Max L. Ramenofsky

Chest injuries in childhood.

Differences in anatomy and mechanisms of injury are believed to contribute to the unique response of children to thoracic trauma. To characterize the scope and consequences of childhood chest injury, we reviewed the records of 105 children (ages 1 month to 17 years, mean 7.6 years) with chest injuries admitted to a level I pediatric trauma center from 1981 to 1988. Nearly all injuries (97.1%) were due to blunt trauma, and more than 50% were traffic related. Rib fractures, commonly multiple, and pulmonary contusions occurred with nearly equal frequency (49.5% and 53.3%, respectively), followed by pneumothorax (37.1%) and hemothorax (13.3%). One fourth of all pneumothoraces were under tension. Significant intrathoracic injuries occurred without rib fractures in 52% of cases with blunt trauma. Associated head, abdominal, and orthopedic injuries were present in 68.6% of children reviewed. One in five received endotracheal intubation and ventilatory support for 1 to 109 days. Presence or absence of head injury neither increased the need for respiratory support (29.4% vs. 17.2%, respectively; p = 0.24) nor affected the duration of support for those who were ventilated (6.8 +/- 8.9 days vs. 3.3 +/- 2.6 days, excluding one ventilator-dependent head-injured patient and five early deaths). The presence of associated injuries, intubation, and pneumothorax or hemothorax all resulted in significantly longer hospitalizations and more severe injury as measured by Injury Severity Score (ISS). Age, rib fracture, and contusion had no effect. Rarely encountered were ruptured diaphragm (2 cases), transection of the aorta (1), major tracheobronchial tears (3), flail chest (1), and cardiac contusion (2). Only two of the three children with penetrating injuries and three of the 83 (3.6%) with blunt injuries underwent chest operations. Six children (7%) died, one from a penetrating injury and five from blunt mechanisms. Chest Abbreviated Injury Scale (AIS) and ISS correlated significantly with mortality; age and head AIS did not. Rib fractures, lung contusions, and associated head, abdominal, and skeletal injuries are common because of the predominance of blunt-injury mechanisms. Nearly one half of chest injuries occurred without rib fractures. The need for ventilatory support is uncommon; when required, its duration is generally brief. Aortic transection, flail chest, and penetrating injuries more frequently encountered in adults and are uncommon in children. Thoracotomy generally is not required.(ABSTRACT TRUNCATED AT 400 WORDS)

Mortality and head injury: The pediatric perspective

The records of 10,098 children entered into the National Pediatric Trauma Registry (NPTR) were analyzed to define the characteristics of pediatric head injury and the impact of extracranial trauma on Central Nervous System (CNS) injury. The 4,400 NPTR head injuries were then compared with 16,524 head injuries recently reported from a predominantly adult trauma registry to illustrate potential population differences. Results indicate that children have a lower mortality, that the addition of extracranial injury significantly reduces recovery potential, that CNS injury is the predominant and most common cause of pediatric traumatic death, and that the automobile is the most lethal component of a childs environment.

Laparoscopy for questionable appendicitis: can it reduce the negative appendectomy rate?

Laparoscopy has been performed in 32 patients in whom the diagnosis of appendicitis was suspected, but in whom clinical findings were equivocal and insufficient to establish the diagnosis. These patients represented 13.6% of the total group of patients admitted with questionable appendicitis during this period. Fifty per cent of these 32 patients had unusual clinical features, such as a prolonged history of symptoms, significant intercurrent disease, prior treatment with antibiotics or steroids, etc. At laparoscopy, the diagnosis of acute appendicitis was made in 17 patients. Another disease was diagnosed in 8 patients, and 7 were judged to have no pathologic abnormalities. There were two false negative examinations and one false positive, but no ruptured appendices resulted. Twelve patients (37.5%) were spared operation by laparoscopy. The negative appendectomy rate was decreased from 10 to 1%.

Continuous upper esophageal pH monitoring in infants and children with gastroesophageal reflux, pneumonia, and apneic spells

Gastroesophageal reflux (GER) to the upper esophagus (grade 3) has been incriminated as a cause of recurrent or refractory pneumonia and apneic spells. Others have used continuous esopha-geal pH monitoring to assess the significance of GER. However, only the distal esophagus has been monitored, which gives no information on the frequency with which upper GER (grade 3) occurs. On the assumption that only grade 3 GER will cause pneumonia or apneic spells, we have used continuous upper esophageal pH monitoring to evaluate these patients. Thirty-four patients (GER pneumonia—13 and GER apnea—21) were evaluated by continuous, 24-hr upper esophageal pH monitoring. The effect of postional therapy (chair, supine, prone), thickened feedings, and 2 hr before (a.c.) and after (p.c.) feedings were analyzed and were compared to a group of normal controls reported elsewhere. There was no significant difference in the number of reflux episodes between and apnea groups. A small group of patients (5) with GER pneumonia treated nonsurgically had fewer episodes of GER than the group of patients with GER pneumonia surgically treated ( p p p

Esophageal biopsy in the diagnosis of reflux esophagitis

Esophagitis in infancy and childhood produces characteristic histologic changes in the mucosa and lamina propria of the distal esophagus. The use of biopsy in addition to endoscopic evaluation considerably enhances the accuracy of the diagnosis of esophagitis, particularly when the degree of inflammatory change is mild. In the absence of severe inflammatory changes, such as ulceration or mucosal slough, esophageal biopsy appears to be essential for the accurate diagnosis of esophagitis. In children of any age with GER who have symptoms of esophagitis, antacid therapy and vigorous efforts to control reflux are indicated. Failure to respond to this program is an indication for esophageal biopsy to confirm or rule out the presence of esophagitis. The degree of inflammatory change in the biopsy is a reliable guide to expected response to antiacid therapy.

Anterior ectopic anus: A common cause of constipation in children

Anterior ectopic anus is increasingly being recognized as a cause of constipation in infancy. Experience is reported with surgical treatment of 20 patients with anterior ectopic anus. This form of anal ectopia is associated with a syndrome of constipation that begins at birth, straining on defecation, and anterior displacement of an otherwise normal anus and sphincter. It is seen almost exclusively in females. Posterior anoplasty with sphincterotomy is curative.

Laparoscopy in infants and children

Laparoscopy has been performed in 60 infants and children over a 32-mo period. Indications included: the problem of possible appendicitis, chronic abdominal pain, possible regional enteritis, possible biliary atresia, and liver biopsy. Fifty-two per cent of patients were spared laparotomy, while in 32% the need for operation was established. There were 2 errors in diagnosis, 3 failures, and 1 complication. Laparoscopy is considered to be a safe, effective, and economical diagnostic procedure that deserves wider application in the pediatric patient.

The effects of intrapleural pressure on respiratory insufficiency

Newborns with congenital diaphragmatic hernia generally survive operative repair of the hernia but develop progressive respiratory insufficiency that proves fatal. One cause for the progressive respiratory insufficiency may be the overexpansion of the contralateral lung. It is postulated that the overexpansion occurs due to the empty space created by the lack of expansion of the hypoplastic lung on the side of the hernia. To test this theory, an animal experiment was devised to mimic the postoperative state in patients with diaphragmatic hernia. It was concluded that (1) A decrease in intrapleural pressure below normal in an empty hemithorax causes the opposite lung to overexpand into the empty hemithorax in neonatal Beagle puppies. (2) The overexpansion resulted in progressive respiratory insufficiency. (3) Increasing the intrapleural pressure by insufflation of air into the empty hemithorax stopped the overexpansion of the contralateral lung. (4) By not allowing the contralateral lung to overexpand, progressive respiratory insufficiency was prevented. (5) This may be a useful technique in neonates with congenital diaphragmatic hernia.

Gastroesophageal reflux and torticollis.

1 140 THE JOURNAL OF BONE AND JOINT SURGERY The Sandifer syndrome is a combination of hiatal hernia and abnormal posturing of the head and neck. The abnormal posturing has been attributed to an attempt to decrease the pain of esophagitis resulting from gastroesophageal reflux and hiatal hernia l,IO.12#{149} We saw five patients with a variant of the Sandifer syndrome: gastroesophageal reflux, esophagitis, and torticollis, but no hiatal hernia. In each patient, following fundoplication the torticollis disappeared, with the return of normal motion and appearance of the head and neck.

Computed tomography in diagnosis of abdominal masses in infancy and childhood. Comparison with excretory urography.

Computed tomography (CT) of the abdomen and pelvis was performed in 26 instances of suspected mass in 24 infants and children. The information obtained was compared to that of standard abdominal radiography and excretory urography (IVP). Results were analyzed prospectively. CT was able to detect and define masses more precisely than abdominal radiography and IVP. The information obtained by CT, in a single noninvasive examination emitting minimal ionising radiation, seems comparable to that offered by a combination of multiple radiological and other imaging procedures. It is conceivable that with accumulating experience and further technological improvement CT may become an excellent screening procedure in the investigation of abdominal and pelvic masses. The high cost of CT scanning may be offset by the benefits cited.