Alpine ski and snowboarding traumatic injuries: incidence, injury patterns, and risk factors for 10 years.

BACKGROUND: Alpine skiing and snowboarding are popular winter sports in Canada. Every year participation in these activities results in traumatic injury. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with ski and snowboarding injuries. METHODS: A comprehensive 10-year retrospective review of Alpine ski and snowboarding injuries from 1996 to 2006 was conducted. The Alberta Trauma Registry was used as the primary source of data. RESULTS: A total of 196 patients (56.6% skiers, 43.4% snowboarders) were identified as having major traumatic injuries (Injury Severity Score, >or=12). Forty-three patients required intensive care unit support. The majority of injuries were related to falls and collisions with natural objects. Head injuries were most common, followed by chest, spinal, and extremity trauma. Seventy-nine patients required emergency surgery. CONCLUSIONS: Skiing and snowboarding represent activities with high potential for traumatic injury. Safety initiatives should be developed to target this population.

Ten years of major equestrian injury: are we addressing functional outcomes?

BACKGROUND: Horseback riding is considered more dangerous than motorcycle riding, skiing, automobile racing, football and rugby. The integral role of rehabilitation therapy in the recovery of patients who have sustained a major horse-related injury is previously not described. The goals of this paper were to (1) define the incidence and pattern of severe equestrian trauma, (2) identify the current level of in-patient rehabilitation services, (3) describe functional outcomes for patients, and (4) discuss methods for increasing rehabilitation therapy in this unique population. METHODS AND RESULTS: A retrospective review of the trauma registry at a level 1 center (1995-2005) was completed in conjunction with a patient survey outlining formal in-hospital therapy. Forty-nine percent of patients underwent in-patient rehabilitation therapy. Injuries predictive of receiving therapy included musculoskeletal and spinal cord trauma. Previous injury while horseback riding was predictive of not receiving therapy. The majority (55%) of respondents had chronic physical difficulties following their accident. CONCLUSION: Rehabilitation therapy is significantly underutilized following severe equestrian trauma. Increased therapy services should target patients with brain, neck and skull injuries. Improvements in the initial provision, and follow-up of rehabilitation therapy could enhance functional outcomes in the treatment resistant Western equestrian population.

Chest tube complications: how well are we training our residents?

BACKGROUND: Thoracic trauma is commonly treated with tube thoracostomy. The overall complication rate associated with this procedure is up to 30% among all operators. The primary purpose of this study was to define the incidence and risk factors for complications in chest tubes placed exclusively by resident physicians. The secondary objective was to outline the rate of complications occult to postinsertional supine anteroposterior (AP) chest radiographs (CXRs). METHODS: Over a 12-month period at a regional trauma centre, we retrospectively reviewed all severely injured trauma patients (injury severity score >or= 12) who underwent tube thoracostomy (338/761 patients). Insertional, positional and infective complications were identified. Patients were assessed for complications on the basis of resident operator characteristics, patient demographics, associated injuries and outcomes. Thoracoabdominal CT scans and corresponding CXRs were also used to determine the rate of complications occult to postinsertional supine AP CXR. RESULTS: Of the patients, 338 (44%) had CXR and CT imaging. Out of 76 (22%) chest tubes placed by residents in 61 (18%) patients (99% of whom had blunt trauma injuries), there were 17 complications; 6 (35%) were insertional; 9 (53%) were positional and 2 (12%) were infective. Tube placement outside the trauma bay (p = 0.04) and nonsurgical resident operators (p = 0.03) were independently predictive of complications. The rates of complications according to training discipline were as follows: 7% general surgery, 13% internal and family medicine, 25% other surgical disciplines and 40% emergency medicine. Resident seniority, time of day and other factors were not predictive. Six of 11 (55%) positional and intraparenchymal lung tube placements were occult to postinsertional supine AP CXR. CONCLUSIONS: Chest tubes placed by resident physicians are commonly associated with complications that are not identified by postinsertional AP CXR. Thoracic CT is the only way to reliably identify this morbidity. The differential rate of complications according to resident specialty suggests that residents in non-general surgical training programs may benefit from more structured instruction and closer supervision in tube thoracostomy.

Equestrian injuries: incidence, injury patterns, and risk factors for 10 years of major traumatic injuries.

BACKGROUND: Horseback riding is more dangerous than motorcycle riding, skiing, football, and rugby. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with severe equestrian trauma. METHODS: All patients with major equestrian injuries (injury severity score > or = 12) admitted between 1995 and 2005 were reviewed. A 46-question survey outlining potential rider, animal, and environmental risk factors was administered. RESULTS: Among 7941 trauma patients, 151 (2%) were injured on horseback (mean injury severity score, 20; mortality rate, 7%). Injuries included the chest (54%), head (48%), abdomen (22%), and extremities (17%). Forty-five percent required surgery. Survey results (55%) indicated that riders and horses were well trained, with a 47% recidivism rate. Only 9% of patients wore helmets, however, 64% believed the accident was preventable. CONCLUSIONS: Chest trauma previously has been underappreciated. This injury pattern may be a result of significant rider experience. Helmet and vest use will be targeted in future injury prevention strategies.

Traumatic Injury of the Superior Mesenteric Vein: Ligate, Repair or Shunt?

We report a case of SMV injury in a critically ill patient. The patient was a 19-year-old woman involved in a motor vehicle collision. Her injuries included grade II splenic and renal lacerations, devascularized and lacerated right and transverse colon, a transected transverse mesocolon, a massive shear injury of her abdominal wall, and two partial SMV transections. At initial damage control laparotomy, the SMV was ligated, the devascularized bowel resected and a temporary abdominal closure applied. At re-operation, a mesocaval shunt using saphenous vein was employed. The shunt failed and the patient required a saphenous vein jump graft. Although visceral vascular injuries are rare, ligation of the SMV in a damage control situation is acceptable. This case study is the first to discuss appropriate treatment when interruption to a patient's collateral visceral venous drainage limits the surgeon's ability to ligate. In these situations, bypass shunts may be successful.

The impact of multiple casualty incidents on clinical outcomes.

BACKGROUND: Multiple casualty incidents (MCI) highlight discrepancies between patient needs and available resources. It is generally thought that heavy patient loads adversely affect trauma health care delivery. The purpose of this study was to identify the impact of multiple casualty situations on the clinical outcomes of injured patients. METHODS: All severely injured trauma patients (Injury Severity Score [ISS] > or = 12) who presented during a 12-month period to a regional trauma center were retrospectively reviewed. MCIs were defined as treating and admitting three or more trauma patients within a maximum of 3 hours. This cohort was compared with all other patients who did not meet MCI criteria. RESULTS: Ten percent (88/861) of all trauma patients were treated in an MCI setting. Groups did not vary among sex, age, ISS, or mechanism of injury (p > 0.05). MCI patients displayed a greater length of hospital stay, time to first surgical procedure, time to emergency laparotomy, and time spent in the emergency room (p < 0.05). MCI and non-MCI patients did not differ in ICU length of stay, postadmission morbidity, or mortality (p > 0.05). CONCLUSION: The impact of a MCI on the quality of trauma care has not been previously defined. MCI events delay definitive care and prolong a patient's length of stay. This is particularly concerning in the emergency department where a trauma center's ability to treat MCI patients effectively via an increased surge capacity relies on swift patient triage and flow. We are now investigating these issues in other trauma centers.

Minimal postoperative pain using properitoneal nontension sutured repair of direct inguinal hernias.

BACKGROUND: Numerous repairs exist for direct inguinal hernias. These repairs are limited by the shortcomings of their respective technique. Reported recurrence rates for all currently employed hernia repairs for direct inguinal hernias range from 1% to 10%. With recurrence rates for nontension mesh repairs <2%, the evaluation of postoperative outcomes has shifted instead to that of pain and return to normal activities. METHODS: We describe a novel inexpensive technique that employs the placement of conventional properitoneal tension-free mesh for repair of direct inguinal hernia. This technique, performed as day surgery with the patient under local anaesthetic, offers the beneficial aspects of contemporary mesh repair while avoiding its limitations. RESULTS: Three-year independent follow-up of 52 patients undergoing this repair demonstrated 1 (1.9%) early failure. Postoperative pain was measured using a visual analog pain scale (0 to 10) at 2 months (mean +/- SD; 1.39 +/- .58), 1 year (.37 +/- .27), 3 years (.58 +/- .40), at work (.59 +/- .33), and with recreational activity (.73 +/- .40). More than one third of patients had returned to work 1 week after surgery (37.8%) with 62.2% returning by 2 weeks and 100% by 6 weeks. Most significantly, 90.9% of patients had resumed full recreational activities by 8 weeks. CONCLUSIONS: In addition to providing minimal recurrence, these results of our technique demonstrate that this it provides less postoperative pain than has been reported in other nontension types of repair. Furthermore, use of this procedure results in earlier return to work and full recreational activities, thus it has significant social and economic implications.