Volume 19 · Issue 06 · 2016

The intraorbital wooden foreign body is often misdiagnosed or missed on computed tomography (CT) scan, due to the invisible or unclear images. The residual foreign bodies often occur during surgical removal. The clinical manifestations, imaging features and treatment of intraorbital wooden foreign bodies were discussed in this study.

We retrospectively analyzed 14 cases of intraorbital wooden foreign bodies managed at our hospital between January 2007 and May 2015. All patients underwent orbital CT examination before surgery, and surgery was performed under general anesthesia with orbital wound debridement and suture, as well as exploration and removal of wooden foreign bodies.

At first, 11 cases underwent removal of foreign bodies, including 1 case with incomplete removal and then receiving a secondary surgery. Foreign bodies were not found in three cases with preoperative misdiagnosis and orbital MRI found residual foreign bodies in the orbit. Operations were performed via primary wound approach in eight cases, conjunctival approach in two cases, and anterior orbitotomy in four cases. Postoperatively, one case was complicated with eye injuries, three cases with ocular muscle injuries, eight cases with visual loss, and eight cases with orbital abscess. The length of foreign bodies ranged from 1.8 cm to 11.0 cm. The maximum of four foreign bodies were removed at the same time.

Because the imaging of orbital wooden foreign bodies is complex and varied, MRI should be combined when they are invisible on CT scan. At the same time injuries trajectory and clinical manifestations of patients should be taken into account. Surgical exploration should be extensive and thorough, and foreign bodies and orbital abscess must be cleared.

Ocular trauma is the third leading cause of hospitalization in ophthalmology patients, imposing direct and indirect physical and psychological costs on society. This study aims to investigate the status of ocular trauma in hospitalized patients in the industrialized city of Kashan in 2011.

This cross-sectional descriptive applied study was conducted in 2012 on patients hospitalized for ocular trauma. Data, including age, gender, occupation, education, timing of admission following accident, location of accident, type of injury, damaging instrument, and type of trauma, were collected using a questionnaire designed by a trained nurse, and analyzed using SPSS-16 software by means of means ± standard deviation, frequency, and percentage for descriptive data and t-test, one-way analysis of variance, Chi-square and Fisher exact test for analysis at significance level of p < 0.05.

In total, 82 patients were hospitalized due to ocular traumas. The majority of patients were male (65 patients, 79.3%). Their mean age was (25.4 ± 21.4) years, with an age range of 20-40 years (30 patients, 36.6%). Hyphema was the most common injury (26 patients, 25.5%), home was the most frequent incident location (32 patients, 39%), and knife or other cutting tools were mostly responsible for injuries (18 patients, 21.9%). Patients were hospitalized for 1-6 days, and the average length of stay in hospital was 2.63 days. Frequency distribution of injuries based on whether or not ruptures differed significantly among different age groups.

The majority of ocular trauma occurred in young males. Knife was the principle culprit for eye injuries, followed by vehicles. To reduce such incidents, it is recommended that people be trained to avoid high-risk behaviors when using knives and to better heed driving rules and regulations.

Traumatic optic neuropathy (TON) is a serious complication of head trauma with the incidence rate of 0.5%-5%. The aim of this study was to investigate the therapeutic efficacy of endoscopic decompression of the optic canal for optic nerve injuries.

In this study, 11 patients treated in our hospital from January 2009 to January 2015 with the visual loss resulting from TON were retrospectively reviewed for preoperative vision, visual evoked potential (VEP) scan, surgical approach, postoperative visual acuity, complications, and follow-up results.

All these patients received endoscopic decompression of the optic canal. At the 3-month follow-up, the visual acuity improvement rate of the 11 patients was 45.5%. The vision acuity of 2 cases improved from hand movement to 0.08 and 0.3 after operation. Another patient's vision acuity returned to 0.05 compared to light sensation preoperatively. Two cases had finger counting before surgery but they had a vision acuity of 0.4 and light sensation respectively after surgery. However, the other 6 cases' vision did not improve after surgery.

Endoscopic decompression of the optic canal is an effective way to cure TON. VEP could be used as an important reference for preoperative and prognosis evaluation. Operative time after trauma is only a relative condition that may affect the therapeutic effect of optic canal decompression. Poor results of this procedure may be related to the severity of the optic nerve injury.

Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short therapeutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI.

Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15.

Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio between blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p = 0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%.

High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

To assess the clinical curative effect of different treatment methods for large area avulsion injury in the lower limb.

Between January 2010 and December 2013, 54 patients with large area avulsion injury in the lower limb were treated in the trauma center of our hospital, including 34 males and 20 females with a mean age of 35.7 years (range, 16-65 years). The injury mechanism was traffic accident in 44 cases, hitting by heavy objects in 8 cases, and fall from height in 2 cases, involving 31 thighs, 19 legs and 4 feet involved. The sizes of the avulsed wounds ranged from 10 cm × 15 cm to 50 cm × 30 cm. There were 16 cases combined with hemorrhagic shock, 5 with femoral fractures, and 7 with tibiofibula fractures. Averagely the patients were sent to our hospital within 3.5 h (range, 1.5-10 h) after injury. For the 54 patients, three different surgical strategies were performed based on the wound area and condition of the avulsed skin: in Group A, 24 patients were treated by debridement and preservation of subcutaneous vascular network + vertical mattress suture of full thickness skin flap + tube drainage; in Group B, 25 patients were treated by split-thickness skin flap meshing and grafting + vacuum sealing drainage (VSD); and in Group C, the other 5 patients were treated by debridement and VSD at stage I + reattachment of autologous reserved frozen split-thickness skin graft at stage II.

All the 54 patients recovered and were discharged eventually, without any deaths or amputees. In each group, there were no statistical differences (all p > 0.05) among different injury sites in terms of survival rate and length of hospital stay, except for the infection rate, which was much higher (p = 0.000) at the leg area than that at the thigh (32.54% ± 2.97% vs. 2.32% ± 2.34% in Group A and 50.00% ± 0.00% vs. 0 in Group C) or the foot (50.00% ± 0.00% vs. 0 in Group C). Moreover comparison of the three surgical methods showed a significant different (all p < 0.05) between each other for all the three assessed parameters, i.e. flap survival rate, length of hospital stay, and infection rate.

Treatment choices for skin avulsion on the lower limb should be based on the viability of the avulsed skin flap and the location of the wound. Proper choice can not only reduce the economic burden caused by using VSD, but also shorten the long hospital stay due to repeated wound dressing change or second stage surgery.

To report complications in the management of complex closed proximal tibial fractures.

A retrospective study was conducted to analyze the infectious and noninfectious complications encountered in the management of high-energy Schatzker type V and VI tibial plateau fractures. All patients were treated at the level 1 trauma centre between January 2011 and March 2014. Sixty two patients were included in the study. The mean patient age was (43.16 ± 11.59) years with 60 males and 2 females. Infectious complications like superficial and deep infection, wound dehiscence, malalignment in the immediate postoperative period and in follow-up period were noted.

The overall complication rate was 30.65% (19 out of 62). Infectious complications were noted in 20.97% cases (13/62). In majority of the cases (8/13), superficial infection was seen which managed with regular dressing and antibiotic administration. The patients (5/13) who had developed deep-seated infection were subjected to repeated debridements, flap coverage, implant removal or amputation depending upon the host response. Thirteen patients had experienced noninfectious complications. Hardware related complications were noticed in six patients and four among them received a secondary procedure. Malalignment was observed in seven patients but only single patient underwent subsequent operative intervention.

Proximal tibial plateau fractures especially Shatzker type V and VI are associated with extensive soft tissue damage even in closed injuries. The complications encountered in the management of these fractures can be minimized with appropriate patient selection and minimal soft tissue dissection.

To describe an indirect reduction technique during minimally invasive percutaneous plate osteosynthesis (MIPPO) of tibial shaft fractures with the use of a distraction support.

Between March 2011 and October 2014, 52 patients with a mean age of 48 years (16-72 years) sustaining tibial shaft fractures were included. All the patients underwent MIPPO for the fractures using a distraction support prior to insertion of the plate. Fracture angular deformity was assessed by goniometer measurement on preoperative and postoperative images.

Preoperative radiographs revealed a mean of 7.6^°(1.2^°-28^°) angulation in coronal plane and a mean of 6.8^°(0.5^°-19^°) angulation in sagittal plane. Postoperative anteroposterior and lateral radiographs showed a mean of 0.8^°(0^°-4.0^°) and 0.6^°(0^°-3.6^°) of varus/valgus and apex anterior/posterior angulation, respectively. No intraoperative or postoperative complications were noted.

This study suggests that the distraction support during MIPPO of tibial shaft fractures is an effective and safe method with no associated complications.

To evaluate the efficacy of intramedullary Kirschner wires for the treatment of unstable tibial shaft fractures in children.

This prospective study was conducted at the Department of Orthopaedic Surgery in Maharishi Markandeshwar Medical College from June 2005 to June 2010. Sixty-six children having closed fracture of the tibial shaft with a mean age of 7.7 years (range, 2-14 years) were recruited from emergency and outpatient department. They were treated with percutaneous intramedullary Kirschner wires. The clinical results of our study were rated on the basis of the criteria of union, nonunion, delayed union or malunion. All children were followed for one year.

Children achieved union in a mean time of 8 weeks (range, 6-10 weeks). Postoperatively, three children (4.55%) had delayed union, one (1.52%) valgus deformity of lower leg, three (4.55%) post-operative knee pain and twelve (18.18%) skin irritation at pin site. Wires were removed after 8-22 weeks without any complications. No patient was lost to follow-up. The results were excellent in 95.45% and good in 4.55% children.

This technique is cost-effective, simple, quick to perform, safe and reliable and avoids prolonged hospitalization with good results.

To describe our clinical experience with a system named SureShot™ Distal Targeting (Smith & Nephew, Memphis, USA) based on magnetic field presence and discuss our suggestions on this technique.

We analysed prospectively 47 patients affected by humeral, tibial or femoral fractures, treated in our institution during a 3-year period of time (August 2010 to September 2013). We considered the following parameters: the time to set up, the time to position a single screw, the effectiveness of the system (drilling ad screwing), the irradiation exposure time during distal locking procedure and surgical complications.

A total number of 96 screws were inserted. The mean preparation time of the device was 5.1 min ± 2 min (range 3-10 min). The mean time for single screw targeting was 5.8 min ± 2.3 min (range 4-18 min). No major complications occurred. Only a few locking procedures were needed to be practiced in order to obtain the required expertise with this targeting device.

According to our results, this device is reliable and valid whenever the correct technique is followed. It is also user friendly, exposes to lower radiation and needs less surgical time compared to relative data from the literature. However, the surgeon should always be aware of how to use the free hand technique in case of malfunctioning of the system.

To compare the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of displaced calcaneal fractures.

Reports of studies using case-controlled trials (CCT) to compare the percutaneous poking reduction and fixation with the open reduction and fixation in the management of calcaneal fractures were retrieved from the Cochrane Library, PubMed Database, CNKI, Chinese Biomedical Database, Wanfang Data (from January of 2005 to August of 2015). Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.0 was used for data-analysis.

Fifteen articles were included in the meta-analysis. Comparison of the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of calcaneal fractures revealed statistical significance in the incidence of complications after operation [RR = 0.32, 95% CI (0.20, 0.5), p < 0.05]. However, there were neither statistical significance in the degrees of recovery for calcaneal Bohler angle [WMD=-1.65, 95% CI (-3.43, 0.14), p > 0.05] and calcaneal Gissane angle [WMD=-3.21, 95% CI (-6.75, 0.33), p > 0.05], nor statistical significance in the rate of good foot function after operation [RR = 0.95, 95% CI (0.90, 1.00), p > 0.05].

For the treatment of calcaneal fractures, percutaneous poking reduction and fixation is superior to open reduction and fixation in terms of the incidence of postoperative complications. But both techniques can obtain satisfactory clinical function.