William G. Delong

Clearing the cervical spine: initial radiologic evaluation

The identification of unstable cervical spine injury (UCSI) in blunt high-energy transfer injury (BHETI) patients is critical to management. In a prospective study of BHETI patients identified to be at high risk for UCSI, the use of lateral cervical spine view (LCV), three-view cervical spine series (FCS), and limited computerized tomography (CT) in the initial evaluation of these patients was analyzed. Thirteen of 204 patients sustained UCSI. Sensitivity of the LCV alone was 0.85 and the predictive value of the negative test was 0.97. Sensitivity and predictive value of a negative study were maximized by the use of FCS combined with CT when plain X-rays were inadequate. We conclude that technically adequate, normal FCS can be safely used to eliminate the presence of UCSI. If these studies are technically inadequate, the addition of a limited CT can be used to clear the spine.

Delayed identification of skeletal injury in multisystem trauma: the 'missed' fracture.

Delay in diagnosis of musculoskeletal injury in multiply injured patients may potentially lead to functional or cosmetic disability in survivors. In an 18-month prospective study to determine the incidence and spectrum of delayed recognition of skeletal injury at our Level I trauma center, delayed diagnosis of 39 fractures was made in 26 of 1,006 consecutive blunt trauma patients. The delay in recognition ranged from 1-91 days. Twenty-one (55%) of the fractures were not X-rayed at the time of admission, but nine (23%) fractures were clearly visible on admission films. Four (10%) fractures were missed because of technically inadequate X-rays, and five (13%) had adequate X-rays but could not be identified on admission films. In only two instances was a second anesthetic exposure required for operative therapy. For the patients in this series, the delay of fracture identification was not felt to contribute to additional long-term cosmetic, functional, or neurologic problems. Continued clinical and radiologic surveillance is required in multiply injured patients to prevent musculoskeletal diagnostic failure.

Clinical predictors of unstable cervical spinal injury in multiply injured patients

All victims of major blunt trauma have been said to be at risk of cervical spinal injury. In a prospective study of 410 such patients at our institution, we identified 13 patients (6.12 per cent) with unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological deficit consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervical spine. Immediate radiographic investigation of the cervical spine is mandatory in such patients, but may not be required in patients without these signs.

Ender Nail Fixation in Long Bone Fractures: Experience in a Level I Trauma Center

Early fixation of extremity fractures in polytrauma patients is a well accepted and desirable treatment. In our patient population, the indications for immediate Ender nail fixation was for Grade I and Grade II open long bone fractures and closed long bone fractures in patients with small intramedullary canals. Ender nails were also used in patients in whom reaming was undesirable. This included patients with open physes for immediate fracture fixation and in those with Grade III open wounds in a delayed fashion. These flexible nails were also implemented for use to minimize anesthesia time as a life saving measure in the severely injured. This study is a retrospective review of a 30-month period in which 68 patients with 91 fractures underwent Ender intramedullary nailing. The mean Injury Severity Score (ISS) was 12.4. There were 16 humerus fractures, 26 femur fractures, and 49 tibia fractures. Thirty-three per cent (30 fractures) were open fractures. The average operating time per fracture was 70 minutes (range, 15 to 150 minutes). The estimated blood loss per fracture was 150 cc with a range of 25 to 500 cc. The average followup is currently 19 months (range was 8 to 29 months). This approach achieved an excellent result in 95% of the patients treated. There were no wound, soft-tissue, or bony infections experienced. Major complications were seen in five patients: three nonunions and two malunions.(ABSTRACT TRUNCATED AT 250 WORDS)

Pelvic crush injuries with occlusion of the iliac artery

During a 1-year period, three patients presented with acute traumatic thrombosis of the common or external iliac artery concomitant with a massive crush injury to the pelvis. All had vascular compromise of the involved extremity on initial physical examination, but in two patients with open pelvic trauma, exsanguination, major visceral injury, hypothermia, and a coagulopathy precluded emergency vascular reconstruction. Both required hindquarter amputation for adequate debridement. The third patient presented without exsanguination or visceral trauma. Angiography and vascular reconstruction were undertaken, but myonecrosis compounded the initial vascular compromise, and eventually required a hip disarticulation for debridement. It was concluded that: exsanguination and/or major visceral injury takes priority over emergency vascular reconstruction; soft-tissue injury may preclude limb salvage despite vascular reconstruction. If a cadaveric limb exists, early radical amputation, including hindquarter amputation, should be undertaken.

Dynamic computerized tomography of the occiput-atlas-axis complex in trauma patients with odontoid lateral mass asymmetry

Over a 23-month period, 25 patients aged 11 to 74 years presented to our Level I trauma center with odontoid lateral mass asymmetry of 2 to 5 mm on properly centered AP open-mouth X-rays: 32% of patients were asymptomatic, 68% had cervical pain, and 32% had limited range of motion. Patients with cervical spine fractures or dislocations and those with fixed deformity were excluded. The clinical significance of asymmetry was determined utilizing dynamic axial CT scanning of the occiput (C0), atlas (C1) and axis (C2) with the head neutral and with 15 degrees to 30 degrees active rotation. Nineteen patients demonstrated greater than 5 degrees of relative motion of C1 on C2 bilaterally. Three patients had less than 5 degrees of relative motion bilaterally and three patients had less than 5 degrees relative motion with left rotation only. No patient had formal treatment and all had nearly normal cervical range of motion on clinical examination at the time of hospital discharge. The finding of an asymmetric odontoid-lateral mass interspace on properly centered open-mouth AP X-rays in the presence of otherwise normal cervical spine X-rays, in conscious patients without fixed deformity, appears to be incidental and requires no further evaluation or treatment.

Graft-versus-host disease in extremity transplantation: Digital image analysis of bone marrow in situ

The development of either unstable immune chimerism and lethal graft-versus-host disease or stable immune chimerism and alloimmune tolerance can result from extremity transplantation. LBN rats served as recipients of Lewis vascularized extremity (limb) transplants. Recipients received no immune suppression and were immunologically unmodified. The bone marrow of transplanted and contralateral limbs was analyzed in situ for distribution of nuclei, nuclear area, and staining intensity by digital image analysis and computerized morphometry. Cellularity was significantly increased, and fat content was significantly decreased in the graft-versus-host disease animals marrow versus the tolerant animals marrow for both the transplanted and contralateral limbs. Tolerant animals demonstrated significantly increased nuclear staining compared with graft-versus-host disease animals for both transplanted and contralateral limbs. Additionally, there were significant changes between the host and the transplanted limbs for marrow intensity and cellularity within tolerant and graft-versus-host disease groups. The significant differences in the graft-versus-host disease-positive recipients suggested that both autoimmune dysregulation and alloimmune reactions were in effect for both donor and host bone marrow compartments. Cellular alterations in the tolerant recipients marrow were suggestive of subtle subclinical graft-versus-host responses.

Early use of the Brooker-Wills interlocking intramedullary nail (BWIIN) for femoral shaft fractures in acute trauma patients

During a 33-month period, 40 multiply injured patients underwent 43 Brooker-Wills interlocking intramedullary nailings (BWIIN) for femur fractures in the setting of a Level I trauma unit. There were 12 open fractures (28%), 66% of the closed fractures underwent BWIIN within the first 24 hours of injury, and 33 fractures (77%) had comminution of Winquist-Hansen Type II or greater, and either static or dynamic locking techniques were used in 38 (88%) of the cases. There were three intraoperative technical problems. The estimated blood loss and operative times were consistent with other reported series for interlocking nailing techniques. The average followup was 65 weeks. Only one fracture went on to nonunion. There were no problems with angulation or rotation. One patient had 1.5 cm of shortening. There were four major (9%) and four minor (9%) complications. Rod removal was successful in 17 of 18 cases. Mechanical failure (deformation and/or fracture) of the proximal end of the rod was found in four (22%) of the extracted nails and caused failure of removal in one. The Brooker-Wills nail is a versatile device which can be used to treat complex fractures of the entire femoral shaft in acutely injured patients.