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1.
Medicine (Baltimore) ; 99(28): e20935, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664091

RESUMO

During ganglion impar block, the needle may approach the presacral space and the sacrum may be penetrated during caudal anesthesia. Because the rectum is in front of the sacrococcyx and is thus at risk for puncture, it is important to determine the distance between the sacrococcyx and rectum, as well as the thickness of the sacrococcyx.Computed tomography was used to measure the distance between the rectum and sacrococcyx, as well as the thickness of the sacrococcyx. The distances between the coccyx and rectum, sacrococcygeal joint and rectum, sacral level 5 ('sacrum 5') and rectum, and 'sacrum 4 to 5 junction' and rectum were measured. The results were compared based on the presence or absence of stools in the rectum. The thickness of the sacrococcyx was measured at the sacrum 4 to 5 junction and sacrococcygeal joint.In total, 1264 patients were included in this study. All distances were less than 1 mm in both males and females, with the exception of the distance between the coccyx and rectum in males. In both males and females, there was no significant difference in distance between the sacrococcyx and rectum according to the presence or absence of feces in the rectum, but there was a difference in the distance between sacrum 5 and the rectum in males (P = .048). Several male and female patients showed thicknesses of less than 5 mm at the sacrococcygeal joint.Some patients have a distance of less than 1 mm between the sacrum and rectum. Practitioners should exercise caution when applying a needle to the presacral space. If the sacrum is accidentally penetrated during caudal block, rectum puncture cannot be ruled out. Excretion of feces does not influence the distance between the sacrococcyx and rectum in females.


Assuntos
Anestesia Caudal/instrumentação , Cóccix/anatomia & histologia , Agulhas , Reto/anatomia & histologia , Reto/lesões , Sacro/anatomia & histologia , Ferimentos Penetrantes/etiologia , Ferimentos Penetrantes/prevenção & controle , Adulto , Idoso , Pesos e Medidas Corporais , Cóccix/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Sacro/diagnóstico por imagem , Tomografia Computadorizada por Raios X
5.
J Trauma Acute Care Surg ; 88(5): 696-703, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32068717

RESUMO

INTRODUCTION: The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. METHODS: The US and UK combat trauma registries were scrutinized for patients with penetrating neck injury (PNI) at deployed coalition MTF between March 2003 and October 2011. A multivariate mixed effects logistic regression model (threshold, p < 0.05) was used stratified by MTF location and year of injury. The dependent variable was fatality on leaving Role 3, and the independent variables were ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon. RESULTS: A total of 3,357 (4.9%) of 67,586 patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2,186 (83%) were PNIs and the remainder were blunt injuries. When service members killed in action were included, the incidence of neck injury rose from 4.9% to 10%. Seven hundred nine (32%) of 2,186 patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230 (41%) of 555 underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64 (28%) of 228 of patients. Fatality status was positively associated with ISS on arrival (odds ratio, 1.05; 95% confidence interval, 1.04-1.06; p < 0.001) and the casualty being a local national (odds ratio, 1.74; 95% confidence interval, 1.28-2.38; p < 0.001). CONCLUSION: Significant differences in the treatment and survival of casualties with PNI were identified between nations in this study; this may reflect differing cervical protection, management protocols, and surgical capability and is worthy of further study. In an era of increasing specialization within surgery, neck exploration remains a skill that must be retained by military surgeons deploying to Role 2 and Role 3 MTF. LEVEL OF EVIDENCE: Retrospective cohort study, level III.


Assuntos
Medicina Militar/métodos , Lesões do Pescoço/terapia , Lesões Relacionadas à Guerra/terapia , Ferimentos Penetrantes/terapia , Adolescente , Adulto , Campanha Afegã de 2001- , Afeganistão/epidemiologia , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Iraque/epidemiologia , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Medicina Militar/estatística & dados numéricos , Lesões do Pescoço/etiologia , Lesões do Pescoço/mortalidade , Sistema de Registros/estatística & dados numéricos , Análise de Sobrevida , Reino Unido/epidemiologia , Estados Unidos/epidemiologia , Lesões Relacionadas à Guerra/etiologia , Lesões Relacionadas à Guerra/mortalidade , Guerra/estatística & dados numéricos , Ferimentos Penetrantes/etiologia , Ferimentos Penetrantes/mortalidade , Adulto Jovem
6.
Wilderness Environ Med ; 31(1): 78-81, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31983600

RESUMO

Stingrays are found in open waters and are also kept in exhibits in many aquariums throughout the world. They are generally nonaggressive creatures by nature, but they can inflict injuries with their spines if provoked. We present a case of a 62-y-old diver who was pierced in the chest by the barb of a stingray while transferring the animal to another tank as part of his work in a public aquarium. He was rescued immediately from the tank but was found to be in cardiac arrest. Bystander cardiopulmonary resuscitation was promptly initiated by his colleagues. He was rapidly evacuated to the nearest emergency department, where he was noted to be in pulseless electrical activity. A single puncture wound was noted over the right second intercostal space, with the spine of the stingray still impaled in the chest. Trauma surgeons were activated promptly, and resuscitation was continued based on advanced cardiac and trauma life support guidelines, which included ongoing cardiopulmonary resuscitation, securing the airway, and emergency blood transfusion. An emergency department thoracotomy was performed, but despite aggressive resuscitation the thoracic injury was fatal. An autopsy revealed transection of the aorta by an impaled barb. We present a review of stingray injuries and suggest a general approach to management.


Assuntos
Aorta/lesões , Mordeduras e Picadas/complicações , Elasmobrânquios , Traumatismos Ocupacionais/complicações , Traumatismos Torácicos/complicações , Ferimentos Penetrantes/complicações , Animais , Animais de Zoológico , Mordeduras e Picadas/etiologia , Evolução Fatal , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismos Ocupacionais/etiologia , Traumatismos Torácicos/etiologia , Ferimentos Penetrantes/etiologia
7.
BMJ Case Rep ; 12(11)2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31772131

RESUMO

Penetrating ocular injuries from writing instruments that are thrown, especially by children, in the community can result in significant ocular morbidity. Often these cases present to the accident and emergency department. Accurate and prompt assessment is key in saving sight. We present a case of one such injury and how it was surgically managed.


Assuntos
Corpos Estranhos no Olho/cirurgia , Ferimentos Oculares Penetrantes/diagnóstico por imagem , Vitrectomia/métodos , Ferimentos Penetrantes/etiologia , Adolescente , Ferimentos Oculares Penetrantes/patologia , Ferimentos Oculares Penetrantes/cirurgia , Humanos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Acuidade Visual/fisiologia , Ferimentos Penetrantes/diagnóstico
8.
Undersea Hyperb Med ; 46(5): 719-722, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31683373

RESUMO

Introduction: Stingray spine injuries are among the most common marine animal injuries in humans. While most resolve with immersion in warm water, a few become infected and require antibiotics. We present a case report of a presumptive stingray injury that evolved to a major slough and which required prolonged healing in a patient with diabetes mellitus. Our literature review was unable to find a similarly reported case. Materials: A co-author was asked to evaluate and manage an ominous-appearing wound on the right foot of a diabetic. The problem developed after the individual had been wading in shallow ocean beach water. The patient's diabetic sensory neuropathy obscured the immediate association of the problem with a stingray injury, but this became the presumptive diagnosis when pain developed and necessitated that he seek medical care. Findings/Clinical Course: After an initial urgent care visit, increasing pain and worsening appearance of the patient's foot necessitated a visit to our emergency department. The patient was admitted the next day due to symptoms of systemic sepsis. On the fourth hospital day, a large bulla on the lateral side of the right foot was excised. This unroofed a full-thickness slough to the periosteum level of the underlying bones. Not until the 16th hospital day had enough improvement occurred to discharge the patient. Over the next 16 weeks, the wound improved, developed a vascular base and epithelialized. Conclusion: With a dearth of literature about stingray injuries in patients with diabetes mellitus reported, our case is unique: The patient's wound course more closely resembled a toxic inoculation than the typical puncture wound-cellulitis presentations associated with stingray injuries.


Assuntos
Mordeduras e Picadas/complicações , Traumatismos do Pé/terapia , Rajidae , Ferimentos Penetrantes/terapia , Adulto , Animais , Antibacterianos/uso terapêutico , Mordeduras e Picadas/terapia , Vesícula/etiologia , Vesícula/terapia , Complicações do Diabetes/terapia , Diabetes Mellitus , Traumatismos do Pé/etiologia , Humanos , Masculino , Necrose , Infecções Estreptocócicas/diagnóstico , Infecções Estreptocócicas/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Cicatrização , Ferimentos Penetrantes/etiologia
9.
Am Surg ; 85(10): 1142-1145, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657311

RESUMO

The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC+USC (January 2008-July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (<1%), 54,826 patients were enrolled. The median age was 35 [IQR 23-53]. The median Injury Severity Score was 4 [1-10]. The most common mechanisms of injury were falls (n = 14,166; 31%), auto versus pedestrian collisions (n = 11,921; 26%), and motor vehicle collisions (n = 11,024; 24%). Penetrating trauma comprised 16 per cent (n = 8,686). The busiest hour for TTAs was 19:00 to 20:00, although penetrating trauma was most common between 23:00 and 01:00. Emergent surgical intervention in absolute numbers was most frequent between 20:00 and 01:00. As a proportion of the number of TTAs per hour, emergent operative intervention was most frequent between 23:00 and 06:00. In conclusion, the volume of TTAs and the triggering mechanism of injury vary significantly by time of day. The need for operative intervention is highest overnight. This information can be used to help increase hospital preparedness and allocate resources accordingly.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/etiologia , Ferimentos Penetrantes/etiologia , Escala Resumida de Ferimentos , Adulto , California/epidemiologia , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Triagem , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto Jovem
11.
Adv Skin Wound Care ; 32(9): 1-5, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31403477

RESUMO

OBJECTIVE: To test the hypothesis that platelet-rich plasma (PRP) improves wound healing in rabbits by analyzing morphologic alterations in lesions with the use of PRP alone or combined with rosuvastatin (RSV). METHODS: Eight adult male New Zealand rabbits were used in this study. Researchers created four wounds on the back of each rabbit with an 8-mm punch. The control wound was treated with a 0.9% sodium chloride solution. Experimental wounds were treated with PRP, RSV, or both PRP and RSV. Dressings were changed with a new application of PRP and RSV every 4 days for 16 days. Wounds were biopsied on days 0, 7, 10, 14, and 17 for histopathologic evaluation of the scar tissue. MAIN RESULTS: Histopathology revealed reepithelialization in 100% of wounds treated with PRP alone after 17 days of treatment, compared with 50% of wounds treated with RSV alone and 75% of the wounds treated with PRP and RSV. Further, combining RSV and PRP reduced blood loss. The use of PRP alone induced 100% neovascularization, compared with 50% and 62.5% in wounds treated with PRP and RSV and RSV alone, respectively. All experimental wounds had a higher percentage of collagen fibers on day 17 postlesion when compared with control wounds (78.27% ± 4.69%). There were no significant differences among treatments; however, wounds treated with RSV alone had the lowest amount of collagen fibers (85.98% ± 3.51%). Wounds treated with PRP alone or PRP and RSV had 90.07% ± 6.20% and 90.76% ± 3.51% collagen fibers, respectively. CONCLUSIONS: The results of this study indicate that PRP elicits higher healing activity in the first 7 days postlesion. Treatments with RSV alone or RSV and PRP did enhance other healing phases.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Plasma Rico em Plaquetas , Rosuvastatina Cálcica/uso terapêutico , Úlcera Cutânea/terapia , Ferimentos Penetrantes/terapia , Animais , Modelos Animais de Doenças , Masculino , Coelhos , Úlcera Cutânea/etiologia , Úlcera Cutânea/patologia , Fatores de Tempo , Cicatrização , Ferimentos Penetrantes/etiologia , Ferimentos Penetrantes/patologia
12.
Orthopedics ; 42(5): e410-e414, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31408523

RESUMO

Nail gun injuries are common among users, and most frequently involve the hands and lower extremities. A wide variation in costs and time are missed from work due to these injuries, and training on the proper use of nail guns has been shown to decrease workplace-related injuries. Minimal long-term disability can be expected, and orthopedic evaluations provide an opportunity to inform patients on proper use of these devices. In this article, management of nail gun injuries is discussed, including the necessity for a high suspicion for wound contamination because foreign material is often deposited with the nail, as well as treatment with debridement and antibiotics. [Orthopedics. 2019; 42(5):e410-e414.].


Assuntos
Indústria da Construção , Traumatismos da Mão/terapia , Traumatismos Ocupacionais/terapia , Ortopedia , Ferimentos Penetrantes/terapia , Acidentes de Trabalho , Traumatismos da Mão/etiologia , Humanos , Masculino , Traumatismos Ocupacionais/etiologia , Ferimentos Penetrantes/etiologia
13.
S Afr J Surg ; 57(3): 59, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31392871

RESUMO

SUMMARY: A significant number of otorhinolaryngological emergency visits are caused by foreign bodies, and occasionally they can result in life-threatening injury. This report highlights the value of neck CT in the evaluation of suspected radiolucent foreign bodies penetrating the neck from the oral cavity. This guided the surgical approach to remove the foreign body safely without complication.


Assuntos
Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/cirurgia , Lesões do Pescoço/cirurgia , Ferimentos Penetrantes/cirurgia , Criança , Corpos Estranhos/complicações , Humanos , Boca , Lesões do Pescoço/etiologia , Tomografia Computadorizada por Raios X , Ferimentos Penetrantes/etiologia
14.
Ulus Travma Acil Cerrahi Derg ; 25(4): 417-423, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31297784

RESUMO

Steel rod impalements, mostly experienced by construction workers due to falls from heights, are known entities, but only some individuals unfortunately suffer spinal cord injury. The management of the spine involved injuries is challenging due to the lack of guidelines, various clinical presentations resulting from different trajectories, and high risk of infection. We report a case of steel rod impalement involving the spinal canal and review the literature to enhance the management strategies and to identify the risk factors for possible complications, particularly infection. A 37-year-old male construction worker presented to our emergency department due to falling onto a concrete reinforcing steel rod that penetrated through his perineum to the L4 vertebra. Examination revealed paralysis and sensory loss of the left foot. The rod was removed in the operating room (closed removal) under general anesthesia, followed by laparotomy. Rectal laceration was primarily repaired, and colostomy was performed. In a separate session, laminectomy was performed. At 3 months post-discharge, the patient was ambulatory with armrest based on the same motor examination performed on presentation This case is a good example of careful preoperative planning, multidisciplinary involvement, and appropriately sequenced interventions resulting in an acceptable outcome for an injury with high morbidity and mortality and demonstrates the feasibility and potential benefits of closed removal of the rod in an operating room just before laparotomy. The presence of an intestinal perforation increases the infection risk, but infections can still be prevented in this setting. Shorter time intervals between the incidence and surgery may reduce the infection rate.


Assuntos
Acidentes por Quedas , Vértebras Lombares/lesões , Traumatismos da Medula Espinal/etiologia , Traumatismos da Coluna Vertebral/etiologia , Ferimentos Penetrantes/etiologia , Adulto , Colonografia Tomográfica Computadorizada , Colostomia , Humanos , Lacerações , Vértebras Lombares/diagnóstico por imagem , Imagem por Ressonância Magnética , Masculino , Períneo/lesões , Fatores de Risco , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/diagnóstico por imagem , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Aço , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/cirurgia
15.
Medicine (Baltimore) ; 98(22): e15750, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31145290

RESUMO

RATIONALE: Penetrating neck traumas are dangerous and have a high mortality rate, particularly in patients with common carotid artery injuries. Advances in diagnostic imaging technology have shifted management of penetrating neck injuries from mandatory exploration to selective management. The question is now regarding optimal selection of auxiliary examinations to assess "stability" rapidly and guide clinics in managing such patients. PATIENT CONCERNS: A 56-year-old man suffered neck trauma with the right common carotid artery caused by a percussive drill. The carotid artery could not be clearly displayed in computed tomography (CT) angiography imaging. DIAGNOSES: Penetrating neck trauma due to percussive drill bit with common carotid artery injury. INTERVENTIONS: X-ray and bedside duplex ultrasound with color Doppler flow imaging were used to assess the state of trauma and the foreign body was removed under general anesthesia. OUTCOMES: The patient was discharged at postoperative day 10 with no complication. The patient had no sequelae from this injury at 6-month follow up. LESSONS: X-ray provides a comprehensive assessment of damage, and can efficiently detect foreign bodies in the skull and cervical vertebrae. Duplex ultrasound to be a viable method to exclude macrovascular injury in unstable patients who are not eligible for computed tomography angiography (CTA) or catheter angiography imaging. Widely available duplex ultrasound and x-ray should be considered in emergency situations.


Assuntos
Lesões das Artérias Carótidas/cirurgia , Artéria Carótida Primitiva/cirurgia , Corpos Estranhos/cirurgia , Lesões do Pescoço/cirurgia , Ferimentos Penetrantes/cirurgia , Lesões das Artérias Carótidas/etiologia , Indústria da Construção/instrumentação , Corpos Estranhos/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Lesões do Pescoço/etiologia , Ferimentos Penetrantes/etiologia
16.
BMC Infect Dis ; 19(1): 472, 2019 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-31138139

RESUMO

BACKGROUND: Bicycle-spoke injuries rarely cause late complications of infection, including sepsis and sepsis-associated encephalopathy, with appropriate treatments. CASE PRESENTATION: We experienced a 2-year-old girl who developed the signs of encephalopathy with fever 6 months after a spoke-injury. On admission, the injured skin was inflamed with cellulitis. The blood culture was positive for methicillin-sensitive Staphylococcus aureus. Electroencephalogram showed diffuse slow-wave activity. Diffusion-weighted magnetic resonance imaging detected a high-intensity lesion with decreased diffusivity at the right frontal cortex. She received immunoglobulin and combined antibiotics treatments in the intensive care unit, and successfully overcame the sepsis-associated encephalopathy without neurological impairments. CONCLUSION: This is the first report demonstrating that sepsis and its associated encephalopathy occurs in a remote period after the bicycle-spoke injury.


Assuntos
Bacteriemia/etiologia , Ciclismo/lesões , Encefalopatias/etiologia , Infecções Estafilocócicas/etiologia , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Encefalopatias/diagnóstico por imagem , Pré-Escolar , Eletroencefalografia , Feminino , Febre/tratamento farmacológico , Humanos , Imagem por Ressonância Magnética , Infecções Estafilocócicas/tratamento farmacológico , Ferimentos Penetrantes/etiologia
18.
Ir Med J ; 112(2): 875, 2019 02 14.
Artigo em Inglês | MEDLINE | ID: mdl-30892853

RESUMO

Aim To highlight the dangers of hurling helmet modification. Methods A case report highlighting the consequences of modifying a hurling helmet from factory settings. Results Photographic evidence of a penetrating injury from helmet modification. Conclusion Rule changes to allow referees to inspect helmets before games take place.


Assuntos
Traumatismos em Atletas/etiologia , Traumatismos dos Dedos/etiologia , Dispositivos de Proteção da Cabeça/efeitos adversos , Lesões dos Tecidos Moles/etiologia , Ferimentos Penetrantes/etiologia , Traumatismos em Atletas/patologia , Traumatismos em Atletas/cirurgia , Traumatismos dos Dedos/patologia , Traumatismos dos Dedos/cirurgia , Humanos , Masculino , Lesões dos Tecidos Moles/patologia , Lesões dos Tecidos Moles/cirurgia , Resultado do Tratamento , Ferimentos Penetrantes/patologia , Ferimentos Penetrantes/cirurgia , Adulto Jovem
19.
Eur Ann Otorhinolaryngol Head Neck Dis ; 136(5): 393-395, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30878510

RESUMO

INTRODUCTION: Penetrating craniofacial injuries caused by stick-like foreign bodies occur as a result of accidents particularly in children, and often lead to significant morbidity. CASE SUMMARY: We describe a 5-year-old boy who sustained facial trauma after falling on a wooden stick which penetrated his left cheek. At the initial visit, his vital and neurological signs were normal. However, the stick had penetrated the frontal lobe to a depth of 3cm via the orbital cavity and the anterior skull base. The stick was successfully removed while visualizing the anterior skull base in an endoscopic transethmoidal approach. A follow-up examination one year after the accident demonstrated normal visual acuity and ocular motility, with no diplopia, tearing or pain. DISCUSSION: Penetrating facial injuries caused by stick-like objects carry a significantly higher risk of serious neurological involvement. Even if penetrating facial injuries sometimes appear trivial, the external injury site is often insufficient to determine the position of the object within the head. Although the cheek is a rare entry site for intracranial injuries, the extent of damage should be assessed fully before attempting removal.


Assuntos
Bochecha/lesões , Corpos Estranhos/complicações , Lobo Frontal/lesões , Ferimentos Penetrantes/complicações , Bochecha/cirurgia , Pré-Escolar , Endoscopia , Seio Etmoidal/diagnóstico por imagem , Seio Etmoidal/lesões , Seio Etmoidal/cirurgia , Corpos Estranhos/cirurgia , Lobo Frontal/diagnóstico por imagem , Lobo Frontal/cirurgia , Humanos , Imageamento Tridimensional , Masculino , Órbita/diagnóstico por imagem , Órbita/lesões , Órbita/cirurgia , Tomografia Computadorizada por Raios X , Ferimentos Penetrantes/etiologia , Ferimentos Penetrantes/cirurgia
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