Degloved foot sole successfully reconstructed with split thickness skin grafts.

INTRODUCTION: The current opinion is that split thickness skin grafts are not suitable to reconstruct a degloved foot sole. The tissue is too fragile to carry full bodyweight; and therefore, stress lesions frequently occur. The treatment of choice is the reuse of the avulsed skin whenever possible, or else the use of a full thickness fascio-cutaneus flap. PRESENTATION OF THE CASE: A young male sustained a crush injury to his right foot with deglovement of the plantar surface and part of the dorsum. DISCUSSION: Split thickness skin grafts are not suitable for full weight bearing, but in special circumstances, certain patients, a lot of time and patience, early mobilization and gradual increasing partial weight bearing it is worthwhile to try. To toughen the foot sole pressure distribution is necessary and can be reached in several ways, soft and springy materials of the inlay, but also socks, orthopedic shoes, casting, orthotics or walking aids. CONCLUSION: This case-report illustrates that the reconstruction of a degloved foot sole with split-thickness skin grafts can be successful; a silicon inner sole was used to prevent stress lesions.

Trends in moderate to severe paediatric trauma in Central Netherlands.

INTRODUCTION: Trend analyses of hospital discharge data can raise signals for prevention policies, but are often flawed by changes in health care consumption. This is a trend analysis of the clinical incidence of paediatric trauma that used international criteria to overcome this bias. The objective is to describe trends in clinical incidence of moderate to severe paediatric trauma, and to identify target groups for prevention activities. PATIENTS AND METHODS: Included were all paediatric trauma patients (0-18 years) that were discharged from the hospitals of trauma care region Central Netherlands from 1996 to 2009. Selection was made on ISS ≥ 4, and on trauma related International Classification of Diseases diagnostic codes, and trauma related external causes of injury and poisoning codes. Trend analyses were performed using Poisson loglinear regression with correction for age and gender. RESULTS: 23,682 Patients were included, the mean incidence rate was 477/100,000 person-years. Since 2001 the incidence rate of moderate to severe trauma increased with 1.1% annually (95% confidence interval (CI) 0.7-1.5), caused by an increase of falls (3.9%, 95% CI 3.3-4.5), sport injuries (5.4%, 95% CI 4.3-6.5), and bicycle injuries (3.8%, 95% CI 2.8-4.8). The incidence of falls and sport injuries peaked in young children (0-9) and older boys (10-18) respectively. Bicycle injuries affected all children between 5 and 18. CONCLUSIONS: The incidence of paediatric trauma in the centre of the Netherlands increased since 2001. Trend analyses on moderate and severe injuries may identify target groups for prevention in a trauma region.

The effects of regionalization of pediatric trauma care in the Netherlands: a surveillance-based before-after study.

BACKGROUND: System changes in pediatric trauma care may reduce childhood injury mortality. The Dutch system of trauma care has been regionalized in 1999/2000. We evaluated changes in referral behavior and in-hospital mortality before and after regionalization of trauma care in the Netherlands. METHODS: A surveillance-based before-after study was performed on all children aged up to 18 years that were discharged from one of the hospitals of the trauma care region "Central Netherlands" between 1996 and 1998 and between 2001 and 2006. The in-hospital mortality rate and referral behavior was compared before (1996-1998) and after (2001-2006) regionalization of trauma care in the Netherlands. RESULTS: A total of 21,585 children were included, with a mean (SD) age of 9.6 (5.5) years and a mean (SD) Injury Severity Score (ISS) of 4.3 (4.4). After regionalization, the mean ISS was lower (p = 0.000), and the mean length of stay was lower (p = 0.000). The in-hospital mortality rate was significantly lower for the adolescent group (age, 13-18 years; n = 7,846; standardized mortality ratio, 0.64; 95% confidence interval, 0.34-0.93) after correction for the ISS. No changes were found for the younger children (age, 0-12 years; n = 13,739). No significant differences were found in referral behavior for both age categories. CONCLUSION: Regionalization of trauma care in the Netherlands reduced the in-hospital mortality rates for adolescents in the last decade. However, this reduction was not caused by a change in referral behavior. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Long-term health condition in major pediatric trauma: a pilot study.

PURPOSE: Major trauma is the leading cause of death in children of developed countries. However, little is known about its long-term health consequences in survivors. Our aim was to describe the health condition in children at long-term after major trauma. METHODS: Prospective cohort study of severely injured children (Injury Severity Score > or =16, age <16) admitted to a Dutch level I trauma center in 1999 to 2000 (N = 40). About 7 years after trauma (median, 7.3; range, 6.3-8.2 years), survivors' health condition was assessed with the following: guides to the evaluation of permanent impairment of the American Medical Association (AMA-guides), Glasgow Outcome Scales (GOS/GOSE), Vineland Adaptive Behavior Scales (VABS), Child Behavior Checklist (CBCL), and Strengths and Difficulties Questionnaire (SDQ). RESULTS: Of 40 children, 28 were followed up. Most (n = 16; 57%) had no impairments (AMA guides); minor to severe impairments were found in 12 of the respondents. About 80% (n = 22) had good recovery (GOS 5 and GOSE 7/8); the remaining had moderately disability (GOS 4 or GOSE 5/6). The mean scores on the VABS and the frequency of behavioral problems on the CBCL (24%) and the SDQ (20%) were comparable to healthy peers. CONCLUSIONS: This long-term follow-up study after major trauma revealed that most children had a health condition comparable to healthy peers; about 40% of the respondents was physically impaired or restricted in daily activities. Our experiences with different measures may be helpful to apply age-appropriate outcome measures for the clinical follow-up of children after major trauma and to design future longitudinal studies.

Long-Term Health-Related Quality of Life in Major Pediatric Trauma: A Pilot Study.

BACKGROUND: Major trauma is the leading cause of mortality and morbidity in children of developed countries. Little research has been done about the health-related quality of life (HRQL) in these children. The aim of the current research is to describe the HRQL of children in the long term after major trauma and to compare it with healthy peers. METHODS: A prospective cohort study of severely injured children (ISS ≥ 16, age < 16 years) who survived the trauma and were admitted to the emergency department of a Dutch level 1 trauma center in 1999 and 2000 (n = 40) was conducted. Between 6 and 8 years after trauma (mean 7.3, SD 0.7 years), outcome was assessed by the Pediatric Quality of Life Inventory (PedsQL 4.0), the EuroQol 5D (EQ-5D), and the EuroQol Visual Analogue Scale (EQ-VAS). RESULTS: The mean age at the time of the accident was 8.9 years (SD 4.6 years), the mean ISS was 24.9 (SD 11.1), and 25 (63%) cases were male; 28 out of 40 patients were followed up. The mean score on the PedsQL was 81.2 and this did not differ significantly from the norm value. On the EQ-5D, more health problems were reported than in a healthy reference population. The mean EQ-VAS score was 79.4 and was significantly lower than in healthy peers. The lowest scores on the PedsQL and the EQ-VAS were seen in teenagers and in respondents with spinal cord and/or severe cerebral injury. CONCLUSION: The results on HRQL in children in the long term after major trauma are inconclusive. Special attention should be given to teenagers with spinal cord or severe cerebral injury who reported the lowest HRQL.

Health-related quality-of-life measures for long-term follow-up in children after major trauma.

OBJECTIVE: Our objective was to review measures of health-related quality of life (HRQL) for long-term follow up in children after major trauma and to determine the measures that are suitable for a large age range, reliable and valid, and cover a substantial amount of the domains of functioning using the International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization (WHO). METHODS: The Medline and EMBASE databases were searched in all years up to October 2007 for generic HRQL measures suitable for children aged 5-18 years old and validated in English or Dutch. Measures were reviewed with respect to the age range for which the measure was suitable and reliability, validity, and content related to the ICF. RESULTS: The search resulted in 1,235 hits and 21 related articles. Seventy-nine papers met the inclusion criteria, describing in total 14 measures: Child Health and Illness Profile Adolescent and Child Edition (CHIP-AE/CE), Child Health Questionnaire Child and Parent Forms (CHQ-CF87/PF50/PF28), DISABKIDS, Functional Status II (FS II)(R), Health Utilities Index Mark 2 (HUI 2), KIDSCREEN 52/27, KINDL, Pediatric Quality of Life Inventory (PedsQL), TNO Institute of Prevention and Health and the Leiden University Hospital (TNO-AZL), TNO-AZL Children's Quality Of Life (TACQOL), and Youth Quality of Life Instrument--Research Version (YQOL-R). Measures that were suitable for a large age range were CHQ-PF50/PF28, DISABKIDS, FS II(R), HUI 2, KIDSCREEN, PedsQL, and TACQOL. All measures had moderate to good psychometric properties, except for CHQ-PF50/PF28, KINDL, and TACQOL, which had either low internal consistency or bad test-retest reliability. The measures that covered more than six chapters of the ICF domains were CHIP-AE/CE, CHQ-CF87/PF50, DISABKIDS, KIDSCREEN-52, PedsQL, and TACQOL. CONCLUSIONS: DISABKIDS, KIDSCREEN 52, and PedsQL are suitable for long-term follow-up measurement of HRQL in children after major trauma. They cover a large age range, have good psychometric properties, and cover the ICF substantially.