RESUMEN
A 7 yr old castrated male domestic shorthair presented for assessment of a chronic left head tilt, losses of balance, and positional nystagmus. A computed tomographic scan of the head revealed several fragments of a metallic foreign body in the left tympanic cavity. The foreign material was removed under endoscopic assistance through a minimally invasive ventral bulla osteotomy. No complications were noted during the immediate postoperative period. Follow-up 5 mo after surgery revealed complete resolution of the neurological signs with no evidence of recurrence. Foreign bodies associated with middle ear infection have not been previously reported in the cat. They should now be included in the differential diagnosis of vestibular disease. Endoscopic-assisted foreign body removal in the middle ear seems to be a safe and efficient way to retrieve small foreign bodies in bullae in cats.
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Enfermedades de los Gatos , Cuerpos Extraños , Osteotomía , Animales , Masculino , Gatos , Cuerpos Extraños/veterinaria , Cuerpos Extraños/cirugía , Osteotomía/veterinaria , Osteotomía/métodos , Enfermedades de los Gatos/cirugía , Heridas por Arma de Fuego/veterinaria , Heridas por Arma de Fuego/cirugía , Cirugía Asistida por Video/veterinaria , Oído Medio/cirugíaRESUMEN
BACKGROUND AND OBJECTIVES: Patients with intracranial gunshot wounds (IC-GSWs) often present with severe neurological injuries requiring prompt neurological evaluation. Neurosurgical intervention is reserved for those with reasonable chances of survival. Handguns and long guns, such as shotguns and rifles, have differing mechanisms of injury which may influence surgical candidacy and outcomes. This study aims to compare rates and types of neurosurgical intervention and inpatient outcomes in patients with IC-GSWs handguns and long guns. METHODS: The National Trauma Data Bank was retrospectively queried for patients with IC-GSWs from 2017 to 2019. Patients with long gun IC-GSWs were propensity score matched with those with handgun IC-GSWs based on patient demographics, comorbidities, insurance status, injury extent and severity, and hospital trauma level. Group differences were compared using Student's t-tests and Pearson's χ2 tests, and multivariable logistic regression was used to identify predictors of in-hospital mortality. RESULTS: Overall, patients in the long gun group were more likely to undergo neurosurgical intervention (21% vs 17%, P = .02). Following propensity score matching, the long gun group had lower rates of in-hospital mortality (35% vs 43%, P < .01), lower rates of cardiac arrest (5% vs 8%, P = .02), and lower rates of reoperation (0% vs 2%, P = .02) than the handgun group. In multivariable regression, independent predictors of survival included long gun IC-GSWs (odds ratio [OR] 0.65, CI 0.52-0.83), neurosurgical foreign body removal (OR 0.44, CI 0.33-0.58), intracranial debridement (OR 0.47, 0.33-0.67), and craniectomy (OR 0.46, CI 0.34-0.63). CONCLUSION: Patients with IC-GSWs present to the hospital with severe neurological injury. Neurosurgical intervention was independently associated with decreased mortality. After matching, patients with long gun IC-GSWs experienced lower in-hospital mortality rates compared with those from handguns. This study suggests that patients suffering from long gun IC-GSW may respond particularly well to neurosurgical intervention and firearm type should be considered when determining neurosurgical candidacy.
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Mortalidad Hospitalaria , Procedimientos Neuroquirúrgicos , Puntaje de Propensión , Heridas por Arma de Fuego , Humanos , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/mortalidad , Masculino , Femenino , Adulto , Procedimientos Neuroquirúrgicos/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Armas de Fuego/estadística & datos numéricos , Adulto JovenRESUMEN
CASE: Bean bag projectiles (BBPs) are less lethal munition composed of a cloth bag filled with lead pellets and marking powder housed in a plastic casing fired from a 12-gauge shot gun. Two patients sustained penetrating BBP injuries that resulted in open fractures and retained BBP. Patient clothing and all BBP components were found deep in the wounds with marking powder surrounding fracture edges. Both patients healed without infection. CONCLUSION: Surgical exploration of penetrating BBP injuries is recommended to remove marking powder, fabric, plastic, and potentially other forms of contamination. Fracture stabilization should adhere to existing guidelines pertaining to open contaminated wound conditions.
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Cuerpos Extraños , Fracturas Abiertas , Heridas por Arma de Fuego , Humanos , Cuerpos Extraños/diagnóstico por imagen , Cuerpos Extraños/cirugía , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/complicaciones , Masculino , Fracturas Abiertas/cirugía , Fracturas Abiertas/diagnóstico por imagen , AdultoRESUMEN
BACKGROUND: High-energy casualties such as firearm injuries may result in extensive loss of soft tissue and bone in the lower extremities. Although the primary aim in these types of injuries is the preservation of the extremity, repeated surgical procedures for extremity salvage and subsequent restoration of function could have detrimental effects on the patient both physically and psychologically. The main aim of this study is to evaluate the physical and psychological outcomes of patients who underwent lower extremity amputation in the early period after a firearm injury compared with the results of patients who underwent amputation in the late period. We also evaluated the factors affecting the prognosis in patients undergoing late below-knee amputation (BKA). METHODS: This retrospective study included patients who underwent BKA following a lower extremity injury caused by firearms between March 2016 and March 2022. Patients who underwent emergency BKA at the first center they were taken to immediately after the injury constituted the early amputation (EA) group. Patients who were transferred to our tertiary-level referral center for continuation of treatment after the first intervention at another center and later underwent BKA constituted the late amputation (LA) group. The patients were evaluated regarding age, gender, amputation side, presence of phantom limb pain (PLP), and post-traumatic stress disorder (PTSD). RESULTS: Information was available from hospital records for a total of 35 patients; 16 in the EA group and 19 in the LA group. All patients were male. The mean age at the time of injury was 25.5±5.3 years (range, 20-45 years), and the mean follow-up period was 37±17 months (range, 25-84 months). In the comparison of PLP experienced, the difference between the groups was statistically significant, with PLP experienced by 1 (10%) patient in the EA group and by 9 (90%) in the LA group (p=0.010). PTSD was diagnosed in 3 (23%) patients in the EA group and 10 (77%) patients in the LA group (p=0.039). CONCLUSION: Patients who underwent late BKA were found to be affected by PLP and PTSD at a higher rate. When deciding on extremity-preserving surgery for patients with severe open injuries to the lower extremity, it is crucial to consider the poor outcomes associated with late BKA. Patients should be thoroughly informed about these negative outcomes.
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Amputación Quirúrgica , Heridas por Arma de Fuego , Humanos , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/complicaciones , Masculino , Estudios Retrospectivos , Adulto , Femenino , Estudios de Seguimiento , Persona de Mediana Edad , Traumatismos de la Pierna/cirugía , Extremidad Inferior/lesiones , Extremidad Inferior/cirugía , Factores de Tiempo , Adulto Joven , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to evaluate the longterm outcomes of open tibia fractures treated using the Ilizarov external circular fixation (ECF) technique in the Military Medical Academy. PATIENTS AND METHODS: Between January 1992 and December 2011, a total of 134 male military personnel (median age: 22.5 years; range, 18 to 36 years) with Gustilo-Anderson type 3 open tibia fractures treated with ECF were retrospectively analyzed. All patients underwent multiple surgeries and eventually Ilizarov fixation surgery. The radiological and functional outcomes were evaluated using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, and complications were noted. RESULTS: The median follow-up was 17.7 (range, 10 to 29) years. The median time to union was 4.7 (range, 3 to 8) months. All frames were removed from the limb, when union was observed. No re-fracture, limb length discrepancy more than 2.5 cm, or below-knee amputation after Ilizarov treatment was seen in any patient. Chronic osteomyelitis was observed at in 40% (n=54) of the patients at a median time ranging from 17 to 148 months. The overall ASAMI bone scores were excellent in 40 (30%), good in 20 (15%), fair in 20 (15%), and poor in 54 (40%) patients with osteomyelitis. The ASAMI functional scores were excellent in 40 (30%), good in 40 (30%), and fair in 54 patients (40%). No poor score was observed. Minor pin site infections were observed in 63 patients (47%). CONCLUSION: Our long-term study results showed that all patients returned to their social life and were mobilized without support after treatment with the use of Ilizarov ECF method of open tibia fractures caused by high-energy ballistic injuries. However, complications such as pin tract infections and osteomyelitis after several years must be kept in mind in the treatment of comminuted bone fractures caused by firearms and ballistic missiles injuries.
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Fijadores Externos , Técnica de Ilizarov , Personal Militar , Fracturas de la Tibia , Heridas por Arma de Fuego , Humanos , Masculino , Fracturas de la Tibia/cirugía , Adulto , Adolescente , Estudios Retrospectivos , Adulto Joven , Técnica de Ilizarov/instrumentación , Heridas por Arma de Fuego/cirugía , Resultado del Tratamiento , Fracturas Abiertas/cirugía , Factores de Tiempo , Curación de Fractura , Estudios de SeguimientoRESUMEN
CASE: A 25-year-old right-hand dominant male police officer presented to the emergency department with a gunshot wound to his left shoulder. Magnetic resonance imaging demonstrated an osteochondral defect overlying the humeral head along the mid to lower aspect of the glenohumeral joint. A staged operation with shoulder arthroscopy followed by an osteochondral allograft (OCA) of the humeral head was performed. During his 6-month postoperative visit, he had returned to full work duty with no restrictions and reported that his pain was well controlled. CONCLUSION: Humeral head OCA transplantation may be an effective treatment option for traumatic osteochondral lesions of the glenohumeral joint.
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Heridas por Arma de Fuego , Humanos , Masculino , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/diagnóstico por imagen , Adulto , Cabeza Humeral/cirugía , Cabeza Humeral/diagnóstico por imagen , Aloinjertos , Trasplante Óseo/métodos , Artroscopía , Lesiones del Hombro , Imagen por Resonancia Magnética , Articulación del Hombro/cirugía , Articulación del Hombro/diagnóstico por imagenRESUMEN
PURPOSE: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management. METHODS: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated. RESULTS: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews. CONCLUSIONS: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes. LEVEL OF EVIDENCE: Level III, Diagnostic Study.
Asunto(s)
Tomografía Computarizada por Rayos X , Humanos , Estudios Retrospectivos , Masculino , Adulto , Femenino , Tomografía Computarizada por Rayos X/métodos , Persona de Mediana Edad , Reproducibilidad de los Resultados , Traumatismos de la Rodilla/diagnóstico por imagen , Traumatismos de la Rodilla/clasificación , Traumatismos de la Rodilla/cirugía , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/cirugía , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/clasificación , Heridas por Arma de Fuego/cirugía , Adulto Joven , Anciano , Adolescente , Lesiones del Hombro/diagnóstico por imagen , Fracturas Intraarticulares/clasificación , Fracturas Intraarticulares/diagnóstico por imagen , Fracturas Intraarticulares/cirugíaRESUMEN
The current state of the literature for a bullet embolization to the heart and/or pulmonary vasculature indicates the occurrence is rare but could increase due to the rise in civilian low-kinetic-energy firearm acquisition and use. We present the case of an older teenage male who sustained a gunshot wound to the left flank. The bullet entered the iliac vein, travelled through the heart and lodged in the pulmonary artery. Successful relocation of the bullet to the internal iliac vein was performed by the interventional radiologist. This article highlights the advancement of interventional radiology as a successful non-invasive endovascular technique for bullet embolus removal.
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Procedimientos Endovasculares , Migración de Cuerpo Extraño , Arteria Pulmonar , Heridas por Arma de Fuego , Humanos , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/cirugía , Masculino , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/lesiones , Arteria Pulmonar/cirugía , Resultado del Tratamiento , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Migración de Cuerpo Extraño/cirugía , Migración de Cuerpo Extraño/terapia , Procedimientos Endovasculares/instrumentación , Adolescente , Radiografía Intervencional , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/lesiones , Vena Ilíaca/cirugía , Angiografía por Tomografía Computarizada , Embolia Pulmonar/etiología , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/cirugía , Embolia Pulmonar/terapiaRESUMEN
INTRODUCTION: Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality. RESEARCH QUESTION: There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients. METHODS AND MATERIALS: An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness. RESULTS: The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up. CONCLUSION: Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects.
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Pérdida de Líquido Cefalorraquídeo , Heridas por Arma de Fuego , Humanos , Masculino , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/complicaciones , Niño , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Paresia/etiología , Paresia/cirugía , Extremidad Superior/cirugía , Extremidad Superior/lesiones , Traumatismos del Cuello/cirugía , Traumatismos del Cuello/complicacionesRESUMEN
The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions.
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Traumatismos Abdominales , Laparoscopía , Traumatismos Torácicos , Cirugía Torácica Asistida por Video , Heridas por Arma de Fuego , Humanos , Heridas por Arma de Fuego/cirugía , Ucrania , Masculino , Adulto , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/diagnóstico , Cirugía Torácica Asistida por Video/métodos , Laparoscopía/métodos , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/diagnóstico , Hospitales Militares , Adulto Joven , Resultado del Tratamiento , Estudios Retrospectivos , Laparotomía/métodosRESUMEN
BACKGROUND CONTEXT: Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE: To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING: A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE: Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES: Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS: Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS: A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS: Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.
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Traumatismos Vertebrales , Heridas por Arma de Fuego , Humanos , Masculino , Femenino , Adulto , Heridas por Arma de Fuego/terapia , Heridas por Arma de Fuego/epidemiología , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/mortalidad , Estudios Retrospectivos , Traumatismos Vertebrales/terapia , Traumatismos Vertebrales/epidemiología , Traumatismos Vertebrales/cirugía , Persona de Mediana Edad , Adulto Joven , Centros Traumatológicos/estadística & datos numéricos , Estados Unidos/epidemiología , AdolescenteAsunto(s)
Conjuntiva , Cuerpos Extraños en el Ojo , Humanos , Conjuntiva/cirugía , Masculino , Cuerpos Extraños en el Ojo/cirugía , Cuerpos Extraños en el Ojo/etiología , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/complicaciones , Cuerpos Extraños/cirugía , Cuerpos Extraños/diagnóstico por imagen , Lesiones Oculares Penetrantes/cirugía , Lesiones Oculares Penetrantes/etiología , Lesiones Oculares Penetrantes/diagnóstico por imagenRESUMEN
INTRODUCTION: Retained shrapnel from gunshots is a common occurrence; however, retained shrapnel within the spinal canal is exceedingly uncommon. Guidelines for removal and treatment of these cases are a difficult topic, as surgical removal is not necessarily without consequence, and retention can lead to possible further injury or a secondary disease process of plumbism, which can be difficult to diagnose in this population. CASE PRESENTATION: This case report provides a unique example of a young patient with retained shrapnel from a gunshot. This patient suffered an initial spinal cord injury due to a gunshot and secondarily presented with abdominal pain, fatigue, elevated blood lead levels, and was diagnosed with plumbism. This was addressed with operative removal of shrapnel and posterior instrumented spinal fusion, resulting in decreased lead levels and symptom resolution postoperatively. DISCUSSION: Lead toxicity risk in patients with retained shrapnel, particularly in the spine, warrants vigilant monitoring. While management guidelines lack consensus, symptomatic lead toxicity may necessitate intervention. Residual neurological deficits complicate evaluation, emphasizing individualized management decisions.
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Cuerpos Extraños , Intoxicación por Plomo , Traumatismos de la Médula Espinal , Heridas por Arma de Fuego , Humanos , Masculino , Cuerpos Extraños/complicaciones , Cuerpos Extraños/cirugía , Plomo/sangre , Intoxicación por Plomo/diagnóstico , Intoxicación por Plomo/etiología , Traumatismos de la Médula Espinal/diagnóstico , Fusión Vertebral/métodos , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/cirugía , NiñoRESUMEN
Bladder stones represent approximately 5% of all cases of urolithiasis and are typically identified and managed long before causing irreversible renal injury. We present a case of a man in his 40s with a prior history of a gunshot wound to the abdomen who presented with leakage from a previously healed suprapubic tube tract and was found to have a giant bladder stone with a resulting renal injury. He subsequently underwent a combined open cystolithotomy and vesicocutaneous fistulotomy during his hospitalisation, which helped to improve his renal function. In addition to there being few reported cases of bladder stones >10 cm, this represents the first report in the literature of an associated decompressive 'pop-off' mechanism through a fistulised tract.
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Fístula Cutánea , Cálculos de la Vejiga Urinaria , Heridas por Arma de Fuego , Humanos , Masculino , Cálculos de la Vejiga Urinaria/diagnóstico , Cálculos de la Vejiga Urinaria/cirugía , Cálculos de la Vejiga Urinaria/diagnóstico por imagen , Fístula Cutánea/etiología , Fístula Cutánea/cirugía , Fístula Cutánea/diagnóstico , Adulto , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/cirugía , Fístula de la Vejiga Urinaria/etiología , Fístula de la Vejiga Urinaria/diagnóstico , Fístula de la Vejiga Urinaria/cirugíaRESUMEN
Pancreaticoureteric Fistula (PUF) is a very rare complication secondary to penetrating abdominal trauma involving the ureter and pancreatic parenchyma. Pancreatic injuries carry h igh morbidity due to the involvem ent of surrounding structures and are d ifficult to diagnose due to thei r retroperitoneal location. A case of a patient is reported at Civil Hospital, Hyderabad who presented with a history of firearm injury and missed pancreatic duct involvement on initial exploration that eventually led to the development of Pan creaticoureteric Fistula. He was managed v ia p erc ut aneous nep hrostomy ( PCN ) for the right ureteric injury and pancreatic duct (PD) stenting was done for distal main pancreatic duct injury (MPD).
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Traumatismos Abdominales , Armas de Fuego , Fístula , Enfermedades Pancreáticas , Heridas por Arma de Fuego , Masculino , Humanos , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/cirugía , Páncreas/diagnóstico por imagen , Páncreas/cirugía , Conductos Pancreáticos/diagnóstico por imagen , Conductos Pancreáticos/cirugía , Enfermedades Pancreáticas/complicaciones , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/cirugíaRESUMEN
Retroperitoneal abscess as a sequela of penetrating trauma can pose a difficult clinical scenario for surgeons and literature to inform decision making is sparse. It is logical to follow a "step-up" approach applied to other etiologies of infected retroperitoneal fluid collections, such as infected pancreatic necrosis and perinephric abscess. Video-assisted retroperitoneal debridement (VARD) is a well-established approach in infected pancreatic necrosis when surgical debridement is warranted. Minimally invasive retroperitoneal approaches have emerged in a broadening range of etiologies and specialties. We describe our experience utilizing VARDs in two patients that developed retroperitoneal abscesses following gunshot injuries to bowel and proximal urinary system. Both failed a conservative approach including antibiotic and percutaneous drains. Rapid improvement and subsequent discharge were observed within days of VARD procedure. We believe VARD to be a viable approach to post-trauma retroperitoneal abscesses when surgical drainage is indicated, and anatomy is favorable.
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Absceso Abdominal , Desbridamiento , Cirugía Asistida por Video , Heridas por Arma de Fuego , Humanos , Absceso Abdominal/etiología , Absceso Abdominal/cirugía , Desbridamiento/métodos , Drenaje/métodos , Espacio Retroperitoneal , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/complicacionesRESUMEN
INTRODUCTION: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE: III.
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Fracturas del Fémur , Ácido Láctico , Tiempo de Internación , Fracturas de la Tibia , Humanos , Tiempo de Internación/estadística & datos numéricos , Tiempo de Internación/economía , Masculino , Femenino , Ácido Láctico/sangre , Adulto , Persona de Mediana Edad , Fracturas de la Tibia/cirugía , Fracturas de la Tibia/economía , Fracturas del Fémur/cirugía , Fracturas del Fémur/economía , Heridas no Penetrantes/economía , Heridas no Penetrantes/cirugía , Complicaciones Posoperatorias/economía , Estudios Retrospectivos , Mortalidad Hospitalaria , Costos de Hospital/estadística & datos numéricos , Heridas por Arma de Fuego/economía , Heridas por Arma de Fuego/cirugíaRESUMEN
CASE: A 23-year-old right-hand dominant man presented with a high-velocity gunshot wound injury to the right thumb with severe soft-tissue damage, vascular injury, and large osseous defect of the right thumb metacarpal. The patient was successfully treated with metacarpophalangeal joint arthrodesis and metacarpal reconstruction using definitive external fixation, an intramedullary Kirschner wire, and use of the Masquelet bone grafting technique. CONCLUSION: The authors' treatment approach for a mangled thumb injury with definitive external fixation and utilization of the Masquelet technique resulted in restoration of a large osseous defect, avoidance of infection, and limited loss of mobility.
Asunto(s)
Traumatismos de la Mano , Procedimientos de Cirugía Plástica , Heridas por Arma de Fuego , Humanos , Masculino , Adulto Joven , Fijadores Externos , Fijación de Fractura/métodos , Traumatismos de la Mano/cirugía , Pulgar/cirugía , Heridas por Arma de Fuego/cirugíaRESUMEN
BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS: We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSION: Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Asunto(s)
Servicio de Urgencia en Hospital , Toracotomía , Heridas por Arma de Fuego , Humanos , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/mortalidad , Masculino , Femenino , Adulto , Toracotomía/estadística & datos numéricos , Toracotomía/métodos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Pennsylvania/epidemiología , Escala Resumida de Traumatismos , Persona de Mediana Edad , Traumatismos Penetrantes de la Cabeza/cirugía , Traumatismos Penetrantes de la Cabeza/mortalidad , Estudios Retrospectivos , Adulto Joven , Puntaje de Gravedad del Traumatismo , Traumatismos Craneocerebrales/cirugía , Traumatismos Craneocerebrales/mortalidad , AdolescenteRESUMEN
OBJECTIVES: Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS: From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS: One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION: We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.