Management of hemorrhage in severe pelvic injuries.

BACKGROUND: Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. METHODS: In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. RESULTS: Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. CONCLUSION: Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Alternaria alternata soft tissue infection in a forearm transplant recipient.

BACKGROUND: Composite tissue allograft recipients require intensive immunosuppression and are therefore at risk of infections. Filamentous fungal infections are among the complications most difficult to manage in organ transplant recipients. METHODS: Case report and literature review. CASE REPORT: Two years after bilateral forearm transplantation, a 35-year-old patient presented with a tumor-like lesion on his thigh after a penetrating injury caused by a sliver acquired during hiking. The lesion was excised completely, and microscopic examination revealed a filamentous fungal infection. Alternaria alternata was identified as the causative agent. Induction therapy with liposomal amphotericin B for one week followed by oral itraconazole maintenance therapy for eight weeks was successful, with no signs of recurrence or side effects at 18 months' follow-up. CONCLUSION: This is the first reported case of invasive A. alternata infection in a composite tissue allograft recipient. The infection was managed successfully with local excision and systemic antifungal treatment.

Mineralization density and apparent density in mandibular condyle bone.

OBJECTIVES: This study evaluated a method for determining the density and distribution of bone of mandibular condyles using proprietary computerized tomography (CT) software. STUDY DESIGN: Thirty-eight condylar specimens were investigated with a high-resolution multislice CT. The density was determined by using bone density analysis algorithms available within the proprietary software. Apparent density was estimated over the total cross-sectional area, the total trabecular bone area apart from the cortical fraction, and on individually selected points. Color-coded pictures were created to demonstrate density differences. RESULTS: The cortical bone presented significantly higher densities than the trabecular bone. The anterior cortical bone had significantly higher densities than the posterior. The central anterior cortical and the central trabecular areas showed significantly higher densities than the medial and lateral areas. CONCLUSION: This technique proved to be a valuable method for determination of the differences in density in the mandibular condyle. It shows potential in providing clinicians with an imaging modality for specific clinical use.

Complete hepatic ischemia due to torsion of a large accessory liver lobe: first case to require transplantation.

Anatomical abnormalities of the liver are extremely rare. Although the majority of cases with an accessory liver are not detected, it can give rise to various clinical symptoms like recurrent abdominal pain and impaired liver function. Here we present the first case of orthotopic liver transplantation in a patient with hepatic ischemia caused by complete vascular occlusion due to a twisted accessory liver lobe. Although rare, an accessory liver lobe may cause serious and life-threatening problems and should therefore be kept in mind in patients presenting with acute abdominal pain.