2013年 · 第16卷第03期

Abstract：Although most of nerve injuries associated with Monteggia fracture-dislocation in children are neurapraxias and will recover spontaneously after conservative treatment,surgical exploration of the involved nerve is always required in the cases with the entrapment of posterior interosseous nerve (PIN).However,the necessity and time frame for surgical intervention for specific patterns of nerve dysfunction remains controversial.The aim of the report is to observe and understand the pathology of PIN injury associated with Monteggia fracture-dislocation in children,and to propose the possible indication for the exploration of nerve.Methods:Eight cases,six boys and two girls,with Monteggia fracture-dislocation complicated by PIN injury,managed operatively at the authors' Hospital from 2007 to 2008 were retrospectively reviewed.All the patients underwent the attempted closed reduction before they received exploration of PIN,with open reduction and internal fixation or successful closed reduction.Results:The PIN was found to be trapped acutely posterior to the radiocapitellar joint in 4 out of 5 Type Ⅲ Bado's Monteggia fractures.In the remaining cases,since there were longer time intervals from injury to operation,chronic compressive changes and epineural fibrosis of radial nerve were visualized.After a microsurgical neurolysis performed,the complete recovery in the nerve function was obtained in all the cases during the follow-up.Conclusion:The findings from this study suggest that every case of type Ⅲ Monteggia fracture-dislocation with decreased or absent function of muscles innervated by PIN and an irreducible radial head in children should be viewed as an indication for immediate surgical exploration of the involved nerve to exclude a potential PIN entrapment。

Abstract：We report electroversion in treatment of atrial fibrillation (AF) and atrioventricular nodal reentry tachycardia (AVNRT) in a patient with Wolff-Parkinson-White syndrome and cervical spinal cord injury.At first,the patient sustained respiratory failure and weak cough reflex,thereafter repeated bronchoscopy was used to aspirate the sputum as well as control the pneumonia,which resulted in arrhythmia (AF and AVNRT).Two doses of intravenous amiodarone failed to correct the arrhythmia.After restoration of sinus rhythm by electroversion,he was successfully weaned from mechanical ventilation and discharged from the intensive care unit without recurrent arrhythmia。

Abstract：To review long-term respiratory effects of mustard gas on Iranian veterans having undergone IraqIran war.Electronic databases of Scopus,Medline,ISI,IranMedex,and Irandoc sites.were searched.We accepted articles published in scientific journals as a quality criterion.The main pathogenic factors are free radical mediators.Prevalence of pulmonary involvement is approximately 42.5％.The most common complaints are cough and dyspnea.Major respiratory complications are chronic obstructive pulmonary disease,bronchiectasis,and asthma.Spirometry resuits can reveal restrictive and obstructive pulmonary disease.Plain chest X-ray does not help in about 50％ of lung diseases.High-resolution CT of the lung is the best modality for diagnostic assessment of parenchymal lung and bronchi.There is no definite curative treatment for mustard lung.The effective treatment regimens consist of oxygen administration,use of vaporized moist air,respiratory physiotherapy,administration of mucolytic agents,bronchodilators,corticosteroids,and long-acting beta-2 agonists,antioxidants,surfactant,magnesium ions,therapeutic bronchoscopy,laser therapy,placement of respiratory stents,early tracheostomy in laryngospasm,and ultimately lung transplantation.High-resolution CT of the lung is the most accurate modality for the evaluation of the lung parenchyma and bronchi.The treatment efficacy of patients exposed to mustard gas depends on patient conditions (acute or chronic,upper or lower respiratory tract involvement).There are various treatment protocols,but unfortunately none of them is defmitely curable。

Abstract：To study the influence and mechanism of acute ethanol intoxication (AEI) on rat neuronal apoptosis after severe traumatic brain injury (TBI).Methods:Ninety-six Sprague-Dawley rats were randomly divided into four groups:normal control,AEI-only,TBI-only and TBI+AEI (n=24 for each).Severe TBI model was developed according to Feeney's method.Rats in TBI+AEI group were firstly subjected to AEI,and then suffered head trauma.In each group,animals were sacrificed at 6 h,24 h,72 h,and 168 h after TBI.The level of neuronal apoptosis and the expression of Bcl-2 protein were determined by TUNEL assay and immunohistochemical method,respectively.Results:Apoptotic cells mainly distributed in the cortex and white matter around the damaged area.Neuronal apoptosis significantly increased at 6 h after trauma and peaked at 72 h.Both the level of neuronal apoptosis and expression of Bcl-2 protein in TBI-only group and TBI+AEI group were higher than those in control group (P＜0.05).Compared with TBI-only group,the two indexes were much higher in TBI+AEI group at all time points (P＜0.05).Conclusion:Our findings suggest that AEI can increase neuronal apoptosis after severe TBI。

Abstract：Road traffic accident (RTA)and its related injuries contribute to a significant portion of the burden of diseases in Iran.This paper explores the association between driver-related factors and RTA in the country.Methods:This cross-sectional study was conducted in Iran and all data regarding RTAs from March 20,2010 to June 10,2010 were obtained from the Traffic Police Department.We included 538 588 RTA records,which were classified to control for the main confounders:accident type,final cause of accident,time of accident and driver-related factors.Driver-related factors included sex,educational level,license type,type of injury,duration between accident and getting the driving license and driver's error type.Results:Atotal of 538 588 drivers (91.83％ male,sex ratio of almost 13:1) were involved in the RTAs.Among them 423 932 (78.71％) were uninjured; 224 818 (41.74％) had a diploma degree.Grade 2 driving license represented the highest proportion of all driving licenses (290 811,54.00％).The greatest number of accidents took place at 12:00-13:59(75 024,13.93％).The proportion of drivers involved in RTAs decreased from 15.90％ in the first year of getting a driving license to 3.13％ after 10 years' of driving experience.Neglect of regulations was the commonest cause of traffic crashes (345 589,64.17％).Non-observance of priority and inattention to the front were the most frequent final causes of death (138 175,25.66％ and 129 352,24.02％,respectively).We found significant association between type of accident and sex,education,license type,time of accident,final cause of accident,driver's error as well as duration between accident and getting the driving license (all P＜0.001).Conclusion:Our results will improve the traffic law enforcement measures,which will change inappropriate behavior of drivers and protect the least experienced road users。

Abstract：Since appropriate and timetable methods in trauma care have an important impact on patients' outcome,we evaluated the effect of Advanced Trauma Life Support (ATLS) program on medical interns'performance in simulated trauma patient management.Methods:A descriptive and analytical study before and after the training was conducted on 24 randomly selected undergraduate medical interns from Imam Reza Hospital in Mashhad,Iran.On the first day,we assessed interns' clinical knowledge and their practical skill performance in confronting simulated trauma patients.After 2 days of ATLS training,we performed the same study and evaluated their score again on the fourth day.The two findings,preand post-ATLS periods,were compared through SPSS version 15.0 software.P values less than 0.05 were considered statistically significant.Results:Our findings showed that interns' ability in all the three tasks improved after the training course.On the fourth day after training,there was a statistically significant increase in interns' clinical knowledge of ATLS procedures,the sequence of procedures and skill performance in trauma situations (P＜0.001,P=0.016 and P=0.01 respectively).Conclusion:ATLS course has an important role in increasing clinical knowledge and practical skill performance of trauma care in medical interns。

Abstract：Terrorism-related bomb attacks on civilian population have increased dramatically over the last decade.Craniocerebral injuries secondary to improvised explosive devices have not been widely reported in the context of unarmored civilians.This series intends to report the spectrum of these injuries secondary to suicidal and implanted bombs as encountered at the Aga Khan University Hospital,Pakistan (AKUH).Further,a few pertinent management guidelines have also been discussed.Methods:The hospital database and clinical coding during a 5-year period were examined for head injuries secondary to terrorism-associated blasts.In addition to patient demographics,data analysis for our series included initial Glasgow Coma Scale,presenting neurological complaints,associated non-neurological injuries,management (conservative or operative) to associated complications,and discharge neurological status.Results:A total of 16 patients were included in this series.Among them 9 were victims of suicidal blasts while 7 were exposed to implanted devices.The patients presented with diverse patterns of injury secondary to a variety of shrapnel.A follow-up record was available for 12 of the 16 patients (mean follow-up:7.8 months),with most patients having no active complaints.Conclusion:The results of this series show that civilian victims of suicidal and improvised bombings present with a wide range of neurological symptoms and injury patterns,which often differ from the neurological injuries incurred by military personnel in similar situations,and thereby often require individualized care。

Abstract：Injection of insulin-like growth factor-1 (IGF-1) can prevent bone loss in sciatic nerve transaction rats.We try to investigate the action mechanism of IGF-1 on bone formation.Methods:A total of 40 adult male Spragne-Dawley rats were divided into two groups (experimental group and control group) with 20 animals in each.Sciatic neurectomy was performed to model disuse osteoporosis in all rats.IGF-1was administered in experimental group with the dose of 100 μg/kg per day for 3 days.Meanwhile,the rats in control group were treated with saline.Bone mineral density was measured by dual-energy X-ray absorptiometry 4 and 6 weeks after neurectomy respectively.Expression of Osterix and Runx2 was determined by reverse transcription-polymerase chain reaction (RT-PCR) assay.Results:There was a significant increase in the bone mineral density of experimental group compared with control group.There was a significant decrease in the level of receptor activator of nuclear factor-κ B-ligand but an increase in the level of osteoprotegerin 4 and 6 weeks after neurectomy in the experimental group compared with control one.The expression of Osterix and Runx2 was up-regulated in the bone marrow of experimental group compared with control group.Conclusion:IGF-1 can increase bone formation by stimulation of osteoblast number and activity,and reduce bone resorption by restriction of differentiation of osteoclast,suggesting that IGF-1 may improve the therapeutic efficacy for disuse osteoporosis。

Abstract：Multiple variables can influence triage decision in multiple trauma.Recognition of priorities and selection of the destination can be successfully achieved by field triage and individualized clinical judgment.This narrative review summarizes the new options and protocols for transport of injured subjects.There are four levels of emergency medical providers including first responders and three levels of emergency medical technicians.Two distinct accepted protocols for transport are known as scoop and run and treat and then transfer.The former provides minimum lifesaving treatment at the scene of accident followed by transferring the patient(s) as soon as possible,and the latter mainly emphasizes the need for complete stabilization as a prerequisite for safe transport.The destination and mode of transport are selected according to clinical capabilities of the receiving hospital,transfer time from the scene to the facility,patient's medical condition,accessibility of the scene,and weather.Two common methods of transfer are ground transport,including various type of ambulances,and air medical transport,i.e.helicopter and airplane。

Abstract：High-grade spondylolisthesis is very rare.We came across a case of high-grade spondylolisthesis at the L5-S1 level in a 32-year-old manual labourer who was hit by a heavy object on his flexed back.The patient presented to us with persistent deformity in the back.He complained of back pain on prolonged standing and after moderate work.Because of that he was unable to return to his work.On clinical examination there was a large step in the lower lumbar region.Detailed neurological evaluation of the lower limbs did not reveal any sensory or motor deficit,neither did bowel or bladder involvement.Radiographic examination showed L5 over S1 traumatic spondyloptosis.CT scan revealed that neural canal was in normal width.MRI confirmed spondyloptosis of L5 over S1 without any compromise of the spinal canal and with normal-looking cauda.Concerning the delayed presentation and no neurological deficit,the patient was managed conservatively after thorough counsel.At 6 months,the patient returned to his work and at the latest follow-up (15 months) he was free from back pain.Conservative means of treatment can lead to satisfactory outcome,especially when the patient has delayed presentation。

Abstract：Dislocation of the radial head in adults is uncommon.A simultaneous dislocation of the radial head and fracture of the ipsilateral distal end of radius with no other associated injuries is extremely rare.As far as we know,such an injury after an unusual mode of injury has been seldom reported in the English literature.We report such a case without any associated injuries or comorbidity.Closed reduction was performed within two hours after injury and results were satisfactory.Immobilisation was continued for 3 weeks.Gradual mobilisation was started after removal of the plaster under the supervision of a physiotherapist.At 6 months' follow-up,the patient had no residual pain at the elbow with full flexion & extension.Almost full supination with a restriction of last 10 degrees of pronation was achieved.There was no evidence of instability of the elbow。

Abstract：Breakage of K-wires and stainless steel wires which are used for fracture fixation is not uncommon,but migration is rare.We report a case of migration of broken K-wire used for patella tension band wiring to the popliteal fossa.The broken hardware was removed surgically.We would like to suggest that K-wire and wire fixation used for treatment ofpatellar fractures can migrate into the posterior compartment of the knee and cause clinical symptoms.Close clinical and radiological follow-up after internal fixation to identify the presence of hardware breakage or movement and removal of wires once fracture has united can avert such complications。

Abstract：Scaphoid dislocation is a rare injury.Traditionally it has been classified into isolated dislocation and dislocation associated with axial carpal disruption.We present a unique case of scaphoid dislocation associated with proximal migration of the entire distal carpal row as a single unit and hamate fracture with no axial carpal disruption.This injury complex has not been previously described in the literature.The purpose of this case report is to emphasize that in absence of axial carpal dissociation with scaphoid dislocation,a careful evaluation of injury to other bones should be done and treated accordingly to maximize the chances of favourable outcome with reconstructive surgery。