Paul J. Bode

Abdominal ultrasound as a reliable indicator for conclusive laparotomy in blunt abdominal trauma.

The purpose of this study was to evaluate the ability of abdominal ultrasound (US) to detect intra-abdominal injuries that required surgical repair. We therefore retrospectively reviewed 353 patients with nontrivial blunt abdominal trauma. All patients underwent abdominal evaluation as part of our routine trauma protocol within the first minutes of arrival at our emergency center. Hemoperitoneum and intraperitoneal parenchymal damage were correctly identified by US with a sensitivity of 92.8%, and a specificity of 100%. Accuracy was 99.4%, the positive predictive value was 100%, and the negative predictive value was 99.4% (prior probability of disease was 7.65%). We believe that abdominal US should be considered an important tool and an integral part in the work-up of major trauma victims.

Routine cervical spine radiography for trauma victims: Does everybody need it?

OBJECTIVE The purpose of this study was to evaluate the indication for routine cervical spine radiography in trauma patients. METHODS Prospective analysis of radiologic and clinical findings was performed during a 5-year period. Patients suitable for a clinical decision rule were reviewed separately. RESULTS Of the 1,757 consecutive patients included in the study, 38 were diagnosed with a cervical spine injury. Of the 599 patients suitable for the clinical decision rule, 62 had midline cervical tenderness, including 2 with cervical spine injury. No additional cervical spine injuries were found during follow-up. CONCLUSION It is within good practice, and it is also cost-effective, to obtain a cervical spine radiograph only on clinical parameters in trauma patients with no apparent bodily trauma and optimal parameters. With this clinical decision rule, 30.6% of all cervical spine series were redundant, and no (occult) spinal fractures would have been undetected.

Posterolateral dislocation of the elbow with concomitant fracture of the lateral humeral condyle : case report

We describe a case of a 6-year-old girl with a posterolateral elbow dislocation and a concomitant fracture of the lateral humeral condyle. After reduction of the dislocation, the fracture was diagnosed and treated by open reduction and fixation, with a good functional result. In doubtful cases, oblique, heterolateral, and varus stress films, or even arthrography may be necessary.

DEGENERATIVE CHANGES AT THE KNEE AND ANKLE RELATED TO MALUNION OF TIBIAL FRACTURES

We re-examined clinically and radiologically 88 patients with a fracture of the lower leg at a mean follow-up of 15 years. Forty-three fractures (49%) had healed with malalignment of at least 5 degrees. More arthritis was found in the knee and ankle adjacent to the fracture than in the comparable joints of the uninjured leg. Malaligned fractures showed significantly more degenerative changes. Eighteen patients (20%) had symptoms in the fractured leg. There was a significant correlation between symptoms in the knee and arthritis but not between symptoms and ankle arthritis or malalignment. We conclude that fractures of the lower leg should be managed so that the possibility of angular deformity and thereby late arthritis is minimised.

Unstable pelvic fractures: a retrospective analysis

Thirty-nine patients with unstable pelvic fractures were analysed retrospectively. The mean age of the group was 41 years (range 15-77). Of these cases 35 had sustained high energy trauma. The mean Hospital Trauma Index-Injury Severity Score of the population was 32 (16-66). Nine cases were haemodynamically unstable on admission. The type of unstable pelvic fracture was classified according to Tile. Sixteen patients had a type B fracture and 23 had a vertical instability (type C) fracture. In two patients, an open fracture was seen. Directly associated injuries were diagnosed in 11 patients, of which eight showed damage of the urogenital system, three of the rectum and three of the peripheral nerve system. In seven cases the fracture was treated non-operatively; in the remaining 32 patients the pelvic ring was stabilized operatively. Additional therapy for hypovolaemic shock due to pelvic bleeding was necessary in six cases. The overall mortality in this series was 13 per cent. Early and aggressive resuscitation and standardized treatment in well-equipped and staffed injury centres is mandatory in these severely traumatized patients to achieve optimal results and to minimize the risk of fatal outcome.

Efficiency of a Standardized Diagnostic Protocol in Trauma Management

Background: The objective of this study was to evaluate the efficiency of a radiologic trauma protocol which was implemented to ensure swift and accurate diagnosis, reduce unnecessary hospitalization and detect parameters that will efficiently predict surgical findings.Patients and Methods: 1,757 patients were included in this prospective study which was carried out over a 5-year period. All parameters, mechanisms of trauma and radiologic findings were recorded. Results: A total of 472 patients could be discharged the same day. Positive findings in all radiologic modalities ranged between 3.9% and 50% when grouped by trauma scores. Conclusions: Implementation of our protocol resulted in a reduced number of patients admitted for clinical observation. A nontrivial number of positive findings was detected in all separate RTS (Revised Trauma Score) GCS (Glasgow Coma Scale) and trauma mechanism groups, with an increase in positive findings for groups specified by deteriorating trauma scores. Due to the unreliability of physical examination, especially in nonresponsive patients, radiologic work-up remains an important tool in the assessment of trauma patients.

Pediatric Splenic Injury: Nonoperative Management First!

Background and Purpose:In the past splenectomy was the standard procedure for traumatic blunt splenic injury, when bleeding of the spleen occurred. Since the spleen performs important immunological functions the advantage of a spleen-saving approach is preservation of immunological functions. Especially in the pediatric population splenic preservation is an important objective. Spleen-saving treatment, in particular selective nonoperative management, has gained ground in the past 20 years. An 18-year retrospective review was performed to evaluate our cumulative experience with nonoperative management. Endpoints: hemodynamical instability and splenectomy.Methods:Forty-six patients were identified. Demographics, methods of management, mechanism of injury, injury grade, associated injuries, hemodynamical parameters, bloodtransfusion, complications, ICU and hospital stay were documented and analyzed to determine statistical significance between modes of management.Results:Initially, 34 patients were managed nonoperatively, while 12 patients underwent laparotomy – with 7 (58.3% of the operative group) of these having splenectomy performed. Three patients (out of 34) failed nonoperative management and required delayed splenorraphy or splenectomy, a 91.2% (3 out of 34 failed) success rate for intended nonoperative management versus 85.7% for intended splenorraphy (1 out of 7 failed). Thus, overall rates of 67.4% nonoperative management and 82.6% splenic conservation were achieved. Analysis of parameters between treatments showed significant differences between nonoperative management and splenorraphy for splenic injury grade II and IV.Conclusion:We recommend based on our data on children with splenic injury grades II and IV that the standard treatment for children aged 0 to 18 years due to blunt abdominal trauma should be nonoperative management. However management of blunt splenic injury remains a clinical decision, for this reason does not preclude on CT-scan grade V for nonoperative management.

Cerebral fat embolism

The fat embolism syndrome (FES) is a well-known entity. In the literature, a few MRI reports on cerebral findings in FES have been published [1]. In these reports, T2-weighted spin-echo (SE) images revealed multiple small focal hyperintensities in the cerebral deep white matter, basal ganglia, brain stem and cerebellar hemispheres. The lesions demonstrated low signal intensity (SI) on T1-weighted SE images. Presumably these radiographic lesions reflect focal parenchymal ischemic changes (edema, gliosis). In only one patient, high SI was found on T1-weighted images, which was attributable to the presence of blood products [2]. In contrast to the obscure pathophysiology of FES, the pathologic findings are well documented [3]. The macroscopic hallmark of FES is the finding of widespread petechiae in the white matter of the cerebral and cerebellar hemispheres, the posterior limb of the internal capsule and in the white matter of the midbrain, pons and medulla. The classic microscopic features are intraluminal fat emboli, ball and ring hemorrhages and foci of ischemic necrosis. The discrepancy between the radiologic and pathologic findings with respect to the presence of cerebral parenchymal blood in FES might be attributed to the relative lack of sensitivity of SE MRI sequences for blood products. Gradient-echo sequences are reported to be more sensitive for hemorrhagic lesions in the brain. We report FES in a 34-year-old man involved in a motor-vehicle accident. Seventy-four hours after the accident, a MR examination of the brain was performed, which showed no abnormalities on T1-weighted SE images. However, on T2-weighted fast SE images multiple small areas of high SI were seen in both the subcortical and the deep white matter of both hemispheres. A repeated MR examination performed 1 month after the accident showed diffuse hyperintense areas in the deep white matter on T2-weighted images. Gradient-echo images showed no signs of hemorrhage. To the best of our knowledge, our FES case is the first in the literature to be imaged with gradient-echo sequences. However, even using a gradient-echo sequence, we found no signs of hemorrhage in the cerebral lesions. Thus, although the macroscopic hallmark of FES is the presence of petechiae, our case illustrates that, even when using techniques sensitive for the presence of blood products, cerebral lesions attributable to FES may lack radiologic evidence of a hemorrhagic component. References