long parcours de réhabilitation.

Ballistic injuries are disabling. Its functional impact is determined by its trajectory. Whether the injury affects a limb that could jeopardize its preservation, visceral lesions or craniocerebral and vertebro-medullary wounds, the nurse is at the heart of multidisciplinary care to limit and compensate for the after-effects. Directed healing, appropriate analgesia, settling in, technical training for this new, modified body (stoma, self-catheterization, appliances, etc.) and support in accepting the injury are all part of the nurse's role in helping the injured person rebuild his or her life.

Surgical and Nonsurgical Treatment of Penetrating Spinal Cord Injury: Analysis of Long-term Neurological and Functional Outcomes.

Objective: To describe long-term neurological and functional outcomes for patients with penetrating spinal cord injury (PSCI) following surgical (SX) and nonsurgical (NSX) treatment. Methods: We identified all patients with PSCI in the Spinal Cord Injury Model Systems database from 1994-2015. Patients with PSCI were divided into surgical (SX) and nonsurgical (NSX) groups. Outcomes were measured using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and the Functional Independence Measure (FIM) motor scores. Outcomes were then analyzed separately for patients with complete and incomplete PSCI during acute hospitalization, SCI rehabilitation, and 1-year follow-up. Results: For patients with complete PSCI, acute hospital length of stay (LOS) was increased in the SX group (19 days vs 14 days; p < .0001) while median FIM motor scores were similar at 1-year follow-up (74 vs 75; p = .4). The percentage of patients with complete PSCI remained similar between groups at discharge from SCI rehabilitation (88% vs 88%; p = 0.5). For patients with incomplete PSCIs, acute hospital LOS was similar between groups (13 vs 11; p = .3) and no difference was observed in ASIA Impairment Scale improvement at discharge from rehabilitation (38% vs 37%; p = .9) or in FIM scores at 1 year (84 vs 85; p = .6). Conclusion: Surgery for patients with complete PSCI is associated with increased acute hospital LOS for complete PSCI and is not associated with improvement in neurological or functional outcomes in patients with either complete or incomplete PSCI.

Knee sliced open by skate blade: complete patellar tendon rupture in an elite long track speed skater.

A long track speed skater sustained a deep horizontal cut to the right knee just distally to the patella, after he got hit by the skate blade of the pair mate. The injury included a complete patellar tendon rupture from the apex of the patella, a 1 mm deep transverse cut in the femoral condyle and a partial rupture of the anterior cruciate ligament. The tendon rupture was repaired with transosseous suture repair without augmentation. A knee brace was used for 8 weeks, with a gradual decrease in flexion restraints. A rehabilitation programme was overseen by a dedicated physiotherapist. At 6 months, he started a gradual return to skating sessions. After 1 year, he had symmetrical single-legged hop performance, but quadriceps weakness due to pain. The patient returned to competition speed skating at national levels after 11 months, and within the first postoperative year, he was breaking new personal records on the ice.

Structural Dynamics of the Fibrous Basis of Reparative Regenerate during Spontaneous Healing of the Skin Wound.

Structural dynamics of the fibrous basis of the reparative regenerate during spontaneous skin wound healing comprises multiple stages, it successively transforms from one organization level to another more complex level, forms a multilevel 3D structure including molecular, supramolecular, fibrillar, fiber, and tissue elements. The formed reparative regenerate is integrated with the preserved skin, together they have common fibrous basis consisting of three parts that are different in organization of fibrous structures: atypical (central), tissue organospecific (peripheral), and transitional.

Characterization of disability following traumatic through knee and transfemoral amputations.

INTRODUCTION: The purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries. METHODS: A retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data. RESULTS: A total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129). DISCUSSION/CONCLUSION: Among this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don't believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.

Penetrating Colon Trauma Outcomes in Black and White Males.

INTRODUCTION: Racial disparities have been both published and disputed in trauma patient mortality, outcomes, and rehabilitation. In this study, the objective was to assess racial disparities in patients with penetrating colon trauma. METHODS: The National Trauma Data Bank was searched for males aged ≥14years from 2010 through 2014 who underwent operative intervention for penetrating colon trauma. The primary outcomes for this study were stoma formation and transfer to rehabilitation; secondary outcomes were postoperative morbidity and mortality. Analyses were performed in 2016-2018. RESULTS: There were 7,324 patients identified (4,916 black, 2,408 white). Black and white patients underwent fecal diversion with stoma formation at a similar rate (19.6% vs 18.5%, p=0.28). Black patients were more likely than white patients to be uninsured (self-pay; 37.1% vs 29.9%) and more likely to be injured by firearms (88.3% vs 70.2%, p<0.001), but had a lower overall postoperative morbidity rate (52.6% vs 55.3%, p=0.04). The odds of stoma formation (OR=0.92, 95% CI=0.78, 1.09, p=0.35) and the odds of transfer to rehabilitation (OR=1.03, 95% CI=0.82, 1.30, p=0.78) were similar for black versus white patients. CONCLUSIONS: Black patients experienced similar rates of stoma formation and transfer to rehabilitation as white patients with penetrating colon trauma. Multivariate analysis confirmed expected findings that trauma severity increased the odds of receiving an ostomy and rehabilitation placement. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to healthcare disparities. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Reparación protésica de una hernia lumbar postraumática en un adulto / Prosthetics repair of a post-traumatic lumbar hernia in an adult

Se describe el caso clínico de un paciente de 45 años de edad, quien sufrió accidente laboral por objeto metálico romo, que le ocasionó trauma contuso en región lumbosacra derecha. A los 30 días de dicho trauma, notó aumento de volumen en la zona afectada y acudió a la consulta de cirugía herniaria del Hospital General Universitario Dr Juan Bruno Zayas Alfonso, donde clínicamente se le diagnosticó una hernia lumbar derecha postraumática. Fue operado de forma electiva con anestesia orotraqueal. Se realizó profilaxis antimicrobiana y antitrombótica; además, se implantó prótesis preperitoneal de polipropileno. No hubo complicaciones perioperatorias y el paciente tuvo seguimiento durante 3 años, sin recurrencias

The case report of a 45 years patient who had an industrial accident with a blunt metallic object that caused him bruised trauma in the right lumbosacral region is described. After 30 days of this trauma, he noticed increase of volume in the affected area and went to the hernia surgery service of Dr Juan Bruno Zayas Alfonso University General Hospital, where he was clinically diagnosed with a right post-traumatic lumbar hernia. He was operated in an elective way with orotracheal anesthesia. Antimicrobian and antithrombotic prophylaxis was carried out; also, a polypropylene preperitoneal prosthesis was implanted. There were not perioperative complications and the patient had follow up during 3 years, without recurrences

The provisional matrix: setting the stage for tissue repair outcomes.

Since its conceptualization in the 1980s, the provisional matrix has often been characterized as a simple fibrin-containing scaffold for wound healing that supports the nascent blood clot and is functionally distinct from the basement membrane. However subsequent advances have shown that this matrix is far from passive, with distinct compositional differences as the wound matures, and providing an active role for wound remodeling. Here we review the stages of this matrix, provide an update on the state of our understanding of provisional matrix, and present some of the outstanding issues related to the provisional matrix, its components, and their assembly and use in vivo.

[[Durable persistence of a biocompatible foreign body in a vertebral channel in open penetrating trauma of a spinal cord: clinico-experimental and pathomorphological peculiarities].]

Simulation model of open penetrating wound of a spinal cord (SC) with its durable com- pression by biocompatible foreign body, was tasted. Experimental animals - mature male rats (inbred line, descendent from a Wistar breed); the trauma simulation model - a left- sided transsection of the SC half on the Txi level; experimental groups: the main (a SC trau- ma + homotopic implantation of microporous hydrogel fragment - foreign body [n=10]), groups of comparison (the SC trauma [n=16]; the SC trauma + homotopic implantation of chemically identical analogue of hydrogel - NeuroGelTM [n=20]). A SC compression by a foreign body worsens the regeneration process course essentially: during first 2 mo the function index of a hind ipsilateral extremity in experimental animals of the main group was the lowest in the experiment - (1.30 ? 0.94) points in accordance to BBB scale, during 3 - 4 mo - the function index had enhanced trustworthy - up to (2.35 ? 0.95) points in accor- dance to BBB scale, what is connected with lowering of a local pressure on a SC tissue due to change of the foreign body form and volume. In 24 weeks the function index of hind ipsi- lateral extremity had constituted (8.45 ? 0.92) points - while application of NeuroGeTM and (2.35 ? 0.95) points - of the foreign body; the tissue processes in the implants localization zone had differed essentially. The tasted simulation model reproduces satisfactory a mechanical component of the foreign body impact on a SC tissue. The SC compression reduction, even in a late follow-up period, had improved the conditions and results of recenerative process essentially.

Trauma inguinal penetrante com formação de fístula arteriovenosa e pseudoaneurisma: relato de caso / Acquired arteriovenous fistula and pseudoaneurysm secondary to penetrating inguinal trauma: a case report

Os autores apresentam um relato de caso de vítima de acidente de trabalho com ferimento penetrante em região inguinal direita com peça metálica em espiral, que evoluiu com fístula arteriovenosa da artéria femoral profunda com a veia femoral profunda associado a pseudoaneurisma envolvendo essas estruturas e a veia femoral comum. As fístulas arteriovenosas ocorrem frequentemente após traumas e a associação com pseudoaneurisma é fato raro, devendo ser tratadas precocemente após seu diagnóstico. O ultrassom duplex é atualmente o exame mais utilizado para a avaliação inicial e a arteriografia, o padrão ouro para diagnóstico. No paciente em questão foi realizado tratamento convencional com abordagem cirúrgica direta, sutura arterial e ligaduras venosas. Entretanto, nos dias atuais a cirurgia endovascular e a compressão guiada por ultrassom são métodos terapêuticos que têm sido utilizados com sucesso. O paciente evoluiu sem intercorrência, recebendo alta para acompanhamento ambulatorial com preservação do membro.

This article describes the case of a work accident victim with a penetrating wound to the right inguinal region caused by a metal spiral. The patient developed an arteriovenous fistula between the deep femoral artery and deep femoral vein, combined with a pseudoaneurysm surrounding these structures and the common femoral vein. Arteriovenous fistulas frequently occur after traumas, but the combination of fistula and pseudoaneurysm is rare. It is recommended that they be treated immediately after diagnosis. Duplex ultrasound is the most widely used method for initial assessment and arteriography is the gold standard for diagnosis of arteriovenous fistulas. Endovascular surgery has recently been used successfully in such cases. However, this patient was treated conventionally using a direct surgical approach, arterial suture and venous ligatures, and the limb was saved. The patient developed no complications and was discharged to outpatients follow-up.

Cranial injuries secondary to assault with a machete.

BACKGROUND: Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit. MATERIALS AND METHODS: Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover. RESULTS: Of 185 patients treated 172 (93%) were male. Mean age was 31±11.4 years. Mean GCS on admission was 13±2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1-145). The median GOS at discharge was 5 (range 1-5). Twelve patients died within the same admission (6.5%). CONCLUSION: Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration.

Physical training, with especial reference to the training of convalescents.

Lieutenant-Colonel Netterville Barron, MVO RAMC, identified that although there was a moral and practical reason for providing training for convalescents, there lacked the scientific knowledge and structure to deliver it correctly. He should perhaps be considered the pioneer of rehabilitation within the military, with this paper providing the embryonic foundation from which the present DMRP has evolved. There is now very good science to support physical training and the delivery of rehabilitation, which now begins at the earliest time possible in the intensive care unit. From there, a robust structure of rehabilitation supports the patient back to duty or to the point of discharge. What has not altered is the seemingly never-ending debate about the provision of continued support (or lack of) after soldiers are finally discharged. Despite this fact, it is highly likely that Lt. Col Barron would be very satisfied with how far "physical training, with especial reference to the training of convalescent" has progressed.

Herida cardiaca penetrante: presentación de un caso / Penetrating cardiac injure. A case presentation

Las lesiones múltiples en tórax que comprometen área cardíaca resultan infrecuentes y se acompañan de mortalidad elevada. Se presenta un caso de herida penetrante en tórax en adulto joven, causada por arma blanca, con lesión cardíaca y taponamiento cardíaco. La lesión interesó ventrículo izquierdo, diafragma, provocó lesión pulmonar en segmentos basales anteriores y cara diafragmática del pericardio. Dichos daños fueron reparados por toracotomía anterolateral izquierda, miocardiorrafia, frenorrafia, neumorrafia, drenaje pericárdico en sello de agua y doble toracotomía por sonda de Overholt. El paciente mostró una buena evolución, con estadía hospitalaria de 11 días. La actuación rápida y efectiva, tanto en el traslado como en las conductas médicas aplicadas en cada momento, contribuyeron a su evolución y recuperación favorable(AU)

The multiple thorax lesions that compromise the cardiac area are infrequent and they present an elevated mortality. It was presented a case of a penetrating injure caused by a weapon with a cardiac lesion and tamponade. The lesion affected the left ventricle and the diaphragm and provoked a pulmonary injure in the anterior basal segments and the diaphragmatic side of the pericardium. Those injures were repaired by anterolateral left thoracotomy, myocardiography, phrenorraphy, pneumorraphy, pericardiac drainage in water seal, and double thoracotomy in Overholt probe. The patient showed a good evolution with hospital stay of 11 days. The fast and effective performance in the transportation as well as in the medical decisions applied every moment, contributed to the evolution and favourable recovery(EU)

Epithelial stem cells and implications for wound repair.

Activation of epithelial stem cells and efficient recruitment of their proliferating progeny plays a critical role in cutaneous wound healing. The reepithelialized wound epidermis has a mosaic composition consisting of progeny that can be traced back both to epidermal and several types of hair follicle stem cells. The contribution of hair follicle stem cells to wound epidermis is particularly intriguing as it involves lineage identity change from follicular to epidermal. Studies from our laboratory show that hair follicle-fated bulge stem cells commit only transient amplifying epidermal progeny that participate in the initial wound re-epithelialization, but eventually are outcompeted by other epidermal clones and largely disappear after a few months. Conversely, recently described stem cell populations residing in the isthmus portion of hair follicle contribute long-lasting progeny toward wound epidermis and, arguably, give rise to new interfollicular epidermal stem cells. The role of epithelial stem cells during wound healing is not limited to regenerating stratified epidermis. By studying regenerative response in large cutaneous wounds, our laboratory uncovered that epithelial cells in the center of the wound can acquire greater morphogenetic plasticity and, together with the underlying wound dermis, can engage in an embryonic-like process of hair follicle neogenesis. Future studies should uncover the cellular and signaling basis of this remarkable adult wound regeneration phenomenon.

Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice.

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in a growing number of seriously injured soldiers who are evacuated to the United States for comprehensive medical care. Trauma-related pain is an almost universal problem among these war-injured soldiers, and several military and Department of Veterans Affairs initiatives have been implemented to enhance pain care across the continuum of medical services. This article describes several innovative approaches for improving the pain care provided to OEF and OIF military personnel during acute stabilization, transport, medical-surgical treatment, and rehabilitation and presents summary data characterizing the soldiers, pain management services provided, and associated outcomes. We also identify some of the pain assessment, classification, and treatment challenges emerging from work with this population and provide recommendations for future research and practice priorities.

Do trauma centers improve functional outcomes: a national trauma databank analysis?

BACKGROUND: The development of a tiered trauma care system has lead to improved survival for the critically injured. The question as to whether the increased survival associated with the establishment of tiered levels of trauma care is paralleled by an improved functional outcome has not, however, been addressed. METHODS: Multivariate logistic regression analysis of the National Trauma Data Bank from 1994 to 2001 was performed with functional independence measure (FIM) as the primary outcome. Trauma centers were dichotomized as Level II or above versus Level III or below. Blunt and penetrating trauma patients were analyzed separately. Other covariates included age, gender, shock, comorbidities, alcohol, drugs, as well as head, chest, abdominal, spine, and lower extremity injury. Confidence intervals were set at an alpha of 0.05. RESULTS: A total of 474,024 patients were analyzed. Among minimally injured penetrating trauma patients, those receiving care at a higher tiered center had a higher likelihood of total independence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0, 2.0). Among minimal, moderate and severely injured blunt trauma patients those receiving care at a higher tiered center had a higher likelihood of total independence (OR = 1.2, 95% CI = 1.0, 1.4, OR = 1.3, 95% CI = 1.1, 1.6, OR = 1.3, 95% CI = 1.3, 1.5, respectively). CONCLUSIONS: These data indicate that the complex care delivered by advanced level trauma centers is associated with improved functional outcomes. Further investigations to identify the reasons for differences in these outcomes are necessary to improve care at lower tiered hospitals particularly for minimally injured patients.

Heridas penetrantes cardíacas / Penetrating wound of the heart

a) The greater number of cases of hearts wounds due to stabs belong in first place to Turkey and secondly to Chile b) We present two cases in which heart operations were realized with good results in our hospital. The operated cases are in good health and working c) In our country the most frequent cases of wounds caused by steel weapons, affected the right ventriculed) Traumatized people like these, will fall like fulminated, or faint with the sensation of fear, showing alarmingly the symptoms of shock and hemorrhage e) Opportunity of transport and the immediate operation are as important as the operation itself Pleural Complications regulary accompany nearly all cases

[Primary implantation of posterior chamber lenses after traumatic cataract peneration]. / Primäre Hinterkammerlinsenimplantation nach penetrierender Hornhautverletzung mit traumatischer Katarakt.

PURPOSE: To analyze the postoperative outcome and complication rate after phacoemulsification, lens aspiration or lensectomy with primary intraocular lens (IOL) implantation after traumatic cataract penetration. METHODS: We retrospectively reviewed the data of 15 patients who were admitted to our hospital from 1997 to 2001 because of traumatic cataract with corneal laceration with and without intraocular foreign body (IOFB). In all patients phacoemulsification, lens aspiration or lensectomy and primary IOL implantation were performed. Removal of IOFB was performed in 6 patients. RESULTS: The mean follow-up was 19.6 months, 8 eyes (53%) achieved a final visual acuity of 20/40 or better and 12 eyes achieved 20/100 or better final visual acuity. One patient (final visual acuity=1/40) had an additional macular pathology. Due to irregular astigmatism two patients achieved a final vision of less than 20/100. Major causes of limited visual acuity were central corneal scars and in one patient a photopic maculopathy. Four eyes (25%) developed secondary cataract and underwent YAG laser capsulotomy. In one patient PVR retinal detachment had to be treated by pars-plana vitrectomy with silicone oil tamponade. CONCLUSIONS: Primary implantation of posterior chamber lenses after penetrating ocular trauma is associated with a favourable visual outcome and a low rate of postoperative complications.