RESUMO
OBJECTIVES: To determine whether point-of-care elbow ultrasound (US), with history and physical examination, can decrease radiography for patients with elbow trauma. Secondary outcomes included evaluation of pediatric emergency department (PED) length of stay (LOS) and test performance characteristics. STUDY DESIGN: This was a prospective study of patients up to age 21 years with elbow trauma necessitating radiography. After clinical examination and before radiography, pediatric emergency physicians performed elbow ultrasonography of the posterior fat pad and determined whether radiography was required. All patients underwent elbow radiography and received clinical follow-up. Times for US and radiography were recorded. RESULTS: A total of 100 patients with a mean age of 7.9 years were enrolled, 42 of whom had a fracture. In 23 patients, the physician determined that radiography could be eliminated. Elbow US combined with clinical suspicion for fracture had a sensitivity of 100% (95% CI, 92%-100%). Elbow US took a median of 3 minutes (IQR, 2-5 minutes), and completion and interpretation of elbow radiography took a median of 60 minutes (IQR, 43-84 minutes). The overall sensitivity of elbow US was 88% (95% CI, 75%-96%). CONCLUSIONS: Elbow US has a high sensitivity to rule out fracture and is best used in patients with a low clinical suspicion of fracture. The use of conventional radiography and PED LOS may be reduced in patients with a low clinical concern for fracture and normal elbow US.
Assuntos
Traumatismos do Braço/diagnóstico por imagem , Lesões no Cotovelo , Cotovelo/diagnóstico por imagem , Sistemas Automatizados de Assistência Junto ao Leito , Radiografia , Ultrassonografia , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Fraturas Ósseas/diagnóstico por imagem , Humanos , Tempo de Internação , Masculino , Estudos Prospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND: The structural characteristics of the fibula, strength, shape, length and limited donor site morbidity make it more suitable for reconstructing long bone defects larger than 6cm in the limbs. MATERIAL AND METHODS: A descriptive study was conducted using a non-probabilistic sample of consecutive cases undergoing on limb reconstruction with free fibular flap in the period from January 2010 to January 2015 in the Mexican Institute of Social Security No. 21, Monterrey Nuevo Leon. RESULTS: The mean age of the ten cases included was 25 years, with the most common diagnosis being trauma in 4 patients, osteosarcoma in 2, followed by one congenital pseudoarthrosis of the tibia, one non-union fracture, and one gunshot wounds, respectively. The most common location was tibia, followed by humerus, radius, ulna and femur. CONCLUSIONS: This study has shown that the fibular free flap can be an excellent option for management of long bone defects, regardless of cause of the injury. One or more skin islands can be added for coverage in exposure of deep tissue and osteosynthesis material, thus preserving the septocutaneous perforators.
Assuntos
Braço/cirurgia , Fíbula/cirurgia , Retalhos de Tecido Biológico/irrigação sanguínea , Perna (Membro)/cirurgia , Salvamento de Membro/métodos , Microcirurgia/métodos , Adulto , Braço/diagnóstico por imagem , Traumatismos do Braço/diagnóstico por imagem , Traumatismos do Braço/cirurgia , Neoplasias Ósseas/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Perna (Membro)/diagnóstico por imagem , Traumatismos da Perna/diagnóstico por imagem , Traumatismos da Perna/cirurgia , Masculino , Pessoa de Meia-Idade , Osteossarcoma/cirurgia , Estudos RetrospectivosRESUMO
OBJECTIVES: To determine the clinical and forensic utility of head computed tomography (CT) in children younger than 2 years of age with an acute isolated extremity fracture and an otherwise-negative skeletal survey. STUDY DESIGN: Retrospective chart review of children younger than 2 years of age who obtained a skeletal survey in the Cincinnati Children's Hospital Medical Center Emergency Department during the 159-month study period. Clinically important head injury was determined based on previously defined Pediatric Emergency Care Applied Research Network criteria. Forensically significant head injury was defined as that which increased the concern for inflicted injury. The rate of head CT relative to patient age and location of fracture (proximal vs distal extremity, upper vs. lower extremity) was determined via χ2 tests. RESULTS: Of the 320 children evaluated, 37% received neuroimaging, 95.7% of which had no signs of skull fracture or intracranial trauma. Five children (4.3%) with head imaging had traumatic findings but no children in the study had clinically significant head injury. Three of these children had previous concerns for nonaccidental trauma and findings on head CT that were forensically significant. There was a greater rate of head imaging in children in the younger age groups and those with proximal extremity fractures (P < .05). CONCLUSIONS: In young children who present with an isolated extremity fracture, clinicians should consider obtaining head CT in those who are younger than 12 months of age, have proximal extremity fractures, or who have previous evaluations for nonaccidental trauma. Evaluation with head CT in children without these risk factors may be low yield.
Assuntos
Fraturas Ósseas/diagnóstico por imagem , Fraturas Cranianas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Fatores Etários , Traumatismos do Braço/diagnóstico por imagem , Maus-Tratos Infantis/prevenção & controle , Pré-Escolar , Estudos de Coortes , Traumatismos Craniocerebrais/diagnóstico por imagem , Serviço Hospitalar de Emergência , Feminino , Hospitais Pediátricos , Humanos , Lactente , Traumatismos da Perna/diagnóstico por imagem , Masculino , Traumatismo Múltiplo/diagnóstico por imagem , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: An earthquake occurred in Haiti on January 12, 2010. The center of earthquake and the most extensive damage occurred near the capital Port-au-Prince. There were an estimated 230,000 deaths with more than 250,000 others injured. The Israeli Defense Forces Field Hospital (IDF hospital) is a military unit composed of army-recruited (volunteer) medical personnel that was sent to Haiti to serve as a stand-alone center for early response until larger medical missions could become functional and take on the task of more sophisticated and long-lasting medical support. This study describes the use of external fixator frames for orthopedic damage control whereby bone stabilization in conjunction with soft tissue care serves as a stopgap until more comprehensive therapy is forthcoming. METHODS: Data were collected from patients' files (generated at the IDF hospital) regarding the use and immediate outcome of limbs stabilized by external fixator frames. RESULTS: During the 10 days of the IDF hospital's activity, a total of 1,111 patients were admitted; 244 surgical procedures were performed under general or regional anesthesia and of these, the orthopedists performed 221 (90%) surgical procedures. Seventy-three fractures were stabilized operatively by application of an external fixator. Most of the frames were applied on fractures (closed and open) of the lower limbs (48 on femur and 24 on tibia/fibula). All procedures were performed in a field-style operating room. Sterile technique was possible only for elements actually inserted into the patient. Limb alignment was based on manual palpation: intraoperative fluoroscopy was not available; soft tissue care followed bone stabilization. No patient died. All patients completed urgent stabilization at the IDF hospital and were transferred to other facilities or discharged for home care. CONCLUSIONS: We describe "orthopedic damage control" using external fixator frames for bone stabilization and soft tissue care as a viable approach in the context of a mass casualty scenario. Technical aspects are described in detail in addition to the advantages and limitations of this approach, which could serve as guidelines for future military and civilian scenarios where large-scale orthopedic damage control would be practiced.
Assuntos
Terremotos , Fixadores Externos , Fixação de Fratura/instrumentação , Fraturas Ósseas/cirurgia , Adolescente , Adulto , Idoso , Traumatismos do Braço/diagnóstico por imagem , Traumatismos do Braço/cirurgia , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Tratamento de Emergência/métodos , Feminino , Fixação de Fratura/métodos , Consolidação da Fratura/fisiologia , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/epidemiologia , Haiti , Hospitais Militares , Humanos , Escala de Gravidade do Ferimento , Traumatismos da Perna/diagnóstico por imagem , Traumatismos da Perna/cirurgia , Masculino , Incidentes com Feridos em Massa/mortalidade , Pessoa de Meia-Idade , Procedimentos Ortopédicos/normas , Procedimentos Ortopédicos/tendências , Radiografia , Medição de Risco , Resultado do Tratamento , Triagem , Adulto JovemRESUMO
Objetivo: Evaluar retrospectivamente las indicaciones, la evolución y los resultados obtenidos en defectos graves de partes blandas cubiertos con Colgajo Libre Paraescapular. Material y Métodos: Evaluamos retrospectivamente ocho pacientes con defectos severos de tejidos blandos tratados con colgajo libre Paraescapular entre Julio de 2006 y Mayo de 2009. La edad promedio fue de 28 años. En un paciente se asoció con el colgajo Escapular, en uno con el colgajo Dorsal Ancho libre, y en otro con el colgajo Dorsal Ancho pediculado rotatorio. Cuatro pacientes fueron atendidos en otros centros y derivados a nuestra institución para realizar tratamiento definitivo con un promedio de demora de 5 días postrauma. En dos pacientes se asoció un sistema de aspiración negativo (VAC), y en otros dos, con defecto óseo asociado, se colocó un espaciador de cemento con antibiótico en forma temporaria. Resultados: El seguimiento promedió 18,7 meses. Un paciente presentó una necrosis del colgajo en antepié que requirió la amputación del mismo, otro paciente presentó una necrosis del centímetro distal del colgajo y requirió un simple desbridamiento y retensado del mismo, mientras que el resto evolucionaron en forma favorable. Todos los pacientes pudieron retomar a sus actividades habituales, excepto un paciente que sufrió amputación de su miembro superior contralateral en el trauma inicial y que presentó una severa lesión de la mano ipsilateral al colgajo. Conclusiones: El colgajo Paraescapular tiene su principal indicación en aquellas lesiones superiores a los 10 x 6 cm en las cuales se encuentran expuestos elementos nobles (vasos, nervios, tendones y hueso) que deben ser protegidos. Es fundamental contar tanto con un cirujano microvascular experimentado como con un equipo multidisciplinario.(AU)
Assuntos
Humanos , Adulto , Lesões dos Tecidos Moles/cirurgia , Retalhos Cirúrgicos , Traumatismos do Braço , Traumatismos da Perna , Resultado do Tratamento , Estudos Retrospectivos , Seguimentos , Traumatismos do Braço/diagnóstico por imagem , Traumatismos da Perna/diagnóstico por imagemRESUMO
BACKGROUND: The radiologic study of choice for evaluation of traumatic arterial injuries is conventional arteriography, but it poses the risks of an invasive procedure. Computed tomographic arteriography (CTA) is emerging as a new way to study arterial anatomy, with the additional advantages of being noninvasive and a technique that allows evaluation of different body areas simultaneously. Our experience using CTA for evaluation of traumatic arterial injuries is provided in this study. METHODS: A retrospective review over a 22-month period of all adult patients undergoing CTA for evaluation of traumatic injuries to the extremities was performed. RESULTS: A total of 97 CTA studies were performed in the 95 patients. CTA adequately demonstrated the nature and location of all the arterial injuries when compared with conventional arteriography or surgical exploration. Abnormal CTA results included 21 arterial occlusions, 2 intimal flap defects, and 2 pseudoaneurysms. Nine of these 25 injuries were confirmed by surgery only, 10 by surgery and arteriography, and 6 by arteriography only. Normal CTA results were confirmed with arteriography in 10 cases. No missed injuries were encountered in patients with normal CTA results. CONCLUSION: CTA is a reliable technique for the detection and characterization of traumatic extremity arterial injuries. These results suggest CTA may be an alternative to conventional arteriography for the diagnosis of traumatic arterial injuries.
Assuntos
Falso Aneurisma/diagnóstico por imagem , Angiografia , Traumatismos do Braço/diagnóstico por imagem , Artérias/lesões , Extremidades/irrigação sanguínea , Processamento de Imagem Assistida por Computador , Traumatismos da Perna/diagnóstico por imagem , Tomografia Computadorizada Espiral , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagem , Adolescente , Adulto , Idoso , Amputação Cirúrgica , Falso Aneurisma/cirurgia , Traumatismos do Braço/cirurgia , Artérias/cirurgia , Fasciite Necrosante/diagnóstico por imagem , Fasciite Necrosante/cirurgia , Feminino , Humanos , Escala de Gravidade do Ferimento , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Traumatismos da Perna/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgiaRESUMO
PURPOSE: To present our experience with helical computed tomographic (CT) arteriography as the initial diagnostic examination in patients suspected to have focal arterial injuries of the proximal extremities. MATERIALS AND METHODS: During 19 months, 142 arterial segments in the proximal portions of the extremities of 139 patients with trauma were evaluated with helical CT arteriography. CT arteriograms were interpreted on site by the radiologist in charge of emergency procedures and retrospectively with consensus interpretation between two radiologists. CT study quality and the presence of arterial injuries were noted. CT arteriographic findings were compared with those of surgery, conventional arteriography, and/or clinical follow-up. RESULTS: Five (3.6%) patients had nondiagnostic studies and underwent conventional arteriography. In the remaining 137 arterial segments in 134 patients, helical CT arteriography demonstrated arterial injuries in 61 segments and normal arteries in 76 segments. These segments were treated initially with surgery (55 segments) or endovascular intervention (four segments) or were observed (78 segments); 77 of the 78 observed segments remained stable at 3-18 months (mean follow-up, 5.2 months). There were no differences between the on-site and consensus interpretations (kappa = 1.0). The sensitivity of CT arteriography was 95.1%, and the specificity was 98.7%. CONCLUSION: Helical CT arteriography can be performed as the initial diagnostic method in most patients suspected to have focal arterial injuries of the proximal portions of the extremities.
Assuntos
Traumatismos do Braço/diagnóstico por imagem , Braço/irrigação sanguínea , Artérias/lesões , Traumatismos da Perna/diagnóstico por imagem , Perna (Membro)/irrigação sanguínea , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Angiografia/métodos , Humanos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodosRESUMO
PURPOSE: The purpose of this work was to assess the performance of helical CT angiography (CTA) in the diagnosis of injuries to large arteries of the extremities. METHOD: We performed helical CTA on 45 consecutive patients referred for conventional angiography for evaluation of suspected arterial injuries after sustaining trauma to the extremities (13 upper, 32 lower). Two radiologists interpreted the helical CTA studies independently. Diagnostic performance parameters evaluated included sensitivity, specificity, receiver operating characteristic (ROC) curves, and interobserver agreement (kappa statistics). Conventional angiography was used as the standard of reference for determination of final diagnoses. RESULTS: Forty-three of 45 patients (96%) had diagnostic helical CTA examinations. Final diagnoses in these 43 patients were arterial occlusion (n = 7), partial obstruction (n = 3), pseudoaneurysm (n = 5), arteriovenous fistula (n = 1), pseudoaneurysm and arteriovenous fistula (n = 3), and normal findings (n = 24). Sensitivity and specificity were 90% [95% confidence interval (CI), 80-99] and 100% (95% CI, 99-100), respectively, for Reader 1 and 100% (95% CI, 99-100) and 100% (95% CI, 99-100), respectively, for Reader 2. ROC curve analysis revealed high diagnostic performance, with areas under the curve of >0.9 for both readers. Interobserver agreement was 0.9. CONCLUSION: The diagnostic performance of helical CTA for detection of major injuries of large arteries of the extremities is high.
Assuntos
Angiografia/métodos , Traumatismos do Braço/diagnóstico por imagem , Braço/diagnóstico por imagem , Artérias/lesões , Traumatismos da Perna/diagnóstico por imagem , Perna (Membro)/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Ferimentos Penetrantes/diagnóstico por imagem , Adolescente , Adulto , Angiografia/estatística & dados numéricos , Braço/irrigação sanguínea , Meios de Contraste , Humanos , Iopamidol , Perna (Membro)/irrigação sanguínea , Pessoa de Meia-Idade , Variações Dependentes do Observador , Estudos Prospectivos , Estudos Retrospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/estatística & dados numéricosRESUMO
OBJECTIVE: To evaluate duplex ultrasonography for diagnosis of arterial trauma in limbs and neck. METHOD: Fifty-one wounds in 47 patients, with indication for arteriography, were prospectively studied and grouped according to the presence (PCS group: 21 wounds, 41.2%) or absence (ACS group: 30 wounds, 58.8%) of clinical signs of arterial injury. All underwent duplex ultrasonography and arteriography. RESULTS: Arteriography disclosed arterial injury in 21 wounds, of which 19 were visualized by duplex ultrasonography. In the other 30 wounds neither methods disclosed any arterial injury. The sensitivity of duplex ultrasonography was 90.5%, the specificity was 100% and the accuracy was 96.1%. In PCS group duplex ultrasonography showed 14 injuries (93.3%) and one false-negative result, and in ACS group, five injuries (83.3%) and one false-negative result in the ACS group. CONCLUSIONS: Duplex ultrasonography reproduces the results of arteriography as a non-invasive diagnostic method in trauma of the limbs and neck.
Assuntos
Traumatismos do Braço/diagnóstico por imagem , Artérias/diagnóstico por imagem , Artérias/lesões , Traumatismos da Perna/diagnóstico por imagem , Lesões do Pescoço/diagnóstico por imagem , Ultrassonografia Doppler Dupla , Adolescente , Adulto , Angiografia , Braço/irrigação sanguínea , Criança , Pré-Escolar , Feminino , Humanos , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Pescoço/irrigação sanguínea , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
PURPOSE OF THE STUDY: Rupture of the distal tendon of the biceps is an uncommon occurrence. 43 cases were analyzed in a multicentric study in order to define etiological factors and treatment of this lesion. MATERIAL AND METHODS: 43 cases were reviewed from Fort de France, Paris, Marseille, Lyon and Suresnes. There were only male patients with an average age of 50 years. The mechanism of injury, the clinical and radiographic features, the anatomical findings and the results of surgical treatment were analyzed. 4 patients were treated conservatively and 39 surgically. In 28 cases, anatomical reattachment of the tendon was performed. In 11 cases the tendon was simply attached to the brachialis anterior muscle. RESULTS: The mechanism of injury in all patients was passive extension against active flexion 17 patients had sustained injury while engaged in sports activities and 17 during domestic activities. Most of the patients were diagnosed clinically. Ultrasound and CT scan was useful in cases seen a long time after injury. In 34 cases avulsion of the bicipital tuberosity was found. Subjective results were good in 28 cases and poor in 5 cases. Objective testing was performed one year after injury using the criteria described by Baker: flexion and suppination force (maximum force) and endurance (ability to perform repeated contractions). Following attachment to the brachialis anterior, there was an average loss of 33 per cent of flexion strength and 52 per cent of supination strength. Following anatomical reattachment, the loss was 5 per cent for flexion and 15 per cent for supination. There were two cases of radial nerve palsies and 1 case of radio-ulnar synostosis. DISCUSSION: Attachment of the biceps brachialis tendon to the brachialis anterior muscle is unable to restore supination force. Complications only occur following anatomical reattachment. Radial nerve palsies can be avoided by using two separate incisions as described by Boyd. CONCLUSION: Surgical reinsertion onto the radial tuberosity restore more strength. Attachment to the brachialis muscle can be sued in cases seen a long time after injury.