[Role of anatomic and physiologic trauma scoring systems in forensic cases]. / Adli olgularda anatomik ve fizyolojik travma skorlama sistemlerinin rolü

BACKGROUND: The Turkish Penalty Law has recently been changed. The novel law asks the practitioner to report if there is any 'Situation Placing a Life in Danger '. Herein, we evaluate the anatomic (ISS, TRISS) and physiologic (RTS) trauma scores assessing mortality. METHODS: Study data were obtained from a retrospective chart screening of cases who were accepted to the emergency department in GATA Faculty of Medicine in 2007 and from archived forensic reports. Demographic features and the time period of admittance were recorded. Trauma scores were calculated. All parameters were evaluated with the reported condition of "life threat" and mortality. RESULTS: Forensic reports were completed for 373 patients and 6.16% of them were noted as being in a life-threatening condition. Mortality rate was 1.34%. A significant rate of trauma patients suffered from firearm injury and stab wounds (p<0.001). There was no statistical difference between ISS, TRISS and RTS with respect to predictive value of a 'life-threatening condition' (Area under curve [AUC] in the receiver operating characteristic [ROC] curve analysis: ISS: 0.968, TRISS: 0.922, RTS: 0.196). There was also no statistical difference between ISS, TRISS and RTS scores regarding mortality prediction (AUC in the ROC analysis: ISS: 0.992, TRISS: 0.0995, RTS: 0.005). CONCLUSION: We assume that there is no difference between physiologic and anatomic scoring systems to predict mortality for deciding a life-threatening condition.

Urban paediatric trauma due to stab wounds: an Israeli hospital experience.

OBJECTIVE: To assess the incidence and types of stab wounds to hospitalized children and adolescents. SUBJECTS: The sample consisted of patients, age 6-18 years, who were admitted to our hospital with sustained injury between 1991 and 2007. RESULTS: In total, 83 patients were admitted as a result of penetrating (n = 51) and superficial (n = 32) injuries. Eighty-two were hospitalized, and one was declared dead upon arrival. Only 11 patients were hospitalized during the 1991-2000 period, and 71 during the 2001-2007 period. Ten patients were admitted to the intensive care unit (ICU); 23 patients were operated (hospital mortality = 0). Evacuation time (time from injury to hospital) was 10 min (mean time; maximum 35 min). CONCLUSION: This study found higher rates of hospitalization compared with those over a decade ago. These rates reflect not only changes in hospitalization trends and/or population growth in the hospital area but also an increase of urban violence. Israeli hospitalization system deals with paediatric trauma effectively, being well trained because of permanent terrorist activity.

[The anaesthetist's liability and bullfights]. / Responsabilité de l'anesthésiste et corrida.

Whether you are an aficionado or completely uninitiated, everyone has an opinion on bull-fighting. The bull-fighter is in constant risk of injury. A medical team made up of surgeons, anesthetists, emergency physicians and nurses remains present throughout the show. For the anaesthetist and surgeon, a wounded bullfighter is an emergency because the vital and functional prognosis are engaged. The team must act in conformity with normal practice and the Code of Medical Ethics because any lack of coordination between the practitioners is punishable by law in the same way as technical fault. Several specific aspects of this type of medical procedure should be highlighted: firstly, the legal restrictions within the corrida, and secondly, the nature of the medical team, which may be comprised of doctors normally based within a public health institution and others who practice in a private health establishment. The particularity of the situation reveals differences in the system of liability, and civil liability must be distinguished from administrative liability: both of these allow the victim to obtain compensation for harm caused, but the consequences of each are different according to doctor status. The fact that the anaesthetists frequently work on a voluntary and benevolent basis does not exonerate them from liability. Lastly, a question frequently addressed is whether or not the doctor is covered by his professional insurance when he is on ringside duty.

Triage and outcome of patients with mediastinal penetrating trauma.

BACKGROUND: A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT). METHODS: Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera. RESULTS: Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries. CONCLUSIONS: In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.

[Treatment of cardiac stab wounds. A thirty-one-year experience]. / Tratamentul plagilor cardiace înjunghiate. O experienta de 31 ani.

Penetrating cardiac wounds represent a dramatically pathology of the general surgery because of their clinical presentation and outcome. The cardiorrhaphy with the three successive times, carried out with maximum rapidity is the only safe and efficient surgical technique which leads to hemostasis and healing. The aim of this study was to evaluate our results and experience of penetrating cardiac injuries treated at the Clinic of Surgical Emergencies from Iasi. 20 patients, 17 men and 3 women, of mean age 34 years (range 18-51), with stab wounds, underwent cardiorrhaphy between 1974 and 2004. The clinical aspects were: "white injured" (hemorrhagic shock) in 3 patients, "blue injured" (cardiac tamponade) in 8 patients, both being implied with some patients, one of the aspects being predominant. 9 patients (45%) had only cardiac injuries and 11 (55%) had other associated injuries. There were 7 intraoperative cardiac arrests and 2 postoperative pulmonary complications. In 16 cases the outcome of patients with cardiac stab wounds was favourable. We recorded 4 deaths. Mortality results from the wounds of the right auricle. The high rate of survival (80%) proves that a penetrating cardiac injury with a heavy prognosis may be turned into a relative traumatism harmless for those patients who will remain alive until they arrive in hospital.

Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale.

PURPOSE: Ureteral injuries are uncommon and challenging. In this study we report our institutional experience with ureteral injuries. We evaluated the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for ureteral injuries as a predictor of outcomes for complexity of repair, morbidity, mortality and associated injuries. MATERIALS AND METHODS: We performed a retrospective, 120-month study (January 1992 to December 2002) at an urban, level I trauma center. RESULTS: In the 57 patients mean hospital Admission blood pressure +/- SD was 115 +/- 25 mm Hg, mean Revised Trauma Score was 7.38 +/- 0.84 and mean Injury Severity Score was 15 +/- 1.15. The mechanism of injury was penetrating in 55 cases (96.5%), including gunshot wound in 52 (54.5%) and stab wound in 2 (5.5%), and in blunt 2 of motor vehicle accidents (3.5%). The anatomical location was the left side in 33 cases (58%), right side in 23 (40%) and bilateral in 1 (2%). The distribution of injuries was proximal in 15 cases (26%), mid in 21 (37%) and distal in 21 (37%). Associated injuries were present in 56 patients (98%). An intraoperative diagnosis was made in 44 cases (77%). Of the patients 50 (88%) required complex repairs or an adjunct procedure, including a double pigtail stent in 33 (58%), ureteroureterostomy in 20 (35%), ureteroneocystostomy with a psoas hitch in 10 (18%), external diversion in 9 (16%), suprapubic cystostomy in 8 (14%), nephrostomy in 2 (3.5%), nephrectomy in 2 (3.5%) and ligation in 2 (3.5%). Injury grade was I to V in 5 (8%), 8 (13%), 13 (22.8%), 18 (31.6%) and 13 (22.8%) cases, respectively. Overall 51 patients (89%) survived. No deaths were related to ureteral injury. Renal salvage was achieved in 49 of the 51 surviving patients (96%). CONCLUSIONS: Ureteral injuries are uncommon. The complexity of repair and number of associated injuries increase with AAST-OIS injury grade. Mortality increases with AAST-OIS injury grade but it is not related to the ureteral injury. Excellent results can be achieved with complex techniques of primary repair, leading to renal salvage.

Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center.

PURPOSE: Patients with penetrating trauma often have multiorgan involvement that may complicate the management of any single organ system. Here we review the incidence of associated injuries in patients with penetrating renal trauma and our extended experience treating these patients at a busy inner city trauma center. MATERIALS AND METHODS: All trauma cases presenting to Temple University Trauma Center during a 6-year period were identified through our institutional databases and were reviewed (5,276). Penetrating trauma represented 41% of all cases (2,163). Of these we identified 123 patients with penetrating renal trauma (5.7%). A total of 93 cases were available for review. Multiorgan injury was staged in the operating room if patients were hemodynamically unstable or radiographically if they were stable. Renal injuries were staged by high dose, single shot excretory urogram in patients taken immediately to surgery or by computerized tomography if stable. Renal injuries were classified using the American Association for Surgery of Trauma (AAST) grading system. AAST classifications were subcategorized for purposes of streamlining. Grade 1 and 2 injuries were grouped as low grade, grades 3 and 4 nonvascular injuries were grouped as intermediate grade, and AAST grade 4 vascular and grade 5 injuries were grouped as high grade. Demographic, clinical and intraoperative variables, as well as number and severity of associated injuries, were then assessed to determine the relationship with various renal surgical outcomes including the requirement of surgical intervention, type of surgical intervention, need for nephrectomy and associated adverse outcomes. RESULTS: The median age of injured patients was 28 years (range 14 to 80). The majority of victims were male (93%). The mechanism of injury was predominantly gunshot wound (GSW, 86%) while 14% were due to stab wounds. Renal injuries were low grade (19%), intermediate grade (44%) and high grade (37%). Nearly all patients with penetrating renal injury had associated multiorgan injury (94.6%). Associated injuries for penetrating renal trauma on the right side predominately involved the liver, small bowel and vertebra while injury to the left kidney was most often associated with trauma to the stomach, colon and spleen. Patients suffered extensive renal injury as evidenced by the high rate of intraoperative urinomas (30.1%) and hematomas (97.5%) identified. In the absence of an expanding hematoma and/or hemodynamic instability, associated injuries by themselves did not increase the risk of nephrectomy. Despite multiorgan penetrating injury 54% of kidneys were salvageable. CONCLUSIONS: Isolated penetrating trauma to the kidney is rare. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding hematoma with hemodynamic instability, associated multiorgan injuries did not increase the risk of nephrectomy. With appropriate radiographic and/or surgical staging, it is possible to repair and salvage many of these kidneys despite extensive associated intraabdominal trauma.

[Successful management of abdominal stab wounds with clinical evaluation: experiences of an South-African trauma unit with 496 consecutive patients]. / Erfolgreiches selektives Management abdomineller Stichverletzungen durch klinische Evaluation Erfahrungen einer südafrikanischen Trauma-Unit mit 496 konsekutiven Patienten.

BACKGROUND: Up to 80% of all operations performed in South African trauma units are due to penetrating injuries. This study will evaluate our own clinical guidelines for the management of penetrating abdominal injuries. METHODS: Absolute indication for operation in patients with penetrating abdominal injuries have been: haemodynamic instability, evisceration of bowels or organs, peritonitis, free air under the diaphragm on plain abdominal x-rays, the evidence of fresh blood on rectal examination or in the stomach. No ultrasonography or CT scanning has been performed. RESULTS: 496 patients were included in this study. In 248 (50%) patients an operation has been performed. 50 (20%) of them were initially selected for abdominal observation. In 230 (93%) patients, peritoneal penetration was diagnosed during laparotomy. In 18 (7%) patients the laparotomy was negative and in 24 (10%) non-therapeutic.6 (2%) patients died. Specifically 93.2% (CI 90.2-96.2%), positive prediction 92.7% (89.5%-95.7%). CONCLUSION: The clinical evaluation of patients with abdominal stab wounds is a safe method to detect possible fatal injuries in hospitals without unlimited access to ultrasonography and CT scanning. 80% of all patients with a selective conservative approach needed no operation.

Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study.

OBJECTIVE: The purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries. METHODS: All patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient's surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck. RESULTS: During a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry. CONCLUSION: Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.

Immunohistochemical detection of fibronectin and tenascin in incised human skin injuries.

Immunohistochemical detection of molecules involved in inflammatory reaction can be useful for the diagnosis of vitality in skin wounds. We studied the expression of fibronectin (FN) and tenascin (TN) in 58 human skin wounds (48 vital and 10 postmortem). The age of vital injuries ranged from 3 min to 8 h and postmortem specimens were collected after a postinfliction interval of 15-180 min. One hundred thirty-seven formalin-fixed paraffin-embedded sections (mean: 2.3 sections per case) were stained with each of two monoclonal antibodies against FN and TN using the streptABC technique. A reticular staining for FN in wound edge and dermis was observed in 50% of vital specimens versus 0% in postmortem cases. Immunoreactivity was reduced in 10 autolysed cases. FN positivity exclusively at the injury margin was observed in 39.4% of vital wounds and 10% of postmortem cases. TN was negative in all specimens. Vital and postmortem hemorrhage areas showed positivity for FN and TN. Due to its low sensitivity, immunohistochemical analysis of FN is useful for determining vitality only in a minority of cases. Different factors in everyday practice, including autolysis and technical problems often produce false negative reactions with the result that FN cannot be regarded as a reliable parameter of vitality. Positive reactions (network staining) are more valuable than negativity but are not pathognomonic. Both vital and postmortem hemorrhages show an enhanced positivity for FN and TN, thus impeding the diagnosis.

The prognostic importance of trauma scoring systems for morbidity in children with penetrating abdominal wounds: 17 years of experience.

BACKGROUND/PURPOSE: Risk factors that may independently predict morbidity in children with penetrating abdominal wounds (PAW) have not been elucidated fully. The aim of this study was to identify not only correlated risk factors for morbidity in children with PAW, but also to evaluate the independent predictive value of 3 different trauma scoring systems: the Injury Severity Score (ISS), the Penetrating Abdominal Trauma Index (PATI), and the Pediatric Trauma Score (PTS). METHODS: Between January 1983 and November 2000, 119 children (99 boys, 20 girls) presenting with PAW were reevaluated by an analysis of the relationship between overall morbidity and potential risk factors. RESULTS: Wounds were caused by firearm trauma in 85 children and stabbing in 34. Univariate analysis found that age greater than 10 years, trauma mechanism, number of intraabdominal organs injured (NOI) greater than 2, presence of penetrating injury, and ISS and PATI score were associated with greater than 3-fold increased incidence of morbidity (P <.05). The relative risk of a postoperative septic complication was higher than 2 for the following risk factors: age greater than 10 years, shotgun injury, number of organs injured greater than 2, presence of colon injury, ISS greater than 15, and PATI score greater than 15. Multivariate analysis showed that only ISS (P =.02), and PATI score (P =.03) were independently significant in predicting morbidity. CONCLUSION: ISS and PATI score were the most important indicators found to be independently associated with morbidity.

[Practical application of the Injury Severity Score (ISS) in expert forensic testimony]. / Zur praktischen Anwendung des Injury Severity Scores (ISS) in der forensischen Begutachtung.

The retrospective analysis of the autopsy records of 50 homicides showed that the Injury Severity Score (ISS), a numerical scoring system initially developed to quantify the severity of injuries sustained in road traffic accidents, can also be useful for objectively describing and ranking the overall severity of trauma with regard to forensic issues. The present case report illustrates to what extent the ISS can help to assess the contribution of each assailant in homicides committed by several perpetrators. In the case presented the court was convinced that one perpetrator had inflicted four deep stab wounds to the victim's face (each with bony lesions), 2 stabs to the chest piercing the right lower pulmonary lobe and causing a haemothorax of 200 ml, an abdominal stab wound without involvement of a parenchymatous organ as well as multiple defence wounds of the arms. Thereafter, a second perpetrator was thought to have inflicted several heavy blows with a full water bottle causing severe contusions on the right side of the forehead, the chin, the left side of the face and a spider's web fracture of the frontal bone. Using the ISS an injury severity score of 24 was assigned to the first complex of injuries and a score of 10 to the second complex. The forensic conclusions with regard to prognosis and lethal outcome are discussed.

Stab wounds to the gluteal region: a management strategy.

OBJECTIVE: To examine the utility of a protocol for treating stab wounds to the gluteal region. These are uncommon and potentially lethal, and the location of injury influences the rate and severity of associated injuries. This was a retrospective, uncontrolled study. METHODS: Patients who sustained gluteal stab wounds and were treated according to our predetermined protocol that classifies injuries as upper or lower zone were reviewed, and associated injuries and outcome were measured. RESULTS: Of 27 gluteal stab wounds in 17 patients, 53% were classified as upper zone and 47% as lower zone injuries. Sixty-six percent of the upper zone injuries had associated neurologic, vascular, or visceral injuries that required invasive procedures or surgery, compared with 12.5% for lower zone injuries (p < 0.05). CONCLUSION: Upper zone gluteal stab wounds require prompt multisystem evaluation with mandatory angiography and aggressive management. Lower zone wounds need observation and repeated evaluations.

Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classification.

A comparative study of 174 homicidal and 105 suicidal sharp force deaths in the Stockholm area is presented in order to identify variables of importance in the differentiation between homicides and suicides. In homicides, a significantly (p < 0.05) higher number of cut and stab wounds were seen in the head, upper and lower extremities and a significantly higher number of vertical stab wounds were found in the chest. Lower numbers were seen in the wrist and the crook of the arm. When counting the injured areas, irrespective of the number of injuries, abdominal wounds and horizontal chest stab wounds were also significantly more often found in victims of homicide. Injuries to the back and to the genitals were not seen in suicides. The suicide victims were significantly older and had significantly lower blood alcohol levels. A new variable pointing at a statistically significant difference between homicides and suicides was found: In homicides, stab wounds with a horizontal axis of entrance wound in the chest was found to be less common than those with a vertical axis. Other variables studied were prevalence of defence and tentative wounds, farewell notes and suicidal ideation, earlier parasuicides, venue, gender of the victims and the types of sharp objects used.

Penetrating neck trauma: lack of universal reporting guidelines.

Penetrating neck injuries constitute a heterogeneous group. Two different classifications of zones of the neck exist in trauma literature. Injuries crossing the midline are not accurately reported. Records of 50 patients with stab wounds (30), gunshot wounds (GSWs; 17), and shotgun wounds (SGWs; 3) were reviewed. Injuries involved zone I in 8 patients, zone II in 37 patients, zone III in 8 patients, posterior triangle in 6 patients, and multiple zones in 5 patients. All 11 patients with transcervical GSWs and SGWs sustained vascular or aerodigestive injuries and had longer hospital stays (14.0 +/- 2.6 days) compared with patients with other GSWs (6.6 +/- 2.0 days) and stab wounds (3.6 +/- 0.5 days). We emphasize the lethal potential of transcervical GSWs and SGWs. We suggest that these particular injuries be reported separately. We recommend the universal adoption of one system of classification of neck zones.

Penetrating cardiac injuries: a prospective study of variables predicting outcomes.

BACKGROUND: Penetrating cardiac injuries are one of the leading causes of death from urban violence. STUDY DESIGN: This is a prospective, 1-year study in a Level I Trauma Center with the objective of analyzing: (1) the parameters measuring the physiologic condition of patients sustaining penetrating cardiac injuries in the field during transport and on arrival, (2) the cardiovascular-respiratory score (CVRS) component of the trauma score, (3) the mechanism and anatomic site of injury, (4) the presence or absence of tamponade, and (5) the cardiac rhythm as a predictor of outcomes. We attempted to correlate cardiac injury grade (AAST-OIS) with mortality. Our main intervention was thoracotomy for resuscitation and definitive repair of cardiac injury. Main outcomes measures were all parameters measuring the physiologic condition of patients, CVRS, mechanism and anatomic site of injury, operative findings and maneuvers, mortality, and grade of injury. RESULTS: The study consisted of 60 patients sustaining penetrating cardiac injuries, 35 gunshot wound (58%) and 25 stab wounds (42%). The injury severity score (ISS) was > 30 in 22 patients; overall survival was 22 of 60 (36.6%); gunshot wound (GSW) survival, 5 of 35 (14%); and stab wound (SW) survival, 17 of 25 (68%). An emergency department thoracotomy was performed in 37 of 60 (61.7%) with 6 of 37 survivors (16%). CVRS: 96% mortality (25 of 26) when CVRS = 0; 67% mortality (6 of 9) when CVRS = 1-3; and 25% mortality (7 of 25) when CVRS > 4 (p < 0.001). Mechanism of injury, and presence of sinus rhythm when pericardium opened predict outcomes (p < 0.001). Anatomic site of injury and tamponade do not predict outcomes (not significant). AAST-OIS injury grade and mortality: grade IV, 31 of 60 (52%); grade V, 20 of 60 (75%), and grade VI, 6 of 60 (100%). CONCLUSIONS: Parameters measuring physiologic condition, CVRS, and mechanism of injury plus initial rhythm are significant predictors of outcomes in penetrating cardiac injuries. The need for aortic crossclamping and the inability to restore an organized rhythm or blood pressure after thoracotomy were also predictors of outcomes. The presence of pericardial tamponade was not.

Multiple chop wounds in Hong Kong. An epidemiological study of an unusual injury.

Knife injuries can be classified into stabbing injuries and multiple laceration or multiple chops, the latter being much more common in Chinese communities. It is the mark of criminal gang attacks with their tendency to use long knives and choppers rather than guns. The intention is often to wound rather than kill. A survey of 89 cases revealed that 90% of the victims are men, with a mean age of 27 years; 75% was admitted to the hospital at night, and in 78% of the cases the assailants were persons unknown, or so we were told by the victims. The reasons for the attacks were also not given. Most of the women victims were assaulted by their spouse. Some 74% of the patients suffered three to six lacerations; 62% of the injuries were on the extensor surfaces of the upper limbs, while the hand and the back of the trunk were also common sites. The type of management differs from that for stabbing injuries. There were no fatalities, and less than half of the patients required blood transfusion. The average hospital stay was 6.2 days. The morbidity of these injuries involves damaged tendons and nerves.